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Cardín AA, Pereira A, Mendes A, Duarte J, Pereira A. Maxillary reconstruction with horizontally oriented scapular tip free flap: outcomes in orbital support and palate closure. J Plast Reconstr Aesthet Surg 2024; 95:221-230. [PMID: 38936333 DOI: 10.1016/j.bjps.2024.05.042] [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: 03/19/2024] [Revised: 05/17/2024] [Accepted: 05/24/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Current indications of maxillary reconstruction with scapular tip free flap (STFF) are palatoalveolar defects associated with zygomaticomaxillary buttress and/or orbital floor defects. STFF can be placed either horizontally or vertically. Horizontal placement usually allows ideal palatal conformation, preventing oronasal communication, but has been argued to compromise orbital support and projection of the midface, whereas vertical placement is advocated for midface support but may be insufficient for the complete closure of the palate. The present study focuses on the horizontal placing of STFF to allow complete palate reconstruction and fistulae prevention while still obtaining optimal midface projection and orbital support. MATERIALS AND METHODS This study included 21 case complex maxillary reconstructions with this flap, in which the horizontally placed scapular tip component replaced the palate, a muscular flap component was included for midface volume restoration, and an alloplastic implant was utilized for supporting the orbital content when needed. RESULTS None of the patients presented palatal fistulas or alterations in the orbital support. CONCLUSION A multilevel approach was proposed according to the maxillectomy defect. This experience supported the horizontal insetting of STFF to allow palatal fistulae prevention while still obtaining an optimal midface projection and orbital support.
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Affiliation(s)
- Adrián A Cardín
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Donostia, San Sebastián, Spain.
| | - André Pereira
- Department of Stomatology, Instituto Português de Oncologia Francisco Gentil, Lisbon, Portugal.
| | - Ana Mendes
- Department of Plastic and Reconstructive Surgery, Instituto Português de Oncologia Francisco Gentil, Lisbon, Portugal.
| | - José Duarte
- Department of Plastic and Reconstructive Surgery, Instituto Português de Oncologia Francisco Gentil, Lisbon, Portugal.
| | - Alberto Pereira
- Department of Plastic and Reconstructive Surgery, Instituto Português de Oncologia Francisco Gentil, Lisbon, Portugal; Department of Plastic and Reconstructive Surgery, Hospital da Luz Lisboa, Lisbon, Portugal.
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Ferri A, Perlangeli G, Zito F, Ferrari S, Bianchi B, Arcuri F, Poli T. Technical refinements of the scapular tip-free flap for mandibular reconstruction. Microsurgery 2024; 44:e31176. [PMID: 38553855 DOI: 10.1002/micr.31176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/07/2024] [Accepted: 03/14/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND The use of scapular tip chimeric free flaps (STFFs) for reconstructing mandibular defects has recently become popular, but its utility relative to other bone-containing free flaps remains debatable. The aim of the report is to describe how technical modification of STFF impacted in its use for mandibular reconstruction also commenting results obtained in a unicentric series of patients. PATIENTS AND METHODS Patients undergoing mandibular reconstruction using an STFF from January 1, 2014 to June 1, 2022 were retrospectively enrolled in this report. We collected data on chimeric flap type, bone management, vascular pedicles, and the final outcomes. In total, 31 patients (13 men and 18 women) with a mean age of 68 years were enrolled. According to the classification system of Urken, 15 patients had body defects, while 7 had ramus defects, another 7 had symphysis defects, and 2 had both ramus and bodily defects. STFF was always harvested working in two equips simultaneously, in supine position. Dissection included preparation of chimeric components of the flap as latissimus dorsi, serratus and scapular tip. After pedicle dissection scapular bone was cut basing on reconstructive needing with a rectangular (stick) shape including the border of the scapula. In cases of longer bone harvesting, circumflex pedicle was also included to perfuse the upper portion of the scapular border. In five cases, the STFF was harvested with only the scapular angle component, and was thus a composite osteomuscular flap; for the remaining 26 cases, a chimeric STFF was used. Circumflex pedicle was included for eight patients. Six of the seven patients with symphyseal defects underwent a single osteotomy. RESULTS The average length of the harvested was 69.92 mm (maximum length = 104 mm). The average height of transplanted bone was 26.78 mm (maximum height = 44.2 mm). Mouth-opening was normal in 25 patients, limited in 6 patients, and severely impaired in no patients. The cosmetic results were rated as excellent by 20 patients, good by 8 patients, and poor by 3 patients. CONCLUSION The STFF is an excellent option for mandibular reconstruction when other flaps are not available and for patients in poor general condition. Technical innovations here presented made possible to harvest long bone segments with accurate shape thanks to osteotomies if needed and with adequate soft tissues components of the chimeric flap, ensuring satisfactory functional and cosmetic results.
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Affiliation(s)
- Andrea Ferri
- Operative Unite of Maxillo-Facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Giuseppe Perlangeli
- Operative Unite of Maxillo-Facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Francesca Zito
- Operative Unite of Maxillo-Facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Silvano Ferrari
- Operative Unite of Maxillo-Facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Bernardo Bianchi
- Operative Unite of Maxillo-Facial Surgery, Hospital of Genova, Genoa, Italy
| | - Francesco Arcuri
- Operative Unite of Maxillo-Facial Surgery, Hospital of Genova, Genoa, Italy
| | - Tito Poli
- Operative Unite of Maxillo-Facial Surgery Head and Neck Department, University of Parma, Parma, Italy
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Hairston H, Gardner JR, Hagood J, King DL, Vural EA, Moreno MA, Benson DG, Sunde J. Routine Contrasted Chest CT Accurately Identifies Anatomic Variations of the Proximal Subscapular System. Laryngoscope 2024; 134:684-687. [PMID: 37462362 DOI: 10.1002/lary.30839] [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: 02/05/2023] [Revised: 05/15/2023] [Accepted: 06/07/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE The vascular anatomy of the proximal subscapular artery has been previously classified into 2 major types depending on the presence of a common subscapular trunk. The purpose of this study was to determine the utility, reliability, and cost of routine chest imaging to identify these anatomical variations. METHODS Data were collected retrospectively at a tertiary medical center for patients who were undergoing CT chest for various indications between October 2019 and October 2020. Two independent and blinded readers interpreted CT chest with contrast of 52 patients for a total 104 sides. RESULTS The proximal branching pattern of the subscapular system was identified to have a common trunk in 99 (95%) sides. The remaining five sides (5%) demonstrated two arterial pedicles; with one patient exhibiting the variant anatomy bilaterally. CONCLUSION Preoperative CT chest with contrast can accurately identify anatomic variation of the subscapular vascular system. For complex reconstruction requiring a single anastomosis in the vessel depleted neck, preoperative imaging can assure selection of a type I vascular anatomy of the proximal subscapular system. Preoperative imaging with contrasted CT has value in assessing this anatomy when planning for chimeric flaps involving circumflex scapular and thoracodorsal arteries. LEVEL OF EVIDENCE 3 Laryngoscope, 134:684-687, 2024.
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Affiliation(s)
- Hayden Hairston
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - James R Gardner
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Joshua Hagood
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Deanne L King
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Emre A Vural
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Mauricio A Moreno
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Donald G Benson
- Department of Radiology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, U.S.A
| | - Jumin Sunde
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
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Wolter GL, Swendseid BP, Sethuraman S, Ivancic R, Teknos TN, Haring CT, Kang SY, Old MO, Seim NB. Advantages of the scapular system in mandibular reconstruction. Head Neck 2023; 45:307-315. [PMID: 36336798 DOI: 10.1002/hed.27235] [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: 07/24/2022] [Revised: 10/11/2022] [Accepted: 10/19/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Fibula free flaps (FFF) are often considered the first choice for mandibular reconstruction, but scapular system free flaps (SFF) have increased in popularity due to versatility, donor site advantages, and patient factors. METHODS Retrospective chart review of patients undergoing mandibulectomy with FFF or SFF reconstruction from 2016 to 2021. RESULTS Hundred and seventy-six patients (FFF n = 145, SFF n = 31) underwent the aforementioned procedures. Mean FFF operative time was 9.47 h versus 9.88 for SFF (p = 0.40). Two-flap reconstructions required 12.65 h versus 10.09 for SFF with soft tissue (p = 0.002). Donor site complications were identified in 65.6% of FFF with skin grafting. CONCLUSIONS These findings suggest that SFF requires similar operative time and results in reduced donor site morbidity as compared to FFF. Supine, concurrent harvesting of SFF allows for single-flap harvest with significantly shorter operative time. SFF could be considered a primary option for mandible reconstruction for complex defects and in select patients.
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Affiliation(s)
| | - Brian P Swendseid
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Ryan Ivancic
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Catherine T Haring
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stephen Y Kang
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew O Old
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nolan B Seim
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Bollig CA, Walia A, Pipkorn P, Jackson R, Puram SV, Rich JT, Paniello RC, Zevallos JP, Stevens MN, Wood CB, Rohde SL, Sykes KJ, Kakarala K, Bur A, Wieser ME, Galloway TLI, Tassone P, Llerena P, Bollig KJ, Mattingly TR, Pluchino T, Jorgensen JB. Perioperative Outcomes in Patients Who Underwent Fibula, Osteocutaneous Radial Forearm, and Scapula Free Flaps: A Multicenter Study. JAMA Otolaryngol Head Neck Surg 2022; 148:965-972. [PMID: 36074455 PMCID: PMC9459906 DOI: 10.1001/jamaoto.2022.2440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/30/2022] [Indexed: 11/14/2022]
Abstract
Importance Studies comparing perioperative outcomes of fibula free flaps (FFFs), osteocutaneous radial forearm free flaps (OCRFFFs), and scapula free flaps (SFFs) have been limited by insufficient sample size. Objective To compare the perioperative outcomes of patients who underwent FFFs, OCRFFFs, and SFFs. Design, Setting, and Participants This cohort study assessed the outcomes of 1022 patients who underwent FFFs, OCRFFFs, or SFFs for head and neck reconstruction performed at 1 of 6 academic medical centers between January 2005 and December 2019. Data were analyzed from September 17, 2021, to June 9, 2022. Main Outcomes and Measures Patients were stratified based on the flap performed. Evaluated perioperative outcomes included complications (overall acute wound complications, acute surgical site infection [SSI], fistula, hematoma, and flap failure), 30-day readmissions, operative time, and prolonged hospital length of stay (75th percentile, >13 days). Patients were excluded if data on flap type or clinical demographic characteristics were missing. Associations between flap type and perioperative outcomes were analyzed using logistic regression, after controlling for other clinically relevant variables. Adjusted odds ratios (aORs) with 95% CIs were generated. Results Perioperative outcomes of 1022 patients (mean [SD] age, 60.7 [14.5] years; 676 [66.1%] men) who underwent major osseous head and neck reconstruction were analyzed; 510 FFFs (49.9%), 376 OCRFFFs (36.8%), and 136 SFFs (13.3%) were performed. Median (IQR) operative time differed among flap types (OCRFFF, 527 [467-591] minutes; FFF, 592 [507-714] minutes; SFF, 691 [610-816] minutes). When controlling for SSI, FFFs (aOR, 2.47; 95% CI, 1.36-4.51) and SFFs (aOR, 2.95; 95% CI, 1.37-6.34) were associated with a higher risk of flap loss than OCRFFFs. Compared with OCRFFFs, FFFs (aOR, 1.77; 95% CI, 1.07-2.91) were associated with a greater risk of fistula after controlling for the number of bone segments and SSI. Both FFFs (aOR, 1.77; 95% CI, 1.27-2.46) and SFFs (aOR, 1.68; 95% CI, 1.05-2.69) were associated with an increased risk of 30-day readmission compared with OCRFFFs after controlling for Charlson-Deyo comorbidity score and acute wound complications. Compared with OCRFFFs, FFFs (aOR, 1.78; 95% CI, 1.25-2.54) and SFFs (aOR, 1.96; 95% CI, 1.22-3.13) were associated with a higher risk of prolonged hospital length of stay after controlling for age and flap loss. Conclusions and Relevance Findings of this cohort study suggest that perioperative outcomes associated with OCRFFFs compare favorably with those of FFFs and SFFs, with shorter operative times and lower rates of flap loss, 30-day readmissions, and prolonged hospital length of stay. However, patients undergoing SFFs represented a more medically and surgically complex population than those undergoing OCRFFFs or FFFs.
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Affiliation(s)
- Craig Allen Bollig
- Department of Otolaryngology–Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Amit Walia
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Patrik Pipkorn
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Ryan Jackson
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Sidharth V. Puram
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Jason T. Rich
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Randy C. Paniello
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Jose P. Zevallos
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Madelyn N. Stevens
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - C. Burton Wood
- Department of Otolaryngology–Head and Neck Surgery, University of Tennessee Health Science Center, Memphis
| | - Sarah L. Rohde
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin J. Sykes
- Department of Otolaryngology, Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Kiran Kakarala
- Department of Otolaryngology, Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Andres Bur
- Department of Otolaryngology, Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Margaret E. Wieser
- Department of Otolaryngology–Head and Neck Surgery, University of Missouri School of Medicine, Columbia
| | - Tabitha L. I. Galloway
- Department of Otolaryngology–Head and Neck Surgery, University of Missouri School of Medicine, Columbia
| | - Patrick Tassone
- Department of Otolaryngology–Head and Neck Surgery, University of Missouri School of Medicine, Columbia
| | - Pablo Llerena
- Department of Otolaryngology–Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Kassie J. Bollig
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Tyler R. Mattingly
- Department of Otolaryngology Head and Neck Surgery and Communicative Disorders, University of Louisville, Louisville, Kentucky
| | - Tyler Pluchino
- Department of Otolaryngology Head and Neck Surgery and Communicative Disorders, University of Louisville, Louisville, Kentucky
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