Outcome of Reconstruction of Advanced Brown's Maxillary Defect with Free Tissue Transfer: Our Early Experience in a Tertiary Cancer Centre in North-East of India.

Reconstructions of the maxillary defect after tumor resection are challenging surgeries. Maxillary reconstructions are done using obturators, locoregional flaps and free tissue transfers. Free flap options available for maxillary reconstruction are radial forearm, anterolateral thigh free flap, free fibular osteocutaneous flap, rectus abdominis myocutaneous flap, scapular, and iliac crest osteomyocutanous free flap etc. This is a single institutional observational study conducted at a tertiary cancer centre in North East India from May 2018 to April 2019. All the reconstructions are done with free tissue transfer. Post-operative outcome was assessed with University of Washington Quality of Life Questionnaire (UW-QOL v4.1). Data was collected from patient records and hospital online reporting system. All data were analysed using SPSS (statistical package for social sciences) version 21. Brown's classification was used to classify maxillary defects in this study. A p value ≤ 0.05 was considered statistically significant. In our study, we included fourteen patients (n = 14), of which anterolateral thigh free flap was used for reconstruction in thirteen cases and in one case free fibular osteocutaneous flap was done. Mean age is 33.36 ± 14 years; there was two flap failure. Flap failure is associated with a statistically significant low swallowing and appearance score (p value is 0.036 for both). The orbital exenteration is associated with low appearance score but it is not statistically significant (p value 0.70), probably due to small sample size in the series. Our early experience of free tissue transfer in maxillary reconstruction is satisfactory in terms of quality of life of the patient as well as the oncological outcome. With positive initial experience in maxillary reconstruction with free flaps large study population will be considered in near future.

Evaluation of facial symmetry after jaw reconstruction surgery.

The current study proposes a 3D objective method of evaluating facial symmetry after reconstructive surgery of orofacial structures. 3D models of the craniofacial and soft tissue surfaces were reflected about the mid-sagittal plane. The original model was aligned with the reflection and the best plane of symmetry was found. A deviation contour map quantified the areas of asymmetry and gave a global score of the asymmetry. The asymmetry scores were successfully obtained for 18 patients who had underwent reconstruction of lower face. The asymmetry values at craniofacial and soft tissue levels were moderately correlated (R2=0.39). Overall, the developed method effectively highlights areas of asymmetry and can help evaluate aesthetic outcomes of facial reconstruction surgery.

Natural History and Consequences of Nonunion in Mandibular and Maxillary Free Flaps.

OBJECTIVE: To describe the natural history of bone segment union in head and neck free flap procedures and detail the association of poor segment union with postoperative complications. STUDY DESIGN: Case series with chart review. SETTING: Single tertiary care referral center. SUBJECTS AND METHOD: Patients with mandibular or maxillary defects reconstructed with osseous or osteocutaneous free flaps were analyzed (n = 104). Postoperative computed tomography or positron emission tomography/computed tomography scans were reviewed for signs of osseointegration and nonunion. Postoperative wound complications were correlated with imaging findings. RESULT: Thirty-seven percent of appositions had partial union on nonunion. Appositions between osteotomized free flap segments form complete unions at a higher rate than appositions with native bone (65% vs 53%, P = .0006). If an apposition shows a gap of ≥1 mm, the chances of failing to form a complete union are greatly increated (79% vs 8%, P = .0009). Radiographic nonunion was associated with an increased likelihood of postoperative wound complications (40% vs 19%, P = .025) and in most cases was present before development of complications. CONCLUSION: Radiographic evidence of partial union or nonunion of free flap osseous segments greatly exceeds reported rates of clinically evident nonunion. Unions likely form between free flap appositions before unions to the native bone. If initial bone segments are >1-mm apart, the chance of progression to complete union is low. Incomplete osseointegration appears to be a marker for development of wound complications.

Midface Reconstruction: Planning and Outcome.

Reconstruction of the complex anatomy and aesthetics of the midface is often a challenge. A careful understanding of this three-dimensional (3D) structure is necessary. Anticipating the extent of excision and its planning following oncological resections is critical. In the past over two decades, with the advances in microsurgical procedures, contributions toward the reconstruction of this area have generated interest. Planning using digital imaging, 3D printed models, osseointegrated implants, and low-profile plates, has favorably impacted the outcome. However, there are still controversies in the management: to use single composite tissues versus multiple tissues; implants versus autografts; vascularized versus nonvascularized bone; prosthesis versus reconstruction. This article explores the present available options in maxillary reconstruction and outlines the approach in the management garnered from past publications and experiences.

Microsurgical reconstruction of the maxilla: Algorithm and concepts.

INTRODUCTION: The main purpose of this article is to highlight free tissue transfers as the first-choice method for three-dimensional (3D) maxillary reconstruction, particularly in providing enough bone for palate and maxillary arch reconstruction and consequently an implant-retained prosthesis. To achieve this, the myosseous free iliac crest was selected whenever possible as the first choice inside the reconstructive algorithm and free flap armamentarium. A new maxillectomy classification and algorithm reconstruction are proposed. Technical modifications and improvements accomplished over time are discussed, considering palate, dental implants and prosthesis, nasal sidewall, cranial base and dura, as well as recipient vessels. We present functional and aesthetic outcomes of the senior author's past 24-year experience (H. C.) with complex midface reconstructions. MATERIAL AND METHODS: The authors report and analyse a 24-year experience with 57 midface defects in 54 patients (30 males and 24 females). A total of 57 maxillary defects - classified as Class I (limited maxillectomy) = 12, Class II (subtotal maxillectomy) = 15, Class III (total maxillectomy) = 19 and Class IV (orbitomaxillectomy) = 11 - were analysed regarding sex, age, tumour recurrence, free flap, reconstruction and necrosis. In addition, functional outcomes were evaluated regarding diet, speech, globe position and vision, while aesthetic outcomes were evaluated by patient and surgeon scores. RESULTS: A total of 52 free flaps were performed in 47 patients; three patients were operated upon twice; and two other patients needed two sequentially linked flow-through flaps. The free flap survival was 96% with two total flap losses (4%). The other seven patients were fitted with a soft tissue-retained obturator prosthesis. CONCLUSIONS: Microsurgical vascularised osteomyocutaneous free flaps are actually the gold standard for reconstruction of complex defects following maxillectomy. This algorithm is based on the anatomofunctional defect of the maxilla and it facilitates flap selection, which is a must.

Long Term Follow Up of Maxilla Reconstruction Following the Ablative Cancer Surgery

PURPOSE: The objective of this study was to evaluate the outcomes of using the free flap in the reconstruction of maxillary defects. METHODS: 27 consecutive cases of maxillary reconstruction with free flap were reviewed. All clinical data were analyzed, including ideal selection of flap, time of reconstruction, recurrence of cancer, postoperative complications, flap design, and follow-up results. The main operative functional items, including speech, oral diet, mastication, eye globe position and function, respiration, and aesthetic results were evaluated. RESULTS: Among the 24 patients who underwent maxillary reconstruction with the free flap, 14 patients underwent immediate reconstruction after maxillary cancer ablation, and 10 patients underwent delayed reconstruction. There occurred 1 flap loss. Recurrences of the cancer after the reconstruction happened in 2 cases. Postoperative complications were 3 cases of gravitational ptosis of the flap, 2 cases of the nasal obstruction, and 1 case of fistula formation. Out of 27 free flaps, there were 15 latissimus dorsi myocutaneous flaps, 5 radial forearm, 4 rectus abdominis myocutaneous flaps, 1 scapular flap, 2 fibula osteocutaneous flap, respectively. Flaps were designed such as 1 lobe in 9 cases, 2 lobes in 9 cases, and 3 lobes in 5 cases. Among the 14 patients who had intraoral defect or who had palatal resection surgery, 2 patients complained the inaccuracy of the pronunciation due to the ptosis of the flap. It was corrected by the reconstruction of the maxillary buttress and hung the sling to the upper direction. All of the 14 patients were able to take unrestricted diets. In 6 patients who had reconstruction of inferior orbital wall with rib bone graft, they preserved normal vision. Aesthetically, most of the patients were satisfied with the result. CONCLUSION: LD free flap is suggested in uni-maxilla defect as the 1st choice, and fibular osteocutaneous flap and calvarial bone graft to cover the larger defect in bi-maxilla defect.