Vascular Iliac Crest With Inner Table of the Ilium as an Option in Maxillary Reconstruction

Maxillary Reconstruction With a Rib-attached Free Latissimus Dorsi Muscle Flap

In defect reconstruction after maxillary tumor resection, filling the dead space created by resection and reconstruction of surrounding areas are crucial for good cosmetic outcomes. Although various procedures have been described in the literature, most are complex and require advanced surgical skills. Therefore, in this study, the authors aimed to identify a simple procedure for successful reconstruction with minimal bone fixation. Three patients who underwent total maxillectomy and reconstruction using the rib-attached free latissimus dorsi flap at Keio University Hospital between 2012 and 2014 were included and followed up with for a minimum of 5 years. After total maxillectomy, the authors used a free latissimus dorsi flap with a portion of the rib to fill the dead space and reconstructed the orbit, nasal cavity, and oral cavity.The authors performed a rigid reconstruction of the zygomatic ridge using only 2-point plate fixations of the ribs at the outer orbit and anterior nasal spine. Patients were followed up for ≥5 years, and the flap successfully survived in all cases. There was an issue with rib fixation in 1 case; however, all patients were highly satisfied with the procedure's cosmetic results.

Analysis of intraoral microvascular anastomosis in maxillofacial defects reconstruction

This review summarizes the research progress in the field of intraoral microvascular anastomosis techniques (IAT) and attempts to investigate the indications for procedures in which IAT can be applied, the surgical procedure and the difficulties involved, technical assessments, result evaluation and the perspective. Currently, microvascular anastomosis technique is widely used in maxillofacial defects reconstruction from various causes including cutaneous injury or congenital deformity which usually required extensive flap reconstruction and therefore a vascular free flap is routinely used. Conventional microvascular anastomosis reconstruction techniques cannot avoid new incisions, which will affect the postoperative aesthetic situation. Surgeons have therefore attempted to improve this technique to effectively eliminate scars caused by surgery: some patients can be chosen to undergo microvascular anastomosis of the free flap intraorally, thus reducing the extraoral incision caused by the anastomosis located in neck or maxillofacial improving the postoperative appearance of the patients. In addition to preserving the external appearance, intraoral anastomosis technique (IAT) can also solve some other problems of maxillofacial vascular anastomosis, such as insufficient vessel pedicle length and high risk of facial nerve injury.

The Versatility of the DCIA Free Flap: A Forgotten Flap? Systematic Review and Meta-Analysis

BACKGROUND

 Studies reporting on the deep circumflex iliac artery (DCIA) free flap are restricted to a limited number of patients and areas of application. The aim of this review was to assess the reliability and versatility of the DCIA free flap during reconstruction.

METHODS

 A comprehensive review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines using PubMed, Web of Science, Cochrane CENTRAL, and SCOPUS. A critical analysis of pooled data was performed to assess outcomes employing the DCIA free flap.

RESULTS

 A total of 445 DCIA free flaps were included. The main recipient sites were head and neck (72.35%), lower extremity (20.67%), and upper extremity (6.74%). The main indications for reconstruction were tumor resection (73.8%) and trauma (17.43%). Fifty non-DCIA flaps were required to finalize the reconstruction of several defects. The pooled flap failure rate using the DCIA free flap was 4% (95% confidence interval: 1-8%). No significant heterogeneity was present across studies (Q statistic 22.12, p = 0.14; I ² = 27.68%, p = 0.139). Complication rates for head and neck and limb reconstruction were 57.37 and 40.16%, respectively. The average length and surface area of bone flaps were 7.79 cm and 22.8 cm², respectively. The area of the skin paddles was 117 cm².

CONCLUSION

 The DCIA free flap has shown to be a versatile reconstructive alternative for head and neck and short-medium size limb defects. However, the complexity of functions, the recipient site location, and a potential large defect can detract from the use of the DCIA free flap as an initial reconstructive option for head and neck and extensive limb defects.

Accuracy of patient-specific temporal implants using PEKK

The main aim of this study was to evaluate the accuracy of immediate CAD/CAM reconstruction of the temporal hollowing following temporalis muscle surgery, using a patient-specific implant (PSI) PEKK model. This case series included ten patients who underwent maxillofacial reconstruction using temporalis muscle flap (TMF). The study involved the preoperative planning and fabrication of the temporal implant using virtual surgical planning software. The planning was based on multislice CT scans, from which DICOM files were used to fabricate a 3D model of the temporalis muscle using polyetherketoneketone (PEKK). The patients were followed up for 12 months, to check for any signs of infection or mobilization, and to assess accuracy. At the end of the follow-up period, all the patients showed acceptance of the external appearance, with no signs of infection or rejection. These customized implants were measured and compared with their original 3D preoperative planning using a point-based analysis. This revealed a mean difference (±SD) of 0.0373 (±0.3036) mm and a median difference (Q1 to Q3) of 0.0809 (-0.2108 to 0.2769) mm. The study demonstrated that a highly accurate duplication of PSIs can be achieved using this template-molding workflow. The use of PEKK PSIs resulted in uneventful healing and esthetic acceptance by the patients and, therefore, is a relevant treatment option when temporal hollowing has to be corrected.

Protocol and Evaluation of 3D-Planned Microsurgical and Dental Implant Reconstruction of Maxillary Cleft Critical Size Defects in Adolescents and Young Adults

Functional and esthetic final reconstruction of the cleft maxilla is still challenging. Current reconstructive and augmentation techniques do not provide sufficient bone and soft tissue support for the predictable rehabilitation with dental implants due to presence of maxillary bone critical size defects and soft tissue deficiency, scaring and poor vascularity. In this article the protocol for the use of 3D virtual surgical planning and microvascular tissue transfers for the reconstruction and rehabilitation of cleft maxilla is presented. Twenty-five patients (8 male/17 female) aged 14–41 years old with cleft-associated critical size defects were treated by 3D-virtual planned microvascular tissue transfers taken either from fibula, iliac crest, radial forearm, or medial femoral condyle. Follow-up lasted 1–5 years. No significant bone resorption (p > 0.005) nor volume loss of the graft was observed (p = 0.645). Patients received final permanent prosthetic reconstruction of the anterior maxilla based on 2–5 dental implants, depending on the defect severity. This is the first study presenting the use of virtual planning in the final restoration of the cleft maxilla with microvascular tissue transfers and dental implants. Presented protocol provide highly functional and aesthetic results.

The Iliac Crest Osteomuscular Flap for Bony Reconstruction: Beast or Beauty? A Reassessment of the Value and Donor Site Morbidity in the CAD/CAM Era

BACKGROUND

 The iliac crest bone flap (ICBF), based on the deep circumflex iliac artery, has a bad reputation regarding donor site morbidity. However, the ICBF has an ideal curvature and shape for occlusion-based hemimandibular reconstructions with rapid dental rehabilitation and for vertical class III maxillary reconstructions that require bony support and muscular bulk to fill cavities and to provide intraoral lining. Is this notorious donor site reputation still valid with modern flap procurement using computer aided design/computer aided manufacturing (CAD/CAM) and recipient-site closure techniques?

MATERIALS AND METHODS

 We performed a literature search of the public databases PubMed, Cochrane, Google Scholar, and Web of Science for papers using mesh keywords related to donor site morbidity of the ICBF. We report three illustrative case reports using our current protocols for oncologic bony resection and reconstruction, using in-house CAD/CAM and three-dimensional printing to procure a tight-fit ICBF and minimizing donor site morbidity.

RESULTS

 We found 191 articles in the PubMed database of which we considered 176 nonrelevant. Cochrane Library and Google Scholar database searches resulted in the inclusion of 11 additional papers. The second search resulted in 172 articles of which we used five after excluding nonrelevant papers. Accurate preoperative (CAD/CAM) planning, preservation of the anterior superior iliac spine (ASIS), and paying attention to thoroughly donor site closure make the ICBF a very valuable option for accurate maxillofacial reconstructions with very acceptable comorbidities. This corresponds with our clinical findings.

CONCLUSION

 Dogma never is a good teacher; it remains elementary that routine "knowledge" is (re)questioned. Donor site morbidity of the ICBF is comparable to other bone flaps. The shape and bone stock of the ICBF is ideal and often may be first choice. In combination with CAD/CAM planning, the ICBF is an excellent option for specific maxillofacial reconstructions.

Mirror Image Based Three-Dimensional Virtual Surgical Planning and Three-Dimensional Printing Guide System for the Reconstruction of Wide Maxilla Defect Using the Deep Circumflex Iliac Artery Free Flap

A patient was diagnosed with squamous cell carcinoma of the maxillary sinus and consequently underwent a unilateral total maxillectomy and reconstruction using an anterolateral thigh (ALT) free flap. Soft tissue transplantation without a bone graft at the large maxillary defect site caused a midfacial collapse, which worsened, especially after radiotherapy. The 3-dimensional positioning of the composite flap for wide maxillary reconstruction is aesthetically important. To achieve ideal symmetry and aesthetics, a mirror image was created using the normal contralateral side. Through computer simulation, the function and symmetry of the virtually reconstructed maxilla was evaluated, and the surgical guide was made using a 3D printing system. Based on the prepared surgical guide, a deep circumflex iliac artery (DCIA) free flap was harvested, and its implementation in the reconstruction ultimately led to satisfactory results. Utilization of mirror image based virtual surgical planning and a 3D printing guide is a significantly effective method for maxilla reconstruction with DCIA flaps.

Reconstruction of orbitomaxillary defects

PURPOSE

Defects of the orbitomaxillary complex are problematic, not only for the patient, who deals with physical and psychological sequelae of his or her condition, but also for the surgeon, who must select from numerous treatment options to achieve the best possible outcome. As is often the case in surgically managed disease states, there is minimal high-level evidence to direct decision making in this area of medicine. We aim with this case series to at least provide our perspective on orbitomaxillary reconstruction based on a single-surgeon's 6-year experience at the University of Florida in Jacksonville.

MATERIALS AND METHODS

A chart review was performed for patients treated by the maxillofacial surgery division from August 2006 through August 2011, who underwent reconstruction of orbitomaxillary defects (Classes III to VI) resulting from ablative surgery. Data collected included patient demographics, surgery performed, reconstructive methods, pathology, and adjuvant radiotherapy. Inclusion criteria consisted of an initial surgery involving maxillectomy with orbital involvement performed at our institution, adequate follow-up, and complete medical records. Patients treated elsewhere or with inadequate records were excluded from the study.

RESULTS

We identified 21 patients who met the criteria for this study. Their ages ranged from 44 to 79 years, with 8 men and 13 women. Histologic evaluation showed squamous cell carcinoma in the majority of cases (14 patients). All defects were either Brown Class III, IV, V, or VI with the distribution as follows: 7 Class IIIs, 5 Class IVs, 7 Class Vs, and 2 Class VIs. The reconstructions included 8 radial forearm flaps, 4 anterolateral thigh flaps, 2 thoracodorsal artery perforator fasciocutaneous flaps, 1 thoracodorsal angular artery composite flap, 2 latissimus dorsi myofasciocutaneous flaps, and 1 composite fibula flap. Three patients had only an obturator with local flaps or skin grafting. Of the 21 patients, 18 had postoperative radiation. Follow-up ranged from 2 to 60 months. Three patients died of their disease, 14 were alive without disease, and 4 were lost to follow-up. Mean follow-up was 24.5 months.

CONCLUSIONS

On the basis of our patient experience, we believe that we can offer the following perspective: patients reconstructed for these larger defects, Classes III to VI, were less likely to be discontented with their reconstruction as compared with those who underwent obturation. The choice of bone versus soft tissue-only reconstruction was not a significant issue for our patient population because the vast majority of patients were not interested in dental implants because of out-of-pocket costs. In the era of perforator flaps, we believe that the use of these flaps provides a more predictive outcome compared with musculocutaneous flaps, which will atrophy over time and lead to a change in facial contour.

The Microvascular Corticocancellous Femur Flap for Reconstruction of the Anterior Maxilla in Adult Cleft Lip, Palate, and Alveolus Patients

Objective

Free nonvascularized alveolar bone grafting in severe defects of the cleft region often results in poor implant bed conditions. Here an alternative augmentation technique using a new technique of vascularized bone transfer is described.

Design

In five patients with clefts of the lip, palate, and alveolus (four unilateral, one bilateral) there was a severe defect of the anterior maxillary alveolar ridge after tooth loss. The patients previously had augmentative surgery one to three times without success. The defect was covered using a microvascular corticocancellous transplant from the medial distal femur. The defects to be corrected measured 2.5 to 4.0 cm long, 1.0 to 1.5 cm wide, and 1 to 1.5 cm high. The microvascular pedicle of the femur bone flap was 3 to 7 cm long. The descending genicular artery was anastomosed to the facial or labial superior artery and the accompanying veins accordingly. In every case, the anastomoses were performed via an intraoral transmucosal approach.

Results

There were no serious complications and no flap loss. In all patients the defect was covered by a flap of the correct size and design. All patients were treated with dental implants (13 total) 6 months after successful reconstruction of the ridge. The implants were loaded 4 to 6 months after placement with fixed superstructures. There were good peri-implant conditions and no implant loss.

Conclusion

The microvascular osteoperiosteal femur flap can be used successfully in individual reconstruction of segmental defects of the alveolar ridge in adult cleft patients.

Comparative study of the osseointegration of dental implants after different bone augmentation techniques: vascularized femur flap, non-vascularized femur graft and mandibular bone graft

OBJECTIVES

The purpose of this study was to evaluate the osseointegration of the dental implants placed into the mandible augmented with different techniques in pigs.

MATERIAL AND METHODS

Four adult domestic pigs were used. Horizontal augmentation of the mandible was performed in animals by using vascularized femur flap (VFF), non-vascularized femur graft (NVFG) and monocortical mandibular block graft (MG). After 5 months of healing 10 dental implants were placed into each augmented site. The pigs were sacrificed after 3 months of healing. Undecalcified sections were prepared for histomorphometric analysis.

RESULTS

Mean bone-implant contact (BIC) values for implants placed into MG, NVFG and VFF were 57.38 ± 11.97%, 76.5 ± 7.88%, 76.53 ± 8.15%, respectively. The BIC values of NVFG and VFF group were significantly greater than MG group (P<0.001). On the other hand, there was not statistically significant difference between NVFG group and VFF group (P=0.999).

CONCLUSION

NVFG as well as VFF can be considered as a promising method for augmentation of alveolar defects and the placement of the implants. The selection of non-vascularized graft or vascularized flap depends on the condition of the recipient site.

Reconstruction of velopharyngeal competence for composite palatomaxillary defect with a fibula osteocutaneous free flap

Velopharyngeal competence reconstruction is indispensable for acquiring the fine speech and ingesting function. However, the maxillary prosthesis becomes unstable in some patients who have undergone extensive palatomaxillary. We present a case of total palatomaxillary defect resulting from squamous cell carcinoma ablation of the palate, which was reconstructed using a fibula-free osteocutaneous flap. Velopharyngeal competence was reconstructed owing to the flap so that the patient could ingest a soft diet and speak without hypernasality 2 weeks after surgery.

Free microvascular transfer of segmental corticocancellous femur for reconstruction of the alveolar ridge

In seven patients with deficiency of the alveolar ridge of the maxilla or mandible the defect was covered with the help of a microvascular corticocancellous transplant of femur. The defects to be corrected measured 3-10 cm long, 1.5-4 cm wide, and 1-1.5 cm high. The microvascular pedicle was between 4 and 10 cm long. The descending genicular artery was anastomosed to the facial or labial superior artery and the accompanying veins accordingly. There were no serious complications and no transplant was lost. In all patients the defect was covered by the correct size and design. All patients were treated with dental implants six months after successful reconstruction of the ridge. The microvascular osteoperiosteal femur transplant can be used successfully in individual reconstruction of segmental defects of the alveolar ridge.

Analysis of salvage treatments following the failure of free flap transfer caused by vascular thrombosis in reconstruction for head and neck cancer

BACKGROUND

Few authors have reported the subsequent treatment for patients in whom free tissue transfers in the head and neck have failed as a result of vascular thrombosis.

METHODS

Between 1993 and May of 2005, 502 free flaps were transferred after head and neck cancer ablation in the authors' hospital, 19 of which resulted in total necrosis caused by vascular thrombosis. The authors categorized these 19 cases into four groups and analyzed the salvage treatment.

RESULTS

For failed free jejunal transfer, early initiation of oral intake was obtained when another free jejunum was transferred. For failed free soft-tissue transfer for intraoral defects, reconstruction with common free (first choice) or pedicled flaps was used: a voluminous musculocutaneous flap for extensive defects, forearm flap or pedicled pectoralis major flap for intermediate defects, and direct closure for small defects of the oral floor. For failed secondary soft-tissue transfer to improve a certain function, salvage flap transfer was not chosen in the acute setting. For failed secondary maxillary reconstruction, simple reconstruction using the rectus abdominis musculocutaneous flap combined with costal cartilage achieved stable results. The overall success rate of the repeated free flap was 89 percent (eight of nine patients).

CONCLUSIONS

When a free flap is judged unsalvageable, surgeons should determine subsequent treatments, considering the success rate as one of the most important factors. The authors believe that simple reconstruction using a common free flap is the first choice in most cases. When regional or general conditions do not permit further free flap transfer or when defects are comparatively small, reconstruction with a pedicled flap or direct closure of the defect may be considered.

The versatility of vascularized iliac crest with internal oblique muscle flap for composite upper maxillary reconstruction

The middle third defects of the face following total or partial oncologic maxillectomy include very important facial structures, both for esthetical and for functional reasons. Among the outcomes, large oronasal or oromaxillary fistulas due to destruction of big bone segments and soft tissues have long been the consequences of such extensive surgical ablations. In the last few years, immediate reconstruction of maxillary bones and soft tissues has proved to be a reliable morphofunctional reconstruction technique following surgery for large oncological defects or the late effects of radiation therapy. Among other free flaps such as composite fibula, composite scapula, or composite radial, the use of vascularized iliac crest with the internal oblique flap has become our flap choice for morphofunctional maxillary reconstruction for bone segments within 6-15 cm of length, and when there is no need for overlying facial skin or oral sphincter reconstruction. The advantages of this composite bone flap are its available large and resizable bone stock; the quality of the bone for transfer (optimal height, depth, and contour to maintain a good facial profile); and the possibility to properly reconstruct the oral lining, orbital content; and maxillary soft tissues with a portion of the internal oblique muscle flap raised with the same pedicle. In addition, this flap's soft tissue will epithelialize during the healing stages.

The use of temporal polyethylene implant after temporalis myofascial flap transposition: clinical and radiographic results from its use in 21 patients

PURPOSE

The use of temporalis myofascial flap (TMF) as a pedicled flap in craniofacial reconstructive surgery is well established. The transposition of temporalis muscle results in a large hollowing of the temporal fossa that leaves the patient with a cosmetic impairment. Reconstruction of this donor site deformity is desirable. One of the established reconstructive techniques is the use of a prefabricated porous high-density polyethylene (HDPE) temporal implant. In order to evaluate results from its use, we retrospectively reviewed a series of 21 consecutive patients.

MATERIALS AND METHODS

From October 1999 to October 2004, 21 patients (7 men and 14 women) aged 32 to 85 years (mean, 65) had their surgical defects reconstructed with the use of a TMF. The majority of patients (15 of 21) had squamous cell carcinoma of the maxilla or the maxillary sinus. In 17 patients, the reconstructive procedure was performed simultaneously with the oncological resection, whereas in 4, a secondary reconstruction was performed. In 1 patient, bilateral TMFs were used to cover a total maxillectomy defect. Standard surgical approach was used in all patients during TMF elevation. The temporal defect was reconstructed with the use of a prefabricated sterile HDPE implant (Medpor; Porex Surgical Inc, College Park, GA). Fixation of the implant to the recipient infratemporal fossa was performed with black silk sutures (in 2 patients) or titanium miniscrews (in 19 patients). The manufacturer's instructions for the placement of the implant were followed in all cases. One of the 21 operated patients preoperatively received radiotherapy (RT). Of the remaining 20 patients, 5 underwent postoperative RT.

RESULTS

Eighteen patients are alive and free from disease. One died during the perioperative period from myocardial infarction and 2 more from locoregional recurrence of their disease, 18 and 27 months postoperatively. In all 21 patients, the placement of the Medpor temporal implant was successful and no immediate or perioperative complications resulting from its use were encountered, giving an overall success implantation rate of 100%. Follow-up ranged from 9 to 70 months (mean, 39). The condition of the implant was evaluated with computed tomography in 18 of the 21 patients as part of the standard postoperative assessment. Radiographic results of the recipient site did not reveal any abnormalities. In 7 patients, the contour of the HDPE implant could be manually palpated, and in 3, it could be seen to protrude subcutaneously. Esthetic results were judged satisfactory from all patients. The hemicoronal skin flap healed uneventfully in all patients and did not cause a visible scar even to bald male patients.

CONCLUSIONS

The reconstruction of the temporal defect after TMF transposition with the use of a Medpor temporal implant is an easy and safe method. The implant does not seem to cause any tissue reaction, and long-term functional and esthetic results are excellent. When properly used and the relevant manufacturers' instructions are carefully followed, the success rate of the method is extremely high.

Use of vascularized iliac crest with internal oblique muscle flap for mandible reconstruction

In the last decade, immediate reconstruction of maxillary bones following extensive trauma, large oncological defects, or late effects of radiation therapy has proved to be a reliable morpho-functional reconstruction technique. Use of the vascularized iliac crest with an internal oblique flap has become our flap of choice for mandible reconstruction when there is no need for overlying facial skin or oral sphincter reconstruction, and for bone segments within 6-15 cm of length. The advantages of this composite bone flap are the large and resizable bone stock available, the quality of bone transferred with an optimal height, depth, and contour of bone to maintain a good facial profile, and the possibility to reconstruct properly the oral lining, with a portion of the internal oblique muscle flap raised with the same pedicle that epithelializes during the healing stages. We present the experience of the Department of Maxillofacial Surgery of "S. Maria della Misericordia" Regional Hospital in Udine, Italy.