Mid-facial reconstruction after maxillectomy

Reconstruction following extensive resectionof the maxilla has been a challenging problem in the fieldof head and neck cancer surgery. At our institutes, maxillectomy defects have been restored based on the principles of repair involving the important concept of maxillary buttress reconstruction. Reconstruction of the zygomaticomaxillary buttress (ZMB), including the orbital floor, is essential for prevention of the malpositioning of the eyeglobe in preservation of the orbital contents. ZMB reconstruction is also important to provide a good contour of malar prominence. Pterygomaxillary buttress (PMB) reconstruction provides sufficient support for the fitting of a dental prosthesis. In patients with extensive resection of buccal soft tissue, a PMB and nasomaxillary buttress (NMB) should be reconstructed to prevent superior and posterior deviation of the alar base and oral commissure. We advocate that critical assessment of skeletal defects, as well as associated soft-tissue defects, following various types of maxillectomies is essential for a rational approach to achieve satisfactory clinical results.     

Reconstruction of the maxilla and midface: introducing a new classification

Most patients requiring midface reconstruction have had ablative surgery for malignant disease, and most require postoperative radiotherapy. This type of facial reconstruction attracts controversy, not only because of the many reconstructive options, but also because dental and facial prostheses can be very successful in selected cases. This Personal View is based on a new classification of the midface defect, which emphasises the increasing complexity of the problem. Low defects not involving the orbital adnexae can often be successfully treated with dental obturators. For the more extensive maxillary defects, there is consensus that a free flap is required. Composite flaps of bone and muscle harvested from the iliac crest with internal oblique or the scapula tip with latissimus dorsi can more reliably support the orbit and cheek than soft-tissue free flaps and non-vascularised grafts, and also enable an implant-borne dental or orbital prosthesis. Nasomaxillary defects usually require bone to augment the loss of the nasal bones, but orbitomaxillary cases can be managed more simply with local or soft-tissue free flaps. We review the current options and our own experience over the past 15 years in an attempt to rationalise the management of these defects.     

Reconstruction of maxillectomy and midfacial defects with free tissue transfer

The maxillary bones are part of the midfacial skeleton and are closely related to the eyeglobe, nasal airway, and oral cavity. Together with the overlying soft tissues, the two maxillae are responsible to a large extent for facial contour. Maxillectomy defects become more complex when critical structures such as the orbit, globe, and cranial base are resected, and reconstruction with distant tissues become essential. In this article, we describe a classification system and algorithm for reconstruction of these complex defects using various pedicled and free flaps. Most defects that involve resection of the maxilla and adjacent soft tissues may be classified into one of the following four types: Type I defects, Limited maxillectomy; Type II defects, Subtotal maxillectomy; Type III defects, Total maxillectomy; and Type IV defects, Orbitomaxillectomy. Using this classification, reconstruction of maxillectomy and midfacial defects may be approached considering the relationship between volume and surface area requirements, that is, addressing the bony defect first, followed by assessment of the associated soft tissue, skin, palate, and cheek-lining deficits. In our experience, most complex maxillectomy defects are best reconstructed using free tissue transfer. The rectus abdominis and radial forearm free flap in combination with immediate bone grafting or as an osteocutaneous flap reliably provide the best aesthetic and functional results. A temporalis muscle pedicled flap is used for reconstruction of maxillectomy defects only in those patients who are not candidates for a microsurgical procedure.     

咽旁肿瘤切除术(附29例)

目的探讨如何根据术前诊断选择最佳的手术进路,提高疗效,减少并发症和后遗症。方法本组29例,男性16例,女性13例,年龄18~57岁,中位年龄45。均采用手术治疗及术后化疗或放疗。手术进路:口腔入路、颌颈入路、颈侧高位切开下颌骨外旋入路、颌咽入路、上颌骨掀翻入路、上颌骨加咽旁肿瘤切除。结果病理类型:良性21例,恶性8例,随访5年,良性肿瘤均未见复发,骨肉瘤1例术后2个月复发,上颌窦癌1例术后2年复发,口咽侧壁粘液表皮样癌1例术后6年复发,再次术后2年复发,颌下腺腺样囊性癌术后4年复发并肺转移,未继续治疗,恶性淋巴瘤2例化疗后5年无复发。手术均未出现并发症,术后有暂时性的神经功能障碍,均在半年内恢复。结论口腔入路仅适用于紧邻咽粘膜下小肿瘤、颌颈入路适用于咽旁混合瘤、神经鞘瘤和颈动脉体瘤、颈侧高位切开下颌骨外旋入路适用于腮腺深叶肿瘤及高位神经鞘瘤、颌咽入路适用于恶性肿瘤连同下颌升枝一并切除、上颌骨掀翻入路及上颌骨适用于晚期的上颌窦癌及颅底肿瘤侵入咽旁。     

Value of Porous Titanium Alloy Plates for Chest Wall Reconstruction after Resection of Chest Wall Tumors

Objective: To explore the value of porous titanium alloy plates for chest wall reconstruction after resectionof chest wall tumors. Materials and Methods: A total of 8 patients with chest wall tumors admitted in ourhospital from Jan. 2006 to Jan. 2009 were selected and underwent tumor resection, then chest wall repair andreconstruction with porous titanium alloy plates for massive chest wall defects. Results: All patients completedsurgery successfully with tumor resection-induced chest wall defects being 6.5×7 cm~12×15.5 cm in size. Twoweeks after chest wall reconstruction, only 1 patient had subcutaneous fluidify which healed itself after pressurebandaging following fluid drainage. Postoperative pathological reports showed 2 patients with costicartilagetumors, 1 with squamous cell carcinoma of lung, 1 with lung adeno-carcinoma, 1 with malignant lymphoma ofchest wall, 2 with chest wall metastasis of breast cancers and 1 with chest wall neurofibrosarcoma. All patientshad more than 2~5 years of follow-up, during which time 1 patient with breast cancer had surgical treatmentdue to local recurrence after 7 months and none had chest wall reconstruction associated complications. Themean survival time of patients with malignant tumors was (37.3±5.67) months. Conclusions: Porous titaniumalloy plates are safe and effective in the chest wall reconstruction after resection of chest tumors.     

To Study the Effect of Orbital Sling on Post Operative Vision in Cases of Maxillary Carcinoma Undergoing Total Maxillectomy

To study effect of orbital sling on post operative vision in cases of maxillary carcinoma undergoing total maxillectomy. All patients with the principal procedure of “total maxillectomy” for histopathologically proven cases of carcinoma maxilla in department of otorhinolaryngology and head-neck surgery, N.S.C.B. medical college, Jabalapur, Madhya Pradesh, India from July 2011 to October 2013 were included. Out of the 20 patients irrespective of whether orbital sling was created or not, maximum number of patients 8 (40 %) showed a 3 step improvement, and maximum improvement seen was up to five steps. Out of the 14 patients in which orbital sling was created maximum number of patients 7 (50 %) showed a 3 step improvement, and maximum improvement seen was up to five steps. Out of the 6 patients in whom orbital sling was not created maximum number of patients 3 (50 %) showed a 2 step improvement, and maximum improvement seen was up to three steps. Infraorbital repair with the help of sling results in better improvement of vision as compared to those in whom sling was not or could not be made with no significant difference on eye movements.     

Results of multimodality therapy for squamous cell carcinoma of maxillary sinus

BACKGROUND: A wide variety of modalities, including surgery, radiation therapy, and chemotherapy, alone or in combination, have been used for the treatment of squamous cell carcinoma (SCC) of the maxillary sinus to obtain better local control and maintain functions. However, there is still much controversy with regard to the optimum treatment. METHODS: From 1987 to 1999, 33 patients with SCC of maxillary sinus were treated at the Department of Otolaryngology-Head and Neck Surgery, University of Tokyo Hospital. The treatment consisted of 30-40 grays (Gy) of preoperative radiotherapy with concomitant intraarterial infusion of 5-fluorouracil and cisplatin followed by surgery and 30-40 Gy of postoperative radiotherapy, for tumors without skull base invasion. For tumors invading the skull base, preoperative systemic chemotherapy with or without radiotherapy was performed, instead of intraarterial chemotherapy, then followed by skull base surgery. The surgical procedures varied according to the extent of tumor. Results were compared with those of the 108 patients treated in our hospital from 1976 to 1982. RESULTS: Partial maxillectomy was performed in 2 T2 patients and 12 T3 patients. Total maxillectomy was performed in 1 T2 patient, 3 T2 patients, and 7 T4 patients. Skull base surgery was performed in eight T4 patients. Orbital content and hard palate were preserved in 22 patients and 18 patients, respectively. The overall 5-year survival rates were 86% in T 3 patients and 67 % in T4 patients, respectively. CONCLUSIONS: Our multimodal treatment has provided favorable local control and survival outcome with good functional results.     

钛网喉支架重建的动物实验研究

目的:探讨应用钛网进行喉支架重建的可行性。方法:应用钛网在术中根据需要制作喉支架,选用健康成年杂种家犬6只行左侧垂直半喉切除术,保留甲状软骨外膜作为喉支架的衬里,带状肌覆盖钛网喉支架。结果:术后无感染,无呼吸困难。于术后3个月、6个月处死观察,钛网喉支架与其周边的甲状软骨结合稳固,无移位和排出。在光学显微镜下,3个月时,修复部位的喉腔、气管腔面见排列整齐的柱状纤毛上皮细胞。喉支架周围被薄层纤维组织包裹,可见轻微炎性反应,周围组织结构正常。6个月时,无炎性反应。结论:钛网喉支架的应用可避免喉气管腔狭窄,保证呼吸道畅通。     

Carcinoma of the maxillary antrum: Surgery or radiation therapy?

Between the years 1968 and 1978, 57 patients with malignant tumors of the para-nasal sinuses were seen at the Medical College of Virginia. Thirty-nine patients presenting with squamous cell epitheliomas of the maxillary antrum, free of lymph node or distant metastases, and primarily treated at the Medical College of Virginia, form the basis of this study. Nineteen patients underwent radical', craniofacial surgery with orbital exenteration and reconstruction. Twenty patients underwent Caldwell-Luc procedure followed by radical radiation therapy. The crude 3 year disease-free survivals are 50% and 37% in the radiation therapy and the surgery group respectively. Local control, survival, and patterns of failure are discussed.     

Metastasis of malignant peripheral nerve sheath tumor to free vascularized myocutaneous flap

The vascularized free myocutaneous flap graft, a recent advance in microsurgery, is a very useful reconstruction technique for covering massive soft tissue defects or muscular dysfunction caused by wide resection for malignant soft tissue tumors. We have used this technique to treat many patients after resection for malignant soft tissue tumors. Recently we encountered a case in which a malignant peripheral nerve sheath tumor (MPNST) metastasized to a vascularized free myocutaneous flap used for limb reconstruction surgery after wide resection of a primary lesion. To our knowledge, there have been no previous reports of metastasis of a malignant soft tissue tumor (or any other cancer) to a grafted cutaneous or myocutaneous flap.     

额眶部骨纤维结构不良30例：三球法定位视神经管及临床效果评估

目的 研究额眶部骨纤维结构不良患者视神经管减压的适应证,以及术中视神经管定位和减压的方法。方法 收集我科骨纤维异常增殖病例共30例,术前进行充分的影像学评估,有症状者进行手术,包括眶部成型术和视神经管减压术。手术采用额颞硬膜外入路,如有凸眼则行经眶上缘入路。术中有6例进行了CT和MRI融合导航,协助寻找视神经的眶口或者颅口。术中使用三球法行视神经管减压,确认视神经位置。结果 视神经管减压30例,其中1例失明。患者视力和视野有不同程度改善,手术后凸眼消失或者改善。眶顶采用正常内板重建13例,钛板重建5例,未重建9例,2例用增生的碎骨铺于眶顶,但其中复发1例,表现为5年后再次出现眼球突出,而视力无下降。结论 额眶部骨纤维结构不良患者应积极手术治疗,视力下降应选择视神经管减压,合并面部畸形的同时做颅面部成型手术和眶减压术;硬膜外入路从眶口或者颅口定位视神经,结合三球法,可以做到安全且彻底的视神经管减压。     

Pre-prosthetic surgical alterations in maxillectomy to enhance the prosthetic prognoses as part of rehabilitation of oral cancer patient

After maxillectomy, prosthetic restoration of the resulting defect is an essential step because it signals the beginning of patient's rehabilitation. An obturator used to restore the defect should be comfortable, restore adequate speech, deglutition, and mastication, and is acceptable cosmetically, Success will depend on the size and location of the defect and the quantity and integrity of the remaining structures, in addition to pre-prosthetic surgical preparation of the defect sit. Preoperative cooperation between the surgeon oncologists and the maxillofacial surgeon may allow obturation of a resultant defect by preservation of the premaxilla or the tuberosity on the defect side and maintaining the alveolar bone adjacent to the defect of an abutment tooth. This study was carried out to evaluate the importance of Pre-prosthetic surgical alterations at the time of maxillectomy on the enhancement of the prosthetic prognoses as part of rehabilitation of the oral cancer patient. The present study was carried out on 66 cancer patient, 41 males 25 females ages ranging from 33 to 72 years, seeking treatment between 2003-2008 at The National Cancer Institute, Cairo university they underwent immediate prosthetic rehabilitation after maxillectomy surgery to remove the malignant tumor as apart of cancer treatment. Patients were divided into groups according to preprosthetic surgical preparation before prosthetic restoration. GROUP(A): Resection of maxilla followed by preprosthatic surgical preparation 24 cancer patients (13 males- 11 femals). GROUP(B): Resection of maxilla without any preprosthetic surgical preparation. 42 cancer patients (28 males and 14 females). Outcome variables measured included facial contour and aesthetic results, speech understandability, ability to eat solid foods, oronasal separation, socializing outside the home, and return-to-work status. Flap success and donor site morbidity were also studied. This study concluded that the cornerstone to improve the prosthetic restoration of the maxillary defect resulting maxillary resection as part of the treatment of maxillofacial tumor depend on the close cooperation between the prosthodontist and the surgeon, this can be achieved by combination of surgical and prosthetic technique which can be controlled by pre-prosthetic surgery during maxillect omy. KEY WORDS: Maxillary re-construction- Pre-prosthetic surgery- Oral cancer.     

Chest wall reconstruction after full thickness resection: an experience with 22 patients

The authors present their experience of chest wall reconstruction after full thickness resection in 22 patients. The patients are from a series of 80 patients treated by chest wall resection from 1967 to 1989. Whether performed on breasts still in place, for recurrent disease, or for radiation-induced lesions (which are often associated), the defect created by complete resection of the chest wall layers causes difficulties. Large cutaneous flaps, often including the opposite breast were used at the beginning of the series. Then came omentum associated to Mersilene mesh and myocutaneous flaps. The results, in terms of comfort and local control are acceptable, even though surgery is only palliative for cancer patients. We feel that full thickness chest wall resection is the only effective treatment for some primary and recurrent malignant tumors and for extensive thoracic radionecroses. Such procedures are designed to improve the patient's quality of life even if they do not actually prolong survival. The goals guiding the reconstruction programme are: (1) the restoration of a stable parietal rigidity; and (2) the reconstruction of long lasting superficial layers.     

膝部肿瘤切除后关节功能重建的方法分析

目的 探讨膝部肿瘤切除后关节功能重建的方法选择和疗效。方法 54例膝关节周围肿瘤中，骨巨细胞瘤25例，非骨化性纤维瘤2例，成纤维性纤维瘤2例，动脉瘤样骨囊肿1例，软骨黏液性纤维瘤2例，骨肉瘤15例，软骨肉瘤2例，恶性纤维组织细胞瘤5例。23例采用瘤体切除，吻合血管的自体髂骨、腓骨联合移植术，12例瘤段切除灭活再植术，19例瘤段切除人工假体置换术。结果 54例平均随访5年6个月，成活病例术后功能评价优良率为76％。结论 膝部肿瘤切除后关节功能的重建，应根据肿瘤的大小、包壳的完整性、软组织的侵及情况，以及肿瘤的病理组织学性质，选择适当的手术方法。瘤体切除，吻合血管的自体髂骨、腓骨联合移植术，是治疗膝关节周围良性侵袭性肿瘤或低度恶性肿瘤较为理想的方法。     

Complications following operative treatment of primary malignant bone tumours in the pelvis.

AIM: To report the complication rates of limb-salvage reconstruction in the pelvis. Detailed analyses about the type, treatment and outcome of post-operative complications, various reconstruction options are presented. METHODS: Factors that might influence the occurrence of complications were evaluated of 50 consecutive surgically treated patients. RESULTS: The mean follow-up was 57 months. Limb-salvage procedures were used in 42/50 patients, amputations in 8/50 patients. After limb-salvage procedures complications occurred in 32/42 patients, after hemipelvectomy in 6/8 patients. The 1 and 5-year overall survival rate was 92 and 68%, respectively. CONCLUSION: There is a high complication rate in reconstructive techniques using hemipelvic autografts and/or allografts. These procedures are appropriate only in well selected patients. The complication rates following endoprosthetic reconstruction are comparably low.     

Prognostic factors in maxillary sinus and nasal cavity carcinoma

AIMS: The aim of the present study is to define prognostic factors, particularly the impact of treatment on paranasal sinus and nasal cavity malignancies. MATERIAL AND METHODS: Retrospective study of patients with maxillary antrum and nasal fossae malignancies. A maxillectomy classification as performed to treat malignancies in our institution is described. Multivariate analysis of prognostic factors was done using the Cox's model. RESULTS: One hundred and nine patients were evaluated. Squamous cell carcinoma was found in 62 cases and in 95 patients the epicentre of the tumour was located in the maxillary antrum. Ten patients were treated with surgery only, 39 patients with surgery and adjuvant radiation therapy, 37 cases received only radiotherapy, and 18 received radiotherapy followed by surgery; in five cases a combination of chemo-radiotherapy was used. Multivariate analysis identified T classification, orbit invasion, N classification, site of origin of tumour in nasal fossae, and no surgical resection as independent prognostic factors (p=0.0001). CONCLUSION: T4 tumours with orbit invasion present bad prognosis as compared to other T4 tumours. Surgical resection should be included in the treatment strategy. Because of the high frequency of lymph-node metastasis, neck treatment should be considered in T4 tumours.     

累及胸壁的胸部肿瘤的外科治疗——胸壁切除与重建(附12例报告)

背景与目的胸部肿瘤累及胸壁是临床常见事件,若无远处转移,完整切除受累胸壁仍可获得良好疗效。本文结合12例肿瘤患者胸壁切除与重建(chest wall resection and reconstruction,CWRR)的经验就重建人工材料、软组织覆盖等方面作一介绍,并强调切除外科与重建外科合作的重要性。方法总结2005年10月-2011年4月北京大学肿瘤医院胸外一科和重建外科共同参与的CWRR 12例,详细复习自确诊至今的诊治全过程,包括术前治疗、手术方式、切除范围、重建方式,主要的局部及全身并发症及生存情况。结果 12例均为根治性手术,均行骨性胸壁切除,切除后骨性胸壁缺损为25 cm~2-700 cm~2,胸壁软组织缺损为56 cm~2-400 cm~2。骨性胸壁修补材料采用聚丙烯单丝网片(polypropylene mesh),软组织修复采用转移肌瓣、转移肌皮瓣及大网膜瓣。术后1例发生呼吸衰竭,呼吸机辅助通气1个月后痊愈,余例均无并发症,全组12例至今全部存活。结论只有切除外科和重建外科同时参与才能完成符合肿瘤原则的复杂CWRR。由切除外科主导、重建外科协助、了解并熟悉重建材料及胸壁软组织重建,是达到手术根治性及保证远期生存的关键。     

Sternal resection and reconstruction after malignant tumours

Aim  We present our experience of the resection of sternal tumours (both primary and metastatic), followed by reconstruction of soft-tissue and skeletal defects with a mesh and musculocutaneous flap. Methods  Eleven patients were included in this study, all of which underwent sternal tumour resection and immediate chest wall repair. Reconstruction was accomplished with prosthetic material (polytetrafluoroethylene [PTFE]), a sandwich of polypropylene (Marlex-methylmethacrylate or titanium/polypropylene) and a pedicled musculocutaneous flap (pectoralis major, latissimus dorsi or rectus abdominis). Sternal tumours may arise from both primary (chondrosarcoma and neurofibrosarcoma) and secondary (local recurrence of breast carcinoma and metastatic disease from other organs) disease. Results  Extubation did not result in paradoxical respiration in any of the patients in the study. The post-operative mortality rate was seen to be zero. One patient with a PTFE prosthesis had chest failure requiring immediate intubation and posterior prosthesis replacement. One mesh was removed two months after surgery. There was local recurrence in one patient and five patients died from distal metastases. The final patient is still alive with metastases at the time of presenting our results. Conclusions  Wide resection of sternal tumours provides good local control. Reconstruction with mesh and musculocutaneous flap is an effective technique for repairing such defects.     

Free flap reconstruction in the treatment of tumors involving the hard palate.

AIM: To report our experience in free flap reconstruction of the hard palate after malignant tumor resection, in terms of reconstruction method, immediate post-operative course and subjective functional results. PATIENTS AND METHODS: Files from 1988 to 1999 were reviewed for patients having undergone microvascular reconstruction of the hard palate. The immediate post-operative course (during the first month) was reviewed to determine the occurrence of complications. The surgeon's evaluation 1 year post-operatively was used to determine the intelligibility of speech, type of diet and the quality of nasal permeability. RESULTS: Thirty eight patients (28 men and 10 women) with malignant tumors involving the hard palate had undergone surgical reconstruction using microvascular free flap techniques: free radial forearm flap (13 cases), scapular flap (24 cases) or fibular flap (five cases). Two different flaps were employed in two cases (scapula plus fibula). A second flap was used with success in two cases of failure of the first flap, for a total of 42 free flaps for 38 patients. Complications occurred in seven cases, with two cases of flap necrosis. At 1 year, 33 patients achieved a normal diet and 35 normal or easily intelligible speech. CONCLUSIONS: Microsurgical reconstruction using free tissue transfer allows reconstruction of large defects of the hard palate, with low morbidity and an excellent functional outcome. We propose criteria for free flap reconstruction and choice of flap.     

Clinical Research of a Modified Midfacial Degloving in a Maxillectomy （with a Report of a Typical Case）

OBJECTIVE To investigate the feasibility of employing a modified midfacial degloving in maxillectomy. METHODS Eight patients with carcinoma of the maxillary sinus underwent a modified midfacial degloving operation.The tumors were classified according to the 2002 AJCC system.The TNM staging of the cases was as follows:1 T4aN0M0,2 T3N0M0 and 5 T2N0M0.Of the 8 cases,1 patient underwent extended maxillectomy;exenteration of the orbit;tumorectomy of the sphenomaxillary and infratemporal fossae.Two patients received a total maxillectomy,and 5 a partial resection of the maxilla. Postoperative pathological report:4 well-di?erentiated squamous carcinoma,2 moderately-differentiated squamous carcinoma,1 mucoepidermoid carcinoma and 1 adenoid cystic carcinoma. RESULTS A modified midfacial degloving operation can sufficiently expose a field of operation,resect the tumor within a safe margin,and leave no facial cicatricles.One patient died of intracranial metastasis 8 months a er operation.We observed no recurrences or metastasis in other patients during the period of follow-up. CONCLUSION The major advantages of employing the modified midfacial degloving in maxillectomy is that a facial incision can be avoided.It has an advantage of minimal invasive surgery.