Epithetic nasal reconstruction for nasal carcinoma: retrospective analysis on 22 patients

Management of nasal vestibule carcinomas: recommendations by the Oncological Committee of the Italian Society of Otorhinolaryngology - Head and Neck Surgery

Objective

Squamous cell carcinoma of the nasal vestibule (NV SCC) is a head and neck malignancy for which there is no established consensus on most aspects of clinical management. The purpose of this document is to give updated recommendations that incorporate recent evidence on its clinical characteristics and the high efficacy of brachytherapy as primary treatment modality.

Methods

A working group consisting of the members of the Scientific Committee for Oncology and Reconstructive Surgery of the Italian Society of Otorhinolaryngology Head and Neck Surgery and radiation oncologists expert in brachytherapy was formed to achieve a consensus.

Results

Consensus was reached on a set of recommendations, proposing a refined anatomical definition of the nasal vestibule, a novel T staging system of the NV SCC, and brachytherapy as standard of care, with a new method for catheter implantation.

Conclusions

The Committee emphasises the critical role of an accurate classification in clinical practice and encourages further research to validate the novel staging system and further improve treatment strategies. Where appropriate, it is recommended that patients be referred to centres with specific experience in brachytherapy for NV SCC.

Reconstructive Options after Oncological Rhinectomy: State of the Art

BACKGROUND

The nose is a central component of the face, and it is fundamental to an individual's recognition and attractiveness. The aim of this study is to present a review of the last twenty years literature on reconstructive techniques after oncological rhinectomy.

METHODS

Literature searches were conducted in the databases PubMed, Scopus, Medline and Google Scholar. "Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA)" for scoping review was followed.

RESULTS

Seventeen articles regarding total rhinectomy reconstruction were finally identified in the English literature, with a total of 447 cases. The prostheses were the reconstructive choice in 213 (47.7%) patients, followed by local flaps in 172 (38.5%) and free flaps in 62 (13.8%). The forehead flap (FF) and the radial forearm free flap (RFFF) are the most frequently used flaps.

CONCLUSIONS

This study shows that both prosthetic and surgical reconstruction are very suitable solutions in terms of surgical and aesthetic outcomes for the patient.

A Contemporary Review of the Role of Facial Prostheses in Complex Facial Reconstruction

BACKGROUND

Maxillofacial prostheses provide effective rehabilitation of complex facial defects as alternatives to surgical reconstruction. Although facial prostheses provide aesthetically pleasing reconstructions, multiple barriers exist that prevent their routine clinical use. The accessibility of facial prostheses is limited by the scarce supply of maxillofacial prosthodontists, significant time commitment and number of clinic appointments required of patients during prosthesis fabrication, short lifespan of prostheses, and limited outcomes data.

METHODS

A literature review was completed using PubMed and Embase databases, with search phrases including face and maxillofacial prostheses. Patient cases are included to illustrate the use of facial prostheses to reconstruct complex facial defects.

RESULTS

The clinical use of facial prostheses requires a multidisciplinary team including a reconstructive surgeon, a maxillofacial prosthodontist, and an anaplastologist, if available, to provide patients with aesthetically appropriate facial prostheses. Developing technology including computer-aided design and three-dimensional printing may improve the availability of facial prostheses by eliminating multiple steps during prosthesis fabrication, ultimately decreasing the time required to fabricate a prosthesis. In addition, enhanced materials may improve prosthesis durability. Long-term outcomes data using validated measures is needed to support the continued use of facial prostheses.

CONCLUSIONS

Facial prostheses can be used to reconstruct complex facial defects, and bone-anchored prostheses are associated with high patient satisfaction. Multiple barriers prevent prostheses from being used for facial reconstruction. New technologies to assist the design and fabrication of prostheses, and cost reduction measures, may allow their use in the appropriately selected patient.

A Novel Computer-Aided Design/Computer-Aided Manufacturing (CAD/CAM) 3D Printing Method for Nasal Framework Reconstruction Using Microvascular Free Flaps

The need for a total or subtotal nose resection represents a dramatic situation for any patient and a challenge for the reconstructive surgeon. Because even in the most skillful hands, an optimal result may be difficult to achieve. In this way, sometimes a free flap reconstruction is needed. A subtotal nasal reconstruction is presented using a fasciocutaneous free flap supported by computer-aided design (CAD), computer-aided manufacturing (CAM), and novel 3D printed guide to recreate the nasal cartilage framework. A successfully free flap reconstruction of the nasal framework was achieved supported by the CAD/CAM 3D printed template. We present a novel approach for nasal total or subtotal reconstruction using a CAD/CAM 3D printed model to create the nasal framework, based on the anatomical and radiological evaluation of the patient.

[Optimized fitting of a midface implant to anchor a magnetic nasal prosthesis using 3D printing]

Hintergrund

Plattenbasierte Ankersysteme zur fazialen Epithesenversorgung bieten gegenüber extraoralen Einzeltitanimplantaten Vorteile hinsichtlich einer flexibleren Wahl knöcherner Verankerungspunkte und höherer Stabilität. Nachteile werden in einer aufwendigen individuellen intraoperativen Anpassung der Plattensysteme am meist schlecht zugänglichen Knochen deutlich. Wir stellen eine Methode vor, diese Nachteile zu überwinden und die Vorteile plattenbasierter Systeme stärker auszuspielen.

Methodik

Das knöcherne Mittegesicht eines Patienten mit erfolgter Rhinektomie bei Karzinom des Naseneingangs wurde anhand der präoperativen Computertomographie als virtuelles 3‑D-Modell rekonstruiert. Die verwendete Open-Source-Software (3-D-Sclicer) ermöglichte die einfache und schnelle Rekonstruktion sowie Anpassung zum Druck des 3‑D-Modells mittels transparenten Kunststoffs (MED610; stratasys Ltd., MN, USA).

Ergebnisse

Die als Epithesenanker verwendete Titan-Brückenplatte (MEDICON) konnte am 3‑D-Druck des Mittelgesichts äußerst präzise vorangepasst werden. Wichtige anatomische Strukturen wurden geschont und die Verschraubungspunkte entsprechend der gegebenen Knochendicke gewählt. Die Implantation der vorangepassten Titanplatte erfolgte komplikationslos ohne weitere intraoperative Anpassungen.

Schlussfolgerung

Die Voranpassung plattenbasierter Ankersysteme für faziale Epithesen am 3‑D-Druck des Mittelgesichts überwindet deren Nachteile einer aufwendigen ggf. unpräzisen intraoperativen individuellen Anpassung. Diese Methode spielt die Vorteile der besseren Kraftverteilung durch mehr mögliche Verschraubungen, auch in dünnerem Knochen, weiter aus und kann somit Implantatlockerungen vorbeugen. Zudem ermöglicht die Voranpassung am 3‑D-Modell die bessere Identifikation und Schonung wichtiger anatomischer Strukturen und spart Op.-Zeit ein.

A single centre's experience of 23 cases of total rhinectomy for the treatment of squamous cell carcinoma involving the nasal vestibule

PURPOSE

This study aims to analyse the oncological outcomes of total rhinectomy (TR) for squamous cell carcinomas (SCCs) involving the nasal vestibule, and to identify prognostic factors for disease recurrence.

METHODS

A retrospective single-centre study was conducted between September 2003 and February 2021 including all patients who underwent a TR for a SCC involving the nasal vestibule.

RESULTS

23 patients were included in the study. Tumours originated from the anterior septum (n = 12), vestibule (n = 8) or skin (n = 3). Six TRs (26.1%) were salvage procedures, after primary radiotherapy or partial rhinectomy. Seven patients had a concurrent neck dissection and 17 patients (73.9%) received adjuvant treatment (14 patients had radiotherapy and 3 had chemoradiotherapy). After a median follow-up of 32 months, six patients (26.1%) presented with tumour recurrence. Three patients (13%) had nodal-only recurrence. The estimated 5-year overall survival, disease-free survival and disease-specific survival were 67.5%, 66.3% and 80.7%, respectively. Positive excision margins were a predictive factor for tumour recurrence (p = 0.0401).

CONCLUSION

For SCCs involving the nasal vestibule that are not amenable to limited surgical resection, TR along with adjuvant radiotherapy provide good oncological outcomes and should be considered the main treatment option.

Topographic bone thickness maps to evaluate the intuitive placement of titanium miniplates for nasal prostheses

The aim of this study was to evaluate the intuitive placement of titanium miniplates. The hypothesis was that virtual planning can improve miniplate placement. Twenty patients were included in the study. These patients were fitted with 21 titanium miniplates (16 y-plates, three t-plates, and two u-plates) to retain nasal prostheses between 2005 and 2017. Colour-coded topographic bone thickness maps (TBTMs) were created in fused pre- and postoperative computed tomography. Implants were virtually transposed at the position of highest bone thickness. The bone thickness index (BTI) was calculated as the sum of points assigned at each screw (1 point per millimetre up to 4 mm, and 5 points for greater values) divided by the number of screws. One plate broke after 2.8 years, thus plate survival after 5 years was 91% using the Kaplan-Meier method. The BTI for all 21 plates increased from 3.4 to 4.1 points using virtual transposition (P<0.001). No significant changes were observed in t- and u-plates, but the median BTI increased from 3.1 to 4.1 points (P<0.0005) in 16 y-plates. The change was substantial (≥0.5 points) in 9/16 y-plates. Therefore, the hypothesis that virtual planning improves implant placement was accepted.

Implant prognosis in irradiated versus non-irradiated nasal, orbital and auricular sites

The purpose of this systematic review was to evaluate implant survival in irradiated nasal, auricular, orbital sites and to compare them with non-irradiated respective sites. Four electronic databases and seven related journals were searched until December and March 2018, respectively. A total of 7892 articles were identified, 18 of which were included in this review; one non-randomized clinical trial, two prospective cohort, eight retrospective cohort and seven cross-sectional studies. Using the ROBIN-I Cochrane tool for risk assessment, 13 studies were judged at serious, one at moderate and four at critical risk of bias. Thirteen were included in 18 meta-analyses, the results of which showed a significant difference between irradiated and non-irradiated sites, favouring non-irradiated with risk ratio (RR) = 0.93, 95% confidence interval (CI) 0.89-0.97, P=0.001. Comparisons among nasal, auricular and orbital sites revealed no significant differences, whether in irradiated or non-irradiated patients at P<0.05. Hence, it was concluded that, within the limitations of this review, survival of craniofacial implants is negatively affected by radiotherapy, especially in orbital sites. Level of evidence is moderate. Therefore, further prospective cohort studies with calculated sample sizes, restricted or properly managed confounders and no deviations from intended interventions might produce different results.

A Unique Method for Total Nasal Defect Reconstruction - Prefabricated Innervated Osteocutaneous Radial Forearm Free Flap

A 52-Year-old woman underwent a two-stage total nose reconstruction for complete nasal defect due to skin cancer. In the 1^st stage, innervated osteocutaneous radial forearm flap (“Neo nose”) was raised with the help of a 3D template. In the 2^nd stage, well vascularised “Neo-nose” was transferred to the face and covered with pre-expanded forehead flap.

[Nasal cavity mucosal melanoma with skin extension mimicking a malignant lentigo with mucosal extension]

Mucosal melanoma is a rare malignant disease developed from melanocyte. We report the case of a patient with nasal cavity mucosal melanoma with a primary clinical and histological diagnosis of malignant lentigo with mucosal spreading. The presence of a c-Kit mutation, in a second lecture and the evolving nature of the lesion, reorientated the diagnosis of malignant lentigo to mucosal melanoma with skin extension. Extensive surgical resection and foramen free flap with costal graft reconstruction may have a local control of the disease. Yet, after one year, a regional evolution involving a parapharyngeal node was treated by stereotaxic radiotherapy. After 5 years, the patient was considered in clinical and radiological remission. Malignant lentigo with mucosal extension is a very rare situation, this diagnoses must be evoqued after setting mucosal melanoma diagnosis.

Total nasal reconstruction with 3D custom made porous titanium prosthesis and free thoracodorsal artery perforator flap: A case report

Total nasal reconstruction is a challenging surgical procedure which usually involves a free flap, forehead flap, and cartilage grafts. In certain failure situations where patients do not accept the idea of anaplastology, possibilities become very limited. We report the case of a patient who underwent several reconstruction steps with multiple failures including free and local flaps and cartilage harvests which showed recurrent episodes of necrosis and infection leading to melting and collapse of reconstructed structures. Furthermore, the patient did not want any anaplastological rehabilitation. We proposed to the patient an innovative method that consists to print a three-dimensional custom-made porous titanium prosthesis, based on the original shape of his nose, to replace the cartilage support. This implant was first inserted in a thoracodorsal artery perforator flap for primary integration before the free transfer of the complete structure, two months later. The free transfer was successful without any complication. A stable reconstruction and satisfying result was obtained. The patient did not want additional surgical improvement 24 months post-operatively, and resumed his professional activities. The possibility of using three-dimensional custom titanium prostheses to replace the bone and cartilage support seems to be an interesting alternative for patients in the failure situation of nasal reconstruction.