The internal oblique-iliac crest osseomyocutaneous microvascular free flap in head and neck reconstruction

Bone-flap-harvest-related donor site morbidity in reconstructive jaw microsurgery: Retrospective analysis based on 220 patients over a ten-year period

Microsurgery is the gold standard for hard and soft tissue reconstruction in head and neck neoplasia and malformations. Fibular, iliac crest, and scapular free flaps are the main choices for reconstructive surgery of the jaws. Although widely described in the literature, no statistical comparison analysis of the donor site morbidity of these has been performed to our knowledge. Therefore, in this study, the medical records of patients who underwent microsurgical jaw reconstruction at the Maxillofacial Oncological Reconstructive Surgery Unit of Umberto I General Hospital in Rome between 2011 and 2021 were analysed retrospectively. Inclusion criteria were complete clinical and radiological records, microsurgical reconstruction harvesting one of the three flaps, and a minimum follow up of 12 months. Principal donor site complications were recorded and compared among the flaps. The data were analysed using IBM SPSS Statistics (28.0.1.1, IBM Corp). The study enrolled 220 patients: 103 with deep circumflex iliac artery (DCIA) flaps, 87 with fibular free flaps (FFF), and 30 with scapular bone flaps (SBF). The main DCIA donor site complications were dysaesthesia (13.6%), abdominal hernia (2.9%), dehiscence (1.9%), infection (1.9%), and anterior superior iliac spinal fracture (1.9%). Similarly, the main FFF complications were dehiscence (8%), skin graft necrosis (6.9%), infection (5.7%), and dysaesthesia (3.4%). Subcutaneous seroma occurred in 13.3% of SBF patients and dehiscence in 6.7%. Regional dysaesthesia occurred significantly (p < 0.05) more often in DCIA than FFF or SBF patients. Dehiscence was significantly (p < 0.05) more frequent in FFF than DCIA or SBF patients. All flaps were safe and associated with low donor site morbidity. The jaws should be reconstructed selecting the flap that best satisfies the reconstructive needs based on the patient's clinical features.

Current global research on mandibular defect: A bibliometric analysis from 2001 to 2021

Background: Mandibular defects can result from congenital deformities, trauma, tumor resection, and osteomyelitis. The shape was irregular because the lower jaw was radians. This involves teeth and jaw functions; therefore, the difficulty of bone repair is greater than that in other body parts. Several standard treatments are available, but they result in various problems, such as difficulties in skin flap transplantation and possible zone dysfunction, artificial material boneless combining ability, and a long treatment period. This study aimed to introduce the present status of research on mandibular defects to analyze the current introduction and predict future research trends through a bibliometric study. Methods: From 2001 to 2021, publications on mandibular defects were collected for bibliometric visualization using VOSviewer, CiteSpace, and Scimago Graphica software based on the Web of Science Core Collection. Results: This study analyzed 4,377 articles, including 1,080 published in the United States, 563 in China, and 359 in Germany, with an increase in the number of articles published over the past 20 years. Wikesjoe and Ulf Mai E had the most publications (p = 36) and citations (citations = 1,553). Shanghai Jiaotong University published the highest number of papers among the research institutions (p = 88). The most productive journal was Journal of Oral and Maxillofacial Surgery, and the cited literature was primarily classified as dentistry, dermatology, and surgery. Cluster Analysis of Co-occurrence Keywords revealed that highest number of core words were mandibular defects, mandibular reconstruction, and bone regeneration. The highest cited words were head and neck cancer, accuracy, and osteogenic differentiation. High-frequency terms of Cluster Analysis of References were osteosynthesis plate, tissue engineering, and rapid distraction rate. Conclusion: Over the past 20 years, the number of studies on mandibular defects has gradually increased. New surgical procedures are increasingly being used in clinical practice. Current frontier topics mainly focus on areas such as computer-aided design, 3D printing of osteotomy and reconstruction guide plates, virtual surgical planning, and bone tissue engineering.

Reconstruction of Pharyngolaryngeal Defects with the Ileocolon Free Flap: A Comprehensive Review and How to Optimize Outcomes

Several reconstructive methods have been reported to restore the continuity of the aerodigestive tract following resection of pharyngeal and hypopharyngeal cancers. However, high complication rates have been reported after voice prosthesis insertion. In this setting, the ileocolon free flap (ICFF) offers a tubularized flap for reconstruction of the hypopharynx while providing a natural phonation tube. Herein, we systematically reviewed the current evidence on the use of the ICFF for reconstruction of the aerodigestive tract. A systematic literature search was conducted across PubMed MEDLINE, Web of Science, ScienceDirect, Scopus, and Ovid MEDLINE(R). Data on the technical considerations and surgical and functional outcomes were extracted. Twenty-one studies were included. The mean age and follow-up were 54.65 years and 24.72 months, respectively. An isoperistaltic or antiperistaltic standard ICFF, patch flap, or chimeric seromuscular-ICFF can be used depending on the patients' needs. The seromuscular chimeric flap is useful to augment the closure of the distal anastomotic site. The maximum phonation time, frequency, and sound pressure level (dB) were higher with ileal segments of 7 to 15 cm. The incidence of postoperative leakage ranged from 0 to 13.3%, and the majority was occurring at the coloesophageal junction. The revision rate of the microanastomosis ranged from 0 to 16.6%. The ICFF provides a reliable and versatile alternative for reconstruction of middle-size defects of the aerodigestive tract. Its three-dimensional configuration and functional anatomy encourage early speech and deglutition without a prosthetic valve and minimal donor-site morbidity.

A novel loop neurorrhaphy technique to preserve lower lip sensate in mandibular reconstruction using an innervated vascularized iliac bone flap

BACKGROUND

This study aimed to introduce a novel loop neurorrhaphy technique using an innervated vascularized iliac bone flap (VIBF) with vascularized ilioinguinal nerve (IIN) to reconstruct the inferior alveolar nerve (IAN) and preserve lower lip sensation simultaneously with mandibular reconstruction.

METHODS

This study prospectively included patients who underwent mandibular reconstruction using VIBF from May 2018 to April 2020. Subjects were allocated into two groups: (1) Group I; innervated VIBF with loop neurorrhaphy (IIN doubly anastomosed with IAN and mental nerve), (2) Group II (control); conventional VIBF. Evaluation was done with operative time, intraoperative indocyanine green (ICG), lower lip sensory assessment (two-point discrimination [TPD] test and current perception threshold [CPT]), and drooling.

RESULTS

Twelve patients were included; 6 in each group, (7 males and 5 females), age ranging from 18 to 57 years (average: 36.75 years). In all cases, intraoperative perfusion of IIN was confirmed by ICG. Group I showed a statistically significant more flap harvesting time compared with group II (mean difference, 5.67 min; P = 0.0091). There was a significant difference in sensory recovery favoring group I (P < 0.05). The TPD results in group I showed an average of 9.8 ± 6.9 mm and 6.2 ± 5.7 mm on operated and non-operated sides, while Group II showed a poor sensory recovery, and the TPD showed an average of 24.6 ± 6.7 mm and 8.4 ± 2.3 mm on operated and non-operated sides. The CPT results showed a significant difference between both groups. In Group I, the extent of drooling was 3.16 ± 0.75, while in Group II, the score was 1.6 ± 0.81, revealing a significant difference favoring Group I.

CONCLUSIONS

Concurrent mandibular reconstruction using VIBF and loop neurorrhaphy with vascularized IIN to reconstruct IAN successfully restore lower jaw form and preserve lip sensation.

The Versatility of the DCIA Free Flap: A Forgotten Flap? Systematic Review and Meta-Analysis

BACKGROUND

 Studies reporting on the deep circumflex iliac artery (DCIA) free flap are restricted to a limited number of patients and areas of application. The aim of this review was to assess the reliability and versatility of the DCIA free flap during reconstruction.

METHODS

 A comprehensive review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines using PubMed, Web of Science, Cochrane CENTRAL, and SCOPUS. A critical analysis of pooled data was performed to assess outcomes employing the DCIA free flap.

RESULTS

 A total of 445 DCIA free flaps were included. The main recipient sites were head and neck (72.35%), lower extremity (20.67%), and upper extremity (6.74%). The main indications for reconstruction were tumor resection (73.8%) and trauma (17.43%). Fifty non-DCIA flaps were required to finalize the reconstruction of several defects. The pooled flap failure rate using the DCIA free flap was 4% (95% confidence interval: 1-8%). No significant heterogeneity was present across studies (Q statistic 22.12, p = 0.14; I ² = 27.68%, p = 0.139). Complication rates for head and neck and limb reconstruction were 57.37 and 40.16%, respectively. The average length and surface area of bone flaps were 7.79 cm and 22.8 cm², respectively. The area of the skin paddles was 117 cm².

CONCLUSION

 The DCIA free flap has shown to be a versatile reconstructive alternative for head and neck and short-medium size limb defects. However, the complexity of functions, the recipient site location, and a potential large defect can detract from the use of the DCIA free flap as an initial reconstructive option for head and neck and extensive limb defects.

A retrospective study on mandibular reconstruction using iliac crest free flap

PURPOSE

To assess the availability, success rate and complications of microvascular iliac crest free flap for reconstruction of mandibular segmental defects.

METHODS

In this retrospective-descriptive study, we report patients who had undergone segmental mandibular resection for pathologic lesions and received reconstruction with iliac crest microvascular free flap between 2016 and 2019. Clinical and demographic data of all the cases were collected. Success was regarded as complete consolidation of the bone graft in panoramic radiograph. Postoperative complications were defined as major or minor based on the need for intervention. T-test, Kolomogorov_Smirnov, and multivariate analysis were used and the p-value<0.05 was considered to be statistically significant.

RESULTS

Of all 30 patients, 16 were women and 14 were men with an average age of 27.2 years (range 14-40). Patients were followed for 12-60 month (mean: 38.4). One flap was lost due to unsalvageable venous thrombosis. Six other cases had post-op complications while smoking and diabetes were associated with more complications (P = 0.036). Twenty-three patients received primary reconstruction which was more successful than secondary ones (P = 0.003). Osteogenic sarcoma was associated with greater risk of complications (P < 0.01).

CONCLUSIONS

The results of this study suggest that iliac crest microvascular free flap serves as a promising option for the reconstruction of mandibular defects, providing excellent contour and acceptable success rate with low donor site morbidity. Future studies will focus on the role of systemic diseases in post-op complications and flap failures.

Postoperative Imaging Appearance of Iliac Crest Free Flaps Used for Palatomaxillary Reconstructions

The osteomyocutaneous iliac crest free flap is a reconstructive option for segmental mandibular or complex palatomaxillary defects. Familiarity with the radiographic appearance of free flaps such as the iliac crest is necessary for the postoperative evaluation of patients after mandibular, maxillary, or palatal reconstructions because it allows radiologists to properly monitor and interpret the appearance of the flap over time. This study presents a retrospective review of 5 patients who underwent palatomaxillary reconstruction with an iliac crest free flap at our institution. The imaging appearances of the 5 patients were analyzed to determine the key radiographic characteristics of a healthy and successful iliac crest free flap. Radiographic fluency with the imaging appearance of the iliac crest free flap, as well as the new anatomy of the region in the postoperative period, will allow for better interpretation of the flap appearance on imaging and will prevent false identification of tumor recurrence.

Crosstalk between adipocytes and M2 macrophages compensates for osteopenic phenotype in the Lrp5-deficient mice

A loss-of-function mutation in the Lrp5 gene in mice leads to a low bone mass disorder due to the inhibition of the canonical Wnt signaling pathway; however, the role of bone marrow microenvironment in mice with this mutation remains unclear. In this study, we evaluated proliferation and osteogenic potential of mouse osteoblasts using the MTT assay and Alizarin red staining. The levels of alkaline phosphatase, tartrate-resistant acid phosphatase, and adiponectin in culture supernatants were measured using the enzyme-linked immunosorbent assay. Osteoclast bone resorbing activity was evaluated by toluidine staining and the number and area of bone resorption pits were determined. We observed increased osteogenesis in osteoblasts co-cultured with the BM-derived myeloid cells compared to the osteoblasts cultured alone. Mice with global Lrp5 deletion had a relatively higher bone density compared to the mice carrying osteoblast/osteocyte-specific Lrp5 deletion. An increased frequency of M2 macrophages and reduced expression of inflammatory cytokines were detected in the myeloid cells derived from the bone marrow of mice with global Lrp5 deletion. Higher adipogenic potential and elevated levels of adiponectin in the global Lrp5 deletion mice contributed to the preferential M2 macrophage polarization. Here, we identified a novel systemic regulatory mechanism of bone formation and degradation in mice with global Lrp5 deletion. This mechanism depends on a crosstalk between the adipocytes and M2 macrophages in the bone marrow and is responsible for partly rescuing osteopenia developed as a result of decreased Wnt signaling.

One stage microvascular mandible reconstruction by using scapula chimeric flap combined with computer-aided-design and computer-aided-manufacturing plate including bilateral alloplastic TMJ prosthesis: A case report

This report focuses a defect comprising the complete mandible due to osteonecrosis, including both condyles, that required bilateral temporomandibular joint (TMJ) reconstruction with complete mandibular corpus using a computer-aided-design and computer-aided-manufacturing(CAD-CAM) planning to harvest a scapula chimeric free flap combined with plate including bilateral alloplastic TMJ prosthesis. This procedure was realized in one and the same surgery. A 73 year-old-man developed an osteoradionecrosis of the total mandible including both condyles after radiation therapy for a squamous cell carcinoma of the tongue base(cT4aN2bM0G3). A CAD-CAM reconstruction was planned with a plate extended by bilateral individual TMJ prosthesis, individual fossa components and combined with a composite free flap originating from the subscapular vessel system including scapula(circumflex subscapular artery) for reconstruction of the mandibular corpus which was osteotomized in three segments with a resection guide, the parascapular skin paddle (descending branch of circumflex subscapular artery) for compensation of the soft tissue deficiency of the cervical skin and latissimus dorsi muscle(thoracodorsal artery) for the inner mucosal lining and intraoral reconstruction. The subscapular artery was anastomosed to the external carotid artery and two concomitant veins were sutured end-to-side to the internal jugular vein. The patient was discharged without feeding tube and tracheostomy. No complications have been observed after 6 months follow-up. The patient was able to tolerate soft diet and had comprehensible speech. Thus, a total mandibular reconstruction including both condyles using alloplastic and autoplastic reconstruction in one and the same stage is a valid option and may be considered in comparably severe cases.

The Deep Circumflex Iliac Artery Flap for Mandibular Reconstruction and Donor Site Reconstruction with a Patient-Specific Implant: A Case Report

Jaw defects may occur due to various causes such as tumors, trauma, and diseases caused by infection such as osteomyelitis. Reconstruction of jaw defects has been improved by the free flaps and refined microvascular techniques. The deep circumflex iliac artery (DCIA) flap offers a large amount of bone for complex reconstructions of the mandible. However, several complications and adverse effects can occur, such as abnormal hip contour, hernia, severe bleeding tendency, gait disturbance, and hypoesthesia. To reduce these complications, the monocortical DCIA flap can be used, or iliac crest bone defects can be restored with titanium mesh. However, these methods have limitations when used to reduce hip contour reproduction and gait disturbance. In this study, we report a case of iliac bone reconstruction using a 3D-printed patient-specific implant to reduce donor site morbidity in the reconstruction of the DCIA flap in a patient with oral squamous carcinoma.

[Rational choice of revascularized autograft in midface reconstruction]

The article presents an analysis of the results of the use of revascularized autografts in the plastic elimination of combined defects in the middle zone of the face. Difficulties and negative moments of each of them were revealed and recommendations were given on the rationality of their clinical application with the development of the algorithm of surgical tactics.

Iliolumbar artery: a useful pedicle for the iliac crest free flap in maxillofacial reconstruction

The iliac crest free flap is commonly used in maxillofacial reconstruction, and is typically supplied by the deep circumflex iliac artery (DCIA). However, the iliolumbar artery is an alternative blood supply that can potentially be used in such reconstructions. We describe the anatomy of the iliolumbar artery and review publications about its clinical use. We raised four cadaveric iliac crest free flaps using both the DCIA and the iliolumbar artery to illustrate its use in reconstructing maxillofacial defects. It provided a longer pedicle for microvascular anastomosis than the DCIA, was more versatile in orientation of the flap, and allowed the chance of anastomosing both pedicles to "super-charge" the flap's blood supply. We describe a patient in whom this flap was used successfully, which shows that the iliolumbar artery is a suitable pedicle to augment (or replace) the DCIA in an iliac crest free flap.

Restoration of oral competence in double free flap reconstructions of massive lower facial defects with fascia lata slings - Case series and review of the literature

Restoration of adequate oral competence is especially challenging in double free flap reconstructions of massive head and neck defects resulting from composite resections. Our report illustrates that oral competence in double free flap reconstructions of extensive oromandibular defects can be successfully restored with tensor fascia lata suspension slings.

Latissimus dorsi muscle free flap revisited: a novel endoscope-assisted approach

OBJECTIVES/HYPOTHESIS

Achieving a functionally favorable and aesthetically acceptable outcome in oncologic and reconstructive surgery is important in the current era. Latissimus dorsi (LD) flap is traditionally performed with a large incision in lateral position. We report an endoscope-assisted harvest of LD muscle free flap in supine position to avoid a large scar and facilitate a two-team approach for oral cavity reconstruction.

STUDY DESIGN

Consecutive case series.

METHODS

Four consecutive patients underwent LD muscle free flap for various oral cavity reconstructions. LD muscle free flaps were harvested under endoscope assistance.

RESULTS

Endoscope-assisted LD free-flap harvest allowed a small incision in the axillary pit, which can be easily concealed without change of patient position, resulting in shortened operative time. Endoscopic harvest caused no acute complications, and donor site morbidity was minimal. Reconstructions with endoscope-assisted LD muscle free flap of the oral cavity defect site were successful in all cases.

CONCLUSIONS

Endoscope-assisted LD muscle free flap is a feasible and practical option for the reconstruction of selective oral cavity defects with aesthetically excellent donor site scar.

Strategies for avoiding complications with vascularized bone flaps in head and neck microvascular reconstruction

Effective osseous reconstruction of the head and neck after congenital, traumatic, and particularly ablative oncologic procedures is a relatively recent innovation. Whereas pioneers led with individual donor sites, it is only in the past 20 years that most centers have developed teams comfortable with use of the four common donor sites for free flaps: iliac crest, fibula, radius, and scapula. Calvarium, though much less frequently used, is a useful donor site for specific reconstructive challenges. Less commonly used sites such as femur, humerus, and rib have not proved universally reliable. This article aims to illustrate some refinements and pitfalls in vascularized osseous reconstruction of the head and neck using the well-recognized flaps, including calvarium, in a variety of pathologic conditions, recipient-site defects, and comorbidities. Strategies for error avoidance will be emphasized. The authors hope that this will support the concept of a reconstructive "toolbox" for this complex area.

Choice of osseous and osteocutaneous flaps for mandibular reconstruction

Microvascular free flap transfer currently represents one of the most popular methods for mandibular reconstruction. With the various free flap options now available, there is a general consensus that no single kind of osseous or osteocutaneous flap can resolve the entire spectrum of mandibular defects. A suitable flap, therefore, should be selected according to the specific type of bone and soft tissue defect. We have developed an algorithm for mandibular reconstruction, in which the bony defect is termed as either "lateral" or "anterior" and the soft-tissue defect is classified as "none," "skin or mucosal," or "through-and-through." For proper flap selection, the bony defect condition should be considered first, followed by the soft-tissue defect condition. When the bony defect is "lateral" and the soft tissue is not defective, the ilium is the best choice. When the bony defect is "lateral" and a small "skin or mucosal" soft-tissue defect is present, the fibula represents the optimal choice. When the bony defect is "lateral" and an extensive "skin or mucosal" or "through-and-through" soft-tissue defect exists, the scapula should be selected. When the bony defect is "anterior," the fibula should always be selected. However, when an "anterior" bone defect also displays an "extensive" or "through-and-through" soft-tissue defect, the fibula should be used with other soft-tissue flaps. Flaps such as a forearm flap, anterior thigh flap, or rectus abdominis musculocutaneous flap are suitable, depending on the size of the soft-tissue defect.

Two stage reconstruction with revascularized grafts after resection of retromolar and oropharyngeal carcinoma

The clinical outcome of two stage reconstruction with revascularized grafts after resection of extensive retromolar and oropharyngeal squamous cell carcinoma in 17 patients is presented. In the first operation, the intraoral soft tissue defect was covered by a revascularized jejunal flap, and the mandibular defect was bridged by a reconstruction plate. After a period of 5-28 months, mandibular reconstruction was performed with a microsurgically revascularized iliac crest graft that was positioned under the jejunal graft. Clinical follow up included tumour recurrence rate, the form of nutrition, speech disorders and mouth opening restrictions. Quality of life was analysed by the EORTC questionnaires. Fifteen patients were free of recurrence and alive. Twelve patients were able to swallow food. The jejunal flap provided perfect lining of the soft palate, the pharynx and the base of the tongue, thus supporting functional restoration. Despite the gravity of disease and invasiveness of therapy, the two stage procedure leads to satisfying functional and aesthetic results thus obtaining appropriate QOL.

Hard and soft palate reconstruction

Palate reconstruction remains one of the most challenging areas for the head and neck reconstructive surgeon. Although small defects in the palate are managed without significant difficulty, larger defects, particularly total maxillectomy defects, require special attention. The lack of a uniform classification for palate defects has limited prospective comparison of reconstructive methods. In most cases, these defects require bone containing microvascular free flaps for reconstruction if preoperative function is to be approached. Promising results have been documented for fibular, scapular, and iliac crest/internal oblique free flaps in the reconstruction of total or near-total maxillectomy defects. Our lack of ability to reconstruct the dynamic function of the soft palate continues to be disappointing. Limited studies have shown promise in soft palate reconstruction without the complications of velopharyngeal insufficiency.

Mandibular reconstruction using microvascular free flaps: a statistical analysis of 178 cases

For this article, 178 consecutive cases of mandibular reconstruction using microvascular free flaps and performed from 1979 to 1997 were studied. The purpose of this report is to compare flap success rates, complications, and aesthetic and functional results. The ages of the 131 men and 47 women ranged from 13 to 85 years, with an average of 55 years. Donor sites included the rib (11 cases), radius (one case), ilium (36 cases), scapula (51 cases), fibula (34 cases), and soft-tissue flaps with implant (45 cases). Complications included total flap necrosis, partial flap necrosis, major fistula formation, and minor fistula formation. The rate of total flap necrosis involving the ilium and fibula was significantly higher than that of all other materials combined (p < 0.05). The overall rate of implant plate removal, which resulted from the exposure or fracture of the plate, was 35.6 percent (16 of 45 cases). Each mandibular defect was classified by the extent of the bony defect and by the extent of the soft-tissue defect. The extent of the mandibular bony defect was classified according to the HCL method of Jewer et al. The extent of the soft-tissue defect was classified into four groups: none, skin, mucosal, and through-and-through. According to these classifications, functional and aesthetic assessments of deglutition and contour were performed on 115 subjects, and speech was evaluated in 110. To evaluate the postoperative results, points were assigned to each assessment of deglutition, speech, and mandibular contour. Statistical analysis between pairs of bone-defect groups revealed that there was no significant difference in each category. Regarding deglutition, statistical analysis between pairs of soft-tissue-defect groups revealed there were significant differences (p < 0.05) between the none and the mucosal groups and also between the none and the through-and-through groups. Regarding speech, there was a significant difference (p < 0.05) between the none and the through-and-through groups. Regarding contour, there were significant differences (p < 0.01) between the none and the through-and-through groups and between the mucosal and the through-and-through groups. The points given for each function, depending on the reconstruction material, revealed that there was no significant difference between pairs of material groups. From this prospective study, the authors have developed an algorithm for oromandibular reconstruction. When the bony defect is lateral, the ilium, fibula, or scapula should be chosen as the donor site, depending on the extent of the soft-tissue defect. When the bony defect is anterior, the fibula is always the best choice. When the soft-tissue defect is extensive or through-and-through with an anterior bony defect, the fibula should be used with other soft-tissue flaps.

The maxillofacial surgeon and cranial base surgery

The paper reviews the role of the maxillofacial surgeon, surgical approaches and osteotomies available to allow comprehensive access to cranial base tumours. Maxillo facial reconstruction using free vascularised flaps to rehabilitate the patients is highlighted. Such reconstruction may also require vascularised bone grafts. The range of microvascular free tissue transfer in cranial base surgery is discussed. The need not to merely reconstruct but to rehabilitate the patient is stressed. The benefits of the latest imaging and navigation systems are outlined.

Intraoral defect coverage with muscle flaps

PURPOSE

This study investigated whether wound healing after the use of purely muscular flaps for intraoral defect coverage is negatively influenced by insipient muscular atrophy and the absence of a covering layer.

MATERIALS AND METHODS

In an experimental study, microsurgical transplantation of muscle flaps from the anterior abdominal wall was carried out in 18 Lewis rats. A nerve anastomosis for motor reinnervation was not performed. Atrophy of the muscle flaps was determined by measuring the reduction of their size and weight after 3, 8, and 20 weeks. In the clinical part of the study, free muscle transplants from different donor regions (vastus lateralis, pectoralis major, internal oblique, and temporalis muscles) were used for defect coverage in various areas of the oral cavity. To study epithelization, punch biopsy specimens from the muscle surface were taken at periods of 2 to 4 weeks up to 6 months for histologic evaluation. Final evaluation of reconstruction results with special regard to speech, tongue mobility, mouth opening, chewing, and swallowing took place after 6 months.

RESULTS

In the experimental study, average weight loss of the muscle flaps was 67% after 20 weeks, and the remaining surface area was 71%. The number of myocytes was only about 30% compared with control muscles, and parts of the flap appeared as a thin fibrous membrane. Clinically, this atrophy led to restricted mobility in such areas as the floor of the mouth, the buccal plane, and the tongue. Muscle flaps covering solid structures such as bones or reconstruction plates adapted well to the transplant bed, and the atrophy of the muscle led to no constriction of the surrounding tissue. Atrophy also did not have a negative effect when muscle flaps were placed in the region of the pharyngeal wall. Epithelization started from the edges after 2 weeks and was concluded after 8 weeks in all transplants if no additional radiation was performed. The muscle tissue was sufficiently resistant so that infection, fistulization, and necrosis did not occur.

CONCLUSIONS

Muscle flaps undergo considerable atrophy with a cicatricial transformation and reduction of flexibility. Despite these disadvantages they can be used in the hard palate, the alveolar crest, and in the pharyngeal wall without causing functional restriction. Because of constriction of the surrounding tissues, mobile areas such as the buccal plane, the floor of the mouth, and the tongue are not suitable as sites for muscle transplants.

Mandibular reconstruction with free vascularized fibular flap

Although various sources of vascularized bone/composite tissue have been used for mandibular reconstruction, the vascularized fibular flap has been reported to have many advantages over the others and to be the most suitable for bridging a long-span mandibular defect. In this paper, positive experience of 14 consecutive cases in which a free vascularized fibular graft with or without a skin paddle has been used to reconstruct a long mandibular defect is reported. Half of the cases were primarily reconstructed, the rest secondarily. The average length of the fibula graft harvested was 16.7 cm, with a range of 12 to 22 cm. The number of wedge osteotomies ranged from 0 to 4, with an average of 1.67. In ten flaps, a peroneal skin paddle was included. The donor wound was typically closed directly, except in three cases, where a skin graft was used. Vein grafts were performed in five cases to lengthen the pedicle. In two cases, the skin partially necrosed. All scintigrams except one showed good bone viability. But there was no total flap failure. Postoperative facial appearances were fair to excellent, with mouth opening ranging from 21 to 50 mm. Although unusual serious donor wound rupture was experienced in one case, in general the donor site complications were minimal.

Vascularized iliac bone graft based on a pedicle of upper lumbar vessels for anterior fusion of the thoraco-lumbar spine

A new option for the use of a vascularized iliac bone graft, based on the upper (first or second) lumbar vessels, has been developed. As a pedicled graft, this supero-posteriorly-based vascularized iliac bone graft can reach the vertebrae from T8 to the sacrum, and the lower sternum and thoracic cage. In this report, the vascular anatomy of the flap and clinical experience using it for anterior spinal fusion are described.

Tumor-ablative surgery, microvascular free tissue transfer reconstruction, and postoperative radiation therapy for advanced head and neck cancer

OBJECTIVE

The objectives of this study were to determine whether the combination of complex tumor-ablative surgery and microvascular free tissue transfer reconstruction delays the onset of postoperative radiation therapy, whether free tissue transfers are lost after a course of radiation therapy, and what patterns of tumor recurrence and survival rates are present in patients who undergo this type of multidisciplinary treatment.

DESIGN

A retrospective review was conducted in 37 patients who underwent tumor-ablative surgery and reconstruction between November 1987 and August 1991.

MATERIAL AND METHODS

Of the 30 men and 7 women who underwent tumor-ablative surgery, microvascular free tissue transfer reconstruction, and postoperative radiation therapy, recurrent or T4 primary tumors were treated in 84%. Sixty-two percent of the patients had nodal metastatic disease. The median dose of postoperative irradiation was 60 Gy (range, 32.4 to 76.8). Follow-up in all patients was until death (21 patients) or for a median of 17.5 months (range, 4.1 to 43.2).

RESULTS

The median duration of overall survival and the 2-year overall survival rate were 17 months and 46%, respectively. For cause-specific survival, the median duration and 2-year rate were 17 months and 50%, respectively. Local recurrence developed in 8 patients, neck recurrence in 10, and distant metastatic disease in 11. No microvascular free tissue transfers failed.

CONCLUSION

Radiation therapy can begin in most patients within 8 weeks postoperatively, microvascular free tissue transfers seem to tolerate postoperative radiation therapy well at the doses administered, and the rates of local and neck control are reasonable relative to the advanced stage of the cancers treated.

Oral and maxillofacial reconstruction

Advances in surgical technique and dental implant technology have benefitted both patients and practitioners alike. Earlier diagnosis and treatment, along with increased survival, has made it incumbent on the dental professional to be aware of what can be done for the formerly unrestorable patient. This cooperative team approach works to everyone's advantage.

Bone contouring and fixation in functional, primary microvascular mandibular reconstruction

Experience in over 65 cases of microvascular mandibular reconstruction has resulted in the development of reliable techniques for bone fixation and contouring to achieve the best functional results. Methods of graft contouring and the application of rigid internal fixation are described in detail. Unusual situations in which the tumor extends through the buccal cortex of the mandible, and when condylar replacement is necessary, are presented. The options for managing these situations are discussed.