Reconstruction of through-and-through oromandibular defects by the double-skin paddle fibula osteocutaneous flap: Can the skin paddle always be divided?

Reconstruction of Complex Oral and Maxillofacial Defects After Oral Cancer Resection With Individualized Anterolateral Thigh Multiple Paddle Flaps

PURPOSE

This study aimed to use reconstructive methods for complex oral and maxillofacial defects, explore their feasibility, and evaluate the efficacy of defect reconstruction using anterolateral thigh (ALT) multiple paddle flaps.

PATIENTS AND METHODS

The authors performed a retrospective case series of 33 patients who underwent oral and maxillofacial defect reconstruction using the ALT multiple paddle flaps. The design and harvest of the flaps, methods for defects reconstruction, and reconstructive efficacy are described.

RESULTS

All 33 patients were men, with a mean age of 49.5 years. Of the flaps, triple skin paddles plus muscle paddles were included in 3 cases, triple skin paddles were included in 1 case, 2 skin paddles plus muscle paddles were included in 29 cases. The skin paddles measured 3×5 cm to 10×16 cm. Postoperatively, all flaps survived completely. Parotid salivary fistula and orocutaneous fistula occurred in 1 patient of each, thigh wound infection and effusion occurred in 1 and 2 patients, respectively. All patients were followed up for ~2 to 93 months; most patients' oral functions and appearance were acceptable, and thigh motor dysfunction was not observed.

CONCLUSIONS

With separate skin paddles for defects of different positions, individualized muscle flap for dead spaces, combination of different skin paddles for larger defects, effective reduction or avoidance of wound complications, and acceptable donor site morbidity, the ALT multiple paddle flaps are an ideal candidate for complex oral and maxillofacial defects reconstruction.

The Past, Present, and Future of Perforator Flaps in Head and Neck Surgery

A perforator is a vessel that travels through muscle and perfuses the skin. Perforator flaps require intramuscular dissection and can be used as pedicled or free flap. With improved understanding of microvasculature, they can be tailored to have multiple skin paddles, multiple components, or shaped to conform to any defect. Reliable perforator flap-based reconstruction is a meticulous microvascular technique, ultimately allowing the surgeon to harvest any flap in a freestyle fashion and transplant to any recipient vessel. New technologies improve the safety and reproducibility of this type of reconstruction.

Division versus de-epithelialization of fibula osteocutaneous flap for composite oromandibular defects: A propensity score-matched analysis

BACKGROUND

Different fibula osteocutaneous free flap (FOCFF) configurations have been described with a double-skin paddle (DSP) to address composite through-and-through oromandibular defects: division of the skin paddle using different perforators (div-FOCFF) or a de-epithelialized DSP FOCFF (deEpi-FOCFF). This study aimed to compare the surgical outcomes using these two methods (deEpi-FOCFF/div-FOCFF).

METHODS

Patients who underwent segmental mandibulectomy and reconstruction with a DSP FOCFF between 2011 and 2014 were included. We compared postoperative outcomes of patients undergoing reconstruction with deEpi-FOCFF versus div-FOCFF implementing propensity score matching.

RESULTS

Of the 245 patients, 156 cases (78 pairs) were 1:1 matched. Demographic and oncologic variables were comparable between groups. The average age was 57.68 years. A higher number of perforators per flap was evident in the div-FOCFF group (p < 0.001). The deEpi-FOCFF group exhibited a higher total flap loss rate when compared to the div-FOCFF group (15 % versus 5 % p = 0.03). On multivariate analysis, number of perforators per flap (OR 0.31, p = 0.02), using the deEpi-FOCFF (OR 3.88, p = 0.03), and an increased reconstructive time (OR 1.01, p = 0.01) independently affected the likelihood of free flap failure.

CONCLUSION

If the number and location of perforators are optimal, div-FOCFF improves reconstructive outcomes for composite oromandibular defects versus the deEpi-FOCFF.

Management of Through-and-Through Oromandibular Defects after Segmental Mandibulectomy with Fibula Osteocutaneous Flap

BACKGROUND

 Oromandibular defects involving the external skin are a reconstructive challenge. This study aimed to evaluate the use of the fibula osteocutaneous free flap (FOCFF) for through-and-through oromandibular defects by comparing the surgical outcomes and complications of different techniques to close the external skin defect.

METHODS

 A retrospective analysis was conducted of patients who underwent reconstruction of through-and-through oromandibular defects after oncologic segmental mandibulectomy between January 2011 and December 2014. Five groups were analyzed according to the method of external skin coverage: primary closure, locoregional flaps, deepithelialized double-skin paddle FOCFF (deEpi-FOCFF), division of the skin paddle for double-skin paddle FOCFF (div-FOCFF), and a simultaneous second free flap. Intraoperative and postoperative outcomes along with complications were analyzed between groups.

RESULTS

 A total of 323 patients were included. The mean total defect area requiring a simultaneous second free flap was larger in comparison to other groups (p < 0.001). Reconstructions performed with div-FOCFF had a higher number of perforators per flap when compared with deEpi-FOCFF (p < 0.001). External defects closed with another free flap exhibited higher intraoperative time for the reconstructive segment in comparison to other groups (p < 0.05). The overall rate of complications was comparable between groups (24%, p = 0.129).

CONCLUSION

 The FFOCF is a reliable alternative to harvesting multiple simultaneous free flaps for through-and-through oromandibular defects. The authors recommend appropriate curation of the surgical plan based on individual patient characteristics and reconstructive requirements.

Intraoperative salvaging of failure to harvest the bi-paddle anterolateral thigh flap: a case series

Background

The size and versatility of anterolateral thigh (ALT) flap enables a bi-paddle flap to cover complex and extensive defects optimally. However, it is characterized by variations in the sources of blood vessels and in the number of perforators, which increases the chances of failure of harvesting a bi-paddle flap. We present our method to overcome such failure. This is the first study exploring the optimal salvaging algorithm to overcome harvesting failure with the bi-paddle ALT flap.

Methods

From January 2014 to December 2020, in 9 patients to be treated with bi-paddle ALT flap for soft-tissue defects (range, 48–288 cm²), there was failure of flap harvest because of perforator variations. We redesigned and converted the flaps to other forms for harvest intraoperatively, based on the characteristics of the defect, and the number and sources of perforators.

Results

Salvage of flap harvest was successfully performed in all 9 cases. In 4 cases the flap with a single perforator was converted to widened-single-perforator flaps; in 2 cases, a single perforator was converted to a de-epithelialized flap; in 2 cases of 2 perforators from different main branches, conversion was to sequential chimeric flaps; in the remaining case of 2 perforators from the descending branch and transverse branch, conversion was to a combined transverse-and-descending branches flap. Venous compromise occurred in only 1 case, and the patient survived after revised surgery. Local infection in the receiving area occurred in 3 cases, and was cured by wound dressing. All flaps survived (follow-up 5–24 months).

Conclusions

Despite preoperative preparation, anatomic variations resulted in failure of bi-paddle ALT flap harvesting. As shown by our results, it is feasible to redesign and convert the bi-paddle flap to other forms based on the defect characteristics, and the number and sources of perforators.

Application of an L-shaped anterolateral thigh flap in reconstruction after hemiglossectomy

Objective

Tongue defect reconstruction is one of the key components of tongue cancer surgery. In this study, we used an L-shaped flap design adopted as a simple and efficient method to repair tongue defects after hemiglossectomy. Furthermore, we evaluated and contrasted the clinical effects of two methods, the L-shaped and traditional methods.

Study design

Fifteen patients in the L-shaped group and 20 patients in the traditional group were evaluated and compared in terms of postoperative complications, dysphagia, language function and appearance satisfaction.

Results

The results (Table 1) showed that there were 2 cases of donor area invalid traumas, and 2 patients had scar hyperplasia in the traditional group. The degree of global and functional dysphagia of the L-shaped group (2.60 ± 0.29 and 11.47 ± 1.38) was lower than that of the traditional group (3.55 ± 0.29 and 15.75 ± 1.22) (P < 0.05). In the language evaluation, the traditional group (3.20 ± 0.26) had lower scores than the L-shaped group (4.13 ± 0.30) (P < 0.05).

Conclusion

The L-shaped ALTP flap is a simple and efficient modification of ALTP, that can be used for half-tongue repair after radical operations for tongue cancer. It has better performance in the recovery of dysphagia and language function than the traditional ALTP flap.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01473-7.

Oromandibular reconstruction with double-skin paddle fibular free flap: A systematic review and meta-analysis

BACKGROUND

Reconstruction of complex head and neck defects is challenging, especially when more than one soft-tissue subunit is involved. The osteocutaneous fibular flap underwent continual evolution to improve its soft-tissue characteristics, such as including a second skin island. The purpose of this study was to evaluate outcomes regarding oromandibular reconstruction with a double-skin paddle fibular free flap (DSPFFF) using three different techniques: central de-epithelialized skin paddle, distally-based double-skin paddle (DSP), or proximally and distally-based DSP.

METHODS

A systematic review was performed in December 2020 using Pubmed and MedLine Ovid databases according to the PRISMA guidelines. A meta-analysis of functional outcome and complications was performed to estimate single incidence rates.

RESULTS

A total of 449 patients were included, with a follow-up of 1-84 months, where 330 patients underwent reconstruction with the first technique, 23 patients with the second technique, and 96 patients with the third technique. The meta-analysis showed an overall good functional outcome and a low-complication rate for oromandibular reconstruction with DSPFFF. A better functional outcome and a lower complication rate were found when a distally-based DSPFFF was harvested compared to a proximally and distally-based DSPFFF.

CONCLUSION

The DSPFFF was found to be useful and reliable for reconstructing composite and extensive head and neck defects, with an overall good functional outcome and a low-complication rate. The meta-analysis showed a better positive outcome on distally-based DSPFFF rather than proximally and distally-based DSPFFF. In addition, distally-based DSPFFF showed a lower complications rate when compared with proximally and distally-based DSPFFF.

Femoral artery-nourished anteromedial thigh flap: A new perspective in oral and maxillofacial defect reconstruction

OBJECTIVES

The aim of this study was to evaluate the feasibility and efficacy of the femoral artery (FA)-nourished anteromedial thigh (AMT) flap for reconstructing oral and maxillofacial defects.

PATIENTS AND METHODS

The authors analyzed a retrospective case series of 13 patients who underwent the reconstruction of oral and maxillofacial defects with the FA-nourished AMT flap. The flap design and the methods for defect reconstruction are described, and the reconstructive efficacy is reported.

RESULTS

Of the 13 patients, 12 were men, and 1 was woman, with an average age of 52.2 years. Of these FA-supplied AMT flaps, 7 were singly used, 5 were combined with the anterolateral thigh (ALT) flap or its chimeric flaps, and 1 was separately used with the ALT flap. Postoperatively, all flaps survived completely, without vascular compromise or major wound complications.

CONCLUSIONS

The FA-nourished AMT flap can also be used to reconstruct some common oral and maxillofacial defects, especially as a new alternative to the ALT flap. In addition, this flap can be combined with the ALT flap or its chimeric flaps or separately used with the ALT flap for the reconstruction of complex defects.

Reconstruction of the Three-Dimensional Mandibulofacial Defects Using a Single Cutaneous Perforator-Based Fibula Osteocutaneous Flap

The reconstruction of the mandibulofacial defects is a difficult task when there are full-thickness cheek defects involving mandible, inner mucosa and outer skin. There are several reconstructive options for the coverage of large defects, but most of the methods are complicated, and time- and effort-consuming. We hereby present a case of fibula osteocutaneous flap based on a single peroneal artery perforator in the reconstruction of a three-dimensional mandibulofacial defects.

[Harvesting technique of chimeric multiple paddles fibular flap for wide oromandibular defects]

Carcinological head and neck reconstruction still remains a challenge due to the volume and varied tissues needed. Large and wide oromandibular defects require, not just the bone but also soft tissues for the pelvilingual reconstruction and therefore, a second free flap may become necessary in addition to a fibular flap. The option of an unique chimeric flap based on the fibular artery and its branches is less known whereas it offers the advantage of a unique flap with bone, muscle and multiple skin paddles, independent of each other. The aim of this technical note is to present step by step the surgical procedure of this chimeric flap and share this method that avoids a second free flap.

Combined submandibular gland flap and sternocleidomastoid musculocutaneous flap for postoperative reconstruction in older aged patients with oral cavity and oropharyngeal cancers

Background

The growth of aging populations in an increasing number of countries has led to a concomitant increase in the incidence of chronic diseases. Accordingly, the proportion of older aged patients with oral cavity and oropharyngeal cancers and comorbidities has also increased. Thus, improvements must be made in the tolerance and safety of surgical procedures for these patients with complex medical conditions. In this study, we investigated combined submandibular gland flap and sternocleidomastoid musculocutaneous flap for postoperative reconstruction in older aged patients with oral cavity and oropharyngeal cancers in terms of surgical methods, safety, and clinical outcome.

Methods

Between January 2011 and May 2012, 8 patients over the age of 65 years (7 men, 1 woman; aged 66 to 75 years (median, 69.6)) with oral cavity and oropharyngeal cancers underwent combined submandibular gland and sternocleidomastoid myocutaneous flaps for postoperative reconstruction at Ganzhou Tumor Hospital. All eight patients had comorbid cardiovascular, cerebrovascular, or chronic respiratory disease or diabetes. Clinical outcomes, complications, and tolerance to surgical treatment were observed.

Results

Surgical treatment was successful in all eight patients. All submandibular gland flaps survived with well-mucosalized surfaces and with no complications. During the postoperative follow-up period of 12 to 28 months, no patient developed local recurrence or distant metastasis, and all had good recovery of function and local contour.

Conclusions

This combined reconstruction technique enables appropriate restoration of oral function, facial aesthetics and improved quality of life. Further, this technique has several advantages: it is easier to perform, reduces operation time and surgical risk, causes less surgical injury, and has minor impact on contour. The technique provides a new and safe reconstruction option for older aged patients with oral cavity and oropharyngeal cancers.