Anterior Median Skull Base Reconstruction Using a Vascularized Free Flap: Rationale, Patient Selection and Outcome.

Objectives To present our method of median anterior skull base (ASB) reconstruction using a subcranial approach with a free flap in cases of naso-fronto-orbital (NFO) bony segment failure and in patients at high risk for future failure of the bony frontal segment. Design This study presents as a retrospective case series. Setting Tertiary university-affiliated medical center. Participants Adult and pediatric patients who underwent median ASB resection via the subcranial approach with a free flap reconstruction were participated in this study. Main Outcome Measures Pathologic outcome and postoperative quality of life (QoL) as assessed by a validated Hebrew version of the "Anterior Skull Base Quality-of-Life Questionnaire." Results The departmental database yielded 13 suitable patients aged between 15 and 70 years. The main indication ( n = 7) for ASB surgery was osteoradionecrosis (ORN) of the NFO bony segment which was first detected at an average of 3.6 years (range: 2-32 years) postradiation therapy. High-risk patients for future ORN of the NFO segment ( n = 3) were primarily reconstructed using a vascularized free flap. Nine patients had malignant disease, and four of them were alive without evidence of disease during the follow-up period (average, 48 months). Their QoL was comparable to that of patients who had undergone subcranial ASB resection without free flap reconstruction. Conclusions The ASB median free flap method of reconstruction is a safe and reliable in cases of large complex median ASB defects without orbital resection or maxillectomy. This approach is suitable for patients who had undergone previous surgery, radiotherapy and/or those who present with osteoradionecrosis, as well as for patients with high risk of NFO segment ORN.

[PREOPERATIVE THREE-DIMENSIONAL PLANNING FOR COMPLEX HEAD AND NECK RECONSTRUCTION].

BACKGROUND: The treatment of patients with advanced head and neck cancers requires an extensive oromandibular and craniomaxillofacial resection in many cases. The reconstruction after these extensive resections presents many challenges to the reconstructive surgical team. The purpose of the reconstruction is not only to rehabilitate the physical facial appearance, but also to rehabilitate function, in order to improve future quality of life. To achieve this goal, the use of free tissue reconstruction is often required. The main challenge with osseous free flap reconstruction of the facial bones is the need of perfect alignment at the defect site. The use of different 3D technologies including computerized models and printed 3D stereolithographic models in the preoperative setting improves the accuracy and the outcome of the reconstruction.

Surgical approaches for infratemporal fossa tumor resection: Fifteen years' experience of a single center.

BACKGROUND: The aims of this study were to report our center's experience with infratemporal fossa (ITF) tumors, to review the treatment modalities and outcomes. METHODS: Data of patients that underwent resection of ITF tumors in a single tertiary referral medical center were collected and analyzed. RESULTS: Sixty-three patients were included. Sarcoma was the most common pathology (18; 29%). The most common surgical approach was the preauricular-orbitozygomatic approach (24; 38%), followed by endoscopic, craniofacial resection, and combined approaches. Forty-seven patients (75%) required reconstruction, 23 (49%) involving free tissue transfer. Thirty-five patients (76%) with malignant lesions required adjuvant therapy consisting of radiotherapy, chemotherapy, or both. Thirty-three patients suffered from complications related to surgery or adjuvant therapy. The three- and five-years survival rates for malignancy were 82% and 66%, respectively. CONCLUSION: Complete surgical resection of ITF involving tumors is feasible, providing good long-term survival. Multidisciplinary approach is the key for success.

Long-term health-related quality of life after mandibular resection and reconstruction.

PURPOSE: To compare short- and long-term quality of life (QOL) scores in patients undergoing mandibular resection and reconstruction. MATERIALS AND METHODS: All the patients who underwent resection and reconstruction of the mandible between 2000 and 2015 at a large tertiary center were retrospectively reviewed. Their QOL was measured by the University of Washington QOL questionnaire. Between 12 and 189 months (median 83.5 months) had elapsed since the end of treatment. The QOL of the short-term (< 5 years) and long-term (> 5 years) follow-up groups was compared and analyzed. RESULTS: Fifty-eight patients completed the questionnaire. The scores for physical function, emotional function, activity, recreation, and taste domains were significantly higher for the long-term follow-up group. The activity and pain domains posed a significant problem for significantly more patients in the short-term follow-up group. CONCLUSION: Comparison of the short- and long-term QOL scores of patients undergoing mandibular resection and reconstruction revealed that the scores for the latter were significantly higher in several domains. This finding might be indicative of a cumulative effect of time on patients' QOL, even many years post-treatment.

Postoperative myxedema coma in patients undergoing major surgery: Case series.

OBJECTIVE: Myxedema coma is a serious complication of hypothyroidism that can be precipitated by major surgery. It is extremely rare, with only a few reports in the literature. This study aims to present a relatively large case series of post-surgical myxedema coma and to analyze medical and surgical risk factors. METHODS: Analysis of the patients' surgical records and medical charts. RESULTS: Four patients developed postoperative myxedema coma and were evaluated for risk factors. Three had known hypothyroidism. Two had undergone large head and neck composite resections necessitating a free flap repair for malignant disease. One had undergone coronary artery bypass graft for ischemic heart disease, and another had undergone endoscopic cholecystectomy for complicated cholecystitis. All four patients required prolonged hospitalization, including treatment in the intensive care unit. One patient had undergone full cardiopulmonary resuscitation directly related to the myxedema coma state. CONCLUSION: We present a series of four patients who developed myxedema coma following major surgery. We recommend that patients with known hypothyroidism who are scheduled for major surgery should be tested for thyroid function status and assessed for postoperative risk of hypothyroidism. Those who develop complications following major surgery, should be immediately tested for thyroid function to rule out myxedema coma.

Skull Base Reconstruction in the Pediatric Patient.

Introduction Pediatric skull base and craniofacial reconstruction presents a unique challenge since the potential benefits of therapy must be balanced against the cumulative impact of multimodality treatment on craniofacial growth, donor-site morbidity, and the potential for serious psychosocial issues. Objectives To suggest an algorithm for skull base reconstruction in children and adolescents after tumor resection. Materials and Methods Comprehensive literature review and summary of our experience. Results We advocate soft-tissue reconstruction as the primary technique, reserving bony flaps for definitive procedures in survivors who have reached skeletal maturity. Free soft-tissue transfer in microvascular technique is the mainstay for reconstruction of large, three-dimensional defects, involving more than one anatomic region of the skull base, as well as defects involving an irradiated field. However, to reduce total operative time, intraoperative blood loss, postoperative hospital stay, and donor-site morbidity, locoregional flaps are better be considered the flap of first choice for skull base reconstruction in children and adolescents, as long as the flap is large enough to cover the defect. Our "workhorse" for dural reconstruction is the double-layer fascia lata. Advances in endoscopic surgery, image guidance, alloplastic grafts, and biomaterials have increased the armamentarium for reconstruction of small and mid-sized defects. Conclusions Skull base reconstruction using locoregional flaps or free flaps may be safely performed in pediatrics. Although the general principles of skull base reconstruction are applicable to nearly all patients, the unique demands of skull base surgery in pediatrics merit special attention. Multidisciplinary care in experienced centers is of utmost importance.

V-stand--a versatile surgical platform for oromandibular reconstruction using a 3-dimensional virtual modeling system.

PURPOSE: The challenge of oromandibular reconstruction (OMR) after oncologic resections has been repeatedly addressed in the literature. Although final oncologic margins can be decided only during surgery, various attempts have been made to create an ideal and accurate platform for OMR. The purpose of this article is to present the V-stand, a versatile surgical platform for OMR using a 3-dimensional (3D) virtual modeling system. MATERIALS AND METHODS: Seventeen patients requiring an OMR were included in the study. A presurgical computed tomogram was obtained and virtual resection and reconstruction with a free fibular flap were planned using 3D virtual surgery software. The mandible was reconstructed intraoperatively using the V-stand, which served as a template for the lower border of the mandible and the lateral aspects of the stand were fixed to the proximal mandibular segments using 2-mm titanium screws. RESULTS: Patients' average age was 53 years (5 to 72 yr). Median follow-up was 19 months (2 to 35 months). All reconstructed mandibles resulted in good function and esthetics. CONCLUSIONS: The V-stand offers a safe and time-efficient method for OMR. It provides an excellent means for accurate spatial positioning of a fibular free flap. The V-stand preserves the original dimensions of the reconstructed mandible and can overcome surgical ablation modifications because it is not dependent on the precision of the resection, but rather provides a mold for the entire mandible.

The role of free tissue transfer in posterior neck reconstruction.

Reconstruction of the posterior neck is one of the rarer procedures performed by plastic surgeons; we used free flaps for the closure of defects in this area in six cases over the past 4 years. Six patients were located requiring posterior neck reconstruction between the years 2007 and 2013. Five of these patients required reconstruction due to oncologic resections, while one underwent serial removal of a giant congenital nevus. Five of these reconstructions involved the use of a free anterolateral thigh/vastus lateralis flap, and the sixth received a pre-expanded deep inferior epigastric perforator flap. Satisfactory dorsal neck reconstruction was achieved with the free flap approach: it produced excellent healing, contour and coverage of hardware. There was only one early minor complication, allowing early return to daily activities and continuation of planned oncologic treatment. Free flap reconstruction of the posterior neck area is a safe and relatively rapidly performed procedure that yields good results both functionally and aesthetically. In this article, we review the literature on the options available for reconstruction of the posterior neck, describe our surgical experience in such cases, and suggest an algorithm to guide in choosing the optimal approach for a given patient.

Pediatric tissue expansion: our experience with 103 expanded flap reconstructive procedures in 41 children.

BACKGROUND: Tissue expansion is a well-recognized technique for reconstructing a wide variety of skin and soft tissue defects. Its application in the pediatric population has enabled the plastic surgeon to achieve functional and aesthetic goals that were previously unobtainable. OBJECTIVES: To review the use of tissue expansion in the pediatric population, with particular emphasis on indication, operative technique, regional considerations and how to avoid complications. METHODS: We retrospectively reviewed data on 103 expanded flap reconstructions performed in 41 pediatric patients during the period 2003-2006. Tissue expanders were placed on a subcutaneous plane above the fascia and inflated weekly. The expanded skin was used as a transposition flap or a full thickness skin graft for the reconstruction of the involved area. Forty-three tissue expanders were inserted to the head and neck in 21 patients, 45 were inserted to the trunk in 13 patients and 15 were inserted to the groin and lower extremity in 8 patients. Twenty-eight patients had one round of tissue expansion, while 13 patients had two to six rounds. A plastic surgeon, medical student and a lawyer reviewed the patients' photographs and evaluated their aesthetic outcome: RESULTS: Eighty-six percent of the head and neck reconstructions and 40% of the trunk and extremity reconstructions were graded as having excellent aesthetic outcome, and 11% of the head and neck reconstructions and 37% of the trunk and extremity reconstructions were graded with good aesthetic outcome. The remaining patients were graded with moderate outcome. None of our patients was graded as poor aesthetic outcome. Complications included infection in 6 patients (6%), extrusion in 3 (3%), hematoma in 2 (2%), flap ischemia in one patient (1%), and expander perforation after percutaneous stabbing in one patient (1%). CONCLUSIONS: Tissue expansion is an efficient and valuable technique for reconstruction of large skin lesions and scars.

Combination of preoperative embolization and surgery in the treatment of a giant congenital neuroid nevus of the forehead and scalp in a child. Case report.

Congenital melanocytic nevi of neuroectodermal origin are composed primarily of melanocytes and occasional neural elements. A subset of large/giant congenital melanocytic nevi is characterized by neuroidal differentiation resembling the histological pattern of neurofibroma (neuroid congenital melanocytic nevi). The authors report the case of a male infant born with a neuroid congenital melanocytic nevus presenting as a large mass covering extensive portions of his scalp and forehead. The atypical feeding arteries to the nevus were larger in diameter then the patient's internal carotid arteries and formed a rich network of large blood vessels in the nevus. Selective preoperative embolization using calibrated particles was followed by a complete excision and staged reconstruction with tissue expanders. The authors believe that this multidisciplinary approach allowed for a safe surgical procedure with minimal blood loss for this most unusual pediatric head and neck tumor.

The expanded supraclavicular flap, prefabricated with thoracoacromial vessels, for reconstruction of postburn anterior cervical contractures.

Mentosternal contractures are well-known complications after burns, scald injuries, and injuries with acid or lye. These contractures may cause severe deformities that are both functionally and aesthetically crippling. Reconstruction of the neck requires the transfer of large flaps of thin, pliable skin to optimally match the texture and color of the recipient region. With the introduction of free tissue transfer, the availability of flaps for reconstruction of large neck defects has greatly increased. Unfortunately, many of these flaps are bulky and are not well matched to the thin and pliable skin of the neck. This article introduces the expanded supraclavicular flap prefabricated with the thoracoacromial vessels for reconstruction of anterior cervical contractures. Their anatomic location, length, and arc of rotation make the thoracoacromial vessels an excellent choice for prefabricating the supraclavicular skin for its subsequent interpolation into the anterior neck. Skin expansion in the donor region not only allows coverage of the larger unit of the anterior neck but also modifies the morphologic characteristics of the transferred flap through capsule formation and fatty tissue atrophy, which is beneficial for obtaining an optimal neck reconstruction.