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Ferrari M, Taboni S, Chan HHL, Townson J, Gualtieri T, Franz L, Ruaro A, Mathews S, Daly MJ, Douglas CM, Eu D, Sahovaler A, Muhanna N, Ventura M, Dey K, Pandini S, Pasini C, Re F, Bernardi S, Bosio K, Mattavelli D, Doglietto F, Joshi S, Gilbert RW, Nicolai P, Viswanathan S, Sartore L, Russo D, Irish JC. Hydrogel-chitosan and polylactic acid-polycaprolactone bioengineered scaffolds for reconstruction of mandibular defects: a preclinical in vivo study with assessment of translationally relevant aspects. Front Bioeng Biotechnol 2024; 12:1353523. [PMID: 39076208 PMCID: PMC11284118 DOI: 10.3389/fbioe.2024.1353523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 06/10/2024] [Indexed: 07/31/2024] Open
Abstract
Background: Reconstruction of mandibular bone defects is a surgical challenge, and microvascular reconstruction is the current gold standard. The field of tissue bioengineering has been providing an increasing number of alternative strategies for bone reconstruction. Methods: In this preclinical study, the performance of two bioengineered scaffolds, a hydrogel made of polyethylene glycol-chitosan (HyCh) and a hybrid core-shell combination of poly (L-lactic acid)/poly ( ε -caprolactone) and HyCh (PLA-PCL-HyCh), seeded with different concentrations of human mesenchymal stromal cells (hMSCs), has been explored in non-critical size mandibular defects in a rabbit model. The bone regenerative properties of the bioengineered scaffolds were analyzed by in vivo radiological examinations and ex vivo radiological, histomorphological, and immunohistochemical analyses. Results: The relative density increase (RDI) was significantly more pronounced in defects where a scaffold was placed, particularly if seeded with hMSCs. The immunohistochemical profile showed significantly higher expression of both VEGF-A and osteopontin in defects reconstructed with scaffolds. Native microarchitectural characteristics were not demonstrated in any experimental group. Conclusion: Herein, we demonstrate that bone regeneration can be boosted by scaffold- and seeded scaffold-reconstruction, achieving, respectively, 50% and 70% restoration of presurgical bone density in 120 days, compared to 40% restoration seen in spontaneous regeneration. Although optimization of the regenerative performance is needed, these results will help to establish a baseline reference for future experiments.
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Affiliation(s)
- Marco Ferrari
- Guided Therapeutics (GTx) Program International Scholarship, University Health Network (UHN), Toronto, ON, Canada
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
- Unit of Otorhinolaryngology-Head and Neck Surgery, Azienda Ospedale-Università di Padova, Padova, Italy
| | - Stefano Taboni
- Guided Therapeutics (GTx) Program International Scholarship, University Health Network (UHN), Toronto, ON, Canada
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
- Unit of Otorhinolaryngology-Head and Neck Surgery, Azienda Ospedale-Università di Padova, Padova, Italy
- Artificial Intelligence in Medicine and Innovation in Clinical Research and Methodology (PhD Program), Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Harley H. L. Chan
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Jason Townson
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Tommaso Gualtieri
- Guided Therapeutics (GTx) Program International Scholarship, University Health Network (UHN), Toronto, ON, Canada
- Department of Otorhinolaryngology, Head & Neck Surgery, Nuovo Santo Stefano Civil Hospital, Prato, Italy
| | - Leonardo Franz
- Guided Therapeutics (GTx) Program International Scholarship, University Health Network (UHN), Toronto, ON, Canada
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Alessandra Ruaro
- Guided Therapeutics (GTx) Program International Scholarship, University Health Network (UHN), Toronto, ON, Canada
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
- Unit of Otorhinolaryngology-Head and Neck Surgery, Azienda Ospedale-Università di Padova, Padova, Italy
| | - Smitha Mathews
- Osteoarthritis Program, Schroeder Arthritis Institute, Krembil Research Institute, Institute of Biomedical Engineering, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Michael J. Daly
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Catriona M. Douglas
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, Toronto, ON, Canada
- Princess Margaret Cancer Centre, Toronto General Hospital, Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, University Health Network, Toronto, ON, Canada
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Donovan Eu
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, Toronto, ON, Canada
- Princess Margaret Cancer Centre, Toronto General Hospital, Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, University Health Network, Toronto, ON, Canada
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore, Singapore
| | - Axel Sahovaler
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, Toronto, ON, Canada
- Princess Margaret Cancer Centre, Toronto General Hospital, Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, University Health Network, Toronto, ON, Canada
- Head & Neck Surgery Unit, University College London Hospitals, London, United Kingdom
| | - Nidal Muhanna
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, Toronto, ON, Canada
- Department of Otolaryngology-Head and Neck Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Manuela Ventura
- STTARR Innovation Centre, University Health Network, Toronto, ON, Canada
- Human Technopole Foundation, Milan, Italy
| | - Kamol Dey
- Department of Mechanical and Industrial Engineering, University of Brescia Via Branze, Brescia, Italy
- Department of Applied Chemistry and Chemical Engineering, Faculty of Science, University of Chittagong, Chittagong, Bangladesh
| | - Stefano Pandini
- Department of Mechanical and Industrial Engineering, University of Brescia Via Branze, Brescia, Italy
| | - Chiara Pasini
- Department of Mechanical and Industrial Engineering, University of Brescia Via Branze, Brescia, Italy
| | - Federica Re
- Unit of Blood Diseases and Bone Marrow Transplantation, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
- Centro di Ricerca Emato-Oncologica AIL (CREA), ASST Spedali Civili, Brescia, Italy
| | - Simona Bernardi
- Unit of Blood Diseases and Bone Marrow Transplantation, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
- Centro di Ricerca Emato-Oncologica AIL (CREA), ASST Spedali Civili, Brescia, Italy
| | - Katia Bosio
- Unit of Blood Diseases and Bone Marrow Transplantation, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
- Centro di Ricerca Emato-Oncologica AIL (CREA), ASST Spedali Civili, Brescia, Italy
| | - Davide Mattavelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Doglietto
- Neurosurgery Unit, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Shrinidh Joshi
- Osteoarthritis Program, Schroeder Arthritis Institute, Krembil Research Institute, Institute of Biomedical Engineering, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ralph W. Gilbert
- Princess Margaret Cancer Centre, Toronto General Hospital, Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, University Health Network, Toronto, ON, Canada
| | - Piero Nicolai
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
- Unit of Otorhinolaryngology-Head and Neck Surgery, Azienda Ospedale-Università di Padova, Padova, Italy
| | - Sowmya Viswanathan
- Osteoarthritis Program, Schroeder Arthritis Institute, Krembil Research Institute, Institute of Biomedical Engineering, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Luciana Sartore
- Department of Mechanical and Industrial Engineering, University of Brescia Via Branze, Brescia, Italy
| | - Domenico Russo
- Unit of Blood Diseases and Bone Marrow Transplantation, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Jonathan C. Irish
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, Toronto, ON, Canada
- Princess Margaret Cancer Centre, Toronto General Hospital, Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, University Health Network, Toronto, ON, Canada
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Escobar-Domingo MJ, Bustos VP, Akintayo R, Mahmoud AA, Fanning JE, Foppiani JA, Miller AS, Cauley RP, Lin SJ, Lee BT. The versatility of the scapular free flap: A workhorse flap? A systematic review and meta-analysis. Microsurgery 2024; 44:e31203. [PMID: 38887104 DOI: 10.1002/micr.31203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 04/03/2024] [Accepted: 05/24/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND The scapular free flap (SFF) is essential in complex reconstructive surgery and often indicated in complex defects with compromised or poor local tissue integrity. This review aims to assess the versatility and reliability of the SFF during reconstruction. METHODS A comprehensive literature review of multiple databases was conducted following the PRISMA guidelines. An analysis of pooled data was performed to evaluate flap failure rate for any anatomical unit using SFF as the primary endpoints. Secondary endpoints included other complication rates after reconstruction such as partial flap loss, revision surgery, fistula, hematoma, and infection. RESULTS A total of 110 articles were included, with 1447 pooled flaps. The main recipient site was the head and neck region (89.0%). Major indications for reconstruction were malignancy (55.3%), burns (19.2%), and trauma (9.3%). The most common types of flaps were osteocutaneous (23.3%), cutaneous (22.6%), and chimeric (18.0%). The pooled flap failure rate was 2% (95%CI: 1%-4%). No significant heterogeneity was present across studies (Q statistic 20.2, p = .69; I2 .00%, p = .685). Nonscapular supplementary flaps and grafts were required in 61 cases. The average length and surface area of bone flaps were 7.2 cm and 24.8cm2, respectively. The average skin paddle area was 134.2cm2. CONCLUSION The SFF is a useful adjunct in the reconstructive surgeon's armamentarium as evidence by its intrinsic versatility and diverse clinical indications. Our data suggest a low failure rate in multicomponent defect reconstruction, especially in head and neck surgery. SFFs enable incorporation of multiple tissue types and customizable dimensions-both for vascularized bone and cutaneous skin-augmenting its value in the microsurgeon's repertoire as a chimeric flap. Further research is necessary to overcome the conventional barriers to SFF utilization and to better comprehend the specific scenarios in which the SFF can serve as the preferred alternative workhorse flap.
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Affiliation(s)
- Maria J Escobar-Domingo
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami, Miami, Florida, United States
| | - Rachel Akintayo
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Amir-Ala Mahmoud
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - James E Fanning
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jose A Foppiani
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Amitai S Miller
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan P Cauley
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Bottini GB, Joos V, Steiner C, Zeman-Kuhnert K, Gaggl A. Advances in Microvascular Reconstruction of the Orbit and Beyond: Considerations and a Checklist for Decision-Making. J Clin Med 2024; 13:2899. [PMID: 38792440 PMCID: PMC11122336 DOI: 10.3390/jcm13102899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
This paper aims to discuss the microvascular reconstruction of the orbit and adjacent regions and to propose a checklist to aid the reconstructive surgeon in this challenging undertaking. The discussion is based on a literature review that includes 32 retrospective case series, 5 case reports published in the last 34 years in PubMed, and 3 textbook chapters. Additionally, it relies on the senior author's expertise, described in a case series, and two case reports published elsewhere. Classifications and treatment algorithms on microvascular orbit reconstruction generally disregard patient-related factors. A more holistic approach can be advantageous: patient-related factors, such as age, comorbidities, prognosis, previous interventions, radiotherapy, and the wish for maximal dental rehabilitation and a prosthetic eye, have the same importance as defect-related considerations and can inform the choice of a reconstructive option. In this manuscript, we examine defect- and patient-related factors and new technologies, provide a checklist, and examine future directions. The checklist is intended as a tool to aid in the decision-making process when reconstructing the orbital region with microvascular flaps.
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Affiliation(s)
- Gian Battista Bottini
- Department of Oral and Maxillofacial Surgery and Centre for Reconstructive Surgery, University Hospital of the Private Medical University Paracelsus, 5020 Salzburg, Austria; (G.B.B.); (C.S.); (K.Z.-K.)
| | - Veronika Joos
- Private Practice for Dentistry and Oral and Maxillofacial Surgery, 5026 Salzburg, Austria
| | - Christoph Steiner
- Department of Oral and Maxillofacial Surgery and Centre for Reconstructive Surgery, University Hospital of the Private Medical University Paracelsus, 5020 Salzburg, Austria; (G.B.B.); (C.S.); (K.Z.-K.)
| | - Katharina Zeman-Kuhnert
- Department of Oral and Maxillofacial Surgery and Centre for Reconstructive Surgery, University Hospital of the Private Medical University Paracelsus, 5020 Salzburg, Austria; (G.B.B.); (C.S.); (K.Z.-K.)
| | - Alexander Gaggl
- Department of Oral and Maxillofacial Surgery and Centre for Reconstructive Surgery, University Hospital of the Private Medical University Paracelsus, 5020 Salzburg, Austria; (G.B.B.); (C.S.); (K.Z.-K.)
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Mohamed AAS, Mai L, Mashrah MA, Fan S, Wang S, Lin Z, Pan C. Medial sural artery perforator free flap versus radial forearm free flap in oral cavity reconstruction and donor site morbidity. Clin Oral Investig 2024; 28:269. [PMID: 38656417 DOI: 10.1007/s00784-024-05618-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 03/12/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE Radial Forearm Free flap (RFFF) is widely used in head and neck reconstruction, yet its donor site defect remains a significant drawback. The Medial Sural Artery Perforator Free Flap (MSAPFF) is considered an alternative flap to RFFF. This study aims to comprehensively analyze their characteristics, outcomes, and their impact on patient quality of life. METHODS All patients who underwent oral cavity reconstruction using RFFF and MSAPFF between February 2017 and April 2023 were included in this study. Flap characteristics, outcomes and post-operative complications were recorded and compared. Subjective donor site morbidity, aesthetic and functional results, and quality of life were also analyzed. RESULTS The study included 76 patients: 37 underwent reconstruction with RFFF, and 39 with MSAPFF. There was no significance difference between the RFFF and MSAPFF regarding the success rate (97.2% vs 97.4%), flap size (4.8 × 8.8 cm2 vs 5 × 9.8 cm2), hospital of stay (15.5 days vs 13.5 days) and recipient site complications (P > 0.05). However, MSAPFF showed larger flap thickness (P = 0.001), smaller arterial caliber (P = 0.008), shorter pedicle length (P = 0.001), and longer harvesting time (P < 0.001). No significant difference was observed between the pre-and postoperative ranges of wrist and ankle movements or in recipient site complications. MSAPFF showed a significant difference in donor site morbidity (P < 0.05). CONCLUSION The MSAPFF is an excellent alternative to the RFFF for repairing oral cavity defects, with additional advantage of a well-hidden scar on the posterior calf, a larger flap thickness, accepted pedicle length and arterial caliber. However, one should consider the harvesting time and surgical skills required in comparison to the RFFF. CLINICAL RELEVANCE The study highlights the importance of the MSAPFF as an alternative option for RFFF with less donor site morbidity and high success rate in oral cavity reconstruction and improved patient Quality of life after ablative surgery.
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Affiliation(s)
- Abdo Ahmed Saleh Mohamed
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Lianxi Mai
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Mubarak Ahmed Mashrah
- Department of Oral Implant, Guangdong Engineering Research of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Song Fan
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Shuang Wang
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Zhaoyu Lin
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou, 510120, China.
| | - Chaobin Pan
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou, 510120, China.
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Hairston H, Gardner JR, Hagood J, King DL, Vural EA, Moreno MA, Benson DG, Sunde J. Routine Contrasted Chest CT Accurately Identifies Anatomic Variations of the Proximal Subscapular System. Laryngoscope 2024; 134:684-687. [PMID: 37462362 DOI: 10.1002/lary.30839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 05/15/2023] [Accepted: 06/07/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE The vascular anatomy of the proximal subscapular artery has been previously classified into 2 major types depending on the presence of a common subscapular trunk. The purpose of this study was to determine the utility, reliability, and cost of routine chest imaging to identify these anatomical variations. METHODS Data were collected retrospectively at a tertiary medical center for patients who were undergoing CT chest for various indications between October 2019 and October 2020. Two independent and blinded readers interpreted CT chest with contrast of 52 patients for a total 104 sides. RESULTS The proximal branching pattern of the subscapular system was identified to have a common trunk in 99 (95%) sides. The remaining five sides (5%) demonstrated two arterial pedicles; with one patient exhibiting the variant anatomy bilaterally. CONCLUSION Preoperative CT chest with contrast can accurately identify anatomic variation of the subscapular vascular system. For complex reconstruction requiring a single anastomosis in the vessel depleted neck, preoperative imaging can assure selection of a type I vascular anatomy of the proximal subscapular system. Preoperative imaging with contrasted CT has value in assessing this anatomy when planning for chimeric flaps involving circumflex scapular and thoracodorsal arteries. LEVEL OF EVIDENCE 3 Laryngoscope, 134:684-687, 2024.
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Affiliation(s)
- Hayden Hairston
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - James R Gardner
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Joshua Hagood
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Deanne L King
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Emre A Vural
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Mauricio A Moreno
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Donald G Benson
- Department of Radiology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, U.S.A
| | - Jumin Sunde
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
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6
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Reconstructive Surgery. J Oral Maxillofac Surg 2023; 81:E263-E299. [PMID: 37833026 DOI: 10.1016/j.joms.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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7
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Barton BM, Mamdani M, Lumley C, Blumberg J, Huang BY, Patel SN. Osseointegration and Bone Resorption of Scapula Tip Free Flaps in Mandibular Reconstruction. Laryngoscope 2023; 133:2597-2602. [PMID: 36651328 DOI: 10.1002/lary.30574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/05/2022] [Accepted: 01/05/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Bone resorption of more conventional vascularized bone grafts have been well described showing minimal resorption over time. Few studies have evaluated osseous union and bone resorption in scapula tip free flaps (STFF) in the reconstruction of mandibulectomy defects. We aimed to describe our series on STFF with respect to osseous union and bone resorption over time. METHODS Retrospective chart review of patients receiving STFF from January 2014-January 2017 (n = 25). A neuroradiologist analyzed follow-up CT scans to assess (1) STFF complete, partial, or no osseous union with native mandible and (2) STFF volume change over time in a subset with multiple follow-up scans (n = 18). RESULTS Twenty-three of 25 patients (92%) showed complete or partial STFF osseous union with native mandible either distally or proximally. STFF volume change ranged from +4.8 to -54% (median -0.5%) over median follow-up interval of 23 months. History of chemoradiation therapy, bisphophonate use, sex, age, or smoking history did not correlate with bone resorption. CONCLUSIONS STFFs shows high rates of osseous union and limited bone resorption that is equivalent to, or less than, vascularized fibular and iliac crest flaps. Clinically, this translates into both optimal healing and functional and cosmetic outcomes, especially in the setting of prior therapies. LEVEL OF EVIDENCE 4 Laryngoscope, 133:2597-2602, 2023.
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Affiliation(s)
- Blair M Barton
- Department of Otorhinolaryngology, Ochsner Medical Center, New Orleans, Louisiana, U.S.A
| | - Mohammed Mamdani
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Catherine Lumley
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Jeffrey Blumberg
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Benjamin Y Huang
- Department of Radiology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Samip N Patel
- Department of Otolaryngology, Mayo Clinic, Jacksonville, Florida, U.S.A
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8
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Arcuri F, Laganà F, Bianchi B, Ferrari S, Ferri A. Double Arterialized Scapular Tip Free Flap for Mandibular Reconstruction. J Craniofac Surg 2023; 34:1744-1747. [PMID: 37433202 DOI: 10.1097/scs.0000000000009512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 05/15/2023] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION Scapular tip free flap (STFF) has become today one of the workhorse flaps for maxillary reconstruction; recently, the possibility of extending the vascular supply by adding to the angular branch of the circumflex pedicle up to its periosteal entrance in the lateral border of the scapula has been proposed as a reliable technique to improve the length of perfused bone when STFF is used for mandibular reconstruction. The purpose of this study was to evaluate the patients who had received microvascular reconstruction of the mandible with STFF vascularized by both the circumflex scapular artery via the periosteal branch and the thoracodorsal artery via the angular artery. METHODS A retrospective chart review was conducted for all patients who underwent reconstruction with an STFF for mandibular defect between January 2016 and December 2020 at the University Hospital of Parma. The outcome was evaluated by assessing dietary intake (unrestricted, soft, liquid, and tube feed) and speech (normal, intelligible, partially intelligible, and unintelligible). RESULTS The final study sample included 9 patients (5 men and 4 women). The average patient age was 68.9 years (range, 59.9-74.8 y) at the time of surgery. There was no flap loss. A 1-year postoperative computed tomography scan revealed full osteointegration of the flap. CONCLUSIONS Our results show that the STFF is a valuable reconstructive option, especially in patients with complex head and neck defects requiring soft and hard tissues.
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Affiliation(s)
- Francesco Arcuri
- Unit of Maxillo-Facial Surgery, IRCCS "Policlinico San Martino", Genoa
| | - Francesco Laganà
- Unit of Maxillo-Facial Surgery, IRCCS "Policlinico San Martino", Genoa
| | - Bernardo Bianchi
- Unit of Maxillo-Facial Surgery, IRCCS "Policlinico San Martino", Genoa
| | - Silvano Ferrari
- Unit of Maxillo-Facial Surgery, "Ospedale Maggiore di Parma" Parma, Italy
| | - Andrea Ferri
- Unit of Maxillo-Facial Surgery, "Ospedale Maggiore di Parma" Parma, Italy
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9
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Donor Site Morbidity and Quality of Life after Microvascular Head and Neck Reconstruction with a Chimeric, Thoracodorsal, Perforator-Scapular Flap Based on the Angular Artery (TDAP-Scap-aa Flap). J Clin Med 2022; 11:jcm11164876. [PMID: 36013116 PMCID: PMC9410144 DOI: 10.3390/jcm11164876] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 11/17/2022] Open
Abstract
Extensive defects in the head and neck area often require the use of advanced free flap reconstruction techniques. In this study, the thoracodorsal perforator-scapular free flap technique based on the angular artery (TDAP-Scap-aa flap) was postoperatively evaluated regarding the quality of life and the donor site morbidity using the standardized SF-36 and DASH questionnaires (short form health 36 and disabilities of the arm, shoulder and hand scores). Over a five-year period (2016−2020), 20 selected cases (n = 20) requiring both soft and hard tissue reconstruction were assessed. On average, the harvested microvascular free flaps consisted of 7.8 ± 2.1 cm hard tissue and 86 ± 49.8 cm2 soft tissue components. At the donor site (subscapular region), only a mild morbidity was observed (DASH score: 21.74 ± 7.3 points). When comparing the patients’ postoperative quality of life to the established values of the healthy German norm population, the observed SF-36 values were within the upper third (>66%) of these established norm values in almost all quality-of-life subcategories. The mild donor site morbidity and the observed quality of life indicate only a small postoperative impairment when using the TDAP-Scap-aa free flap for the reconstruction of extensive maxillofacial defects.
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Bottini GB, Hutya V, Kummer D, Steiner C, Zeman-Kuhnert K, Wittig J, Gaggl A. Microvascular reconstruction of the orbit and adjacent regions: A case series. ADVANCES IN ORAL AND MAXILLOFACIAL SURGERY 2022. [DOI: 10.1016/j.adoms.2022.100297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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The Use of Scapular Bone Flaps During Head-and-Neck Reconstruction: Functional, Orthopedic, and Quality of Life Analyses of Flap-Harvest-Related Deficits. J Craniofac Surg 2022; 33:2031-2034. [PMID: 35034085 DOI: 10.1097/scs.0000000000008472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/04/2022] [Indexed: 11/27/2022] Open
Abstract
ABSTRACT The authors sought correlations between harvesting of the scapular bone tip free flap used for head-and-neck reconstruction and any shoulder function deficit, particularly at the level of the rotator cuff. The flap permits reconstruction of large and diverse regions of the head and neck, but long-term harvest morbidity has not been investigated extensively. The authors analyzed the clinical records of all patients who underwent head-and-neck reconstructions using free scapular tip flaps in our department over the past 5 years. The inclusion criteria were complete clinical and radiological documentation and follow-up for at least 12 months. Two populations, a surgical and control population, were analyzed. All patients in both populations underwent the simple shoulder test, an internationally validated self-administered test that highlights functional shoulder deficits, and 3 additional tests at orthopedic visits: the external rotation test, Patte test, and external rotation lag sign test. A head-and-neck cancer-specific questionnaire (University of Washington Quality of Life, version 4) was completed by the surgical patients. All statistical analyses were performed using Software IBM SPSS Statistics (IBM Corp., Armonk, NY).A total of 19 patients met the inclusion criteria: 11 males (57.8%) and 8 females (42.2%) of mean age 60.9 years (range 23-75 years). In addition, 20 age-and sex-matched volunteers with no history of shoulder pathology were evaluated in terms of shoulder functionality. The average score on the simple shoulder test was 10.55 in the healthy population versus 8.31 in the study population (P < 0.001); in particular, shoulder strength differed between the groups. Similarly, the orthopedic examinations revealed clinically significant differences between the controls and patients on the Patte test and external rotation lag sign test (both P < 0.001), but not the external rotation test (P > 0.001). The mean University of Washington Quality of Life was 73.39; most patients reported good quality of life (52.6%), followed by very good (15.7%).The free scapular bone tip flap is valuable for reconstruction of head-and-neck defects; the long and reliable vascular pedicle allows rapid patient mobilization. Morbidity was confined to small reductions in shoulder strength and external rotation, which do not affect quality of life.
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Failure of preoperative co-morbidity indices to predict the successful use of the composite scapula free flap for maxillofacial reconstruction in patients with significant medical co-morbidities. Int J Oral Maxillofac Surg 2021; 51:746-753. [PMID: 34794850 DOI: 10.1016/j.ijom.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/24/2021] [Accepted: 10/29/2021] [Indexed: 11/21/2022]
Abstract
The aim of this study was to evaluate the accuracy of validated preoperative patient co-morbidity assessments, including the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), with the use of the composite scapula free flap (CSFF) in maxillofacial reconstruction in patients with significant medical co-morbidities. A retrospective cohort review was performed at an academic institution, covering the period from July 2010 through January 2019. All patients who underwent reconstruction with a CSFF with significant medical co-morbidities were included. Co-morbidity assessments and risk factors were analyzed by comparing predicted versus observed early and late medical and surgical complications. Forty-five patients met the inclusion criteria. The surgical complication rate was 47%; the medical complication rate was 38%. Over 90% of patients returned to successful function at 3 months post-surgery. The ACS-NSQIP prediction of complications ranged from 58% to 75% for accuracy, 76% to 100% for sensitivity, and 50% to 69% for specificity. The prediction of a serious complication was statistically significant in patients with a Charlson Co-morbidity Index ≥7. Age ≥80 years did not significantly increase the risk of a serious complication (P = 0.23). The ACS-NSQIP failed to predict the successful use of the CSFF for patients with significant co-morbidities undergoing maxillofacial reconstruction. The selection of patients who will tolerate complex reconstruction cannot be based solely on co-morbidity charts and standardized preoperative indices.
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Scapular osseous free flap in head and neck reconstruction: An assessment of the postoperative function of the donor site. J Plast Reconstr Aesthet Surg 2021; 75:753-760. [PMID: 34810144 DOI: 10.1016/j.bjps.2021.09.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 06/20/2021] [Accepted: 09/27/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The scapular osseous free flap (SOFF) has become an important reconstructive option for complex head and neck defects. Postoperative donor site function is, however, an important consideration. The objective of this study was to prospectively investigate SOFF donor site morbidity and to relate the findings to hand dominance and neck dissection. METHODS Objective assessment included bilateral measurement of shoulder, elbow, and hand range of motion (ROM), hand strength, and distal nerve function in consecutive patients with head and neck cancer SOFF reconstruction at a tertiary referral center in Sweden between 2016 and 2019. The subjective function was assessed by the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS Sixteen of 20 consecutive patients were evaluated (median follow-up 10 months [range 3-17]). Significant side differences in shoulder range of motion (ROM) (flexion, abduction, external and internal rotation) were observed for patients where the SOFF had been harvested from the same side as their dominant hand (n = 9; Ps ≤ 0.04). For patients where the SOFF was harvested from the non-dominant hand side, no significant shoulder ROM side differences were observed (n = 7; Ps ≥ 0.08). There were significant side differences in shoulder ROM for patients who underwent neck dissections (n = 12; Ps ≤ 0.03), not for the other four patients. Patients reported low but varying DASH scores (median 2.5, range 0-57). CONCLUSION Postoperative donor site morbidity seems to be quite acceptable after SOFF surgery. The results indicate possible benefits of choosing the non-dominant hand side for the SOFF and that a neck dissection affects postoperative shoulder outcome. Further studies are however needed.
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Rubin SJ, Sayre KS, Kovatch KJ, Ali SA, Hanks JE. Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty. Curr Opin Otolaryngol Head Neck Surg 2021; 29:407-418. [PMID: 34387289 DOI: 10.1097/moo.0000000000000755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Options for segmental mandibular reconstruction in patients poorly suited to undergo fibula free flap (FFF). RECENT FINDINGS Although FFF is the current 'gold standard' for segmental mandibular reconstruction, other reconstructive options must be considered when FFF is contraindicated or disfavoured and/or patient frailty precludes a lengthy anaesthetic. In addition to various nonvascularized and soft tissue only reconstructions, excellent osseous free flap alternatives for functional segmental mandibular reconstruction may be employed. The subscapular system free flaps (SSSFF) may be ideal in frail and/or elderly patients, as SSSFF allows for early mobility and does not alter gait. In extensive and/or symphyseal defects, functional mandibular reconstruction in lieu of a free flap is extremely limited. Pedicled segmental mandibular reconstructions remain reasonable options, but limited contemporary literature highlights unpredictable bone graft perfusion and poor long-term functional outcomes. SUMMARY There are several excellent free flap alternatives to FFF in segmental mandibular reconstruction, assuming adequate cervical recipient vessels are present. On the basis of the current literature, the optimal mandibular reconstruction for the medically frail, elderly and/or patients with extreme vessel-depleted necks is limited and debatable. In qualifying (i.e. limited, lateral) defects, soft tissue only reconstructions should be strongly considered when osseous free flaps are unavailable.
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Affiliation(s)
- Samuel J Rubin
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine
| | - Kelly S Sayre
- Department of Oral and Maxillofacial Surgery, Boston University School of Dentistry
| | - Kevin J Kovatch
- Department of Otolaryngology-Head and Neck Surgery, Geisinger Medical Center
| | - S Ahmed Ali
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System
| | - John E Hanks
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine
- Department of Otolaryngology-Head and Neck Surgery, VA Boston Medical Center, MA, USA
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Mandibular Reconstruction with Scapular Systems: A Single-Center Case Series Involving 208 Flaps. Plast Reconstr Surg 2021; 148:625-634. [DOI: 10.1097/prs.0000000000008301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Versatility of a single piece scapular tip and lateral border free flap for mandibular reconstruction: A virtual study on angle correspondence. Oral Oncol 2021; 121:105379. [PMID: 34140234 DOI: 10.1016/j.oraloncology.2021.105379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/04/2021] [Accepted: 06/07/2021] [Indexed: 11/20/2022]
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Sridharan SS, Ramprasad VH, Keller RG, Day TA, Lentsch EJ, Skoner JM. Scapular free flap reconstruction of pharyngoesophageal defects. Clin Otolaryngol 2021; 46:1110-1113. [PMID: 33797863 DOI: 10.1111/coa.13777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 01/03/2021] [Accepted: 03/07/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Shaum S Sridharan
- Department of Otolaryngology-Head & Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vaibhav H Ramprasad
- Department of Otolaryngology-Head & Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert G Keller
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Terry A Day
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Eric J Lentsch
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Judith M Skoner
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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Bauer E, Mazul A, Zenga J, Graboyes EM, Jackson R, Puram SV, Doering M, Pipkorn P. Complications After Soft Tissue With Plate vs Bony Mandibular Reconstruction: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2020; 164:501-511. [PMID: 32838614 DOI: 10.1177/0194599820949223] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Mandibular reconstruction for segmental defects is a well-studied topic. However, there are conflicting data on the risks of delayed plate-related complications. The objective of this systematic review and meta-analysis was to assess long-term plate-related complications following reconstruction of the mandible with soft tissue and a plate as compared with immediate vascularized bony reconstruction. DATA SOURCES A medical librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946-), Embase (1947-), Scopus (1960-), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Clinicaltrials.gov. REVIEW METHODS Candidate articles were independently reviewed by 2 authors. Inclusion/exclusion criteria were uniformly applied. Articles were considered eligible if they included adequate reporting of plate extrusion and/or fracture and had follow-up ≥12 months. RESULTS A total of 2379 patients were included. The risk of plate fracture was low in cases of soft tissue with a plate (5%; 95% CI, 0.03-0.08) and osseous reconstruction (1%). The risk of extrusion following soft tissue and plate reconstruction was 20% (95% CI, 0.15-0.27). In the osseous reconstruction group, the risk of extrusion was 10% (95% CI, 0.06-0.18). Revision surgery was performed twice as often following soft tissue with a plate as compared with vascularized bony reconstruction (32% [95% CI, 0.25-0.40] vs 14% [95% CI, 0.09-0.21], respectively). CONCLUSION Delayed plate-related complications remain a significant problem following segmental defect reconstruction. Soft tissue and plate reconstruction techniques may increase the risk of plate removal and revision surgery.
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Affiliation(s)
- Eric Bauer
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, Missouri, USA
| | - Angela Mazul
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, Missouri, USA
| | - Joseph Zenga
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ryan Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, Missouri, USA
| | - Michelle Doering
- Bernard Becker Medical Library, School of Medicine, Washington University, St Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, Missouri, USA
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Three-dimensional modeling of the scapular tip for anterolateral and lateral mandibular defects. Oral Oncol 2020; 107:104718. [DOI: 10.1016/j.oraloncology.2020.104718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/12/2020] [Accepted: 04/11/2020] [Indexed: 11/19/2022]
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Wolfer S, Wohlrath R, Kunzler A, Foos T, Ernst C, Schultze-Mosgau S. Scapular free flap as a good choice for mandibular reconstruction: 119 out of 280 cases after resection of oral squamous cell carcinoma in a single institution. Br J Oral Maxillofac Surg 2020; 58:451-457. [PMID: 32201048 DOI: 10.1016/j.bjoms.2020.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 02/25/2020] [Indexed: 11/16/2022]
Abstract
Microsurgical procedures for reconstruction after resection of head and neck tumours have become standardised and reliable. Among them, the scapular free flap is used less often, mostly to avoid excessive operating times. We hypothesise that complex reconstructions after resection of oral squamous cell carcinoma (OSCC) are successful even with time-consuming free flaps such as the scapular free flap. In this retrospective, single-centre study, we used the evaluation of medical records to investigate the postoperative outcome of microvascular reconstruction after ablative surgery of OSCC. Associations among the categorical variables were analysed using Pearson's chi squared test or Fisher's exact test. Among the continuous variables, the t test or Mann-Whitney U test were used as appropriate. For multivariate analysis, the logistic regression model was calculated. In the sample of 280 free flap reconstructions, we performed 142 radial forearm and 119 scapular free flaps. The American Society of Anesthesiology (ASA) score (p=0.006) and the duration of the operation (p=0.010) are independent factors which influence the need for operative revisions. The type of free flap is irrelevant for that. With 4.2% flap losses, scapular free flaps were successful; even in patients ≥ 70 years old (0 flap losses). Complex reconstructions after surgical resection of OSCC are successful even in aged patients. The scapular free flap is a good choice for mandibular reconstruction despite the time-consuming intraoperative repositioning of the patient. In an increasingly ageing group of patients, who have more vascular diseases, scapular free flaps could be a very successful alternative after ablative surgery of oral squamous cell carcinoma.
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Affiliation(s)
- S Wolfer
- Department of Oral and Maxillofacial & Plastic Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany.
| | - R Wohlrath
- Department of Oral and Maxillofacial & Plastic Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - A Kunzler
- Department of Oral and Maxillofacial & Plastic Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - T Foos
- Department of Oral and Maxillofacial & Plastic Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - C Ernst
- Department of Oral and Maxillofacial & Plastic Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - S Schultze-Mosgau
- Department of Oral and Maxillofacial & Plastic Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
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Ettinger KS, Alexander AE, Morris JM, Arce K. Novel Geometry of an Extended Length Chimeric Scapular Free Flap for Hemimandibular Reconstruction: Nuances of the Technique Streamlined by In-House Virtual Surgical Planning and 3D Printing for a Severely Vessel-Depleted Neck. J Oral Maxillofac Surg 2020; 78:823-834. [PMID: 32061631 DOI: 10.1016/j.joms.2020.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 11/30/2022]
Abstract
Subscapular-based flaps have historically maintained an unparalleled ability to provide a multitude of bone and soft tissue components based on a single vascular pedicle. However, these flaps are often not thought of as an ideal choice for composite defects requiring extended lengths of bone for reconstruction. The ability to harvest long segments of bone and reliably perform multiple contouring osteotomies is fundamental to long-span composite mandibular reconstruction, and microvascular surgeons are often met with significant reconstructive challenges when fibular free flaps cannot be used owing to variant vascular anatomy or occlusive atherosclerotic disease in these specific clinical scenarios. This challenge is further compounded by treatment-related vessel depletion in the neck, which reduces the availability of suitable recipient vessels in close proximity to the reconstruction. We present a case in which all of the aforementioned challenges presented in a single individual, who concomitantly required hemimandibular reconstruction with treatment related vessel depletion in the neck and unsuitable bilateral vascular anatomy in the legs precluding the use of a fibular free flap. This case demonstrates a previously unreported flap component geometry for hemimandibular reconstruction using an extended-length chimeric scapular free flap with scapular tip, lateral scapular border, and parascapular fasciocutaneous skin paddle components.
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Affiliation(s)
- Kyle S Ettinger
- Assistant Professor, Section of Head and Neck Oncologic Surgery and Reconstruction, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN.
| | - Amy E Alexander
- Senior Biomedical Engineer, 3D Anatomic Modeling Laboratory, Mayo Clinic, Rochester, MN
| | - Jonathan M Morris
- Assistant Professor of Radiology, Division of Neuroradiology, Department of Diagnostic Radiology, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - Kevin Arce
- Assistant Professor of Surgery and Division Chair, Section of Head and Neck Oncologic Surgery and Reconstruction, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
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Worley ML, Patterson TM, Graboyes EM, Wu Y, Brody RM, Hornig J, Walton Z. Association of the Anterolateral Thigh Osteomyocutaneous Flap With Femur Structural Integrity and Assessment of Prophylactic Fixation. JAMA Otolaryngol Head Neck Surg 2019; 144:769-775. [PMID: 30054621 DOI: 10.1001/jamaoto.2018.1014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance The chimeric anterolateral thigh osteomyocutaneous (ALTO) free flap is a recently described microvascular option for head and neck osseous defects associated with complex soft-tissue requirements. To date, the association of ALTO flap harvest with femur structural integrity and the need for routine prophylactic fixation following harvest has been incompletely described. Objective To investigate the association of ALTO flap harvest, with and without prophylactic fixation, on femur structural integrity as measured by 4-point bend and torsional biomechanical testing. Design and Setting At a research laboratory, 24 synthetic fourth-generation composite femurs with validated biomechanical properties underwent 10-cm-long, 30% circumferential osteotomies at the proximal middle third of the femur; 6 femurs served as controls. Osteotomized femurs with and without fixation underwent torsional and 4-point bend biomechanical testing. Femur fixation consisted of intramedullary nail and distal interlock screw placement. Main Outcomes and Measures Force and torque to fracture (expressed in kilonewtons [kN] and Newton meters [N∙m], respectively) were compared between controls, osteotomized femurs without fixation, and osteotomized femurs with fixation. Additional outcome measures included femur stiffness and fracture patterns. Results On posterior to anterior (PA) 4-point bend testing, force to fracture of osteotomized femurs was 22% of controls (mean difference, 8.3 kN; 95% CI, 6.6-10.0 kN). On torsional testing the torque to fracture of osteotomized femurs was 12% of controls (mean difference, 351.1 N∙m; 95% CI, 307.1-395.1 N∙m). Following fixation there was a 67% improvement in PA force to fracture and a 37% improvement in torque to fracture. However, osteotomized femurs with fixation continued to have a reduced PA force to fracture at 37% of controls (mean difference, 6.8 kN; 95% CI, 4.5-9.2 kN) and torque to fracture at 16% of controls (mean difference, 333.7 N∙m; 95% CI, 306.8-360.6 N∙m). On torsional testing, all osteotomized femurs developed similar spiral fractures through a corner of the distal osteotomy site. This fracture pattern changed after prophylactic fixation with femurs developing nondisplaced fractures through the proximal osteotomy site. There were no underlying hardware failures during testing of osteotomized femurs with fixation. Conclusions and Relevance Anterolateral thigh osteomyocutaneous flap harvest results in significant changes in the structural integrity of the femur. Postoperative stabilization should be strongly considered, with future research directed at investigating the clinical significance of residual biomechanical changes following femur fixation.
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Affiliation(s)
- Mitchell L Worley
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Travis M Patterson
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston.,Cancer Control Program, Hollings Cancer Center, Charleston, South Carolina
| | - Yongren Wu
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston
| | - Robert M Brody
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Joshua Hornig
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Zeke Walton
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston
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A Design for the Dual Skin Paddle Circumflex Scapular Artery Perforator Flap for the Reconstruction of Complex Soft-Tissue Defects in Children. Ann Plast Surg 2019; 83:439-446. [DOI: 10.1097/sap.0000000000001814] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shouldering the load of mandible reconstruction: 81 cases of oromandibular reconstruction with the scapular tip free flap. Head Neck 2018; 41:30-36. [DOI: 10.1002/hed.25342] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 01/24/2018] [Accepted: 05/07/2018] [Indexed: 11/07/2022] Open
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Tracy JC, Brandon B, Patel SN. Scapular Tip Free Flap in Composite Head and Neck Reconstruction. Otolaryngol Head Neck Surg 2018; 160:57-62. [DOI: 10.1177/0194599818791783] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives To describe the use of the scapular tip free flap (STFF) in the reconstruction of head and neck defects. Study Design Case series with chart review. Setting Academic medical center. Subjects and Methods A review of the electronic medical record was performed of all patients who underwent head and neck reconstructive surgery with STFFs from January 1, 2014, through January 1, 2016. Details regarding the disease, defect reconstructed, and surgical outcomes were quantified. Results Thirty-one consecutive cases were performed at our institution within the period reviewed. The procedures included reconstruction of 5 maxillectomy and 26 mandibulectomy defects. The mean length of mandible reconstructed was 6.8 cm (95% CI, 6.01-7.59; range, 4.0-10.2). Osteotomies were made to contour the scapular bone in 11 cases, including double osteotomies performed in 2 cases. The most common surgical complications were orocutaneous fistula and postoperative hematoma, which occurred in 3 (10%) and 2 (6.5%) of 31 patients, respectively. Conclusion This series describes a large number of STFFs performed in head and neck reconstruction. The average length of bony defect repair can be significantly larger than what was previously described. Performing osteotomies to the STFF allows for application to anterior mandibular defects. The STFF offers a large soft tissue component, a relatively long pedicle, and acceptable donor site morbidity. The STFF is a versatile reconstructive option that should be considered to address composite defects of the head and neck.
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Affiliation(s)
- Jeremiah C. Tracy
- Department of Otolaryngology–Head and Neck Surgery, University of Massachusetts, Worcester, Massachusetts, USA
| | - Bryan Brandon
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Samip N. Patel
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
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Prasad J, Sahovaler A, Theurer J, Yeh DH, Fung K, MacNeil SD, Yoo J, Nichols AC. Predictors of plate extrusion in oromandibular free flap reconstruction. Microsurgery 2018; 38:682-689. [DOI: 10.1002/micr.30349] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 05/03/2018] [Accepted: 06/08/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Jessica Prasad
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry; Western University; London Ontario Canada
| | - Axel Sahovaler
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry; Western University; London Ontario Canada
- General Surgery Department, Head and Neck Surgery Unit; Italian Hospital of Buenos Aires; Buenos Aires Argentina
| | - Julie Theurer
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry; Western University; London Ontario Canada
| | - David H. Yeh
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry; Western University; London Ontario Canada
| | - Kevin Fung
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry; Western University; London Ontario Canada
| | - S. Danielle MacNeil
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry; Western University; London Ontario Canada
| | - John Yoo
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry; Western University; London Ontario Canada
| | - Anthony C. Nichols
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry; Western University; London Ontario Canada
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Reconstruction of a Compound Oromandibular Defect by Means of Chimeric Scapular–Parascapular Free Flap Assisted by Virtual Surgical Planning. J Craniofac Surg 2018; 29:e248-e250. [DOI: 10.1097/scs.0000000000004266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kakarala K, Shnayder Y, Tsue TT, Girod DA. Mandibular reconstruction. Oral Oncol 2018; 77:111-117. [DOI: 10.1016/j.oraloncology.2017.12.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 12/18/2017] [Accepted: 12/29/2017] [Indexed: 11/24/2022]
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‘Sit and tilt’ preparation for subscapular system free flaps. The Journal of Laryngology & Otology 2018; 132:180-183. [DOI: 10.1017/s0022215117002511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:The ablation of advanced head and neck cancer often results in large three-dimensional defects that require free tissue transfer to optimally address functional and cosmetic issues. The subscapular system is a highly versatile donor site for flaps used for head and neck reconstruction. Traditional methods of harvesting subscapular flaps require repositioning and re-preparing, which significantly increases the operative time and prevents simultaneous harvesting of the flap.Method:This paper presents our experience of a single-stage ‘sit and tilt’ technique, which provides a convenient method for harvesting subscapular system free flaps without significant repositioning.Results and conclusion:This technique was used for a variety of head and neck defects, and body habitus did not seem to affect free tissue harvesting. It is hoped that utilisation of this preparation and harvesting technique will make head and neck surgeons more willing to take advantage of the subscapular system.
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Graboyes EM, Hornig JD. Evolution of the anterolateral thigh free flap. Curr Opin Otolaryngol Head Neck Surg 2018; 25:416-421. [PMID: 28786847 DOI: 10.1097/moo.0000000000000394] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW To review the recent literature on the evolution and advanced uses of the anterolateral thigh (ALT) free flap in reconstruction of oncologic defects of the head and neck. RECENT FINDINGS The ALT free flap is a versatile flap that can be harvested in a chimeric fashion with independent, vascularized skin, muscle, fascia, nerve and bone. Various techniques for chimeric flap harvest and flap inset have been described for reconstruction of pharyngocutaneous, oromandibular and radical parotidectomy defects. These reports expand the indications for the ALT free flap while demonstrating good functional and aesthetic outcomes. SUMMARY The ALT free flap remains popular for reconstruction of head and neck oncologic defects because of its versatility. Continued evolution in chimeric flap harvest techniques for pharyngocutaneous, osseous and radical parotidectomy defects highlights novel advanced reconstructive uses for the ALT free flap.
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Affiliation(s)
- Evan M Graboyes
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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O'Connell JE, Bajwa MS, Schache AG, Shaw RJ. Head and neck reconstruction with free flaps based on the thoracodorsal system. Oral Oncol 2017; 75:46-53. [DOI: 10.1016/j.oraloncology.2017.10.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 11/29/2022]
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Rapid prototyped patient specific guiding implants in critical mandibular reconstruction. J Craniomaxillofac Surg 2017; 45:63-70. [DOI: 10.1016/j.jcms.2016.10.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 09/22/2016] [Accepted: 10/26/2016] [Indexed: 11/21/2022] Open
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Likhterov I, Urken M. Mount Sinai Medical Center and Their Experience with Unfavorable Microsurgical Head and Neck Reconstruction. Clin Plast Surg 2016; 43:631-8. [PMID: 27601388 DOI: 10.1016/j.cps.2016.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Radiation effects on tissues greatly complicate reconstruction of head and neck defects. We discuss the unfavorable surgical conditions set up by prior surgery and radiation in patients undergoing salvage ablation of recurrent cancer. With the focus on vessel selection, flap donor site characteristics, and management of potential complications, we hope to highlight some of the lessons learned from these complex cases. Special attention is given to the topic of laryngopharyngeal reconstruction.
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Affiliation(s)
- Ilya Likhterov
- Head and Neck Oncologic and Reconstructive Surgery, Department of Otolaryngology, Mount Sinai Beth Israel, 10 Union Square East, Suite 5B, New York, NY 10003, USA.
| | - Mark Urken
- Division of Head and Neck Surgical Oncology, Department of Otolaryngology, Mount Sinai Beth Israel, 10 Union Square East, Suite 5B, New York, NY 10003, USA
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Scapular Tip Free Flap for Head and Neck Reconstruction. Clin Exp Otorhinolaryngol 2015; 8:422-9. [PMID: 26622965 PMCID: PMC4661262 DOI: 10.3342/ceo.2015.8.4.422] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/09/2015] [Accepted: 02/19/2015] [Indexed: 11/10/2022] Open
Abstract
Objectives Head and neck reconstruction is still challenging in terms of esthetic and functional outcomes. This study investigated the feasibility of the angular branch-based scapular tip free flap (STFF). Methods This was a retrospective study of 17 patients undergoing maxillectomy and mandibulectomy and either primary or secondary reconstruction by STFF. This study included surgical, esthetic, and functional outcomes, and detailed data are presented regarding the flap, such as pedicle length, size of the harvested bone, and failure rate. Medical photographs were used to estimate the esthetic outcome, and computed tomography was used to check the flap status postoperatively. Results The data were collected from April 2013 to April 2014. Eight patients underwent maxillary reconstruction, and nine underwent mandibular reconstruction. Maxillary defects usually included unilateral alveolar structures and the palate; mandibular defects were usually those involving mandibular angle and short segment. Vein grafting was not required in any of the patients. Flap failure occurred in one of the 17 patients (5.9%) with successful reconstruction after revision. Of the eight maxillectomy patients, orbital revisions for diplopia after maxillary reconstruction were performed in two patients (25%), and oroantral fistula repair was performed in one patient (12.5%). Conclusion This study demonstrated the reconstructive advantages of the angular branch-based STFF, long pedicle, low flap failure, 3-dimensional nature of bone and soft tissues (chimeric flap), and small rate of donor site morbidity with free ambulation. This flap is an excellent option for use in complex three-dimensional head and neck reconstruction.
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Colletti G, Tewfik K, Bardazzi A, Allevi F, Chiapasco M, Mandalà M, Rabbiosi D. Regional Flaps in Head and Neck Reconstruction: A Reappraisal. J Oral Maxillofac Surg 2015; 73:571.e1-571.e10. [DOI: 10.1016/j.joms.2014.10.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 10/07/2014] [Accepted: 10/21/2014] [Indexed: 10/24/2022]
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