Supine positioning for the subscapular system of flaps: A pictorial essay

Scapula harvest in the supine position for immediate mandibular reconstruction

PURPOSE

The scapula is the second most popular donor site for mandibular reconstruction after the fibula. Scapula harvest is generally performed in the lateral decubitus position and the requirement of positional changes hamper the widespread use of the scapula. This study compared scapula harvest for immediate mandibular reconstruction between the supine and lateral decubitus positions.

METHODS

We reviewed the outcomes of 16 patients who underwent segmental mandibulectomy and immediate reconstruction of the scapula based on the angular branch of the thoracodorsal artery. The scapula was harvested in the lateral decubitus (lateral decubitus group) or supine position (supine group) in eight patients each. Several perioperative parameters were compared between the two groups.

RESULTS

One scapula was lost because of inadvertent injury of the angular branch in the supine group. The operative time was significantly shorter in the supine group than in the lateral decubitus group.

CONCLUSION

Harvesting of the scapula in the supine position is a feasible option for immediate mandibular reconstruction. Although deep anatomic knowledge and technical expertise are necessary, this strategy can eliminate positional change and significantly reduce the operative time.

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.

A Multi-institutional Analysis of Late Complications in Scapula, Fibula, and Osteocutaneous Radial Forearm Free Flaps

OBJECTIVES

(1) Evaluate the association of flap type with late complications in patients undergoing osseous head and neck reconstruction with the fibula free flap (FFF), osteocutaneous radial forearm free flap (OCRFFF), and scapula free flap (SFF). (2) Compare the prevalence of late complications based on minimum duration of follow-up.

STUDY DESIGN

Retrospective cohort study.

SETTING

Multiple academic medical centers.

METHODS

Patients undergoing FFF, OCRFFF, or SFF with ≥6-month follow-up were stratified by type of flap performed. The association of flap type with late complications was analyzed via univariable and multivariable logistic regression, controlling for relevant clinical risk factors. Additionally, the frequency of late complications by minimum duration of follow-up was assessed.

RESULTS

A total of 617 patients were analyzed: 312 (50.6%) FFF, 230 (37.3%) OCRFFFF, and 75 (12.2%) SFF. As compared with the SFF, the FFF (adjusted odds ratio [aOR], 3.05; 95% CI, 1.61-5.80) and OCRFFF (aOR, 2.17; 95% CI, 1.12-4.22) were independently associated with greater odds of overall late recipient site wound complications. The SFF was independently associated with the lowest odds of hardware exposure when compared with the FFF (aOR, 2.61; 95% CI, 1.27-5.41) and OCRFFF (aOR, 2.38; 95% CI, 1.11-5.12). The frequency of late complications rose as minimum duration of follow-up increased until plateauing at 36 months.

CONCLUSIONS

This multi-institutional study suggests that the long-term complication profile of the SFF and OCRFFF compares favorably to the FFF. The SFF may be associated with the fewest overall late recipient site complications and hardware exposure, while the FFF may be associated with the most of these 3 options.

Advantages of the scapular system in mandibular reconstruction

BACKGROUND

Fibula free flaps (FFF) are often considered the first choice for mandibular reconstruction, but scapular system free flaps (SFF) have increased in popularity due to versatility, donor site advantages, and patient factors.

METHODS

Retrospective chart review of patients undergoing mandibulectomy with FFF or SFF reconstruction from 2016 to 2021.

RESULTS

Hundred and seventy-six patients (FFF n = 145, SFF n = 31) underwent the aforementioned procedures. Mean FFF operative time was 9.47 h versus 9.88 for SFF (p = 0.40). Two-flap reconstructions required 12.65 h versus 10.09 for SFF with soft tissue (p = 0.002). Donor site complications were identified in 65.6% of FFF with skin grafting.

CONCLUSIONS

These findings suggest that SFF requires similar operative time and results in reduced donor site morbidity as compared to FFF. Supine, concurrent harvesting of SFF allows for single-flap harvest with significantly shorter operative time. SFF could be considered a primary option for mandible reconstruction for complex defects and in select patients.

Management of Palatal Defects after Free-Flap Reconstruction and Radiotherapy

Palatal fistulas have significant effects on quality of life. Traditional prosthetic rehabilitation and surgical reconstruction of palate defects in radiation-naïve tissues are well described. However, palatal fistulas developing after initial tumor extirpation, free-flap reconstruction, and adjuvant radiation or chemoradiation are associated with challenging secondary tissue effects. In this review, we will discuss the management of palatal fistulas after surgical reconstruction and radiotherapy.

Variations of the thoracodorsal axis: application for scapular tip free flap harvesting

PURPOSE

To illustrate variations of the vascular anatomy of the subscapular system highlighting practical implications on surgical access, patient positioning, and strategies to maximize the exposure of vascular pedicle.

METHODS

A retrospective review of patients undergoing reconstruction with a scapular tip free flap over a 2-year period at a tertiary referral center.

RESULTS

Forty patients were included. In 25 (62.5%) cases, the thoracodorsal artery (TD) ended bifurcating into latissimus dorsi (LD) and angular branch (AB), with the serratus artery branch arising from the LD pedicle; this vascular pattern was defined as "LD-dominant." In 10 (25%) cases, the TD bifurcated into LD and AB, with the serratus artery branch arising from the latter vessel, defined as "AB-dominant." Lastly, there was a trifurcation pattern in 5 (12.5%) patients. There was considerable variability in the distal branching pattern. Twenty-two (55%) patients had 2 LD branches; in 11 (27.5%) cases, there was only 1 LD branch, and 7 (17.5%) cases had 3. Thirty-seven patients (92.5%) had 1 AB; in the remaining three cases (7.5%), there were 2. The entry point of AB was located 4.86 cm (mean) ± 0.75 cm from the fibrous tip. The arm positioning and scapular retraction were the key maneuvers to facilitate pedicle exposure and dissection, with the shoulder abducted and scapula retracted away from the body.

CONCLUSION

The subscapular vascular anatomy is highly variable. Knowledge of anatomic variability alongside surgical pearls to harvest STFF could facilitate the introduction of this flap into the toolkit of head and neck reconstructive teams.

Synchrony in head and neck surgery: Feasibility and outcomes of simultaneous scapular free flap reconstruction

BACKGROUND

The scapula free flap is a versatile option in head and neck reconstruction but is less amenable to simultaneous harvest and ablation.

METHODS

Retrospective series (2015-2021) of consecutive scapula flaps. Cases categorized as simultaneous versus sequential, compared for operative time, oncological and patient-reported outcomes.

RESULTS

Seventy consecutive scapula free flaps were performed (n = 21 simultaneous, n = 49 sequential). Mandible reconstruction was performed in 51.0% and 61.9% of sequential and simultaneous cases, respectively; 49.0% and 38.1% addressed bony maxillary defects. Simultaneous surgery reduced operative time by 37.9% (151 min, p < 0.00001) and there were fewer tracheostomies performed (p < 0.005). Rates of positive margins and free flap compromise were equivalent (n = 1, 4.8% vs. n = 2, 4.1%). There was no difference in patient-reported outcomes.

CONCLUSIONS

This series demonstrates feasibility, efficacy, and outcomes of bony scapula reconstruction of maxillofacial defects comparing simultaneous and sequential approaches. Benefits of the two-team approach are highlighted including decreased operative time.

Lateral border and scapular tip free flaps: Old school versus new school

Free tissue transfer from the subscapular system provides a wide array of options for both soft tissue and bony reconstruction. When bone stock is required for head and neck reconstruction, both the lateral scapular border free flap (LSBFF), supplied by the circumflex scapular artery, and the scapular tip free flap (STFF), supplied by the angular artery, are excellent options. Issues with positioning had previously prevented the widespread use of these bony subscapular system flaps. However, through the use of a Spider Limb Positioner, current clinical practice patterns allow for two team approaches in both of these free flaps. The following pictorial essay compares and contrasts the specific positioning and harvesting technique used for both the LSBFF and STFF, while discussing the clinical advantages and drawbacks of each. Both the lateral border scapula and scapular tip free flaps provide excellent bone stock for head and neck reconstruction. By positioning with currently available technology, both of these free flaps can be harvested through a two team approach.

Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty

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.

Risk factors for surgical site infection after major oral oncological surgery: the experience of a tertiary referral hospital in China

Objective

To identify risk factors associated with surgical site infection (SSI) after major oral oncological surgery.

Methods

This retrospective study reviewed data from patients that underwent major surgery for oral cancer at a tertiary referral hospital in China between January 2005 and July 2016. SSI was diagnosed within 30 days. Demographic, cancer-related, preoperative, perioperative and postoperative data were analysed using descriptive statistics and univariate and multivariate analyses of the risk factors for SSI.

Results

A total of 786 patients were enrolled, of whom 125 had SSI (15.9%), which were all incisional. Independent risk factors for SSI, identified by multivariate analysis, were diabetes mellitus (odds ratio [OR] 2.147, 95% confidence interval [CI] 1.240, 3.642), prior radiotherapy (OR 4.595, 95% CI 1.293, 17.317) and oral–neck communication (OR 2.838, 95% CI 1.263, 7.604); and factors reflecting large extent resections were tracheostomy (OR 2.235, 95% CI 1.435, 3.525), anterolateral thigh flap (OR 1.971, 95% CI 1.103, 3.448) and latissimus dorsi flap (OR 4.178, 95% CI 1.325, 13.189).

Conclusions

Multiple risk factors were associated with SSI after major oral oncological surgery. To minimize SSI risk, surgeons managing oral cancer patients should have a better understanding of the risk factors, including diabetes mellitus, prior radiotherapy, tracheostomy, oral–neck communication and flap reconstruction.

Maxillectomy defects: Virtually comparing fibular and scapular free flap reconstructions

BACKGROUND

This study virtually compares patient-specific fibular and scapular reconstructions for maxillectomies.

METHODS

Nine maxillectomy defects were created on 10 maxillas and virtually reconstructed with patient-specific fibulas and scapulas. Reconstructions were compared for restoring midface cephalometrics, dental implantability, and pedicle length.

RESULTS

Of 90 maxillectomy defects, the vertically oriented scapula provided improved orbital floor and maxillary height reconstructions (p < 0.001), albeit at the cost of dental implantability compared to the fibula (p < 0.001). In two defects crossing the midline, the fibula, allowing for more osteotomies, provided improved maxillary projection. In the remaining three defects crossing the midline, the horizontally oriented scapula was comparable to the fibula. Fibular and scapular reconstructions were amenable for dental implantation and had similar pedicle lengths, although favoring scapula in extensive defects.

CONCLUSION

Fibular and scapular reconstructions of maxillectomy defects provide unique strengths. This virtual analysis can guide a goal-oriented reconstruction based on defect type and patient-specific goals.

Revisiting pedicled latissimus dorsi flaps in head and neck reconstruction: contrasting shoulder morbidities across mysofascial flaps

Free tissue transfer has become the gold standard for reconstruction within the head and neck. However, there are still many instances where pedicled locoregional flaps are the optimal reconstructive option. When myofascial tissue is needed, several options have been described throughout the literature. Various trapezius flaps have been used, although these have variable vascular anatomy and significant donor site morbidity. The pectoralis major myofascial flap has become a mainstay in head and neck reconstruction for its ease of harvest and reliability but suffers from similar issues with donor site morbidity. The pedicled latissimus dorsi flap (PLDF) is another reliable option that has been used for multiple different ablative sites within the head and neck. The thin, pliable structure of the latissimus dorsi makes it a viable option for many defects, and recent reports also support its feasibility for use in an interdisciplinary two-team approach. Furthermore, the donor site morbidity of the PLDF is minimal compared to other similar myofascial options. In this article, we describe the surgical considerations and operative techniques for PLDF transfer along with a review of its associated donor site morbidity.

Custom Presurgical Planning for Midfacial Reconstruction

Resection and reconstruction of midface involve complex ablative and reconstructive tools in head and oncology and maxillofacial prosthodontics. This region is extraordinarily important for long-term aesthetic and functional performance. From a reconstructive standpoint, this region has always been known to present challenges to a reconstructive surgeon due to the complex three-dimensional anatomy, the variable defects created, combination of the medical and dental functionalities, and the distance from reliable donor vessels for free tissue transfer. Another challenge one faces is the unique features of each individual resection defect as well as individual patient factors making each preoperative planning session and reconstruction unique. Understanding the long-term effects on speech, swallowing, and vision, one should routinely utilize a multidisciplinary approach to resection and reconstruction, including head and neck reconstructive surgeons, prosthodontists, speech language pathologists, oculoplastic surgeons, dentists, and/or craniofacial teams as indicated and with each practice pattern. With this in mind, we present our planning and reconstructive algorithm in midface reconstruction, including a dedicated focus on dental rehabilitation via custom presurgical planning.

Application of the Spider Limb Positioner to Subscapular System Free Flaps

OBJECTIVE

To demonstrate the application and surgical time savings of the Spider Limb Positioner for subscapular system free flaps in head and neck reconstructive surgery.

METHODS

Single institution retrospective chart review and analysis of patients between 2011 and 2019 that underwent a subscapular system free flap either with or without use of the Spider Limb Positioner. One hundred five patients in total were reviewed with 53 patients in the Spider group. The surgical times were compared between the two groups. Patient-specific information regarding average age, laterality of donor site, recipient site, gender, and flap type were reviewed.

RESULTS

Forty-one patients in both groups underwent a latissimus free flap. Twelve of 53 in the Spider group and 11/52 in the control group underwent a scapula free flap. The average age in the Spider group at the time of surgery was 64 years. The recipient sites for the Spider groups were reviewed. The free flap was ipsilateral to the defect in 81% of cases. The mean surgical time for the 105 patients without the Spider was 568 minutes versus 486 minutes with a Spider P-value of .003478.

CONCLUSION

Use of the Spider Limb Positioner allows for a simultaneous two-team approach during free flap elevation of the subscapular system, which eliminates both dependence on an assistant to support the arm and time consuming positioning changes during flap elevation.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:525-528, 2021.