Total Maxillary Reconstruction With a Bi-Paddle Double-Barrel Osteocutaneous Fibular Flap and Arteriovenous Saphenous Loop After a Globe-Sparing Total Maxillectomy Due to Osteosarcoma

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.

Customized reconstruction of complex soft tissue defects in the upper extremities with variants of double skin paddle anterolateral thigh perforator flap

BACKGROUND

Complex soft tissue defects in the upper extremities are challenging to reconstruct. The purpose of this study was to share our experience with using four variants of double skin paddle Anterolateral Thigh Perforator (ALT) flap to achieve the customized reconstruction of the complex defects.

PATIENTS AND METHODS

From January 2007 to December 2019, 15 patients (14 male and 1 female) aged 15-61 years underwent double skin paddle ALT flap reconstruction of the upper extremities. 10 wounds were located in the wrist or hand, while four wounds were located in the forearm, and one wound in the elbow. All the wounds were large with non-adjacent defects and with or without a dead space. Four variants of double skin paddle anterolateral thigh perforator flaps were harvested according to the patient's needs.

RESULTS

The flaps received were consisted of 7 classic double skin paddle ALT flap, 4 vastus lateralis muscle-chimeric double skin paddle ALT flap, 2 microdissected thin double skin paddle ALT flap, and 2 flow-through double skin paddle ALT flap. The size of the skin flap ranged from 6 × 6 cm² to 26 × 7 cm², and the size of the muscle segment ranged from 5 × 2 × 1 cm³ to 16× 6 × 2 cm³. Flap necrosis related to the pedicle kinking was observed in one patient, while the rest of the flaps survived without complications. The follow-up period ranged from 7 to 54 months, with a median of 15.6 months. The mean value of the qDASH scores at the last follow-up was 27.12 ± 16.51 (range, 11.4-59.1). None of the patients showed wrist flexion deformity. Postoperatively, three patients developed finger joint stiffness, which correlated with the severity of the injury.

CONCLUSIONS

Variants of double skin paddle ALT flaps provide versatile design and allow customized reconstruction of complex soft tissue defects in the upper extremities with limited donor site morbidity. We believe that the algorithm provided will help the surgeons with deciding among variants of double skin paddle ALT flap.

Palatomaxillary Reconstruction: Fibula or Scapula

Palatomaxillary reconstruction presents a unique challenge for the reconstructive surgeon. The maxillofacial skeleton preserves critical aerodigestive functions-it provides a stable hard palate to support mastication and separate the nasal and oral cavities, and buttress support to provide adequate midface contour. Free tissue transfer has become a routine part of the reconstructive ladder in managing palatomaxillary defects. While there is a wide variety of options for bony reconstruction within the head and neck, the fibula and the scapula, and their variations, have become two of the most commonly used options for midface reconstruction. This review will discuss the advantages and disadvantages of both in specific regard to reconstruction of the palatomaxillary area.

Primary Reconstruction After Maxillectomy Defects Using Ultra Flex Mesh Plate and Rectus Abdominis Myocutaneous Free Flap Including Aponeurosis of External Abdominal Oblique Muscle

BACKGROUND

In primary reconstruction after maxillectomy for cancer, simple and less invasive surgical techniques considering functionality and aesthetics are necessary. The authors performed reconstruction for tissue defects after maxillectomy using an Ultra flex mesh plate and a free rectus abdominis myocutaneous flap including the aponeurosis of the external abdominal oblique muscle.

METHOD

A 72-year-old male with a maxillary squamous cell carcinoma underwent subtotal maxillectomy. For maxillary defects, including those in the orbital floor and hard palate, the authors performed rigid reconstruction using an Ultra flex mesh plate produced after simulation surgery using a 3-dimensional solid model, and palatal and soft tissue reconstruction using a free rectus abdominis myocutaneous flap including the aponeurosis of the external abdominal oblique muscle. After screw fixation of the mesh plate at the surrounding normal bone, the skinpaddle of the rectus abdominis flap was transferred to the oral defect. The surface of the mesh plate was completely covered with the aponeurosis of the external abdominal oblique muscle, and the remaining rectus abdominis flap was inserted into the maxillary sinus.

RESULTS

At present, 1 year after the operation, there is no recurrence, complications, such as infection, or titanium mesh breakage/exposure, and his facial shape is favorably maintained.

CONCLUSION

Reconstruction using this method is simple and less invasive. Postoperative infection and plate exposure were prevented by the complete coverage of the mesh plate with the aponeurosis of the external abdominal oblique muscle and flap. Mesh plates, when properly used, are useful reconstruction materials, but are susceptible to infection compared with autologous tissue, requiring long-term follow-up.