Microvascular craniofacial reconstruction in cancer patients

Background: Resections of large malignancies involving the middle and upper thirds of the face and cranium result in complex defects, posing a difficult challenge for the reconstructive surgeon. Free tissue transfer may be the best means of reconstruction. Methods: We reviewed 54 consecutive microvascular craniofacial reconstructions after tumor ablation performed at the University of Texas M.D. Anderson Cancer Center from May 1988 to September 1992. Information regarding patient characteristics, tumor stage and histology, history of prior therapy, the defect after tumor ablation, and the details of the reconstruction were entered in a microcomputer database at the time of the initial surgery. Free flap outcome, the number and type of complications, control of malignant disease, and the use of adjuvant therapy were recorded prospectively. Results: Patients had defects of the scalp and cranium (15 of 50) or of the maxilla/orbit/cranial base (35 of 50) after resections for a variety of tumors. Immediate reconstruction was completed in 40 patients and delayed in 10. Prior therapy included surgery (39 of 50) and/or radiotherapy (35 of 50). The free flap success rate was 96% (52 of 54). In patients with successful flaps, significant wound complications occurred in 13.5% of patients (seven of 52) and donor site problems in 11.1% (six of 54) for an overall complication rate of 24.1% (13 of 54). There were no operative deaths or neurologic complications. The timing of surgery or a history of prior surgical therapy or radiotherapy did not significantly influence the complication rates. Conclusion: Free tissue transfers provide optimal restoration of large craniofacial defects resulting from cancer resection. Presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, March 18–21, 1993.     

Microvascular reconstruction of nasal defects

Microvascular reconstruction of nasal defects is a complex procedure and must consider 3 nasal components: skin, osteocartilaginous framework, and intranasal lining. These layers can be reconstructed with various flaps and grafts. The commonly used flaps are the first dorsal metacarpal flap, dorsalis pedis flap, auricular helical rim flap, and radial forearm and prelaminated flaps. These flaps can be composed of skin and cartilage or skin and bone. The decision is based on the patient's needs taking into consideration the extent of the defect and presence or absence of nasal septum and columella.     

Custom implants for reconstruction of craniofacial defects.

This method deals with the fabrication of a custom silicone implant using Dow Corning Medical Grade Elastomer 382 (room-temperature vulcanizing silicone). The technique has been utilized in 34 cases during the past five years with a satisfactory end result in 33 of the 34 cases. This method, which appears to be quite accurate in obliterating the obvious defect, is simple in its execution and reduces the overall amount of operative time, since no carving or manipulation is necessary. It avoids unsightly "donor scars," and in some instances, the surgery can be done on an outpatient basis.     

Free composite reconstruction of a complex craniofacial defect

A case report is presented illustrating the use of a recently developed composite free flap from the chest wall to reconstruct a complex defect involving the scalp, cranial vault and orbit following the excision of a malignant tumour.     

Free anterolateral thigh flap for reconstruction of major craniofacial defects

Free-tissue transfer has revolutionized skull-base surgery by expanding the ability to perform cranial base resection and by improving the quality of reconstruction. The anterolateral thigh flap has come recently into use in the field of head and neck reconstruction. Its role in craniofacial and midface reconstruction has not been specifically defined. This study involved a total of 18 patients who were treated over a 5-year period from 1998 to 2003. Seventeen patients had locally advanced head and neck cancer, requiring craniofacial resection, and one patient had a complicated gun shot wound of the forehead. Thirteen patients were treated at the National Cancer Institute, Cairo University, Egypt, and five patients at the University of Miami, Florida. The patients presented with defects of the anterior skull base (5), lateral skull base (3), scalp and calvarium (3), and the midface (7). The anterolateral thigh flap was used as a myocutaneous flap in 11 cases and as a perforator fasciocutaneous flap in seven cases. Musculocutaneous perforators supplied the majority of flaps (17/18). Total flap survival occurred in 17 cases; one patient developed complete flap necrosis. The most commonly used recipient vessels were the facial vessels and the external jugular vein. Major complications included one case with meningitis; the patient died after failure of treatment. Another patient died 6 weeks postoperatively from pulmonary embolism. One patient developed CSF leak that stopped spontaneously. In addition, two patients developed minor wound dehiscence that healed spontaneously. The donor-site wound healed without problems except in two cases. One patient had an incomplete take of the skin graft; the other developed wound infection and superficial sloughing. Both wounds healed spontaneously. In addition to the feasibility of simultaneous flap harvesting with tumor resection, the flap's advantage in skull base reconstruction is its reliable blood supply, which can provide adequate dural cover and protection of the brain. Its size and moderate thickness are suitable for reconstruction of scalp and calvarial defects. The abundance of reliably vascularized fat in the flap may be an advantage in long-term maintenance of the volume of the flap in midface reconstruction. Similar to other soft tissue flaps, additional skeletal reconstruction may still be required to achieve an optimal functional and aesthetic result.     

Combined reconstruction of complex defects of the chest wall.

Defects of the chest wall are often encountered, and good results can be obtained both cosmetically and functionally from their treatment. We treated 13 patients with full thickness chest wall defects. Follow up ranged from 12 days to 19 months. Three had had recurrent breast carcinoma, seven relapse after excision of a sarcoma, two had had lesions of the chest wall after irradiation, and one had a sternal fistula. Local skin, musculocutaneous and free latissimus dorsi and anterolateral thigh flaps were done to cover soft tissue. Fascia lata, polypropylene (Marlex) mesh, and Marlex mesh-methylmethacrylate sandwich prosthesis, were used to stabilise the skeleton in nine patients. Two of the patients died postoperatively, one early. The use of Marlex mesh-methylmethacrylate sandwich prostheses for the stabilisation of the skeleton and local musculocutaneous flaps for covering soft tissues after resection of three or more ribs is effective.     

Composite cervicofacial flap for reconstruction of complex cheek defects.

The authors present the reconstructive technique for complex cheek defects using the composite cervicofacial flap and study the possibilities, advantages, disadvantages, and results that can be expected. The design follows the classic outline of Mustardé's flap. The skin is undermined for 2 cm anterior to the ear, then after incision of the superficial musculoaponeurotic system (SMAS), undermining is continued below the plane of the SMAS, level with the facial nerve branches. It is continued forward to the facial vessels, which give rise to branches that ensure the blood supply of this composite flap and contribute to its high reliability. In the cervical region, undermining is done beneath the platysma, which is transected transversely in the lower cervical region to allow good upward mobility and satisfactory transposition of the flap. The flap is adapted to the defect and the medial suture line is placed as near as possible to the medial limit of the cheek aesthetic unit. The authors carried out a retrospective study of 7 patients with complex facial reconstruction after excision of malignant lesions. The defects measured from 4x4 cm to 9x7 cm. In 4 patients excision included the periosteum, and in 1 patient excision involved the entire thickness and removed the entire anterior half of the cheek. In 4 patients reconstruction involved the cheek and eyelid. In spite of the advanced age of the patients (88, 69, 91, 67, 70, 82, and 59 years), there was no distal edge necrosis. The only complication was a single case of facial paresis, which resolved spontaneously. The results were considered very good in all 7 patients. The authors conclude that the composite flap increases the possibilities of the cervicofacial flap. It is more mobile, more reliable, thicker, and more adaptable. It can be used in complex cheek defects that involve the periosteum, or even in full-thickness defects. The quality of the results obtained using this flap represents a considerable advance in facial reconstruction.     

Microvascular reconstruction of the traumatized thumb.

Microvascular reconstruction of the thumb is technically exacting and requires a firm grasp of anatomic variations of toe blood supply. Careful preoperative planning and meticulous microsurgical technique result in a low primary failure rate and maximize functional and aesthetic results.     

Microvascular free flaps in breast reconstruction.

There is no longer any doubt that free flaps can achieve the best breast reconstruction. Proof is the rapidly increasing popularity of the method. Its many advantages, the indications for each flap, and the technical refinements are presented.     

Sculpturing a fibular flap: combined horizontal/vertical osteotomy and ostectomy for reconstruction of complex craniofacial defects with one flap

A fibular flap has great versatility in reconstructive procedures. Osteomies and ostectomies enable the flap to be used for variable defects. We used combined horizontal/vertical osteotomy and ostectomy for reconstruction of complex craniofacial defects with one flap in two patients. Vertical osteotomy transforms the tubular structure of a fibula into a flat bone that can be used for reconstruction of wider defects with less vertical height. Neither vertical osteotomy nor ostectomy had negative effects on viability and bony healing of the segments in our patients. We think that the fibular flap, thanks to its versatility, can be used for reconstruction of complex orbito-zygomatic and orbito-cranial defects successfully.     

Combined reconstruction of complex defects of the chest wall

Defects of the chest wall are often encountered, and good results can be obtained both cosmetically and functionally from their treatment. We treated 13 patients with full thickness chest wall defects. Follow up ranged from 12 days to 19 months. Three had had recurrent breast carcinoma, seven relapse after excision of a sarcoma, two had had lesions of the chest wall after irradiation, and one had a sternal fistula. Local skin, musculocutaneous and free latissimus dorsi and anterolateral thigh flaps were done to cover soft tissue. Fascia lata, polypropylene (Marlex®) mesh, and Marlex® mesh-methylmethacrylate sandwich prosthesis, were used to stabilise the skeleton in nine patients. Two of the patients died postoperatively, one early. The use of Marlex® mesh-methylmethacrylate sandwich prostheses for the stabilisation of the skeleton and local musculocutaneous flaps for covering soft tissues after resection of three or more ribs is effective.     

Microvascular soft tissue reconstruction of the digits.

INTRODUCTION: Composite tissue loss to digits following trauma may require flap coverage. Local reconstruction techniques are popular but can result in a functional limitation at the donor site. Small free flaps though complex, may provide a superior alternative. METHOD: We retrospectively reviewed the case-notes of all patients who had a small free flap to a digit following trauma. The time period was 4 years (2000-2004). Sixteen patients with 18 digital free flaps were identified. These comprised of 10 venous flow-through flaps, one lateral arm flap, one great toe to thumb pulp transfer, three first web space flaps from the foot, one medial plantar flap and two free posterior interosseous flaps. All 16 patients were invited for clinical review at an out-patients clinic. Ten patients (11 flaps) attended follow-up. Standardised assessment of outcome in terms of scar quality at both the recipient and donor sites, sensibility, range of motion and function of the hand was completed. RESULTS: Overall the average follow-up period was 14 months, with 16 out of 18 flaps surviving. Of the patients that attended for clinical review, the majority recovered excellent function of the hand (quick-DASH--av. 5.7) with satisfactory aesthetics, minimal pain or limitations in range of motion. The flaps were all soft and durable. Ten flaps recovered protective but not discriminative sensation (only one flap was innervated). The three patients whose donor site was the first-web space of the foot developed significant hypertrophic scarring. CONCLUSION: Small free flaps provide an acceptable method of reconstructing digital defects. Venous flow-through flaps provided the best overall results in this series. The donor site for first-web space flaps is probably unacceptable.     

Biomaterials in craniofacial reconstruction

Biomaterials have become an integral component of craniofacial reconstruction. Their increasing ease of use, long "shelf-life," and safety enables them to be used effectively and play an important role in reducing operating times. There are various biomaterials currently available and specific usages have been characterized well in the literature.This article reviews different biomaterials that can be used in craniofacial reconstruction,including autogenous bone, methyl methacrylate and hard tissue replacement,hydroxyapatite, porous polyethylene, bioactive glass, and demineralized bone.     

Microvascular second toe transfer for digital reconstruction.

Reconstruction of a severely damaged hand, with multiple amputations of digits, presents a difficult reconstructive problem. The development of a safe method of transfer of the great toe for thumb reconstruction, using the dorsalis pedis artery and the saphenous vein, suggested the possibility of one-stage microvascular transfer of the second toe for reconstruction of fingers. In two patients a one-stage transfer of the second toe was done to replace an index finger and in another for restoration of part of the left ring finger. The transplants survived without anticoagulants and vessel complications were not encountered. Sensory return was adequate and a significant improvement in function was achieved.     

Microvascular reconstruction of the hand

For the patient with a demonstrated occlusion in either the major arterial supply of the hand or in the distal digital circulation, modern microsurgery offers an opportunity for reconstruction with restoration of normal flow and sensibility. Observation should not be the mainstay of therapy for digital or upper extremity ischemic symptoms. The surgeon may select from a myriad of sophisticated invasive and noninvasive tests that permit definitive identification of microvascular pathology. Until further improvement in pharmacologic treatment occurs, microsurgery offers the greatest opportunity for correction of these conditions.