Free Fibula Osteocutaneous Flap for Primary Reconstruction of T3-T4 Gingival Carcinoma

Mandibular reconstruction in head and neck cancer: which is the gold standard?

INTRODUCTION

The aim of this study is to perform a systematic review to compare the outcomes of the different surgical options for mandibular reconstruction in head and neck cancer.

MATERIAL AND METHODS

93 articles were selected. Four groups were identified: titanium plate without flaps, titanium plate covered by soft tissue flap, bone tissue flaps and double flaps. We compared patients' characteristics, site of mandibulectomy, type of reconstruction and complications.

RESULTS

4697 patients were reported. The groups were not homogeneous regarding the type of defect and the treatment history. A significant difference in terms of post-operative complications was found between group 1 and group 2 (p < 0.00001), and between group 2 and group 3 (p < 0.00001). Total complications rate for group 4 was significantly higher when compared to group 3 (p < 0.00001), but no significant difference was found with group 2.

CONCLUSION

These results suggest that mandibular reconstruction using a microvascular bone flap is the best surgical option in patients without significant comorbidities.

Full-Thickness Oral Mucoperiosteal Defects: Challenges and Opportunities

Regenerative engineering strategies for the oral mucoperiosteum, as may be needed following surgeries, such as cleft palate repair and tumor resection, are underdeveloped compared with those for maxillofacial bone. However, critical-size tissue defects left to heal by secondary intention can lead to complications, such as infection, fistula formation, scarring, and midface hypoplasia. This review describes current clinical practice for replacing mucoperiosteal tissue, including autografts and allografts. Potentially paradigm-shifting experimental regenerative engineering strategies for mucoperiosteal wound healing, such as hybrid grafts and engineered matrices, are also discussed. Throughout the review, the advantages and disadvantages of each replacement or regeneration strategy are outlined in the context of clinical outcomes, quality of life for the patient, availability of materials, and cost of care. Finally, future directions for research and development in the area of mucoperiosteum repair are proposed, with an emphasis on identifying globally available and affordable solutions for promoting mucoperiosteal regeneration. Impact statement Unassisted oral mucoperiosteal wound healing can lead to severe complications such as infection, fistulae, scarring, and developmental abnormalities. Thus, strategies for promoting wound healing must be considered when mucoperiosteal defects are incident to oral surgery, as in palatoplasty or tumor resection. Emerging mucoperiosteal tissue engineering strategies, described in this study, have the potential to overcome the limitations of current standard-of-care donor tissue grafts. For example, the use of engineered mucoperiosteal biomaterials could circumvent concerns about tissue availability and immunogenicity. Moreover, employment of tissue engineering strategies may improve the equity of oral wound care by increasing global affordability and accessibility of materials.

Partial and Total Flap Failure after Fibula Free Flap in Head and Neck Reconstructive Surgery: Retrospective Analysis of 180 Flaps over 19 Years

Fibula free flap (FFF) is widely used in head and neck reconstructive surgery and is considered as a standard and therapy of choice after ablative cancer surgery. The aim of this retrospective monocenter study was to determine the success rates of fibula free flaps for jaw reconstruction after ablative tumor surgery. The disease course of patients who underwent jaw reconstructive surgery with FFF from January 2002 to June 2020 was evaluated regarding the flap success rate. Flap failure was analyzed in detail and categorized into two groups: partial flap failure (PFF) and total flap failure (TFF). A total of 180 free fibular flaps were performed over the last 19 years and a total of 36 flap failures were recorded. TFF occurred in n = 20 (56.6%) and PFF in n = 16 cases (44.4%) cases. No statistically significant differences were found concerning patients' age at flap transfer, sex, BMI, ASA-Score, preoperative non-virtual or virtual surgical planning (non-VSP vs. VSP), and time of reconstruction (immediately vs. delayed). Duration of hospitalization shows statistically significant differences between both groups (p = 0.038), but no differences concerning operating time and duration on Intensive Care Unit (ICU). Partial flap failure appears to be underreported in literature. Sub- and complete failure of the skin paddle leads to clinical complaints like uncovered bone segments and plate exposure. Partial or complete FFF failure lead to infections on the recipient site and prolonged wound healing and therefore may cause a delay of the beginning of adjuvant radiation therapy (RT). PFF of hard tissue can be induced by RT.

CAD-CAM vs conventional technique for mandibular reconstruction with free fibula flap: A comparison of outcomes

INTRODUCTION

Mandibular reconstruction always pose a challenge to the reconstructive surgeon. With the use of Computer aided designing and computer aided manufacturing (CAD-CAM) it is now possible to reconstruct mandibular defects to near normal configuration with good function and aesthetic outcomes.

AIMS/OBJECTIVES

To compare the efficacy of CAD-CAM technique vs conventional technique in mandibular reconstruction with free fibula flap.

MATERIALS AND METHODS

40 consecutive patients that required mandibular reconstruction using free fibula flap were included in the study. All patients were treated using CAD-CAM technique and then compared retrospectively with 40 patients treated with conventional technique. Comparison was done between total intraoperative time, aesthetic outcome and post-operative occlusion.

RESULTS

Total intraoperative time in the CAD-CAM group was significantly reduced (562 min) as compared to the conventional group (662 min). Patients in the CAD-CAM group also obtained a better Aesthetic score (3.6/5) when compared to the conventional group (2.5/5). Postoperative malocclusion was noted in 1 patient in the CAD-CAM group as opposed to 6 patients in the conventional group.

CONCLUSION

Use of CAD-CAM technology in mandibular reconstruction with free fibula flap offers reduced surgical time with precise and accurate reconstruction that produces better functional and aesthetic outcomes.

Association of Bolster Duration With Uptake Rates of Fibula Donor Site Skin Grafts

Importance

The fibula free flap donor site is associated with both short-term and long-term morbidity. Split-thickness skin graft (STSG) loss can lead to long delays in donor site healing and is associated with significant adverse sequelae. Patients may experience initial good STSG uptake after bolster removal but may have subsequent partial or total loss related to contact pressure or shearing.

Objective

To determine if increased duration of bolster use is associated with increased STSG uptake rates following fibula free flap reconstruction.

Design, Setting, and Participants

This retrospective cohort study included patients 18 years and older undergoing fibula free flap reconstruction following head and neck extirpative surgery at a tertiary care academic medical center from May 2013 to March 2019. The donor sites were photographed 4 weeks postoperatively, and areas of graft uptake were measured using image processing software. The baseline demographic, comorbidity, and operative characteristics were also collected.

Interventions

A fine mesh gauze with 3% bismuth tribromophenate and petrolatum blend bolster was sutured over leg STSGs placed on fibula free flap donor sites intraoperatively, and the ankle and lower leg were immobilized for 5 days in a plaster splint. Bolsters were either removed on postoperative day 5 or 14. Thereafter, the STSGs were covered with a petroleum and bismuth gauze and a cotton dressing.

Main Outcomes and Measures

Rates of donor site infection and STSG percentage uptake at 4 weeks.

Results

Of the 42 included patients, 31 (74%) were male, and the mean (SD) age was 62.1 (13.1) years. A total of 20 patients were included in the 5-day group, and 22 were included in the 14-day group. The 14-day bolster group had a higher mean percentage skin graft uptake rate compared with the 5-day bolster duration group (77.5% vs 59.9%), with an effect size of -0.632 (95% CI, -1.260 to -0.004). Patients with Adult Comorbidity Evalution-27 scores of 3 had poorer rates of STSG uptake compared with patients with Adult Comorbidity Evalution-27 scores of 0 to 2 (65.9% vs 82.9%), with an effect size of 0.599 (95% CI, -0.191 to 1.389). No donor site infections were noted in either group.

Conclusions and Relevance

Fourteen-day bolster application to the fibula free flap donor site was associated with better STSG uptake rates than 5-day bolster application.

The Pros and Cons of Computer-Aided Surgery for Segmental Mandibular Reconstruction after Oncological Surgery

Computer-aided surgery (CAS) started being used for head and neck reconstruction in the late 2000s. Its use represented a paradigm shift, changing the concept of head and neck reconstruction as well as mandible reconstruction. Reconstruction using CAS proceeds through 4 phases: planning, modeling, surgery, and evaluation. Thus, it can overcome a number of trial-and-error issues which may occur in the operative field and reduce surgical time. However, if it is used for oncologic surgery, it is difficult to evaluate tumor margins during tumor surgery, thereby restricting pre-surgical planning. Therefore, it is dangerous to predetermine the resection margins during the pre-surgical phase and the variability of the resection margins must be taken into consideration. However, it allows for the preparation of a prebending plate and planning of an osteotomy site before an operation, which are of great help. If the current problems are resolved, its applications can be greatly extended.

Monosotic fibrous dysplasia and solitary intramuscular myxoma of the head and neck: A unique presentation of Mazabraud's syndrome and a literature review

Mazabraud's syndrome (MS) is a rare disease that is a combination of fibrous dysplasia and intramuscular myxomas. MS is a benign lesion and there is little data on the disease due to its low incidence. In the present study, the case of a 38-year-old patient who presented with a soft-tissue mass involving the masseter and swelling at the mandibular body and mandibular ramus is reported. Since the mandible is an important aesthetic and functional organ in the oral and maxillofacial region, surgery was primarily aimed at resecting the tumor, with good safety margins, and reconstructing the resultant defect. The lesions were pathologically diagnosed as MS. The unique features of this case included the painless and monostotic fibrous dysplasia, the solitary intramuscular myxomas involving the jaw and the male gender of the patient. MS usually occurs in the lower extremities, with an unusual predilection for the right limb; however, it rarely occurs in the head and neck region. A retrospective analysis of the clinical features and management of MS was also performed in the present study, together with a literature review. From the literature, it was concluded that the incidence of MS is ~2.3-fold greater in female patients than in male patients, and that the age of onset of MS ranges between 17 and 82 years, with an average age of 46.25 years.

Rehabilitation with dental implants in microvascular iliac graft after solid ameloblastoma resection: a case report

PURPOSE

Ameloblastoma is a true odontogenic tumor that is most frequently found in clinical practice. Osseous resection with clear margins is the recommended treatment followed by bone reconstruction, such as a vascularized graft. The use of osseointegrated dental implants for rehabilitation is advisable, as it allows the recovery of the masticatory function.

MATERIALS AND METHODS

This case report includes 1 subject, a patient who presented with a large ameloblastoma treated by resection, a microvascular iliac graft, and dental implants.

RESULTS

After 6 months of regular control, the patient exhibited perfect healing of both the soft tissues and bone graft. At the time of this report, the patient had undergone 36 months of clinical and radiographic follow-up and had not exhibited any sign of osseous loss, implant mobility, or tumor recurrence.

CONCLUSIONS

The outcome of this case indicates that a microvascular graft and subsequent dental implantation is a good treatment plan that aids in a quick functional rehabilitation in ameloblastoma patients.

Improved operative efficiency of free fibula flap mandible reconstruction with patient-specific, computer-guided preoperative planning

BACKGROUND

Free fibula osteocutaneous flaps are the primary option for reconstruction after segmental mandibulectomies. This study evaluates the impact of CT-guided preoperative planning on operative outcomes after free fibula mandible reconstruction.

METHODS

We conducted a retrospective review of all patients undergoing free fibula reconstruction of the mandible from 2002 to 2011.

RESULTS

Fifty-seven patients underwent free fibula osteocutaneous flap reconstruction for head and neck cancers involving the mandible. Twelve patients had shaping of the neomandible performed on the back table while 20 patients underwent shaping in situ without the use of any adjunctive technology. The remaining 25 patients underwent preoperative CT imaging, which significantly decreased operative time (707 minutes vs 534 minutes; p < .0003) as well as overall costs ($24,532.50 vs $20,950.48). There were no significant differences in outcomes or complications.

CONCLUSION

Preoperative, patient-specific CT modeling, and cutting guide fabrication outweigh the costs associated with the additional technology without jeopardizing overall outcomes or increasing complication rates.

Exploratory benchtop study evaluating the use of surgical design and simulation in fibula free flap mandibular reconstruction

Background

Surgical design and simulation (SDS) is a useful tool to help surgeons visualize the anatomy of the patient and perform operative maneuvers on the computer before implementation in the operating room. While these technologies have many advantages, further evidence of their potential to improve outcomes is required. The present benchtop study was intended to identify if there is a difference in surgical outcome between free-hand surgery completed without virtual surgical planning (VSP) software and preoperatively planned surgery completed with the use of VSP software.

Methods

Five surgeons participated in the study. In Session A, participants were asked to do a free-hand reconstruction of a 3d printed mandible with a defect using a 3d printed fibula. Four weeks later, in Session B, the participants were asked to do the same reconstruction, but in this case using a preoperatively digitally designed surgical plan. Digital registration computer software, hard tissue measures and duration of the task were used to compare the outcome of the benchtop reconstructions.

Results

The study revealed that: (1) superimposed images produced in a computer aided design (CAD) software were effective in comparing pre and post-surgical outcomes, (2) there was a difference, based on hard tissue measures, in surgical outcome between the two scenarios and (3) there was no difference in the time it took to complete the sessions.

Conclusion

The study revealed that the participants were more consistent in the preoperatively digitally planned surgery than they were in the free hand surgery.

Quality of life outcome measures using UW-QOL questionnaire v4 in early oral cancer/squamous cell cancer resections of the tongue and floor of mouth with reconstruction solely using local methods

Cancer treatment either by surgery alone or in a combination of surgery, radiotherapy±chemotherapy has significant consequences on the physical, mental, emotional and psychosocial wellbeing of the patient. Measurement of quality of life (QOL) is necessary to understand the patient's perception of their own treatment, as clinicians' views can be biased. Reconstruction of a cancerous defect with a free vascular flap is ideal in large, often composite defects, provided it is appropriate to the advanced stage and prognosis of the disease, medical condition of the patient, availability of surgical and financial resources and allows the prosthetic rehabilitation of the anatomic area. Using University of Washington Quality of life 4 questionnaire (UW-QOL4), we assessed the QOL of 38 patients, who underwent local surgical reconstructions after resection of T1/T2 tongue/floor of mouth squamous cell carcinoma defects. Objective assessment of speech and swallow function was also carried out using therapy outcome measure (TOM) scores by the speech and language therapy team (SALT) aiming to see the differences in the scores obtained in patients who underwent post-operative radiotherapy. Our study, conducted 6months after completion of all oncologic treatment for the primary disease, showed satisfactory levels of quality of life parameters with good function showing that local reconstructive methods are successful and may have benefits in the management of early oral cancers involving the tongue and floor of mouth. They are beneficial by providing a good quality in terms of function, by reducing the operating time, the surgical morbidity, simplifying post-operative care and thereby becoming an efficient, effective and a cost effective method.

Bimaxillary reconstruction with a single free fibular osteoseptocutaneous flap

Flap combinations including free fibula have been commonly used to reconstruct composite maxillomandibular defects. On the other hand, a single free osteoseptocutaneous may be rarely used to reconstruct the bimaxilla. In this article, we report a bimaxillary reconstruction in a 63-year-old man with a single fibular osteoseptocutaneous free flap.