Maxillary reconstruction using microvascular free flaps

Maxillary reconstruction with horizontally oriented scapular tip free flap: outcomes in orbital support and palate closure

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.

A study on the morphology of iliac crest based on the objectives of jaw bone defect reconstruction

OBJECTIVES

to understand the morphological characteristics of iliac crest and provide advice and assistance for jaw bone reconstruction with iliac bone flap by evaluating the thickness and curvature of iliac crest.

MATERIALS AND METHODS

100 patients who had taken Spiral CT of the Abdominal region before surgeries between 2020 and 2022 were included in this study. 3D reconstruction images of the iliac bones were created. 5 vertical planes perpendicular to the iliac crest were made every 2 cm along the centerline of the iliac crest (VP2 ~ VP10). On these vertical planes, 4 perpendicular lines were made every 1 cm along the long axis of the iliac crest (D1 ~ D4). The thicknesses at these sites, horizontal angle (HA) of iliac crest and the distance between inflection point and the central point of anterior superior iliac spine (DIA) were measured.

RESULTS

The thickness of iliac bone decreased significantly from D1 ~ D4 on VP6 ~ VP10 and from VP2 ~ VP10 on D3 and D4 level (P<0.05). HA of iliac crests was 149.13 ± 6.92°, and DIA was 7.36 ± 1.01 cm. Iliac bone thickness, HA and DIA had very weak or weak correlation with patient's age, height and weight.

CONCLUSIONS

The average thicknesses of iliac crest were decreased approximately from front to back, from top to bottom. The thickness and curvature of the iliac crest were difficult to predict by age, height and weight.

CLINICAL RELEVANCE

Virtual surgical planning is recommended before jaw bone reconstruction surgery with iliac bone flap, and iliac crest process towards alveolar process might be a better choice.

Application of supraclavicular island flap in oral and maxillofacial reconstruction

Several surgical modalities are available for maxillofacial reconstruction as locoregional or microvascular free flaps.

PURPOSE

(a) Evaluate the reliability of the supraclavicular flap in cervico-orofacial region; (b) investigate the role of computed tomography angiography (CTA) in predicting the post-operative viability of the flap; (c) assess the speech, feeding, and esthetics after reconstruction using this flap.

METHODS

Eleven patients included in this study underwent either conventional or delayed harvesting of the supraclavicular flap (SCF). All the patients had diagnostic computed tomography angiography (CTA) of the supraclavicular flap before the surgery.

RESULTS

The mean harvesting time of the flap was 45.45 ± 4.16 min. The average length of the flap was 22.64 ± 1.12 cm, whereas the mean width of the flap was 6.14 ± 1.14 cm. The flap survived in 9 patients, while two patients had complete flap loss. After the surgery, three patients complained of speech difficulties. Two patients had swallowing problems. After the surgery, three patients complained of speech difficulties. Two patients had swallowing problems. Only two patients complained of weakness in the donor site. None of the patients reported that the weakness or pain at the donor site affected their daily activities or quality of life.

CONCLUSION

The pedicled SCF represents a safe and feasible option that can be used to reconstruct a wide array of maxillofacial oncologic defects. However, a study with a larger sample size is recommended to achieve more reliable clinical results for the modified delayed technique modification in terms of their effect on the survival of the supraclavicular flap.

Advances in Microvascular Reconstruction of the Orbit and Beyond: Considerations and a Checklist for Decision-Making

This paper aims to discuss the microvascular reconstruction of the orbit and adjacent regions and to propose a checklist to aid the reconstructive surgeon in this challenging undertaking. The discussion is based on a literature review that includes 32 retrospective case series, 5 case reports published in the last 34 years in PubMed, and 3 textbook chapters. Additionally, it relies on the senior author's expertise, described in a case series, and two case reports published elsewhere. Classifications and treatment algorithms on microvascular orbit reconstruction generally disregard patient-related factors. A more holistic approach can be advantageous: patient-related factors, such as age, comorbidities, prognosis, previous interventions, radiotherapy, and the wish for maximal dental rehabilitation and a prosthetic eye, have the same importance as defect-related considerations and can inform the choice of a reconstructive option. In this manuscript, we examine defect- and patient-related factors and new technologies, provide a checklist, and examine future directions. The checklist is intended as a tool to aid in the decision-making process when reconstructing the orbital region with microvascular flaps.

Maxillofacial Microvascular Free-Flap Reconstructions in Pediatric and Young Adult Patients-Outcomes and Potential Factors Influencing Success Rate

Background: Maxillofacial microvascular free-flap reconstructions are significant interventions in the management of congenital defects, traumatic injuries, malignancies, and iatrogenic complications in pediatric and young adult patients. Craniofacial disorders within this demographic can result in profound functional, cosmetic, and psychosocial impairments, highlighting the critical need for thorough investigation into factors that may influence procedural success and postoperative quality of life. This retrospective chart review aims to examine the outcomes and potential influencing factors, aiming to offer valuable insights into optimizing the effectiveness of these reconstructions and improving patient outcomes. Methods: A single head and neck surgical team performed all the included 136 procedures. Demographic and surgical patient data were recorded. Type of transfer performed in each recipient site and major complications were analyzed. Relevant influencing factors, such as age, gender, and etiology of defect were determined using the ANOVA test and χ2 test of independence. Results: The results indicate a 90% success rate. No significant relationship was found between the incidence of total flap loss and patient age, etiology, or graft source. The maxillary reconstructions showed a higher incidence of total flap loss compared to mandibular reconstructions (11 vs. 3 cases). Conclusions: Despite the high success rate, the findings underline the necessity for further research to validate these observations and enhance surgical methods for pediatric and young adult patients.

Development and validation of a novel craniofacial statistical shape model for the virtual reconstruction of bilateral maxillary defects

Bilateral maxillary defects are a challenge for fibula free flap reconstruction (FFFR) surgery due to limitations in virtual surgical planning (VSP) workflows. While meshes of unilateral defects can be mirrored to virtually reconstruct missing anatomy, Brown class c and d defects lack a contralateral reference and associated anatomical landmarks. This often results in poor placement of osteotomized fibula segments. This study was performed to improve the VSP workflow for FFFR using statistical shape modeling (SSM) - a form of unsupervised machine learning - to virtually reconstruct premorbid anatomy in an automated, reproducible, and patient-specific manner. A training set of 112 computed tomography scans was sourced from an imaging database by stratified random sampling. The craniofacial skeletons were segmented, aligned, and processed via principal component analysis. Reconstruction performance was validated on a set of 45 unseen skulls containing various digitally generated defects (Brown class IIa-d). Validation metrics demonstrated promising accuracy: mean 95th percentile Hausdorff distance of 5.47 ± 2.39 mm, mean volumetric Dice coefficient of 48.8 ± 14.5%, compactness of 7.28 × 105 mm2, specificity of 1.18 mm, and generality of 8.12 × 10-6 mm. SSM-guided VSP will allow surgeons to create patient-centric treatment plans, increasing FFFR accuracy, reducing complications, and improving postoperative outcomes.

Bone resorption after maxillary reconstruction with the vascularized free iliac flap

The aim of this study was to evaluate the resorption of the iliac bone after maxillary reconstruction with a vascularized free iliac flap. Twenty-seven patients with maxillary defects who underwent maxillary reconstruction with the vascularized free iliac flap between January 2017 and January 2021 were included. Computed tomography (CT) images taken at 1 week, approximately 6 months, and 1 year after the surgery were used for evaluation. The total iliac bone thickness and height, cortical bone thickness, and cancellous bone density were measured in the CT images. Compared with 1 week after the surgery, the total thickness and height of the iliac bone were reduced significantly 1 year after the surgery, and the cortical bone thickness and cancellous bone density were reduced significantly at 6 months and 1 year after the surgery. Compared with 6 months after the surgery, cancellous bone density was reduced significantly 1 year after the surgery. In conclusion, during the first year after maxillary reconstruction with a vascularized free iliac flap, there was significant resorption of iliac bone, including the total iliac bone thickness and height, the cortical bone thickness, and the cancellous bone density.

Vascularized Free Fibular Flap in Oral and Maxillofacial Reconstruction: A 20-year Experience at a Single Institution Using 2640 Flaps

BACKGROUND

This retrospective study reviewed all patients who underwent oral and maxillofacial reconstruction with fibular flaps in the last 2 decades at a single hospital.

MATERIALS AND METHODS

We reviewed all patients with fibular flaps from 1999 to 2018. The following data were collected: sex; age; reconstruction region; diagnosis; the number of days spent in the hospital after surgery; time spent using a tourniquet for harvesting a fibula flap; vessels at the recipient site; the prevalence of unplanned reoperations; the prevalence of flap failure; history of preoperative radiotherapy; virtual surgical planning; segments of the fibula.

RESULTS

In total, 2640 patients were included. The mean age was 45.5 years. The most prevalent region of reconstruction was the mandible (n=2347, 88.9%). The most common diagnosis was squamous cell carcinoma (n=1057, 40.0%). The mean number of days spent in the hospital after surgery decreased year-by-year from 18.3 days to 10.4 days. The first choice of recipient artery was the facial artery (n=1643, 62.2%) and that of the recipient vein was the external jugular vein (n=1196, 45.3%). The prevalence of surgical success was 97.6%. Prevalence of unplanned reoperations was 7.5%.

CONCLUSIONS

The fibular flap was a good choice for oral and maxillofacial bony reconstruction in most cases.

Reconstruction of nasal airway in patients of class IIId maxillary defect with vastus lateralis muscle-chimeric double skin paddle ALT flap

BACKGROUND

A reconstructive challenge in patients with class IIId maxillary defect is how to obliterate the defect and restore a patent nasal airway. The current strategy using the single anterolateral thigh (ALT) fasciocutaneous flap for reconstruction may result in permanent mouth breathing. As the ALT flap was a common option in reconstruction processes, this study aimed to evaluate the benefits of vastus lateralis (VL) muscle-chimeric double skin paddle ALT flap in simultaneous defect and nasal airway reconstruction.

METHODS

This study included 21 patients with class IIId maxillary defect who underwent free ALT flap reconstruction (n = 11, single ALT flap group; n = 10, VL muscle-chimeric double skin paddle ALT flap (chimeric ALT flap) group) at the China Medical University Hospital from August 2015 to September 2019. Associated parameters collected for analysis included gender, age, body mass index (BMI), operative time, hospitalization, clinical stage, preoperative treatment, flap/defect size, comorbidities, postoperative RT, mouth breathing and short/long term complications.

RESULTS

No significant differences were observed in age, BMI, hospitalization, clinical stage, preoperative treatment, defect size, comorbidities, and postoperative RT between the two groups; however, the chimeric ALT flap group as dominated by male patients (p = 0.009), and had longer operative times (12.1 h vs. 10.1 h, p = 0.002) and larger flap sizes (180 cm² vs. 96.7 cm², p = 0.013). Compared with the chimeric ALT flap group, the single ALT flap group suffered from permanent mouth breathing.

CONCLUSION

Nasal airway reconstruction should be considered in patients with class IIId maxillary defect. Compared to the single ALT flap, the chimeric ALT flap is a superior reconstructive option for patients with class IIId maxillary defect, although a longer surgical duration and larger flap size are required.

Outcome of Reconstruction of Advanced Brown's Maxillary Defect with Free Tissue Transfer: Our Early Experience in a Tertiary Cancer Centre in North-East of India

Reconstructions of the maxillary defect after tumor resection are challenging surgeries. Maxillary reconstructions are done using obturators, locoregional flaps and free tissue transfers. Free flap options available for maxillary reconstruction are radial forearm, anterolateral thigh free flap, free fibular osteocutaneous flap, rectus abdominis myocutaneous flap, scapular, and iliac crest osteomyocutanous free flap etc. This is a single institutional observational study conducted at a tertiary cancer centre in North East India from May 2018 to April 2019. All the reconstructions are done with free tissue transfer. Post-operative outcome was assessed with University of Washington Quality of Life Questionnaire (UW-QOL v4.1). Data was collected from patient records and hospital online reporting system. All data were analysed using SPSS (statistical package for social sciences) version 21. Brown's classification was used to classify maxillary defects in this study. A p value ≤ 0.05 was considered statistically significant. In our study, we included fourteen patients (n = 14), of which anterolateral thigh free flap was used for reconstruction in thirteen cases and in one case free fibular osteocutaneous flap was done. Mean age is 33.36 ± 14 years; there was two flap failure. Flap failure is associated with a statistically significant low swallowing and appearance score (p value is 0.036 for both). The orbital exenteration is associated with low appearance score but it is not statistically significant (p value 0.70), probably due to small sample size in the series. Our early experience of free tissue transfer in maxillary reconstruction is satisfactory in terms of quality of life of the patient as well as the oncological outcome. With positive initial experience in maxillary reconstruction with free flaps large study population will be considered in near future.

Vascular iliac myofascial flap to repair compound defect of the jaw

The vascular iliac myofascial flap is a compound flap with the deep circumflex iliac artery (DCIA) as the vascular pedicle, carrying the iliac bone and parts of the internal oblique, external oblique and muscle-fascial tissue that cover the surface of the iliac crest and inside the iliac bone. The aim of this study was to advocate a feasible surgical strategy for maxillofacial surgeons through our review of clinical applications and to improve the quality of life of patients after the operation. In recent years, Stomatology Hospital of Wuhan University has performed dozens of vascularized iliac myofascial flaps, not only to repair jaw defects but also to complete the repair of intraoral soft tissue defects. 20 patients were followed up. These patients with jaw tumors who received a vascular iliac myofascial flap to repair compound defects of the jaw from 2018 to 2020. The Quality of Life Questionnaire-Head and Neck Cancer-37 (QLQ-H&N37) was used to evaluate their speech function (Z=-0.061, P>0.05) and postoperative aesthetics (Z=-2.824, P<0.05). All patients obtained good surgical results and satisfaction in terms of aesthetics and function. The successful reconstruction of these cases prove that the vascularized iliac composite flap with myofascial tissue is a reliable flap for the reconstruction of maxillofacial defects.

Evolution of midface microvascular reconstruction: three decades of experience from a single institution

PURPOSE

Midface reconstruction poses a complex set of challenges for reconstructive surgeons. The optimal midface reconstruction must possess a durable underlying bone construct capable of integrating dental implants. Facial contour is restored by the overlying microvascular soft tissue reconstruction with reestablishment of the oral cavity. A plethora of microvascular flaps used in clinical practice have been described including those harvested from the iliac crest, scapula, fibula, forearm and back (latissimus dorsi). The objective was to share our experiences with each of these treatment options that have continued to evolve over time for the benefit of patients.

METHODS

Our institution has over three decades of experience in reconstructing complex midface defects and this article summarizes midface reconstruction from an evolutionary perspective (for type II, III and IV defect; Browns classification, Supplementary Table I). We broadly divide this into (i) flaps supplied by the subscapular system (ii) autologous reconstruction with titanium mesh and (iii) fibula microvascular flaps using 3D planning.

RESULTS

The advantages and disadvantages for each approach are discussed (Supplementary Table II).

CONCLUSION

In the future, it is expected that 3D planning coupled with rapid prototyping, intraoperative navigation and CT imaging will become standard procedural practice.

Changing trends in the microvascular reconstruction and oral rehabilitation following maxillary cancer

Purpose

The maxillectomy defect is complex and the best means to achieve optimal reconstruction, and dental rehabilitation is a source of debate. The refinements in zygomatic implant techniques have altered the means and speed by which rehabilitation can be achieved and has also influenced the choice regarding ideal flap reconstruction. The aim of this study is to report on how the method of reconstruction and oral rehabilitation of the maxilla has changed since 1994 in our Institution, and to reflect on case mix and survival.

Methods

Consecutive head and neck oncology cases involving maxillary resections over a 27-year period between January 1994 and November 2020 were identified from hospital records and previous studies. Case note review focussed on clinical characteristics, reconstruction, prosthetic rehabilitation, and survival.

Results

There were 186 patients and the tumour sites were: alveolus for 56% (104), hard palate for 19% (35), maxillary sinus for 18% (34) and nasal for 7% (13). 52% (97) were Brown class 2 defects. Forty-five patients were managed by obturation and 78% (142/183) had free tissue transfer. The main flaps used were radial (52), anterolateral thigh (27), DCIA (22), scapula (13) and fibula (11). There were significant changes over time regarding reconstruction type, use of primary implants, type of dental restoration, and length of hospital stay. Overall survival after 24 months was 64% (SE 4%) and after 60 months was 42% (SE 4%).

Conclusion

These data reflect a shift in the reconstruction of the maxillary defect afforded by the utilisation of zygomatic implants.

Reconstruction of Complete Bilateral Maxillary Defects With Free Flaps

ABSTRACT

Reconstruction of complete bilateral maxillary defects (CBMDs) can be challenging due to the extensive loss of bone and soft tissues. This is a retrospective case series of 46 consecutive patients with CBMDs that were reconstructed with different microvascular free flaps. The authors aimed to evaluate the surgical outcomes and discuss the different reconstruction options in this case series. Thirty-six patients underwent reconstruction following ablation surgery for malignant tumors, 6 for benign tumors, 3 patients were treated for osteomyelitis, and 1 patient underwent free flap reconstruction for posttraumatic defects. Free fibula flap (n = 26) is the most commonly used reconstruction method in this case series, which was used in all defect types. This is followed by anterolateral thigh flap (n = 10), 5 rectus abdominis myocutaneous free flap, 3 radial forearm free flaps, and 2 composite free flaps. In this series, 44 free flaps survived, whereas only 2 flaps were lost. All patients could resume a soft diet postoperatively. Reconstruction of CBMDs with vascularized free flaps is a safe and reliable procedure.

Multiple Sequential Free Flap Reconstructions of the Head and Neck: A Single-Center Experience

BACKGROUND

Free flap reconstruction is the standard of care in extensive defects of the head and neck area, and although most patients may be treated sufficiently with one flap, recurrence of a malignant tumor or failure of a previous reconstruction may make the use of a second (or more) flap necessary. The aim of this study was to evaluate the indications and success rates of multiple consecutive reconstructive procedures in a large cohort of patients.

METHODS

Nine hundred ninety-six free flap reconstructions were retrospectively analyzed and cases of sequential reconstructions in the same patient were identified. Indications, success rates, perioperative procedures, and frequently used flaps were evaluated.

RESULTS

Two hundred twenty cases of sequential microvascular reconstructions were identified, ranging from two to six flaps per patient. The overall flap success rate was 89.1 percent. A history of diabetes was identified as a risk factor for flap failure (p = 0.029). There was no association of flap loss with the number of reconstructive procedures per patient.

CONCLUSIONS

The use of several free flaps in the same patient is a feasible option for patients suffering from recurrent tumors or to improve quality of life by a secondary reconstruction. A salvage free flap transfer to replace a lost transplant exhibits good success rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Rehabilitation of Maxillary Defect Using Zygomatic Implant Retained Obturator

Tumors involving the hard palate, maxillary sinus, or nasal cavity require maxillectomy based on the extent of the lesion. Lack of these boundaries affects the speech, esthetics, and masticatory function. Prosthetic rehabilitation of these defects can be done utilizing zygomatic implants. This present case describes the use of a zygomatic implant to retain a maxillary obturator in a 22-year-old male patient following partial maxillectomy (Brown's Class 2b) due to odontogenic myxoma. A surgical obturator was secured in position subsequent to the implant placement. Following the healing period, an interim obturator using heat cure acrylic was fabricated. Mechanical retention for the definitive obturator was obtained through the ball attachment suspended from the multiunit abutment of the zygomatic implant. The case was followed up closely for a year to evaluate the function of the prosthesis. The prosthetic rehabilitation not only promoted esthetics and function but also improved the patient's quality of life.

Virtual Surgical Planning of Deep Circumflex Iliac Artery Flap for Midface Reconstruction

Objective

Midface reconstruction is challenging for functional and esthetic reasons. The present study analyzed the effect of virtual surgical planning (VSP) of the deep circumflex iliac artery (DCIA) flap for midface reconstruction.

Patients and Methods

Thirty-four patients who underwent midface reconstruction with the DCIA flap were included in this retrospective study. Of the 34 patients, 16 underwent preoperative VSP, which used a three-dimensionally printed surgical guide, computer-assisted navigation system, and pre-bent titanium implants to transfer VSP into real-world surgery. The other 18 patients underwent traditional midface reconstruction. The following were compared between the two groups: bony contact rate in the buttress region (BCR), dental arch reconstruction rate (DAR), surgical approach, position of vascular anastomosis, and dental implantation rate. The independent-samples t-test and Fisher's exact test were used for analysis. P < 0.05 was considered statistically significant.

Results

In total, 12 males and 22 females were included in this study. All patients underwent midface reconstruction using the DCIA flap at the same institution. The median age of patients was 33 years (range: 16-68 years). The average BCR and DAR values in the VSP group were 59.4% ± 27.9% and 87.5% ± 18.9%, respectively, which were significantly higher compared with the non-VSP group (P = 0.049 and P = 0.004, respectively). The dental implantation rate in the VSP group (50.0%) was significantly higher compared with the non-VSP group (11.1%; P = 0.023). The intraoral approach for tumor ablation and vascular anastomosis was the most frequent choice in both groups. There was no significant difference between the two groups. All patients were satisfied with facial symmetry postoperatively.

Conclusions

VSP could effectively augment the effect of midface reconstruction with the DCIA flap. Stronger bone contact in the buttress region and higher DAR provide more opportunity for dental implantation, which might be the best solution to improve masticatory function in patients with midface defects.

Protocol and Evaluation of 3D-Planned Microsurgical and Dental Implant Reconstruction of Maxillary Cleft Critical Size Defects in Adolescents and Young Adults

Functional and esthetic final reconstruction of the cleft maxilla is still challenging. Current reconstructive and augmentation techniques do not provide sufficient bone and soft tissue support for the predictable rehabilitation with dental implants due to presence of maxillary bone critical size defects and soft tissue deficiency, scaring and poor vascularity. In this article the protocol for the use of 3D virtual surgical planning and microvascular tissue transfers for the reconstruction and rehabilitation of cleft maxilla is presented. Twenty-five patients (8 male/17 female) aged 14–41 years old with cleft-associated critical size defects were treated by 3D-virtual planned microvascular tissue transfers taken either from fibula, iliac crest, radial forearm, or medial femoral condyle. Follow-up lasted 1–5 years. No significant bone resorption (p > 0.005) nor volume loss of the graft was observed (p = 0.645). Patients received final permanent prosthetic reconstruction of the anterior maxilla based on 2–5 dental implants, depending on the defect severity. This is the first study presenting the use of virtual planning in the final restoration of the cleft maxilla with microvascular tissue transfers and dental implants. Presented protocol provide highly functional and aesthetic results.

Primary Maxillary Reconstruction With Fibula Flap and Dental Implants: A Comparative Study Between Virtual Surgical Planning and Standard Surgery in Class IIC Defects

PURPOSE

Oncological patients who undergo bilateral subtotal maxillectomies develop functional and esthetic sequelae that require immediate reconstruction. The purpose of this study is to evaluate the primary reconstruction of maxillary defects with fibula flap and dental implants assisted by virtual surgical planning (VSP) and to assess the postoperative outcomes compared with standard surgery.

MATERIAL AND METHODS

A retrospective study was designed between January 2016 and April 2020 with 12 oncologic patients who underwent subtotal bilateral maxillectomy. Six consecutive patients were treated by standard surgical procedure (SS) at the beginning of the study. In 2018, the VSP was implemented, and 6 consecutive patients were treated using this technique. All patients were rehabilitated with Ticare implants and implant prostheses. Anatomic position of the bone, bone apposition, change of vertical distance, and horizontal shift, the operative and ischemia time, the esthetic results, and the functional rehabilitation were evaluated and compared.

RESULTS

The position of the bone in anatomical position was 100% in the VSP group vs 66% in the SS group. The bone apposition was 100% in the VSP group vs 83.3%. The change of vertical distance and the horizontal shift were lower in the VSP group (P < .05). The ischemia time and operative time were shorter in the VSP group (P < .05). A good esthetic result was achieved in 83.3% in the VSP group vs 33.3% in the SS group; 81 dental implants and 1 zygomatic implant were placed. The success rate was 95% in the VSP group and 92.6% in the SS group. All patients were rehabilitated with implant prosthesis.

CONCLUSIONS

VSP improves the accuracy of midface reconstruction (class IIC defect) with a better anatomical position of the bone, a higher rate of bone contact, and a lower change in vertical distance compared with standard surgery. It significantly improves the esthetic result, reduces ischemia time, and operation time.

Revascularized Fibula Free Flap Reconstruction and Curvilinear Transport Distraction Osteogenesis in Closure of Large Postmaxillectomy Defects: A New Gold Standard?

Introduction:

The revascularized fibula free flap (RFFF) is the most popular method of postmaxillectomy reconstruction. This article proves that the use of curvilinear transport distraction osteogenesis (CTDO) is an efficacious way in closing large defects in the maxilla and a superior alternative to the RFFF.

Methods and Materials:

In a prospective cohort study of six postmaxillectomy patients, CTDO was applied and the new bone (regenerate) was compared with the parent bone from which it had been regenerated. These results were compared with a retrospective group of six participants of similar age and sex who had undergone RFFF reconstruction as an external control. Clinical measurements taken at the depth of the alveolar vestibule were recorded at three different exact points juxtaposed, namely (A) lateral incisor, (B) first premolar, and (C) first molar. These areas of interest were similar to those chosen on the CT scans. Impressions were taken from all the patients and stone casts were made. The width of the alveolar bone was computed based on the measurements made from the stone casts. The stone casts were then used to calculate the width and depth of the soft tissue and bone in the maxilla in the (A), (B), and (C) regions.

Results:

The regenerate possessed anatomical and physiological characteristics equal to the parent bone. For the CTDO patients, prosthetic rehabilitation of the dentition was supported by dental implants after osseointegration of the latter into the newly created bone and soft tissue.

Discussion:

The production of the curvilinear bone and soft tissue along a horizontal plane has been demonstrated. The new alveolar bone achieved the correct width and depth to create a physiological vestibule and a functional/esthetic zone for the placement of dental implants. In addition, the shape of the palatal vault was also maintained. The CTDO method is a reliable method of maxillary reconstruction and has a better anatomical and functional outcome than the RFFF.

Considerations in Orbital Reconstruction for the Oncologic Surgeon: Critical versus Optimal Objectives

Background Orbital reconstruction following oncologic midface resection is uniquely challenging, and makes critical contributions to patient aesthetics, function, and identity. Approach is largely dependent on surgeon and patient preferences, and there exists no consensus on defect characterization. Objective The goal of the study is to provide a mental framework for the reconstructive oncologic surgeon to use as a foundation during his or her approach to the orbit. Design The design of the study is based on the review of current literature and expert opinion. Conclusions Critical versus optimal objectives must be set in orbital reconstruction, and a systematic approach should be followed. We approach orbital reconstruction by first deciding whether globe-sparing surgery is possible, or if orbital exenteration will be necessary. We then set critical and optimal objectives for our chosen pathway. Critical goals in globe-sparing reconstruction include maintaining orbital volume and preserving visual function, and an optimal goal includes preservation of the nasolacrimal system. Critical goals in orbital exenteration include obliterating the defect, sealing the skull base and nasal cavities, and allowing eye protection to be worn over the contralateral eye postoperatively. Optimal goals in exenteration include preparation for prosthetics, volume and bony replacement, eyelid-sparing technique, and consideration of postoperative radiation.

Creation of Bone and Soft Tissue in Postmaxillectomy Patients Using Curvilinear Transport Distraction Osteogenesis

BACKGROUND

Large surgical defects in the maxilla due to trauma or tumor are usually reconstructed with revascularized-free fibula flaps (RFFF). In the past, the use of curvilinear transport distraction osteogenesis (CTDO) has been shown to be an efficacious way in closing large defects in the maxilla, but it had limitations which have now been overcome by the present development. The present distractor is an improvement upon the previous three prototypes and employs the concept of tetrafocal distraction by means of hybridizing the bone with the tooth in the transport disc segment. This article aims to prove that tetrafocal distraction provides a viable alternative to the RFFF.

MATERIALS AND METHOD

In a prospective cohort study of six postmaxillectomy patients, the method of CTDO was applied and investigated to ascertain the outcome. The regenerate bone was compared with the parent bone, using a new maxillary transport distractor. A linear bicortical fracture was created in the maxilla in a vertical direction (segmentally) to develop a mobile, vascularized transport disk. This transport disk underwent further subdivision to produce the concept of tetrafocal distraction.

RESULTS

After osseointegration of the dental implants, prosthetic rehabilitation of the dentition was successful. The authors report the successful outcome of two of the six cases subjected to CTDO to treat defects ranging from 25 mm (using bifocal distraction) to 80 mm along a curved trajectory (using tetrafocal distraction).

CONCLUSIONS

The production of curvilinear bone and soft tissue along a horizontal plane has been demonstrated. From a clinical perspective, the new alveolar bone achieved the correct width and height to create a physiological vestibule and an esthetic zone for dental implants. In addition, the shape of the palatal vault is also reconstituted. The tetrafocal method of the CTDO is a reliable method of maxillary reconstruction.

Cortical bone resorption of fibular bone after maxillary reconstruction with a vascularized fibula free flap: a computed tomography imaging study

This study was performed to evaluate the cortical bone resorption of fibular bone after maxillary reconstruction with a fibula free flap. A total of 35 patients with maxillary defects that were repaired using a fibula flap (62 fibula segments) between January 2011 and January 2016 were enrolled. Computed tomography (CT) images taken 1 week and 1 year postoperative were used to evaluate cortical bone resorption. The 62 fibula segments were measured on four different surfaces in the CT images. At 1 week, the thickness of the cortical bone was 2.57 ± 0.58 mm, 2.72 ± 0.46 mm, 3.84 ± 0.98 mm, and 4.36 ± 0.90 mm for the exterior, interior, superior, and inferior sides, respectively. At approximately 1 year, the cortical bone thickness was significantly reduced to 2.00 ± 0.65 mm (P <  0.01), 2.25 ± 0.60 mm (P <  0.01), 3.37 ± 0.90 mm (P <  0.01), and 2.96 ± 0.84 mm (P <  0.01) for the exterior, interior, superior, and inferior sides, respectively. The cortical bone thickness of fibular bone is significantly reduced 1 year after the restoration of maxillary defects with a fibula free flap, most significantly on the inferior side.

Scapula pre-augmentation in sheep with polycaprolactone tricalcium phosphate scaffolds

A scapula free flap is a commonly used method to reconstruct intraoral defects of the mandible and maxilla. Despite its clear advantages, it shows some deficiencies concerning the amount and shape of the available bone, especially with respect to later implant placement. To overcome these limitations, we pre-augmented the scapula prior to a potential flap-raising procedure with polycaprolactone (PCL) tricalcium phosphate (TCP) scaffolds in a sheep model. In our study, the scapula angle was augmented with a block of PCL-TCP in three adult sheep. After 6 months, the amount of newly formed bone and scaffold degradation were evaluated using cone-beam computed tomography scans and histomorphometric analysis. All animals survived the study and showed no problems in the augmented regions. The scaffolds were attached firmly to the scapula and showed a bonelike consistency. A fair amount of the scaffold material was degraded and replaced by vital bone. Our method seems to be a valid approach to pre-augment the scapula in sheep. In further experiments, it will be interesting to determine whether it is possible to transplant a modified scapula flap to an intraoral defect site.

Mandibular Reconstruction: Overview

INTRODUCTION

Mandibular reconstruction has changed significantly over the years and continues to evolve with the introduction of newer technologies and techniques.

PURPOSE

This article reviews the history of oromandibular reconstruction, biomechanics of mandible, summarizes the reconstruction options available for mandible with defect classification, goals in reconstruction, the various donor sites, current reconstructive options, dental rehabilitation and persistent associated problems.

SUMMARY

Oromandibular reconstruction, although a challenge for the head and neck reconstructive surgeon, is now reliable and highly successful with excellent long-term functional and aesthetic outcomes with the use of autogenous bone grafts and current reconstructive options. The ideal reconstruction would provide a solid arch to articulate with the upper jaw, restoring swallowing speech, mastication, and esthetics. Autogenous vascularized bone grafts in combination with microsurgical techniques have revolutionized mandibular reconstruction in oral cancer surgery. Current trends in mandibular reconstruction aim to achieve reestablishment of a viable mandible of proper form and maxillary mandibular relationship while decreasing the need for invasive autogenous graft procurement. However the optimal reconstruction of mandibular defects is still controversial in regards to reconstructive options which include the donor site selection, timing of surgery and method of reconstruction.

Midfacial Reconstruction - A Systematic Review

AIM:

Different lesions affecting the midfacial regions require surgical reconstruction. The aim of this study was to assess the different methods used in midfacial reconstruction after maxillectomy procedures. The various reported surgical reconstructive techniques focusing on the esthetic and functional outcomes are to be reviewed in this article.

MATERIAL AND METHODS:

A thorough PUBMED and hand-search of journals of relevance was performed on related terms and yielded 772 titles of which 45 abstracts were selected and obtained as full articles for further evaluation while the rest were excluded by title/abstract. According to the inclusion criteria; 14 of these studies were used to complete this article.

RESULTS:

In this review we showed that fibular and radial vascularized grafts were the most commonly reported methods in literature with a few other options. Computer aided design and surgical planning has been also reviewed and seems to be a rapidly evolving option for maxillofacial reconstruction. Lack of RCTs (randomized controlled trials) and large scale case series was noticed in this review making the evidence of poor quality.

CONCLUSION:

Methods of evaluation of reconstruction options mainly qualitative and subjective made the evaluation of the techniques in this review difficult.

Free flap reconstruction for patients with bisphosphonate related osteonecrosis of the jaws after mandibulectomy

INTRODUCTION

Bisphosphonate related osteonecrosis of the jaws (BRONJ) is a recognised unwanted effect of these drugs which affect bone remodelling. Treatment options range from conservative approaches through local bone debridement to free flap reconstruction following segmental resection. This current study aims to evaluate clinical outcomes after microvascular tissue transfer in BRONJ patients.

MATERIAL AND METHODS

A total of 212 BRONJ patients were included in this prospective investigation. Those who met defined inclusion criteria and received a surgical intervention were reviewed regularly during a follow-up period of at least 6 months.

RESULTS

Twenty-five patients (11.8%) received free flap reconstructions. A mean of 2.12 local debridements were performed before microvascular tissue transfer. A mean of 29.25% showed BRONJ recurrence after minimalist surgical intervention, compared to significantly less in patients after resection and free flap reconstruction. The postoperative fistula rate was significantly higher in patients, who received mucoperiosteal flaps.

DISCUSSION

This study underlines the importance and effectiveness radical resection and free flap reconstruction in the complex and challenging surgical treatment of BRONJ patients in a large patient cohort study. Nevertheless, all patients received radical intervention after failure of minimally invasive treatment. An individualized analysis and planning is necessary to identify appropriate patients for free flap reconstructions.

Maxillary reconstruction: Current concepts and controversies

Maxillary reconstruction is still an evolving art when compared to the reconstruction of the mandible. The defects of maxilla apart from affecting the functions of the speech, swallowing and mastication also cause cosmetic disfigurement. Rehabilitation of the form and function in patients with maxillary defects is either by using an obturator prosthesis or by a surgical reconstruction. Literature is abundant with a variety of reconstructive methods. The classification systems are also varied, with no universal acceptance of any one of them. The oncologic safety of these procedures is still debated, and conclusive evidence in this regard has not emerged yet. Management of the orbit is also not yet addressed properly. Tissue engineering, that has been hyped to be one of the possible solutions for this vexing reconstructive problem, has not come out with reliable and reproducible results so far. This review article discusses the rationale and oncological safety of the reconstructing the maxillary defects, critically analyzes the classification systems, offers the different reconstructive methods and touches upon the controversies in this subject. The management of the retained and exenterated orbit associated with maxillectomy is reviewed. The surgical morbidity, complications and the recent advances in this field are also looked into. An algorithm, based on our experience, is presented.

Outcome of microvascular free flaps in a high-volume training centre

PURPOSE

Microvascular free tissue transfer allows major ablative defects following oncologic surgical and traumatic reasons to be reliably reconstructed in the head and neck region. A retrospective analysis of the microvascular flap procedures which were performed within one year in a high volume training centre was performed.

PATIENTS AND METHODS

The microvascular free flap procedures of the year 2011 were reviewed and followed up until the 31st December 2012. The type and indication of the reconstructive procedure, operation time, operating team, experience and level of training of the surgeons involved, postoperative IMC (intermediate care unit) and/or ICU (intensive care unit) time, inpatient time, flap revisions, further postoperative complications, preoperative and postoperative radiation of the patients, the placement of dental implants were studied.

RESULTS

From 1st of January 2011 to 31st of December, 2011, the data of 101 patients with 103 microvascular free flap procedures were analysed of which 72% (84 flaps) were harvested by residents. The patients ranged in age from 14 to 89 years (mean age 59 years, 71 males and 40 females). The mean operation time was 591 min with the longest operation times for scapular flaps (744 min) and the shortest operation times for ALT flaps (455 min). Mean inpatient time was 34.2 days with a minimal time for the fibular flaps of 27.2 days and a maximum of 45.7 days for the latissimus dorsi flaps. 24 flaps (23.3%) in total had to be revised with bleeding being the main cause of immediate revisions (41.7% of all revisions). 5 flaps (4.85% of all flaps) were lost despite a revision procedure meaning a successful revision rate in 79.2% of all revisions.

CONCLUSION

Microvascular reconstruction procedures are safe and should be considered as standard procedures for reconstruction of large defects especially in high volume training centres. Intensive flap monitoring and early revisions maximize the flap outcome.

Development of the clinical use of distant flaps for head and neck reconstruction

The reconstruction of hard and soft tissue defects, mainly after ablative oncologic surgery in the head and neck area, is an evolving field. The use of free flaps for reconstruction of the head and neck is considered to be the surgical standard. In our analysis of more than 1000 free flaps we give an overview of the development of the use of different types of free tissue transfer to the head and neck area over the last 25 years. We show that the evolving field of head and neck reconstruction raises new possibilities with new types of flaps, whereas other types of flaps disappear in the everyday clinical use. The spectrum of reconstruction possibilities broadens with the number of different flap types available to the head and neck surgeon.

Comparison of outcome of microvascular bony head and neck reconstructions using the fibular free flap and the iliac crest flap

Several microvascular free flaps are available for reconstruction of the osseous components after resections for head and neck cancer. We have prospectively evaluated patients treated by bony microsurgical reconstruction to identify predictors of adverse outcomes for delayed wound healing and failure of free flaps. All patients from July 2007 to June 2011 who had reconstructions with microvascular fibular or iliac crest flaps immediately after resection of the tumour were evaluated. There were a total of 156 bony free flaps: 120 (77%) fibular and 36 (23%) iliac crest flaps. A total of 133 (85%) were successful. Delayed wound healing was more common with the iliac crest flap (p=0.01) at the intraoral site (p=0.04). Significantly more iliac crest free flaps failed (p=0.02). Anastomosis to the facial artery (p=0.05) and facial vein (p=0.04), and duration of overall operating time were associated with a significantly higher risk of failure of the flap. Patients with cancer of the head and neck who require microsurgical bony reconstruction are at increased risk of postoperative complications. Significantly more complications were found with the iliac crest flap, whereas the fibular flap was associated with a significantly longer operating time.

Classification of maxillectomy defects: a systematic review and criteria necessary for a universal description

STATEMENT OF PROBLEM

Maxillectomy defects are complex and involve a number of anatomic structures. Several maxillectomy defect classifications have been proposed with no universal acceptance among surgeons and prosthodontists. Established criteria for describing the maxillectomy defect are lacking.

PURPOSE

This systematic review aimed to evaluate classification systems in the available literature, to provide a critical appraisal, and to identify the criteria necessary for a universal description of maxillectomy and midfacial defects.

MATERIAL AND METHODS

An electronic search of the English language literature between the periods of 1974 and June 2011 was performed by using PubMed, Scopus, and Cochrane databases with predetermined inclusion criteria. Key terms included in the search were maxillectomy classification, maxillary resection classification, maxillary removal classification, maxillary reconstruction classification, midfacial defect classification, and midfacial reconstruction classification. This was supplemented by a manual search of selected journals. After application of predetermined exclusion criteria, the final list of articles was reviewed in-depth to provide a critical appraisal and identify criteria for a universal description of a maxillectomy defect.

RESULTS

The electronic database search yielded 261 titles. Systematic application of inclusion and exclusion criteria resulted in identification of 14 maxillectomy and midfacial defect classification systems. From these articles, 6 different criteria were identified as necessary for a universal description of a maxillectomy defect. Multiple deficiencies were noted in each classification system. Though most articles described the superior-inferior extent of the defect, only a small number of articles described the anterior-posterior and medial-lateral extent of the defect. Few articles listed dental status and soft palate involvement when describing maxillectomy defects.

CONCLUSIONS

No classification system has accurately described the maxillectomy defect, based on criteria that satisfy both surgical and prosthodontic needs. The 6 criteria identified in this systematic review for a universal description of a maxillectomy defect are: 1) dental status; 2) oroantral/nasal communication status; 3) soft palate and other contiguous structure involvement; 4) superior-inferior extent; 5) anterior-posterior extent; and 6) medial-lateral extent of the defect. A criteria-based description appears more objective and amenable for universal use than a classification-based description.

Implant mandibular rehabilitation postoncologic segmental resection: a clinical report

In cases of reconstruction of a discontinuity defect of the mandible, the surgeon has a major responsibility to maximize function as well as cosmetics and to preserve quality of life, restoring mastication, speech, and appearance. Treatment of mandibular discontinuity defects is a complex process and, among other methods, includes the use of free vascularized flaps. A variety of donor sites have been used for this purpose, including the iliac crest, radius, scapula, and fibula.At this time, the iliac crest free flap represents a versatile reconstruction method after mandibular ablation. This article reports a clinical case using the iliac crest free flap for comprehensive reconstruction of discontinuity defects in the mandible after resections of an aggressive odontogenic tumor. The immediate implant positioning reduced the number of surgical procedures and the rehabilitation time.