Orbital floor reconstruction using a tensor fascia lata sling after total maxillectomy

Necessity of infraorbital wall reconstruction in patients with residual periosteum after total maxillectomy

BACKGROUND

To date, there have been no reports regarding the necessity or methods of reconstruction for cases where the orbital periosteum remains even though the orbital floor bone has been resected in primary reconstruction after total maxillectomy. This study investigated the reconstruction methods for infraorbital wall reconstruction in patients with residual orbital periosteum.

METHODS

This was a retrospective cohort study at a single center from June 2010 to June 2019. The following two main cohorts were evaluated: non-reconstruction and reconstruction groups (reconstructed with fascia or costal cartilage) according to whether the orbital floor was reconstructed after total maxillectomy with residual orbital periosteum. The main outcomes were the deviation of the globe evaluated using computed tomography images and subjective signs of diplopia obtained from medical records.

RESULTS

Enophthalmos occurred in all five cases in the non-reconstruction group, and diplopia appeared in four cases. In five out of six cases in the reconstruction group, deviation of the globe was not observed. Exophthalmos occurred in one case reconstructed with costal cartilage. Diplopia was not observed in the reconstruction group. In the statistical assessment, a significant difference was observed in the globe deviation between the two groups (P = 0.004).

CONCLUSIONS

In cases where the orbital periosteum remains, it is necessary to actively reconstruct the infraorbital wall. Moreover, we believe that the reconstruction with fascia is convenient and useful because it is less invasive, the surgical procedure is simple, and the fascia can be collected from the same surgical field when the flap is elevated.

LEVEL OF EVIDENCE

4 (retrospective cohort study).

Modified individualized titanium mesh in orbital floor reconstruction for preventing exposure

Objective

To describe a novel method of medial fixation of titanium mesh with a right-angled screwdriver for orbital floor and maxillary reconstruction and to compare the reconstruction outcome of orbital floor reconstruction with modified and traditional methods.

Methods

The data of 23 patients who underwent maxillectomy and orbital floor defect reconstruction by individualized titanium mesh in Peking University School and Hospital of Stomatology between 2018 and 2021 were retrospectively reviewed. While eight patients received modified orbital floor reconstruction with titanium mesh and angled screwdriver (group A), 15 patients received traditional orbital floor reconstruction (group B). The contact area with buccal flap for titanium mesh in groups A and B was calculated. Titanium mesh deformation, fracture or exposure was recorded. Postoperative ophthalmic function and success of esthetic restoration were assessed.

Results

Mean follow-up was for 15.7 months (range, 9-22 months). The contact area with buccal flap for the modified titanium mesh in group A (13.11 ± 1.41 cm2) was significantly less than that of the traditional titanium mesh in group B (21.83 ± 1.23 cm2; p < .05). The exposure of titanium mesh occurred in two patients in group B. The self-evaluation of facial symmetry for 23 patients showed no significant difference between group A (7.75 ± 0.71) and group B (6.68 ± 1.30; p > .05). No specific complications were reported.

Conclusion

We propose a novel method of zygomatic medial fixation of titanium mesh with a right-angled screwdriver for orbital floor and maxillary reconstruction, which has the potential to prevent the postoperative exposure of titanium mesh.

Level of Evidence

Level III (Retrospective comparative study).

Advances and Prospects in Materials for Craniofacial Bone Reconstruction

The craniofacial region is composed of 23 bones, which provide crucial function in keeping the normal position of brain and eyeballs, aesthetics of the craniofacial complex, facial movements, and visual function. Given the complex geometry and architecture, craniofacial bone defects not only affect the normal craniofacial structure but also may result in severe craniofacial dysfunction. Therefore, the exploration of rapid, precise, and effective reconstruction of craniofacial bone defects is urgent. Recently, developments in advanced bone tissue engineering bring new hope for the ideal reconstruction of the craniofacial bone defects. This report, presenting a first-time comprehensive review of recent advances of biomaterials in craniofacial bone tissue engineering, overviews the modification of traditional biomaterials and development of advanced biomaterials applying to craniofacial reconstruction. Challenges and perspectives of biomaterial development in craniofacial fields are discussed in the end.

Long-term Effect of Individualized Titanium Mesh in Orbital Floor Reconstruction After Maxillectomy

OBJECTIVE

The aim of this study was to determine the clinical outcomes and long-term stability of individualized titanium mesh combined with free flap for orbital floor reconstruction after maxillectomy and to identify the risk factors for titanium mesh exposure.

MATERIAL AND METHODS

The data of 66 patients who underwent maxillectomy and orbital floor defect reconstruction by individualized titanium mesh in Peking University School and Hospital of Stomatology between 2011 and 2019 were retrospectively reviewed. Postoperative ophthalmic function and success of aesthetic restoration were assessed. Titanium mesh exposure was recorded and the risk factors were identified.

RESULTS

Mean follow-up was for 24.8 months (range, 6-92 months). Ophthalmic function was successfully restored in 63/66 patients. Aesthetic restoration was not considered satisfactory by 10 patients. Titanium mesh exposure occurred in six patients (exposure rate, 9.1%). Preoperative radiotherapy was identified as an independent risk factor for mesh exposure (OR = 28.8, P = 0.006). Previous surgery, postoperative radiotherapy, pathological type of the primary lesion, the type of tissue flap applied, and the use of intraoperative navigation were not significant risk factors. Six patients with titanium mesh exposure underwent second surgery, but mesh exposure recurred in two patients due to insufficient soft tissue coverage.

CONCLUSION

Individualized titanium mesh with free flap can effectively restore maxilla-orbital defects. Preoperative radiotherapy is an independent predictor of postoperative titanium mesh exposure. Adequate soft tissue coverage of the mesh may reduce the risk of mesh exposure.

LEVEL OF EVIDENCE

Level 4 (case-control study) Laryngoscope, 2021.

Management of orbital complications in palatomaxillary reconstruction: A review of preemptive and corrective measures

BACKGROUND

Reconstruction of orbit-sparing palatomaxillary defects requires consideration of globe dystopia, orbital volume, eyelid position and function, and the nasolacrimal system to preserve and optimize vision, globe protection, and appearance. We describe the fundamentals of orbital and eyelid anatomy, common orbital complications related to palatomaxillary reconstruction, and preemptive and corrective surgical techniques to be utilized during and after globe-sparing palatomaxillary reconstruction.

METHODS

We present a review of the literature supplemented by clinical case examples.

RESULTS

We advocate for the use of preemptive and corrective techniques to ensure optimal aesthetic and functional outcomes for patients with orbital defects.

CONCLUSIONS

Recognition and anticipation of problems in patients undergoing midface ablative and reconstructive procedures are vital to the implementation of corrective measures. Incision choice, orbital volume restoration, appropriate orbital floor reconstruction, and permanent or temporary lower eyelid suspension during the primary surgery can all significantly impact the development of long-term orbital complications.

The maxillary artery as a recipient vessel option for complex midface and anterior skull base microsurgical repair: A cadaveric study

INTRODUCTION

Variations in the operative situation for complex head and neck defect reconstructions resulting from mechanisms such as trauma, oncologic resection, and prior radiation exposure can result in situations of a vessel-depleted neck. This requires an awareness of alternate, innovative options for use in reconstructive repairs. The purpose of this study was to provide characterization of the third segment of the maxillary artery necessary to consider its use as a recipient vessel in free flap repair of complex midface defects.

MATERIALS AND METHODS

Seventeen cadaver hemifaces were used for anatomic demonstration of the maxillary artery third segment by a transmaxillary approach to obtain descriptive measures for statistical analysis.

RESULTS

The average artery intraluminal cross-section diameter was obtained for the sphenopalatine (1.39 ± 0.12 mm) descending palatine (0.94 ± 0.10 mm), and terminal maxillary (1.68 ± 0.17 mm) arterial vessels. The mean transmaxillary depth with was (43 ± 1.2 mm). Mean mobilizable lengths for sphenopalatine, descending palatine, and terminal maxillary arteries were (30 ± 2 mm), (29 ± 2 mm), and (20 ± 2 mm), accordingly. Vessel patterns were characterized using Morton and Kahn classification for sphenopalatine-descending palatine bifurcation as well as the Kwak classification for maxillary artery third segment morphology.

CONCLUSIONS

In situations where primary recipient vessel sites are unavailable, the maxillary artery represents an innovative option to be considered with suitable recipient artery characteristics.