Microsurgical reconstruction of the isolated columellar defect with a prelaminated radial forearm free flap. A case report and a review of the literature

Reconstruction of the columella with interposition of nasogenian flaps: A case report

INTRODUCTION

Reconstructing large defects of the columella and upper lip is an interesting challenge in facial reconstruction due to the high visibility of this aesthetic subunit and the difficulties posed by the unique characteristics of the skin in these areas, which differs from that of the surrounding regions. Among the various techniques proposed, the use of local flaps remains the most commonly used and effective method in this type of reconstruction.

PRESENTATION OF THE CASE

A 47-year-old man in good clinical condition presented with a nodular lesion on the columella and upper lip. The lesion was excised (revealing it to be a squamous cell carcinoma) and reconstructed using two opposing nasogenian flaps, resulting in an optimal aesthetic and functional restoration.

DISCUSSION

The use of local flaps remains the most effective technique for columella defect reconstruction. However, many described techniques require multiple surgical stages or result in visible scarring. Additionally, they do not guarantee effective reconstruction in cases involving the upper lip. On the other hand, the use of free flaps, while more expensive and requiring expert teams, may not ensure optimal color and skin texture matching.

CONCLUSIONS

The use of opposing nasogenian flaps allows for a rapid and effective reconstruction of defects involving the columella and upper lip, leading to a swift return to normal life for the patient.

Microsurgical Reconstruction of the Columella

BACKGROUND

Traditionally, the columella can be difficult to reconstruct because of its unique contours, paucity of adjacent soft tissues, and tenuous vascularity. When local or regional tissues are unavailable, microsurgical transfer can provide a means for reconstruction. In this retrospective review, the authors report their experience with microsurgical reconstruction of the columella.

METHODS

Seventeen patients were enrolled in this study and divided into two groups: group 1, isolated columella defects; and group 2, defects of the columella and portions of adjacent soft tissues.

RESULTS

There were 10 patients in group 1. Their average age was 41.2 years. Average follow-up was 10.1 years. Causes of the columellar defects included trauma, complication of nasal reconstruction, and complication of rhinoplasty. The first dorsal metacarpal artery flap was used in seven cases, and the radial forearm flap was used in five. Two flap losses were salvaged with a second free flap. The average number of surgical revisions was 1.5. In group 2, there were seven patients with an average follow-up of 10.1 years. Causes of the columella defects included cocaine injury, carcinoma, and complication of rhinoplasty. The average number of surgical revisions was 3.3. The radial forearm flap was used in all cases. There were no flap losses. All 17 cases in this series were brought to a successful conclusion.

CONCLUSIONS

The authors' experience shows that microsurgical reconstruction of the columella provides a reliable and aesthetic means for reconstruction. This technique avoids the facial disfigurement and visible scarring that often accompany use of local flaps. In addition, microsurgical flaps can be preformed "off site," which may provide certain advantages in selected cases.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Survival of Dental Implants Placed in Iliac, Fibula, and Radial Forearm Flaps: A Comprehensive Review

Various donor sites have been extensively documented in the literature for bone free flaps in head and neck reconstruction. These include the radius, scapula, rib, ilium, femur, fibula, and metatarsal bone. Among them, the fibula, ilium, and scapula are the most commonly used and studied for placing endosseous implants and for rehabilitation purposes. Each donor site has its own advantages and disadvantages, which depend on factors such as whether the reconstruction is for the maxilla or mandible, the required volume and length of the bone and soft tissue, and the location, extent, and type of defect that needs to be reconstructed. The aim of this current review is to comprehensively assess the existing literature on the survival of implants in fibula, radial, and iliac flaps.

Radial Forearm Free Flap for Head and Neck Defect Reconstruction: An Up-to-date Review of the Literature

The radial forearm free flap has emerged as the mainstay of free flaps for oral cavity soft tissue reconstructions because of its versatility and ability to be used in the reconstruction of large and medium-sized defects. This flap is commonly used to restore head and neck defects, including full-thickness lip and oral cavity defects. This flap offers the opportunity to cover severe defects of the facial region due to its long vascular pedicle and elasticity. In addition to its ease of being harvested, the radial forearm free flap provides a sensate, pliable, and thin skin paddle with a long vascular pedicle. However, it can cause severe morbidity at the donor site, mainly due to exposure of the flexor tendon that results from a failed harvesting of the skin graft, changed sensation in the radial nerve, aesthetic deformity, and reduced range of motion and grip strength. This article aims to review all the up-to-date studies discussing the use of radial forearm free flap in head and neck reconstruction.

Prelamination of the Radial Forearm Free Flap Using Free Full-Thickness Eyelid Skin Grafts: A New Approach for Intraoral Defect Reconstruction

ABSTRACT

Free flap transfer for reconstruction of intraoral defects is a common procedure in oral and maxillofacial surgery. For tumor-related defects, the radial forearm flap is widely used for soft tissue restoration. However, transfer of free skin grafts to the donor site region is often required for wound closure after free flap harvesting, resulting in esthetic disturbances due to shrinkage of the grafted skin, attendant scarring, or mismatches in skin texture or color. Furthermore, free flap transfer may result in hair follicle transfer into the oral cavity, causing unfavorable intraoral hair growth in adult men in particular. Free flap prelamination can help reduce the potential disadvantages of free flaps, in terms of both flap design and size and donor site morbidity. For surgical treatment of oral cancer in middle-aged and elderly patients, eyelid dermatochalasis may present as a comorbidity leading to esthetic impairments or, in cases involving the upper eyelid, even a reduced field of view. In these cases, bilateral blepharoplasty can reduce the excess eyelid skin. The present study is the first to attempt to use excised skin after bilateral blepharoplasty as full-thickness skin grafts for radial forearm free flap prelamination. This approach combined surgical therapy of eyelid dermatochalasis with free flap prelamination, thereby avoiding the need to harvest free skin grafts from other anatomically healthy regions to close the donor site defect and preventing the accompanying disadvantages. The reconstruction results and clinical outcomes of patients revealed that radial forearm free flap prelamination using bilateral free full-thickness eyelid skin grafts was an easy and feasible method for intraoral defect reconstruction. In particular, this approach could avoid intraoral hair growth and additional skin grafting from other healthy anatomical regions, yielding good esthetic and functional results at the flap's recipient and donor sites.

Microsurgical Techniques and Postoperative Outcomes After Total and Subtotal Nasal Reconstruction: A Systematic Review

BACKGROUND

Multiple microsurgical techniques for nasal reconstruction have been described in the literature. Given the gaps in the literature regarding evidence-based reviews for total and subtotal nasal reconstruction using microsurgical techniques, the purpose of this study was to provide a thorough presentation of the most popular microvascular techniques and their outcomes (functional and aesthetic) for total or subtotal nasal defects.

METHODS

A systematic search was performed using PubMed, Google Scholar, and Cochrane Library on free flap techniques for restoration of nasectomy defects. The keywords were "nasal reconstruction," "nose," "nasectomy," "rhinectomy," and "microvascular." Inclusion criteria for analysis in the study were the largest clinical case series published in English within the past 15 years with more than 8 patients.Studies were analyzed for patient demographics, etiology of nasal loss, surgical approaches to reconstruction, outcomes, and complications. The current study was registered at the International Prospective Register of Systematic Reviews and conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

The initial search yielded 302 results. Eleven articles with a total of 232 patients met the inclusion criteria. The radial (n = 85) and ulnar forearm flaps (n = 20), auricular helical rim (n = 87), and anterolateral thigh flap (n = 30) were the most commonly reported free flaps in nasal reconstruction. The main etiologic factors were malignancy and trauma. The most common complication was partial flap necrosis.

CONCLUSIONS

The auricular helical and radial forearm flaps represent the most used free flaps for total and/or subtotal nasal defects with satisfactory patient outcomes.

Prelaminated flaps in head and neck cancer reconstructive surgery: A systematic review

Background

Prelamination is a reconstructive technique providing fasciomucosal or composite flaps with low donor‐site morbidity. We conducted a systematic review of retrospective studies to assess the application of prelaminated flaps in reconstructive surgery of head and neck cancer patients, and to evaluate the advantages and disadvantages of this technique.

Methods

This systematic review adhered to the recommendations of the PRISMA (Preferred Reporting Items of Systematic Reviews and Meta‐analysis) 2009 guidelines. A computerized MEDLINE search was performed using the PubMed service of the U.S. National Library of Medicine (www.pubmed.org) and Scopus database (www.scopus.com), running the following search string: “prelamination OR prelaminated AND flap.” Two authors screened the articles, then selected and extracted data on malignancies characteristics, reconstructive techniques, outcomes and complications.

Results

A total of 19 articles were selected and reviewed from 128 identified. Seven of 19 articles were case reports, 12 articles were case series. One‐hundred‐two patients underwent reconstructive treatment by prelamination technique using a wide variety of flaps (92 free, 10 pedicled). The sites of reconstruction were oral cavity (66 floor of the mouth, 3 retromolar trigone, 6 hard palate, 4 cheek, 4 tongue), 8 facial skin (5 of them sited on the nose), 4 oropharyngeal defects, 1 laryngotracheal region. No case of total flap loss was reported. Partial flap loss or shrinkage requiring minor surgical revisions was observed in 18 patients (17.6%). Primary closure of the donor site was achieved in 97 cases (97%) and 3 (3%) required revision surgery of the donor site.

Conclusion

Prelamination is an effective and versatile technique, with low donor‐site morbidity. Further studies would be needed to investigate the impact on the patient's oncologic outcome. More comparative studies with standard reconstructive techniques are essential to understand when it is worth performing this sophisticated procedure.