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Chen J, Wang J, Guo J, Wang X, Kang Y, Wang Y, Guo C. Prediction of jaw opening function after mandibular reconstruction using subject-specific musculoskeletal modelling. J Oral Rehabil 2024; 51:1050-1060. [PMID: 38544336 DOI: 10.1111/joor.13670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 02/09/2024] [Accepted: 02/16/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Mandibular reconstruction patients often suffer abnormalities in the mandibular kinematics. In silico simulations, such as musculoskeletal modelling, can be used to predict post-operative mandibular kinematics. It is important to validate the mandibular musculoskeletal model and analyse the factors influencing its accuracy. OBJECTIVES To investigate the jaw opening-closing movements after mandibular reconstruction, as predicted by the subject-specific musculoskeletal model, and the factors influencing its accuracy. METHODS Ten mandibular reconstruction patients were enrolled in this study. Cone-beam computed tomography images, mandibular movements, and surface electromyogram signals were recorded preoperatively. A subject-specific mandibular musculoskeletal model was established to predict surgical outcomes using patient-averaged muscle parameter changes as model inputs. Jaw bone geometry was replaced by surgical planning results, and the muscle insertion sites were registered based on the non-rigid iterative closest point method. The predicted jaw kinematic data were validated based on 6-month post-operative measurements. Correlations between the prediction accuracy and patient characteristics (age, pathology and surgical scope) were further analysed. RESULTS The root mean square error (RMSE) for lower incisor displacement was 31.4%, and the error for peak magnitude of jaw opening was 4.9 mm. Age, post-operative infection and radiotherapy influenced the prediction accuracy. The amount of masseter detachment showed little correlation with jaw opening. CONCLUSION The mandibular musculoskeletal model successfully predicted short-range jaw opening functions after mandibular reconstruction. It provides a novel surgical planning method to predict the risk of developing trismus.
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Affiliation(s)
- Junpeng Chen
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Engineering Research Center of Oral Biomaterials and Digital Medical Devices & Beijing Key Laboratory of Digital Stomatology, Beijing, China
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Zhejiang University Medical College, Zhejiang, China
| | - Jing Wang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Engineering Research Center of Oral Biomaterials and Digital Medical Devices & Beijing Key Laboratory of Digital Stomatology, Beijing, China
| | - Jianqiao Guo
- MOE Key Laboratory of Dynamics and Control of Flight Vehicle, School of Aerospace Engineering, Beijing Institute of Technology, Beijing, China
| | - Xinyue Wang
- MOE Key Laboratory of Dynamics and Control of Flight Vehicle, School of Aerospace Engineering, Beijing Institute of Technology, Beijing, China
| | - Yanfeng Kang
- Department of Prosthodontics, Center for Oral Functional Diagnosis, Treatment and Research Peking University School of Stomatology, Beijing, China
| | - Yang Wang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Engineering Research Center of Oral Biomaterials and Digital Medical Devices & Beijing Key Laboratory of Digital Stomatology, Beijing, China
| | - Chuanbin Guo
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Engineering Research Center of Oral Biomaterials and Digital Medical Devices & Beijing Key Laboratory of Digital Stomatology, Beijing, China
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Cohen Z, Graziano FD, Shamsunder MG, Shahzad F, Boyle JO, Cohen MA, Matros E, Nelson JA, Allen RJ. Miniplate Versus Reconstruction Bar Fixation for Oncologic Mandibular Reconstruction with Free Fibula Flaps. J Reconstr Microsurg 2024; 40:87-95. [PMID: 37030287 PMCID: PMC11334751 DOI: 10.1055/a-2070-8677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2023]
Abstract
BACKGROUND Fibula free flaps (FFF) are the gold standard tissue for the reconstruction of segmental mandibular defects. A comparison of miniplate (MP) and reconstruction bar (RB)-based fixation of FFFs has been previously described in a systematic review; however, long-term, single-center studies comparing the two plating methods are lacking. The authors aim to examine the complication profile between MPs and RBs at a single tertiary cancer center. We hypothesized that increased components and a lack of rigid fixation inherent to MPs would lead to higher rates of hardware exposure/failure. METHODS A retrospective review was performed from a prospectively maintained database at Memorial Sloan Kettering Cancer Center. All patients who underwent FFF-based reconstruction of mandibular defects between 2015 and 2021 were included. Data on patient demographics, medical risk factors, operative indications, and chemoradiation were collected. The primary outcomes of interest were perioperative flap-related complications, long-term union rates, osteoradionecrosis (ORN), return to the operating room (OR), and hardware exposure/failure. Recipient site complications were further stratified into two groups: early (<90 days) and late (>90 days). RESULTS In total, 96 patients met the inclusion criteria (RB = 63, MP = 33). Patients in both groups were similar with respect to age, presence of comorbidities, smoking history, and operative characteristics. The mean follow-up period was 17.24 months. In total, 60.6 and 54.0% of patients in the MP and RB cohorts received adjuvant radiation, respectively. There were no differences in rates of hardware failure overall; however, in patients with an initial complication after 90 days, MPs had significantly higher rates of hardware exposure (3 vs. 0, p = 0.046). CONCLUSION MPs were found to have a higher risk of exposed hardware in patients with a late initial recipient site complication. It is possible that improved fixation with highly adaptive RBs designed by computer-aided design/manufacturing technology explains these results. Future studies are needed to assess the effects of rigid mandibular fixation on patient-reported outcome measures in this unique population.
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Affiliation(s)
- Zack Cohen
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Francis D Graziano
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Meghana G Shamsunder
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Farooq Shahzad
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jay O Boyle
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc A Cohen
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert J Allen
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
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Mathews S, Jaiswal D, Yadav P, Shankhdhar VK, Hadgaonkar S, Mantri M, Bindu A, Pilania V, Mohammad A, Escandón JM. Management of Through-and-Through Oromandibular Defects after Segmental Mandibulectomy with Fibula Osteocutaneous Flap. J Reconstr Microsurg 2024; 40:1-11. [PMID: 36958344 DOI: 10.1055/a-2060-9950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND Oromandibular defects involving the external skin are a reconstructive challenge. This study aimed to evaluate the use of the fibula osteocutaneous free flap (FOCFF) for through-and-through oromandibular defects by comparing the surgical outcomes and complications of different techniques to close the external skin defect. METHODS A retrospective analysis was conducted of patients who underwent reconstruction of through-and-through oromandibular defects after oncologic segmental mandibulectomy between January 2011 and December 2014. Five groups were analyzed according to the method of external skin coverage: primary closure, locoregional flaps, deepithelialized double-skin paddle FOCFF (deEpi-FOCFF), division of the skin paddle for double-skin paddle FOCFF (div-FOCFF), and a simultaneous second free flap. Intraoperative and postoperative outcomes along with complications were analyzed between groups. RESULTS A total of 323 patients were included. The mean total defect area requiring a simultaneous second free flap was larger in comparison to other groups (p < 0.001). Reconstructions performed with div-FOCFF had a higher number of perforators per flap when compared with deEpi-FOCFF (p < 0.001). External defects closed with another free flap exhibited higher intraoperative time for the reconstructive segment in comparison to other groups (p < 0.05). The overall rate of complications was comparable between groups (24%, p = 0.129). CONCLUSION The FFOCF is a reliable alternative to harvesting multiple simultaneous free flaps for through-and-through oromandibular defects. The authors recommend appropriate curation of the surgical plan based on individual patient characteristics and reconstructive requirements.
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Affiliation(s)
- Saumya Mathews
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Dushyant Jaiswal
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Prabha Yadav
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vinay Kant Shankhdhar
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sumit Hadgaonkar
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Mayur Mantri
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Ameya Bindu
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vineet Pilania
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Arbab Mohammad
- Aarupadai Veedu Medical College and Hospital, Puducherry, India
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
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Chan TG, Nickel C, Solares C, Irizarry R, Pipkorn P, Baddour HM, Gross JH. Stacked fibula flap for unilateral total maxillectomy reconstruction with orbital preservation. Head Neck 2024; 46:218-227. [PMID: 37933883 DOI: 10.1002/hed.27567] [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: 08/04/2023] [Revised: 10/12/2023] [Accepted: 10/23/2023] [Indexed: 11/08/2023] Open
Abstract
Unilateral total maxillectomy is indicated for locally advanced maxillary tumors that require complete removal of the midface bony structure and inferior orbital rim. Reconstruction of this defect is challenging due to aesthetic and functional concerns. A retrospective review of patients at two tertiary-care institutions undergoing unilateral total maxillectomy reconstruction with a stacked fibula flap from 2018 to 2022 was performed. Each patient's clinical course was reviewed, and attention was focused on the demonstration of surgical steps with photos. Twenty patients underwent stacked fibula flap reconstruction for unilateral total maxillectomy orbital preservation defects. Surgical extirpation was performed for malignancy (80%, 16/20) and for osteoradionecrosis or benign tumor in 20% (4/20). The complication rate was 30% (6/20). Most flaps survived (95%, 19/20). We present a modified, reproducible method of fibula flap reconstruction for unilateral total maxillectomy with orbital preservation that only requires two segments and maintains positive aesthetic and functional results.
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Affiliation(s)
- Tyler G Chan
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Chris Nickel
- Department of Otolaryngology - Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Clementino Solares
- Department of Otolaryngology - Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Rachel Irizarry
- Department of Otolaryngology - Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Patrik Pipkorn
- Department of Otolaryngology - Head and Neck Surgery, Siteman Cancer Institute, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Harry Michael Baddour
- Department of Otolaryngology - Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jennifer H Gross
- Department of Otolaryngology - Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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Sun Q, Zhu Z, Meng F, Zhao R, Li X, Long X, Li Y, Dong H, Zhang T. Application of a modified osteotomy and positioning integrative template system (MOPITS) based on a truncatable reconstruction model in the precise mandibular reconstruction with fibula free flap: a pilot clinical study. BMC Oral Health 2023; 23:842. [PMID: 37940900 PMCID: PMC10630995 DOI: 10.1186/s12903-023-03596-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Mandibular defects can greatly affect patients' appearance and functionality. The preferred method to address this issue is reconstructive surgery using a fibular flap. The current personalized guide plate can improve the accuracy of osteotomy and reconstruction, but there are still some problems such as complex design process and time-consuming. Therefore, we modified the conventional template to serve the dual purpose of guiding the mandible and fibula osteotomy and facilitating the placement of the pre-bent titanium. METHODS The surgery was simulated preoperatively using Computer-Aided Design (CAD) technology. The template and truncatable reconstruction model were produced in the laboratory using 3D printing. After pre-bending the titanium plate according to the contour, the reconstruction model was truncated and the screw trajectory was transferred to form a modified osteotomy and positioning integrative template system (MOPITS). Next, the patient underwent a composite template-guided vascularized fibula flap reconstruction of the mandible. All cases were reviewed for the total operative time and accuracy of surgery. RESULTS The procedures involved 2-4 fibular segments in 15 patients, averaging 3 fibular segments per procedure. The osteotomy error is 1.01 ± 1.02 mm, while the reconstruction angular error is 1.85 ± 1.69°. The preoperative and postoperative data were compared, and both p > 0.05. During the same operation, implant placement was performed on four patients, with an average operative time of 487.25 ± 60.84 min. The remaining malignant tumor patients had an average operative time of 397.18 ± 73.09 min. The average postoperative hospital stay was 12.95 ± 3.29 days. CONCLUSIONS This study demonstrates the effectiveness of MOPITS in facilitating precise preoperative planning and intraoperative execution of fibula flap reconstruction. MOPITS represents a promising and reliable tool for reconstructive surgery, particularly for inexperienced surgeons navigating the challenges of mandible defect reconstruction.
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Affiliation(s)
- Qing Sun
- Department of Plastic Surgery, Peking Union Medical College &, Chinese Academy of Medical Science, Beijing, China
| | - Zhihui Zhu
- Department of Stomatology, Peking Union Medical College &, Chinese Academy of Medical Science, Beijing, China
| | - Fanhao Meng
- Department of Stomatology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ruiqi Zhao
- Department of Stomatology, Peking Union Medical College &, Chinese Academy of Medical Science, Beijing, China
| | - Xing Li
- Department of Stomatology, Peking Union Medical College &, Chinese Academy of Medical Science, Beijing, China
| | - Xiao Long
- Department of Plastic Surgery, Peking Union Medical College &, Chinese Academy of Medical Science, Beijing, China
| | - Yansheng Li
- Beijing University of Technology, Beijing, China
| | - Haitao Dong
- Department of Stomatology, Peking Union Medical College &, Chinese Academy of Medical Science, Beijing, China
| | - Tao Zhang
- Department of Stomatology, Peking Union Medical College &, Chinese Academy of Medical Science, Beijing, China.
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Wüster J, Hesse B, Rothweiler R, Bortel E, Gross C, Bakhtiyari S, King A, Boller E, Gerber J, Rendenbach C, Fretwurst T, Preissner S, Heiland M, Nelson K, Nahles S. Comparison of the 3D-microstructure of human alveolar and fibula bone in microvascular autologous bone transplantation: a synchrotron radiation μ-CT study. Front Bioeng Biotechnol 2023; 11:1169385. [PMID: 37691907 PMCID: PMC10486015 DOI: 10.3389/fbioe.2023.1169385] [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: 02/19/2023] [Accepted: 08/01/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction: Autologous bone transplantation is successfully used in reconstructive surgery of large/critical-sized bone defects, whereby the microvascular free fibula flap is still regarded as the gold standard for the reconstruction of such defects in the head and neck region. Here, we report the morphological and lacunar properties of patient-paired bone samples from eight patients from the jaw (AB; recipient site) and the fibula (FB; donor site) on the micron length-scale using Synchrotron µ-CT. Insights into differences and similarities between these bone structures could offer a better understanding of the underlying mechanism for successful surgical outcomes and might clear the path for optimized, nature-inspired bone scaffold designs. Methods: Spatial vessel-pore arrangements, bone morphology, fluid-simulation derived permeability tensor, osteocyte lacunar density, and lacunar morphology are compared. Results: The orientation of the vessel system indicates a homogenous vessel orientation for AB and FB. The average mineral distance (50%) to the closest vessel boundary is higher in AB than in FB (the mean is 96 μm for AB vs. 76 μm for FB; p = 0.021). Average osteocyte lacunar density is found to be higher in AB than in FB (mean 22,874 mm3 vs. 19,376 mm3 for FB; p = 0.038), which might compensate for the high distance from the mineral to the nearest vessel. No significant differences in lacunar volume are found between paired AB and FB. Discussion: A comparable vessel network and similar distribution of vessel porosity between AB and FB may allow the FB graft to exhibit a high regeneration potential when connected to AB, and this might correlate with a high osteoinductive and osteoconductive potential of FB when connected to AB. Since widely used and potent synthetic bone grafts exist, new insight into the bone structure of well-established autologous bone grafts, such as the free fibula flap, could help to improve the performance of such materials and therefore the design of 3D scaffolds.
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Affiliation(s)
- Jonas Wüster
- Department of Oral and Maxillofacial Surgery, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bernhard Hesse
- Xploraytion GmbH, Berlin, Germany
- European Synchrotron Radiation Facility, Grenoble, France
| | - Rene Rothweiler
- Department of Oral- and Craniomaxillofacial Surgery, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | | | - Christian Gross
- Department of Oral- and Craniomaxillofacial Surgery, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | | | | | - Elodie Boller
- European Synchrotron Radiation Facility, Grenoble, France
| | | | - Carsten Rendenbach
- Department of Oral and Maxillofacial Surgery, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Tobias Fretwurst
- Department of Oral- and Craniomaxillofacial Surgery, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Saskia Preissner
- Department of Oral and Maxillofacial Surgery, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Katja Nelson
- Department of Oral- and Craniomaxillofacial Surgery, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Susanne Nahles
- Department of Oral and Maxillofacial Surgery, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
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Murugan S, Bera RN, Tiwari P. Outcome of Mandibular Reconstruction with Fibula free Flaps: Retrospective Analysis of Complications. Indian J Otolaryngol Head Neck Surg 2023; 75:563-570. [PMID: 37274963 PMCID: PMC10235393 DOI: 10.1007/s12070-022-03344-2] [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: 04/19/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022] Open
Abstract
Rationale: Fibula free flap has become the workhorse for head and neck reconstruction. In this retrospective study we aimed at determining the outcomes of mandibular reconstruction with fibula free flaps. Methods: Any patient who underwent a mandibulectomy and reconstructed with vascularised fibula flap was included in the study. The predictor variables were age, sex, type of lesion, tobacco and alcohol use, tracheostomy, neck dissection, post operative radio and chemotherapy. Flap failure, fistulas, dehiscence, bone exposure and hardware complications were the outcomes. A P value of < 0.05 was considered statistically significant. Results: 242 patient records were selected for evaluation. PORT, CRT, neck dissection, no. of segments were the factors significantly associated with every complication. Malignant lesion was significantly associated with every complication except for plate fracture. Plate fracture although occurred more frequently with malignant diseases, the association was insignificant. Tobacco consumption was significantly associated with increased incidence of post -operative complications. Alcohol consumption was significantly associated with plate fracture, screw loosening, fistulas, bone exposure and flap failure. Conclusion: Overall the fibula free flap has a success rate of 90.0% with fistulas being the most significant complication. Supplementary Information The online version contains supplementary material available at 10.1007/s12070-022-03344-2.
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Affiliation(s)
- Senthil Murugan
- Department of Oral and Maxillofacial Surgery, Saveetha Dental College and Hospital, Chennai, India
| | - Rathindra Nath Bera
- Department of Oral and Maxillofacial Surgery, Dental Institute, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Preeti Tiwari
- Faculty of Dental Sciences Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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Anagnos VJ, Brody RM, Carey RM, De Ravin E, Tasche KK, Newman JG, Shanti RM, Chalian AA, Rassekh CH, Weinstein GS, O'Malley BW, Cannady Md SB. Post-operative Monitoring for Head and Neck Microvascular Reconstruction in the Era of Resident Duty Hour Restrictions: A Retrospective Cohort Study Comparing 2 Monitoring Protocols. Ann Otol Rhinol Laryngol 2023; 132:310-316. [PMID: 35473389 DOI: 10.1177/00034894221088176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To determine whether 2 different methods of post-operative head and neck free flap monitoring affect flap failure and complication rates. METHODS A retrospective chart review of 803 free flaps performed for head and neck reconstruction by the same microvascular surgeon between July 2013 and July 2020 at 2 separate hospitals within the same healthcare system. Four-hundred ten free flaps (51%) were performed at Hospital A, a medical center where flap checks were performed at frequent, scheduled intervals by in-house resident physicians and nurses; 393 free flaps (49%) were performed at Hospital B, a medical center where flap checks were performed regularly by nursing staff with resident physician evaluation as needed. Total free flap failure, partial free flap failure, and complications (consisting of wound infection, fistula, and reoperation within 1 month) were assessed. RESULTS There were no significant differences between Hospitals A and B when comparing rates of total free flap failure, partial free flap failure, complication, or re-operation (P = .27, P = .66, P = .65, P = .29, respectively). There were no significant differences in urgent re-operation rates for flap compromise secondary to thrombosis and hematoma (P = .54). CONCLUSIONS In our series, free flap outcomes did not vary based on the degree of flap monitoring by resident physicians. This data supports the ability of a high-volume, well-trained, nursing-led flap monitoring program to detect flap compromise in an efficient fashion while limiting resident physician obligations in the age of resident duty hour restrictions.
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Affiliation(s)
- Vincent J Anagnos
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Brody
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan M Carey
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Emma De Ravin
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kendall K Tasche
- Department of Otorhinolaryngology: Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jason G Newman
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Rabie M Shanti
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Department of Oral and Maxillofacial Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Ara A Chalian
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher H Rassekh
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory S Weinstein
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Bert W O'Malley
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven B Cannady Md
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
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9
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An Analysis of Volume, Length and Segmentation of Free Fibula Flap in Reconstruction of the Jaws: Investigation of Their Role on Flap Failure. REPORTS 2023. [DOI: 10.3390/reports6010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Reconstruction of defects of the jaws is mainly performed via free fibula flap. An incidence of 2–21% of overall flap failure is still described. We investigated the roles of volume, length and number of fibula flap segments on flap survival using novel three-dimensional segmentation tools. We also analyzed the role of other possible risk factors. Seventy-one consecutive patients with a follow up of at least three months and who underwent free fibula flap reconstruction in a single center between 2002 and 2022 have been evaluated. A total of 166 fibula segments were analyzed. Malignancies were the main reason of resection (45.1%). In 69% of the cases a reconstruction of the mandible was performed. The flaps were mainly divided in two segments (39%) (range 1–4), with a mean length of 2.52 cm and a mean volume was 3.37 cm3. Total flap failure (TFF) occurred in 12 cases, (16.9%), while partial flap failure (PFF) appeared in 3 patients (4.2%). Volume, length and number of fibula flap segments did not seem to influence flap failure incidence in uni- and multivariate analysis. Reconstruction of the maxilla and use of a recipient vessel different from the facial artery seemed to significantly impact on flap failure. Smoking and previous surgeries showed a higher trend to flap failure, but they did not reach statistical significance. Prospective and multicentric analysis on a wider population should be assessed.
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10
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Risk factors associated with postoperative complications following free flap reconstruction of head and neck defects. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e894-e898. [PMID: 34971838 DOI: 10.1016/j.jormas.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/08/2021] [Accepted: 12/21/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Free flap reconstruction of head and neck defects is routinely performed with a high success rate nowadays. However, postoperative complications are still commonly observed. The aim of this study is to investigate risk factors correlated with postoperative complications following free flap reconstruction of head and neck defects. METHODS A retrospective study of all patients undergoing free flap reconstruction of head and neck defects between January 2018 and January 2020 at Sun Yat-sen Memorial Hospita, Guangzhou, China was performed. Preoperative, intraoperative, and postoperative data were collected retrospectively. The primary outcome variables were postoperative complications, which were divided into medical and surgical complications. All patients were grouped by either complications or no complications. Univariate and multivariate logistic regression models were used to identify risk factors predicting complications. RESULTS 850 patients underwent free flap reconstruction of head and neck defects during the study period (Male: 65.29%; Mean [SD] age: 54.90 [13.78] years). Postoperative complications developed in 125 (14.71%) patients, among which, 101 (11.88%) patients developed surgical complications, 29 (3.41%) patients developed medical complications and 5 (0.59%) patients developed both surgical and medical complications. Total flap necrosis was observed in 11 (1.29%) patients. After multivariate analysis, several risk factors incluing postoperative ICU admission, coronary heart disease, post radiotherapy surgery and flap types were identified correlated with postoperative complications. CONCLUSIONS Our study identified related variables for a higher risk of postoperative complications development following free flap reconstruction of head and neck defects. Early detection of these risk factors will improve prognosis.
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Nocini R, Favero V, Chiarini L, Nocini PF. Bilateral reconstruction of the mandibular body with symphyseal preservation using a single fibula free flap: operative technique. J Otolaryngol Head Neck Surg 2022; 51:29. [PMID: 35902896 PMCID: PMC9330650 DOI: 10.1186/s40463-022-00579-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/20/2022] [Indexed: 11/14/2022] Open
Abstract
Background Mandibular osteonecrosis may occur in 5% of the patients who undergo radiotherapy for the treatment of head and neck malignancies. Resection and microvascular reconstruction is the treatment of choice in complicated osteoradionecrosis, however multifocal presentation may complicate the management of the disease given the poor quality and limited availability of adequate recipient vessels.
Operative technique A 74-year-old man affected by multifocal severe osteoradionecrosis of the mandible underwent bilateral resection of the mandibular bodies while preserving the symphysis. The defects were reconstructed with a single fibula flap composed by two bony segments connected by a central segment, corresponding to the symphyseal region, in which the bone was dissected and removed. The anastomosis was performed on a single side of the neck. Healing was uneventful and the adopted technique allowed for a quick functional and esthetic recovery.
Conclusion The presented technique provided a safe and efficacious, although technically challenging, solution in a case presenting multifocal osteonecrosis of the jaw. The morbidity of the procedure was limited because the tissue resection and reconstruction processes were minimized. Graphical Abstract ![]()
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Affiliation(s)
- Riccardo Nocini
- Unit of Otolaryngology - Head and Neck Department, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Vittorio Favero
- Unit of Maxillo-Facial Surgery and Dentistry - Head and Neck Department, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy.
| | - Luigi Chiarini
- Unit of Cranio-Maxillo-Facial Surgery, University of Modena and Reggio Emilia, Via del Pozzo 71, 41125, Modena, Italy
| | - Pier Francesco Nocini
- Unit of Maxillo-Facial Surgery and Dentistry - Head and Neck Department, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
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Puricelli E, Chem RC. Thirty-eight-year follow-up of the first patient of mandibular reconstruction with free vascularized fibula flap. Head Face Med 2021; 17:46. [PMID: 34711252 PMCID: PMC8554960 DOI: 10.1186/s13005-021-00293-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The mandible is responsible for vital functions of the stomatognathic system, and its loss results in functional and aesthetic impairment. Mandibular reconstruction with free fibula flap is considered the gold standard for mandibular reconstruction. CASE PRESENTATION We describe here the 38-year follow-up of the patient who was the first case of mandibular reconstruction with free fibula flap reported in the literature. The original report describes a 27-year-old woman who had undergone extensive mandibulectomy due to an osteosarcoma. A microvascularized fibula flap was used for mandibular reconstruction in 1983. Two years later, a vestibulo-lingual sulcoplasty with skin graft was performed to allow the construction of a total dental prosthesis. Fifteen years after the initial treatment, an autologous iliac crest graft was placed in the fibula flap, aimed at increasing bone thickness and height for rehabilitation with implant supported prosthesis. In 2015, a rib graft was positioned in the mental region, enhancing the support to the soft tissues of the face and improving the oral function. A recent review of the patient shows well-balanced facial morphology and optimal functional results of the procedure. CONCLUSIONS The fibula flap method, described in 1975 and first reported for mandibular reconstruction in 1985, continues to be applied as originally described, especially where soft tissue damage is not extensive. Its use in reconstructive surgery was expanded by advancements in surgery and techniques such as virtual surgical planning. However, there is still a lack of evidence related to the long-term evaluation of outcomes. The present work represents the longest-term follow-up of a patient undergoing mandibular reconstruction with free vascularized fibula flap, presenting results showing that, even after 38 years, the procedure continues to provide excellent results.
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Affiliation(s)
- Edela Puricelli
- Oral and Maxillofacial Surgery Unit, School of Dentistry, Clinical Hospital of Porto Alegre (HCPA), Federal University of Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, RS, 2492-90035-003, Porto Alegre, Brazil.
| | - Roberto Correa Chem
- Department of Plastic Surgery and Reconstructive Microsurgery, Santa Casa de Misericordia de Porto Alegre, Rua Professor Annes Dias , RS, 295-90020-090, Porto Alegre, Brazil
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Zhu WY, Choi WS, Wong MCM, Pu JJ, Yang WF, Su YX. The Learning Curve of Computer-Assisted Free Flap Jaw Reconstruction Surgery Using 3D-Printed Patient-Specific Plates: A Cumulative Sum Analysis. Front Oncol 2021; 11:737769. [PMID: 34604076 PMCID: PMC8481918 DOI: 10.3389/fonc.2021.737769] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/27/2021] [Indexed: 11/27/2022] Open
Abstract
Background Computer-assisted jaw reconstruction (CAJR) has benefits in reducing operation time and improving reconstruction accuracy, compared to conventional freehand jaw reconstruction. However, no information is available regarding learning curves in CAJR with the use of 3D-printed patient-specific surgical plates (PSSP). The purpose of this study was to assess surgical outcomes and learning curve for the first 58 consecutive CAJR using 3D-printed PSSP performed by a single surgical team in a single institution. Methods In a prospective study, consecutive patients who underwent free flap CAJR using 3D-printed PSSP were included. The determination of proficiency, based on the cumulative sum of surgical success (no major adjustment of 3D-printed PSSP, flap survival) passing the acceptable boundary line of cumulative sum analysis, was the primary outcome. To find out any potential factors influencing the learning curve, baseline characteristics of patients were compared before and after proficiency achievement. Secondary outcomes included inflexion points of the total operation time, blood loss, length of hospital stay, and bone graft deviation, measured by the cumulative sum analysis. Results From December 2016 to November 2020, 58 consecutive cases underwent surgery performed by a single surgical team. The overall surgical success rate was 94.8% (55/58). A three-stage learning curve of primary outcome was observed. The proficiency was achieved after 23 cases. The proportions of advanced tumor staging and concomitant surgery after obtaining proficiency were significantly higher than those before achieving proficiency (p = 0.046 and p < 0.001, respectively). Mean values of operation time, intraoperative blood loss, length of hospital stay, and bone graft deviation were 532.5 ± 119.2 min, 1,006.8 ± 547.2 ml, 16.1 ± 6.3 days, and 0.9 ± 1.2 mm, respectively. Two trends of learning curve were observed in the CUSUM analyses of total operation time, length of hospital stay, and bone graft deviation, in which the first and second inflexion points occurred between 8 and 17 cases and between 43 and 46 cases, respectively. Conclusion Our results revealed a three-stage learning curve of CAJR with the use of PSSP, including initial learning, plateau, and overlearning. Based on CUSUM analysis, the surgical proficiency was achieved after 23 cases, and total operation time, length of hospital stay, and bone graft deviation stabilized after 8–17 cases.
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Affiliation(s)
- Wang-Yong Zhu
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, SAR, China
| | - Wing Shan Choi
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, SAR, China
| | - May Chun Mei Wong
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, SAR, China
| | - Jingya Jane Pu
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, SAR, China
| | - Wei-Fa Yang
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, SAR, China
| | - Yu-Xiong Su
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, SAR, China
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