Valentina Taglietti

Free Flaps in Head and Neck Reconstruction after Oncologic Surgery Expected Outcomes in the Elderly

Objective To provide surgeons and clinicians with a critical review of microvascular reconstructive options and their expected outcomes after head and neck cancer resection in the elderly. Data Sources Medline, Isiweb, and Cochrane databases. Review Methods A literature search was performed in May 2014 and included studies published between 2000 and 2014. Keywords were used for articles identification, and inclusion criteria were defined for consideration in the present review. Conclusions Evaluation of the pertinent literature is hampered by a number of biases, such as a lack of general consensus of a definition of “elderly,” differences among scales used to quantify comorbidities, and subjective evaluation of flap-related and systemic complications. However, our findings showed no differences in terms of free flap success, surgical complications, or mortality rate between older and younger patients. Moreover, recipient site complications do not seem to be affected by age. Implication for Practice Microvascular reconstruction in the elderly can be performed with high success rates, even though medical complications can occur more frequently compared to younger patients. Minor and major surgical complications in the elderly appear to be comparable to those in the younger population and do not affect final outcome or the perioperative mortality rate. Flap outcome does not seem to be significantly affected by age. Careful preoperative assessment and postoperative monitoring are mandatory to prevent adverse events, and prompt management is warranted whenever present.

Evolution of complex palatomaxillary reconstructions: the scapular angle osteomuscular free flap.

Purpose of reviewThis review summarizes the worldwide experience (105 patients) in primary and secondary reconstruction of palatomaxillary oncologic defects with the angular branch-based subscapular system of free flaps, comparing the advantages and disadvantages of the technique with those of other well known osseous donor sites such as the fibula and iliac crest. Recent findingsThe most recognized indications for angular branch-based osteomuscular free flaps are class II (especially in association with zygomaticomaxillary buttress and/or floor of the orbit removal) and class III defects according to the Okay classification. Defects involving clearance of the orbital content have also been reconstructed in this manner. One of the most important drawbacks of this technique (i.e., need for intraoperative patient repositioning) is no longer considered an issue, and evidence has been provided that harvesting of angular branch-based scapular flaps may be routinely performed in a supine position. Three-dimensional morphologic similarity of the tip of the scapula with the native hard palate and other maxillary structures makes flap fabrication easy and practical, with at least two (horizontal and vertical) most commonly used flap orientations applied to reconstruct different defects. SummaryAngular branch-based osteomuscular scapular free flaps represent a major advance in palatomaxillary reconstruction: their versatility, long pedicle with large caliber donor vessels, morphologic similarity with maxillary bony structures, and limited donor-site morbidity compare favorably with those of other osteomuscular and osteomusculocutaneous free flaps described for such challenging reconstructive purposes.

Is it time to incorporate 'depth of infiltration' in the T staging of oral tongue and floor of mouth cancer?

Purpose of reviewTo summarize recent acquisitions in three-dimensional tongue and floor of mouth anatomy that can help in better evaluation of the pathways of cancer progression within these oral subsites, thus giving some hints for refining of the current TNM staging system. Recent findingsThe Visual Human Project is an initiative aimed at establishing a three-dimensional dataset of anatomy of two cadavers made available free to the scientific community. Visual human data have been analyzed by specific software thus improving our three-dimensional understanding of the tongue myostructure. It is already known that there is limited prognostic utility in using the two-dimensional surface diameter alone as criterion for T1–T3 definition. Recently, also the T4a categorization for the infiltration of ‘deep’ or extrinsic tongue muscles has been criticized. This is largely because the descriptor ‘deep’ does not take into account the fact that considerable portions of these muscles lie in a very superficial plane. Different prognosticators have been proposed for inclusion into the TNM staging system of oral cancer but ‘depth of tumor infiltration’ seems to be the most robust, universally recognized, and reproducible in the preoperative, intraoperative, and postoperative settings. SummaryOral tongue and floor of mouth cancer needs to be classified according to a revised TNM staging system in which ‘depth of infiltration’ should be taken into account. An ‘ideal cut off’ for distinguishing ‘low’ (T1–T2) from ‘high-risk’ (T3–T4) categories has been proposed based on the literature review, but needs retrospective as well as large prospective trials before its validation.

Microvascular head and neck reconstruction in the elderly: The University of Brescia experience

Microvascular reconstruction in head and neck surgery is increasing in the elderly because of prolonged life expectancy. The purpose of this study was to evaluate the impact of age on outcomes after microvascular reconstruction.

Deep inferior epigastric artery perforated rectus abdominis free flap for head and neck reconstruction

The deep inferior epigastric artery perforated rectus abdominis (DIEAP-ra) free flap is a modification of the classic myocutaneous DIEA free flap in which only fasciocutaneous tissue is harvested based on the paraumbilical perforators of the medial row. The aim of this retrospective study is to describe our experience with this reconstructive technique in head and neck surgery. Between 2004 and 2009, 24 patients affected by oncologic maxillofacial, skull base, oral, and oropharyngeal defects were submitted to reconstruction with DIEAP-ra. After harvesting the DIEAP-ra, the longitudinally split muscular belly was sutured and the anterior rectus sheath closed with a nonabsorbable mattress suture without inlay mesh interposition. Surgical defects encompassed half of the hard palate in ten patients, orbit and part of the cranial vault in one, radical extended parotidectomy in four, subtotal glossectomy in seven, and total glossectomy in two cases. The only complete flap necrosis (4%) developed as a consequence of an orocutaneous fistula and required a second latissimus dorsi free flap. Another case (4%) developed a partial necrosis for oropharyngeal fistula after total glossectomy that healed after transposition of a pedicled myofascial pectoralis major. Two patients (8%) presented a minor salivary fistula that healed by medication alone. No major complication of the donor site was observed. DIEAP-ra is a valid alternative to the DIEA free flap when applied to complex maxillofacial or tongue major defects. Its greatest advantages are the reduced donor site morbidity and a more adjustable thickness of the skin paddle, particularly in females and obese patients.

Fasciocutaneous free flaps for reconstruction of hypopharyngeal defects

Different reconstructive options are available for defects following total laryngectomy (TL) and circumferential (CH) or partial hypopharyngectomy (PH). We evaluated the flap success, pharyngocutaneous fistula, and pharyngoesophageal stenosis rates in two groups of patients treated by different policies.