Total nasal reconstruction with 3D custom made porous titanium prosthesis and free thoracodorsal artery perforator flap: A case report.

Total nasal reconstruction is a challenging surgical procedure which usually involves a free flap, forehead flap, and cartilage grafts. In certain failure situations where patients do not accept the idea of anaplastology, possibilities become very limited. We report the case of a patient who underwent several reconstruction steps with multiple failures including free and local flaps and cartilage harvests which showed recurrent episodes of necrosis and infection leading to melting and collapse of reconstructed structures. Furthermore, the patient did not want any anaplastological rehabilitation. We proposed to the patient an innovative method that consists to print a three-dimensional custom-made porous titanium prosthesis, based on the original shape of his nose, to replace the cartilage support. This implant was first inserted in a thoracodorsal artery perforator flap for primary integration before the free transfer of the complete structure, two months later. The free transfer was successful without any complication. A stable reconstruction and satisfying result was obtained. The patient did not want additional surgical improvement 24 months post-operatively, and resumed his professional activities. The possibility of using three-dimensional custom titanium prostheses to replace the bone and cartilage support seems to be an interesting alternative for patients in the failure situation of nasal reconstruction.

Carbon Dioxide Laser Sequestrectomy for Osteoradionecrosis: A Case Series.

Objective: To demonstrate a new approach to sequestrectomy using a carbon dioxide (CO2) laser for a clinic-based technique. Background: Osteoradionecrosis (ORN) of the jaw is a debilitating complication of radiotherapy for head and neck malignancies. Often refractory to medical therapy, surgical intervention for early staged disease with curettage and mechanical bone removal has mixed success, making this disease extremely difficult to treat. Therefore, new approaches to treat ORN of the jaw is needed. Methods: We describe five cases of early-to-intermediate-staged ORN illustrating a novel clinic-based sequestrectomy technique using a CO2 laser. Results: The exposed bone lesions involved the mandibular fixed gingiva, maxillary fixed gingiva, and hard palate. None of the patients had diabetes. Four patients required a total of two laser treatments and one patient needed only one treatment. All five patients demonstrated an excellent response with complete resolution of their ORN-related pain and complete mucosal coverage of the exposed bone with durable results (follow-up range, 7-19 months). Conclusions: This small series demonstrates encouraging results for CO2 laser sequestrectomy for ORN. This novel office-based intervention merits further study in larger prospective series and exploration in other disease populations, such as medication-related osteonecrosis of the jaws.

Outcomes of mandibular reconstruction using three-dimensional custom-made porous titanium prostheses.

BACKGROUND: Our aim was to report the long-term outcomes of mandibular reconstruction using CAD-CAM-designed 3D-printed porous titanium implants in patients not amenable to a free vascularized fibula flap reconstruction. METHODS: The implants were designed with ProPlan CMF® 2.2 software and manufactured with a Selective Laser Melting (SLM) "layer-by-layer" 3D-printing of pure porous titanium powder beds. Primary endpoints were implant exposure and implant removal calculated using Gray's tests. Secondary endpoints were predictive factors of implant exposure and implant removal, and rates of dental rehabilitation. RESULTS: Thirty-six patients were operated between 2015 and 2017 and were included in this study. Reconstruction using a porous titanium 3D-printed implant was proposed due to medical contraindication for a fibula free flap (n = 13), due to the failure of a previous fibula free flap reconstruction (n = 7), or due to refusal of a fibula free flap reconstruction by the patient (n = 16). The medical indications for mandibular reconstruction were a primary tumor requiring mandibulectomy in nine patients, mandibular osteoradionecrosis requiring mandibulectomy in nineteen patients, and secondary reconstruction in eight patients. The 2-year rates of implant exposure and implant removal were 69.4% and 52.8%. Reconstruction of the symphysis was a high-risk exposure variable (OR 30; p = 0.0003). Only one patient underwent a successful dental rehabilitation. CONCLUSION: The use of a porous titanium 3D- implant for mandibular reconstruction in head and neck cancer patients resulted in high rates of implant exposure and of implant removal, notably when symphysis involvement.

Head and neck Ewing sarcoma: French surgical practice analysis pleads for surgery centralization.

This study aimed to analyze surgical procedures for head and neck Ewing sarcoma (HNES) with regard to oncological, functional, and esthetic outcomes. A blinded multidisciplinary retrospective chart review of operated French HNES patients (Euro-EWING 99 trial, 1999-2014) was performed to assess patient/tumor characteristics, treatment details, and outcomes. Primary surgery without reconstruction was undertaken in 13 patients (emergency context/misdiagnosis). However, because of contaminated surgical margins, all patients had to undergo systematic postoperative radiotherapy. Twenty-six patients underwent multidisciplinary evaluation and were scheduled to undergo postchemotherapy surgery, with 19 patients scheduled for immediate reconstruction. All cases showed R0 margins after postchemotherapy surgery of the initial tumor bed by multidisciplinary surgical teams, while n = 3/4 of local relapses (very poor prognosis) had R1a margins after surgery of the residual tumor volume following chemotherapy. Only three surgical expertise centers operated on ≥ 4 patients over the 15-year period. Thirty patients developed long-term sequelae, with increased complications following radiotherapy. Referring patients to surgical expertise centers following a suspected diagnosis, with planned postchemotherapy surgery of the initial tumor bed at these centers, might limit the need for intralesional resections, allowing radical R0 resections and thus reducing long-term sequelae as well as the risk of secondary radio-induced malignancy by limiting the need for postoperative radiotherapy.

Thoracodorsal artery perforator free flap with vascularized thoracodorsal nerve for head and neck reconstruction following radical parotidectomy with facial nerve sacrifice: Step-by-step surgical technique video.

Oncological surgery of the parotid region sometimes requires the sacrifice of the facial nerve (parotid cancers, extensive skin cancers of the face, soft tissue sarcomas). The sacrificed portion of nerve can be reconstructed by a vascularized nerve graft, especially if the patient must undergo radiotherapy after surgery. In those cases, the facial nerve sacrifice is associated to an important loss of substance from the parotid region (skin, masseter, parotid, and sometimes jaw). Chimeric flap permit the reconstruction at the same time of the external skin, soft tissues for the volume (fat or muscle), nerve, and bone (ramus and angular part of the mandible). An other option was to raise two flaps but it increased the risk of failure (time of surgery, number of anastomosis, etc.). Reconstruction with a chimeric flap appears to be an ideal choice. Based on these observations, we offer our patients at the Gustave Roussy Institute (Villejuif, France) a thoracodorsal artery perforator (TDAP) free flap including the motor nerve of the latissimus dorsi and vascularized by the thoraco-dorsal pedicle, thus allowing reconstruction in a single surgery. The surgical technique is explained with a step-by-step video. Functional outcomes are also shown in the video. The TDAP or chimeric scapulo-dorsal flap with vascularized nerve has many advantages in the facial reanimation of patients suffering from parotid region cancers. This video article explains surgical steps for other teams.

Ewing's Sarcoma of the Head and Neck: Margins are not just for surgeons.

BACKGROUND, METHODS: To describe the characteristics, treatments (systemic/local), and outcome (oncological/functional) of French patients with head and neck Ewing's sarcomas (HNES) registered in the Euro-Ewing 99 (EE99) database. Specific patient-level data were reviewed retrospective. RESULTS: Forty-seven HNES patients in the EE99 database had a median age of 11 years, 89% had bone tumors (skull 55%, mandible 21%, maxilla 11%), 89% had small tumors (<200 mL), and they were rarely metastatic (9%). Local treatment was surgery radiotherapy (55%), exclusively surgery (28%), or radiotherapy (17%). Metastatic relapses occurred in five patients with high relapse risk factors (metastasis at diagnosis, poor histological response, large tumors). Local progression/relapses (LR) after exclusive radiotherapy occurred in three patients with persistent extra-osseous residue and in four patients considered R0 margins (postchemotherapy surgery, without postoperative radiotherapy [PORT]), reclassified by pathological review as R1a. Pathological review reclassified 72% of R0 margins: 11/18 to R1a and 2/18 to R2. Five patients had confirmed R0 margins after postchemotherapy surgery without PORT and had no LR Eight patients had R2 margins (initial surgery without previous chemotherapy, with PORT) and had no LR With a median follow-up of 9.3 years, the 3-year LR rate, EFS, and OS were 84.8%, 78.6%, and 89.3%, respectively. Among the 5-year survivors, 88% had long-term sequelae. CONCLUSION: To optimize HNES management, patients should be treated from diagnosis in expert centers with multidisciplinary committees to discuss treatment strategy (type of surgery, need for PORT) and validate surgical margins.

Reconstruction of large mandibulofacial defects with the composed double skin paddle fibula free flap: a review of 32 procedures.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to analyze our experience with the composed double skin paddle fibula free flap to reconstruct large mandibulofacial defects. STUDY DESIGN: Between 2006 and 2011, a total of 32 composed double skin paddle fibula free flap procedures were performed on 32 patients (mean age 54.4 ± 9.7 years, mean follow-up period of 3.4 ± 1.7 years). METHODS: A chart review was drawn up to determine the type of defects covered by each skin paddle, the vascular anatomy, the origin of the perforators, and any associated complications. RESULTS: The distal septocutaneous skin paddle (Nakajima type B) was used for the reconstruction of the floor of the mouth in most cases. The proximal paddle (Nakajima type D) was used for base of the tongue, mobile tongue, soft palate, internal cheek, inferior lip, and the skin of the chin and neck. The lateral soleus pedicle arose from the fibular pedicle in 28 cases and directly from the tibial-fibular trunk in four cases. There were two partial soleus skin paddle losses. Seven complications required revision surgery: due to a cervical abscess in two cases, due to a hematoma in two cases, due to a disunion of the second skin paddle leading to an orostoma in two cases, and due to an exposition of the osteosynthesis material in one case. CONCLUSION: In large mandibulofacial defects, a second skin paddle raised on the soleus perforators may be of benefit when reconstructing the soft palate, neck, cheek, or tongue as the length of its pedicle renders a second free flap unnecessary. LEVEL OF EVIDENCE: IV.

Modification of flap design for total mobile tongue reconstruction using a sensitive antero-lateral thigh flap.

Reconstruction of large carcinologic tongue defect is mandatory to recover adequate speech and swallowing. Free flaps provide thin and pliable tissues needed to restore the shape and the volume of the tongue but their functional outcomes, especially in case of total mobile tongue reconstruction, are still limited. The authors describe a modification of flap design called the 'cathedral triptych' used with the antero-lateral thigh flap. This modified design recreates a near normal neotongue shape with more projected tip and vertical bulk that can contact the palate and the upper lip. Ten patients underwent total mobile tongue reconstruction with a sensitive antero-lateral thigh flap and a 'cathedral triptych' design. This modification of flap shaping and folding optimises postoperative oral function.

Cine-MRI swallowing evaluation after tongue reconstruction.

OBJECTIVE: To determine the feasibility of cine-MRI for non-invasive swallowing evaluation after surgery for lingual carcinoma with reconstruction using microvascular free flaps. METHODS: Ten patients with stage IV carcinoma of the mobile tongue and/or tongue base treated by surgical resection and reconstruction with a free flap were evaluated after an average of 4.3 years (range: 1.5-11 years), using cine-MRI in "single-shot fast spin echo" (SSFSE) mode. Fiberoptic laryngoscopy of swallowing was performed before MRI to detect aspiration. The tolerance and ability to complete the exam were noted. The mobilities of the oral and pharyngeal structures visualized were evaluated as normal, reduced or increased. RESULTS: Cine-MRI was well tolerated in all cases; "dry" swallow was performed for the 2 patients with clinical aspiration. Tongue base-pharyngeal wall contact was observed in 5 cases. An increased anterior tongue recoil, increased mandibular recoil, increased posterior oropharyngeal wall advancement and an increased laryngeal elevation were observed in 4 cases. One case of a passive "slide" mechanism was observed. CONCLUSIONS: Cine-MRI is a safe, non-invasive technique for the evaluation of the mobility of oral and oropharyngeal structures after free-flap reconstruction of the tongue. For selected cases, it may be complementary to clinical examination for evaluation of dysphagia after surgery and free-flap reconstruction. Further technical advances will be necessary before cine-MRI can replace videofluoroscopy, however.

Reconstruction of floor of mouth defects by the facial artery musculo-mucosal flap following cancer ablation.

BACKGROUND: The purpose of this study is to review our experience with the use of the facial artery musculo-mucosal (FAMM) flap for floor of mouth (FOM) reconstruction following cancer ablation to assess its reliability, associated complications, and functional results. METHODS: This was a retrospective analysis of 61 FAMM flaps performed for FOM reconstruction from 1997 to 2006. RESULTS: No total flap loss was observed. Fifteen cases of partial flap necrosis occurred, with 2 of them requiring revision surgery. We encountered 8 other complications, with 4 of them requiring revision surgery for an overall rate of revision surgery of 10% (6/61). The majority of patients resumed to a regular diet (85%), and speech was considered as functional and/or understandable by the surgeon in 93% of the patients. Dental restoration was successful for 83% (24/29) of the patients. CONCLUSION: The FAMM flap is well suited for FOM reconstruction because it is reliable, has few significant complications, and allows preservation of oral function.