A classification system and algorithm for reconstruction of maxillectomy and midfacial defects

Correlation between maxillary defect and facial asymmetry

The aim of this study was to evaluate the correlation between maxillary defects and facial asymmetry, and to establish categories for visual perception of facial asymmetry. The facial data of 47 patients who underwent maxillary resection due to tumors were captured using stereophotogrammetry. Facial asymmetry was measured using a landmark-independent method and assessed with a Likert scale. Facial asymmetry was classified into three grades (I-III) based on visual perception. Statistically significant differences (P < 0.001) were found in the asymmetry of the suborbital, zygomatic, buccal, and superolabial areas among the different visual perception categories, and the symmetry of these areas significantly influenced the visual perception (P < 0.001). The maxillary defect magnitude significantly influenced facial asymmetry perception (P < 0.001). Substantial statistical variations (P < 0.001) in the asymmetry of four facial areas, excluding the masseteric and nasal areas, across the different classes of maxillary defect were noted. Maxillary defects significantly affect the midface soft tissue symmetry. Reconstruction should focus on sufficient soft tissue support in the zygomatic, buccal, suborbital, and superolabial areas. Corrective measures are generally unnecessary for grade I asymmetry. For grade II asymmetry, reconstruction can be decided individually. For grade III asymmetry, reconstruction is essential.

The Submental Artery Island Flap for Reconstruction of Acquired Maxillary and Palatal Defects After Tumor Ablation: Reversed Flow Versus the Extended Antegrade Design

BACKGROUND

The submental artery island flap (SIF) is a valid option for palatal reconstruction. However, the main limitation for its application for palatal defects is the arc of rotation. A novel modification for tunneling of the antegrade design of SIF that allows a compliant easy reach to the defect is described.

METHODS

Eighteen patients with Brown class II maxillectomy defects were included. Reconstruction started using reversed flow SIF in five patients then shifted to the modified antegrade technique in the remaining patients. Speech, swallowing, chewing, other parameters, and oncological outcomes were assessed.

RESULTS

The reversed flow group has high complications. In the antegrade SIF group, all flaps survived. One developed marginal flap necrosis that healed spontaneously. The follow-up period ranged from 1 to 4.2 years with favorable functional outcome and with no evidence of recurrence.

CONCLUSION

The modified SIF antegrade design is a reliable option for palate reconstruction that allows favorable functional and oncological outcome.

Japanese clinical practice guidelines for oral cancer, 2023

The Japanese Society of Oral Oncology and Japanese Society of Oral and Maxillofacial Surgeons have jointly developed clinical practice guidelines for oral cancer (oral squamous cell carcinoma) to improve and standardize the quality of oral cancer treatment in Japan. The first, second, and third editions were published in 2009, 2013, and 2019, respectively, and the 2023 edition was recently developed. In the development of the 2023 edition, 60 clinical questions (CQs) were listed. Systematic reviews following the GRADE approach were performed for 11 of these CQs. This article outlines the 2023 edition and describes the most relevant guidelines and CQs for the diagnosis, treatment, follow-up, and supportive care of oral cancer patients in Japan.

Bibliometric Analysis of Orbital Surgery Using Web of Science Database

AIM

There are more than 100 different clinical pathologies that affect the orbit, originating from the orbit or surrounding structures. Various surgical approaches have been described to solve this number of lesions. To date, there have been few evaluations of research productivity in the field of orbital surgery. The aim of this study is to analyze the research productivity of articles on orbital surgery.

METHODS

On October 20, 2024, using the advanced search section in the Web of Science (WoS) Core Collection database, a search was made about orbital surgery. From 1980 to November 20, 2024, research articles in the relevant field were analyzed. Language restrictions are not used. The filter was "Topic=Orbital Surgery OR Orbit Surgery OR Oculoplastic OR Oculoplastics OR Oculoplasty OR Orbitotomy OR Orbital Tumor Surgery OR Optic Nerve Surgery OR Orbital Decompression OR Orbital Reconstruction OR Orbital Exenteration OR Orbital Implant Surgery (Should - Search within topic)." Filters were applied, and as a result, 4590 publications were included in this study. VOSviewer software was used to perform bibliometric analyses.

RESULTS

The number of publications and citations for each year mostly increases until 2021. Among the countries with the most documents and citations, the United States ranks first in both rankings. Also, the organization with the most publications is the University of California, Los Angeles. Ophthalmic Plastic and Reconstructive Surgery is the journal that publishes the most documents and receives the most citations. The most cited 3 document is about Graves orbitopathy. The most recurring keywords were related to treatment and disease management.

CONCLUSIONS

This study would provide a novel perspective to the studies about orbital surgery and contribute to the researchers about the limits of the topic, and being aware of the active journals that publish the papers on this issue would facilitate the work of the researchers.

Current classifications of midface resections: scoping review and proposal of a new classification

Midface resection is a surgical procedure with varying degrees of complexity, ranging from partial upper jaw removal to exposure of the dura mater after resection. Existing classifications for the resulting midfacial defects are inconsistent and have issues regarding terminology, therefore a consensus is needed. The aim of this review was to analyse the previously published classifications, identify defining parameters, determine their strengths and weaknesses, and propose a universal classification for midfacial defects with the goal of being sufficiently detailed yet easily applied in clinical practice. A scoping review was conducted according to the PRISMA guidelines using the PubMed, Embase, and Wiley Online Library electronic resources. Analysis of the various midfacial resection classifications identified in the search revealed common parameters including anatomical landmarks, the walls removed, and the presence of oroantral communication, as well as an accompanying algorithm and options for reconstruction. The articles with the most detailed descriptions were noted. A new classification is proposed that includes elements of the three most detailed existing classifications, incorporating the vertical and horizontal extents of the defect, but with more specific details concerning severity and aimed at greater practical clinical utility.

Health-related quality of life among patients undergoing jaw resection at a referral hospital in Western Kenya

In many developing countries, successful care for patients with jaw tumours often focuses on morbidity and survival rates. Limited attention is accorded to the impact of the disease and its treatment on patients' health-related quality of life (HRQoL). This study evaluated HRQoL among patients before and in the short term following jaw resection as treatment for oral tumours using the University of Washington quality of life (UW-QoL) questionnaire. Forty participants were consecutively recruited over a period of two years; 70% of whom were female, 75% had mandibular lesions and half of them had ameloblastoma. Their mean age was 34.4 years. Participants returned high scores on most of the 12 disease-specific domains, suggesting a low level of dysfunction. Shoulder dysfunction, taste and speech returned the best scores, whereas chewing, appearance, and saliva returned the lowest scores. Saliva had reduced scores after surgery, with an increase in proportion of participants who reported it as an important issue. Mean scores for physical functions were lower than were for socio-emotional functions. Surgical care had a positive impact on socio-emotional functions such as activity, mood and recreation, but with a negative impact on physical functions such as chewing, swallowing, and saliva. Male patients as well as patients with benign and mandibular tumours returned higher scores when compared with female patients as well as patients with malignant and maxillary tumours, respectively. This study revealed important changes in the HRQoL of patients with jaw tumours in Kenya, which ought to be considered during their care.

Anatomical Landmark-guided Strategy for Computer-assisted Reconstruction of Infrastructure Maxillary Defects Using Free Fibula Flap

Background

Computer-assisted surgery in head and neck reconstruction yields predictable and favorable clinical outcomes. However, there is a lack in the optimal arrangement of the fibula bone segments to re-establish the function and aesthetics of the maxilla.

Methods

This study proposed a novel anatomical landmark-guided strategy for the virtual surgical planning (VSP) of infrastructure maxilla reconstruction using a free fibula flap. The optimal positioning of fibula segments was validated with a retrospective clinical study. Patients who underwent computer-assisted infrastructure maxillectomy and reconstruction with a free fibula flap from May 2017 to April 2024 were reviewed. Reproducibility of the landmarks and associated clinical parameters was assessed in VSP compared with the preoperative maxilla. Additionally, a structured quantitative approach was adopted for postoperative surgical outcome analysis by comparison of the postoperative maxilla and the VSP.

Results

Twenty patients fulfilled the criteria of this study. In 11 cases, we conformed to the proposed reconstruction strategy (group A). In 9 cases, we adopted a modified approach (group B) with deviations in the count of fibula segments and positioning strategy. In group A, the pooled median landmark error was 2.19 mm (interquartile range, 1.63-2.91 mm) in the VSP compared with the preoperative maxilla; in group B, the error was 4.54 mm (interquartile range, 2.05-6.15 mm). The clinical parameters demonstrated satisfactory recapture of the alveolar arch and maxillary width.

Conclusions

This anatomical landmark-guided strategy was validated with satisfactory reproducibility of the quantitative metrics in the VSP. The anatomical landmarks and associated clinical parameters provided a structured quantitative approach for postoperative analysis of computer-assisted maxillary reconstruction using FFFs.

Endoscopic-Assisted Maxillectomy: A Combined Approach for the Management of Maxillary Malignant Tumors

Maxillary sinus cancer presents unique challenges due to its slow growth and concealed location, often leading to delayed diagnosis and advanced stage at presentation. Wide resection, including maxillectomy, is frequently necessary for curative treatment. However, achieving clear resection margins while preserving function and aesthetics remains crucial. This article evaluates a combined surgical approach for maxillectomy, aiming to optimize oncological outcomes while minimizing morbidity and preserving function and aesthetics. A retrospective evaluation of patients undergoing endoscopic-assisted maxillectomy was conducted, focusing on demographics, tumor characteristics, surgical techniques, and outcomes. Data including operative time, complications, reconstruction methods, and follow-up were collected and analyzed. Ten patients underwent endoscopic-assisted maxillectomy, with favorable outcomes in terms of oncological radicality and functional preservation. Complications were minimal, and all patients achieved R0 margins. Adjuvant therapies were tailored based on individual patient characteristics, with promising survival outcomes and acceptable morbidity. The combined approach offers advantages over traditional methods by providing precise visualization and control in both endonasal and intraoral aspects of the resection. It allows for en-bloc tumor removal with minimal morbidity. Endoscopic-assisted maxillectomy offers a safe and effective approach for achieving optimal oncological outcomes while preserving function and aesthetics. It represents a significant evolution in the management of maxillary tumors, demanding further investigation and refinement.

Osseous Maxillary Reconstruction with Immediate Dental Implant Placement: An Optimized Workflow for the Oncologic Patient

BACKGROUND

Maxillary reconstruction is a complex undertaking characterized by a 3-dimensional surgical site with deficiencies in multiple tissue types. Before virtual surgical planning (VSP), bony reconstruction was inaccurate and inefficient; thus, reconstructions defaulted to soft-tissue flaps or obturators. The current study describes an efficient and accurate approach to bony maxillary reconstruction with immediate dental implant placement (IDIP).

METHODS

A reconstructive workflow was developed for osseous reconstruction to improve functional and aesthetic outcomes. Critical aspects include VSP, 3-dimensionally printed plates, and IDIP. Review of a prospectively maintained database identified patients who underwent osseous maxillary reconstruction with a fibula flap and immediate dental implants from 2017 to 2022, with a focus on oncologic characteristics and reconstructive outcomes.

RESULTS

During the study, 20 patients underwent maxillary reconstruction with VSP and IDIP. One dental implant of 55 failed to osseointegrate, and no flaps were lost. Three patients experienced partial loss of the fibula skin island; 1 required palatal closure with a radial forearm flap, and 2 were managed with outpatient débridement. Fifteen patients achieved either an interim or final retained dental prosthesis. All prostheses achieved acceptable aesthetic results without the instability associated with non-bone-borne devices (eg, dentures/obturators). No patients experienced delays in oncologic treatment.

CONCLUSIONS

VSP technology has enabled surgeons to replace like with like to achieve better outcomes with acceptable morbidity for maxillary defects. IDIP provides all patients an opportunity for a fixed prosthesis even though not all complete the process. This maxillary reconstruction workflow can be safely accomplished in oncologic patients with promising and effective early results.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Maxillary Reconstruction with Free Vascularized Fibula: 15-Year Experience

BACKGROUND

Reconstruction of the midface after maxillectomy is extremely challenging because of the need to reestablish the contour of the midface, maintain oronasal separation, support the orbit, and to restore the dentition. In this study, the authors present their specific technique, surgical and functional outcomes, and pitfalls to avoid for reconstruction of the midface with the fibula osteocutaneous free flap.

METHODS

A retrospective review of patients who underwent maxillary reconstruction with a fibula osteocutaneous free flap was performed.

RESULTS

Eighty-five flaps were performed in 73 patients (61 patients received a fibula flap only; 12 patients received an additional soft-tissue free flap). Reconstructions were performed for Cordeiro type 2 (82.2%) and Cordeiro type 3a (18.8%) defects. Osseointegrated dental implants were placed in 95.9% of patients, 13.7% of whom underwent immediate implant placement. Concurrent orbital floor reconstruction was performed in 16.2% of patients. The rate of operative take-back was 18.9%, and total flap loss occurred in 2.7%. Hardware exposure occurred in 11.0% at a mean of 4.4 years postoperatively and palatal fistulas occurred in 5.5%, usually within the first 3 weeks following reconstruction. Functionally, 79.5% demonstrated excellent speech and 80.9% had unrestricted diet postoperatively. The mean follow-up period was 3.4 years.

CONCLUSIONS

The present study shows that maxillary reconstruction with free fibula flap provides reliable reconstruction that restores dental, orbital, and midfacial support. Modifications and nuances to the reconstructive technique learned over time to avoid complications and improve outcomes are described herein.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Identifying High-Risk Patients with Advanced Midface Cancer: Personalized Surgical and Reconstructive Approach for Radical Resection

BACKGROUND

Individually personalized reconstructive microsurgery is more and more universally recognized and applied as a one-time, part of a few, or even the only highly effective treatment of patients with locally advanced midface cancer. Among the increasing number of publications focused on this field, most present different reconstructive techniques used for a single patient (case reports), and fewer papers evaluate a group including more than 100 patients.

METHODS

A dataset of 119 locally advanced midface cancers in stage T3 or T4 was used to analyze whether there is any correlation between clinical factors, resection defect parameters, and the free flaps chosen for reconstruction.

RESULTS

In general, the 5-year OS was 95% and 77% for the DFS, which inversely correlated with the increasing Cordeiro's type of resective defects. Local recurrence occurred in 23% of cases. Taxonomic dendrograms allow the selection of four (A-D) different case clusters. Cluster B, which characterizes a tumor size of 8-18 cm2, Cordeiro type IIIA, and an uncertain radicalism of resection, has the worst prognosis with a very high (89%) risk of local recurrence. On the contrary, the most favorable was found in cluster C, characterized by Cordeiro type IIA, a tumor size of 8 cm2, and negative resective margins, because it has a very low (6%) risk of local recurrence.

CONCLUSIONS

The results of the present analysis have led to design algorithms for midface resection and reconstruction. However, these should not be considered obligatory but rather as a useful general guideline.

Advanced reconstructive techniques following orbital exenteration: The role of LCFA free flaps

BACKGROUND

Orbital exenteration is a severe and disabling surgical procedure that involves the removal of all orbital contents. Effective reconstruction is crucial to managing the resulting defects. This study aims to propose a reconstructive algorithm utilizing free flaps derived from the lateral circumflex femoral artery (LCFA) system for orbital exenteration defects, based on our clinical experience.

PATIENTS AND METHODS

Patients who underwent orbital exenteration and subsequent reconstruction using LCFA-based free flaps between January 2013 and January 2022 were included in this study.

RESULTS

A total of 44 patients underwent orbital exenteration, followed by LCFA free flap reconstruction. The choice of reconstructive technique depended on defect type and dura mater exposure, adhering to the proposed algorithm. The procedures included 20 standard ALT (Anterolateral thigh) flaps, 13 chimeric ALT flaps, 1 SALT chimeric flap with skin grafting, 7 SALT flaps with skin grafting, and 3 buried SALT flaps. Complications were recorded in 10 cases at the recipient site and 2 cases at the donor site.

CONCLUSION

Orbital exenteration presents significant challenges both surgically and reconstructively, with a high risk of local recurrence and postoperative mortality. The reconstruction algorithm using LCFA-based free flaps, as proposed in this study, may guide surgeons in selecting the most appropriate technique, tailored to the specific defect and considering postoperative treatments such as adjuvant radiotherapy.

Delayed Maxillary Reconstruction with Free Osteocutaneous Fibula Flap Using CAD-CAM Technology

Background  Maxillary reconstruction poses unique challenges for the reconstructive surgeon because of the complex three-dimensional (3D) anatomy of the maxilla. Undertaking this endeavor on secondary reconstruction makes it more difficult due to problems in recreating the true defect. This study is an attempt to demonstrate the role of virtual surgical planning (VSP), 3D printing, and mock surgery in reconstructing such defects using free fibula flaps. Materials and Methods  This was a prospective study involving 10 patients of maxillary defects who underwent delayed reconstruction with a free fibula flap. The planning was done preoperatively using computer-aided design and computer-aided manufacturing (CAD-CAM) technology. A mock surgery with 3D printed models was done before the surgery. After the surgery, the accuracy results were obtained by overlapping and measuring fixed point distances between preoperative virtual planning and postoperative computed tomography (CT) scan data. Results and Discussion  Nine patients underwent successful reconstruction and were satisfied with the outcome. One patient had flap loss. The mean shift along the horizontal, vertical, and 3D axes was less than 5 mm between the preoperative virtual planning and postoperative CT scan data, indicating accurate reconstruction. We also suggest strategies for soft-tissue and bony inset including inferolateral pedicle origin, anteriorly facing lateral fibular surface, and two bony struts for the alveolus. Conclusion  VSP and CAD-CAM technology in maxillary reconstructions help achieve an anatomically accurate neo-maxilla. The addition of mock surgery to the routine and the use of cutting guide avoid unpredictability and reduce the need for adaptation activities on the operating table. CAD-CAM technology despite its limitations is invaluable in maxillary reconstruction and is an important tool for a reconstructive plastic surgeon.

Custom Endoprosthesis-Assisted Pediatric Microsurgical Jaw Reconstruction

Surgical treatment of pediatric maxillary and mandibular tumors can cause significant postresection disfigurement, mastication, and speech dysfunction. The need to restore form and function without compromising growth at the recipient and donor sites poses a particular reconstructive dilemma. This study evaluates outcomes of the custom endoprosthesis (CE) compared with noncustom reconstruction (NCR) and introduces an algorithm using CE to optimize available soft tissue reconstructive options. An Institutional Review Board-approved retrospective review of all patients undergoing maxillary or mandibular reconstruction between 2016 and 2022 was completed. The independent variable of interest was CE utilization. Primary outcomes of interest included hardware failure/removal or exposure, major complications, and revision surgeries. Covariates of interest included patient demographics, medical comorbidities, tumor size, and pathologic diagnosis. Statistical analyses including independent t test, χ 2 analyses, and univariate/multivariate logistic regression were performed using RStudio version 4.2.1. Fifty-one patients (37 mandible and 14 maxilla) underwent CE or NCR. Of patients, 37% (n = 19) received CE. Of patients who underwent mandibular reconstruction, there were significantly lower rates of hardware exposure (14.3% versus 47.8%, P = 0.018), failure (7.1% versus 43.5%, P = 0.048), major complications (28.6% versus 78.2%, P = 0.008), and revisions (11.1% versus 50.0%, P = 0.002) in the CE cohort compared with the NCR cohort. The rates of hardware failure, exposure, major complications, and revisions did not significantly differ in maxillary reconstructions, however, CE successfully reconstructed significantly larger defects (179.5 versus 74.6 cm 3 , P = 0.020) than NCRs. Deviating from NCR, the authors propose an algorithm considering anatomical location, extent of resection, and patient age for soft tissue selection. This algorithm yielded improved mandibular reconstructive outcomes and no increase in complications rate in maxillary reconstruction despite larger resection defects. Furthermore, the authors' initial findings demonstrate that CE is a safe option for pediatric maxillary and mandibular reconstruction that may, in addition, facilitate improved form and function.

The use of a sling suture for ventral orbital stabilization after inferior orbitectomy in three dogs

OBJECTIVE

To describe a novel surgical technique for the ventral stabilization of the orbit after inferior orbitectomy by using a sling suture and report outcomes in three dogs.

ANIMALS

A 7-year-old male neutered Swiss shepherd, a 4-year-old female neutered golden retriever and a 9-year-old female neutered Rhodesian ridgeback.

STUDY DESIGN

Short case series.

METHODS

All dogs presented with caudal unilateral maxillary masses. Surgical resection necessitated a caudal maxillectomy and inferior orbitectomy with a combined dorsolateral and intraoral approach. A sling suture was used to support the globe. A nylon suture was placed rostrally through the osteotomized maxilla and caudally through the osteotomized zygomatic arch via predrilled holes. The suture was tightened until the position of the globe subjectively appeared normal and was secured with a surgeon's knot. The periorbita was secured over the nylon suture with poliglecaprone suture material in a simple interrupted or continuous pattern. The surgical approach was routinely closed.

RESULTS

Follow-up ranged from 7 to 63 days. The surgical wounds healed uneventfully, and no postoperative complications associated with the stabilization technique were noted. No orbital deviation was noted and the zygomatic regions appeared subjectively symmetrical.

CONCLUSION

The nylon sling suture provided a quick, easy, safe and effective technique to stabilize the ventral orbit during a combined maxillectomy and orbitectomy in dogs.

Modern Oncologic Maxillary Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Have a broad understanding of the oncological principles relating to cancers involving the maxilla. (2) Define anatomically the various types of maxillectomy defects and their associated morbidity. (3) Understand the goals and principles of maxillary reconstruction. (4) Demonstrate an understanding of the strengths, limitations, and alternative reconstructive options for the various types of maxillectomy defects.

SUMMARY

Reconstruction of the maxilla following cancer resection has evolved over the past decade. Underpinned by advances in virtual surgery technology and an increased focus on dental rehabilitation, more sophisticated workflows using free bone flaps have become more commonplace. There are few reconstructions anywhere in the body that require the restoration of similarly intricate bone and soft-tissue relations with implications for both form and function, like the maxilla. Success demands careful anatomical definition of the defect, an understanding of the goals and principles of reconstruction, and the understanding of relative strengths and limitations of the various reconstructive options. Equally, as no one technique is without shortcomings and maxillary surgery can be associated with a significant complication profile, it is just as important to match the patient and oncologic context to the reconstruction. This article is intended to provide the reader with a broad overview of these core factors.

Simultaneous Reconstruction of the Bilateral Maxillae and Nasal Hard Structure Using a Vascularized and Nonvascularized Fibula

Midfacial reconstruction for extensive defects of the hard nasal structures and bilateral maxillae is challenging. Postoperative radiotherapy causes skin contracture, making secondary reconstruction extremely difficult. A 57-year-old man underwent resection of the nasal bone, nasal cartilage, and hard palate for cancer of the nasal cavity. Postoperative radiotherapy (70 Gy) resulted in bilateral osteoradionecrosis. Severe depression deformity of the midface causes a disorder in closing the mouth, resulting in difficulty in conversation and oral intake. We performed simultaneous reconstruction of the bilateral maxillary and nasal hard structures using double free flaps (fibular osteocutaneous and anterolateral thigh flaps). A 16-cm right fibular osteocutaneous flap was elevated, and an 8-cm proximal bone was resected to obtain the length of the peroneal vessels. The distal 8 cm was cut into three pieces while maintaining the blood flow. The removed nonvascularized fibula was processed into two pieces of cortex: nasal bridge and columella. All areas of the skin island were de-epithelialized to bilaterally fill the maxillary sinuses. Next, the ipsilateral anterolateral thigh flap was elevated with the central 6-cm part for closure of the palate and the proximal area to fill the nasal cavity. The distal area consisted of a fascial flap to cover the reconstructed nasal structure. The chimeric double flap allowed for oral intake, conversation, and nasomaxillary prominence. Computed tomography performed 8 months postoperatively showed maintained bony structures. We used the extra fibula as a nonvascularized cortex piece to prevent infection and exposure, which enabled simultaneous reconstruction of the bilateral maxillae and hard nasal structure.

Reconstruction of Maxillary Defects Using Virtual Surgical Planning and Additive Manufacturing Technology: A Tertiary Care Centre Experience

Introduction

Maxillary reconstruction is often a challenging task for the surgeons because of the complex anatomy. However, with the advances in virtual surgical planning (VSP) and 3D printing technology there is a new avenue for the surgeons which offers a suitable alternative to conventional flap-based reconstructions.

Patients and Methods

In this article, we have described 4 case scenarios which were managed with the help of VSP and additive manufacturing technology for complex maxillary reconstruction procedures. Use of the technologies aided the clinician in achieving optimal outcomes with regards to form, function and esthetics.

Discussion

Virtual surgical planning (VSP) has gained a lot of impetus in past 1 decade. These aides the surgeon in determining the extent of disease and also carry out the treatment planning. In addition to VSP, the concept of additive manufacturing provides a viable alternative to the conventional reconstruction modalities for maxillary defect rehabilitation. Increased accuracy, rehabilitation of normal anatomical configuration, appropriate dental rehabilitation, decreased intra-operative time and post-operative complications are some of the advantages. In addition, patient-specific implants eliminate the need for a separate donor site. Apart from the treatment of pathologies, they also can be used for reconstruction of post-traumatic defect, where endosteal implant placement is not possible.

Conclusion

These modalities show promising results for reconstruction of complex maxillary defects.

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.

Microvascular Free Flap Outcomes in Maxillectomy Defects from Invasive Fungal Sinusitis

OBJECTIVES

Microvascular free tissue transfer is routinely used for reconstructing midface defects in patients with malignancy, however, studies regarding reconstructive outcomes in invasive fungal sinusitis (IFS) are lacking. We aim to describe outcomes of free flap reconstruction for IFS defects, determine the optimal time to perform reconstruction, and if anti-fungal medications or other risk factors of an immunocompromised patient population affect reconstructive outcomes.

METHODS

Retrospective review of reconstruction for IFS (2010-2022). Age, BMI, hemoglobin A1c, number of surgical debridements, and interval from the last debridement to reconstruction were compared between patients with delayed wound healing versus those without. Predictor variables for delayed wound healing and the effect of time on free flap reconstruction were analyzed.

RESULTS

Twenty-seven patients underwent free flap reconstruction for IFS. Three patients were immunocompromised from leukemia and 21 had diabetes mellitus (DM). Patients underwent an average of four surgical debridements for treatment of IFS. The interval from the last IFS debridement to flap reconstruction was 5.58 months (±5.5). Seven flaps (25.9%) had delayed wound healing. A shorter interval of less than 2 months between the last debridement for IFS and reconstructive free flap procedure was associated with delayed wound healing (Fisher Exact Test p = 0.0062). Other factors including DM, BMI, HgA1c, and bone reconstruction were not associated with delayed wound healing.

CONCLUSION

Patients with maxillectomy defects from IFS can undergo microvascular-free flap reconstruction with good outcomes while on anti-fungal medication. Early reconstruction in the first 2 months after the last IFS debridement is associated with delayed wound healing.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1642-1647, 2024.

Reconstruction of a Large Composite Hemicraniofacial Defect with Bipedicled DIEP/TRAM Flaps

Head and neck reconstructions are often challenging due to the mix of functional and aesthetic goals. It can be tricky when different tissue types are required to reconstruct each subunit. Craniofacial reconstructions require a large volume of tissue to cover defects that span across a large convex area. The latissimus dorsi muscle flap is a workhorse free flap used frequently by surgeons due to its ability to cover over a large surface area. However, there are unique situations when even the latissimus dorsi muscle is not enough to provide the bulk cover for the craniofacial defect. We present a complex case of a hemicraniofacial reconstruction after a hemifacial orbital exenteration and cranial resection of a large neglected basal cell carcinoma.

Application of double layer with collagen-elastin matrix (Matriderm®) and polyglycolic acid sheet (Neoveil®) for oroantral and oronasal fistula closure after maxillectomy: a retrospective single center experience

PURPOSE

This study investigates the effectiveness of a new double-layer approach for closing oroantral and oronasal fistulas (OA/ONFs) using Matriderm® and Neoveil®. Matriderm®, an acellular dermal matrix composed of collagen and elastin fibers, supports tissue regeneration, while Neoveil®, a biodegradable mesh sheet, serves as a barrier to prevent leakage and scarring.

MATERIAL AND METHODS

A retrospective study of 12 maxillectomy patients with oral cancer between January 2022 and May 2023 was conducted. Patient data, including tumor stage, bone invasion, and defect size, were analyzed. Surgical techniques included sinus mucosa preservation, and either buccal fat grafting combined with the double layer technique or the double layer technique alone, with statistical analysis performed using R software to evaluate outcomes.

RESULTS

The results indicate a 41.7% incidence rate of fistula formation with lower T stages, absence of bone invasion, smaller defect dimensions, and intact sinus mucosa correlating with reduced fistula risk (p < 0.05). Notably, no patients required fistula-related surgical revisions, validating the efficacy of the approach.

CONCLUSION

This study introduced a novel double-layer technique using Matriderm® and Neoveil® for closing OA/ONFs after maxillectomy. The technique demonstrated promising outcomes in addressing these post-operative complications. Lower tumor stages, no bone invasion, smaller defects, and intact sinus mucosa correlated with reduced fistula risk. This technique holds potential to enhance maxillectomy outcomes, offering a comprehensive approach to functional concerns, but warrants further investigation.

Transoral versus transfacial surgical approach to maxillary tumors: evaluation of outcomes and perspectives

Neoplasms of the maxilla have multiple different origins and histology, and often extend towards the infratemporal fossa, orbit, or skull base. Extensive resection may be required, often leading to poor esthetic and functional results. Usually, these lesions are removed via a transfacial approach. The aim of this study was to compare the outcomes of the transoral versus transfacial approach for maxillary tumors. A single-institution retrospective study was conducted on patients with maxillary-midface tumors, treated between January 2009 and December 2019. The patients were divided into two groups according to the surgical approach, transfacial or transoral, and the following outcomes were assessed: extent of the resection based on Brown's classification; postoperative pathology margin assessment; reconstruction technique; esthetic/functional results. A total of 178 patients were included. A satisfactory resection was obtained in both groups, with the transoral cohort achieving a higher rate of clear oncological margins (positive margins: transoral group 3.7% versus transfacial group 6.8%, P = 0.389) and a significantly higher University of Washington Quality of Life score (mean 72.2 versus 67.8, P < 0.001). Even large and invasive tumors can be treated successfully with the transoral approach, avoiding unesthetic facial scars while still providing complete resection of the tumor.

Stacked fibula flap for unilateral total maxillectomy reconstruction with orbital preservation

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.

Restoring Quality of Life: Assessing the Impact of Free Flap Reconstruction in Coronavirus Disease 2019-Associated Rhino-Orbital Mucormycosis Patients

Background  In India, between May 5 and July 2021, 41,512 cases and 3,554 deaths due to mucormycosis were reported in coronavirus disease 2019 (COVID-19)-infected patients or COVID-19-recovered patients. COVID-19-associated rhino-orbital mucormycosis (CAROM) has been associated with adverse effects that can affect oral health, vision, and physical as well as emotional functioning. After the radical debridement of CAROM and antifungal therapy, reconstructive surgery should be employed to restore function and aesthetics; however, limited clinical data exist on its potential effect on the quality of life (QOL) of these patients. Objective  Our objective was to assess the QOL among CAROM patients reconstructed with free flap surgery. Materials and Methods  This analysis studied 19 patients of CAROM who had maxillectomy and/or orbital exenteration defects reconstructed with free flaps at a tertiary care center. All these patients were free from any residual disease, as confirmed by tissue biopsy taken from the affected area. The QoL of these patients was assessed 1 week preoperatively and 4 to 6 months postoperatively using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC QLQ-HN43) questionnaire module. Results  There was a statistically significant improvement in 10 out of the total 19 parameters ( p  < 0.05) which include pain in the mouth, problems opening mouth, speech, swallowing, weight loss, dry mouth and sticky saliva, body image, fear of progression, social contact, and social eating. Conclusion  The EORTC QLQ-HN43 questionnaire module presented a statistically significant improvement in the functional as well as psychological status of the CAROM patients undergoing reconstruction by free flap surgery.

Necessity of infraorbital wall reconstruction in patients with residual periosteum after total maxillectomy

BACKGROUND

To date, there have been no reports regarding the necessity or methods of reconstruction for cases where the orbital periosteum remains even though the orbital floor bone has been resected in primary reconstruction after total maxillectomy. This study investigated the reconstruction methods for infraorbital wall reconstruction in patients with residual orbital periosteum.

METHODS

This was a retrospective cohort study at a single center from June 2010 to June 2019. The following two main cohorts were evaluated: non-reconstruction and reconstruction groups (reconstructed with fascia or costal cartilage) according to whether the orbital floor was reconstructed after total maxillectomy with residual orbital periosteum. The main outcomes were the deviation of the globe evaluated using computed tomography images and subjective signs of diplopia obtained from medical records.

RESULTS

Enophthalmos occurred in all five cases in the non-reconstruction group, and diplopia appeared in four cases. In five out of six cases in the reconstruction group, deviation of the globe was not observed. Exophthalmos occurred in one case reconstructed with costal cartilage. Diplopia was not observed in the reconstruction group. In the statistical assessment, a significant difference was observed in the globe deviation between the two groups (P = 0.004).

CONCLUSIONS

In cases where the orbital periosteum remains, it is necessary to actively reconstruct the infraorbital wall. Moreover, we believe that the reconstruction with fascia is convenient and useful because it is less invasive, the surgical procedure is simple, and the fascia can be collected from the same surgical field when the flap is elevated.

LEVEL OF EVIDENCE

4 (retrospective cohort study).

Risk Factors for Postoperative Infection After Maxillary Reconstruction Using Skeletal Grafts

Skeletal grafts are usually required to reconstruct defects after maxillectomy for acceptable aesthetic and functional results. Postoperative infection is a serious complication; however, few studies have evaluated the vulnerability to infection of various skeletal reconstructive materials used for maxillary reconstruction. A retrospective study was conducted on 53 cases in which maxillary skeletal reconstruction was performed between 2010 and 2021. The postoperative infection rate was compared between various skeletal reconstructive materials, including costal cartilage, scapula, fibula, ilium, cranium, and titanium mesh. In addition, the risk factors for postoperative infection were evaluated using 2-group comparison tests. Of 53 patients, 14 (25.4%) contracted an infection postoperatively. No significant differences were observed in the infection rates among the materials used for skeletal reconstruction. Cases undergoing secondary reconstruction tended to have a higher infection rate (34.4%) than primary reconstruction (14.3%). For nonvascularized skeletal grafts (41 cases), the concomitant use of soft-tissue flaps decreased the infection rate from 30.8% to 17.9%. Costal cartilage was the most frequently used material (31 cases), primarily for orbital floor reconstruction. Regarding the costal cartilage, nasal wall reconstruction had a higher infection rate (100%) than reconstruction of other parts of the maxilla (0.0%-17.9%). Nonvascularized skeletal grafts, mainly costal cartilage grafts, were safely used for maxillary reconstruction. However, caution should be exercised for postoperative infection in secondary cases and in cases where costal cartilage is used for nasal wall reconstruction. Covering nonvascularized skeletal grafts with soft-tissue flaps may be an effective countermeasure.

Navigation-guided resection of locally advanced midface malignancies. Does it improve the safety of oncologic resection?

INTRODUCTION

Treatment of malignant midface tumors is a surgical challenge with an increased difficulty to obtain free surgical margins. The computer assisted surgery (CAS) and intraoperative navigation (ION) can be very helpful in complex midface resections. The main objective of this paper is to evaluate if the ION could improve the rate of free surgical margins in locally advanced midface malignancies.

MATERIALS AND METHODS

A retrospective cohort study was performed including 40 patients with a locally advanced malignant midface tumor (T4a/b) surgically treated from September 2016 to September 2022. Patients were divided in two groups, a control group included 20 patients operated on without ION and the study group included 20 patients treated with Navigation assisted surgery. A systematic analysis was performed comparing surgical margins in both groups.

RESULTS

Squamous cell carcinoma was the most common histological type. Oral cavity was the most common primary location. Overall, considering each specimen as an hexahedrium, 240 surgical margins were analyzed. 15 out of 120 margins analyzed in the navigation group (12.5 %) were positive while 30 out of 120 margins analyzed in control group (25 %) were affected (p 0.013). Concerning margin location, the ION group showed less involvement of the upper surface of specimen than in control group (p 0.048).

CONCLUSION

Navigation Assisted Surgery seems to improve the rate of free surgical margins in patients with locally advanced midface malignancies, specially concerning involvement of the superior margin. Further studies are recommended to corroborate these results and its potential influence in survival rates.

Palatal mucoperiosteal flap for oro-nasal fistula following maxillectomy for maxillary sinus cancer

OBJECTIVES

This study aimed to describe the technique and clinical outcomes of using a palatal mucoperiosteal flap for oro-nasal fistula closure following resection of maxillary sinus cancer.

METHODS

The study was conducted with the permission of the internal review board of the Japanese Red Cross Wakayama Medical Center. Five consecutive cases from 2016 to 2020 of surgically treated maxillary sinus cancer in which the oro-nasal fistulas were closed using a palatal mucoperiosteal flap were retrospectively reviewed.

RESULTS

Following tumor resection, the oro-nasal fistula was closed using a palatal mucoperiosteal flap. Complete separation of the oral and nasal cavities was achieved in four patients. Oral intake was resumed within two weeks in four patients. All the patients were able to eat foods similar to those in the preoperative period. Their postoperative speech function was excellent, with no difficulty in communicating with others.

CONCLUSION

In the selected cases of maxillary sinus cancer, preservation of the palatal mucosa and closure of an oro-nasal fistula using a palatal mucoperiosteal flap was possible with reasonable outcomes for swallowing and speech functions. The use of this local flap is recommended as a minimally invasive procedure that can be performed especially in patients with limited physiological reserves which preclude free flap reconstruction.

Classification of maxillectomy in edentulous arch defects, algorithm, concept, and proposal classifications: A review

OBJECTIVES

Aramany's classification of postsurgical maxillectomy defects was introduced for partially edentulous situations, and has been widely used for education and effective communication among practitioners. Numerous classifications of maxillofacial defects, based on surgical procedure, resultant defects, or prosthodontist's perspective after rehabilitation, exist in the literature. However, no single classification has incorporated all these factors. The purpose of this review was to highlight the classification systems and describe a pragmatic classification series for edentulous maxillary arch defects (maxillectomy) by applying the Aramany classification criteria, to enhance treatment outcomes and communication among practitioners.

MATERIAL AND METHODS

An electronic search of the literature published in English was conducted using the PubMed/MEDLINE and Google Scholar database. Keywords used were "maxillectomy classification" AND "surgical resection," "maxillectomy classification" AND "complete edentulous." In addition, a manual search was also performed followed the same criteria in the following journals: Journal of Prosthetic Dentistry and Journal of Prosthodontics.

RESULTS

Several classification systems for partial dentition were found in terms of size, location, dentition, and extension of the defect (isolated or communication defects). The findings revealed a variety of maxillectomy defect classifications for partially dentate, considering surgical factors and rehabilitation. However, no study or classification system exist for the edentulous arch defects.

CONCLUSIONS

Different classification systems for maxillectomy defects exist in the literature, only for partially dentate patients. To the authors best knowledge, no classification system for completely edentulous maxillary arch defects have been proposed till date. A simple classification system with clear characteristics for edentulous maxillectomy dental arch defects has been proposed. This classification was modeled after Aramany classification for easier memorization and application.

Virtual Surgical Planning in Free Tissue Transfer for Orbito-Maxillary Reconstruction

Since its introduction, virtual surgical planning (VSP) has been rapidly adopted as a part of reconstructive surgeon's armamentarium. VSP allows reconstructive surgeons to simulate resection, plan osteotomies, and design custom plates. These unique advantages have been especially beneficial for head and neck reconstructive surgeons as there is small room for error and high technical demand in head and neck reconstruction. Despite its popularity, most surgeons have limited experience in using VSP for orbito-maxillary reconstruction as tumors that involve the midface are relatively rare compared with other head and neck oncologic defects. In our institution, we routinely use VSP for orbito-maxillary reconstruction using free fibula flap to provide support for orbit, to restore normal dental occlusion, and to restore midface projection. In this chapter, we will discuss the role of virtual surgical planning and our algorithmic approach of performing orbito-maxillary reconstruction using free tissue transfer.

Current Concepts in Maxillary Reconstruction

SUMMARY

Defects involving the midface and maxilla pose unique challenges to reconstructive surgeons. The maxilla serves as the central keystone of the face and interfaces with various other facial subunits to affect form and function. Reconstructive methods range from prosthetics to free tissue transfer, and the indications for different options are reviewed here. Finally, special considerations including management of the orbit, dental rehabilitation, and future directions are discussed.

The Role of Full-Thickness Skin Grafts in Patient’s Rehabilitation after Maxillectomy and Midface Defects

(1) Background: Nowadays, microvascular grafts are the gold standard in the reconstruction of midface defects after maxillectomy, however, not all patients may qualify for this type of surgery. The purpose of present study is to evaluate the benefits of alternative reconstruction methods such as full-thickness skin grafts for these conditions. (2) Methods: The research group consisted of 37 patients who underwent maxillectomy due to cancer of the mid-face and had full-thickness skin graft reconstruction. The study covered the period from 2011 to 2020. (3) Results: Based on the clinical examination and the subjective assessment of patients, a positive effect of the use of free skin grafts on their convalescence and rehabilitation was found. In particular, they contributed to the reduction in postoperative pain and pain associated with prosthetic stages (VAS Scale). (4) Conclusion: Full-thickness skin grafts in combination with individual prosthetic restorations are a good alternative to rehabilitation in patients who do not qualify for microsurgical treatment.

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.

Influence of socioeconomic status on psychological distress and treatment satisfaction levels among patients undergoing prosthetic rehabilitation following maxillectomy: An observational study

Aim:

The aim of this study was conducted to evaluate the effect of socioeconomic status (SES) on psychological distress and treatment satisfaction levels of patients who underwent maxillectomy and rehabilitation with obturator prosthesis.

Settings and Design:

Prospective, observational, analytic study.

Materials and Methods:

Forty-three patients undergoing maxillectomy were enrolled and divided into upper, middle, and lower SES groups, according to the updated Kuppuswamy SES scale. Psychological distress levels were assessed using Hospital Anxiety and Depression Scale (HADS) before maxillectomy (T0) and at 3 weeks after delivery of definitive obturator (T1). Treatment satisfaction levels with obturator prosthesis were assessed using Obturator Functioning Scale (OFS) at T1. HADS and OFS scores were then correlated with the SES of the participants.

Results:

Out of 43 participants, 7 were lost to follow up. The total number of participants in upper, middle, and lower SES groups was 14, 11, and 11, respectively. Before surgery, there was no significant difference in anxiety levels (P > 0.05) among different SES groups. However, the depression levels were the highest in the lower SES and decreased significantly with increasing SES. Prosthetic rehabilitation led to statistically significant (P < 0.05) fall in the levels of both anxiety and depression assessed at 3 weeks after delivery of prosthesis. The upper SES group was found to be less anxious and depressed compared to middle and lower SES groups after prosthodontic rehabilitation. Treatment satisfaction level was found to be significantly low (P = 0.005) in lower SES group as compared to upper SES group while no difference was found in between the middle SES when compared to higher or lower SES groups.

Conclusions:

SES has a profound impact on the patient's psychosocial well-being and treatment satisfaction. Patients of lower SES reported with higher psychological distress and lesser treatment satisfaction compared to those belonging to upper SES.

The Zygomatic Implant Perforated (ZIP) flap reconstructive technique for the management of low-level maxillary malignancy - clinical & patient related outcomes on 35 consecutively treated patients

BACKGROUND

The zygomatic implant perforated (ZIP) flap technique provides immediate reconstruction and rapid dental rehabilitation for low-level malignant tumors.

METHODS

Patients who underwent ZIP flap reconstruction between December 2015 and February 2021 were followed prospectively.

RESULTS

Thirty-five consecutively treated patients were studied with 16 undergoing surgery alone and 19 undergoing surgery followed by radiotherapy. The median time to fit the prosthesis was 29 days with all patients requiring adjuvant radiotherapy receiving their fixed dental prosthesis prior to its commencement. Vascularized flap (100%), zygomatic implant (98.4%), and prosthesis (97%) survival were excellent and the ZIP flap protocol was highly rated by patient-related outcome measures especially for the chewing domain.

CONCLUSIONS

The ZIP flap technique provides an excellent means of providing an autogenous oronasal seal and a foundation for immediate cortically anchored fixed dental rehabilitation.

CLINICAL SIGNIFICANCE

This technique provides rapid and robust rehabilitation for patients presenting with low-level maxillary malignancy despite the use of radiotherapy.

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.

Anatomic Subunit Approach to Composite Reconstruction of Facial Gunshot Wounds

ABSTRACT

With a rise in gun violence in the United States, surgeons are tasked with effectively managing penetrating facial trauma. The purpose of this study is to assess methods used for successful composite reconstruction of each anatomical facial subunit following penetrating trauma. A retrospective chart review was performed in subjects undergoing craniofacial reconstruction following penetrating trauma. Reconstructive methods were analyzed through operative reports. Subjects were categorized by anatomical subunit reconstructed (mandible, maxilla (malar complex and roof/palate), orbit, and cranium) and method of reconstruction (open reduction internal fixation only, bone graft, free flap, implant, and tissue expansion). Thirty-six subjects underwent reconstruction for penetrating facial trauma. Involved subunits include 24 mandible, 11 malar complex, 13 palate, 18 orbit, and 11 cranium. Predominate reconstruction method was open reduction internal fixation only for mandible (45.8%), bone grafting for malar complex (81.8%), implant for orbit (66.7%) and cranium (63.6%), and local tissue rearrangement for palate (84.6%). The predominate bone graft donor site was iliac for mandible (42.9%), rib for malar complex (36.3%) and orbit (40.0%), and frontal bone for cranium (42.8%). The predominate free flap was osteocutaneous for all mandible, orbit, and cranium and 7 of 10 (70.0%) palate reconstructions. Tissue expansion was used in all subunits except cranium. In conclusion, bone grafting, implants, free tissue transfer, and tissue expansion are all viable reconstruction options for penetrating trauma. There is no single approach to use, and decisions regarding definitive reconstruction method should be based upon anatomical subunit involved and the size/area of defects.

Association of Virtual Surgical Planning With External Incisions in Complex Maxillectomy Reconstruction

Importance

Maxillectomy can commonly be performed through a transoral approach, but maxillectomy defect reconstruction can be difficult to precisely design, contour, and inset through this approach.

Objective

To evaluate whether the use of virtual surgical planning (VSP) and 3-dimensional (3-D) modeling is associated with a decrease in the requirement of lateral rhinotomy (LR) for patients undergoing total and partial maxillectomy reconstruction.

Design, Setting, and Participants

This retrospective cohort study was conducted among patients undergoing subtotal or total maxillectomy with microvascular free flap reconstruction with or without VSP and 3-D modeling at a single tertiary care academic medical center between January 1, 2008, and October 3, 2019.

Interventions

Maxillectomy and free flap reconstruction with or without VSP.

Main Outcomes and Measures

Necessity of LR or other external incision for contouring, placement, and fixation of reconstruction as well as surgical complications.

Results

Fifteen patients (12 men [80%]; mean age, 64 years) underwent maxillectomy with free flap reconstruction without VSP. Eight patients (53%) in this group underwent total maxillectomy, and 4 patients in this group (27%) underwent partial maxillectomy. Twenty-three patients (18 men [78%]; mean age, 58 years) underwent maxillectomy with free flap reconstruction and VSP and 3-D modeling. Twelve of these patients (52%) underwent total maxillectomy, and 11 (48%) underwent partial maxillectomy. Lateral rhinotomy was necessary for 1 patient (4%) in the VSP group vs 12 patients (80%; 95% CI, 54%-98%) in the pre-VSP group. There were no LR complications in the VSP group vs 6 in the pre-VSP group. Among both groups, 14 patients underwent fibula free flap, 22 patients underwent subscapular system free flap, and 2 patients underwent cutaneous or osteocutaneous radial forearm free flap. There were no flap failures in the LR group and 1 flap failure in the group without LR.

Conclusions and Relevance

This cohort study suggests that the use of VSP and 3-D modeling for maxillectomy reconstruction is associated the a decrease in the need for external incisions without compromising reconstructive flap utility.

Free Periosteal Flaps with Scaffold: An Overlooked Armamentarium for Maxillary and Mandibular Reconstruction

Simple Summary

Head and neck bone reconstruction with revascularized free periosteal flaps and scaffold is an overlooked option in the literature. Aim of the present paper was to systematically analyse the results of maxillary and mandibular reconstruction with this technique. We found a total of 7 studies with 55 patients fitting with our inclusion criteria. The overall rate of complications was 43.7%. The success rate intended as scaffold integration resulted to be 74.5%. Our paper therefore highlighted that maxillary and mandibular reconstruction with revascularized free periosteal flaps and scaffold is a possible alternative in patient unable to bone free flap complex reconstruction, with a success rate higher to that of other secondary options.

Abstract

Introduction: Head and neck bone reconstruction is a challenging surgical scenario. Although several strategies have been described in the literature, bone free flaps (BFFs) have become the preferred technique for large defects. Revascularized free periosteal flaps (FPFs) with support scaffold represents a possible alternative in compromised patient, BFF failure, or relapsing cancers as salvage treatment. However, only few clinical applications in head and neck are reported in literature. Purpose of the study was to systematically analyse the results of functional and oncologic maxillary and mandibular reconstruction with FPF with scaffold. Materials and Methods: A comprehensive review of the dedicated literature was performed according to the PRISMA guidelines searching on Scopus, PubMed/MEDLINE, Cochrane Library, Embase, Researchgate and Google Scholar databases using relevant keywords, phrases and medical subject headings (MeSH) terms. An excursus on the most valuable FPF’ harvesting sites was also carried out. Results: A total of 7 studies with 55 patients were included. Overall, the majority of the patients (n = 54, 98.1%) underwent an FPF reconstruction of the mandibular site. The most used technique was the radial forearm FPF with autologous frozen bone as scaffold (n = 40, 72.7%). The overall rate of complications was 43.7%. The success rate intended as scaffold integration resulted to be 74.5%. Conclusions: Maxillary and mandibular reconstruction with FPF and scaffold is a possible alternative in patient unfit for complex BFF reconstruction and it should be considered as a valid alternative in the sequential salvage surgery for locally advanced cancer. Moreover, it opens future scenarios in head and neck reconstructive surgery, as a promising tool that can be modelled to tailor complex 3D defects, with less morbidities to the donor site.

Postoperative Complications Associated with the Choice of Reconstruction in Head and Neck Cancer: An Outcome Analysis of 4,712 Patients from the ACS-NSQIP Database

BACKGROUND

 Microsurgical free flaps have largely supplanted pedicled flaps as the gold standard for head and neck cancer reconstruction. However, incidence of postoperative complications after accounting for patient comorbidities based on choice of reconstruction has not been well-defined in the literature in recent years.

METHODS

 Patients undergoing head and neck reconstruction were identified in the 2011-2016 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database and stratified into groups by free flap, myocutaneous pedicled flap, and other reconstruction. Demographics were analyzed and covariates balanced using overlap propensity score-based weighting. Logistic regression was used for binary outcomes and Gamma generalized linear model was used for length of stay.

RESULTS

 A total of 4,712 patients met inclusion criteria out of which 1,297 patients (28%) underwent free flap, 208 patients (4%) pedicled flap, and 3,207 patients (68%) had other, or no reconstruction performed. After adjusting for patient and disease-specific factors, pedicled flap reconstruction was associated with a higher risk of deep vein thrombosis (odds ratio [OR] = 2.64, confidence interval [CI] 1.02-6.85, p = 0.045), sepsis (OR = 2.95, CI 1.52-5.71, p = 0.001), and infection (OR = 2.03, CI 1.39-2.96, p <0.001) compared with free flap reconstruction. Free flaps had the longest mean operative time compared with the other two groups (unadjusted 578 vs. 440 vs. 326, p <0.001). Pedicled flaps had a lower incidence of bleeding requiring transfusion (adjusted OR = 0.65, CI 0.50-0.85, p = 0.002), and lower incidence of prolonged mechanical ventilation (adjusted OR = 0.33, CI 0.12-0.92, p = 0.034) compared with free flaps. There was no difference in rates of reoperation, hospital readmission, or hospital length-of-stay between pedicled and free flaps.

CONCLUSION

 Myocutaneous pedicled flaps are associated with higher overall short-term postoperative complications compared with free flaps in head and neck reconstruction, which demonstrate a more favorable morbidity profile without significantly impacting hospital readmission, reoperation, or length-of-stay.

Non-Surgical Touch-Up with Hyaluronic Acid Fillers Following Facial Reconstructive Surgery

The use of hyaluronic acid (HA) injectable fillers has become increasingly widespread in facial recontouring and rejuvenation. We report our experiences to emphasize the role of HA fillers as tools beyond aesthetic treatments in cases of post-surgical facial sequelae. HA fillers are generally used for aesthetic rejuvenation, but one potential new horizon could be their application in trauma, reconstructive, and craniofacial surgery. This study was conducted retrospectively, evaluating medical reports of patients treated at the Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, Naples, for lip incompetence, trauma, oncological, reconstructive, and craniosynostosis surgery sequelae. Visual analog scale (VAS) evaluation was performed to assess patient satisfaction. No major complications (i.e., impending necrosis or visual loss) were reported. Bruising and swelling was reported for 48 h after lip injection. At the immediate VAS evaluation, 67% of the patients were “extremely satisfied” and 33% “satisfied”. In those 33%, VAS scores changed to “extremely satisfied” at 6–9 weeks and 3–6 months of VAS evaluation (contextually to improvement in tissue flexibility, elasticity, and aesthetic appearance). Results indicate that this minimally invasive approach achieves a high level of aesthetic enhancement, improving patient satisfaction. The concept of HA filler applications could be a frontier that may be applicable to other areas of reconstructive facial plastic surgery.

The Role of Folded Multi-Island Vertical Rectus Abdominis Myocutaneous Flap in Reconstruction of Complex Maxillectomy and Midfacial Defects

ABSTRACT

The rationale and outcomes for reconstruction of complex maxillectomy and midfacial defects using a folded multi-island vertical rectus abdominis myocutaneous free flap (MI-VRAM) are analyzed in this study.A retrospective review of prospectively collected database was conducted on all VRAM free flaps used in head and neck reconstruction from 2013 to 2019. A total of 39 cases were identified, of which 21 patients underwent immediate VRAM flap reconstruction for complex maxillectomy and midfacial defects. Variables including age, sex, pathologic subtypes, tumor staging, type of resection, defect classification, adjuvant therapy, complications, follow-up time, and reconstructive details were collected.Single skin-island VRAM was used in 10 (47.6%) patients. Eleven (52.4%) patients required the use of folded MI-VRAM flap. In 6 (28.6%) patients a triple skin-island VRAM was used and 5 (23.8%) received a double skin-island VRAM. The average size of harvested skin paddle was 15 × 7.2 cm. Secondary flap contouring was required in 6 (28.6%) patients. There were no cases of total flap loss and no major donor site complications recorded.Folded MI-VRAM flap is a reliable method for reconstruction of complex maxillectomy and midfacial defects. It provides multiple independent skin islands with excellent plasticity and abundant volume of tissue for restoration of facial contours.