Reconstruction of total maxillectomy defects with preservation of the orbital contents

Stacked fibula flap for unilateral total maxillectomy reconstruction with orbital preservation

Unilateral total maxillectomy is indicated for locally advanced maxillary tumors that require complete removal of the midface bony structure and inferior orbital rim. Reconstruction of this defect is challenging due to aesthetic and functional concerns. A retrospective review of patients at two tertiary-care institutions undergoing unilateral total maxillectomy reconstruction with a stacked fibula flap from 2018 to 2022 was performed. Each patient's clinical course was reviewed, and attention was focused on the demonstration of surgical steps with photos. Twenty patients underwent stacked fibula flap reconstruction for unilateral total maxillectomy orbital preservation defects. Surgical extirpation was performed for malignancy (80%, 16/20) and for osteoradionecrosis or benign tumor in 20% (4/20). The complication rate was 30% (6/20). Most flaps survived (95%, 19/20). We present a modified, reproducible method of fibula flap reconstruction for unilateral total maxillectomy with orbital preservation that only requires two segments and maintains positive aesthetic and functional results.

Necessity of infraorbital wall reconstruction in patients with residual periosteum after total maxillectomy

BACKGROUND

To date, there have been no reports regarding the necessity or methods of reconstruction for cases where the orbital periosteum remains even though the orbital floor bone has been resected in primary reconstruction after total maxillectomy. This study investigated the reconstruction methods for infraorbital wall reconstruction in patients with residual orbital periosteum.

METHODS

This was a retrospective cohort study at a single center from June 2010 to June 2019. The following two main cohorts were evaluated: non-reconstruction and reconstruction groups (reconstructed with fascia or costal cartilage) according to whether the orbital floor was reconstructed after total maxillectomy with residual orbital periosteum. The main outcomes were the deviation of the globe evaluated using computed tomography images and subjective signs of diplopia obtained from medical records.

RESULTS

Enophthalmos occurred in all five cases in the non-reconstruction group, and diplopia appeared in four cases. In five out of six cases in the reconstruction group, deviation of the globe was not observed. Exophthalmos occurred in one case reconstructed with costal cartilage. Diplopia was not observed in the reconstruction group. In the statistical assessment, a significant difference was observed in the globe deviation between the two groups (P = 0.004).

CONCLUSIONS

In cases where the orbital periosteum remains, it is necessary to actively reconstruct the infraorbital wall. Moreover, we believe that the reconstruction with fascia is convenient and useful because it is less invasive, the surgical procedure is simple, and the fascia can be collected from the same surgical field when the flap is elevated.

LEVEL OF EVIDENCE

4 (retrospective cohort study).

Risk Factors for Postoperative Infection After Maxillary Reconstruction Using Skeletal Grafts

Skeletal grafts are usually required to reconstruct defects after maxillectomy for acceptable aesthetic and functional results. Postoperative infection is a serious complication; however, few studies have evaluated the vulnerability to infection of various skeletal reconstructive materials used for maxillary reconstruction. A retrospective study was conducted on 53 cases in which maxillary skeletal reconstruction was performed between 2010 and 2021. The postoperative infection rate was compared between various skeletal reconstructive materials, including costal cartilage, scapula, fibula, ilium, cranium, and titanium mesh. In addition, the risk factors for postoperative infection were evaluated using 2-group comparison tests. Of 53 patients, 14 (25.4%) contracted an infection postoperatively. No significant differences were observed in the infection rates among the materials used for skeletal reconstruction. Cases undergoing secondary reconstruction tended to have a higher infection rate (34.4%) than primary reconstruction (14.3%). For nonvascularized skeletal grafts (41 cases), the concomitant use of soft-tissue flaps decreased the infection rate from 30.8% to 17.9%. Costal cartilage was the most frequently used material (31 cases), primarily for orbital floor reconstruction. Regarding the costal cartilage, nasal wall reconstruction had a higher infection rate (100%) than reconstruction of other parts of the maxilla (0.0%-17.9%). Nonvascularized skeletal grafts, mainly costal cartilage grafts, were safely used for maxillary reconstruction. However, caution should be exercised for postoperative infection in secondary cases and in cases where costal cartilage is used for nasal wall reconstruction. Covering nonvascularized skeletal grafts with soft-tissue flaps may be an effective countermeasure.

The Use of Patient-Specific Orbital Reconstruction Implants During Maxillectomy Reconstruction

Background: Reconstruction of the orbital floor after maxillectomy can result in significant functional and aesthetic morbidity. Study Objective: To measure eyelid position, self-reported visual outcomes, and complications in patients undergoing concurrent maxillectomy and reconstruction with a patient-specific orbital reconstruction implant (PSORI). Design Type: Case series. Materials and Methods: Case series including 12 patients who received PSORI for orbital floor reconstruction after tumor extirpation. Primary outcomes gathered were diplopia, ectropion, and wound healing complications. Results: The majority of patients were men (75%) and the mean age was 53.3 years. Ten patients underwent free flap reconstruction with the majority receiving fibula free flaps (n = 6). Median follow-up was 415.5 days. Three patients (25%) experienced long-term complications, including diplopia (n = 1) and hardware extrusion (n = 3). Each of these occurred in the context of total maxillectomy and radiation. This prompted subsequent use of a modified implant design for the final six patients and the preferential use of a midface-degloving approach. These interventions eliminated extrusions in subsequent patients. Conclusion: PSORIs can be used for orbital floor reconstruction following maxillectomy in combination with free tissue transfer. Implant design is critical to reduce complications. The use of a midface degloving approach and a modified low-profile design was associated with a low rate of complications.

Considerations in Free Flap Reconstruction of the Midface

Midface reconstruction has been a consistent challenge for reconstructive surgeons even with the significant advances in technology and technique achieved over the recent years. A meticulous preoperative assessment of the patient is required to properly assess the defect or anticipated defect, determine proper reconstructive surgical plan, and discuss expected functional and aesthetic outcomes with the patient. For years we have employed local flaps, regional flaps, obturators, alloplastic implants, free flaps, or a combination of the previously mentioned techniques to address complex midface reconstruction. Free flap reconstruction in the midface requires special considerations for the pedicle, flap selection, and flap design to ensure an optimal outcome. The introduction of virtual surgical planning for reconstruction has enhanced patient outcomes to include advances in immediate dental rehabilitation at the time of free flap surgery. Postoperative considerations including quality of life, functional and aesthetic outcomes, and management of complications will also be discussed.

Effect of submental flap reconstruction versus obturator rehabilitation after maxillectomy on quality of life: a randomized clinical trial

The surgical removal of a maxillary tumour will result in an oronasal communication, which can negatively affect the patient's life and daily functions. Following maxillectomy, the defect can be treated with a prosthetic obturator or microvascular flap. However, the gold standard technique remains controversial. The aim of this study was to evaluate and compare quality of life (QoL) outcomes of submental island flap versus maxillary obturator reconstruction after partial maxillectomy. Sixty patients indicated for maxillectomy were allocated randomly to two equal-sized groups. Control group patients underwent reconstruction with a surgical obturator, while intervention group patients underwent submental island flap reconstruction. Patient QoL was evaluated at the 6-month follow-up using the University of Washington Quality of Life Questionnaire. Statistically significant differences in QoL were found between the two groups. Chewing (P = 0.034), swallowing (P < 0.001), speech (P = 0.009), taste (P = 0.04), mood (P = 0.01), and anxiety (P = 0.003) domains showed a statistically significant improvement in the submental group compared to the obturator group. However, the obturator group showed a greater improvement in appearance (P < 0.001). The masticatory function scores in the obturator group were significantly higher after obturator rehabilitation (P < 0.001). In conclusion, this study found that submental flap reconstruction provided better function and QoL than the obturator. This reconstruction was associated with less pain and better pronouncing of words, chewing, swallowing food, and psychosocial adjustment.

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.

Use of Anterolateral Thigh Flap and Fibula Flap in Oncologic Maxillary Reconstruction: An Algorithm Approach

BACKGROUND

Maxillary defects after oncologic resection can lead to not only cosmetic deformity but also functional problem. Reconstruction of maxillary defects remains the most challenging endeavor for plastic surgeons. An algorithm to guide plastic surgeons in selecting either the anterolateral thigh flap or the fibula flap for oncologic maxillary reconstruction has not been well established.

METHODS

Patients who underwent oncologic maxillectomy and free flap reconstruction from August 2012 to April 2018 were enrolled for retrospective chart review. Their operative findings and postoperative outcomes were analyzed as a case series. The reconstructive plan was decided using the 4 essential components in sequence: the anterior maxillary arch, orbital floor, eyeball, and oro-sinonasal communication, which are the main considerations in the established classification systems. Accordingly, when the anterior maxillary arch was lost or when the orbital floor was lost with eyeball preservation, a fibula flap was used. Otherwise, an anterolateral thigh flap was used.

RESULTS

Various maxillectomy defects were successfully reconstructed using an anterolateral thigh flap and a fibula flap. The defect types and corresponding reconstruction were fit into our proposed algorithm and classification. The corresponding outcomes were satisfactory.

CONCLUSION

The proposed algorithm by using the anterolateral thigh flap and the fibula flap for oncologic maxillary reconstruction is feasible, simple, and effective.

3D titanium implant for orbital reconstruction after maxillectomy

The surgical treatment of maxillary tumours often consists of an open subtotal or total maxillectomy with a subsequent significant defect. Reconstruction is, therefore, a major challenge for head and neck surgeons. Along with 3D printing development, titanium pre-bent implants have been created for orbital wall and floor reconstruction. The aim of this study was to evaluate the post-operative tolerance of these implants in patients who had undergone this procedure in our department. Implant tolerance was the primary endpoint, evaluated by whether or not surgery was required for infection or extrusion 6 months after the procedure. The secondary endpoints were satisfactory functional and aesthetic characteristics of the reconstruction as well as the quality of life. Eleven patients underwent a maxillectomy with orbital floor resection for tumours and reconstruction using the titanium PorousiTi® (Materialise®, Leuven, Belgium) implant beginning in 2013 in Lariboisière Hospital, Paris. The mean follow-up time was 17 months (range, 6-34). During the follow-up period, two patients (n = 2/11; 18.2%) were operated again for implant extrusion and exposure through the skin 1 month later or during their radiotherapy course. During the follow-up period, no post-operative infection occurred in any of the patients. In our experience, the implant was well-tolerated with few post-operative complications and satisfactory aesthetic and functional results.

Ophthalmic Changes Following Maxillectomy With or Without Postoperative Radiation Therapy

PURPOSE

To evaluate ophthalmic complications and quantitatively assess anatomic changes following maxillectomy with or without adjuvant radiotherapy in patients with midface malignancy.

METHODS

Twenty-four patients who underwent maxillectomy for sinus and/or paranasal cancer were included for retrospective review. Patients with complete ophthalmic examinations were evaluated for postoperative findings corresponding to sequelae of treatment. When available, anatomical changes including eyelid position were quantified from preoperative and postoperative full-face photos using computer software.

RESULTS

The most common complications identified in patients after maxillectomy were retraction/ectropion (50%), epiphora (29%), and exposure keratopathy/dry eye syndrome (25%). Patients treated with maxillectomy with adjuvant radiation therapy were more frequently found to have ophthalmic complications following treatment. In patients with available postoperative photos (n = 10), the mean ipsilateral margin reflex distance (MRD)2 and inferior scleral show were 8.4 mm and 2.4 mm, respectively. In patients with available preoperative photos (n = 5), the mean change in MRD2 and inferior scleral show following maxillectomy was 3.4 mm and 2.8 mm, respectively.

CONCLUSION

Patients undergoing maxillectomy for the treatment of head and neck malignancy may be at significant risk for development of specific periocular complications. Lower eyelid malposition was the most significant postoperative quantitative eyelid change following maxillectomy, which may be exacerbated by adjuvant radiotherapy and inferior orbital rim removal.

Primary Reconstruction After Maxillectomy Defects Using Ultra Flex Mesh Plate and Rectus Abdominis Myocutaneous Free Flap Including Aponeurosis of External Abdominal Oblique Muscle

BACKGROUND

In primary reconstruction after maxillectomy for cancer, simple and less invasive surgical techniques considering functionality and aesthetics are necessary. The authors performed reconstruction for tissue defects after maxillectomy using an Ultra flex mesh plate and a free rectus abdominis myocutaneous flap including the aponeurosis of the external abdominal oblique muscle.

METHOD

A 72-year-old male with a maxillary squamous cell carcinoma underwent subtotal maxillectomy. For maxillary defects, including those in the orbital floor and hard palate, the authors performed rigid reconstruction using an Ultra flex mesh plate produced after simulation surgery using a 3-dimensional solid model, and palatal and soft tissue reconstruction using a free rectus abdominis myocutaneous flap including the aponeurosis of the external abdominal oblique muscle. After screw fixation of the mesh plate at the surrounding normal bone, the skinpaddle of the rectus abdominis flap was transferred to the oral defect. The surface of the mesh plate was completely covered with the aponeurosis of the external abdominal oblique muscle, and the remaining rectus abdominis flap was inserted into the maxillary sinus.

RESULTS

At present, 1 year after the operation, there is no recurrence, complications, such as infection, or titanium mesh breakage/exposure, and his facial shape is favorably maintained.

CONCLUSION

Reconstruction using this method is simple and less invasive. Postoperative infection and plate exposure were prevented by the complete coverage of the mesh plate with the aponeurosis of the external abdominal oblique muscle and flap. Mesh plates, when properly used, are useful reconstruction materials, but are susceptible to infection compared with autologous tissue, requiring long-term follow-up.

Flap selection for reconstruction of wide palatal defect after cancer surgery

BACKGROUND

The resection of head and neck cancer can result in postoperative defect. Many patients have difficulty swallowing and masticating, and some have difficulty speaking. Various types of flaps are used for palatal reconstruction, but flap selection remains controversial. Therefore, our study will suggest which flap to choose during palatal reconstruction.

METHODS

Thirteen patients who underwent palatal reconstruction from 30 January, 1989 to 4 October, 2016 at our institution. Size was classified as small when the width was < 4 cm², medium when it was 4-6 cm², and large when it was ≥ 6 cm². Based on speech evaluation, the subjects were divided into a normal group and an easily understood group. After surgery, we assessed whether flap selection was appropriate through the evaluation of flap success, complications, and speech evaluation.

RESULTS

Defect size ranged from 1.5× 2.0 cm to 5.0× 6.0 cm. In four cases, the defect was in the anterior third of the palate, in eight cases it was in the middle, and there was one case of whole palatal defect. There were three small defects, two medium-sized defects, and eight large defects. Latissimus dorsi free flaps were used in six of the eight large defects in the study.

CONCLUSION

The key to successful reconstructive surgery is appropriate selection of the flap with reference to the characteristics of the defect. Depending on the size and location of the defect, the profiles of different flaps should be matched with the recipient from the outset.

Use of a temporalis fascia transposition flap for ventral orbital stabilization after ventral orbitectomy in a dog

OBJECTIVE

To describe a novel surgical technique for ventral orbital reconstruction after ventral orbitectomy by using a temporalis fascia transposition flap.

STUDY DESIGN

Case report.

METHODS

A 7-year-old, spayed female Boston terrier was treated for multilobular osteochondrosarcoma arising from the cranial aspect of the left zygomatic arch, causing asymmetry of the face and mild exophthalmos of the left eye. A ventral orbitectomy with a wide surgical excision (including the cranial aspect of the zygomatic bone, the medial aspect of the lacrimal bone, and the dorsal aspect of the maxilla) was performed with preservation of the left eye. To support and maintain the left eye in a normal position, a temporalis fascia transposition flap was elevated and used. No complications occurred during the procedure.

RESULTS

Thirteen days after surgery, the referring veterinarian reported no complications. Complete excision was confirmed on histopathology. Eighty-three days after surgery, the dog remained asymptomatic with only mild epiphora of the left eye. Follow-up information from the owner 11 months after surgery indicated that the dog was asymptomatic with minimal ventral globe deviation.

CONCLUSION

Additional ventral support of the globe after ventral orbitectomy via a temporalis fascia transposition flap resulted in an excellent functional and cosmetic outcome.

CLINICAL SIGNIFICANCE

A temporalis fascia transposition flap can be used to reconstruct the ventral aspect of the orbit in dogs.

Modified maxillary reconstruction technique for Brown's class III defects by subdividing a rhomboid shaped iliac crest into 2 subunits

BACKGROUND

Men and women share a common maxillary morphology with heterogeneity in size. This indicated that our technique of reconstruction with a rhomboid-shaped iliac crest bone flap incorporating a 30° vertical wedge osteotomy may be widely used for Brown's class III maxillectomy defect reconstruction among a population with class I skeletal profile. The reconstruction of Brown's class III maxillary defects is extremely challenging. The purpose of this study was to closely study the maxilla geometrically in order to establish a standardized maneuver, which facilitates conversion of the iliac bone flap into a natural maxilla's contours.

METHODS

We evaluated the geometries of 40 adult maxillas. The perimeter lengths of perinasal and infraorbital subunits were analyzed, in addition to the intersecting angle (δ) of both subunits. Sex variation was evaluated using the Student's t test.

RESULTS

In the 80 studied unilateral maxillas (40 maxillas from 18 men and 22 women), there were no significant sex differences for δ (P = .1527). In addition, both sexes shared common morphological features, hence, in surgical reconstruction, the δ can be constantly set at 150°. Perimeter of bone segments had a greater intersubject variability (coefficient of variation [CV] of approximately 4.5-11). From both cadaveric dissections and clinical applications, our results have shown that our standard maneuver was reproducible and reliable in reestablishing natural facial contours.

CONCLUSION

Our standard maneuver can serve as a universal guideline, with individualized perimeter manipulations, to yield an aesthetically natural and functional outcome.

Cancers of the nose, sinus, and skull base

Malignancies of the nose, sinus, and skull base are rare. The most common histologies are squamous cell carcinoma and adenocarcinoma. The most common primary sites are the nasal cavity and maxillary sinus. Management of these tumors is technically challenging because they often present in advanced stages with extensive disease invading important structures such as the orbit and the skull base. In the last few decades advances in surgical resection techniques, as well as improved strategies to deliver adjuvant radiation, have substantially improved the outcomes in patients with malignancies of the sinonasal tract and skull base.

Optimizing Reconstruction with Periorbital Transplantation: Clinical Indications and Anatomic Considerations

Complex periorbital subunit reconstruction is challenging because the goals of effective reconstruction vary from one individual to another. The purpose of this article is to explore the indications and anatomic feasibility of periorbital transplantation by reviewing our institutional repository of facial injury.

METHODS

Institutional review board approval was obtained at the R Adams Cowley Shock Trauma Center for a retrospective chart review conducted on patients with periorbital defects. Patient history, facial defects, visual acuity, and periorbital function were critically reviewed to identify indications for periorbital or total face (incorporating the periorbital subunit) vascularized composite allotransplantation. Cadaveric allograft harvest was then designed and performed for specific patient defects to determine anatomic feasibility. Disease conditions not captured by our patient population warranting consideration were reviewed.

RESULTS

A total of 7 facial or periorbital transplant candidates representing 6 different etiologies were selected as suitable indications for periorbital transplantation. Etiologies included trauma, burn, animal attack, and tumor, whereas proposed transplants included isolated periorbital and total face transplants. Allograft recovery was successfully completed in 4 periorbital subunits and 1 full face. Dual vascular supply was achieved in 5 of 6 periorbital subunits (superficial temporal and facial vessels).

CONCLUSIONS

Transplantation of isolated periorbital structures or full face transplantation including periorbital structures is technically feasible. The goal of periorbital transplantation is to re-establish protective mechanisms of the eye, to prevent deterioration of visual acuity, and to optimize aesthetic outcomes. Criteria necessary for candidate selection and allograft design are identified by periorbital defect, periorbital function, ophthalmologic evaluation, and defect etiology.

Maxillary reconstruction: Current concepts and controversies

Maxillary reconstruction is still an evolving art when compared to the reconstruction of the mandible. The defects of maxilla apart from affecting the functions of the speech, swallowing and mastication also cause cosmetic disfigurement. Rehabilitation of the form and function in patients with maxillary defects is either by using an obturator prosthesis or by a surgical reconstruction. Literature is abundant with a variety of reconstructive methods. The classification systems are also varied, with no universal acceptance of any one of them. The oncologic safety of these procedures is still debated, and conclusive evidence in this regard has not emerged yet. Management of the orbit is also not yet addressed properly. Tissue engineering, that has been hyped to be one of the possible solutions for this vexing reconstructive problem, has not come out with reliable and reproducible results so far. This review article discusses the rationale and oncological safety of the reconstructing the maxillary defects, critically analyzes the classification systems, offers the different reconstructive methods and touches upon the controversies in this subject. The management of the retained and exenterated orbit associated with maxillectomy is reviewed. The surgical morbidity, complications and the recent advances in this field are also looked into. An algorithm, based on our experience, is presented.

Lengthening the pedicle of a scapular osseous free flap by angular branch reconnection within the subscapular artery system

This report describes a case of a patient who underwent secondary reconstruction of the maxilla using a combined scapular osseous and thoracodorsal artery perforator (TAP) flap, in which the pedicle of the scapular osseous flap was lengthened by reconnecting the angular branch of the thoracodorsal artery to the serratus branch. The patient was a 62-year-old man who had undergone left total maxillectomy for maxillary carcinoma and came for reconstruction of left deformity. A reconstructive procedure involving a vascularized scapular osseous and TAP flap transfer was planned. However, the patient's ipsilateral superficial temporary artery and facial artery was found stenosed due to previous radiotherapy and chemotherapy and were not suitable for use as recipient vessels. Thus, a long flap pedicle was needed for anastomoses to the contralateral recipient vessels. We lengthened the pedicle of the scapular osseous flap by reconnecting the angular branch of the thoracodorsal artery to the serratus branch within the chimeric free flap and then anastomosed it to the contralateral facial vessels. The postoperative course was uneventful, and the left cheek deformity was well corrected. Using the technique of reconnection of branches within the blood supply system, a chimeric flap with a long pedicle may be elevated safely whilst avoiding the need for vein grafts.

A new nasal cavity and maxilla reconstruction method using jejunum flap with non-vascularised bone

Reconstruction of the midface is still challenging for reconstructive surgeons because of its complex structure and the need for an aesthetic result. We used a free jejunum flap for the nasal cavity and non-vascularised bone covered by the jejunal seromuscular patch for the facial bone structure. One patient who had a midface defect received reconstructive surgery using free jejunum flap with non-vascularised bone. The nasal cavity reconstruction using jejunal mucosa was moisturised and had less crust formation. The nasal cavity space was very large and patients could breathe easily via the nose. The non-vascularised bone covered by the jejunal seromuscular patch did not dry out or become less absorbent. The reconstruction of the nasal cavity and maxilla using free jejunum flap with non-vascularised bone is novel and useful in some surgical cases.

Simple maxillary reconstruction following total maxillectomy using artificial bone wrapped with vascularized tissue: five key points to ensure success

CONCLUSION

Our new method for hard tissue maxillary reconstructions using artificial bone implants provides stable results during long-term follow-up.

OBJECTIVE

To date, vascularized bone/cartilage grafting has been the most popular method for hard tissue reconstruction after total maxillectomy; however, such three-dimensional reconstruction requires complex and lengthy invasive surgery. We have developed a simple maxillary reconstruction procedure using artificial bone.

METHODS

This study included six patients who had undergone hard tissue reconstructions using artificial bone (Ceratite(TM)) implants after total maxillectomies between October 2002 and October 2010. We considered the following five key points to ensure success: (1) the procedure was conducted in two stages without communicating with the nasal cavity and sinuses; (2) when constructing the artificial bone, the curvature was reduced; (3) the space for the implant was kept to a minimum; (4) the artificial bone implant was closely and accurately fixed to the stump of the zygomatic arch; and (5) the artificial bone implant was wrapped with a vascularized tissue flap.

RESULTS

The follow-up period ranged from 12 to 94 months. The postoperative zygomatic contour was maintained satisfactorily in all patients with no signs of late complications.

[Reconstruction of complex midfacial defects with individualized titanium implants]

BACKGROUND

Loss of hard and soft tissue structures of the midface due to resection or trauma is associated with substancial functional and aesthetic deficits. Besides reconstruction of bony contours for preservation of orbit position and facial symmetry, reconstruction often requires simultaneous transplantation of soft tissue flaps for separation of nasal and oral cavities and refilling of soft tissue volume deficits.

PATIENTS AND METHODS

A well-established procedure of our institution will be demonstrated in 10 exemplary patients, in which titanium meshes are customized for individual defect situations using computer-assisted techniques in combination with soft tissue transfer if required.

RESULTS

According to our experience, this procedure provides satisfactory results in functional as well as in aesthetic respects. Especially in patients with loss of bony structures of the orbit and preservation of orbital contents, this procedure forms optimal preconditions for prevention of enophthalmos and diplopia by preservation of the original orbital volume.

CONCLUSION

Individualized titanium implants should be used more frequently in clinical routine for reconstruction of complex midfacial defects.

Cephalometric analysis for microvascular head and neck reconstruction

BACKGROUND

While a large body of literature exists involving normative measurements for the craniofacial skeleton, few have analyzed the necessary dimensions that are pertinent in reconstruction using microvascular free flaps.

METHODS

Cephalometric analysis was performed using 3-dimensional CT scans from 70 adults. Relevant dimensions of the fibula were obtained from a subset of 20 patients.

RESULTS

Normative cephalometric values, including various distances and angles, for the mandible and maxilla were obtained and compared to the dimensions of the fibula. Comparisons were made between measurements from men and women, and patients with full dentition and edentulous patients. Schematics for designing mandibular and maxillary reconstructions are presented.

CONCLUSION

When premorbid craniofacial anatomy cannot be discerned in the setting of extensive trauma or tumor involvement, normative dimensions may be a helpful guide for flap design and should be in the armamentarium of surgeons engaged in complex head and heck reconstruction.

Radical maxillectomy as a successful treatment for gunshot-induced maxillary and nasal cavity trauma in a dog

OBJECTIVE

To report the successful treatment of gunshot-induced maxillary and nasal cavity damage with total maxillectomy in a two-year-old Labrador retriever dog.

METHODS

Radical maxillectomy was performed on highly comminuted maxillary and nasal cavity fractures resulting from gunshot trauma. The procedure was performed to remove the damaged region and reconstruct the remaining tissue.

RESULTS

Treatment of the fractures by total maxillectomy was successful in reconstruction of the remaining structures following debridement and in re-establishing return to normal activities and high owner satisfaction.

CLINICAL SIGNIFICANCE

The outcome in this case suggests that severe maxillary and nasal cavity trauma in other dogs may be treated with radical maxillectomy given appropriate patient and owner selection.

Reconstruction of osteomyelitis defects of the craniofacial skeleton

Osteomyelitis of the craniofacial skeleton closely resembles osteomyelitis elsewhere in the body in its pathophysiology and medical management; subsequent reconstruction after debridement remains distinctly challenging. The goals of reconstruction must include the restoration of the complex and readily visible morphology of the cranium and face, as well as the adequate return of vital sensory, expressive, and digestive functions. In this article, the various reconstructive modalities will be discussed including pedicled and nonpedicled flaps with or without an osseous component, nonvascularized bone grafts, alloplastic implants, and bone regeneration using protein therapy. Although reconstruction of craniofacial defects after osteomyelitis commonly proves formidable, the satisfactory return of form and function remains a plausible reconstructive goal.

Reconstruction of the maxilla with loss of the orbital floor and orbital preservation: a case for the iliac crest with internal oblique

Although many techniques have been described to reconstruct the midface and the maxilla, there remains little agreement on the most effective methods when the orbit itself is preserved but there is loss of the maxilla, orbital floor, and often the medial wall. If the principle of replacing form and function is to be preserved, then a complex three-dimensional bony shape is required, which can support the orbital floor and provide a functioning dentition through an implant-retained prosthesis. At the same time, the oral fistula must be closed and a nasal lining provided. The iliac crest with internal oblique provides a bone structure that can be shaped for the defect and can easily articulate with the malar remnant, the nasal bones, and the upper alveolus. The internal oblique muscle effectively closes the oral fistula and lines the nasal cavity and becomes epithelialized resulting in a natural appearance. This article describes the principles of use of the iliac crest with internal oblique in the reconstruction of this defect and compares this technique with the many other methods reported in the literature. The article is mainly descriptive as there are few comparative studies comparing reconstructive techniques for a similar defect.

Microsurgical free flap in head and neck reconstruction

Microsurgical free flaps are today considered state of the art in head and neck reconstruction after composite tumor resections. Free flaps provide superior functional and aesthetic restoration with less donor-site morbidity. This article details our approach to this challenging and complex procedure. Free tissue transfer can be viewed as consisting of 4 essential stages: (1) defect assessment, (2) preparation of recipient vessels, (3) flap selection and harvest, and (4) flap inset and microsurgical anastomoses. The essential details of each step are highlighted. Meticulous attention to each step is important because each plays a crucial role in the overall success of the procedure. Workhorse flaps in our practice are the anterolateral thigh, radial forearm, fibula, and jejunum flaps. Unique issues related to postoperative care and monitoring of head and neck free flaps are discussed. The management of complications, in particular those threatening flap survival, are reviewed in detail.