Computed Tomographic Angiography Perforator Localization for Virtual Surgical Planning of Osteocutaneous Fibular Free Flaps in Head and Neck Reconstruction

Reverse Pedicle U-Shaped Palatal Flap: An Innovative Technique for Repair of Severe Caudal Palatal Defects in Two Dogs

An acquired palatal defect in dogs is a pathologic condition in which there is communication between the oral cavity and nasal cavities, maxillary recesses, or orbits. Many different causes exist and must be considered. Two dogs were presented for severe palatal defects secondary to a foreign body trapped between maxillary dental arches. Numerous techniques have been previously described to repair palatal defects, and the most appropriate choice is based on the clinical features of the defect and information obtained from advanced diagnostic imaging. Acquired palatal defects are not predictable in shape, size, and location; therefore, although the literature contains many different surgical techniques, these are not always reliable. The aim of this article is to describe an innovative surgical approach to repair severe acquired caudal palatal defects in two different dogs.

Introduction and preliminary application report for a novel 3D printed perforator navigator for fibular flap surgery

The aim of this study was to introduce and report on a 3D-printed perforator navigator and its clinical application. Integrated imaging and 3D printing techniques were employed for the design and manufacture of a perforator navigator. Key techniques included establishing a digital image coordinate system, localizing perforator fascia piercing points, creating a reference plane for the perforator course, and projecting the perforator course onto the body surface. All cases of maxillofacial defect repaired with free fibular myocutaneous flaps, from January 2019 to January 2022, were reinvestigated. Patients treated using traditional perforator localization methods were assigned into group Ⅰ, while those who had a navigator used during treatment were allocated to group Ⅱ. Outcome measurements included perforator positioning accuracy, perforator preparation time (PT), and flap growth score. Capillary refilling time and degree of flap swelling were recorded on the 1st, 3rd, and 7th days after surgery. On the 10th day after surgery, the flap survival situation was graded. In total, 25 patients were included in the study. Perforator preparation time for group Ⅱ was significantly less (p ＝ 0.04) than for group Ⅰ (1038.6 ± 195.4 s versus 1271.4 ± 295.1 s. In group Ⅱ, the mean positioning deviation for the perforator navigator was 2.12 cm less than that for the high-frequency color Doppler (p ＝ 0.001). Group Ⅱ also had a higher score than group Ⅰ for overall flap growth evaluation (nonparametric rank sum test, p ＝ 0.04). Within the scale of the study, it seems that perforator localization and navigation using a 3D-printed navigator is technically feasible, and helps to improve the clinical outcome of free fibular flaps. The perforator navigator will play a useful role in displaying the perforator course, improving the accuracy of perforator localization, reducing surgical injury, and ultimately enhancing flap success rate.

Virtual Surgical Planning in Free Tissue Transfer for Orbito-Maxillary Reconstruction

Since its introduction, virtual surgical planning (VSP) has been rapidly adopted as a part of reconstructive surgeon's armamentarium. VSP allows reconstructive surgeons to simulate resection, plan osteotomies, and design custom plates. These unique advantages have been especially beneficial for head and neck reconstructive surgeons as there is small room for error and high technical demand in head and neck reconstruction. Despite its popularity, most surgeons have limited experience in using VSP for orbito-maxillary reconstruction as tumors that involve the midface are relatively rare compared with other head and neck oncologic defects. In our institution, we routinely use VSP for orbito-maxillary reconstruction using free fibula flap to provide support for orbit, to restore normal dental occlusion, and to restore midface projection. In this chapter, we will discuss the role of virtual surgical planning and our algorithmic approach of performing orbito-maxillary reconstruction using free tissue transfer.

Impact of Periosteal Branches and Septo-Cutaneous Perforators on Free Fibula Flap Outcome: A Retrospective Analysis of Computed Tomography Angiography Scans in Virtual Surgical Planning

Background

Virtual surgical planning (VSP) for jaw reconstruction with free fibula flap (FFF) became a routine procedure and requires computed tomography angiography (CTA) for preoperative evaluation of the lower limbs vascular system and the bone. The aim of the study was to assess whether the distribution and density of periosteal branches (PB) and septo-cutaneous perforators (SCP) of the fibular artery have an impact on flap success.

Method

This retrospective clinical study assessed preoperative CTA of the infra-popliteal vasculature and the small vessel system of 72 patients who underwent FFF surgery. Surgical outcome of flap transfer includes wound healing, subtotal, and total flap loss were matched with the segmental vascular supply.

Result

A total of 72 patients (28 females, 38.9 %; 44 males, 61.1 %) fulfilled the study inclusion criteria. The mean age was 58.5 (± 15.3 years). Stenoses of the lower limbs’ vessel (n = 14) were mostly detected in the fibular artery (n = 11). Flap success was recorded in n = 59 (82.0%), partial flap failure in n = 4 (5.5%) and total flap loss in n = 9 (12.5%). The study found a mean number (± SD) of 2.53 ± 1.60 PBs and 1.39 ± 1.03 SCPs of the FA at the donor-site. The proximal FFF segment of poly-segmental jaw reconstruction showed a higher rate of PB per flap segment than in the distal segments. Based on the total number of prepared segments (n = 121), 46.7% (n = 7) of mono-, 40.4% (n = 21) of bi-, and 31.5 % (n = 17) of tri-segmental fibula flaps were at least supplied by one PB in the success group. Overall, this corresponds to 37.2% (45 out of 121) of all successful FFF. For total flap loss (n = 14), a relative number of 42.9% (n = 6) of distinct supplied segments was recorded. Wound healing disorder of the donor site was not statistically significant influenced by the detected rate of SCP.

Conclusion

In general, a correlation between higher rates of PB and SCP and the flap success could not be statistically proved by the study sample. We conclude, that preoperative PB and SCP mapping based on routine CTA imaging is not suitable for prediction of flap outcome.

Computed Tomography Angiography (CTA) before Reconstructive Jaw Surgery Using Fibula Free Flap: Retrospective Analysis of Vascular Architecture

Computed tomography angiography (CTA) is widely used in preoperative evaluation of the lower limbs' vascular system for virtual surgical planning (VSP) of fibula free flap (FFF) for jaw reconstruction. The present retrospective clinical study analysed n = 72 computed tomography angiographies (CTA) of lower limbs for virtual surgical planning (VSP) for jaw reconstruction. The purpose of the investigation was to evaluate the morphology of the fibular bone and its vascular supply in CTA imaging, and further, the amount and distribution of periosteal branches (PB) and septo-cutaneous perforators (SCPs) of the fibular artery. A total of 144 lower limbs was assessed (mean age: 58.5 ± 15.3 years; 28 females, 38.9%; 44 males, 61.1%). The vascular system was categorized as regular (type I-A to II-C) in 140 cases (97.2%) regarding the classification by Kim. Absent anterior tibial artery (type III-A, n = 2) and posterior tibial artery (type III-B, n = 2) were detected in the left leg. Stenoses were observed mostly in the fibular artery (n = 11), once in the anterior tibial artery, and twice in the posterior tibial artery. In total, n = 361 periosteal branches (PBs) and n = 231 septo-cutaneous perforators (SCPs) were recorded. While a distribution pattern for PBs was separated into two clusters, a more tripartite distribution pattern for SCPs was found. We conclude that conventional CTA for VSP of free fibula flap (FFF) is capable of imaging and distinguishing SCPs and PBs.

Impact of Planning Method (Conventional versus Virtual) on Time to Therapy Initiation and Resection Margins: A Retrospective Analysis of 104 Immediate Jaw Reconstructions

Simple Summary

Computer-aided design and manufacturing of osseous reconstructions are currently widely used in jaw reconstructive surgery, providing an improved surgical outcome and decreased procedural stumbling block. However, data on the influence of planning time on the time-to-surgery initiation and resection margin are missing in the literature. This retrospective, monocentric study compares process times from the first patient contact in hospital, time of in-house or out-of-house biopsy for tumor diagnosis and surgical therapy of tumor resection, and immediate reconstruction of the jaw with free fibula flaps (FFF). Two techniques for reconstruction are used: Virtual surgical planning (VSP) and non-VSP. A total of 104 patients who underwent FFF surgery for immediate jaw reconstruction from 2002 to 2020 are included. The study findings fill the gaps in the literature and obtain clear insights based on the investigated study subjects.

Abstract

Virtual surgical planning (VSP) and patient-specific implants are currently increasing for immediate jaw reconstruction after ablative oncologic surgery. This technique contributes to more accurate and efficient preoperative planning and shorter operation time. The present retrospective, single-center study analyzes the influence of time delay caused by VSP vs. conventional (non-VSP) reconstruction planning on the soft and hard tissue resection margins for necessary oncologic safety. A total number of 104 cases of immediate jaw reconstruction with free fibula flap are included in the present study. The selected method of reconstruction (conventionally, non-VSP: n = 63; digitally, VSP: n = 41) are analyzed in detail. The study reveals a statistically significant (p = 0.008) prolonged time to therapy initiation with a median of 42 days when the VSP method compared with non-VSP (31.0 days) is used. VSP did not significantly affect bony or soft tissue resection margin status. Apart from this observation, no significant differences concerning local tumor recurrence, lymph node, and distant metastases rates are found according to the reconstruction method, and affect soft or bone tissue resection margins. Thus, we conclude that VSP for immediate jaw reconstruction is safe for oncological purposes.

Reconstruction of Bilateral Mandibular Condyles Using a Single Vascularized Fibula

Patients with end-stage temporomandibular joint (TMJ) pathology present with loss of vertical ramus height with resulting retrognathia, anterior open bite, and restricted jaw function requiring joint reconstruction. Costochondral grafts, long considered the gold standard for TMJ reconstruction, carry risks of bony ankylosis and resorption. Custom-made alloplastic TMJ prostheses show excellent objective and subjective outcomes but are also associated with complications such as infection or metal sensitivity, and necessitate hardware explantation in some cases. Revision surgeries are rare but present a real challenge. We present the case of a 50-year-old woman with longstanding TMJ arthritis, having undergone many surgical procedures to her TMJ, including explantation of failed alloplastic replacement, who presented with bilateral facial weakness as well as difficulty chewing and swallowing food. She had class II malocclusion with retrodisplacement of her mandible and anterior open bite, and moderate trismus with an inter-incisal opening of only 15 mm, consistent with fibrous ankylosis. After weighing all the reconstructive options, bilateral mandibular condyle and ramus reconstruction with a single fibula free flap (FFF) was planned with the use of preoperative virtual surgical planning (VSP) and 3D-printing of osteotomy and repositioning guides. A 2-team approach increases efficiency of the procedure and decreases operative time. The procedure and postoperative recovery were uncomplicated, and at her 2-month follow-up, she had increased range of motion and maintained the planned position of her mandible. Her masticatory function and deglutition were also improved due to the correction of her malocclusion and repair of her anterior open bite.

Contemporary reconstruction after complex facial trauma

Complex facial trauma requires complex repair and solutions. This process is challenging for the surgeon who seeks to manage the expectations of the patient and family while achieving the best possible result. Historically, the use of pedicled flaps, and then free tissue transfer, were the primary techniques utilized. Advancements in soft-tissue reconstruction, such as perforator flaps and pre-expanded and prefabricated flaps, allow refinement of the soft-tissue reconstruction process to create the best initial soft-tissue coverage. The advent of contemporary technologies, such as virtual surgical planning, stereolithography and customized implants and plates, facilitates a tailored approach to the patient’s reconstructive needs for precise bony reconstruction. When surgical and technological techniques are combined in complementary multistage reconstructions, better reconstructive and aesthetic outcomes are achievable than ever before. In this review, the authors present a summary of the management of complex facial trauma based on the senior author’s broad experience. Initial management and contemporary reconstructive techniques and technology to provide optimal outcomes are reviewed. A case series of complex facial traumas and their reconstructive process is also presented to demonstrate how complementary staged procedures can yield an optimal result. We believe the reconstructive surgeon managing complex facial trauma should strive to incorporate contemporary technologies and techniques into their armamentarium to provide the best patient care.

Oromandibular reconstruction using microvascularized bone flap: report of 1038 cases from a single institution

This retrospective study was performed to review 1038 patients who underwent mandibular reconstruction with free vascularized bone flaps at a single institution between 2006 and 2017. Of these patients, 827 (79.67%) had fibula flaps, 197 (18.98%) had deep circumflex iliac artery perforator (DCIA) flaps, and 11 (1.06%) had scapula bone flaps. The most common pathological diagnosis was ameloblastoma (n=366, 35.26%), followed by squamous cell carcinoma (n=278, 26.78%) and osteoradionecrosis (n=152, 14.64%). Fifty-seven patients (5.49%) had major complications requiring surgical intervention and one patient died of a pulmonary embolism. Venous crisis was the most frequent major complication (n=20, 1.93%), followed by haematoma (n=17, 1.64%) and flap necrosis (n=14, 1.35%). One-stage mandibular reconstruction was preferred whenever possible, as this generally decreases the financial and hospitalization burden. The four-segment method of jaw reconstruction appeared to achieve good aesthetic appearance results in Asian patients and this was not associated with a higher risk of segment ischemia compared with the three-segment method.