Avoiding Facial Incisions with Midface Free Tissue Transfer

Intraoral anastomosis technique as part of the reconstruction strategy following resection of intermediate and low-grade head and neck cancer

INTRODUCTION

The gold standard for curative treatment of facial, oral, nasal, paranasal and pharyngeal cancers is excision and reconstruction surgery. Patients are increasingly demanding carcinologically effective and minimally invasive surgery with near ad integrum functional and aesthetic reconstruction. In malignant tumors with no indication for lymph node dissection, when the defect size dictates free flap reconstruction, the intrabuccal anastomosis technique comes closest to meeting these requirements.

MATERIAL AND METHODS

In this single-center retrospective observational study, we reported a series of 5 patients with intermediate or low-grade head and neck cancer treated by surgery between 2022 and 2023 at the Cervico-facial Surgery Department of the Gustave Roussy Cancer Center. We collected clinical, therapeutic, histologic, and carcinologic data.

RESULTS

All patients underwent tumor resection with fascio-cutaneous free flap reconstruction and dental rehabilitation in accordance with best practice recommendations. None of the patients had an indication for lymph node dissection. The histologic subtypes were glandular, epithelial, and cartilaginous-related. All anastomoses were performed on the facial vessels using an intraoral anastomosis technique.

CONCLUSION

Free flap with intraoral anastomosis technique may be the first intention reconstruction strategy for large defects following resection of intermediate and low-grade malignant tumors of the face and oral, oropharyngeal, nasal or paranasal cavities.

Anatomical Landmarks of the Facial Artery and Vein for Intraoral Anastomosis: A Cadaveric Study

BACKGROUND

Intraoral anastomosis is a widely used technique for microvascular alveolar ridge augmentation and midface reconstruction. However, the predictable anatomical positioning of facial structures, such as the vessels, parotid duct, and facial nerve in the buccal region, has remained unclear. Therefore, we aimed to obtain the anatomical characteristics of these locations to establish surgical landmarks for the intraoral anastomosis of facial vessels.

METHODS

A total of 26 sides from 13 formaldehyde-fixed cadavers approximately a month after fixation with a mean age at death of 86.6 ± 11.2 years (range: 55-104 years) were anatomically examined. Facial vessels, nerves, and the parotid duct were dissected intraorally. From the oral cavity side, the X-axis was defined as the line from the labial commissure to the lowest point of the intertragic notch.

RESULTS

From the oral cavity side, all branches of the facial nerve were found under the facial artery and vein. The positioning order along the X-axis was the facial artery, vein, and parotid duct exit. The facial artery was 21.3 ± 2.2 mm and the facial vein was 39.2 ± 2.7 mm from the labial commissure. Ninety-two percent of facial veins were found within 15-20 mm of the facial artery on the X-axis. The parotid duct exit was 46.8 ± 2.0 mm from the labial commissure. In the buccal region, the vessel calibers of the facial artery and vein were 1.8 ± 0.2 and 2.1 ± 0.2 mm, respectively.

CONCLUSION

Knowledge of the anatomical relations among the facial artery, vein, parotid duct, and facial nerve from the oral cavity side can enhance the safety and efficacy of midface reconstruction surgeries involving intraoral anastomosis procedures.

Reconstruction of the anterior maxillary defect using a vascularized bone flap with residual teeth in the posterior maxilla

BACKGROUND

Microsurgical bone reconstruction is challenging in cases of anterior maxillary defects because of the presence of residual teeth. The study analyzed the method and feasibility of using vascularized bone flaps to reconstruct anterior maxillary defects.

METHODS

We retrospectively analyzed 15 patients treated at the Department of Oral and Maxillofacial Surgery, Peking University School, and Hospital of Stomatology between November 2017 and January 2023.

RESULTS

A total of 14 patients were successfully reconstructed using the digital technique: 6 deep circumflex iliac artery (DCIA) flaps and 8 fibular free flaps. Palatal and buccal pedicle paths were used in 4 and 10 cases, respectively, for vascular anastomosis. The implant coverage rates of the DCIA and fibular free flaps were 87.2% and 92.6%, respectively (p > 0.05).

CONCLUSION

Anterior maxillary defects reconstructed with the DCIA and fibular free flaps are reliable methods. Furthermore, the palatal and buccal paths are recommended for vascular anastomosis.

Intraoral Microvascular Anastomosis in Immediate Free Flap Reconstruction for Midfacial Tumor Defects: A Retrospective Multicenter Study

(1) Background: The current landscape of midface reconstruction is marked by ongoing evolution, with notable advancements in surgical techniques, microvascular procedures, and the implementation of multidisciplinary approaches, all of which have significantly enhanced both functional and aesthetic outcomes. Conventionally, microvascular anastomoses for free flaps in midfacial reconstruction have been executed using cervical vessels. However, this approach necessitates neck access, resulting in extraoral scars and a substantial pedicle length. In light of these considerations, using intraoral anastomoses via the facial vessels emerges as a promising alternative. This retrospective multicentric study aims to provide a comprehensive account of immediate midface reconstruction through intraoral anastomoses. (2) Methods: Between 2020 and 2023, patients were included who underwent intraoral resection of midface/orbit segments (Brown Classes I-VI) as a result of malignant diseases. In all cases, immediate reconstruction was accomplished by utilizing the facial vessels through an intraoral approach. Outcome criteria were identification of vessels, parotid duct or facial nerve damage, success of vascular anastomoses, and flap survival. (3) Results: A total of 117 patients with 132 flaps (91 osseous and 41 cutaneous) were included. The intraoral preparation of facial vessels was successfully completed in less than 1 h, and no complications related to the dissection or anastomoses were observed. In two cases, the vessel diameter was insufficient to facilitate anastomoses, necessitating adopting an extraoral approach. During a follow-up period of 48 months, two osseous flaps were lost, accounting for a 1.5% loss rate out of 132 flaps used. Additionally, 3 flaps experienced partial loss, including a skin island of a scapula, the border zone of a femur, and a rectus flap, resulting in a 2.3% partial loss rate out of 130 flaps utilized. (4) Conclusions: This case series underscores the feasibility of employing intraoral anastomoses for immediate complex midface reconstruction following oncological resection. This approach is particularly advantageous for flaps with shorter pedicles, as it helps mitigate external scarring and minimizes the risk of facial nerve injury.

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.

A Buccal Space Approach for Midface Free Flap Reconstruction

This article describes a transbuccal approach to reach the facial vessels. The anatomy of this intraoral approach is predictable, minimizing the risk of facial nerve dysfunction. This technique provides the possibility of free flap midface reconstruction with short pedicles and avoids the need to use vein grafts. Moreover, it is esthetically preferable. Through cadaver dissection and anatomical drawings, we describe extensively the different surgical steps. Using the combination of the previous knowledge and recent anatomical understandings, we can provide a reliable step-by-step approach to find the facial artery and vein through a transbuccal approach for microvascular midface free flap repair.

Technical Considerations in Pedicle Management in Upper and Midfacial Free Flap Reconstruction

OBJECTIVES

Mid and upper face free flaps frequently are associated with challenges due to pedicle length. We sought to evaluate the frequency at which alternative pedicle maneuvers were required for these reconstructions and determine if there was any association with flap survival or postoperative complications.

STUDY DESIGN

Retrospective review at three tertiary care institutions.

METHODS

Database review.

RESULTS

Free flap reconstruction of the upper and midface was performed in 295 patients (108 bony, 187 soft tissue). In 82% of cases, the vessels reached the ipsilateral neck for anastomosis to traditional target vessels. Arterial grafts were required in 2% of reconstructions (4% bony and 1% soft tissue). Venous grafting was required in 7% of reconstructions (21% fibula, 16% scapula, and 3% soft tissue) and was associated with an increase in flap failure rate (19% vs 3%, P = .003). The most common recipient artery for revascularization was the cervical facial artery (78%). Alternate recipient vessels were selected in 13% of cases, including the superficial temporal vessels (7%), distal facial branches through a separate facial incision (4%), and angular vessels (2%). Vein grafting was associated with a higher flap failure rate. Alternative maneuvers did not affect need for intraoperative pedicle revision or complications.

CONCLUSIONS

In upper and midface reconstruction, vascular grafting, targeting more distal branches of the facial system, or additional maneuvers to optimize pedicle orientation is often required to secure revascularization. Vein grafting is associated with a higher free flap failure rate. Scapular border flaps often require vascular grafting or atypical anastomotic locations.

LEVEL OF EVIDENCE

3-Non randomized cohort study 4 Laryngoscope, 2021.

Intraoral anastomosis in maxillary microvascular reconstruction after oncological excision

Microvascular anastomosis using an intraoral approach can avoid unnecessary external incisions thus improving patient satisfaction. Furthermore, in case of short pedicle flaps, the lack of proximity of the recipient vessels can be a problem in microvascular reconstruction of the midface. We present our experience in six patients treated for tumours affecting the midface and reconstructed with microvascular flaps through anastomosis to the intraoral aspect of the facial vessels, with the aim of reviewing the use of this technique. Our results showed that intraoral anastomosis is a feasible technique that can be used in the reconstruction after tumours resection, avoiding additional external incisions in patients with no previous cervicotomy incisions. In two cases, a vein graft was interposed to perform the intraoral arterial anastomosis in a tension-free situation without increasing morbidity. The technical features and advantages of intraoral anastomosis were reviewed.

Anatomy, Exposure, and Preparation of Recipient Vessels in Microsurgical Head and Neck Reconstruction

Successful microvascular reconstruction of head and neck defects requires the ability to safely identify, isolate, and utilize recipient vessels. To date, however, a comprehensive review of the anatomy and techniques relevant to the available anatomic regions has not been undertaken. This review covers the relevant clinical anatomy of the anterior triangle, posterior triangle, submandibular region, intraoral region, preauricular region, chest, and arm, taking particular care to highlight the structures that are crucial to identify while performing each dissection. Finally, a step-by-step technique for safely dissecting the recipient vessels at each site is provided.

WITHDRAWN: Expanded Transoral Microvascular Mandibular Reconstruction: A Scar-Free Approach

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[Virtual surgical planning and intraoperative navigation for mandibular reconstruction: from accurate to minimal invasive]

Simultaneous restoration of function and appearance should be performed in mandibular reconstruction. Option of reconstructive techniques is determined by cause, location, extent, and classification of the mandibular defects. Vascularize bone graft is one of the most popular technique in current clinical practice of mandibular reconstruction. Fibula is the most common donor site for mandibular reconstruction. The disadvantage of low height of neo-mandible reconstructed by single fibular segment can be solved by vascularized double barrel fibula graft. Using virtual surgical planning and intraoperative navigation for mandibular reconstruction leads to simplify surgical procedure, reduce operating time and injury, and decrease donor site morbidity so that accurate mandibular reconstruction could be completed. Direction of minimal invasive surgery for mandibular reconstruction will be developed by intraoral approach and intraoral anastomosis.