CAD/CAM and conventional reconstruction of the mandibular condyle by fibula free flap: a clinical and radiological evaluation.

The aim of this study was to analyse the radiological and clinical outcomes of condylar reconstruction by fibula free flap (FFF), comparing conventional freehand and CAD/CAM techniques. Fifteen patients (nine CAD/CAM, six freehand) who underwent condylar reconstruction with a FFF were reviewed retrospectively regarding pre- and postoperative computed tomography/cone beam computed tomography scans and clinical function. After surgery, all patients were free of temporomandibular joint pain. Mean postoperative mouth opening was 30.80 mm, with no significant difference between the freehand and CAD/CAM groups. In all patients, laterotrusion was decreased to the contralateral side (P = 0.002), with no difference between freehand and CAD/CAM, while the axis of mouth opening deviated to the side of surgery (P < 0.001). All patients showed significant radiological deviation of the fibular neocondyle in the laterocaudal direction (lateral: P = 0.015; caudal: P = 0.001), independent of the technique. In conclusion, reconstruction of the mandibular condyle by FFF provided favourable functional results in terms of mouth opening, reduction of pain, and mandibular excursions. Radiological deviation of the neocondyle and deviation of laterotrusion and mouth opening did not impair clinical function. CAD/CAM planning facilitated surgery, decreased the surgery time, and improved the fit of the neocondyle in the fossa.

Alternatives to free flap surgery for maxillofacial reconstruction: focus on the submental island flap and the pectoralis major myocutaneous flap.

BACKGROUND: Microvascular tissue transfer (MTT) has been established as the gold standard in oral- and maxillofacial reconstruction. However, free flap surgery may be critical in multimorbid elderly patients and after surgery or radiotherapy, which aggravate microsurgery. This study evaluates indications and outcome of the submental island flap (SMIF) and the pectoralis major myocutaneous flap (PMMF) as alternatives to the free radial forearm flap (RFF). METHODS: This retrospective study included 134 patients who had undergone resection and reconstruction with SMIF, PMMF, or RFF at our department between 2005 and 2020. The level of comorbidity was measured with the Age-adjusted Charlson comorbidity index (ACCI). Primary outcome variables were flap success, complications, wound dehiscence, surgery duration, as well as time at the ICU and the ward (hospitalization). Chi-square tests, t-tests, and ANOVA were performed for statistics. RESULTS: 24 SMIFs, 52 RFFs, and 58 PMMFs were included in this study. The flap types did not significantly differ in terms of flap success, complications, and healing disorders. The SMIF presented a success rate of 95.8% and was significantly more often used in elderly patients (mean age = 70.2 years; p < 0.001) with increased comorbidities than the PMMF (p < 0.01) and RFF (p < 0.001). SMIF reconstruction reduced surgery duration (p < 0.001) and time at the ICU (p = 0.009) and the ward (p < 0.001) more than PMMF and RFF reconstructions. PMMF reconstruction was successful in 91.4% of patients and was more frequently used after head and neck surgery (p < 0.001) and radiotherapy (p < 0.001) than SMIF and RFF reconstructions. Patients undergoing PMMF reconstruction more frequently required segmental jaw resection and had presented with advanced tumor stages (both p < 0.001). Nicotine and alcohol abuse was more frequent in the RFF and PMMF groups (both p < 0.001) than in the SMIF group. CONCLUSIONS: The pedicled SMIF represents a valuable reconstructive option for elderly patients with increased comorbidity because of the shorter duration of surgery and hospitalization. On the other hand, the PMMF serves as a solid backup solution after head and neck surgery or radiotherapy. The rates of flap success, complications, and healing disorders of both pedicled flaps are comparable to those of free flap reconstruction.

Magnetic resonance angiography for free fibula harvest: anatomy and perforator mapping.

The purpose of this study was to outline lower leg vessel anatomy and to investigate reliability and limitations of magnetic resonance angiography (MRA) in patients proposed for microvascular fibula transplantation (free fibula flap (FFF)). We retrospectively investigated MRAs of 99 patients considered for FFF. Frontal MRA planes and maximal intensity projections (MIPs) were evaluated for fibula lengths, anatomical branching pattern, arterial stenoses and fibular perforator positions in both legs (n=198). Normal branching patterns were observed in 168 (85.3%) legs. Twenty-nine (14.7%) legs presented abnormal branching patterns. Once (0.5%) the anterior, 19 times (9.6%) the posterior tibial artery were absent or hypoplastic. Nine (4.6%) lower legs presented an arteria peronea magna. Average length of the tibiofibular trunk (TFT) was 3.3±0.15cm. A total of 492 perforators were found with an average of 2.5 (±0.82±0.99) perforators per leg. A mapping of perforator run-offs was illustrated true to scale. Lower limb stenoses were distributed in the anterior tibial artery (14.1%), in the posterior tibial artery (11.1%) and in the fibular artery (8.1%). Smoking (P=0.828), diabetes (P=0.727) and peripheral arterial occlusive disease (P=0.172) did not correlate with presence of stenoses. Preoperative lower limb angiography avoids postoperative complications. MRA reliably and non-invasively identifies anatomical variants and arterial stenoses without radiation. Illustration of perforator run-offs enhances incision planning for fibula harvest.

Health-related quality of life: a retrospective study on local vs. microvascular reconstruction in patients with oral cancer.

BACKGROUND: New medicinal and surgical oncological treatment strategies not only improve overall survival rates but continually increase the importance of Health-Related Quality of Life (HRQOL). The purpose of this retrospective cross-sectional study was to analyze HRQOL of patients with oral squamous cell carcinoma after ablative surgery and to evaluate predictive factors for HRQOL outcome. METHODS: The study included 88 patients with histologically confirmed oral squamous cell carcinoma of whom 42 had undergone local reconstruction (LR) and 46 microvascular reconstruction (MVR). During follow-up, all patients completed the University of Washington Quality of Life Questionnaire (UW-QOL) containing 12 targeted questions about the head and neck. Descriptive analyses were made for the tumor site, the T-stage, and adjuvant therapies. HRQOL was compared between the LR and the MVR group with parametric tests. Further analyses were impact of the tumor site, the T-status, and the time from surgery to survey on HRQOL. Statistics also included multivariate correlations and different interaction effects. RESULTS: HRQOL in the LR group was 'very good' with 84.3 ± 13.7 and 'good' in the MVR group with 73.3 ± 16.5 points. The physical domains swallowing (p = 0.00), chewing (p = 0.00), speech (p = 0.01), taste (p = 0.01), and pain (p = 0.04) were significantly worse in the MVR group. An increase in the T-status had a significant negative effect on swallowing (p = 0.01), chewing (p = 0.01), speech (p = 0.03), recreation (p = 0.05), and shoulder (p = 0.01) in both groups. Regarding the tumor site and subsequent loss of HRQOL, patients with squamous cell carcinoma on the floor of the mouth had significantly worse results in the categories pain (p = 0.002), speech (p = 0.002), swallowing (p = 0.03), activity (p = 0.02), and recreation (p = 0.01) than patients with tumors in the buccal mucosa. Speech (p = 0.03) and pain (p = 0.01) had improved 1 year after surgery. CONCLUSION: Patients with flap reconstruction because of oral squamous cell carcinoma showed very good overall HRQOL. Outcomes for microvascular reconstruction were good, even in the case of larger defects. The T-status is a predictor for HRQOL. Swallowing, chewing, speaking, taste, and pain were the most important issues in our cohort. Implementing HRQOL questionnaires for the assessment of quality of life could further increase the treatment quality of patients with oral cancer.

Luminescence ratiometric oxygen imaging (LROI) in microvascular anastomosed fibular and radial forearm flaps.

BACKGROUND: In a preliminary trial, we were able to show first promising results in the analysis of perioperative and postoperative perfusion of free flaps by means of a new monitoring system for detecting thrombotic vessel occlusion before clinical signs become evident. OBJECTIVE: We investigated whether flap monitoring by measuring perfusion-dependent parameters differs between radial forearm and fibular free flaps and whether a threshold value requiring anastomosis revision could be determined. METHODS: 37 radial forearm flaps (RF) and 15 fibular flaps (FF) were harvested and transplanted. Perfusion was determined by measuring a fluorescent oxygen sensor foil covering a flap's skin surface with a handheld fluorescence microscope. The sensor contained an oxygen reservoir, which was consumed by the tissue corresponding to the perfusion status of the flap. Measurements were done before explantation, after successful anastomosis and one day after surgery. RESULTS: We found a significant difference (p < 0.005) in the relative transdermal oxygen consumption (RTOC) between clinically well-perfused grafts (RF: mean: 0.13 ± 0.08; FF: mean: 0.15 ± 0.07) and clinically poorly perfused grafts (RF: mean: 0.40 ± 0.09; FF: mean: 0.55 ± 0.28). A threshold RTOC value of 0.3 for differentiating between well-perfused and poorly perfused flaps was confirmed for both RF and FF.

Simple, fast and reliable perfusion monitoring of microvascular flaps.

BACKGROUND: Free tissue transfer in head and neck reconstructions has a very high success rate, but thrombotic vessel occlusion is still a serious complication occurring in up to 10% of all cases. Thus, a simple, fast and reliable monitoring system for free flaps would be of advantage. OBJECTIVE: The aim of this study was to investigate whether free flap monitoring by measuring perfusion-dependent parameters is a suitable method for discovering vessel thrombosis in free flaps. METHODS: 10 patients requiring tissue reconstruction after tumour surgery or because of chronic wounds were included in this study. 10 microvascular flaps were harvested and transplanted. Perfusion was determined by measuring a fluorescent oxygen sensor foil covering the flap's skin surface by means of a USB-handheld fluorescence microscope prototype. The sensor contained an oxygen reservoir which was consumed by the tissue corresponding to the perfusion status of the flap. Measurements were done before explantation, after successful anastomosis and 1 day after surgery. RESULTS: Clinically well-perfused grafts showed slope values between 0.07 and 0.27 (mean: 0.18 ± 0.07), and clinically poorly perfused grafts showed slope values between 0.35 and 0.75 (mean: 0.52 ± 0.19). In the present study, we used a threshold slope value of 0.3 for differentiating between well-perfused and poorly perfused flaps. CONCLUSION: Flap monitoring via oxygen imaging by means of fluorescent sensor foils appears to be a fast, non-invasive, cost-effective and thus suitable method for analyzing flap perfusion with the additional advantage of aiding decision making on flap revision.

[Condylar resection alone versus alloplastic reconstruction. Comparison of long-term functional and cosmetic results]. / Alleinige Kondylusresektion versus alloplastische Rekonstruktion. Vergleich funktioneller und ästhetischer Langzeitergebnisse.

After condylar resection a decision on whether to proceed immediately to reconstruction has to be decided. In this paper, two patients who had undergone hemimandibulectomy including exarticulation, in one because of an expanded keratocystic odontogenic tumour and in the other because of oral squamous cell carcinoma, are presented. In one patient a metallic condylar reconstruction plate combined with an iliac crest graft was implanted for primary mandibular reconstruction, whereas in the other the part of the mandible that had been removed and the condylar head were not replaced. One patient was followed up for 5 years and the other for 6 years. Functional (max. incisal distance, protrusive and lateral excursions, occlusion and joint noises) and cosmetic results (scarring, facial nerve function), and also quality of life with and without primary mandibular replacement by a metallic condylar reconstruction plate are compared.