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Kudva A, Srikanth G, Singh A, Chitra A, Suryanarayan RK, Francis M. Reconstruction of Maxillary Defects Using Virtual Surgical Planning and Additive Manufacturing Technology: A Tertiary Care Centre Experience. J Maxillofac Oral Surg 2024; 23:644-652. [PMID: 38911428 PMCID: PMC11190103 DOI: 10.1007/s12663-023-02005-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 08/16/2023] [Indexed: 06/25/2024] Open
Abstract
Introduction Maxillary reconstruction is often a challenging task for the surgeons because of the complex anatomy. However, with the advances in virtual surgical planning (VSP) and 3D printing technology there is a new avenue for the surgeons which offers a suitable alternative to conventional flap-based reconstructions. Patients and Methods In this article, we have described 4 case scenarios which were managed with the help of VSP and additive manufacturing technology for complex maxillary reconstruction procedures. Use of the technologies aided the clinician in achieving optimal outcomes with regards to form, function and esthetics. Discussion Virtual surgical planning (VSP) has gained a lot of impetus in past 1 decade. These aides the surgeon in determining the extent of disease and also carry out the treatment planning. In addition to VSP, the concept of additive manufacturing provides a viable alternative to the conventional reconstruction modalities for maxillary defect rehabilitation. Increased accuracy, rehabilitation of normal anatomical configuration, appropriate dental rehabilitation, decreased intra-operative time and post-operative complications are some of the advantages. In addition, patient-specific implants eliminate the need for a separate donor site. Apart from the treatment of pathologies, they also can be used for reconstruction of post-traumatic defect, where endosteal implant placement is not possible. Conclusion These modalities show promising results for reconstruction of complex maxillary defects.
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Affiliation(s)
- Adarsh Kudva
- Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - G. Srikanth
- Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Anupam Singh
- Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - A. Chitra
- Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Ramya K. Suryanarayan
- Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Mugdha Francis
- Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education (MAHE), Manipal, India
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Kämmerer PW, Tavakoli M, Gaggl A, Maranzano M. Intraoral Microvascular Anastomosis in Immediate Free Flap Reconstruction for Midfacial Tumor Defects: A Retrospective Multicenter Study. J Clin Med 2023; 12:7064. [PMID: 38002676 PMCID: PMC10672123 DOI: 10.3390/jcm12227064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/10/2023] [Accepted: 11/12/2023] [Indexed: 11/26/2023] Open
Abstract
(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.
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Affiliation(s)
- Peer W. Kämmerer
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Milad Tavakoli
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Manchester University NHS Foundation Trust (MFT), Manchester M13 9WL, UK; (M.T.); (M.M.)
| | - Alexander Gaggl
- Department of Oral and Craniomaxillofacial Surgery, Paracelsus Medical University, 5020 Salzburg, Austria;
| | - Massimo Maranzano
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Manchester University NHS Foundation Trust (MFT), Manchester M13 9WL, UK; (M.T.); (M.M.)
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Garg A, Verma VK, Kapoor R, Dabas SK. Intraoral anastomosis for primary microsurgical reconstruction in patients of oral cavity malignancies: Retrospective analysis of 30 cases from a tertiary care center in India. J Plast Reconstr Aesthet Surg 2023; 85:235-241. [PMID: 37527572 DOI: 10.1016/j.bjps.2023.05.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 05/25/2023] [Indexed: 08/03/2023]
Abstract
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.
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Affiliation(s)
- Akhil Garg
- Department of Surgical Oncology and Robotic Surgery, BLK-MAX Super Speciality Hospital, Pusa Road, Rajendra Place, New Delhi 110005, India.
| | - Vinay K Verma
- Department of Surgical Oncology and Robotic Surgery, BLK-MAX Super Speciality Hospital, Pusa Road, Rajendra Place, New Delhi 110005, India
| | - Rahul Kapoor
- Department of Surgical Oncology and Robotic Surgery, BLK-MAX Super Speciality Hospital, Pusa Road, Rajendra Place, New Delhi 110005, India
| | - Surender Kumar Dabas
- Department of Surgical Oncology and Robotic Surgery, BLK-MAX Super Speciality Hospital, Pusa Road, Rajendra Place, New Delhi 110005, India
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Analysis of intraoral microvascular anastomosis in maxillofacial defects reconstruction. J Craniomaxillofac Surg 2023; 51:31-43. [PMID: 36725484 DOI: 10.1016/j.jcms.2023.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
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.
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Qiu SY, Shan XF, Kang YF, Ding MK, Zhang L, Cai ZG. Accurate occlusion-driven maxillary reconstruction with deep circumflex iliac artery flap using computer-assisted techniques and intraoral anastomosis: a case series study. Int J Oral Maxillofac Surg 2022:S0901-5027(22)00450-7. [DOI: 10.1016/j.ijom.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/21/2022] [Accepted: 10/20/2022] [Indexed: 11/16/2022]
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Abstract
SUMMARY Defects involving the midface and maxilla pose unique challenges to reconstructive surgeons. The maxilla serves as the central keystone of the face and interfaces with various other facial subunits to affect form and function. Reconstructive methods range from prosthetics to free tissue transfer, and the indications for different options are reviewed here. Finally, special considerations including management of the orbit, dental rehabilitation, and future directions are discussed.
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Sun J, Li J, Lv MM, Wang L, Gupta A, Shen Y. Expanded Transoral Microvascular Mandibular Reconstruction: A Scar-free Approach. J Oral Maxillofac Surg 2022; 80:1115-1126. [DOI: 10.1016/j.joms.2022.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/03/2022] [Accepted: 01/15/2022] [Indexed: 11/29/2022]
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Sun J, Li J, Lv MM, Wang L, Gupta A, Shen Y. WITHDRAWN: Expanded Transoral Microvascular Mandibular Reconstruction: A Scar-Free Approach. J Oral Maxillofac Surg 2019:S0278-2391(19)31337-0. [PMID: 31838090 DOI: 10.1016/j.joms.2019.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 10/17/2019] [Accepted: 11/12/2019] [Indexed: 11/24/2022]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
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Affiliation(s)
- Jian Sun
- Professor, Department of Oral Maxillofacial-Head Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Jun Li
- Associate Professor, Department of Oral Maxillofacial-Head Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Ming-Ming Lv
- Resident, Department of Oral Maxillofacial-Head Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Liang Wang
- Resident, Department of Oral Maxillofacial-Head Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Anand Gupta
- Associate Professor, Department of Oral and Maxillofacial Surgery, Government Medical College Hospital, Chandigarh, India
| | - Yi Shen
- Associate Professor, Department of Oral Maxillofacial-Head Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
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Zheng L, Lv X, Shi Y, Zhang J, Zhang J. Intraoral anastomosis of a vascularized iliac-crest flap in maxillofacial reconstruction. J Plast Reconstr Aesthet Surg 2019; 72:744-750. [DOI: 10.1016/j.bjps.2018.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/10/2018] [Indexed: 10/27/2022]
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Sun J. [Virtual surgical planning and intraoperative navigation for mandibular reconstruction: from accurate to minimal invasive]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:821-826. [PMID: 30129302 DOI: 10.7507/1002-1892.201806027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Simultaneous restoration of function and appearance should be performed in mandibular reconstruction. Option of reconstructive techniques is determined by cause, location, extent, and classification of the mandibular defects. Vascularize bone graft is one of the most popular technique in current clinical practice of mandibular reconstruction. Fibula is the most common donor site for mandibular reconstruction. The disadvantage of low height of neo-mandible reconstructed by single fibular segment can be solved by vascularized double barrel fibula graft. Using virtual surgical planning and intraoperative navigation for mandibular reconstruction leads to simplify surgical procedure, reduce operating time and injury, and decrease donor site morbidity so that accurate mandibular reconstruction could be completed. Direction of minimal invasive surgery for mandibular reconstruction will be developed by intraoral approach and intraoral anastomosis.
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Affiliation(s)
- Jian Sun
- Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, National Research Center of Stomatology, Shanghai, 200011,
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Zygomatico-maxillary Reconstruction with Computer-aided Manufacturing of a Free DCIA Osseous Flap and Intraoral Anastomoses. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1226. [PMID: 28280668 PMCID: PMC5340483 DOI: 10.1097/gox.0000000000001226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 12/16/2016] [Indexed: 11/26/2022]
Abstract
Craniomaxillofacial reconstruction using virtual surgical planning, computer-aided manufacturing, and new microsurgical techniques optimizes patient-specific and defect-directed reconstruction. A 3D customized free deep circumflex iliac artery (DCIA) flap with intraoral anastomoses was performed on a 23-year-old man with a posttraumatic right zygomatico-maxillary defect with failure of alloplastic implant reconstruction. An osseous iliac crest flap was sculpted based on a customized 3D model of the mirror image of the patient's unaffected side to allow for perfect fit to the zygomatico-maxillary defect. An intraoral dissection of the facial artery and vein was performed within the right cheek mucosa and allowed for end-to-end microvascular anastomoses. 3D preoperative planning and customized free DCIA osseous flap combined with an intraoral microsurgical technique provided restoration of facial esthetics and function without visible scars. In cases where zygomatico-malar reconstruction by alloplastic material fails, a customized free DCIA osseous flap can be designed by virtual surgical planning to restore facial appearance and function.
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Avoiding Facial Incisions with Midface Free Tissue Transfer. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1218. [PMID: 28280662 PMCID: PMC5340477 DOI: 10.1097/gox.0000000000001218] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 12/07/2016] [Indexed: 12/02/2022]
Abstract
Background: We have adopted an intraoral microsurgical anastomosis to the facial vessels to eliminate the need for any visible facial incisions. Methods: Cadaveric dissection was used to demonstrate accessibility of the facial artery and vein through an intraoral approach. Additionally, 5 patients underwent free tissue transfer for reconstruction of major defects of the midface through an intraoral, transmucosal approach, obviating the need for visible skin incisions. Results: The pathology included palatal defects due to mucoepidermoid carcinoma and ischemic necrosis from cocaine abuse, maxillary defects secondary to fibrous dysplasia and avascular necrosis from traumatic blast injury, and a residual posttraumatic bony deformity of the zygoma. Reconstructions were performed with a free ulnar forearm flap, a free vastus lateralis muscle flap, a deep circumflex iliac artery myoosseous flap, a free fibula flap, and a deep circumflex iliac artery osseous flap, respectively. The facial artery and vein were used as recipient vessels for microvascular anastomosis for all cases. Mean follow-up was 12.2 months. All free tissue transfers were successful, and each patient had a satisfactory aesthetic outcome with no associated facial scars. Conclusion: This technique can be employed during reconstruction of an array of bony or soft-tissue midface deficits with minimal morbidity. This small series effectively demonstrates the varied pathologies and tissue deficiencies that can be successfully reconstructed with free tissue transfer using an entirely intraoral approach to the recipient facial vessels, resulting in no visible scars on the face and an improvement in the overall aesthetic outcome.
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