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Objective: This study aims to highlight the versatility of the subscapular system free flaps in head and neck reconstruction within a Veteran population. Methods: We describe a case series of patients (n = 8) from the Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX between 2019 and 2021. Patient demographics, comorbidities, surgical variables, complications, flap outcomes and post-operative imaging were gathered from the electronic medical record. Results: Six patients underwent mandibular reconstruction using horizontally oriented bony scapular flaps with variable soft tissue components. One patient underwent composite maxillary and oral cavity reconstruction using a chimeric scapular tip and myocutaneous latissimus dorsi free flap. Finally, we report a successful application of a chimeric scapular tip free flap for cranioplasty in the setting of a chronically infected wound secondary to osteoradionecrosis, which has not previously been reported. All flaps survived without compromise and no donor site complications were reported postoperatively. Conclusion: The subscapular system provides highly robust and versatile tissue for complex head and neck reconstruction. Multiple bony and soft tissue components provide options to construct chimeric flaps with unparalleled spatial mobility. Creative designs used to reconstruct mandibular, maxillary, and now calvarial defects represent an expanding role of the subscapular system as a reliable option for complex head and neck reconstruction in a highly co-morbid Veteran population.

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. [ABSTRACT FROM AUTHOR]

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.

The iliac crestal flap is often used in maxillofacial reconstruction surgery because it has a similar bone contour to jaw bone. However, complications occur frequently in this flap, and the avulsion fracture of the anterior superior iliac spine (ASIS) occurs only in rare cases. The purpose of this study is to evaluate the risk factors affecting fractures that may occur after iliac crestal flap harvesting. In this study, we performed preoperative and postoperative CT scans of the iliac bones of 22 patients who underwent iliac crestal flaps between February 2013 and July 2019. Three of these patients had fractures within 1 month after surgery. After converting DICOM files to a three-dimensional model using Mimics software, some reference points were defined for analysis. The patients were classified into fracture and non-fracture groups. The patients' age and sex, harvested bone, residual bone and absolute bed rest (ABR) periods were investigated. The patients' age and sex were not associated with fracture occurrence. There was a statistically significant difference in the width of the anterior–superior part of residual bone. The fracture group showed statistically significantly shorter ABR periods. In the case of the iliac crestal flap, it was found that the factors that can affect the occurrence of fractures are the width of the residual bone and the ABR period. Iliac avulsion fracture can be prevented when the remaining bone is sufficient and the ABR period is prolonged sufficiently. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the present prospective cohort study was to report on an approach for maxillary reconstruction with autogenous bone grafts allowing implant placement for immediate function with fixed bridges after 6 months. Materials and methods: A total of 35 bilateral bone grafting procedures were performed on 35 consecutive patients (mean age 54.5 years). The iliac crest was used as donor site for all patients. The method for retaining the immediate prosthesis after bone graft ranged from mucosa retention (6 patients), implant retention (10 patients with immediate-function implants placed in non-grafted bone at the same surgical step as the bone graft procedure), teeth retention (6 patients) or palatal implant retention (13 patients). The graft was considered to be successful when it allowed the placement of the planned implants for immediate function rehabilitation with a fixed bridge. Results: All bone-grafting procedures were successful, allowing all patients to be rehabilitated after 6 months with a fixed bridge supported by immediate-function implants. The cumulative survival rate of the palatal implants was 94% after 2 months. A total of 219 immediate-function implants were placed in grafted bone and loaded occlusally. Two patients dropped out of the study 2 and 4 months after the bone graft procedure, while one patient with four implants dropped out of the study 13 months after the rehabilitation with implants. The cumulative survival rate of the implants was 97.3% at 1-year and 96.7% at 5-years (up to 129 months; minimum of 29 months; median of 52.5 months). Seven implants failed to integrate in the grafted bone. The marginal bone resorption for the implants placed in grafted areas at 1-year and 5-year follow-up was 2.0 mm (SD = 1.2mm) and 2.0mm (SD = 1.1mm), respectively. Conclusions: Maxilla reconstruction with autogenous grafted bone is a viable process, allowing, in some cases, the use of a removable or fixed prosthetic rehabilitation immediately after grafting. Maxillary rehabilitation with immediate-function implants in grafted bone is possible, with the implant success rate achieved at 5 years comparable to other rehabilitations with implants placed in grafted bone, but lower than the results obtained with implants placed in residual bone. [ABSTRACT FROM AUTHOR]

The iliac crestal flap is often used in maxillofacial reconstruction surgery because it has a similar bone contour to jaw bone. However, complications occur frequently in this flap, and the avulsion fracture of the anterior superior iliac spine (ASIS) occurs only in rare cases. The purpose of this study is to evaluate the risk factors affecting fractures that may occur after iliac crestal flap harvesting. In this study, we performed preoperative and postoperative CT scans of the iliac bones of 22 patients who underwent iliac crestal flaps between February 2013 and July 2019. Three of these patients had fractures within 1 month after surgery. After converting DICOM files to a three-dimensional model using Mimics software, some reference points were defined for analysis. The patients were classified into fracture and non-fracture groups. The patients’ age and sex, harvested bone, residual bone and absolute bed rest (ABR) periods were investigated. The patients’ age and sex were not associated with fracture occurrence. There was a statistically significant difference in the width of the anterior–superior part of residual bone. The fracture group showed statistically significantly shorter ABR periods. In the case of the iliac crestal flap, it was found that the factors that can affect the occurrence of fractures are the width of the residual bone and the ABR period. Iliac avulsion fracture can be prevented when the remaining bone is sufficient and the ABR period is prolonged sufficiently.

Background: Ossifying fibroma is a variant of fibrous dysplasia and catagorized as osteofibrosis lesion. It commonly affects long bones but occasionally involves jaws. Mandible affected more common than maxilla. The treatment of ossifying fibroma include excision and resection. Excision of lesion and resection of maxilla could cause facial defect which cannot be reconstructed with bone graft. Purpose: The aim of this case report is to report the potential use of polypropylene mesh in facial reconstruction after hemimaxillectomy in patients diagnosed with ossifying fibroma of the maxilla. Case: A 17-years-old female patient came to Oral and Maxillofacial Surgery clinic, Dental Hospital, Faculty of Dentistry, Airlangga University, with chief complaint of swelling in the upper left cheek of 2 years duration which was not related to any history of toothache. Patient also complained of the itchiness and pain on the swelling area occasionally as well as salty discharge from the mass. The FNA was done and the citology result indicated a benign mesenchimal tumor. Incisonal biopsy was subsequently performed and the histopathology report confirmed the diagnosis of cementifying fibroma. Case management: Left hemimaxillectomy was done, and post surgical defect in the facial and buccal aspect was immediately reconstructed using three layers of polypropylene mesh. On follow-up, eleven months post-operatively, the patient was well and there was no facial deformity or asymmetry. Conclusion: Polypropylene mesh is a potential material for facial reconstruction as it can reduce the risk of facial deformity after hemimaxillectomy of patients with tumor of the maxilla.Latar belakang: Ossifying fibroma merupakan varian dari fibrous dysplasia dan termasuk di dalam kategori lesi osteofibrosis. Umumnya mengenai tulang panjang tetapi dapat juga mengenai rahang dan lebih banyak menyerang tulang mandibula dibanding maksila. Perawatan ossifying fibroma dilakukan dengan eksisi atau reseksi. Perawatan eksisi atau reseksi tulang maksila dapat mengakibatkan deformitas wajah yang tidak dapat direkontruksi dengan bone graft. Tujuan: Laporan kasus ini bertujuan untuk melaporkan penggunaan polipropylene mesh pada rekonstruksi wajah setelah hemimaxillectomy pada pasien dengan diagnose ossifying fibroma pada maksila. Kasus: Penderita wanita berusia 17 tahun datang ke Klinik Bedah Mulut dan Maksilofasial, Rumah Sakit Gigi dan Mulut Fakultas Kedokteran Gigi Universitas Airlangga, dengan keluhan utama pembengkakan pada pipi kiri atas yang muncul sejak 2 tahun yang lalu tanpa ada riwayat keluhan sakit gigi. Penderita mengeluh gatal, kadang sakit dan keluarnya cairan asin pada daerah benjolan. Hasil FNA dan test sitologi menunjukkan gambaran tumor jinak mesensimal. Pemeriksaan dengan biopsi dan histopatologi mengkonfirmasi diagnosa cementifying fibroma. Tatalaksana kasus: Dilakukan hemimaksilektomy pada sebelah kiri, dan defek pasca pembedahan pada sisi fasial dan bukal segera direkontruksi dengan pemasangan polipropylene mesh 3 lapis. Sebelas bulan setelah operasi kondisi pasien baik dan tidak ada deformitas atau asimetri wajah. Kesimpulan: Polypropylene mesh merupakan bahan yang potensial untuk rekonstruksi wajah karena dapat mengurangi terjadinya deformitas wajah setelah hemimaxillectomy pada pasien dengan tumor maksila.

Introduction: The defect complexity and reconstructive options make the maxillary reconstruction a controversial theme and in a constant debate. The maxilla is a fundamental aesthetic and functional structure of the face. Microsurgical vascularized flaps replaced the usage of prosthetic material and pedicled flaps as a 'gold standard' for the reconstruction of complex defects following maxillectomy. Methods: The authors report their experience of 24 maxillectomies with immediate microsurgical reconstruction, performed by the senior author (H.C.) between 1998 and 2011. They evaluate and classify the defects and the reconstructive options according to the classification system as proposed by Cordeiro and Santamaria in 2000, by a patient questionnaire and post-operative surgeon follow-up for the functional (diet, speech, and vision) and aesthetic end results. Results: There were no flap failures. The main etiology was squamous cell carcinoma and the most used flap was rectus abdominis free flap. Classes I and II were responsible for the cases in which the reconstructive algorithm was not followed. Most patients responded as having a normal diet, a nearly normal speech and unaffected vision. In a score of 1 to 5, the mean score in esthetic given by the patient was 3.62, while the mean score given by the surgeons was 4.13. Conclusions: Microsurgical reconstruction of maxillectomy defects with free flaps is the best reconstructive option, being the osteomyocutaneous flaps as the gold standard. Although with limited rehabilitation, good functional and aesthetic results are to be expected with myocutaneous flaps. The existence of an algorithm facilitates the classification and systematization of maxillary reconstruction. However, due to defect complexity and large number of reconstructive options, a perfect solution does not exist. The individual assessment of the patient and the defect always provides the best method for the reconstructive planning, mainly when choosing free flaps. Level of Evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

The objective of this study was to analyze the stress distribution on zygoma implants and their supporting bones, superstructures and abutments under occlusal loads after maxilla reconstruction with prostheses. Four three-dimensional (3D) finite element models (FEMs) were constructed based on computed tomography (CT) data. One model of normal structure was constructed (Model 1) and three models of defects were simulated and restored with conventional prosthesis, one and two zygoma-implant-retained prostheses respectively (Models 2-4). Vertical and lateral loads of 150 N were loaded and the stresses distribution were observed and compared. The stresses distributed along the three mechanical pillars of maxillofacial parts in Model 1, which concentrated at the superstructure at Model 2. The zygoma implant can reduce the stresses at clasps and abutments in Model 3, while two zygoma implants can well share the stresses of affected side in Model 4. The distribution of stresses on prostheses were more rational with the help of zygoma implants which can share the stresses on the affected side adequately, so that it is fit for the reconstruction of unilateral maxilla defects. [ABSTRACT FROM AUTHOR]

Bilateral maxillary defect remains a challenging task for surgeons. Composite three-dimensional maxillary wounds often require double free flaps for satisfactory outcome. Chimeric free flap has recently been evolving as a good alternative option. From our experience of harvesting the submental flap, we noticed that at least one perforator from the submental artery coursed towards the inferior border of the mandible, which is potentially a new osteocutaneous chimeric flap. We reported one case of composite defect created after maxillectomy for osteosarcoma of the anterior upper jaw, which was successfully reconstructed by a pedicled submental osteocutaneous chimeric mandible flap. To our knowledge, this innovative design of osseous flap in chimeric style based on the submental vessels has not been described. [ABSTRACT FROM AUTHOR]

Defects of the maxilla and mandible can cause significant functional and aesthetic problems for patients. Vascularized calvarium was used to reconstruct six mandible and four maxillary defects between 1991 and 1998. The ages of patients ranged from 15 to 68 years.Full thickness calvarial bone was preferred for the repair of segmental mandibular defects but split thickness calvarial bone onlay was used to reconstruct contour deformities. When full thickness calvarial bone was used, the donor site defect was covered with split thickness cranial bone. In small defects, a bipedicled galea pericranial flap was used for reconstruction. The bone was supplied by the superficial temporal vessels in all cases. A tunnel in the subcutaneous plane was used for the flap transfer to avoid facial nerve branches. Immediate expansion was performed during the preparation of the tunnel to prevent pedicle compression. Bone vascularization was checked with bone scan and serial X-rays and clinical examinations were also performed in the postoperative period. Flap necrosis was observed in one case, satisfactory functional and aesthetic results were achieved in all other patients. Vascularized cranial bone has not only the same structural features as facial bones but also a reliable vascular supply. The superficial temporal fascia and hairy skin may be included in the cranial bone flap to treat complex defects. The donor site scar is well hidden in the scalp. There is minimal donor site discomfort. In conclusion, vascularized cranial bone is a good method of treatment in selected cases. [ABSTRACT FROM AUTHOR]

Summary 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. [ABSTRACT FROM AUTHOR]

Background: Maxillary defects caused by tumor ablative surgery might lead to deformity of the face and malfunction of mastication, swallowing, phonation and respiration. Microsurgical reconstruction of maxilla is technical challenging and time consuming. The study aims at reporting our experience of maxilla reconstruction using free flaps. Methods: We evaluated bony reconstruction after maxillectomy with deep circumflex iliac artery free flap (DCIA) and fibular flap. For fibular flap, preoperative surgical simulation was performed based on CT scans of maxillofacial region and low extremity. Resection template, segmentation template and transfer template were designed and fabricated via rapid prototyping technique. Tumor resection, fibula segmentation and bone graft transfer were performed according to the templates. Results: The surgical procedures were all performed successfully. No major post-operative complications were observed. Dental implants were done in selected cases, with satisfactory functional outcome. Conclusion: With preoperative surgical simulation, microsurgical reconstruction of maxilla defects with free flap can be accurately performed. [Copyright &y& Elsevier]