Andrea Battisti

Scapula free flap for complex maxillofacial reconstruction.

Introduction:Composite tissue defects of the mandible and maxilla, after resection of head and neck malignancies, osteoradionecrosis, malformations, or traumas, cause functional and aesthetic problems. Nowadays, microvascular free flaps represent the main choice for the reconstruction of these defects. Among the various flaps proposed, the scapula flap has favorable characteristics that make it suitable for bone, soft tissue, or combined defects. Materials:We report 7 cases of reconstruction of complex maxillofacial defects with subscapular system flaps. The patients treated had Romberg syndrome (1 case), malignant tumors (5 cases), and result of previous trauma (1 case).Location of deficit was the maxilla (3 cases), the mandible (2 case), the ethmoidal-maxillary region (1 case) and the upper and middle thirds of the face in the last case. Methods:In 2 cases, a parascapular system flap was used; in 5 cases, a composite flap with latissimus dorsi muscle and scapular bone. Results:Neither failure of the harvested flaps nor complications in the donor site were evidenced. A good aesthetic and functional outcome was obtained in all cases. Discussion:Many free flaps have been proposed for the reconstruction of defects in the maxillofacial region such as fibula, deep circumflex iliac artery, scapula, among the bone flaps; and forearm, rectus abdominis, and anterolateral thigh, among the soft tissue flaps. The choice of the flap to use depends on the length of the bone defect and the amount of soft tissues required. The subscapular system has the advantage of providing different flaps based on the same pedicle. The osteofasciocutaneous scapular free flap, in particular, allows wide mobility of soft tissues (parascapular flap) with respect to its bone component (scapular bone), resulting suitable for defects of large size involving both the soft tissues and the bone. Conclusions:Although the fibula flap and the deep circumflex iliac artery flap remain the first choice for bone reconstructions of the mandible and maxilla, the scapula flap has some features that make its use extremely advantageous in some circumstances. In particular, we advocate the use of the osteomuscular latissimus dorsi-scapula flap for reconstruction of large-volume defects involving the bone and soft tissues, whereas fasciocutaneous parascapular flaps represent a valid alternative to forearm flap and anterolateral thigh flap in the reconstruction of soft tissue defects.

Surgical planning in reconstruction of mandibular defect with fibula free flap: 15 Patients

The authors present a descriptive work on the reconstruction of large oromandibular defects with revascularized fibula free flaps in a group of patients treated by surgical resection of bony and soft tissues of the mandible. The principal objective is preoperative planning for the best morphological, functional, and aesthetic result. The authors report 15 reconstructions of wide oromandibular defects by revascularized fibula free flaps. The average patient age was 42 years. The mean follow-up period was 18 months. Correct surgical planning reduces surgical timing, minimizes the chance of failure during the reconstruction, and contemporaneously increases treatment efficacy and the best functional and aesthetic results.

Anterolateral thigh flap for the reconstruction of head and neck defects: alternative or replacement of the radial forearm flap?

This paper presents our clinical experience with head and neck reconstruction using radial forearm flap and our preliminary experience with anterolateral thigh (ALT) flap. We analyze the advantages and disadvantages of these 2 flaps from the complications we have encountered. From 1993 to 2006, the radial forearm flap has been used in 75 patients, whereas we began using the ALT flap in 2006. Since this time, we have used the ALT flap in 10 patients. One flap partial loss was observed in a patient who underwent reconstruction of the ethmoid region and nasal bones with an osteofasciocutaneous radial flap. In one patient who underwent reconstruction with ALT flap, inadequate venous outflow was discovered, and the flap was salvaged with reexploration, removing of the cutaneous component of the flap and using antithrombotic agents. Donor-site complications were experienced in 8 of 75 patients who underwent reconstruction with radial forearm flap, whereas all donor thighs healed uneventfully. Anterolateral thigh flap gives optimal results either at the donor site or at the accepting site, being easy to harvest and providing an ideal reconstructive option. Nevertheless, radial forearm flap remains a valuable alternative in case of a thin soft tissue reconstruction because of its thinness and versatility; furthermore, it can provide a long and constant pedicle of large caliber. However, since we began using the ALT flap, we had only performed this flap with respect to radial forearm flap because of its lower donor-site morbidity.

One-stage reconstruction of a defect of the oral commissure and of the cheek with a radial forearm free flap.

Several reconstructive methods have been proposedfor complex clinical cases. These methods are basedon composite graft tissue flaps which allow to obtain modest aesthetic-functional results. Only recently, revascularized flaps (fasciocutaneous free flap of radial) have been used. In this work, the authors present a clinical report of cheek mucosal carcinoma extended to the omolateral lip commissure, which has required the full thickness removal of the cheek, the lip commissure, and part of both lips; the use of a bileft free fasciocutaneous flap ofradial (to reconstruct with a single flap both thecutaneous and mucosal deficits) has allowed foradequate reconstruction with good aesthetic and functional results.

Management of clinically negative neck in maxillary carcinoma.

Maxillary cancers include neoplasms arising in both maxillary sinus and oral cavity (upper alveolar ridge, hard palate) according to the American Joint Committee on Cancer. Although it is universally accepted that the combination of surgery and radiotherapy seems to be the treatment of choice, there is no accordance about the treatment of clinically negative neck. We retrospectively analyzed 20 patients with maxillary sinus cancer and 37 with an upper alveolar ridge or hard palate cancer, evaluating the incidence of N-disease and the recurrence at local site. On the basis of our findings, we can affirm that elective treatment of the neck in maxillary carcinoma is not recommended. Considering only squamous cell carcinoma, cervical node metastases are most frequent in case of tumors staged as T1 o T2. High-grade squamous cell carcinomas seem to be related to a higher incidence of nodal involvement. T recurrence has demonstrated to be the most frequent neoplastic event, so that radical surgery is considered one of the most important prognostic factors. Nevertheless, other prospective studies are necessary.

Single-step nasal reconstruction with osteocutaneous forearm flap after total rhinectomy.

Purpose Nasal defects resulting from tumor excision can be classified according to tissues involved, such as skin, cartilage, and bone. Although in the case of “simple” defects, reconstruction with loco-regional flap eventually associated with cartilage grafts can lead to satisfactory results; in the case of total or partial rhinectomy, a minimum of 3 and a maximum of 7 operations have to be performed in the current series to achieve an acceptable end result. We present the case of a total rhinectomy reconstruction in a single-step procedure with an osteocutaneous forearm free flap (RFOFF). Clinical Report A 50-year-old man underwent total rhinectomy to excise a pathologically proven T4aN0 moderately differentiated squamous cell carcinoma of the nose; contemporary single-step reconstruction with an RFOFF was performed. Adjuvant radiotherapy was performed. Result At 18 months of follow-up, the patient is free of disease and no postirradiation flap damage has been experienced; the flap notably did not appear to be bulky. Conclusions We believe that the RFOFF is morphologically and functionally better than other flaps owing to its capability to adapt to the new environments of the nasal cavity, and to avoid, when possible, a three-dimensional reconstruction of the same.

Endoscopic approach to benign lesion involving the mandibular condyle.

Benign lesions involving the mandibular condyle are rare. Odontogenic keratocyst has been always an interesting subject to debate since Philipsen first described it as a distinct entity in 1956. Nevertheless, the large variability and the lack of homogeneity between patients in the different studies did not allow to develop universally recognized guidelines for the keratocyst odontogenic tumor treatment. The aim of this article was to present a new surgical technique to approach high-dimension benign lesion located at the level of the mandibular ramus and condyle, consisting enucleation and curettage under endoscopic vision.

Rare Complication in Third Maxillary Molar Extraction: Dislocation in Infratemporal Fossa

Aim: Removal of impacted third maxillary molar is frequently carried out without difficulties and low rate of intraoperative complications. The rare and particularly challenger to manage it is the third molar dislocation into the infratemporal fossa (IF). In this clinical report, the authors present their solution to manage and resolve this particular complication. Methods: A 28-year-old woman was referred to the emergency rescue unit of the authors’ hospital by her dentistry, after the attempt to extract the left impacted maxillary third molar. During the procedure the tooth accidentally dislodged and was lost sight of it. The patient had significant mouth-opening limitation, omolateral mid face swelling and pain. Computer tomography was immediately performed to determine the exact position of the tooth, showing the dental element dislocated into the IF. Results: Considering all of possible complications the best surgical option must guarantee a direct approach and a constant eye contact of the tooth, even in case of further displacement during the procedure, and allow early surgery. The authors used an endoscopic transoral approach through the preexisted access and solved all the issues reducing morbidity. Conclusion: Removing tooth from the IF could be burdened by serious risk of bleeding and/or nerve injury. The endoscopic approach provides direct view of the IF reducing morbidity.

Metastatic Uterine Leiomyosarcoma in the Upper Buccal Gingiva Misdiagnosed as an Epulis

Uterine leiomyosarcoma (LMS) is a rare tumor constituting 1% of all uterine malignancies. This sarcoma demonstrates an aggressive growth pattern with an high rate of recurrence with hematologic dissemination; the most common sites are lung, liver, and peritoneal cavity, head and neck district being rarely interested. Only other four cases of metastasis in the oral cavity have been previously described. The treatment of choice is surgery and the use of adjuvant chemotherapy and radiation has limited impact on clinical outcome. In case of metastases, surgical excision can be performed considering extent of disease, number and type of distant lesions, disease free interval from the initial diagnosis to the time of metastases, and expected life span. We illustrate a case of uterine LMS metastasis in the upper buccal gingiva that occurred during chemotherapy in a 63-year-old woman that underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy for a diagnosis of LMS staged as pT2bN0 and that developed lung metastases eight months after primary treatment. Surgical excision of the oral mass (previously misdiagnosed as epulis at a dental center) and contemporary reconstruction with pedicled temporalis muscle flap was performed in order to improve quality of life. Even if resection was achieved in free margins, “local” relapse was observed 5 months after surgery.