Plate Exposure After Anterolateral Thigh Free-Flap Reconstruction in Head and Neck Cancer Patients With Composite Mandibular Defects

Risk Factors for Plate Infection, Exposure, and Removal in Mandibular Reconstruction

OBJECTIVE

Mandibular plate reconstruction (MPR) is often indicated after tumor ablation, osteoradionecrosis excision, and traumatic bone loss to restore oral functionality and facial cosmetics. There are limited analyses identifying risk factors that lead to plate infection (PIn), exposure, and removal ("plate complications").

STUDY DESIGN

Retrospective cohort study.

SETTING

Academic tertiary medical center.

METHODS

Patients who underwent MPR from 2013 to 2022 were identified. Risk factors for plate complications were analyzed based on demographic, clinical, intraoperative, and postoperative factors. Multivariable analysis was conducted with logistic regression. Survival analysis was conducted with a Cox model.

RESULTS

Of the 188 patients analyzed, 48 (25.5%) had a plate complication [infection: 22 (11.7%); exposure: 23 (12.2%); removal: 35 (18.6%)]. Multivariate analysis revealed predictive associations between at least 1 plate complication and the following variables: smoking status, soft tissue defect size, number of plates, average screw length, and various postoperative complications. Other associations approached the threshold for significance. Prior and adjuvant radiation therapy, type of free flap, stock versus custom plates, and perioperative antibiotic prophylaxis regimens were not associated with plate complications. No plate complication was independently associated with lower overall survival. PIn (hazard ratio, HR: 7.99, confidence interval, CI [4.11, 15.54]) and exposure (HR: 3.56, CI [1.79, 7.08]) were independently associated with higher rates of plate removal.

CONCLUSION

Plate complications are relatively common after MPR. Smoking history, specific disease characteristics, hardware used during surgery, and postoperative complications may help identify higher-risk patients, but additional larger-scale studies are needed to validate our findings and resolve discrepancies in the current literature.

Hardware Complication Risks in Head and Neck Cancer Patients Undergoing Reconstructive Surgery With Segmental Mandibulectomy

BACKGROUND

The primary objective of this study was to ascertain the risk factors associated with hardware complications following segmental mandibular reconstruction in head and neck cancer patients. Additionally, we sought to develop a nomogram model that enables accurate risk prediction.

METHODS

Patients who underwent segmental mandibulectomy with immediate free or local regional tissue transfer between January 2016 and December 2020 were reviewed. Hardware complications were defined. Patient demographics and perioperative parameters were analyzed.

RESULTS

A total of 510 patients were analyzed. Postoperative radiation therapy (OR = 2.296, 95% CI = 1.339-3.938, p = 0.003), postoperative wound infection (OR = 2.367, 95% CI = 1.472-3.806, p < 0.001), and debridement for flap-related complications (OR = 5.484, 95% CI = 3.269-9.199, p < 0.001) were identified as independent risk factors. The nomogram model demonstrated good discriminatory ability.

CONCLUSION

This comprehensive analysis identified three independent risk factors, and the nomogram provides a valuable tool for predicting the risks. Further research is needed to validate these findings and explore preventive strategies.

A preliminary study of the mechanical properties of 3D-printed personalized mesh titanium alloy prostheses and repair of hemi-mandibular defect in dogs

This study is a preliminary investigation exploring the mechanical properties of three-dimensional (3D)-printed personalized mesh titanium alloy prostheses and the feasibility of repairing hemi-mandibular defects. The ANSYS 14.0 software and selective laser melting (SLM) were used to produce personalized mesh titanium alloy scaffolds. Scaffolds printed using different parameters underwent fatigue property tests and scanning electron microscopy (SEM) of the fracture points. Models of hemi-mandibular defects (encompassing the temporomandibular joint) were created using beagle dogs. Freeze-dried allogeneic mandibles or 3D-printed personalized mesh titanium alloy prostheses were used for repair. Gross observation, computed tomography (CT), SEM, and histological examinations were used to compare the two repair methods. The prostheses with filament diameters of 0.5 and 0.7 mm could withstand 14,000 times and >600,000 cycles of alternating stresses, respectively. The truss-structure scaffold with a large aperture and large aperture ratio could withstand roughly 250,000 cycles of alternating forces. The allogeneic mandible graft required intraoperative shaping, while the 3D-printed mesh titanium alloy prostheses were personalized and did not require intraoperative shaping. The articular disc on the non-operated sides experienced degenerative changes. No liver and kidney toxicity was observed in the two groups of animals. The 3D-printed mesh titanium alloy prostheses could effectively restore the shape of the mandibular defect region and reconstruct the temporomandibular joint.

The use of customized 3D-printed mandibular prostheses with pressure-reducing device: A clinical trial

BACKGROUND

Segmental bone defects of the mandible result in the complete loss of the affected region. We had incorporated the pressure-reducing device (PRD) designs into the customized mandible prostheses (CMP) and conducted a clinical trial to evaluate this approach.

METHODS

Seven patients were enrolled in this study. We examined the association among the history of radiotherapy, the number of CMP regions, the number of chin regions involved, and CMP exposure.

RESULTS

We included five men and two women with an average age of 55 years. We excised tumors with an average weight of 147.8 g and the average weight of the CMP was 68.5 g. No significant difference between the two weights was noted (p = 0.3882). Three patients received temporary dentures and the CMP remained stable in all patients.

CONCLUSION

The use of PRD in CMP may address the previous challenges associated with CMP, but further research is necessary.

Titanium plates salvage in irradiated facial areas with the lipomodeling technique

Major defects of the facial structures cause severe functional and aesthetic impairment. For composite defects with bone loss, the use of a titanium plate bridging the bony defect, associated or not to a soft tissue pedicled flap is to be considered in complex cases, or for patients with high comorbidities. The principal limit of this technique is the risk of plate exposure, especially for patients who had adjuvant radiation therapy. We present two clinical cases of patients who had a facial reconstruction using a titanium plate associated with a locoregional soft tissue flap, and who presented a near-exposed plate a few years after the first surgery and adjuvant radiation therapy. In order to prevent plate exposure, we performed several lipomodeling sessions between skin and plate. Our results are very encouraging, with no plate exposure and thickening of the soft tissues which cover the plate at 10-years follow-up. The knowledge of the possibility to use fat grafting transfer could therefore lead to a strong return to the use of titanium plates in facial reconstruction.

Use of reconstruction plates prebent on three-dimensional models to reduce the complications of mandibular reconstruction

Background/purpose

Though the gold standard method for mandible reconstruction of the defect from segmental mandibulectomy is by osseous flap or graft, using reconstruction plates is still indicated in some cases. Traditionally, the plate is bended immediately after the segmental mandibulectomy by freehand. However, it's difficult to fit well to the original position of mandible, which may result in more complications. This study therefore aimed to investigate whether using prebent plates on computer-aided 3D printing models could reduce the complication rate.

Materials and methods

Patients who received mandible reconstruction by reconstruction plate from 2018 to 2022 were enrolled and evaluated in this study. The data, including demographics, indications for surgery, pre-existed preoperative and postoperative therapies, classification of defects, and postoperative outcomes were collected and analyzed.

Results

A total of 52 patients were enrolled in our study. The prebent group exhibited a significantly lower complication rate than that of the immediately bent group (P = 0.012). Other risk factors of plate complications included postoperative adjuvant radiotherapy (P = 0.017) and previous surgery (P = 0.047). The complication-free survival rate was also better in the prebent group in a 3-year follow-up period (P = 0.012).

Conclusion

Prebent plates on computer-aided printing models proved to be an effective approach to reduce the complications for mandibular reconstruction in segmental mandibulectomy.

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.

Tenants of Mandibular Reconstruction in Segmental Defects

The premises of mandibular reconstruction are the restoration of occlusion and mandibular contour for the purpose of preserving the facial identity, oral airway, and effective speech and mastication. Establishing functional occlusion is the primary tenant in all mandibular reconstruction. In cases of segmental defects, particularly in dentate regions of the mandible, there has been a paradigm shift over the past two decades in how surgeons are approaching the restoration of load-bearing mandibular continuity with capacity for dental implantation. Here we discuss considerations for deciding the most effective method of reconstruction in segmental defects.

Managing Oromandibular Hardware Failure after Free Flap Surgery

Hardware failure after oromandibular reconstruction using free tissue transfer can delay additional therapies directed at cancer treatment and prevent patients from returning to normal oral function. Understanding and strict adherence to principles of rigid fixation is critical in preventing complications. Early surgical intervention for hardware exposure as well as utilization of locoregional flaps may prevent the need for more extensive revision surgery.

Plate-related complication and health-related quality of life after mandibular reconstruction by fibula flap with reconstruction plate or miniplate versus anterolateral thigh flap with reconstruction plate

BACKGROUND

Plate-related complications are major long-term complications in mandible reconstruction. There are controversies regarding the use of a reconstruction plate versus miniplates and a bone flap versus a soft tissue flap with a bridging plate. Direct comparisons of a fibula flap and an anterolateral thigh flap, the applicability between a reconstruction plate and miniplate, and the correlation between plate-related complications and quality of life remain unclarified. Therefore, this study aimed to the explore complications of different flaps and plates and how they impact the patients' quality of life.

METHODS

We retrospectively reviewed the medical records of a total of 205 patients aged >18 years who underwent segmental mandibulectomy and reconstruction using fibula flap with reconstruction plate (FR; n = 86), fibula flap with miniplate (FM; n = 61), and anterolateral thigh flap with reconstruction plate (AR; n = 58) due to cancer ablation, osteoradionecrosis, or benign tumor excision between August 2010 and December 2019. Data on characteristics, complications, and health-related quality of life were collected and analyzed.

RESULTS

The plate-related complication rate was the highest in the AR group (37.9%), then in the FR group (25.6%), and was the lowest in the FM group (13.1%; p = 0.0079). The plate exposure rate was the highest in the AR group (24.1%), then in the FR group (15.7%), and was the lowest in the FM group (4.9%; p = 0.0128). The plate fracture and dislodge rates for the AR group were both higher than those for the FR and FM groups (24.1% versus 9.3% versus 9.8%, respectively; p = 0.023). The AR group had worse complication-free survival (hazard ratio [HR]: 3.61, 95% CI: 1.99-6.56, and p < 0.0001) than the FR and FM groups. Osteoradionecrosis (HR: 6.19, 95% CI: 2.11-18.21, and p = 0.0009) and postoperative radiotherapy (HR: 2.87, 95% CI: 1.34-6.12, and p = 0.0402) were both independent adverse factors for complication-free survival, whereas patient treated primarily (HR: 0.35, 95% CI: 0.17-0.73, and p = 0.0048) was an independent protective factor. Plate-related complication negatively impacted the quality of life based on pain scores (β: -0.56, SE: 0.26, and p = 0.034).

CONCLUSIONS

Using a fibular flap fixed with miniplates and avoiding the use of a reconstruction plate may yield a reduced plate exposure rate and better health-related quality of life, particularly for patients with osteoradionecrosis or those who need postoperative radiotherapy.

Comparison of the Accuracy and Clinical Parameters of Patient-Specific and Conventionally Bended Plates for Mandibular Reconstruction

Objectives

This retrospective study compared two mandibular reconstruction procedures-conventional reconstruction plates (CR) and patient-specific implants (PSI)-and evaluated their accuracy of reconstruction and clinical outcome.

Methods

Overall, 94 patients had undergone mandibular reconstruction with CR (n = 48) and PSI (n = 46). Six detectable and replicable anatomical reference points, identified via computer tomography, were used for defining the mandibular dimensions. The accuracy of reconstruction was assessed using pre- and postoperative differences.

Results

In the CR group, the largest difference was at the lateral point of the condyle mandibulae (D2) -1.56 mm (SD = 3.8). In the PSI group, the largest difference between preoperative and postoperative measurement was shown at the processus coronoid (D5) with +1.86 mm (SD = 6.0). Significant differences within the groups in pre- and postoperative measurements were identified at the gonion (D6) [t(56) = -2.217; p = .031 <.05]. In the CR group, the difference was 1.5 (SD = 3.9) and in the PSI group -1.04 (SD = 4.9). CR did not demonstrate a higher risk of plate fractures and post-operative complications compared to PSI.

Conclusion

For reconstructing mandibular defects, CR and PSI are eligible. In each case, the advantages and disadvantages of these approaches must be assessed. The functional and esthetic outcome of mandibular reconstruction significantly improves with the experience of the surgeon in conducting microvascular grafts and familiarity with computer-assisted surgery. Interoperator variability can be reduced, and training of younger surgeons involved in planning can be reaching better outcomes in the future.

Evaluating the use of anterolateral thigh flaps to prevent reconstruction plate exposure in patients with oral cancer

OBJECTIVE

Plate exposure remains one of the most serious complications of oromandibular reconstruction. The purpose of this study was to investigate the effect of wrapping reconstruction plates with anterolateral thigh (ALT) free flaps as a way to prevent plate exposure.

STUDY DESIGN

A total of 91 patients with composite oromandibular defects who underwent surgical reconstruction using a reconstruction plate in conjunction with an ALT musculocutaneous flap were recruited. The participants were divided into 2 groups, based on whether the plate was wrapped with or covered by the ALT flap.

RESULTS

The incidence of plate exposure in the experimental group (17%) was significantly lower than that of the control group (43.1%; P < .0001). The mean time from reconstruction until plate exposure in the experimental group was 19.4 ± 23.6 months, whereas the mean time in the control group was 12.3 ± 9.1 months. In the logistic regression model for the occurrence of plate exposure, the only factor found to be associated with plate exposure was how the ALT flap was used (P = .026).

CONCLUSIONS

The results of the present study indicate that wrapping the reconstruction plate with an ALT flap decreased the incidence of plate exposure in patients with oromandibular defects.

A Comprehensive Analysis of Complications of Free Flaps for Oromandibular Reconstruction

OBJECTIVES/HYPOTHESIS

To determine the frequency and management of short- and long-term complications related to oromandibular free flap reconstruction and identify potentially predictive factors of hardware complications.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective database from chart review was formed consisting of 266 oromandibular free flap reconstructions performed at a single institution over a 15-year period. Data were collected on demographics, surgical treatment, complications, and management of complications. Subgroup univariate and multivariate analyses were performed to compare patients with hardware complications and those without.

RESULTS

Eighty-one of 266 patients (30.5%) that underwent oromandibular reconstruction had an early complication (<4 weeks after surgery), and the most common complications were cervical wound dehiscence (11.3%) and fistulas (9.40%). Eighty of 266 patients (30.1%) had a long-term complication (>4 weeks after surgery) and the most common complication was plate exposure (26.7%). Univariate and multivariate analyses showed no association between whether there was hardware extrusion and fibula versus scapula, smoking history, virtual surgical planning (VSP), and dental implantation (P > .05). Only early complications (OR, 3.59, 95% CI, 1.83-7.05, P < .01) and patients undergoing oromandibular reconstruction for osteoradionecrosis (OR, 2.26, 95% CI, 1.10-4.64, P = .03) were strongly and independently associated with subsequent hardware extrusion on univariate analysis.

CONCLUSIONS

Both short- and long-term complications are common after oromandibular reconstruction. The most important predictive factor for a late complication is an early complication and prior radiation. There was no difference of plate complications among the various free flap types. Dental implantation and use of VSP were not associated with hardware complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1997-2005, 2021.

Use of CAD-CAM Bridging Mandibular Prosthesis in Osteonecrosis of the Jaw: The Experience of Our School

Osteonecrosis of the jaw (ONJ) is a disease that affects the jaw. It is mainly related to radiation or bisphosphonates therapy, and the symptoms and signs consist of pain, bone exposure, inflammation of the surrounding soft tissue swelling, and secondary infection or drainage. In the case of advanced disease of the mandibular area, the treatment of choice is mandibular resection and reconstruction. In the present study, we report a case series of patients affected by ONJ and treated with a customised bridging mandibular prosthesis-only technique. From 2016 to 2018, we treated five consecutive patients affected by ONJ: three patients were affected by biphosphonate-related osteonecrosis of the mandible (BRONJ) and two were affected by osteoradionecrosis of the mandible (ORNJ). Three patients needed a soft tissue free flap to permit optimal wound closure, intra- and/or extraorally. All reconstructive procedures were carried out successfully, with no major or minor microvascular complication. The average postoperative follow-up was 24.8 (range 10–41) months. Considering that microvascular bone transfer is a high-risk procedure in BRONJ patients, we can conclude that the positioning of a customised bridging mandibular prosthesis (CBMP), whether or not associated with a microvascular soft tissue transfer, is a safe technique in terms of surgical outcome and feasibility.

Topology optimization of a mandibular reconstruction plate and biomechanical validation

OBJECTIVES

Reconstruction plates, used to bridge segmental defects of the mandible after tumor resection or traumatic bone tissue loss, are subjected to repeated stresses of mastication. High stress concentrations in these plates can result in hardware failure. Topology optimization (TO) could reduce the peak stress by computing the most optimal material distribution in a patient-specific implant (PSI) used for mandibular reconstruction. The objective of this study was biomechanical validation of a TO-PSI.

METHODS

A computer-aided design (CAD) model with a segmental defect was created based on the geometry of a polyurethane mandible model. A standard-PSI was designed to bridge the defect. A TO-PSI was then designed with a maximum stress equal to the ultimate tensile stress of Ti6Al4V (930 MPa) during a loading condition of 378 N. Finite element analysis (FEA) was used to analyze stresses in both PSI designs during loading. The standard-PSI and TO-PSI designs were produced in triplicate by selective laser melting of Ti6Al4V, fixated to polyurethane mandible models with segmental defects identical to the CAD model, and subsequently subjected to continuous compression with a speed of 1 mm/min on a universal testing machine, while recording the load. Peak loads before failure in the TO-PSI group within a 30% range of the predicted peak load (378 N) were considered a successful biomechanical validation.

RESULTS

Fracture of the TO-PSI occurred at a median peak load of 334 N (range 304-336 N). These values are within the 30% range of the predicted peak load. Fracture of the mandible model in the standard-PSI group occurred at a median peak load of 1100 N (range 1010-1460 N). Failure locations during biomechanical testing of TO-PSI and standard-PSI samples corresponded to regions in the FEA where stresses exceeded the ultimate tensile strength of titanium and polyurethane, respectively.

CONCLUSION

This study demonstrates a successful preliminary biomechanical validation of TO in the design process for mandibular reconstruction plates. Further work is needed to refine the finite element model, which is necessary to ultimately design TO-PSIs for clinical use.

Complications After Soft Tissue With Plate vs Bony Mandibular Reconstruction: A Systematic Review and Meta-analysis

OBJECTIVE

Mandibular reconstruction for segmental defects is a well-studied topic. However, there are conflicting data on the risks of delayed plate-related complications. The objective of this systematic review and meta-analysis was to assess long-term plate-related complications following reconstruction of the mandible with soft tissue and a plate as compared with immediate vascularized bony reconstruction.

DATA SOURCES

A medical librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946-), Embase (1947-), Scopus (1960-), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Clinicaltrials.gov.

REVIEW METHODS

Candidate articles were independently reviewed by 2 authors. Inclusion/exclusion criteria were uniformly applied. Articles were considered eligible if they included adequate reporting of plate extrusion and/or fracture and had follow-up ≥12 months.

RESULTS

A total of 2379 patients were included. The risk of plate fracture was low in cases of soft tissue with a plate (5%; 95% CI, 0.03-0.08) and osseous reconstruction (1%). The risk of extrusion following soft tissue and plate reconstruction was 20% (95% CI, 0.15-0.27). In the osseous reconstruction group, the risk of extrusion was 10% (95% CI, 0.06-0.18). Revision surgery was performed twice as often following soft tissue with a plate as compared with vascularized bony reconstruction (32% [95% CI, 0.25-0.40] vs 14% [95% CI, 0.09-0.21], respectively).

CONCLUSION

Delayed plate-related complications remain a significant problem following segmental defect reconstruction. Soft tissue and plate reconstruction techniques may increase the risk of plate removal and revision surgery.

Lateral segmental mandibulectomy reconstruction with bridging reconstruction plate and anterolateral thigh free flap: a case series of 30 consecutive patients

Lateral posterior segmental mandibular defects present a reconstructive challenge and an osseous flap would be the gold standard to reconstruct such a defect. However, combining a mandibular reconstruction plate (MRP) with a soft-tissue free flap (to restore mucosal integrity and provide durable coverage of the plate itself) offers an alternative option for posterior segmental mandibular defects in patients who are not suitable for osseous reconstruction, or do not choose it. We retrospectively reviewed 30 consecutive patients (19 male and 11 female) who underwent reconstruction of a segmental mandibulectomy defect using a bridging MRP and anterolateral thigh (ALT) free flap. The mean (range) age was 67 (31-87) years. The American Society of Anesthesiologists' (ASA) status of the study population comprised Grade 1 (n = 10), Grade 2 (n = 18), and Grade 3 (n = 2). The majority of patients had oral cavity squamous cell carcinoma (n = 26) involving the mandible, two had osteoradionecrosis, and two mucoepidermoid carcinoma. Four patients had complications specific to the reconstruction, and flap loss occurred in one (96.7% success rate). Metalwork infection occurred in three, including one plate extrusion and one plate fracture. The median length of stay was 10 days, and mean (range) duration of follow up 23.3 (1-96) months. This technique is an alternative reconstructive option for the non-tooth-bearing mandible. Reconstructing a posterolateral segmental mandibulectomy defect with a bridging MRP and ALT free flap offers a robust reconstructive alternative with a favourable complication profile.

Evaluation of a novel osteosynthesis plate system for mandibular defects

Continuity defects of the jaw can be reconstructed with titanium plates or microvascular bone flaps; osteosynthesis plates are necessary for both. In this study we performed a retrospective review of patients treated with Medartis MODUS® Mandible Trauma/Reco 2.0-2.5, TriLock bridging plates, mandibulectomy and soft tissue free flap or reconstruction with a bony free flap and TriLock mandibular plates from the same system from January 2015 to August 2019. The variables recorded were sex, age, diagnosis, radiotherapy, date of implantation, date of explantation or death of patient, size of mandibular defect, Jewer classification of defect, number of screws used, segments of bony reconstruction, screws per segment, plate exposure, plate breakage, and pseudarthrosis. The bridging plate group consisted of 41 patients, while the mandibular plate group consisted of 24 patients. The percentage of plate exposure was 17.07% for the bridging plate group and 4.17% for the mandibular plate group. Plate breakage was 0 in both groups. Pseudarthrosis was 4.17% in the mandibular plate group. In the bridging plate group, an anterolateral thigh flap covered all exposures. Of 7 plate exposures, 4 were found in a C defect. The complication rate of the investigated plates was lower than the complication rates of other plate systems.

Investigation of Free-Flap Transfer Reconstruction in Elderly Patients and Oral Intake Function

The authors retrospectively examined 39 patients with head and neck reconstruction using a free-flap transfer with microsurgery in elderly patients aged over 80 years in our hospital. They investigated postoperative local complications, postoperative systemic complications, day of ambulation, the presence of delirium, the postoperative oral intake ratio, and the reconstructive method in mandibular reconstruction patients. There were 12 postoperative local complications. And postoperative systemic complications were detected in 19 patients; however, 17 of these were respiratory disorders due to pneumonia. There were 17 patients with postoperative delirium. Oral intake was resumed after an average of 14.9 days. Of these, 34 patients were eventually able to eat some kind of food. The incidence of local complications in elderly free-flap reconstruction patients was similar to that in young people. However, the rate of systemic complications was much higher in elderly patients. The authors suggest that free-flap reconstruction can be performed relatively safely in elderly people when a detailed preoperative surgical plan.

Reconstruction of Complex Oromandibular Defects in Head and Neck Cancer: Role of the Chimeric Subscapular Free Flap

The purpose of this study is to present the chimeric scapula tip-free flap as a reconstructive choice in composite head and neck defects and to highlight the experiences of the authors in this field.A retrospective study and a literature review were conducted. Data about preoperative condition, intraoperative images, and radiological and clinical documentation were collected.Excision of head and neck advanced cancers may result in large composite defects containing different types of soft tissue and bone. This topic is particularly challenging in salvage surgery after radiation therapy. In this setting, reconstructive techniques are very complex and traditionally require the use of multiple microvascular flaps. Chimeric free flaps, based on the subscapular system, allow complex reconstructions, providing both soft tissue and bone on a single vascular peduncle.The regional anatomy of the subscapular system and the possible chimeric flaps that can be harvested will be discussed, together with the reconstructive surgical technique used and the positioning of the patient. Two representative clinical cases of complex head and neck reconstruction after radiotherapy are presented.Different types of chimeric flap can be harvested from the subscapular system. These flaps can include different tissues: skin, bone, muscle on a single vascular peduncle. This characteristic is particularly useful in complex defects with different tissue types involved, following large en-bloc excision of advanced head and neck tumors.Free flaps based on the subscapular system can be an excellent reconstructive choice in complex head and neck defects.

Is sequential free flap safe in oral cancer reconstruction in the same patient? An outcome and complication analysis

BACKGROUND

Sequential free flap reconstruction in patient with head and neck cancer can provide reliable and effective wound coverage. Only a few studies have reported on the outcome and complications analysis but without consensus on the recipient vessels and flap chosen. Herein, we presented the outcome and analysed the risk factors for complications in sequential free flap reconstruction.

PATIENTS AND METHODS

Patients who had sequential free tissue transfers due to cancer recurrence, second primary cancer, or secondary correction of the soft tissue contractures and volume deficits were all included. Variables extracted included demographics, comorbidities, free flap characteristics, infection, dehiscence and flap necrosis rates.

RESULTS

In total, 40 patients with 92 free flaps were analyzed; 42 initial and 50 sequential free flaps. The most common recipient vessels for sequential flap were contralateral superficial thyroid vessels (68%). The most common flap for both initial and sequential free flap was anterolateral thigh flap (64.3 and 62%). The success rate of sequential free flap was 92.0 compared to 92.9% for initial free flap, which showed no significant difference. Female was independently associated with delayed wound healing with an odds ratio of 90.91 (95% confidence interval 0.001-0.17, P = 0.001), as well as diabetes with an odds ratio of 31.14 (95% confidence interval 2.60-373.19, P = 0.007). Sequential free flap was not a risk factor for any complication.

CONCLUSIONS

Sequential free flap is a reliable method for head and neck surgery without more complication rate comparing to initial free flap reconstruction. More attentions should be paid on patients with preferential risk for certain complications.

A small number of residual teeth after the mandibular resection of oral cancer is associated with titanium reconstruction plate exposure

Objective

Reconstruction plates are used to treat patients with a segmental mandibular defect after oral cancer surgery. Reconstruction plate failure analysis has rarely focused on occlusion, which conducts a mechanical force to the mandible and the plate. To determine the prognostic factors, we retrospectively evaluated patients who underwent reconstruction of a mandibular segmental defect with a reconstruction plate and assessed the number of residual paired teeth.

Material and Methods

From among 390 patients with oral cancer who visited University of Tsukuba Hospital (Tsukuba, Japan) between 2007 and 2017, we selected and analyzed the data of 37 patients who underwent segmental resection of the mandible and reconstruction with reconstruction plates. Prognostic factors evaluated were patient age, sex, TNM classification, plate manufacturer, treatment with radiotherapy or chemotherapy, whether the patient had diabetes or smoked, and whether the patient had a small number of residual paired teeth, plate length, and use of a fibular‐free flap. Among these 37 patients, eight reconstruction plates had intraoral or extraoral exposure and were removed in 5 years.

Results

Kaplan–Meier and log‐rank analyses revealed that the prognosis for the 5‐year plate exposure‐free rate was significantly poorer for patients with a small number of residual teeth than for patients with no teeth or those with a large number of residual teeth (.01). Univariate Cox regression analysis revealed that a small number of residual teeth was a significant prognostic factor in the loss of a reconstruction plate (hazard ratio: 5.63; 95% confidence interval [1.10, 25.85]; .04).

Conclusions

A small number of residual teeth after the segmental resection of oral cancer is significantly involved in reconstruction plate survival and may be important in predicting reconstruction plate prognosis.

[Application of free anterolateral thigh Kiss flap in repair of large scalp defect after malignant tumor resection]

Objective

To investigate the effectiveness of free anterolateral thigh Kiss flap in repair of large scalp defect after malignant tumor resection.

Methods

Between December 2012 and December 2016，18 patients with large scalp defect after malignant tumor resection were treated. There were 16 males and 2 females with an average age of 52.6 years (range, 43-62 years). There were 17 cases of squamous carcinoma and 1 case of dermatofibrilsarcoma protuberan. The size of scalp defect ranged from 15 cm×10 cm to 17 cm×12 cm after resection of tumors. The scalp defects were repaired with the free anterolateral thigh Kiss flap. And the size of flap ranged from 15 cm×6 cm to 20 cm×8 cm. The skull was completely resected in 2 cases, and repaired with Titanium mesh. The sizes of skull defects were 12 cm×10 cm and 10 cm×8 cm. The donor site was sutured directly.

Results

Eighteen flaps survived with primary healing of wounds; and healing by first intention was obtained at the donor sites. One patient died because of intracranial metastasis at 5 months after operation, and no local recurrence occurred in the other 17 patients. The follow-up time ranged from 6 months to 4 years (mean, 26.6 months). The results of both appearance and function were satisfactory, without ulceration during follow-up. No obvious scar was found at donor sites and no obvious impairment was observed after harvesting free anterolateral thigh flap.

Conclusion

Large scalp defects after malignant tumor resection can be effectively repaired by free anterolateral thigh Kiss flap. The donor site can be sutured directly, without skin grafting, thus avoiding the secondary donor site.

Prevention of Mandible Reconstruction Plate Exposure by Costal Cartilage Wrapping

After mandibulectomy in cancer surgery, reconstruction is often performed with a reconstruction plate covered with a soft-tissue free flap in patients in poor condition. However, the rate of complications for mandibular reconstruction is higher with a reconstruction plate than with vascularized bone grafts. We have developed a costal cartilage wrapping method to prevent exposure of the mandible reconstruction plate. The eighth costal cartilage was removed and split into 2 pieces to wrap around the reconstruction plate. In our case, the artificial plate wrapped with costal cartilage graft was not exposed and the skin over the plate did not become atrophic over 27 months follow-up even after irradiation. Wrapping around an artificial reconstruction plate with autologous costal cartilage grafts may be more effective than using only a flap covering to prevent exposure of the plate after tumor ablation and radiation therapy.

Design of a customised bridging mandibular prosthesis for complex reconstruction: a pilot study

The gold standard for mandibular reconstruction is universally recognised and consists of the replacement of the bony part of the mandible with a bony microvascular free flap supported by a reconstructive plate. Although this procedure is feasible and reproducible in most patients, at times poor oncological prognosis or poor performance status force surgeons to consider other reconstructive solutions. In these cases, the main alternative in reconstructing a mandibular defect is represented by bridging plates combined with soft tissue flaps. However, repairing a mandibular defect with a reconstructive plate only can lead to a series of diverse complications. The most frequent complications reported are rupture and oral exposure of the plate. In this paper, we describe a new method for mandibular reconstruction using a customised bridging mandibular prosthesis (CBMP) without bone free flap.