Reconstruction of Through-and-Through Oromandibular Defects With Combined Fibula Flap and Anterolateral Thigh Flap

Reconstruction of Complex Oral and Maxillofacial Defects After Oral Cancer Resection With Individualized Anterolateral Thigh Multiple Paddle Flaps

PURPOSE

This study aimed to use reconstructive methods for complex oral and maxillofacial defects, explore their feasibility, and evaluate the efficacy of defect reconstruction using anterolateral thigh (ALT) multiple paddle flaps.

PATIENTS AND METHODS

The authors performed a retrospective case series of 33 patients who underwent oral and maxillofacial defect reconstruction using the ALT multiple paddle flaps. The design and harvest of the flaps, methods for defects reconstruction, and reconstructive efficacy are described.

RESULTS

All 33 patients were men, with a mean age of 49.5 years. Of the flaps, triple skin paddles plus muscle paddles were included in 3 cases, triple skin paddles were included in 1 case, 2 skin paddles plus muscle paddles were included in 29 cases. The skin paddles measured 3×5 cm to 10×16 cm. Postoperatively, all flaps survived completely. Parotid salivary fistula and orocutaneous fistula occurred in 1 patient of each, thigh wound infection and effusion occurred in 1 and 2 patients, respectively. All patients were followed up for ~2 to 93 months; most patients' oral functions and appearance were acceptable, and thigh motor dysfunction was not observed.

CONCLUSIONS

With separate skin paddles for defects of different positions, individualized muscle flap for dead spaces, combination of different skin paddles for larger defects, effective reduction or avoidance of wound complications, and acceptable donor site morbidity, the ALT multiple paddle flaps are an ideal candidate for complex oral and maxillofacial defects reconstruction.

Reconstruction of Extensive Maxillary Defects Using Flow-Through Fibula Free Flap With Anterolateral Thigh Free Flap

BACKGROUND

The maxillary defects left unreconstructed or inadequately reconstructed often result in significant functional and esthetic impairments. Adequate reconstruction of extensive maxillary defects requires a sufficient volume of hard and soft tissues.

METHODS

A 48-year-old male presenting bilateral extensive maxillary defects underwent secondary reconstruction with a flow-through fibula free flap in combination with an anterolateral thigh free flap.

RESULTS

The use of flow-through technique allowed minimizing the problem of limited recipient vessels and the length of free flap vascular pedicle usually encountered in secondary reconstruction. The bilateral maxillary defects were successfully reconstructed, and the postoperative outcomes were uneventful. The patient was satisfied with the treatment outcomes. He is being followed up and was referred to the implantology department for the placement of osseointegrated dental implants.

CONCLUSIONS

The flow-through fibula free flap, in combination with the anterolateral thigh free flap, was found reliable and feasible for this case of secondary reconstruction of bilateral maxillary defects. This technique has provided satisfactory functional and esthetic outcomes and effectively improved the patient's self-esteem.

Management of Through-and-Through Oromandibular Defects after Segmental Mandibulectomy with Fibula Osteocutaneous Flap

BACKGROUND

 Oromandibular defects involving the external skin are a reconstructive challenge. This study aimed to evaluate the use of the fibula osteocutaneous free flap (FOCFF) for through-and-through oromandibular defects by comparing the surgical outcomes and complications of different techniques to close the external skin defect.

METHODS

 A retrospective analysis was conducted of patients who underwent reconstruction of through-and-through oromandibular defects after oncologic segmental mandibulectomy between January 2011 and December 2014. Five groups were analyzed according to the method of external skin coverage: primary closure, locoregional flaps, deepithelialized double-skin paddle FOCFF (deEpi-FOCFF), division of the skin paddle for double-skin paddle FOCFF (div-FOCFF), and a simultaneous second free flap. Intraoperative and postoperative outcomes along with complications were analyzed between groups.

RESULTS

 A total of 323 patients were included. The mean total defect area requiring a simultaneous second free flap was larger in comparison to other groups (p < 0.001). Reconstructions performed with div-FOCFF had a higher number of perforators per flap when compared with deEpi-FOCFF (p < 0.001). External defects closed with another free flap exhibited higher intraoperative time for the reconstructive segment in comparison to other groups (p < 0.05). The overall rate of complications was comparable between groups (24%, p = 0.129).

CONCLUSION

 The FFOCF is a reliable alternative to harvesting multiple simultaneous free flaps for through-and-through oromandibular defects. The authors recommend appropriate curation of the surgical plan based on individual patient characteristics and reconstructive requirements.

One-stage reconstruction of extensive composite extremity defects with low donor site morbidity: A retrospective case series of combined transfer of a vascularized fibula flap and a perforator flap

BACKGROUND

Extensive composite extremity defects remain a challenge in plastic and reconstructive surgery. To preserve the extremity, we used combined transfer composed of the vascularized fibula flap and a perforator flap from various body parts to reconstruct extensive composite extremity defects.

PATIENTS AND METHODS

From January 2004 to December 2018, 14 male patients aged 9 to 55 years with extensive composite extremity defects (large soft-tissue and long bone defect) underwent reconstructive surgery in our institution. The combined transfer surgery consisted of the vascularized fibula bone flap and a perforator flap, such as anterolateral thigh flap, deep inferior epigastric perforator flap, or thoracodorsal artery perforator flap.

RESULTS

All fourteen patients were treated successfully using the combined transfer method. The dimensions of the different perforator flaps ranged from 13 × 6 cm² to 26 × 11 cm², and the size of the skin paddle of the fibular osteocutaneous flap ranged from 9 × 3 cm² to 21 × 7 cm². The median length of the fibular graft was 15 cm. No serious donor site complications were observed. Only one patient developed venous congestion and was salvaged. Another patient had hematoma at the recipient site and underwent debridement. Though all patients achieved bone union (median time of 8 months), two developed a stress fracture of the transferred free fibula.

CONCLUSION

We were able to minimize donor site morbidity and avoid amputation in these patients using the combined transfer technique Our results show that the combined transfer of perforator flap and vascularized fibula flap with or without a skin paddle is a feasible reconstruction option for the treatment of the extensive composite extremity defects.

Reconstruction of Complex Lateral Skull Base Defects After Oral Cancer Resection With Individualized Anterolateral Thigh Flap

Objectives

Complex lateral skull base defects resulting from advanced or recurrent oral cancer resection are continuously challenging reconstructive surgeons. This study aimed to use reconstructive methods for lateral skull base defects, explore their feasibility, and evaluate the efficacy of defect reconstruction using anterolateral thigh (ALT) flaps.

Patients and Methods

We performed a retrospective case series of 37 patients who underwent lateral skull base defect reconstruction using the ALT/anteromedial thigh (AMT) flap between March 2016 and May 2021 at the Second Xiangya Hospital. The design and harvest of the flaps, methods for defect reconstruction, and reconstructive efficacy are described.

Results

Of the 37 patients, 3 were women and 34 were men, with a mean age of 51.7 years. Among the defects, 26 were through-and-through defects and were reconstructed using ALT chimeric flaps, double ALT flaps, folded ALT flap, combined ALT chimeric flaps and AMT flaps, or combined ALT chimeric flaps and pectoralis major flaps; the large lateral skull base dead spaces were filled with muscle tissues or fatty tissues. Postoperatively, 38 of the 39 ALT/AMT flaps survived completely, and the remaining flap experienced partial necrosis. Venous compromise occurred in one patient who was salvaged after operative exploration. Oral and maxillofacial wound infections occurred in two patients, salivary fistula in three patients, and thigh wound effusion in three patients. The wounds healed gradually in all patients after repeated dressing changes. Thirty-three patients were followed up for approximately 3–60 months; their oral functions and appearance were acceptable, and thigh motor dysfunction was not observed.

Conclusions

With the convenient flap design and muscle flap harvest, large and individualized tissue supply, feasible combination with other flaps, effective reduction or avoidance of wound complications, and acceptable donor site morbidity, the ALT flap is an appropriate choice for complex lateral skull base defect reconstruction.

Femoral artery-nourished anteromedial thigh flap: A new perspective in oral and maxillofacial defect reconstruction

OBJECTIVES

The aim of this study was to evaluate the feasibility and efficacy of the femoral artery (FA)-nourished anteromedial thigh (AMT) flap for reconstructing oral and maxillofacial defects.

PATIENTS AND METHODS

The authors analyzed a retrospective case series of 13 patients who underwent the reconstruction of oral and maxillofacial defects with the FA-nourished AMT flap. The flap design and the methods for defect reconstruction are described, and the reconstructive efficacy is reported.

RESULTS

Of the 13 patients, 12 were men, and 1 was woman, with an average age of 52.2 years. Of these FA-supplied AMT flaps, 7 were singly used, 5 were combined with the anterolateral thigh (ALT) flap or its chimeric flaps, and 1 was separately used with the ALT flap. Postoperatively, all flaps survived completely, without vascular compromise or major wound complications.

CONCLUSIONS

The FA-nourished AMT flap can also be used to reconstruct some common oral and maxillofacial defects, especially as a new alternative to the ALT flap. In addition, this flap can be combined with the ALT flap or its chimeric flaps or separately used with the ALT flap for the reconstruction of complex defects.

Reconstruction for Various Subtypes of Unilateral Buccal Defects After Oncologic Surgery by Using Personalized Anterolateral Thigh Flaps

PURPOSE

Radical resection of buccal carcinoma frequently leads to intraoral or through-and-through buccal defects. Anterolateral thigh (ALT) flaps can be harvested to reconstruct different buccal defect subtypes. The purpose of this study was to investigate clinical outcomes after the application of personalized ALT flaps for the precise reconstruction of unilateral buccal defects.

MATERIALS AND METHODS

Patients with primary unilateral buccal carcinoma who underwent tumor ablation and simultaneous reconstruction of personalized ALT flaps from January 2015 to January 2018 were enrolled in this retrospective case series. Buccal defects were classified into 4 subtypes. Demographic features, defect range and reconstructive method, and perioperative characteristics were reviewed and recorded. Quality of life and mouth opening were assessed by the University of Washington Quality-of-Life questionnaire and interincisal distance (IID), respectively, during follow-up. Descriptive statistics were calculated for each study variable.

RESULTS

Four types of ALT flaps were harvested and used to reconstruct different buccal defects in 146 patients. Of the 193 skin paddles applied, 189 survived, and few recipient- and donor-site complications were observed. One hundred eight patients were assessed with the University of Washington Quality-of-Life questionnaire and followed until 12 months postoperatively. Our results showed that physical, functional, social, and emotional domain scores increased steadily during the follow-up period. Ninety-eight patients showed improvements in mouth opening when the IID before the operation was compared with the IID at 3 and 6 months postoperatively.

CONCLUSIONS

A personalized ALT flap is a suitable choice for reconstructing unilateral buccal defects after oncologic surgery given its high success rate, customizable and flexible design, low complication rate, and satisfactory esthetic and functional results.

Characteristics and Management of Free Flap Compromise Following Internal Jugular Venous Thrombosis

PURPOSE

Free flap compromise after internal jugular venous thrombosis (IJVT) occurs fairly infrequently in oral and maxillofacial rehabilitation and reconstruction but could seriously affect the patient's postoperative recovery. The aim of this study was to analyze and discuss the characteristics and management of such flap compromise.

PATIENTS AND METHODS

The authors performed a retrospective case series of 13 patients who underwent reconstruction of oral and maxillofacial defects with anterolateral thigh flaps and developed flap compromise from IJVT from July 2014 through December 2016 at the Second Xiangya Hospital of Central South University (Changsha, China). The clinical features of flap compromise are described, and the precautions and improvement measures are reported.

RESULTS

All 13 patients were men with an average age of 50.3 years. Flap compromise caused by IJVT occurred on postoperative days 3 to 7, of which 2 flaps were salvaged (15.4%) and 11 flaps failed completely after immediate urgent re-exploration. Four patients presented with orocutaneous fistula after salvage surgery that healed well after a period of wound dressing.

CONCLUSIONS

Because of the late occurrence and low salvage rate of flap compromise caused by IJVT, intensive flap monitoring after reconstruction surgery is necessary for patients with free flap transfer.