The Medial Femoral Condyle Corticoperiosteal Free Flap for Frontal Sinus Reconstruction

Reconstruction of the Large Frontal Sinus Defect With the Small Supporting Bone Pieces in Neurosurgical Anterior Skull Base Surgery

BACKGROUND

Large defects of frontal sinus (FS) might be difficult to manage effectively. Mismanagement of the large defects could lead to serious postoperative complications in anterior skull base surgery. This study introduces a simple and reliable method applying small supporting bone pieces to cover or insert into large FS defects, then the large defect of FS was transformed into the small defects which was sealed by bone wax successfully.

METHODS

Eleven patients underwent anterior skull base surgery for lesions or aneurysms, with the reconstruction of large FS defects by small supporting bone pieces. During craniotomy, mild violations of the FS mucosa were spared and sterilized, while severe violations required mucosal removal. Small supporting bone pieces were obtained from the inner plate of the bone flap and carefully covered or inserted into the large defects. The large defects were transformed into some small ones, which could be sealed effectively by bone wax. Demographic, intraoperative, and postoperative complication data were collected.

RESULTS

Four patients had severe mucosal violations requiring removal, while 7 had mild violations sparing the mucosa. All underwent effective reconstruction with small supporting bone pieces. Median follow-up was 6 months. All cases showed effective FS morphology reconstruction, with no FS-related complications.

CONCLUSIONS

Applying the small supporting bone pieces for large FS defect reconstruction can restore the FS morphology, preserve physiological function, and avoid postoperative complications.

Expanding Indications of the Medial Femoral Condyle Free Flap: Systematic Review in Head and Neck Reconstruction

The medial femoral condyle free flap serves as an attractive reconstructive option for small- to intermediate-sized bony defects. It is commonly applied in the extremities with limited reports in the head and neck.

Methods

A systematic review of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results

Seventeen articles met inclusion criteria, yielding 166 cases for analysis, with a majority of the cohort from a single study (n = 107; 64.4%). However, all included studies represented novel reconstructive sites and surgical indications. Flap components were described in 157 cases; periosteum was used only in four cases (2.5%), whereas all others are composed of cortical bone combined with periosteum, cancellous bone, and/or cartilage (97.5%). Additionally, a skin island was used in 43 cases (25.9%). Flap measurements were reported in 51 cases, averaging 4.5 ± 2.7 cm in length. Seven cases listed skin island dimensions, averaging 20.2 ± 12.8 cm². The descending genicular artery was the primary pedicle employed (n = 162; 97.6%), while the superior medial genicular was used in the descending genicular artery's absence (n = 4; 2.4%). Descending genicular artery pedicle length from 15 reporting cases averaged 6.4 ± 1.2 cm. Successful reconstructions totaled 160 cases (96.4%). Recipient complications were seen in 16 cases (9.6%) with six constituting flap failures (3.6%). Donor site complications were minimal (n = 6; 3.6%); however, this included one major complication of femoral shaft fracture.

Conclusion

The medial femoral condyle free flap is an effective reconstructive option for the head and neck due to its versatile nature, low complication profile at both recipient and donor site, ease of harvest, and two-team approach.

Merits of the free periosteal femoral condyle flap in the management of advanced mandibular osteoradionecrosis

The management of advanced mandibular osteoradionecrosis (ORN) is poorly codified and requires repeated time-consuming, morbid surgical procedures. The free periosteal medial femoral condyle flap could be used for the management of extensive mandibular ORN with fracture, to avoid non-conservative surgery such as mandibulectomy. The purpose of this study was to report the authors' experience using periosteal flaps for advanced ORN and to assess the therapeutic effectiveness of these flaps in this context. A series of 10 patients who underwent bone revascularization with a free periosteal femoral flap for the management of advanced ORN (Notani class III) is reported. The onset of bone consolidation, length of hospital stay, duration of surgery, donor site morbidity, and the option of dental rehabilitation in the event of a successful outcome were assessed. Osteogenesis was observed in 70% of cases. Thirty percent of patients benefited from dental implant rehabilitation. The mean follow-up was 73.1 months. No patient experienced any sequelae at the flap harvest site. In the authors' opinion, the free periosteal medial femoral condyle flap appears to offer a therapeutic solution for patients with advanced stages of ORN.

The Medial Femoral Condyle Flap: A Novel Versatile Tool for Complex Microvascular Maxillofacial Reconstruction

SUMMARY

The medial femoral condyle flap is well-described for reconstruction of small bone defects of the upper and lower extremities. There are limited case reports of its use in other anatomic sites, particularly for reconstruction of complex head and neck defects. In the setting of previous radiation and contaminated fields, vascularized bone is generally preferred to bone grafts, cadaveric allografts, or synthetic implants. The authors present a case series of complex craniofacial defects involving the midface that were reconstructed using medial femoral condyle flaps, focusing on the type of defect and lessons learned from their early experience to promote awareness of this flap among microsurgeons, who may wish to consider the potential of this flap and incorporate its use into their armamentarium.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Sinonasal Squamous Cell Carcinoma, a Narrative Reappraisal of the Current Evidence

Simple Summary

Sinonasal squamous cell carcinomas are a group of diverse tumors affecting the nasal cavity and paranasal sinuses. As a direct consequence of their rarity and heterogeneity, diagnosis is challenging, and treatment does not follow universally accepted protocols. Though surgery represents the mainstay of treatment, neoadjuvant and adjuvant therapies have pivotal roles in improving outcomes of patients treated with curative intent. Indications to endoscopic surgery have been expanding over the last three decades, but a considerable number of patients affected by sinonasal squamous cell carcinoma still need open surgical procedures. Management of the neck in patients affected by sinonasal squamous cell carcinoma is controversial. Curative-intended treatment of recurrent and/or metastatic tumors, alongside palliation of uncurable cases, represent poorly explored aspects of this disease.

Abstract

Sinonasal squamous cell carcinoma is a rare tumor affecting the nasal cavity and paranasal sinuses. Several aspects of this disease, ranging from epidemiology to biology, pathology, diagnosis, staging, treatment, and post-treatment surveillance are controversial, and consensus on how to manage this sinonasal cancer is lacking. A narrative literature review was performed to summarize the current evidence and provide the reader with available data supporting the decision-making process in patients affected by sinonasal squamous cell carcinoma, alongside the authors’ personal opinion on the unsolved issues of this tumor. The review has highlighted several advances in molecular definition of epithelial cancers of the sinonasal tract. Surgery represents the pivot of treatment and is performed through an endoscopic transnasal approach whenever feasible. Open surgery is required for a large proportion of cases. Reconstruction of the defect follows principles of skull base and cranio-maxillo-facial reconstruction. Chemotherapy is given as neoadjuvant treatment or concomitantly to radiotherapy. Photon-based radiation therapy has a crucial role in the adjuvant setting. Particle therapy is providing promising results. Management of the neck should be planned based on the presence of clinically appreciable metastases, primary tumor extension, and need for recipient vessels. Biotherapy and immunotherapy are still underexplored therapeutical modalities.

Donor-Site Morbidity of Vascularized Bone Flaps from the Distal Femur: A Systematic Review

BACKGROUND

Vascularized grafts from the femur, including the medial femoral condyle and medial femoral trochlea, are increasingly being used. It is critical to understand the lower extremity complications from flap harvest.

METHODS

The authors searched available literature reporting on femoral flaps using PubMed, Embase, Cochrane Database, and Web of Science. After article selection, data were collected regarding demographics, procedure details, outcomes, and complications. The authors classified outcomes as good, fair, or poor based on pain, range-of-motion, sensory changes, subjective reporting, patient-reported outcomes, and other donor-site complications, including the need for additional procedures.

RESULTS

Two hundred twenty articles were identified. Forty-five met criteria for review, with data available for 283 patients. No patients had range-of-motion deficits beyond 1 year. Two percent of patients (six of 283) required additional donor-site procedures, with one report of a femur fracture after medial femoral condyle harvest. Only one study on 45 medial femoral trochlea patients presented patient-reported outcomes regarding the knee. Few objective data were presented. Twenty-eight articles presented adequate complication data for 252 patients to be rated as good, fair, or poor. Overall, 89 percent had good outcomes without donor-site complications. Of the 176 medial femoral condyle patients with outcomes reported, 92 percent had good outcomes; and 71 percent of the 48 medial femoral trochlea patients had good outcomes reported.

CONCLUSIONS

Overall, the reported donor-site morbidity from medial femoral condyle and medial femoral trochlea harvest is low. Chronic knee pain and sensory changes are most frequently reported, especially in medial femoral trochlea patients.