The radial forearm osteocutaneous "sandwich" free flap for reconstruction of the bilateral subtotal maxillectomy defect

Palatal mucoperiosteal flap for oro-nasal fistula following maxillectomy for maxillary sinus cancer

OBJECTIVES

This study aimed to describe the technique and clinical outcomes of using a palatal mucoperiosteal flap for oro-nasal fistula closure following resection of maxillary sinus cancer.

METHODS

The study was conducted with the permission of the internal review board of the Japanese Red Cross Wakayama Medical Center. Five consecutive cases from 2016 to 2020 of surgically treated maxillary sinus cancer in which the oro-nasal fistulas were closed using a palatal mucoperiosteal flap were retrospectively reviewed.

RESULTS

Following tumor resection, the oro-nasal fistula was closed using a palatal mucoperiosteal flap. Complete separation of the oral and nasal cavities was achieved in four patients. Oral intake was resumed within two weeks in four patients. All the patients were able to eat foods similar to those in the preoperative period. Their postoperative speech function was excellent, with no difficulty in communicating with others.

CONCLUSION

In the selected cases of maxillary sinus cancer, preservation of the palatal mucosa and closure of an oro-nasal fistula using a palatal mucoperiosteal flap was possible with reasonable outcomes for swallowing and speech functions. The use of this local flap is recommended as a minimally invasive procedure that can be performed especially in patients with limited physiological reserves which preclude free flap reconstruction.

Management of Palatal Defects after Free-Flap Reconstruction and Radiotherapy

Palatal fistulas have significant effects on quality of life. Traditional prosthetic rehabilitation and surgical reconstruction of palate defects in radiation-naïve tissues are well described. However, palatal fistulas developing after initial tumor extirpation, free-flap reconstruction, and adjuvant radiation or chemoradiation are associated with challenging secondary tissue effects. In this review, we will discuss the management of palatal fistulas after surgical reconstruction and radiotherapy.

Two-Layer Palatal Reconstruction Reduces Postoperative Intraoral Complications in Head and Neck Surgery

BACKGROUND

Although microvascular free flaps are commonly performed and have high success rates, postoperative oronasal fistulas or infections do occur. The authors hypothesized that a two-layer closure is effective for prevention of intraoral complications.

METHODS

Patients who underwent palatal reconstruction with a microvascular free flap were evaluated retrospectively. The cases were divided into two groups (palatal reconstruction with or without a two-layer closure). A two-layer closure involves unilateral reconstruction with a free flap, then reconstruction of the nasal lining with a local flap or folding free flap. The postoperative complication rates between these two groups were compared.

RESULTS

One hundred fifty-five cases were evaluated. A two-layer closure was performed in 65 cases (41.9 percent). The incidence of infections, dehiscence of the recipient site, and oronasal fistula were significantly higher in the single-layer closure group than in the two-layer closure group [10.0 percent versus 0 percent (p = 0.011); 15.6 percent versus 4.6 percent (p = 0.036); and 17.8 percent versus 4.6 percent (p = 0.013), respectively].

CONCLUSIONS

A two-layer closure in palatal reconstruction was shown to reduce the rate of infection, intraoral wound dehiscence, and oronasal fistula in the current study. A two-layer closure provides greater support and stability and reduces the risk of failure in reconstruction of the palate with a microvascular free flap.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Reconstruction of Complete Bilateral Maxillary Defects With Free Flaps

ABSTRACT

Reconstruction of complete bilateral maxillary defects (CBMDs) can be challenging due to the extensive loss of bone and soft tissues. This is a retrospective case series of 46 consecutive patients with CBMDs that were reconstructed with different microvascular free flaps. The authors aimed to evaluate the surgical outcomes and discuss the different reconstruction options in this case series. Thirty-six patients underwent reconstruction following ablation surgery for malignant tumors, 6 for benign tumors, 3 patients were treated for osteomyelitis, and 1 patient underwent free flap reconstruction for posttraumatic defects. Free fibula flap (n = 26) is the most commonly used reconstruction method in this case series, which was used in all defect types. This is followed by anterolateral thigh flap (n = 10), 5 rectus abdominis myocutaneous free flap, 3 radial forearm free flaps, and 2 composite free flaps. In this series, 44 free flaps survived, whereas only 2 flaps were lost. All patients could resume a soft diet postoperatively. Reconstruction of CBMDs with vascularized free flaps is a safe and reliable procedure.

Evaluation and comparison of oral function after resection of cancer of the upper gingiva in patients who underwent reconstruction surgery versus those treated with a prosthesis

BACKGROUND

We retrospectively analyzed the articulation, mastication, and swallowing function of patients who underwent reconstruction or used a prosthesis after resection of the upper gingiva.

METHODS

This study included patients who underwent resection of cancer of the upper gingiva from January 2014 to December 2018. Articulatory function was evaluated with Hirose's conversational function evaluation criteria. Mastication function was evaluated with the Yamamoto's occlusion table. Swallowing function was assessed with the MTF (Method of intake, Time, Food) score.

RESULTS

The mean articulatory function score was 8 points in the Reconstruction Surgery Group (RSG) and 8.8 points in the Prosthesis Group (PG). The mean mastication function score was 2.8 points in the RSG and 3.3 points in the PG. The mean swallowing function score was M3T4F4 in the RSG and M4T4F4.3 in the PG.

CONCLUSIONS

The prosthesis depends on the remaining occlusal support area. Our study suggest that prosthesis is better indication when there is more than one occlusal support area.

Reconstruction of the Midface and Palate

The midface is a complex anatomic structure that is fundamental to many physiologic and homeostatic functions. It may be involved in many pathologic processes that require partial or complete removal. When this happens, reconstruction is mandatory to improve cosmetic outcome with its effect on social interaction as well as to provide an opportunity for complete orodental rehabilitation with restoration of all physiologic functions. This article will review the different reconstructive options available for complex defects of the maxillofacial complex. It will highlight the surgical options available to maximize functional restoration. Finally, it will discuss computer modeling to optimize reconstructive planning.

Osteoradionecrosis of the Maxilla: Conservative Management and Reconstructive Considerations

The implementation of radiotherapy in the multimodal treatment of advanced head and neck cancer has greatly improved survival rates. In some patients, however, this benefit comes at the potential expense of the tissue surrounding the primary site of malignancy. Osteoradionecrosis (ORN) of the facial bones, in particular the maxilla, is a debilitating complication of radiation therapy. Exposure to ionizing radiation results in devitalization of underlying bone with necrosis of adjacent soft tissue. Controversy surrounding appropriate early intervention in ORN persists and no consensus for clinical treatment has been established. In the present article, we review the pathophysiology of maxillary ORN and discuss the role of both conservative medical therapy and reconstruction.

The Anterolateral Thigh Flap for Reconstruction of the Defect After Maxillectomy

OBJECTIVE

This study aimed to investigate the efficacy and success rate of the anterolateral thigh flap (ALT) in reconstructing total maxillectomy defects.

METHODS

This retrospective study involved patients with total maxillectomy defects, who underwent free ALT reconstruction from June 2005 to October 2014.

RESULTS

The study included 72 patients (43 males and 29 females; age range, 7-77 years; mean age, 43 years). Four patients experienced major complications related to surgery: total flap loss in one patient, partial flap necrosis requiring reoperation in one patient, hematoma requiring operative evacuation in 1 patient, and diplopia requiring reoperation in 1 patient. Two patients experienced minor complications: partial flap loss healed by secondary intention with local wound care, and donor site suture rupture in 1 patient healed by secondary intention. Six patients died because of cancer-related death (after local recurrence or metastatic disease). The defects in 5 patients involved the facial skin for which the ALT was segmented into three parts to reconstruct the facial skin, nasal lining, and oral lining. The defects in 4 patients involved the orbital floor for which a segment of tensor fascia lata was included with the flap on the same pedicle and used to repair the orbital floor. In the remaining patients, the free ALT flap, including a segment of vastus lateralis, was used to repair the maxillary defect and fill the dead space. All but one of the surviving patients were satisfied with their final appearance postoperatively.

CONCLUSION

The free ALT flap with or without fascia lata to repair the orbital floor is safe, reliable, and acceptable for reconstructing total maxillectomy defects.

Maxillary Reconstruction Using a Gullwing Fibula Osteofascial Flap and Flexor Hallucis Longus Muscle

The appropriate reconstruction of an infrastructure maxillectomy defect requires vascularized bone for maxillary arch restoration, soft tissue bulk for filling the residual defect extending up to the orbital floor, and a thin tissue layer for resurfacing the palate and adjacent cheek mucosa. Although several free tissue flaps have been previously described as reconstructive options, each possesses limitations. We describe the fibula osteofascial flap with flexor hallucis longus muscle, no skin paddle, and a “gullwing” fascial component, as an ideal reconstructive option for these specific maxillary defects. It satisfies the necessary requirements of bone, restoration of intraoral surfaces, as well as additional soft tissue volume to provide the optimal aesthetic and functional result. It also has the added benefit of minimizing morbidity to, and improving aesthetics of, the donor site. This is demonstrated through a case presentation and review of the existing literature.

Radial Forearm Osteocutaneous Free Flap for Reconstruction of Hard Palate With Alveolar Defect

The radial forearm free flap is beneficial for reconstruction of large palatal defect with oronasal fistula.A 51-year-old male patient who had anterior palate defect including alveolus after the radiation therapy of malignant cancer on the nasopharyngeal area undertook the radial forearm osteocutaneous free flap to close the oronasal fisula and restore the alveolar arch. The small radial bone segment was fixed in the alveolar defect and vascular anastomoses were performed with facial vessels in neck. The donor site was closed with split thickness skin graft. All suture wounds in the oral and nasal side had healed primarily with no complication within 1 month. The patient was able to swallow soluble foods in the 3 weeks postoperatively without the leakage phenomena in the nose and decreased hypernasality nature in his speech. Grafted bone union at alveolus was confirmed by follow-up computed tomography scan. There was no complication at left forearm donor site with intact musculoskeletal function.Radial forearm osteocutaneous free flap is a versatile option for its capability of reconstruction in complicated defect of soft and hard plate with alveolar defect.

Large orbital defect reconstruction in the setting of globe-sparing maxillectomy: The titanium hammock and layered fibula technique

INTRODUCTION

The purpose of our study was to describe a novel technique for reconstruction of orbital defects after maxillectomy using a non-anatomic titanium mesh suspension of orbital contents for both support and volume correction. This construct is then articulated with a layered fibula osteocutaneous free flap that restores orbital rim, zygoma, and maxillary alveolus. We herein present our application of this technique, including refinements over time and long-term outcomes.

METHODS

A retrospective review was performed on 12 patients who underwent reconstruction of Brown class III orbitopalatomaxillary defects with extensive orbital involvement (at minimum complete orbital floor and rim absent) with titanium mesh sling and a layered fibula free flap.

RESULTS

Primary reconstruction was accomplished in all 12 patients. The mean postoperative length of stay was 8 days (6-14 days). There were no free flap failures or perioperative re-explorations. Patients were routinely extubated on postoperative day #1 and began oral intake by postoperative day #3. At a mean follow-up length of 48 months, unrestricted eye function was accomplished in all patients. Midfacial symmetry was accomplished in 10 of 12 patients; 2 patients had moderate asymmetry due to extirpation of facial musculature and/or soft tissue. Minor revisions were necessary for lower lid ectropion and exposure of the titanium plate. Two patients required adipofascial free flap coverage of exposed intraoral bone after radiation therapy.

CONCLUSIONS

This technique provides excellent restoration of eye position and function and also allows for implant-based prosthetic rehabilitation. It has become our procedure of choice for orbitomaxillary reconstruction.

Osteocutaneous radial forearm free flap in nonmandible head and neck reconstruction

BACKGROUND

The osteocutaneous radial forearm free flap (RFFF) is a versatile flap primarily used to reconstruct composite defects involving the mandible. The purpose of this study was to describe our experience with this flap for nonmandible reconstruction.

METHODS

All patients undergoing nonmandible osseous reconstruction with free-tissue transfer were reviewed. Patients with osteocutaneous RFFF reconstructions were evaluated. The retrospective review of all osteocutaneous RFFFs was performed from 1998 to 2014.

RESULTS

One hundred forty-two nonmandible osseous reconstructions were performed. Twenty-five patients underwent nonmandible osteocutaneous RFFF reconstruction. Eleven patients failed previous nonmicrovascular reconstruction. Reconstruction was for defects of the: palatomaxillary complex (n = 15), orbitomaxillary complex (n = 4), nasomaxillary complex (n = 4), larynx (n = 1), and clavicle (n = 1). There were no flap compromises. Postoperative complications included: 2 partial intraoral dehiscences; 1 recipient-site infection; and 1 seroma. Eight reconstructions required secondary procedures to improve functional and/or cosmetic outcomes.

CONCLUSION

The osteocutaneous RFFF is a robust flap that can be used to reconstruct composite defects involving bone and soft-tissue beyond the mandible.

Microsurgical reconstruction of the maxilla: Algorithm and concepts

INTRODUCTION

The main purpose of this article is to highlight free tissue transfers as the first-choice method for three-dimensional (3D) maxillary reconstruction, particularly in providing enough bone for palate and maxillary arch reconstruction and consequently an implant-retained prosthesis. To achieve this, the myosseous free iliac crest was selected whenever possible as the first choice inside the reconstructive algorithm and free flap armamentarium. A new maxillectomy classification and algorithm reconstruction are proposed. Technical modifications and improvements accomplished over time are discussed, considering palate, dental implants and prosthesis, nasal sidewall, cranial base and dura, as well as recipient vessels. We present functional and aesthetic outcomes of the senior author's past 24-year experience (H. C.) with complex midface reconstructions.

MATERIAL AND METHODS

The authors report and analyse a 24-year experience with 57 midface defects in 54 patients (30 males and 24 females). A total of 57 maxillary defects - classified as Class I (limited maxillectomy) = 12, Class II (subtotal maxillectomy) = 15, Class III (total maxillectomy) = 19 and Class IV (orbitomaxillectomy) = 11 - were analysed regarding sex, age, tumour recurrence, free flap, reconstruction and necrosis. In addition, functional outcomes were evaluated regarding diet, speech, globe position and vision, while aesthetic outcomes were evaluated by patient and surgeon scores.

RESULTS

A total of 52 free flaps were performed in 47 patients; three patients were operated upon twice; and two other patients needed two sequentially linked flow-through flaps. The free flap survival was 96% with two total flap losses (4%). The other seven patients were fitted with a soft tissue-retained obturator prosthesis.

CONCLUSIONS

Microsurgical vascularised osteomyocutaneous free flaps are actually the gold standard for reconstruction of complex defects following maxillectomy. This algorithm is based on the anatomofunctional defect of the maxilla and it facilitates flap selection, which is a must.

Osteocutaneous free flaps for mandibular reconstruction: systematic review of their frequency of use and a preliminary quality of life comparison

OBJECTIVES

To determine whether the fibula free flap is the most frequently used osteocutaneous flap for mandible reconstruction, and whether it provides quality of life, depression and anxiety advantages.

METHODS

A systematic review of the public Medline database was conducted. Thirteen patients who underwent mandibular reconstruction at our hospital centre completed questionnaires to evaluate quality of life, depression and anxiety outcomes.

RESULTS

The most frequently used free flaps are those of the fibula (n = 982), radial forearm (n = 201), iliac crest (n = 113), subscapular system (n = 50) and rib-serratus (n = 7). In our patient population, there was a trend towards a better quality of life in those with a fibula free flap. However, patients in this group were significantly younger than patients with other flap types (p = 0.025). Patients with a subscapular system free flap were more depressed (p = 0.031); however, they had large through-and-through defects.

CONCLUSION

The flap used most frequently in the literature is the fibula free flap. Comparative quality of life data are lacking, and homogeneous populations should be used to reach significant conclusions.

Principles of head and neck reconstruction: an algorithm to guide flap selection

Advances in head and neck reconstruction have resulted in improved outcomes with single-stage repair of defects ranging from intraoral to pharyngoesophageal to skull base defects. Key to success of surgery is choosing an appropriate reconstructive option based on the patient's wishes and fitness for major surgery. Where possible, free tissue transfer provides the best functional and aesthetic outcomes for the vast majority of defects. In this article, we present an algorithm to guide choice of flap selection and review principles of reconstruction and secondary surgery for head and neck defects.

Current strategies in reconstruction of maxillectomy defects

OBJECTIVE

To outline a contemporary review of defect classification and reconstructive options.

DESIGN

Review article.

SETTING

Tertiary care referral centers.

RESULTS

Although prosthetic rehabilitation remains the standard of care in many institutions, the discomfort of wearing, removing, and cleaning a prosthesis; the inability to retain a prosthesis in large defects; and the frequent need for readjustments often limit the value of this cost-effective and successful method of restoring speech and mastication. However, flap reconstruction offers an option for many, although there is no agreement as to which techniques should be used for optimal reconstruction. Flap reconstruction also involves a longer recovery time with increased risk of surgical complications, has higher costs associated with the procedure, and requires access to a highly experienced surgeon.

CONCLUSION

The surgeon and reconstructive team must make individualized decisions based on the extent of the maxillectomy defect (eg, the resection of the infraorbital rim, the extent of palate excision, skin compromise) and the need for radiation therapy.

Cheek reconstruction: current concepts in managing facial soft tissue loss

Significant defects of the cheek present a reconstructive challenge due to their extremely visible site, as well as limited local tissue supply. In addition, the cheek abuts several structures of expressive function, such as the eye, mouth, and local facial musculature. To achieve satisfactory functional and aesthetic results, reconstruction of such defects requires careful three-dimensional restoration of all missing components, adequate texture matching, as well as functional restoration. Aesthetic reconstruction of facial defects should adhere to the priority goals of first preserving function and second achieving cosmesis. According to the size of the defect, location on the cheek, relationship to adjacent structures, available donor tissue, and existing skin tension lines, a host of techniques is available for closure. As a well-established principle in facial reconstructive surgery, one should use local tissue whenever possible to provide the best tissue for color and contour restoration. However, thoughtful reliance upon the "reconstructive ladder," including direct closure, skin grafting, local flap creation, regional flap placement, and free-flap repair, will invariably guide the surgeon in an optimal approach to cheek reconstruction.

Reconstruction of high maxillectomy defects with the fibula osteomyocutaneous flap in combination with titanium mesh or a zygomatic implant

BACKGROUND

This retrospective review examined the authors' patients who underwent reconstruction of high maxillectomy defects with fibula osteomyocutaneous flaps in combination with titanium mesh or a zygomatic implant. Outcome assessments included aesthetic, speech, and masticatory function.

METHODS

Twenty patients who underwent reconstruction of high maxillectomy defects with fibula osteomyocutaneous flaps in combination with titanium mesh (n = 19) or a zygomatic implant (n = 1) were reviewed. The fibula was fashioned to recreate the alveolar ridge and pterygomaxillary buttress, and the skin paddle was applied to restore the palate and nasal airway. The anterior wall of the maxilla and the orbital floor were reconstructed with titanium mesh in 19 patients. In four patients with extensive soft-tissue defects, a radial forearm flap was combined to restore missing soft tissue. Aesthetics, speech, and masticatory function were evaluated postoperatively.

RESULTS

Nine patients underwent immediate maxillary reconstruction and 11 patients underwent secondary reconstruction. The overall success rate of 24 flaps was 95.8 percent. The exposure rate for titanium mesh and the oronasal fistula rate were both 10.5 percent. The average length of follow-up was 34.7 months. Recurrence occurred in only one patient, who died as a result of the disease. Ten patients received implant-borne prostheses or removable partial dentures. Excellent or good cosmesis and intelligible speech were noted in 19 patients. All patients were ultimately able to tolerate a regular or soft diet.

CONCLUSIONS

Reconstruction of high maxillectomy defects with the fibula osteomyocutaneous flap in combination with titanium mesh or a zygomatic implant is a feasible and acceptable option with a high success rate, a low complication rate, excellent postoperative cosmesis, and well-accepted function.

Microvascular reconstruction of oncologic defects of the midface

Reconstruction of a midfacial defect can represent a formidable challenge for the reconstructive surgeon. Attesting to both the variety and the complexity of midfacial defects, numerous different classification schemes have been proposed, and are reviewed in this article. The approach to reconstruction can be simplified, however, by classifying maxillectomy defects into four types. Understanding the complex three-dimensional anatomy of the maxilla and its relationship to contiguous structures is the first step in approaching reconstruction of the midface. Achieving basic functional and aesthetic goals of maxillary reconstruction can be achieved using free flap reconstruction with good reliability and predictability in the majority of patients. A specific approach to each defect type is outlined.

Zygomatic-maxillary buttress reconstruction of midface defects with the osteocutaneous radial forearm free flap

BACKGROUND

The purpose of this study was to evaluate morbidity, functional, and aesthetic outcomes in midface zygomatic-maxillary buttress reconstruction using the osteocutaneous radial forearm free flap (OCRFFF).

METHODS

A retrospective review of 24 consecutive patients that underwent midface reconstruction using the OCRFFF was performed. All patients had variable extension of maxillectomy defects that requires restoration of the zygomatic-maxillary buttress. After harvest, the OCRFFF was fixed transversely with miniplates connecting the remaining zygoma to the anterior maxilla. The orbital support was given by titanium mesh when needed that was fixed to the radial forearm bone anteriorly and placed on the remaining orbital floor posteriorly. The skin paddle was used for intraoral lining, external skin coverage, or both. The main outcome measures were flap success, donor-site morbidity, orbital, and oral complications. Facial contour, speech understandability, swallowing, oronasal separation, and socialization were also analyzed.

RESULTS

There were 6 women and 18 men, with an average age of 66 years old (range, 34-87). The resulting defects after maxillectomy were (according to the Cordeiro classification; Disa et al, Ann Plast Surg 2001;47:612-619; Santamaria and Cordeiro, J Surg Oncol 2006;94:522-531): type I (8.3%), type II (33.3%), type III (45.8%), and type IV (12.5%). There were no flap losses. Donor-site complications included partial loss of the split thickness skin graft (25%) and 1 radial bone fracture. The most significant recipient-site complications were severe ectropion (24%), dystopia (8%), and oronasal fistula (12%). All the complications occurred in patients with defects that required orbital floor reconstruction and/or cheek skin coverage. The average follow-up was 11.5 months, and over 80% of the patients had adequate swallowing, speech, and reincorporation to normal daily activities.

CONCLUSIONS

The OCRFFF is an excellent alternative for midface reconstruction of the zygomatic-maxillary buttress. Complications were more common in patients who underwent resection of the orbital rim and floor (type III and IV defects) or external cheek skin.

Immediate maxillary reconstruction after malignant tumor extirpation

AIMS

Immediate maxillary reconstruction after malignant tumor extirpation differs from other types of maxillary reconstruction. Our reconstruction algorithm is described in this article.

METHODS

One hundred ninety-four patients who had undergone maxillectomy for malignant tumors were reviewed, and maxillectomy defects were classified with the method of Cordeiro and Santamaria.

RESULTS

Mean total blood loss was 848 ml, and 71 patients died within 2 years after surgery. For type IIIa defects of the orbital floor, titanium mesh or vascularized bone or cartilage was used for reconstruction, but the rate of postoperative complications did not differ between titanium and autografts. Therefore, to reconstruct orbital floor defects we have recently used only titanium mesh. For type I or II defects, we use autografts for only selected cases.

CONCLUSIONS

We strive to perform less-invasive reconstructive surgery after resection for maxillary malignancy.

Reconstruction of maxillectomy and midfacial defects with free tissue transfer

The maxillary bones are part of the midfacial skeleton and are closely related to the eyeglobe, nasal airway, and oral cavity. Together with the overlying soft tissues, the two maxillae are responsible to a large extent for facial contour. Maxillectomy defects become more complex when critical structures such as the orbit, globe, and cranial base are resected, and reconstruction with distant tissues become essential. In this article, we describe a classification system and algorithm for reconstruction of these complex defects using various pedicled and free flaps. Most defects that involve resection of the maxilla and adjacent soft tissues may be classified into one of the following four types: Type I defects, Limited maxillectomy; Type II defects, Subtotal maxillectomy; Type III defects, Total maxillectomy; and Type IV defects, Orbitomaxillectomy. Using this classification, reconstruction of maxillectomy and midfacial defects may be approached considering the relationship between volume and surface area requirements, that is, addressing the bony defect first, followed by assessment of the associated soft tissue, skin, palate, and cheek-lining deficits. In our experience, most complex maxillectomy defects are best reconstructed using free tissue transfer. The rectus abdominis and radial forearm free flap in combination with immediate bone grafting or as an osteocutaneous flap reliably provide the best aesthetic and functional results. A temporalis muscle pedicled flap is used for reconstruction of maxillectomy defects only in those patients who are not candidates for a microsurgical procedure.

Calvarial Bone Grafts and Temporalis Muscle Flap for Midfacial Reconstruction After Maxillary Tumor Resection

Midfacial reconstruction after radical oncological resection is a challenging endeavor and several options can be employed: prosthethic devices, pedicled flaps (with or without the aid of autologous or alloplastic grafts), and microvascular flaps. Each technique has specific indications, advantages and disadvantages. The use of traditional surgical reconstructive procedures seems to be shifted nowadays by microvascular free flaps. Nevertheless, in our experience the myofascial temporalis flap associated with free calvarial bone grafts demonstrate to be a safe and versatile option in primary midfacial reconstruction. From this point of view the authors have developed a technique for one-stage reconstruction of the orbito-maxillary skeleton and soft tissues and without the use of microsurgical flaps; this surgical procedure can be used only on patients for whom a resection of the cutaneous tissues and exenteratio orbitae are not necessary. The aims of this paper is to describe the surgical technique and to show a retrospective analysis on 17 patients which underwent midfacial radical resection and immediate reconstruction with calvarial bone grafts and temporalis muscle flap along 15 years.

Developments in reconstruction of midface and maxilla

Loss of the maxilla and midfacial structures after tumour removal has substantial functional and aesthetic consequences. The variable loss of soft tissue, bone, or both, leading to collapse of the lip, cheek, periorbital soft tissues, and palatal competence present a challenging dilemma for reconstructive surgeons. Efforts have been made to classify these midfacial defects and provide appropriate algorithms for optimum reconstruction. Not only does the cavity need to be obliterated and midfacial contours recreated, but swallowing function, phonation, and mastication need to be restored for an ideal result. Traditionally, these defects would have been repaired by a maxillofacial prosthesis but advances in tissue transfers, particularly of microvascular free flaps, have greatly increased reconstructive options. The wide variety of free flaps that contain both soft tissue and bone offer unique properties that could be applicable depending on the defect. Combinations of free tissue transfer, local flaps, and maxillofacial prostheses might achieve a more ideal result than one technique alone. Advances in osseointegration have also enhanced the ability to achieve the best function and form. No one flap or technique is sufficient to reconstruct midface defects in all patients. The choices should be tailored to the bony and soft-tissue needs of each specific defect, denture-bearing potential of the original tissues, and available prosthodontic support. Use of a multidisciplinary approach to reconstruct these defects can yield excellent results. The complexity of the techniques should match the desired goals and needs of each individual patient.

The full-thickness forehead flap for complex nasal defects: a preliminary study

OBJECTIVE

To report a new technique using a bivalved, full-thickness paramedian forehead flap. The unique vascular anatomy of the supratrochlear artery allows the skin and subcutaneous tissue to be separated from the frontalis muscle and pericranium. The deep layers serve as a pliable, vascularized intranasal lining. Bone and cartilage grafts can be placed as "sandwich" grafts between the deep and superficial layers of the flap.

STUDY DESIGN

A retrospective review of 5 cases.

RESULTS

All flaps survived. Four minor complications occurred in 3 patients. These resolved with minimal treatment.

CONCLUSIONS

The full-thickness forehead flap is a viable option for large defects or for the difficult situation in which intranasal local flaps are not an option.

SIGNIFICANCE

The gold standard for replacement of the intranasal lining is a septal mucosal or vestibular local flap. The full-thickness forehead flap is an option in patients for whom other lining flaps are not available.

EBM RATING

C-3.

Vascularized Rib for Facial Reconstruction

The reconstruction of maxillectomy defects is a complex problem encountered in plastic surgery. Defects can range in size and complexity from small defects requiring only soft tissue to complete maxillectomies requiring large tissue bulk, bone, and one or more skin paddles. The most difficult defects involve the skull base and orbit. The reconstructive surgeon is faced with the challenge of isolating the nasopharynx from the dura and globe while simultaneously restoring the bony framework of the maxilla and orbit to support the soft tissue of the cheek. The authors present a series of six reconstructions using a rectus abdominis muscle flap with associated vascularized rib for reconstruction of complex maxillectomy defects. This flap provides large soft-tissue bulk as well as bony support and a long vascular pedicle. A skin island can be taken with the flap, and the donor-site morbidity is comparable to that seen with a vertical rectus abdominis myocutaneous flap. Six flaps were used in five patients over a 20-month period. All patients had stable support of the orbit at follow-up with adequate soft-tissue coverage, and there were no incidences of visual changes.