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OBJECTIVES/HYPOTHESIS Despite considerable effort being dedicated to contouring reconstruction plates, there remains limited evidence demonstrating an association between contour and reconstructive outcomes. We sought to evaluate whether optimizing mandibular reconstruction plate contouring is associated with reduced postoperative hardware complications. STUDY DESIGN Retrospective cohort study. METHODS A cohort study was performed with adult patients (age ≥18 years) who underwent mandibulectomy and osseous free flap reconstruction following oncologic ablation at the University Health Network in Toronto, Canada, between January 1, 2003 and December 31, 2014. Patients with computed tomography scans performed within 1 year of reconstruction were included. Computer-based three-dimensional models were generated and used to calculate the mean plate-to-bone gap (mm). The primary outcome was plate exposure. Secondary outcome included a composite of plate exposure or intraoral dehiscence. Logistic regression models were fitted for each outcome accounting for other patient and surgical characteristics associated with the primary outcome. RESULTS Ninety-four patients met inclusion criteria, with a mean age of 60.4 (standard deviation [SD] 14.9). The mean follow-up time was 31.4 months (range 3-94). Reconstruction was performed with fibular (57%) and scapular free flaps (43%). In the multivariable model, small mean plate-to-bone gap (

Pharyngocutaneous fistula (PCF) is a major morbidity of salvage total laryngectomy (TL). Understanding the factors predicting PCF is fundamental to managing laryngeal cancer. We aim to assess factors associated with PCF following salvage TL in a multicenter, international retrospective cohort study of academic centers in the US and Canada.In total, 550 patients post-salvage TL were identified (mean [SD; range] age, 64 [10.4; 32-90] years; 465 [85 %] male and 84 [15 %] female) between 2000 and 2014. Rate of PCF was 23 % (n = 127) with median time to PCF of 2.9 weeks. Surgical management of PCF was required in 43 % (n = 54) while 57 % (n = 73) required wound care alone. Rates of PCF differed by primary treatment modality [radiation, 20 % (n = 76); chemoradiation, 27 % (n = 40); not available (n = 6)] and use of vascularized tissue in pharyngeal closure [free/regional flap, 18 % (n = 25); no vascularized tissue/primary closure, 24 % (n = 98); not available (n = 4)]. There was no statistically significant association between PCF and treatment with chemoradiation (HR, 1.32; 95 % CI, 0.91-1.93, p = 0.14) or lack of vascularized tissue reconstruction (HR, 1.41, 95 % CI 0.91-2.18, p = 0.12). Significant association between PCF and advanced stage (T3 or T4), positive margin, close margin (lt;5mm), lymphovascular invasion and pre-operative tracheostomy were identified on univariable analysis. Positive surgical margin (HR, 1.91; 95 % CI, 1.11 to 3.29) was the only significant association on multivariable analysis.We highlight positive surgical margin as the only variable significantly associated with increased risk of PCF following salvage TL on multivariable analysis in a large cohort across several major head and neck oncology centers.

When deforming pathology limits intraoperative plating of the mandible, three-dimensional (3D) models can be generated by digitally replacing the deformed segment of bone with an inverted segment from the contralateral unaffected mandible to adapt a reconstruction plate. The purpose of this study was to use 3D conformance analysis to evaluate the degree of accuracy of this "segmental mirroring" technique.Using a pre-existing melanoma database (January 1, 2005-September 20, 2015), high-resolution computed tomography (CT) scans of the head and neck were obtained from patients without evidence of bony disease or defects involving the mandible. Using 3D software (Mimics, Materialise, Leuven, Belgium), each mandible was segmented based on four defect classes (Ic, II, IIc and III) of the Brown et al. (2016) classification system. An inverted, or "mirrored", image of each segment was digitally created and manually co-registered with the corresponding contralateral segment of the mandible. Conformance analysis was performed by calculating the root-mean-square (RMS) conformance distance and through evaluating 3D generated conformance maps. The primary outcome was degree of conformance. Data were analyzed using descriptive statistics and tests of statistical significance. The significance level was set at a p-value less than or equal to .05.A high degree of conformance (mean RMS 1 mm) was observed when comparing all classes of simulated reconstruction. The closest conformance was observed for class III simulated reconstructions (mean RMS: 0.4 ± 0.2 mm). Inclusion of the condyle resulted in a reduced mean RMS conformance (class II: 0.5 ± 0.3 mm vs class IIc: 0.7 ± 0.5 mm; p = 0.01). There was no significant difference between RMS conformance distances when comparing side of simulated reconstruction. Evaluation of 3D mapping demonstrated reduced conformance with simulated reconstruction of the condyle and coronoid process.The segmental mirroring technique can be used reliably to generate highly accurate three-dimensional models that may assist with mandibular reconstruction in circumstances where bony deformity limits intraoperative adaptation of a reconstruction plate. This technique is less accurate where pathology involves the mandibular condyle and, to a lesser degree, the coronoid process.

Purpose Current nonvascular osseous reconstructive options for reconstruction of the orbital floor after maxillectomy include options such as scapular tip and iliac crest bone grafts. The aim of this study was to determine whether these donor sites were morphologically comparable with the orbital floor. Materials and Methods A retrospective cross-sectional study design was selected. By use of a pre-existing melanoma database (January 1, 2005, through September 20, 2015), computed tomography scans of the head, neck, thorax, and pelvis were obtained from patients without evidence of bony metastases. With the use of 3-dimensional software (Mimics; Materialise, Leuven, Belgium), grafts from the scapulae and iliac crests, the predictor variables, were digitally harvested, co-registered with the orbital floors bilaterally, and analyzed. The primary outcome was conformance. Data were analyzed using descriptive statistics and tests of statistical significance. The significance level was set at P Results The study sample included 10 patients (6 men and 4 women; mean age, 55 ± 18 years). Close conformance was observed when we analyzed the morphology of the orbital floor to the scapular (2.23 ± 0.31 mm) and iliac crest (2.13 ± 0.30 mm) bone grafts, with no significant difference between sites. Conformance mapping showed maximum conformance centrally (scapula, 0.001 ± 0.001 mm; iliac crest, 0.001 ± 0.001 mm), with decreased morphologic similarity peripherally (scapula, 6.09 ± 0.94 mm; iliac crest, 5.74 ± 0.88 mm). There was no significant difference in conformance between sides of graft harvest. Conclusions When considering nonvascularized bone grafts for reconstruction of the orbital floor, both the scapula and iliac crest offer nearly complete conformance to the orbital floor structure and represent reasonable reconstructive options.