Microsurgical Reconstruction of the Nose: The Aesthetic Approach to Total Defects.

BACKGROUND: Reconstruction of complex defects involving nose and close facial units represents an aesthetic and functional challenge. Restoring satisfactory nasal shape, combining aesthetic, nasal function and patent airways is mandatory. In this paper, we describe our approach to total nose defects and we report our 20-year experience in microvascular nose reconstruction.Clinical cases are shown to illustrate different surgical techniques and the evolution of our approach. METHODS: Nasal reconstruction procedures were performed on 21 patients between 2000 and 2020 using the radial forearm flap (RFF) or anterolateral thigh (ALT) flap. Reported reconstructions included total/subtotal nasal defects, caused by cancer resections. The key point of our approach is the expanded forehead flap for skin coverage. Reconstruction is completed by cartilage grafts to restore nasal framework and to shape nasal tip. Ancillary procedures were needed in some cases to optimize aesthetic outcomes. RESULTS: Twenty-one patients completed the multistage nasal reconstruction. The RFF flap was used in 56% of the cases (n = 11), while the ALT flap was used in 44% (n = 10) of our case series. No difference has been detected in the number of reconstructive stages required to achieve the final result comparing RFF and ALT reconstruction (3.3 vs. 3.1 reconstructive steps). Ancillary procedures were performed in 7 patients. CONCLUSION: Microvascular tissue transfer plays a key role in full-thickness nasal defects restoration. Comparing the two groups, both the RFF and ALT are effective and reliable options in lining reconstruction, although with different indications. Expanded forehead flap, combined to free cartilage graft, is our gold standard to provide external skin coverage to rebuild the nasal framework. According to our current approach, accurate preoperative planning, supported by modern technologic tools, multistage reconstruction, and ancillary procedures are useful to accomplish satisfactory functional and aesthetic outcomes.

Navigation-guided resection of maxillary tumours: The accuracy of computer-assisted surgery in terms of control of resection margins - A feasibility study.

INTRODUCTION: Surgical treatment of maxillary tumours is often highly complex. The three-dimensional anatomy of the mid-face renders both correct intraoperative orientation and adequate oncological safety difficult to obtain. Recently, computer-assisted techniques and intraoperative navigation have been applied to oncological surgery treating head and neck cancer. However, only a few studies have explored whether preoperative virtual resection planning and intraoperative control of resection margins allow assessment of the surgical margins of the tumour. In our present feasibility study, we developed a protocol for preoperative mapping of tumour margins using computed tomography and/or magnetic resonance imaging, virtual planning of the surgical resection, and intraoperative navigation during actual resection of advanced maxillary tumours. MATERIALS AND METHODS: Twenty patients were included in this feasibility study. We prospectively selected ten patients requiring surgery to treat malignant maxillary tumours. A control group of ten patients was retrospectively selected. The simulation protocol featured the following steps: 1. "Contouring" of the tumour: identification of the tumour and the borders thereof on the axial, sagittal, and coronal planes; 2. Definition of the resection margins by positioning "landmarks" at least 1 cm from the tumour edges on the axial, sagittal, and coronal planes; 3. Simulation of osteotomy lines passing through the landmarks, and evaluation of the bony defects to be reconstructed. Tumour margins were controlled by using a pointer to identify mobilised regions and then checking the overlap between the planned resection (shown on the LCD screen of the navigation system) and the real anatomical situation. RESULTS: A total of 127 margins were pathologically assessed in the test group, and 85 were assessed in the control group. Overall, 9% of surgical margins were positive in the test group, and 16% were positive in the control group (p = 0.0047). A significant difference was apparent in terms of deep margin evaluation: in test patients, 87% of margins were clear; this figure was 75% for the control group (p = 0.0038). No significant difference in either mucosal or bone margin clearance was evident. The preoperative planning errors were <5 mm for 91% of all planned resection margins. CONCLUSION: The navigation-guided resection protocol seems to improve tumour-free margin status in patients with advanced maxillary tumours. Further confirmatory trial, enrolling a larger cohort of patients, is needed to strengthen these preliminary results and advantages of this procedure.

Orbital Reconstruction: Patient-Specific Orbital Floor Reconstruction Using a Mirroring Technique and a Customized Titanium Mesh.

OBJECTIVE: Enophthalmos is a severe complication of primary reconstruction of orbital floor fractures. The goal of secondary reconstruction procedures is to restore symmetrical globe positions to recover function and aesthetics. The authors propose a new method of orbital floor reconstruction using a mirroring technique and a customized titanium mesh, printed using a direct metal laser-sintering method. METHODS: This reconstructive protocol involves 4 steps: mirroring of the healthy orbit at the affected site, virtual design of a patient-specific orbital floor mesh, CAM procedures for direct laser-sintering of the customized titanium mesh, and surgical insertion of the device. Using a computed tomography data set, the normal, uninjured side of the craniofacial skeleton was reflected onto the contralateral injured side, and a reconstructive orbital floor mesh was designed virtually on the mirrored orbital bone surface. The solid-to-layer files of the mesh were then manufactured using direct metal laser sintering, which resolves the shaping and bending biases inherent in the indirect method. An intraoperative navigation system ensured accuracy of the entire procedure. RESULTS: Clinical outcomes were assessed using 3dMD photogrammetry and computed tomography data in 7 treated patients. CONCLUSION: The technique described here appears to be a viable method to correct complex orbital floor defects needing delayed reconstruction. This study represents the first step in the development of a wider experimental protocol for orbital floor reconstruction using computer-assisted design-computer-assisted manufacturing technology.

Computer-Aided Rehabilitation of Maxillary Oncological Defects Using Zygomatic Implants: A Defect-Based Classification.

PURPOSE: A complete maxillectomy for neoplastic lesions leads to serious oral dysfunction. Zygomatic implants for fixed bridge support are considered beneficial for maxillary defects after tumor resection. MATERIALS AND METHODS: This clinical study examined the management of patients with different maxillary defect types who underwent delayed rehabilitation using zygomatic implants and immediate prosthetic loading. Virtual preoperative planning and intraoperative navigation were performed in all cases. RESULTS: Five patients were treated with this new method. The total number of zygomatic implants positioned was 17. Four patients had immediate loading of a fixed prosthesis and 1 had delayed loading. One patient had 1 failed implant. CONCLUSION: The use of preoperative virtual surgical planning and an intraoperative navigation system allows the surgeon to achieve safer implant positioning in a complex anatomic site. A systematic bone defect classification was created and a specific treatment protocol is proposed for each type of defect.

Aggressive Central Giant Cell Granuloma of the Mandible Treated With Conservative Surgical Enucleation and Interferon-α-2a: Complete Remission With Long-Term Follow-Up.

Central giant cell granuloma (CGCG) is a benign tumor of the jaws. Aggressive lesions present a strong tendency toward recurrence after surgical enucleation; thus, en bloc resection and microvascular bone free flap transfer are usually performed. However, in young patients, aggressive surgical treatment is a not always suitable solution. This report describes the case of a young female patient who developed an aggressive recurrence of CGCG after its diagnosis and enucleation from the mandible. Surgical enucleation with subcutaneous injection of interferon-α-2a was performed. The patient was evaluated every 6 weeks, and after 6 months radiographic evidence of complete bone regeneration was obtained. No sign of recurrence was seen after 8 years of follow-up. A review of the literature proved that interferon treatment is an effective strategy to avoid extensive surgery in patients with aggressive CGCG.

Health-related quality of life as a survival predictor for patients with oral cancer: is quality of life associated with long-term overall survival?

OBJECTIVE: The aim of the present prospective study was to obtain further insight into health-related quality of life (HR-QoL) as a predictor of survival in a selected cohort of patients with oral cancer. STUDY DESIGN: A total of 124 patients were treated with surgery or combined therapy. All of the recruited patients completed the European Organization for Research and Treatment of Cancer questionnaires QLQC30 and H&N35 on 4 occasions. Overall survival was assessed. Univariate and multivariate Cox proportional hazards regression models were conducted. RESULTS: High baseline HR-QoL score and high pain symptom score were significantly associated with a better survival (HR 0.86 and 0.92 respectively). Swallowing (HR 0.94), and speech (HR 0.92) high baseline scores were also significantly associated with a better survival in the adjusted analyses. CONCLUSIONS: Patients who reported a better HR-QoL at tumor diagnosis had a better survival than patients with a lower HR-QoL baseline score.

Intraoperative biopsy of the major cranial nerves in the surgical strategy for adenoid cystic carcinoma close to the skull base.

OBJECTIVE: Adenoid cystic carcinoma of the salivary glands has a propensity for perineural invasion, which could favor spread along the major cranial nerves, sometimes to the skull base and through the foramina to the brain parenchyma. This study evaluated the relationship between neural spread and relapse in the skull base. STUDY DESIGN: During surgery, we performed multiple biopsies with extemporaneous examination of the major nerves close to the tumor to guide the surgical resection. RESULTS: The percentage of actuarial local control at 5 years for patients with a positive named nerve and skull base infiltration was 12.5%, compared with 90.0% in patients who were named nerve-negative and without infiltration of the skull base (P = .001). CONCLUSIONS: Our study shows that local control of disease for patients who are named nerve-positive with skull base infiltration is significantly more complex compared with patients who are named nerve-negative without infiltration of the skull base.

Does microvascular free flap reconstruction in oral squamous cell carcinoma improve patient survival?

OBJECTIVE: We analyzed our experiences with microvascular reconstruction after oncologic resections for oral squamous cell carcinoma. Has microvascular surgery changed the survival rate of these patients? DESIGN: Retrospective study. SUBJECTS AND METHODS: Forty-two consecutive patients enrolled from March 1999 to December 2004. Follow-up time ranged from 1 to 94 months. Survival rates were evaluated by the Kaplan-Meier method and compared among different groups with the use of Cox regression. RESULTS: The actuarial 5-year survival rate was 41.9% (SD = 9.6%). Survival rates were also analyzed according to T, N, and stage. The survival was significantly related only to N, which showed a 72.4% increase in the risk related to the increase of one N stage. CONCLUSIONS: A comparison between our study group and those of 3 previous similar studies would not provide definitive statistical evidence, but it could certainly suggest a trend. The comparison seems to support that microvascular free tissue transfer does not change the survival of these patients.

Biphosphonate-associated osteonecrosis can be controlled by nonsurgical management.

Sixteen patients with jaw biphosphonate-osteonecrosis and with exposed bone areas were subdivided into 2 treatment groups. The first group (7 patients) underwent superficial or radical surgical therapy, while the second (9 patients) underwent antibiotic treatment. A slight reduction of the necrotic areas was observed in 5 of 7 patients in the first group, whereas no change was observed in the remaining 2 patients at 22- and 24-month follow-up. A slight reduction of the necrotic areas was observed in 7 of 9 patients in the second group, whereas no change was observed in the remaining 2 patients at 5- and 24-month follow-up. The statistical analysis showed that the treatment regimen did not significantly influence the dimensional change in the exposed bone. The preliminary results seem to suggest that biphosphonate-associated osteonecrosis can be well controlled by a nonsurgical protocol consisting in long-term administration of antibiotics.

Histology and stability study of cortical bone graft influence on titanium implants.

OBJECTIVE: The mechanisms for integrating titanium implants in recipient bone are still not well defined, and it is not known whether the process of bone formation around implants inserted into grafts is the same as that described for titanium implants in nongrafted cortical bone. This study compared the histology, stability, and osseointegration of titanium implants inserted in cortical bone with and without a simultaneous autologous cortical bone graft in an experimental animal model. METHODS: Thirty titanium implants were inserted in 3 sheep. Half of the implants were inserted to fix the graft to the recipient bone, and the remainder were inserted in the distal part of the tibial metaphysis as controls. The animals were humanely killed at 2, 6, and 8 months after surgery. A stability test (unscrewing torque) was performed immediately on 12 fresh specimens (6 grafted implants and 6 control implants). The remaining unscrewed implants, both grafted and not grafted, were subjected to histomorphometric analysis. RESULTS: After osseointegration, the unscrewing force exceeded the fracture limit of the titanium fixtures in both the grafted samples and controls, demonstrating their optimal stability but failing to demonstrate an improvement in the grafted bone. Histomorphometric analysis demonstrated newly formed tissue that extended from the contact area inside the graft, beginning at 6 months. At 8 months, the implant threads in the graft were surrounded by a large amount of newly formed bone mixed with necrotic fragments. CONCLUSIONS: Our results show that onlay cortical grafts on cortical bone enhance the osteogenic potential of the host bone, ensuring solid, viable bone tissue support that results in a high rate of integration of the titanium fixtures. The loading forces affect the bone-healing process after implant insertion; bone matrix was deposited unequally, being greater proximally (90% versus 40%), which is perpendicular to the maximal load tension lines when the sheep are standing. This implies that in the human jaw, where the tension lines parallel the axis of the implants, the implants can play an important role in guiding new bone formation during osseointegration.

Computed tomography and magnetic resonance features of carcinoma of the tongue.

Computed tomography (CT) and magnetic resonance (MR) imaging allow more accurate staging of the carcinoma of the tongue than the clinical examination alone. The complex anatomy and the tumour margins make the interpretation of CT and MR images challenging. The aim of this paper is to review the technique and semiotic criteria for CT and MR evaluation and staging of carcinoma of the tongue.