Versatility of a single piece scapular tip and lateral border free flap for mandibular reconstruction: A virtual study on angle correspondence

Reconstruction of the anterior maxillary defect using a vascularized bone flap with residual teeth in the posterior maxilla

BACKGROUND

Microsurgical bone reconstruction is challenging in cases of anterior maxillary defects because of the presence of residual teeth. The study analyzed the method and feasibility of using vascularized bone flaps to reconstruct anterior maxillary defects.

METHODS

We retrospectively analyzed 15 patients treated at the Department of Oral and Maxillofacial Surgery, Peking University School, and Hospital of Stomatology between November 2017 and January 2023.

RESULTS

A total of 14 patients were successfully reconstructed using the digital technique: 6 deep circumflex iliac artery (DCIA) flaps and 8 fibular free flaps. Palatal and buccal pedicle paths were used in 4 and 10 cases, respectively, for vascular anastomosis. The implant coverage rates of the DCIA and fibular free flaps were 87.2% and 92.6%, respectively (p > 0.05).

CONCLUSION

Anterior maxillary defects reconstructed with the DCIA and fibular free flaps are reliable methods. Furthermore, the palatal and buccal paths are recommended for vascular anastomosis.

Double Arterialized Scapular Tip Free Flap for Mandibular Reconstruction

INTRODUCTION

Scapular tip free flap (STFF) has become today one of the workhorse flaps for maxillary reconstruction; recently, the possibility of extending the vascular supply by adding to the angular branch of the circumflex pedicle up to its periosteal entrance in the lateral border of the scapula has been proposed as a reliable technique to improve the length of perfused bone when STFF is used for mandibular reconstruction. The purpose of this study was to evaluate the patients who had received microvascular reconstruction of the mandible with STFF vascularized by both the circumflex scapular artery via the periosteal branch and the thoracodorsal artery via the angular artery.

METHODS

A retrospective chart review was conducted for all patients who underwent reconstruction with an STFF for mandibular defect between January 2016 and December 2020 at the University Hospital of Parma. The outcome was evaluated by assessing dietary intake (unrestricted, soft, liquid, and tube feed) and speech (normal, intelligible, partially intelligible, and unintelligible).

RESULTS

The final study sample included 9 patients (5 men and 4 women). The average patient age was 68.9 years (range, 59.9-74.8 y) at the time of surgery. There was no flap loss. A 1-year postoperative computed tomography scan revealed full osteointegration of the flap.

CONCLUSIONS

Our results show that the STFF is a valuable reconstructive option, especially in patients with complex head and neck defects requiring soft and hard tissues.

Virtual surgical planning for maxillary reconstruction with the scapular free flap: An evaluation of a simple cutting guide design

BACKGROUND

The study's objective is to assess the feasibility and utility of VSP for maxillary reconstruction with the scapular free flap.

METHODS

An open-source VSP platform was used to create the reconstruction models and simple guides. Clinical, operative, and postoperative data were collected.

RESULTS

Ten patients in the VSP cohort and 18 in the non-VSP control cohort were included in the study. There was a significant reduction in operative time (256.0 ± 69.4 vs. 448.1 ± 108.2 min, p < 0.01), tracheotomy rate (20% vs. 72%, p < 0.01), increased two-team utilization rate (80% vs. 0%, p < 0.01) and better reconstructive accuracy (7.5 ± 3.4 vs. 11.7 ± 7.6 mm, p = 0.048) for the VSP cohort.

CONCLUSIONS

Maxillary reconstruction planned with an in-house open-source VSP platform and accompanied simple guides can facilitate a two-team approach, reduce operative time, and improve structural accuracy. This open-source technology has great potential to be readily applied in other institutions to improve efficiency and outcomes.

Benefits of Patient-Specific Reconstruction Plates in Mandibular Reconstruction Surgical Simulation and Resident Education

Poorly contoured mandibular reconstruction plates are associated with postoperative complications. Recently, a technique emerged whereby preoperative patient-specific reconstructive plates (PSRP) are developed in the hopes of eliminating errors in the plate-bending process. This study’s objective is to determine if reconstructions performed with PSRP are more accurate than manually contoured plates. Ten Otolaryngology residents each performed two ex vivo mandibular reconstructions, first using a PSRP followed by a manually contoured plate. Reconstruction time, CT scans, and accuracy measurements were collected. Paired Student’s t-test was performed. There was a significant difference between reconstructions with PSRP and manually contoured plates in: plate-mandible distance (0.39 ± 0.21 vs. 0.75 ± 0.31 mm, p = 0.0128), inter-fibular segment gap (0.90 ± 0.32 vs. 2.24 ± 1.03 mm, p = 0.0095), mandible-fibula gap (1.02 ± 0.39 vs. 2.87 ± 2.38 mm, p = 0.0260), average reconstruction deviation (1.11 ± 0.32 vs. 1.67 ± 0.47 mm, p = 0.0228), mandibular angle width difference (5.13 ± 4.32 vs. 11.79 ± 4.27 mm, p = 0.0221), and reconstruction time (16.67 ± 4.18 vs. 33.78 ± 8.45 min, p = 0.0006). Lower plate-mandible distance has been demonstrated to correlate with decreased plate extrusion rates. Similarly, improved bony apposition promotes bony union. PSRP appears to provide a more accurate scaffold to guide the surgeons in assembling donor bone segments, which could potentially improve patient outcome and reduce surgical time. Additionally, in-house PSRP can serve as a low-cost surgical simulation tool for resident education.

Synchrony in head and neck surgery: Feasibility and outcomes of simultaneous scapular free flap reconstruction

BACKGROUND

The scapula free flap is a versatile option in head and neck reconstruction but is less amenable to simultaneous harvest and ablation.

METHODS

Retrospective series (2015-2021) of consecutive scapula flaps. Cases categorized as simultaneous versus sequential, compared for operative time, oncological and patient-reported outcomes.

RESULTS

Seventy consecutive scapula free flaps were performed (n = 21 simultaneous, n = 49 sequential). Mandible reconstruction was performed in 51.0% and 61.9% of sequential and simultaneous cases, respectively; 49.0% and 38.1% addressed bony maxillary defects. Simultaneous surgery reduced operative time by 37.9% (151 min, p < 0.00001) and there were fewer tracheostomies performed (p < 0.005). Rates of positive margins and free flap compromise were equivalent (n = 1, 4.8% vs. n = 2, 4.1%). There was no difference in patient-reported outcomes.

CONCLUSIONS

This series demonstrates feasibility, efficacy, and outcomes of bony scapula reconstruction of maxillofacial defects comparing simultaneous and sequential approaches. Benefits of the two-team approach are highlighted including decreased operative time.

Lateral border and scapular tip free flaps: Old school versus new school

Free tissue transfer from the subscapular system provides a wide array of options for both soft tissue and bony reconstruction. When bone stock is required for head and neck reconstruction, both the lateral scapular border free flap (LSBFF), supplied by the circumflex scapular artery, and the scapular tip free flap (STFF), supplied by the angular artery, are excellent options. Issues with positioning had previously prevented the widespread use of these bony subscapular system flaps. However, through the use of a Spider Limb Positioner, current clinical practice patterns allow for two team approaches in both of these free flaps. The following pictorial essay compares and contrasts the specific positioning and harvesting technique used for both the LSBFF and STFF, while discussing the clinical advantages and drawbacks of each. Both the lateral border scapula and scapular tip free flaps provide excellent bone stock for head and neck reconstruction. By positioning with currently available technology, both of these free flaps can be harvested through a two team approach.