Palatal fistulas complicating osseomyocutaneous reconstruction of oncological maxillectomy defects

Modern Oncologic Maxillary Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Have a broad understanding of the oncological principles relating to cancers involving the maxilla. (2) Define anatomically the various types of maxillectomy defects and their associated morbidity. (3) Understand the goals and principles of maxillary reconstruction. (4) Demonstrate an understanding of the strengths, limitations, and alternative reconstructive options for the various types of maxillectomy defects.

SUMMARY

Reconstruction of the maxilla following cancer resection has evolved over the past decade. Underpinned by advances in virtual surgery technology and an increased focus on dental rehabilitation, more sophisticated workflows using free bone flaps have become more commonplace. There are few reconstructions anywhere in the body that require the restoration of similarly intricate bone and soft-tissue relations with implications for both form and function, like the maxilla. Success demands careful anatomical definition of the defect, an understanding of the goals and principles of reconstruction, and the understanding of relative strengths and limitations of the various reconstructive options. Equally, as no one technique is without shortcomings and maxillary surgery can be associated with a significant complication profile, it is just as important to match the patient and oncologic context to the reconstruction. This article is intended to provide the reader with a broad overview of these core factors.

Application of double layer with collagen-elastin matrix (Matriderm®) and polyglycolic acid sheet (Neoveil®) for oroantral and oronasal fistula closure after maxillectomy: a retrospective single center experience

PURPOSE

This study investigates the effectiveness of a new double-layer approach for closing oroantral and oronasal fistulas (OA/ONFs) using Matriderm® and Neoveil®. Matriderm®, an acellular dermal matrix composed of collagen and elastin fibers, supports tissue regeneration, while Neoveil®, a biodegradable mesh sheet, serves as a barrier to prevent leakage and scarring.

MATERIAL AND METHODS

A retrospective study of 12 maxillectomy patients with oral cancer between January 2022 and May 2023 was conducted. Patient data, including tumor stage, bone invasion, and defect size, were analyzed. Surgical techniques included sinus mucosa preservation, and either buccal fat grafting combined with the double layer technique or the double layer technique alone, with statistical analysis performed using R software to evaluate outcomes.

RESULTS

The results indicate a 41.7% incidence rate of fistula formation with lower T stages, absence of bone invasion, smaller defect dimensions, and intact sinus mucosa correlating with reduced fistula risk (p < 0.05). Notably, no patients required fistula-related surgical revisions, validating the efficacy of the approach.

CONCLUSION

This study introduced a novel double-layer technique using Matriderm® and Neoveil® for closing OA/ONFs after maxillectomy. The technique demonstrated promising outcomes in addressing these post-operative complications. Lower tumor stages, no bone invasion, smaller defects, and intact sinus mucosa correlated with reduced fistula risk. This technique holds potential to enhance maxillectomy outcomes, offering a comprehensive approach to functional concerns, but warrants further investigation.

Effect of preoperative radiation on free flap outcomes for head and neck reconstruction: An updated systematic review and meta-analysis

BACKGROUND

There is an ongoing debate about whether neoadjuvant radiation therapy is associated with higher rates of postoperative complications after head and neck reconstruction. Herle et al. conducted a systematic review in 2014 of 24 studies, finding higher complication rates in irradiated fields. We sought to perform an exhaustive updated systematic review and meta-analysis.

METHODS

We conducted an updated systematic review of the literature, as outlined in our protocol, which was registered on PROSPERO. Databases included Medline, Embase, Cochrane Central, and Web of Science. There were no limits placed on the date range, place of publication, or origin. Exclusion criteria included patients less than 18 years of age, studies with less than 20 participants (n < 20), case studies, skull base reconstructions, and local tissue rearrangements. The combined results of the studies and relative risks (RR) were calculated.

RESULTS

53 studies were included for analysis, including 5,086 free flaps in an irradiated field, and 9,110 free flaps in a non-irradiated field. Of the 53 studies, 21 studies overlapped with those discussed in Herle et al.'s study, with a total of 32 additional studies. Neoadjuvant radiation was found to be a statistically significant risk factor for postoperative complications (RR 1.579, P < 0.001), total flap failure (RR, 1.565; P < 0.001), and fistula (RR, 1.810; P < 0.001). Our work reaffirmed the findings of the Herle et al.

STUDY

CONCLUSION

Preoperative radiation was associated with a statistically significant increase in the risk of total flap failure, fistula, and total complications but not partial flap failure. These high-morbidity complications must be taken into consideration when determining which patients should receive neoadjuvant radiation therapy.

The Effect of Smoking on the Postoperative Course After Head and Neck Reconstruction With a Vascularized Free Flap: A Retrospective Study

OBJECTIVES

The objective of the present study is to determine the impact of smoking on hospital and intensive care unit stay, need for surgical reintervention, Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity, and surgical complications after head and neck reconstructions.

METHODS

All 153 patients who underwent head and neck reconstructions with free tissue transfer at the department of oral and maxillofacial surgery at the University Hospitals of Leuven between January 1, 2015 and December 31, 2018 were enrolled in this retrospective cohort study. Data from medical charts were extracted. Univariate and multiple regression analyses were performed. A level of significance of P < 0.05 (α = 0.05) was used.

RESULTS

Smoking was not associated with Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity, hospital or ICU stay, the incidence of postoperative complications in both flap and donor site, or surgical reintervention.

CONCLUSIONS

Regarding the outcomes included in this study, smoking status should not be considered as a critical factor in patient selection for head and neck reconstructions with a vascularized free flap.