Cases Of Neck Reconstruction Research Articles

Complete Extensive Heterotopic Ossification of the Entire Free Fibula Flap Vascular Pedicle in Maxillary Reconstruction.

Heterotopic ossification is a pathologic extra-skeletal bone formation as a form of aberrant repair process with acquired or genetic etiologies. In plastic surgery, it has been well-described in the burn and trauma patients. Rarely, it can happen along the vascular pedicle of free tissue transfer, and when it happens, it is most commonly in head and neck reconstruction. Here we present a case of complete extensive heterotopic ossification of the entire vascular pedicle from the anastomosis to the bone in an osteocutaneous free fibula flap (FFF). The fibula was used as a 2-segment reconstruction for a maxillary defect resulting from a self-inflicted gunshot wound. The skin paddle was used to reconstruct the anterior palatal defect. Heterotopic ossification of the FFF vascular pedicle is most reported in the head and neck reconstruction cases. It is rare, but when it happens, it occurs earlier, more commonly, and more extensively in cases of maxillary reconstruction than in cases of mandibular reconstruction. Flap loss due to this sequela has not been reported, and surgical debridement is indicated only when symptomatic. Heterotopic ossification of an FFF vascular pedicle is a rare but well-described entity. The periosteal bone formation capacity preservation after revascularization of the flap is thought to be one of the major etiologies of this phenomenon. Hence, some have suggested a modification in the harvesting technique of the FFF that could mitigate return to the operating room, especially when it is for maxillary reconstruction in the trauma patient. Keywords: Keywords: free fibula flap, heterotopic ossification, maxillary reconstruction, mandibular reconstruction.

Application of tensor fascia lata perforator flap in head and neck reconstruction

The aim of this study was to describe the authors’ experience in head and neck reconstruction with the tensor fascia lata perforator flap (TFLPF). Between April 2009 and August 2020, 16 patients underwent head and neck reconstruction with a TFLPF. The flaps were designed in a vertical or transverse fashion based on perforators traveling along the medial or lateral aspect of the posterior edge of the tensor fascia lata muscle. Clinical details and postoperative results were recorded and analyzed. The size of the flap ranged from 7 × 5 cm2 to 25 × 9 cm2. The perforators were mostly septocutaneous (11 patients), allowing a simple and straightforward dissection of the perforator and TFLPF in most patients. There were either one or two perforators in all cases. The overall flap survival rate was 100%. All of the flaps healed uneventfully with no delayed wound healing or donor site dysfunction. Follow-up ranged from 18 to 120 months, during which all patients experienced satisfactory functional and aesthetic results, without serious complications at either the recipient or donor site. The TFLPF is a pliable and reliable flap that could be a first choice in selected head and neck reconstruction cases.

235 Late Start Times Do Not Disproportionately Prolong Operating Times in Major Head and Neck Reconstruction

Abstract Introduction Operating start time delays are deemed as having a detrimental effect on theatre efficiency, subsequent delays, costs, and potentially outcomes. This study assessed the significance of delayed operating start times on major head and neck reconstruction cases and whether later starts led to disproportionately later finishes. Focus was placed on free osteocutaneous fibula flap reconstruction due to long operating times, difficult anaesthesia, frequently overrun and the perception of increased morning efficiency. Method Single centre identification of 26 patients using coding informatics that were diagnosed with an intra oral malignancy or osteoradionecrosis requiring reconstruction with a free osteocutaneous fibula flap. Data was manually retrieved between 2015 to 2020 from electronic patient records and statistical analysis was completed using Microsoft Excel. Results Total number of patients collated was 27, however 1 was excluded due to insufficient electronic logging of patient data. The total mean age was 64.8 (40-79), 50% were male (13) and 50% were female (13). The mean start time was 9:57, end time was 18:52 and duration was 10:50 (4:46 to 13:42). For surgery start times before 10:00 a.m. the mean start time was 9:31, end time was 20:16 and duration was 10:46 (8:30 to 22:56). For surgery start times after 10:00 a.m. the mean start time was 10:22, end time was 19:25 and duration was 10:54 (10:01 to 00:51). Conclusions Delayed operating start times have minimal significance on theatre efficiency and don’t disproportionally prolong operating times in major head and neck reconstruction cases.

Applications of intraoperative angiography in head and neck reconstruction.

SUMMARYObjectiveLaser-assisted angiography with indocyanine green (LAIG) allows objective intraoperative evaluation of tissue vascularity. We endeavored to describe our experience with this technique in the head and neck region.MethodsA retrospective review from February 2016 till October 2018 was conducted. We included patients who underwent head and neck procedures in which LAIG was employed. The main outcome was postoperative wound complications. We analysed the influence of LAIG results in intraoperative decision-making process.ResultsNineteen patients were included, and follow-up was for at least 6 months. LAIG was employed in 11 local flaps, 9 free flaps and 6 cases of pharyngeal closure during total laryngectomies. Wound complications occurred in two cases with distal tip flap necrosis. LAIG findings resulted in changes in decision making intraoperatively in 84% of procedures, which consisted in trimming poorly perfused tissues. There were no pharyngocutaneous fistulas.ConclusionsThis represents a descriptive report on the use of LAIG on diverse head and neck reconstruction cases, with important impact on the decision-making process. A low number of postoperative wound complications were observed.

Usefulness of a template-based anterolateral thigh flap for reconstruction of head and neck defects.

One of the challenges in head and neck reconstruction is to have an adequate understanding of the three-dimensionalities of the defects created after resections due to the high variability of clinical scenarios. Consequently, it is essential to design the flap to match the requirements of the defect in order to facilitate the insetting and to achieve a successful outcome. The anterolateral thigh flap (ALT) is a robust and versatile flap commonly used in head and neck reconstruction. In this study the authors use a hand-made template as a tool to customize ALT flaps and its variations to fit more accurately the different shapes, volume, and components of the resulting defects. The aim of this study is to describe in detail this surgical approach and present the clinical experience in 100 consecutive cases using a template-based ALT flaps in head and neck reconstruction. A retrospective review was performed on all microvascular head and neck reconstruction cases between January 2013 and December 2017 in our institution where a template-based ALT flap design was performed. We describe in detail the surgical technique used and present the clinical outcomes. In addition, we analyzed the use of different designs of the ALT flaps including different flap components in relation to the location of the defect. One hundred reconstructions for head and neck defects were performed in 97 patients. Seven types of ALT free flaps were performed: fasciocutaneous (46%), suprafascial (8%), adipofascial (9%), vastus lateralis muscle (3%), composite fasciocutaneous/adipofascial (9%), chimeric flaps (21%), and vascularized nerve grafts (4%). Oropharyngeal and periauricular defects were mostly reconstructed with fasciocutanoues design. In more complex three-dimensional defects such as skull base or midface defects, a chimeric flap was selected. In all cases the used of template facilitated the insetting of the free flap. The total flap loss was 2%. Customization of ALT flaps using intraoperative templates is a useful method for flap design which facilitates fitting of the flap to a variety of defects in head and neck reconstruction.

Reconstruction of Total Laryngopharyngectomy Defects with Deep Inferior Epigastric Perforator Flaps

Laryngopharyngectomy reconstruction with microvascular free flaps remains challenging. Current methods of reconstruction include anterolateral thigh, radial forearm, and jejunal flaps, all of which have substantial donor site morbidity. We present a novel approach for total laryngopharyngectomy reconstruction using deep inferior epigastric perforator (DIEP) flaps. A retrospective review of head and neck reconstruction cases performed at Harbor-UCLA from 2006 to 2007 was performed. Those undergoing DIEP flaps were identified; management and postoperative course were analyzed. Two patients underwent successful reconstruction of total laryngopharyngectomy defects using DIEP flaps. Flaps up to 10 x 30 cm were harvested. Average donor vessel diameters were 2.5 cm and 3.0 cm for the artery and vein, respectively. The abdominal wounds were closed primarily. Flap survival was 100% with no emergent reexplorations. There were no postoperative bulges or hernias, and no leaks were detected on postoperative swallow evaluation. The DIEP flap is a useful addition to the armamentarium for reconstruction of total laryngopharyngectomy defects. Pedicle length is abundant, and donor vessel caliber is excellent. Large surface-area flaps can be harvested; excess flap can be deepithelialized or utilized for external skin. Primary closure of the donor site can be routinely achieved, negating the need for skin grafts.

Is the deltopectoral flap born again? Role in postburn head and neck reconstruction

After extensive use for head and neck reconstruction, the deltopectoral flap has been supplanted by alternative methods of reconstruction and relegated to historical references. However, it remains a very valuable skin flap and should keep its place in the armamentarium of reconstructive surgeons for postburn head and neck reconstruction. We report here five cases of head and neck reconstruction using the deltopectoral flap: one case of perioral reconstruction after ballistic trauma, one case of nasal reconstruction after burn and three cases of neck reconstruction after burn contracture. Technical simplicity and reliability are the main features of this flap. The skin paddle is thin and pliable, and its surface can be extended after a flap delay. Previous tissue expansion can minimize donor site morbidity. The flap division necessitates a second surgical procedure. The major burn contractures of the neck are, in our opinion, an excellent indication of the deltopectoral flap.

Microvascular head and neck reconstruction in patients with liver cirrhosis

The aim of this retrospective case series was to review the safety, complications, and outcomes of free-tissue transfer in head and neck cancer reconstruction in patients with liver cirrhosis. A retrospective review of all microvascular head and neck reconstruction cases with concomitant liver cirrhosis treated in our institution from 1994 to 2005 was performed. Data collected included patient demographics, etiology, and severity of liver cirrhosis, defect site, choice of free flap, complications, and clinical follow-up. Seven patients were identified. They were all males and underwent microvascular head and neck reconstruction due to ablative cancer surgery. Their Child-Pugh classification of liver cirrhosis was graded as follows: Child A (n = 3); Child B (n = 3); and Child C (n = 1). Eight free flaps were transferred (1 patient received 2), including anterolateral thigh (n = 4); radial forearm (n = 3); and fibula (n = 1). All flaps survived without the need for any microvascular revision procedures. Two patients died within postoperative 30 days due to hepatic decompensation. Other complications included neck hematoma (n = 1), neck wound infection (n = 2), and donor site dehiscence (n = 1). Only 2 patients with Child A cirrhosis remained free from complications and survived more than 1 year after the surgery. Microvascular head and neck reconstruction may be performed in patients with liver cirrhosis with a certain degree of technical success. However, the procedure is associated with significant mortality and morbidity in Child class B and C patients. Therefore, we recommend avoiding free-tissue transfer in patients with head and neck cancer with advanced liver cirrhosis.