Intraoral anastomosis in maxillary microvascular reconstruction after oncological excision

Intraoral Microvascular Anastomosis in Immediate Free Flap Reconstruction for Midfacial Tumor Defects: A Retrospective Multicenter Study

(1) Background: The current landscape of midface reconstruction is marked by ongoing evolution, with notable advancements in surgical techniques, microvascular procedures, and the implementation of multidisciplinary approaches, all of which have significantly enhanced both functional and aesthetic outcomes. Conventionally, microvascular anastomoses for free flaps in midfacial reconstruction have been executed using cervical vessels. However, this approach necessitates neck access, resulting in extraoral scars and a substantial pedicle length. In light of these considerations, using intraoral anastomoses via the facial vessels emerges as a promising alternative. This retrospective multicentric study aims to provide a comprehensive account of immediate midface reconstruction through intraoral anastomoses. (2) Methods: Between 2020 and 2023, patients were included who underwent intraoral resection of midface/orbit segments (Brown Classes I-VI) as a result of malignant diseases. In all cases, immediate reconstruction was accomplished by utilizing the facial vessels through an intraoral approach. Outcome criteria were identification of vessels, parotid duct or facial nerve damage, success of vascular anastomoses, and flap survival. (3) Results: A total of 117 patients with 132 flaps (91 osseous and 41 cutaneous) were included. The intraoral preparation of facial vessels was successfully completed in less than 1 h, and no complications related to the dissection or anastomoses were observed. In two cases, the vessel diameter was insufficient to facilitate anastomoses, necessitating adopting an extraoral approach. During a follow-up period of 48 months, two osseous flaps were lost, accounting for a 1.5% loss rate out of 132 flaps used. Additionally, 3 flaps experienced partial loss, including a skin island of a scapula, the border zone of a femur, and a rectus flap, resulting in a 2.3% partial loss rate out of 130 flaps utilized. (4) Conclusions: This case series underscores the feasibility of employing intraoral anastomoses for immediate complex midface reconstruction following oncological resection. This approach is particularly advantageous for flaps with shorter pedicles, as it helps mitigate external scarring and minimizes the risk of facial nerve injury.

Intraoral anastomosis for primary microsurgical reconstruction in patients of oral cavity malignancies: Retrospective analysis of 30 cases from a tertiary care center in India

INTRODUCTION

In patients undergoing either robotic neck dissection or no neck dissection, the neck recipient vessels for the free flaps remain unexposed. Intraoral vessels have been successfully used as microvascular recipients but their use in intraoral malignancies is uncommon. We describe our initial experience of using intraoral recipients in 30 patients with oral cavity malignancies.

METHODS

For this retrospective observational study, the hospital records of all patients who underwent microvascular reconstruction using intraoral recipient vessels over a 14-month period at a tertiary care hospital in India were studied. Patient demographics, disease profile, details of oncosurgical resection, reconstructive procedure details, and postoperative recovery data were analyzed.

RESULTS

Intraoral anastomosis was successfully performed in 30 patients. The average patient was middle-aged (mean age 54 years) and male (26/30). Location of the postexcision defect was the buccal mucosa in 16/30 and the tongue in 12/30 patients. Anterolateral thigh flap (ALT) was used in 28/30 patients. Recipient vessels were facial vessels in 24/30 patients and lingual vessels in 6/30 patients. Venous anastomotic coupler was used in 27/30 patients. Three patients underwent re-exploration for flap congestion with loss of flap in 2/30 patients.

CONCLUSION

The intraoral approach offers consistent vascular anatomy and can be performed without any external incision and oro-cervical tunneling. Being technically challenging, it has an initial learning phase. Adequate mouth opening and preservation of recipient vessels during excision and neck dissection are important prerequisites. This approach can offer a scarless reconstruction, which can improve the psycho-social rehabilitation of the patients.

Analysis of intraoral microvascular anastomosis in maxillofacial defects reconstruction

This review summarizes the research progress in the field of intraoral microvascular anastomosis techniques (IAT) and attempts to investigate the indications for procedures in which IAT can be applied, the surgical procedure and the difficulties involved, technical assessments, result evaluation and the perspective. Currently, microvascular anastomosis technique is widely used in maxillofacial defects reconstruction from various causes including cutaneous injury or congenital deformity which usually required extensive flap reconstruction and therefore a vascular free flap is routinely used. Conventional microvascular anastomosis reconstruction techniques cannot avoid new incisions, which will affect the postoperative aesthetic situation. Surgeons have therefore attempted to improve this technique to effectively eliminate scars caused by surgery: some patients can be chosen to undergo microvascular anastomosis of the free flap intraorally, thus reducing the extraoral incision caused by the anastomosis located in neck or maxillofacial improving the postoperative appearance of the patients. In addition to preserving the external appearance, intraoral anastomosis technique (IAT) can also solve some other problems of maxillofacial vascular anastomosis, such as insufficient vessel pedicle length and high risk of facial nerve injury.

A Buccal Space Approach for Midface Free Flap Reconstruction

This article describes a transbuccal approach to reach the facial vessels. The anatomy of this intraoral approach is predictable, minimizing the risk of facial nerve dysfunction. This technique provides the possibility of free flap midface reconstruction with short pedicles and avoids the need to use vein grafts. Moreover, it is esthetically preferable. Through cadaver dissection and anatomical drawings, we describe extensively the different surgical steps. Using the combination of the previous knowledge and recent anatomical understandings, we can provide a reliable step-by-step approach to find the facial artery and vein through a transbuccal approach for microvascular midface free flap repair.