Osteomyocutaneous Flap Research Articles

The scapular, parascapular, and latissimus dorsi flap as a single osteomyocutaneous flap for repair of complex oral defects

Complex composite defects of the oral cavity are often created due to en bloc resection of malignant tumors. These defects can involve bone, soft tissue, oral mucosa, and external skin, posing a reconstructive challenge to the microvascular surgeon. Though advances have been made in free tissue transfer via piggybacking techniques and double free-flaps, increases in operative time and morbidity remain limiting factors. Likewise, advancements in single composite flaps (e.g., double-skin paddle fibular free-flap) allow for a single donor site, but limit workable tissue. This report describes our experience with the scapular, parascapular, and latissimus dorsi (SPLD) as a combined single unit osteomyocutaneous flap for composite reconstruction of complex oral defects. A case example is subsequently reviewed for clinical correlation. This is an operative techniques article describing the use of the SPLD single multi-tissue flap for repair of complex oral defects. Cadaveric dissection was performed for instructional purposes. Case example was given for clinical correlation. Relevant history, anatomy, procedural details, and possible complications are presented and subsequently correlated to the case example. A SPLD free-flap as a single multi-tissue flap is a viable and beneficial option for reconstruction of complex oral defects. It provides the volume of tissue necessary to fill composite defects and exists as an alternative to multi-flap procedures, which carry a longer operative time and multiple donor site morbidity.

First Experiences with Simultaneous Skeletal and Soft Tissue Reconstruction of Noma-Related Facial Defects

Noma victims suffer from a three-dimensional facial soft-tissue loss. Some may also develop complex viscerocranial defects, due to acute osteitis, chronic exposure, or arrested skeletal growth. Reconstruction has mainly focused on soft tissue so far, whereas skeletal restoration was mostly avoided. After successful microvascular soft tissue free flap reconstruction, we now included skeletal restoration and mandibular ankylosis release into the initial step of complex noma surgery. One free rib graft and parascapular flap, one microvascular osteomyocutaneous flap from the subscapular system, and two sequential chimeric free flaps including vascularized bone were used as the initial steps for facial reconstruction. Ankylosis release could spare the temporomandibular joint. Complex noma reconstruction should include skeletal restoration. Avascular bone is acceptable in cases with complete vascularized graft coverage. Microsurgical chimeric flaps are preferable as they can reduce the number and complexity of secondary operations and provide viable, infection-resistant bone supporting facial growth.

S42. Pedicled osteomyocutaneous flaps: An alternative option for mandibular reconstruction (local experience)

S42. Pedicled osteomyocutaneous flaps: An alternative option for mandibular reconstruction (local experience)

Sequential Second Free Flap for Head and Neck Reconstruction in a Patient with Fanconi Anemia and Metachronous Squamous Cell Carcinoma

Sir: Fanconi anemia is a rare genetic disease characterized by chromosomal instability, bone marrow failure, congenital malformations, and increased susceptibility to both solid and leukemic malignancies. The incidence of solid malignancies approaches 28 percent by 40 years of age, with a high proportion of these being head and neck tumors.1 In a series of 754 patients with Fanconi anemia, Kutler et al. reported that 3 percent developed head and neck squamous cell carcinoma, with a 50 percent relapse rate by the age of 40.2 Although Fanconi anemia patients may develop multiple tumors over a lifetime, repeated operations/ reconstructions are rarely seen because of their shortened life expectancies. Furthermore, surgeons may be hesitant to treat patients with Fanconi anemia because of an increased risk of complications, particularly if treatment involves extensive resection or possible free tissue transfer. We have previously described a successful mandibular reconstruction with a free fibula free flap in a patient with Fanconi anemia and squamous cell carcinoma of the mandible.3 Unfortunately, the patient developed squamous cell carcinoma of the pharynx 18 months later. We now report subsequent pharyngeal reconstruction with a metachronous free flap. Initially, a 43-year-old woman with Fanconi anemia was referred to our institution with an erosive floor-of-mouth mass ultimately diagnosed as squamous cell carcinoma. She underwent hemimandibulectomy and bilateral neck dissection followed by immediate reconstruction with a right fibular osteomyocutaneous flap. The patient recovered from surgery without complications and underwent adjuvant radiation therapy. Her postoperative result was satisfactory. Eighteen months later, she was found to have squamous cell carcinoma of the hypopharynx. She then underwent total laryngopharyngectomy and construction of a neopharynx using a tubed anterolateral thigh flap. The soft tissues of the right neck were resurfaced with a separate skin paddle based off of a second perforator; the left lateral neck received a split-thickness skin graft. The patient recovered without any hematologic complications but did suffer partial skin graft loss and a small pharyngocutaneous fistula. A modified barium swallow performed 6 weeks postoperatively demonstrated a small leak that resolved 1 month later, resulting in satisfactory cosmetic and functional outcomes. As recommended by our hematologists, during both hospitalizations, the patient's perioperative hemoglobin level and platelet count were maintained above 7 g/dl and 50,000 cells/ml, respectively, by means of hematopoiesis-stimulating agents and blood product transfusions. A total of 42 units of single-donor platelets and 13 units of packed red blood cells were administered while the patient was hospitalized after the second free flap. In conclusion, patients with Fanconi anemia are at increased risk for perioperative hematologic complications. There are two published reports that describe successful free tissue transfer in Fanconi anemia patients.3,4 To our knowledge, this is the first reported case of a patient with Fanconi anemia to undergo a second sequential free flap operation for metachronous head and neck cancer reconstruction. As this case demonstrates, such large-scale reconstructions can be successfully undertaken with careful perioperative management of patients with this disease. Karly A. Kaplan, M.D. Alyssa J. Reiffel, M.D. David I. Kutler, M.D. Christine H. Rohde, M.D. Jason A. Spector, M.D.

Sternocleidomastoid region restoration with lateral hemisoleus muscle incorporatied in free fibular flap for reconstruction of radical neck dissection and hemimandibulectomy

In the treatment of head and neck carcinoma, radical cervical lymphadenectomy leaves the affected side of the neck devoid of the sternocleidomastoid muscle, thus more vulnerable to the unwanted side effects of the adjuvant radiotherapy. It also causes asymmetry and cosmetically unpleasant appearance of the cervical region. In the reported case with widely ulcerated squamous-cell carcinoma over mandible, hemimandibulectomy and radical neck dissection was performed. Following the mandibular reconstruction, the lateral hemisoleus muscle of the harvested osteomyocutaneous fibula flap was utilized to restore the ipsilateral sternocleidomastoid region. This new application promises to be a useful method, which can aid in the restoration of the aesthetic contour of the neck and provide protection against unwanted effects of the adjuvant radiotherapy on the ipsilateral carotid artery.

Use of fibula pedicle as a composite interposition vascular graft to salvage large skin paddle with anomalous vascular supply

We report a case of free fibula osteomyocutaneous flap whose skin paddle had a dominant blood supply from a soleus musculocutaneous perforator which originated in the posterior tibial artery in addition to contribution from the peroneal septocutaneous perforators and was managed by two sets of anastomosis on either side of the neck, one for the peroneal vessels and the other for the dominant musculocutaneous perforator. The second anastomosis was achieved by using the excess length of the flap pedicle vessels (peroneal) as composite (both artery and vein) autologous interposition vascular graft to reach the opposite side of the neck.

Giant Cell-Rich Osteosarcoma or Giant Cell Reparative Granuloma of the Mandible?

Giant cell-rich osteosarcoma (GCRO) is a rare subtype of osteosarcoma, and no literature has reported occurrence in the mandible region up to now. In this article, we report a case of GCRO originating from the mandible in a 67-year-old woman who presented a history of painless mass located in the left side of the mandible after teeth extraction. The curettage biopsy histologic diagnosis is giant cell reparative granuloma before mandibulectomy surgery, but panoramic radiograph revealed an osteolytic lesion. The tumor was completely resected with segmental mandibulectomy and soft tissue with postoperative histologic diagnosis of GCRO. The free fibula osteomyocutaneous flap was performed to reconstruct the defect of the mandible and gingival mucosa. The patient received postoperative radiotherapy and chemotherapy. The 1-year follow-up situation is fine.

Reconstruction of Extensive Composite Mandibular Defects Using Osseous or Nonosseous Free Tissue Transfer

Sir: We read with great interest the article by Mosahebi et al. entitled “Reconstruction of Extensive Composite Posterolateral Mandibular Defects Using Nonosseous Free Tissue Transfer” (Plast Reconstr Surg. 2009;124:1571–1577). The authors claim that the extensive soft-tissue defects cannot be reconstructed always with an osteocutaneous free tissue transfer, although it provides bony reconstruction. The authors reviewed some osteocutaneous flaps that are widely used in reconstruction and explained why they do not like to use them. They prefer to use musculocutaneous flaps such as the vertical rectus abdominis musculocutaneous flap for covering entire through-and-through defects of the mandible and oral cavity. By so doing, they claim to return patients to normal life and oral alimentation more quickly than with other choices of reconstruction. The authors do not prefer osteomyocutaneous flaps, as their pedicle length and skin paddle will not be enough to cover the whole defect. They may be right on those aspects regarding the coverage of posterolateral defects and the oral cavity, but there are some points worth mentioning. First, the fibula osteocutaneous flap has a pedicle nearly 10 to 12 cm long, and the skin coverage can be adequate for most defects. Moreover, if the soleus muscle is also included in the flap, it would be used in closing the oral defect and providing bulk for contour reconstruction.1 However, it is true that the cutaneous part of the flap may not cover the entire posterolateral defect, which can be solved by local flaps alone. The iliac crest osteomyocutaneous flap is also a very reliable flap in reconstruction of bony defects of the mandible.2 It is very useful for contouring and space-filling purposes. Although the pedicle is not as long as a fibular flap, it is nearly 10 cm long and reliable for a large skin island to cover the defect. Skin paddle can be elevated to as large as 16 × 20 cm.3 The internal oblique muscle can be also included in the flap so that it can be used for closing intraoral mucosa defects. This flap has been used for bony reconstruction of oromandibular defects since Urken et al. popularized it in 1998. The claimed donor-site morbidity is under 6 percent in most of the literature, and most of the complications can be avoided if care is taken during its harvest.4 If closure of the defect is performed carefully, no hernias will be seen, and if the anterior superior iliac spine is preserved, no gait disturbances or contour deformities of the hip will occur.4 We also perform this reconstruction very often and did not encounter any significant or persistent donor-site morbidities except for the incision scar. The authors emphasize the importance of early maintenance of oral intake and quality of life. A total of 39 patients could have an oral diet, whereas only seven of 76 patients could have a regular diet. We believe that restoration of oral intake for life quality is directly related to not only swallowing but also chewing. Osteointegrated dental implants can be used after stabilization of the patient and the reconstructed site. If we consider that the patient during his or her remaining life has to eat, chew, talk, and so forth, dental restoration becomes an important issue. The restoration of quality of life is related more to the bony reconstruction if we consider that these patients have to return to normal or nearly normal life and function. Returning to normal oral nutrition does not mean solely having a soft diet in remaining life, but that mastication function has to be regained. Considering that these patients have oncologic diseases, their nutrition is far more important and somewhat defines their prognosis. From the date that bony flaps have been used for mandibular reconstruction, dental implants have been used.5,6 For this purpose, both fibular and iliac crest flaps can be used safely in selected cases. Although the bony segment of the fibular flap is thinner, it is still reliable for dental implants. If the defect is extensive and cannot be covered with one osteomyocutaneous flap alone, combined flaps can be used for reconstruction of bone and soft tissue, although it extends the operative time. Considering these facts, we believe that bony reconstruction of the mandible can be more appropriate even if the defect is extensive. Ersoy Konaş, M.D. Ebru Yoruk, M.D. Serdar N. Nasir, M.D. Department of Plastic Reconstructive and Aesthetic Surgery Hacettepe University Medical School Samanpazari, Ankara, Turkey

A Composite Osteomusculocutaneous Free Flap from the Medial Femoral Condyle for Reconstruction of Complex Defects

This combined anatomic and clinical study illustrates the first experiences of an osteomyocutaneous flap from the medial femoral condyle for reconstruction of composite tissue defects. We analyzed the anatomic consistency and the vascular distribution of this flap and showed that muscle tissue can easily be added as a composite flap. Twenty-one flaps were harvested from fresh adult cadavers with careful identification of the origin and the course of the three different branches of the descending genicular artery. The corresponding skin areas and muscle portion were identified. The clinical application of this flap was described for closure of complex calcaneal defects. The cadaveric study presented a constant pedicle length and diameter of the arteries, combined with a constant venous drainage. Furthermore, the medial condyle provided a corticocancellous segment and separate vascularity for skin and muscle portions. In the case reports, satisfying results of bone union and soft tissue contouring were achieved. The medial femur condyle region is a reliable donor site for composite flaps, providing a good corticocancellous bony structure and a separate skin paddle, as well as a muscle portion. Its vascular distribution shows anatomic consistency. Despite long-term atrophy of muscle transplants, we believe the additional muscle tissue improves the reconstruction results and provides better soft tissue contouring.

Greater Efficacy of Tolerance Induction with Cyclosporine versus Tacrolimus in Composite Tissue Allotransplants with Less Myeloablative Conditioning

Previous studies demonstrated that both cyclosporine and tacrolimus in combination with antilymphocyte globulin could facilitate mixed chimerism and induce tolerance to composite tissue allotransplants under partial myeloablative conditioning. The purpose of this study was to compare the efficacy of cyclosporine and tacrolimus. Brown-Norway and Lewis rats were used as composite tissue allotransplant donors and recipients, respectively. Cyclosporine groups I (n = 6), II (n = 9), and III (n = 5) received subcutaneous injection of 16 mg/kg cyclosporine (days 0 to 10); intraperitoneal injection of 5 mg of antilymphocyte globulin (days -1 and 10); and 0-, 200-, and 400-cGy total body irradiation (day -1), respectively. Tacrolimus groups IV (n = 6), V (n = 7), and VI (n = 8) received intraperitoneal injection of 1 mg/kg tacrolimus (days 0 to 10) and 5 mg of antilymphocyte globulin (days -1 and 10); and 0-, 200-, and 400-cGy total body irradiation (day -1), respectively. Recipients underwent hind-limb osteomyocutaneous flap composite tissue allotransplantation on day 0. Chimerism levels were determined 2 weeks after composite tissue allotransplantation, and acceptance was defined as complete survival of the composite tissue allotransplant to the endpoint of the experiment at 150 days. Chimerism levels 2 weeks after composite tissue allotransplant averaged 3.4, 4.9, 29, 2.4, 4.9, and 16 percent composite tissue allotransplant, and acceptance rates were 0, 33.3, 80, 0, 0, and 13 percent in group I, II, III, IV, V, and VI, respectively. Despite relatively late development for clinical use in transplantation, tacrolimus has not proved advantageous for composite tissue allotransplant acceptance and tolerance when compared with cyclosporine.

Immediate Reconstruction of Bilateral Mandible Defects: Management Based on Computer-Aided Design/Computer-Aided Manufacturing Rapid Prototyping Technology in Combination With Vascularized Fibular Osteomyocutaneous Flap

Since the last century, many researchers have attempted to improve the quality of treatment for facial defects.1 In recent years a computer scan information–aided surgical navigational system was used to accurately compare the intraoperative reduction profile with preoperative computer virtual simulation for exact reduction.2 Fan et al3 used computer-aided design (CAD)/computer-aided manufacturing (CAM) to treat complex periorbital fractures, deeming it a useful clinical tool to assist surgeons in accurate design of the surgical scheme and procedure and achieving improved surgical outcome.

Reconstruction of High Maxillectomy Defects with the Fibula Osteomyocutaneous Flap in Combination with Titanium Mesh or a Zygomatic Implant

This retrospective review examined the authors' patients who underwent reconstruction of high maxillectomy defects with fibula osteomyocutaneous flaps in combination with titanium mesh or a zygomatic implant. Outcome assessments included aesthetic, speech, and masticatory function. Twenty patients who underwent reconstruction of high maxillectomy defects with fibula osteomyocutaneous flaps in combination with titanium mesh (n = 19) or a zygomatic implant (n = 1) were reviewed. The fibula was fashioned to recreate the alveolar ridge and pterygomaxillary buttress, and the skin paddle was applied to restore the palate and nasal airway. The anterior wall of the maxilla and the orbital floor were reconstructed with titanium mesh in 19 patients. In four patients with extensive soft-tissue defects, a radial forearm flap was combined to restore missing soft tissue. Aesthetics, speech, and masticatory function were evaluated postoperatively. Nine patients underwent immediate maxillary reconstruction and 11 patients underwent secondary reconstruction. The overall success rate of 24 flaps was 95.8 percent. The exposure rate for titanium mesh and the oronasal fistula rate were both 10.5 percent. The average length of follow-up was 34.7 months. Recurrence occurred in only one patient, who died as a result of the disease. Ten patients received implant-borne prostheses or removable partial dentures. Excellent or good cosmesis and intelligible speech were noted in 19 patients. All patients were ultimately able to tolerate a regular or soft diet. Reconstruction of high maxillectomy defects with the fibula osteomyocutaneous flap in combination with titanium mesh or a zygomatic implant is a feasible and acceptable option with a high success rate, a low complication rate, excellent postoperative cosmesis, and well-accepted function.

Femur-Vastus Intermedius-Anterolateral Thigh Osteomyocutaneous Composite Chimeric Free Flap: A New Free Flap for the Reconstruction of Complex Wounds

Among the many bone and muscle flaps described in literature, several have stood the test of time and come forward as the preferred donor sites. Each has its own advantages and disadvantages. Yet another bone flap that has never been described in literature is introduced here. This is the vascularized femur bone flap based on the periosteal blood supply from the overlying vastus intermedius muscle. The vastus intermedius muscle free flap has the advantage of easy harvest, consistent vascular anatomy, long pedicle with large-caliber vessels, easy patient positioning, two-team approach, large surface area, minimal thickness, minimal donor site morbidity, and minimal functional loss. In this report, the femur-vastus intermedius-anterolateral thigh osteomyocutaneous chimeric free flap based on the descending branch of the lateral circumflex femoral artery is used in the reconstruction of a complex composite defect of the lower extremity.

Functional Total Heel Reconstruction with a Fibular Osteomyocutaneous Flap

Functional Total Heel Reconstruction with a Fibular Osteomyocutaneous Flap

The Fibula Osteomyocutaneous Flap for Mandible Reconstruction: A 15-Year Experience

This report documents our experience over the previous 15 years using free vascularized fibular flaps for comprehensive reconstruction of large defects in the mandible, after combined resections of aggressive, malignant odontogenic tumors or for post-traumatic defects. Charts were reviewed retrospectively for 117 consecutive patients who underwent microsurgical reconstruction of the oromandibular complex with a fibula osteocutaneous or osteomyocutaneous free flap over a 15-year period, with an average follow-up of 4 years. All charts were reviewed retrospectively for tumor type, stage and location, surgical procedure performed (including type of plate used), dental restoration if done, the use of pre- or postoperative radiotherapy, length of follow-up, and evidence of complications. Fibula osteocutaneous free flaps were used for reconstruction in 117 patients, of whom 60% were men (mean age, 57.1 years) and 40% were women (mean age, 56.6 years). Most cases (61.1%) were secondary to oral malignancies (89.1% of these were squamous cell carcinoma). Thirty-one patients (26.5%) developed postoperative complications, including hardware failure or intolerance in 16 patients (13.7%), total or partial flap failure in 10 patients (8.5%), wound infection in 3 patients (2.6%), and peroneal nerve damage in 2 patients (1.7%). Regarding donor site morbidity, calf paresthesias were recorded in 21% of cases. Similar rates of claw-toe deformity were also observed. In our opinion, the free fibula osteocutaneous flap is the most versatile and reliable option for microsurgical reconstruction of large mandibular defects. It provides a large quantity of bone, which is easily shaped to passively adapt to the remaining mandible. The bone height is suitable for an implant-based prosthetic restoration. Preoperative mapping of the cutaneous perforators of the skin paddle improves the versatility of the flap design and decreases the morbidity at the donor site. In selected cases, other options (iliac crest or scapular free flap) may also be considered.

Osteo-myocutanoeus flap: a novel flap for single toe amputation.

Amputation is frequently required to treat wet gangrene secondary to peripheral vascular disease. Although different types of amputations have been reported, limited digital and ray amputation are the commonest amputations performed. The level of amputation will be determined by the distribution of lower limb disease but for every patient a balance between limb and functional preservation at lower levels versus better wound healing at higher levels should be sought.In this article we describe the novel osteo-myocutaneous flap, which we have used in our patient. We believe that this flap results in improved wound healing and although it results in loss of two digits, it does not impair function.

Vascularized Bone Grafts within Composite Tissue Allotransplants Can Autocreate Tolerance through Mixed Chimerism with Partial Myeloablative Conditioning: An Experimental Study in Rats

Certain composite tissue allotransplants contain vascularized bone grafts (e.g., hand/forearm composite tissue allotransplants). The authors investigated the role of the vascularized bone graft within the hind-limb osteomyocutaneous flap in inducing tolerance. Brown Norway and Lewis rats were used as composite tissue allotransplant donors and recipients, respectively. Experimental groups were as follows: group I, syngeneic controls (Lewis to Lewis); group II, allogeneic controls (both received no pretransplantation total body irradiation); and groups III, IV, and V, which received 5 mg of antilymphocyte globulin administered intraperitoneally (on days -1 and 10), 1 mg/kg of tacrolimus administered intraperitoneally (on days 0 to 10), and total body irradiation (600, 400, and 200 cGy, respectively, 1 day before composite tissue allotransplantation). Each Lewis rat in groups II, III, IV, and V received a composite tissue allotransplant on day 0 in the form of a Brown Norway hind-limb osteomyocutaneous flap. Different donor hematopoietic cell lineages in recipients' peripheral blood were assessed by flow cytometry on posttransplantation days 15, 30, 60, 90, 120, and 150. Secondary Brown Norway skin grafts in recipients with composite tissue allotransplant acceptance were performed at 150 days after transplantation. Allotransplanted hind-limb osteomyocutaneous flaps produced chimerism and donor multilineage hematopoietic cells in groups III, IV, and V; composite tissue allotransplant acceptance rates in these groups were 37.5, 16.7, and 0 percent, respectively. Graft-versus-host disease occurred in 62.5 percent of group III recipients. Recipients with acute graft-versus-host disease produced a higher percentage of donor T cells compared with composite tissue allotransplant-accepting recipients (p < 0.05). Secondary Brown Norway skin graft acceptance in composite tissue allotransplant-accepting recipients confirmed durable tolerance. Vascularized bone grafts contained within composite tissue allotransplants can autocreate chimerism and tolerance in rats with partial myeloablative tacrolimus-based conditioning.

Functional Total Heel Reconstruction with a Fibular Osteomyocutaneous Flap

The fibular osteocutaneous flap is a versatile option for a range of reconstructive challenges. In this report, a novel osteocutaneous fibular flap in which a V-shaped strut of fibula was used to reconstruct the weight-bearing function of the calcaneus has been described. The case raised interesting questions about the vascularity of the fibular flap, which we addressed with an anatomic study of the lower leg. Eight cadavers were injected with the modified lead oxide-gelatin mixture. Two cadavers were selected for three-dimensional reconstructive modeling. Dissections of each layer were performed to outline the course of every perforator in the lateral leg and the region of the ankle. The peroneal artery originated from 5.0 +/- 1.0 cm inferior to the lateral fibular tuberosity (diameter of 2.0 +/- 0.4 mm). The artery gave off 7.6 +/- 1.8 branches and provided blood supply to the fibula bone and its adjacent soft tissue. Proximal perforators from the peroneal artery were large and consistent. Based on the success of this clinical case and the details of the vascular anatomy, the authors feel that distally based osteocutaneous fibular flaps with a V-shaped strut of fibula offer a novel option for reconstruction of complex defects in the heel area in which there are both bony and soft tissue defects.

Postablative Reconstruction Is Better Terminology than Oncoplastic Surgery

Sir: Art, indeed, consists in the conception of the result to be produced before its realisation in the material. —Aristotle in De Partibus Animalium (On The Parts Of Animals), 350 BC Ongoing innovations continue to advance effective surgical primary tumor control and are linked to improved surgical outcomes, minimized patient morbidity, and better quality of life. The term “oncoplastic” was first used in 1996.1,2 It originates from the Greek words onkos (ογκοσ), meaning bulk, mass, or tumor; and plastikos (πλαςτικóσ), meaning molded or shaped. These words together mean the molding of a tumor. This term is therefore unsatisfactory when applied to the combination of oncology surgery and plastic surgery. Surgery is the oldest modality of cancer therapy and still forms the mainstay of treatment for solid tumors. Surgery operates by zero-order kinetics, in which all excised cells are killed. Ablation derives from the Latin ablatus, the irregular past participle of auferre, to carry away (ab-, away; plus latus, carried); it now has a specifically surgical edge, and today it applies principally to the surgical removal of any part of the body.3 During the past two decades, major improvements in both operative technique and the use of combined-modality therapy have significantly reduced the morbidity and mortality associated with the surgical treatment of solid neoplasms. For example, breast-preserving surgery has become an alternative to mastectomy in patients with breast carcinoma, and limb salvage is often possible in patients with bone and soft-tissue sarcomas. Advances in microvascular surgery now permit the free transfer of complex autologous tissues, such as free jejunal grafts to reconstitute the upper aerodigestive system or osteomyocutaneous flaps to reconstruct extremities and other mobile body parts such as the jaw. Intuitively, it appears logical that the term “postablative reconstruction” is an appropriate term for the specialized art of surgery devoted to the restoration of form and function after the surgical removal of solid tumors. Sammy Al-Benna, M.R.C.S., Ph.D. Lars Steinsträßer, M.D. Klinik für Plastische Chirurgie und Schwerbrandverletzte BG Kliniken Bergmannsheil Ruhr-Universität Bochum, Germany

Three-dimensional model simulation and reconstruction of composite total maxillectomy defects with fibula osteomyocutaneous flap flow-through from radial forearm flap

A total maxillectomy always causes composite defects of maxilla, zygomatic bone, orbital floor or rim, and palatal and nasal mucosa lining. This leads to significant functional and cosmetic consequences after ablative surgery. The purpose of this clinical study was to preliminarily 3-dimensionally reconstruct the defect of total maxillectomy with sufficient bone support and soft tissue lining. Three-dimensional model simulation technique and free fibula osteomyocutaneous flap flow-through from radial forearm flap were used to reconstruct a total maxillectomy defect for a 21-year-old female patient. Preoperatively, the 3-dimensional (3D) simulated resin models of skeleton and fibula were used to design the osteotomies and bone segment replacement. At surgery, a 22-cm-length free fibula was divided into 4 segments to make 1 maxilla skeletal framework in the schedule of the preoperative model surgical planning with a radial forearm flap flow-through for the free fibula flap with skin paddle to repair the palatal and nasal region. Free fibula and radial forearm flap were alive, and the patient was satisfied with the results both esthetically and functionally after dental rehabilitation which was carried out 6 months after surgery. This preliminarily clinical study and case demonstrated that: the fibula osteomyocutaneous flap is an ideal donor site in 3D total maxillectomy defect reconstruction, because of its thickness, length, and bone uniformity which makes ideal support for dental rehabilitation; the flow-through forearm radial flap not only serves as the vascular bridge to midface reconstruction, but also provides sufficient soft tissue cover for the intraoral defect; and the 3D model simulation and preoperative surgical planning are effective methods to refine reconstruction surgery, shorten the surgical time, and predict the outcome after operation.