Evaluation of aesthetic outcomes of mandibular reconstruction using artificial intelligence.

BACKGROUND: Although vascularized bone graft (VBG) transfer is the current standard for mandibular reconstruction, reconstruction with a mandibular reconstruction plate (MRP) and with a soft-tissue flap (STF) alone remain crucial options for patients with poor general conditions. However, objective aesthetic outcome evaluations for these methods are limited. METHODS: In a retrospective analysis of 65 patients (VBG, 33; MRP, 19; and STF, 13), mandibular asymmetry value was calculated for each patient's photograph using facial recognition AI, with a higher value indicating worse asymmetry. RESULTS: The MRP group had a value comparable to the VBG group regardless of mandibular defect types. The STF group had a significantly higher value than the VBG group. CONCLUSIONS: Regarding cosmesis, STF was inferior to VBG, whereas MRP was comparable to VBG, even for anterior defects for which rigid reconstruction is mandatory. However, MRP's risks of plate-related complications limit its use to cases where VBG is contraindicated or with poor prognosis.

Scapula harvest in the supine position for immediate mandibular reconstruction.

PURPOSE: The scapula is the second most popular donor site for mandibular reconstruction after the fibula. Scapula harvest is generally performed in the lateral decubitus position and the requirement of positional changes hamper the widespread use of the scapula. This study compared scapula harvest for immediate mandibular reconstruction between the supine and lateral decubitus positions. METHODS: We reviewed the outcomes of 16 patients who underwent segmental mandibulectomy and immediate reconstruction of the scapula based on the angular branch of the thoracodorsal artery. The scapula was harvested in the lateral decubitus (lateral decubitus group) or supine position (supine group) in eight patients each. Several perioperative parameters were compared between the two groups. RESULTS: One scapula was lost because of inadvertent injury of the angular branch in the supine group. The operative time was significantly shorter in the supine group than in the lateral decubitus group. CONCLUSION: Harvesting of the scapula in the supine position is a feasible option for immediate mandibular reconstruction. Although deep anatomic knowledge and technical expertise are necessary, this strategy can eliminate positional change and significantly reduce the operative time.

Machine learning approach to predict tracheal necrosis after total pharyngolaryngectomy.

BACKGROUND: Tracheal necrosis is a potentially severe complication of total pharyngolarynjectomy (TPL), sometimes combined with total esophagectomy. The risk factors for tracheal necrosis after TPL without total esophagectomy remain unknown. METHODS: We retrospectively reviewed data of 395 patients who underwent TPL without total esophagectomy. Relevant factors associated with tracheal necrosis were evaluated using random forest machine learning and traditional multivariable logistic regression models. RESULTS: Tracheal necrosis occurred in 25 (6.3%) patients. Both the models identified almost the same factors relevant to tracheal necrosis. History of radiotherapy was the most important predicting and significant risk factor in both models. Paratracheal lymph node dissection and total thyroidectomy with TPL were also relevant. Random forest model was able to predict tracheal necrosis with an accuracy of 0.927. CONCLUSIONS: Random forest is useful in predicting tracheal necrosis. Countermeasures should be considered when creating a tracheostoma, particularly in patients with identified risk factors.

Soft tissue Reconstruction Using Pedicled Trapezius Musculocutaneous Flap for Cranial Bone Flap Infection in the Occipital Region.

When managing cranial bone flap infections, infected bone flaps are typically removed and subsequently replaced with artificial bones 6 to 12 months after the inflammation subsides. However, defects in the occipital region pose challenges due to concerns regarding brain protection when patients lie in the supine position. Herein, the authors report the case of a 73-year-old woman with an occipital bone flap infection, which was successfully managed by reconstruction with a trapezius musculocutaneous flap immediately after removing the infected bone flap. One year and 2 months postoperatively, the wound had fully healed, and the patient remained symptom-free without any complications, such as sunken flap syndrome. Soft tissue reconstruction using pedicled trapezius musculocutaneous flap is a viable strategy for managing occipital bone flap infections. This flap ensures stable blood flow and requires minimal vascular manipulation, thereby reducing operation time as the patient does not need to change position.

Transverse Cervical Artery for Head and Neck Reconstruction with Free Jejunal Flaps: A Retrospective Study of Computed Tomography Angiography.

BACKGROUND: The transverse cervical artery is less commonly used than other external carotid arteries as a recipient vessel. Therefore, we aimed to compare the utility of the transverse cervical artery as a recipient vessel with that of the external carotid artery system for microvascular head and neck reconstruction by quantitative analysis of dynamic-enhanced computed tomography. METHODS: Fifty-one consecutive patients who underwent free jejunum transfer following total pharyngolaryngectomy between January 2017 and December 2020 were retrospectively reviewed. Ninety-four pairs of the diameters of the transverse cervical artery, superior thyroid artery, and lingual artery, measured via computed tomography angiography, were analyzed. Operative outcomes were compared between the following groups based on the recipient artery: transverse cervical artery (n = 27), superior thyroid artery (n = 17), and other artery (n = 7) groups. RESULTS: In the analysis of the computed tomography angiography, nine transverse cervical arteries (9.6%) could not be identified. However, the percentage was significantly lower than the percentage of superior thyroid arteries (20.2%) and lingual arteries (18.1%) (p < 0.01). Among the identified vessels, the transverse cervical arteries (2.09 ± 0.41 mm) and the lingual arteries (1.97 ± 0.40 mm) were significantly larger than the superior thyroid arteries (1.70 ± 0.36 mm) in diameter at the commonly used level (p < 0.01). Multivariate analysis revealed that prior radiation therapy was not an independent factor significantly affecting transverse cervical artery diameter (p = 0.17). Intraoperative anastomotic revision was required in only two cases of the superior thyroid artery. CONCLUSION: The transverse cervical artery can offer a larger caliber and more reliable candidate than the superior thyroid artery for a recipient artery. More liberal use of the transverse cervical artery may improve the safety of microsurgical head and neck reconstruction.

Simultaneous reconstruction of smiling eye using V-shaped long latissimus dorsi muscle transfer in patients with flaccid facial paralysis.

Various neurovascular free muscle transfers for smile reconstruction in patients with facial paralysis have been reported. However, these methods focused on peri-oral smiling rather than eye smiling. Although the lower eyelid does not contribute significantly to eyelid closure, dynamic reanimation of the upward movement of the lower eyelid, with bulging of the malar region, during smiling is important in smile reconstruction. Herein, we present a novel procedure for smiling eye and peri-oral smiling. The V-shaped latissimus dorsi muscle flap containing the descending branch (DB) of the thoracodorsal nerve (TDN) was employed. Muscle-A (15-17 cm), which is located along the main trunk of the DB, is much longer than muscle-B (10-12 cm), which is along the branch of DB. A distal stump of the TDN involved in muscle-B was prepared. The true trunk and distal stump of the TDN were sutured to the contralateral facial and ipsilateral masseteric nerves, respectively. The central region of muscle-A was positioned at the lateral part of the lower eyelid; the distal end of long muscle-A was affixed to the temporal region, which enabled peri-ocular movements and narrowing of the palpebral fissures alongside peri-oral smiling when muscle-A contracted. Nine patients with complete flaccid facial paralysis were treated. All patients attained muscle contraction induced by the ipsilateral masseteric and contralateral facial nerves. The smiling eye atmosphere was observed in seven of nine patients. This procedure simultaneously improves paralytic ectropion at rest and aids eyelid closure and enables early voluntary smile and a later spontaneous smile.

Vascularized Fibular Grafts for Failed Liquid Nitrogen-treated Autografts in the Humerus: Report of Two Cases.

With advances in chemotherapy and surgical techniques, limb salvage and biological reconstruction, including autologous bone grafting, have become the preferred treatment options for primary malignant bone tumors of the extremities. Although autografts, which involve recycling of tumor-bearing bones, have the advantages of easy accessibility and anatomical matching, fracture is a frequent major complication. However, to our knowledge, salvage of refractory autograft failure has not yet been reported. This report describes free vascularized fibular graft implantation for salvaging failed previous reconstructions. We describe two patients (a 4-year-old girl and a 30-year-old man, respectively) with primary malignant bone tumors. Liquid nitrogen-treated autografts had been used to reconstruct the humerus in both cases. The patients sustained autograft fractures that could not be treated conservatively or by internal fixation. Free vascularized fibular grafts were transferred as double-barrel inlay grafts (length 7.2 and 8.2 cm) and a single-strut onlay graft (length 16 cm). The brachial arteries, brachial veins, and cephalic veins were used as recipient vessels. Bone union between the fibular grafts and humerus was achieved after 29 and 15 months of follow-up, respectively. In conclusion, free vascularized fibular grafts can be used to salvage refractory autograft fractures.

Soft Tissue Reconstruction Using the Free Forearm Fillet Flap in the Salvage of Forequarter Amputations for Recurrent Sarcoma: A Report of 2 Cases.

ABSTRACT: Reconstruction after radical forequarter amputation for recurrent proximal extremity sarcoma is challenging because the defect is significant, and the axillary or subclavian vessels are resected with the tumor, indicating that the pedicle of nearby flaps is often cut off. Free flaps are commonly used to cover the defect, but the donor site morbidity is problematic. Another problem with resecting the axillary or subclavian vessels is difficulty obtaining recipient vessels with matching calibers for another free flap. The authors presented 2 cases that successfully solved all these problems by covering the defects by the forearm fillet flaps.The forearm fillet flap has the advantage of using a portion that is usually discarded, so there is no donor site morbidity. Moreover, using the brachial artery as the pedicle of the flap allows the anastomosis to the stump of the resected axillary or subclavian artery because differences in caliber are slight.The use of the forearm fillet flaps has been reported less frequently than the fillet flaps in the lower extremities, and most cases are posttraumatic. In cases of trauma, complications are reported to occur in about 1 in 4 patients, but in cases after tumor resection, ischemic time can be controlled, and there are no risks of contamination or unnoticed forearm damage, so more stable results can be expected as in this report.Using the free flap from the distal portion of the resected upper limb, especially in cases with a short prognosis, is a viable option that effectively minimizes damage to the donor site and maintains quality of life.

A Novel Risk Model for Predicting Dysphagia after Tongue Reconstruction: A Retrospective Multicenter Study in Japan.

BACKGROUND: There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction. METHODS: This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence. RESULTS: Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m 2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15. CONCLUSION: The authors' risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Internal jugular vein reconstruction using a triple-paneled great saphenous vein graft.

BACKGROUND: Donor-recipient diameter discrepancy can be problematic when using an autologous great saphenous vein graft for internal jugular vein reconstruction. A triple-paneled method of saphenous vein grafting is one solution. CASE PRESENTATION: A 54-year-old man with a thyroid papillary carcinoma underwent total thyroidectomy and bilateral neck dissection. An 8-cm segment of the right internal jugular vein was resected. For reconstruction, a 30-cm segment of the great saphenous vein was harvested and divided into three pieces of equal length. After opening each piece longitudinally, they were sutured together in a side-by-side fashion to create a cylinder that was used to reconstruct the internal jugular vein defect. The graft was patent 10 months after the surgery. CONCLUSION: The triple-paneled method is feasible for autologous great saphenous vein graft reconstruction of the internal jugular vein.

Nasal alar reconstruction using the free auricular helix flap based on the flow-through concept: Report of two cases.

Nasal alar reconstruction with the free auricular helix flap is challenging because the flap is prone to congestion. We report two cases of successful nasal alar reconstruction using free auricular helix flaps utilizing the flow-through concept. Case 1 was a 37-year-old man presented with a basal cell carcinoma in the nasal cavity. After radical excision, we transferred a 20 × 20 mm2 free flow-through auricular helix flap by interposing the T-portion of the superficial temporal artery of the flap to the transected facial artery. Case 2 was a 39-year-old man presented with neurofibromatosis type I and a nasal alar deformity after multiple excision of the neurofibroma. We corrected the deformity with a 26 × 22 mm2 free auricular helix flap. We used a flow-through arterial graft of the descending branch of the lateral circumflex femoral artery to bridge the gap between the flap artery and the recipient facial artery of the submandibular region because an appropriate recipient artery was not available around the defect. Both of the flaps survived without vascular compromise and no donor-site complication occurred. The esthetic results of the nasal ala were satisfactory. The flow-through arterial anastomosis diverted the arterial flow to the peripheral side of the recipient artery and relieved flap congestion. These physiological properties of flow-through anastomosis may stabilize the flap circulation and improve the success rate of free auricular helix flap transfer.

Cholesterol granuloma in facial nerve canal presenting with facial nerve paralysis.

Cholesterol granulomas (CGs) are frequently found in the temporal bone, but their presence in the facial nerve has not been reported. We report a case of a 58-year-old woman who presented with left facial palsy caused by a CG that appeared to have originated in the facial nerve. Temporal bone computed tomography (CT) revealed soft tissue masses in the left middle ear spaces, and the facial canal was dilated from the genu to the vertical portion. Magnetic resonance imaging (MRI) revealed high signal intensity on T1-weighted images and partially high signal intensity on T2-weighted images, although no significant enhancement was observed on gadolinium-enhanced MRI. Surgical findings revealed CG in the middle ear spaces, but the facial canal remained intact and lacked continuity with the internal mass. Histopathological analysis verified the mass as a CG accompanied by cholesterol crystals. The mass was located within and continuous with the epineurium. These findings indicate that hemorrhage in the facial canal may have triggered the formation of the CG, causing left facial palsy due to increased pressure in the facial canal.

Wearable, wireless, multi-sensor device for monitoring tissue circulation after free-tissue transplantation: a multicentre clinical trial.

Wearable sensors have seen remarkable recent technological developments, and their role in healthcare is expected to expand. Specifically, monitoring tissue circulation in patients who have undergone reconstructive surgery is critical because blood flow deficiencies must be rescued within hours or the transplant will fail due to thrombosis/haematoma within the artery or vein. We design a wearable, wireless, continuous, multipoint sensor to monitor tissue circulation. The system measures pulse waves, skin colour, and tissue temperature to reproduce physician assessment. Data are analysed in real time for patient risk using an algorithm. This multicentre clinical trial involved 73 patients who underwent transplant surgery and had their tissue circulation monitored until postoperative day 7. Herein, we show that the overall agreement rate between physician and sensor findings is 99.2%. In addition, the patient questionnaire results indicate that the device is easy to wear. The sensor demonstrates non-invasive, real-time, continuous, multi-point, wireless, and reliable monitoring for postoperative care. This wearable system can improve the success rate of reconstructive surgeries.

Crescent-shaped skin paddle for a fibular flap: Avoiding skin grafting at the donor site.

A fibular osteocutaneous flap is the mainstay of oromandibular reconstruction. This report aimed to present a crescent-shaped skin paddle, a novel fibular skin paddle designed to achieve both sufficient intraoral lining and primary closure of the donor site. A 3-5-cm-wide crescent-shaped skin paddle was harvested according to the locations of the distal septocutaneous perforators on preoperative color Doppler sonography. This narrow skin paddle fits well morphologically into the mucosal defect, enabling a reliable intraoral lining. This advantage becomes more evident when the mandibular defect crosses the midline or extends posteriorly to the maxillary tuberosity as the shape of the mucosal defect becomes arcuate. Primary closure of the donor site is easier to achieve because the required width of the crescent-shaped skin paddle is minimized. This method reduces donor-site morbidity associated with skin grafting while ensuring safe intraoral closure with a fibular osteocutaneous flap.

Free Flap Reconstruction of Oncologic Gluteal Defects.

ABSTRACT: A number of studies have already examined gluteal reconstruction with free flaps. Thus, the aim of this study was to investigate the reliability of free flap reconstruction for oncologic gluteal defects. This retrospective cohort study included 23 patients who underwent immediate soft tissue reconstruction for an oncologic gluteal defect. Fifteen patients underwent reconstruction with a free flap and 8 with a regional flap. The postoperative results were compared between the free and regional flaps. In the free flap group, the latissimus dorsi musculocutaneous flap was used in 12 patients, the thoracodorsal artery perforator flap in 2 patients, and the anterolateral thigh flap in 1 patient. Recipient vessels were the inferior gluteal vessels or their branches in 8 patients and the superior gluteal vessels or their branches in 7 patients. All flaps have fully survived in both groups without vascular compromise. Dehiscence of the gluteal wound tended to be more common in the regional flap group; however, the difference between the groups was not statistically significant. The use of free flap reconstruction for large oncologic defects in the gluteal region is a feasible and reliable option. Tension-free wound closure and simplified suture lines can provide reliable wound coverage irrespective of the postoperative patient's position or movement. Because of the risk of postoperative compression on the vascular pedicle, selecting the appropriate recipient vessel and type of microvascular anastomosis is key for the success of free flap transfer in this region.

Microsurgical Lymphovenous Anastomosis for Pelvic Lymphoceles after Gynecological Cancer Surgery.

BACKGROUND: Pelvic lymphoceles are the most common complications after pelvic lymphadenectomy. Microsurgical procedures have attracted attention as an alternative treatment for lymphoceles. Here, we report six cases of refractory lymphoceles that were successfully treated using lymphovenous anastomosis (LVA). METHODS: Six patients underwent surgery for gynecological cancers and developed pelvic lymphoceles, which did not respond to conventional treatment. We mainly performed LVA on the ipsilateral lower limbs, although some procedures were also performed on the contralateral limbs. The change in the lymphocele volume after LVA was examined using computed tomography and compared using the Wilcoxon test. RESULTS: Five of the six refractory lymphocele cases were successfully treated using LVA, and the remaining case exhibited an 87% reduction in lymphocele volume. The average numbers of anastomoses were 6.7 on the ipsilateral side and 2.8 on the contralateral side (the median numbers: 6 [range: 5-9] vs. 3 [range: 1-4], P = 0.034). The average lymphocele volume decreased significantly from 414.0 mL preoperatively to 8.0 mL postoperatively (the median lymphocele volume: 255.8 [range: 61.5-1,329.2] vs. 0 [range: 0-47.7], P = 0.0313). CONCLUSION: We found that microsurgical treatment was potentially effective for lymphoceles that did not respond to conventional treatment.