Silvano Ferrari

Free flaps: Outcomes and complications in head and neck reconstructions

Between 2000 and 2007, 376 free-flap transfers were performed in 352 patients at the Department of Maxillofacial Surgery, University of Parma, Italy. They included 303 reconstructions after cancer surgery (80.6%), 28 secondary reconstructions (7.4%), 32 transfers for facial paralysis (8.5%) and 13 reconstructions for other pathology (3.5%) such as osteonecrosis and ameloblastoma. We determined the rates of major and minor flap, donor-site and systemic complications and analysed their relationships with factors such as aetiology, patient age, smoking history and the presence of comorbid conditions. For the free flaps examined in this study, the overall complication rate was 47%. Major complications occurred in 20.7% of the cases and minor complications in 26.3%. The major flap, donor-site and systemic complication rates were 11.9, 3.2 and 5.6%, respectively. Total flap loss occurred in 15 cases (4%). The minor flap, donor-site and systemic complication rates were 19.1, 4 and 3.2% respectively. Aetiology, patient age, smoking history and the presence of comorbid conditions were related to higher rates of major and minor complications, although these were not statistically significant.

Fibula Free Flap With Endosseous Implants for Reconstructing a Resected Mandible in Bisphosphonate Osteonecrosis

PURPOSE Bisphosphonates are a class of drugs with several uses. Primarily, they are used to treat bone metastases, multiple myeloma, Pagets disease, and osteoporosis. However, the use of bisphosphonates can lead to osteonecrosis of the jaws. Here, we present our experience treating this widely discussed disease. PATIENT AND METHODS We describe a patient who underwent surgical reconstruction of the mandible with a fibula free flap after total mandibulectomy, performed to treat osteonecrosis induced by the use of intravenous bisphosphonates complicated by a mandibular fracture. Endosseous implants were inserted simultaneously to optimize the length and outcome of surgery. RESULTS Osteonecrosis of the jaws is a treatment challenge, and several approaches have been suggested. In this patient, the use of a fibula free flap to reconstruct the mandible was a winning strategy. The patient is now free from disease, and the esthetic results were optimal. CONCLUSIONS With the simultaneous placement of endosseous dental implants, the functional outcome was optimal, with no significant complications or recurrence.

Free flaps in elderly patients: Outcomes and complications in head and neck reconstruction after oncological resection

INTRODUCTION Free flaps represent the first reconstructive option for many head and neck defects. The increasing life expectancy of the population results in increasing numbers of ageing patients facing complex reconstructive surgery. In this study we evaluated our experience with free-flap transfers in older patients, analysing the post-operative reconstructive and systemic complications. MATERIALS AND METHODS Between 2000 and 2009, 360 patients underwent free flap reconstruction of defects resulting from the treatment of head and neck tumours at the Operative Unit of Maxillofacial Surgery, University - Hospital of Parma, Italy. Fifty-five patients (15.3%) were more than 75 years old at the time of treatment. RESULTS At the end of the follow-up successful free-flap transfer was achieved in 360 of the 373 flaps harvested (96.5%). The overall reconstructive complication rate was 31.4%, (31.8% in the younger group and 29.1% in the remaining patients). Medical complications were observed in 29.2% of cases (less than 75 years: 28.8%; more than 75 years: 30.9%). The ASA status was associated with a statistically significantly higher incidence of complications within patients less than 75 years old (p < 0.0001). DISCUSSION AND CONCLUSIONS The results of this study, in agreement with previous studies, provide evidence that free-tissue transfer may be performed in ageing patients with a high degree of technical success. The chronologic age cannot be considered an appropriate criterion in the reconstructive decision. On the contrary, a careful selection of the patients based on comorbidities and general conditions (ASA status) is of primary importance in reducing post-operative complications and to improving the results of surgery.

Myomucosal cheek flaps: applications in intraoral reconstruction using three different techniques

OBJECTIVE The use of myomucosal flaps harvested from the cheek area for intraoral reconstruction has been recently popularized in the literature. Several surgical techniques have been reported, and each study has described the outcomes and advantages of each method. However, the literature lacks a summary of the various surgical techniques utilizing buccinator myomucosal flaps. This paper examines the use of the 3 most important buccinator myomucosal flaps: the buccinator musculomucosal flap, the facial artery musculomucosal flap, and the buccinator musculomucosal island flap. We clarify the applications of each technique in intraoral reconstruction and discuss the indications for, and advantages and disadvantages of, each flap. STUDY DESIGN Forty-six patients who underwent surgical resection for malignancies of the oral cavity and reconstructions with cheek flaps were retrospectively studied. RESULTS All flaps were harvested and transposed. Complete loss of the flap occurred in only 1 case. In 2 cases, marginal necrosis of the flap took place, with complete spontaneous healing in 2 weeks. CONCLUSION Buccinator musculomucosal flaps are a good option for reconstruction of moderately sized oral cavity defects. A key point in this procedure is flap selection based on not only the size and site of the defect, but also the patients characteristics and type of surgical procedure.

Adenoid cystic carcinoma of intraoral minor salivary glands

We present a retrospective multicentric study of 67 patients with adenoid cystic carcinomas of the intraoral minor salivary glands, who were diagnosed and treated between 1986 and 2004 in the Operative Units of Maxillofacial Surgery of the University of Parma and of the Bellaria Hospital in Bologna. There were 28 males and 39 females with a mean age of 54.5 years (range 28-84 years). The palate was the most common site of involvement, with 71.6% of cases. All the patients were treated with surgery as the primary modality. Neck dissection was performed in 9% of the patients, and more than half (59.7%) were treated with adjuvant radiation therapy. All surviving patients had a minimum of 2 years follow-up, with a range of 2-20 years (median: 12 years). Of the 67 patients examined in this study, 19 were dead at the end of the follow-up, 16 of them due to tumor disease. Distant or loco-regional recurrence was documented in 29 of the 67 patients (43.3%). Disease-free intervals ranged from 1 month to 12 years. Twenty-two percent of patients had loco-regional failure, whereas 29.8% had distant metastases. The disease specific survival rates were 76.1% at 5 years and 74% at 10 and 15 years.The actuarial loco-regional control rates at 5-, 10- and 15-years were 79.7%, 74.8% and 70%, respectively. The actuarial freedom from distant relapse was 76.5% at 5 years, 64.9% at 10 years and 61.1% at 15 years. Stage T, cervical lymph node metastasis and surgical margin status proved to make a statistically significant contribution when describing the outcome.

Facial Animation With Free-Muscle Transfer Innervated by the Masseter Motor Nerve in Unilateral Facial Paralysis

PURPOSE Facial paralysis is a congenital or acquired disorder of varying severity leading to an asymmetric or absent facial expression. It represents an important debilitation from both esthetic and functional points of view. In this article we report our experience with patients treated with gracilis muscle transplantation innervated by the motor nerve to the masseter muscle. We discuss the surgical technique and the functional and esthetic results and evaluate the effectiveness of this donor nerve in providing adequate innervation to the muscle transfer for lower facial reanimation. MATERIALS AND METHODS Fifteen patients with unilateral facial paralysis were seen and surgically treated at the Department of Maxillofacial Surgery, University of Parma, Parma, Italy, between 2003 and 2007. In this study we report on 8 cases treated with gracilis muscle transfer reinnervated by the motor nerve to the masseter muscle. RESULTS In this series all free-muscle transplantations survived transfer, and no flap was lost. Facial symmetry at rest and while smiling was excellent or good in all patients, and we observed a significant improvement in speech and oral competence. With practice, the majority of patients developed the ability to smile spontaneously and without jaw movement. CONCLUSIONS We consider the masseter motor nerve a powerful and reliable donor nerve, allowing us to obtain a commissure and upper lip movement similar to those of the normal site for amount and direction. This is why we think that there may be a larger role for the masseter motor nerve for innervation of patients with unilateral facial paralysis who would otherwise have been considered candidates for cross-facial nerve graft innervation of the muscle transfer.

Facial animation in children with Moebius and Moebius-like syndromes

BACKGROUND Moebius syndrome, a rare congenital disorder of varying severity, involves multiple cranial nerves and is characterized predominantly by bilateral or unilateral paralysis of the facial and abducens nerves. The paralysis of the VI and VII cranial nerves leads to a lack of function in the muscles they supply. Facial paralysis often causes bilabial incompetence with speech difficulties, oral incompetence, problems with eating and drinking, including pocketing of food in the cheek and dribbling, as well as severe drooling. METHODS In this study, we report on pediatric patients with Moebius and Moebius-like syndromes seen and treated surgically from 2003 to September 2007 at the Operative Unit of Maxillofacial Surgery, Head and Neck Department, University of Parma, Italy. RESULTS Twelve patients underwent microsurgical reconstruction for restoration of facial movement. The contralateral facial nerve was used as a motor donor nerve in 4 procedures, the motor nerve to the masseter muscle was used in 8 patients, and the gracilis muscle was used in all operations, with a total of 17 free-muscle transplantations. All free-muscle transplantations survived transfer, and no flap was lost. We observed a significant improvement in drooling, drinking, speech, and facial animation with a high degree of patient satisfaction. CONCLUSIONS The gracilis muscle free transfer is a surgical procedure well tolerated by the young patients and well accepted by their families. We consider it a safe and reliable technique for facial reanimation with good aesthetical and functional results in children with Moebius and Moebius-like syndromes.

Improving Esthetic Results in Benign Parotid Surgery: Statistical Evaluation of Facelift Approach, Sternocleidomastoid Flap, and Superficial Musculoaponeurotic System Flap Application

PURPOSE The purpose of this article was to analyze the efficacy of facelift incision, sternocleidomastoid muscle flap, and superficial musculoaponeurotic system flap for improving the esthetic results in patients undergoing partial parotidectomy for benign parotid tumor resection. The usefulness of partial parotidectomy is discussed, and a statistical evaluation of the esthetic results was performed. PATIENT AND METHODS From January 1, 1996, to January 1, 2007, 274 patients treated for benign parotid tumors were studied. Of these, 172 underwent partial parotidectomy. The 172 patients were divided into 4 groups: partial parotidectomy with classic or modified Blair incision without reconstruction (group 1), partial parotidectomy with facelift incision and without reconstruction (group 2), partial parotidectomy with facelift incision associated with sternocleidomastoid muscle flap (group 3), and partial parotidectomy with facelift incision associated with superficial musculoaponeurotic system flap (group 4). Patients were considered, after a follow-up of at least 18 months, for functional and esthetic evaluation. The functional outcome was assessed considering the facial nerve function, Frey syndrome, and recurrence. The esthetic evaluation was performed by inviting the patients and a blind panel of 1 surgeon and 2 secretaries of the department to give a score of 1 to 10 to assess the final cosmetic outcome. The statistical analysis was finally performed using the Mann-Whitney U test for nonparametric data to compare the different group results. P less than .05 was considered significant. RESULTS No recurrence developed in any of the 4 groups or in any of the 274 patients during the follow-up period. The statistical analysis, comparing group 1 and the other groups, revealed a highly significant statistical difference (P < .0001) for all groups. Also, when group 2 was compared with groups 3 and 4, the difference was highly significantly different statistically (P = .0018 for group 3 and P = .0005 for group 4). Finally, when groups 3 and 4 were compared, the difference was not statistically significant (P = .3467). CONCLUSION Partial parotidectomy is the real key point for improving esthetic results in benign parotid surgery. The evaluation of functional complications and the recurrence rate in this series of patients has confirmed that this technique can be safely used for parotid benign tumor resection. The use of a facelift incision alone led to a high statistically significant improvement in the esthetic outcome. When the facelift incision was used with reconstructive techniques, such as the sternocleidomastoid muscle flap or the superficial musculoaponeurotic system flap, the esthetic results improved further. Finally, no statistically significant difference resulted comparing the use of the superficial musculoaponeurotic system and the sternocleidomastoid muscle flap.

Free and locoregional flap associations in the reconstruction of extensive head and neck defects

Head and neck surgical defects after oncological resection of advanced carcinoma involving the oral cavity are often composite and involve bone, mucosa, soft tissues and skin. For the most extensive defects, the simultaneous association of two free flaps is the best choice to improve the function of the preserved structures. This procedure is difficult and involves prolonged surgery, therefore it is only possible in selected patients. In some composite head and neck defects the association of free and locoregional flaps seems to be indicated. This study, discusses the use of free and locoregional flap association, focusing on its aesthetic advantages and functional results. From January 1995 to December 2006, 30 patients received simultaneous locoregional and free flap transfer for closure of post-ablative oral cavity defects. Microvascular tissue transfer included the radial forearm, anterolateral thigh, rectus abdominis, and fibula and iliac crest free flaps. Locoregional flaps included the cervicofacial, cervicopectoral, deltopectoral, pectoralis major, latissimus dorsi and posterior scalp flaps. Based on the good functional and aesthetic outcome and low rate of complications, the association of free and locoregional flaps represents a good reconstructive option for patients with extensive post-oncological composite head and neck defects.

Iliac Crest Free Flap for Maxillary Reconstruction

PURPOSE Reconstructing defects after maxillary resections presents a challenge for the reconstructive surgeon because of the critical role played by the maxillary skeleton in facial function and esthetics. Obturation, local or locoregional flaps, and soft tissue free flaps are good options for maxillary reconstruction; however, the lack of bone reconstruction often leads to ptosis of the facial tissues, particularly of the nasal base and columella, under the effects of gravity and makes it impossible to place osseous implants for dental rehabilitation. We present our experience with the iliac crest free flap for maxillary reconstruction, focusing on the advantages of this technique and particularly on flap positioning, which is dependent on defect site and size. Finally, 2 representative cases will be presented. PATIENTS AND METHODS Between January 1, 1996, and January 1, 2008, 14 patients were treated for maxillary reconstruction with an iliac crest free flap. In 6 patients, the floor of the orbit was included in the resection. In 5 patients, we performed reconstructions using bone grafts harvested from the iliac crest, whereas in the remaining patient a titanium mesh was used. RESULTS All flaps were harvested and transposed. Minor complications included wound dehiscence in 2 cases, ectropion in 2, and nasal airway obstruction in 1. No major complications or donor site morbidity occurred. No oronasal communication or swallowing impairments developed in any patient. Seven patients completed oral rehabilitation with dental implant placement; the remaining 7 refused the treatment because of financial problems, and 4 patients were rehabilitated with a mobile prosthesis. CONCLUSIONS The iliac crest free flap is an optimal method for maxillary defect reconstruction. The main advantages of the flap are the large amount of bone provided, its height, and the possibility of including the internal oblique muscle. Flap insetting is the key part of the procedure, and whether to use vertical or horizontal placement of the flap is the main consideration. Finally, the low rate of donor site morbidity reported in our patients, as in the recent literature, makes this flap even more safe and reliable.