Faculty Bibliography

OBJECTIVES/HYPOTHESIS: Extirpation via expanded endonasal approaches (EEA) to the skull base can result in defects requiring vascularized rotational flap reconstruction. The buccal fat pad (BFP) is a vascularized graft described in open skull base resections, but its harvest and adequacy of vascular supply have not been examined for use with EEA. STUDY DESIGN: A transfacial cadaveric dissection was carried forth in a latex-injected specimen to characterize the BFP blood supply. Then a cadaveric dissection series was performed involving the endoscopic harvest and rotation of 10 buccal fat pads in five cadaveric specimens to assess defect coverage. METHODS: An endoscopic medial maxillectomy combined with an anterior maxillotomy was performed prior to endoscopic harvest in cadaveric specimens. The BFP was rotated to assess its capability to reconstruct seven possible ventral skull base defects. Finally, the BFP vascular anatomy was further characterized following harvest and transposition. RESULTS: The BFP reconstructed defects at the greater sphenoid wing, inferior and superior clivus, sella, planum, and bilateral ethmoids in all cadaveric specimens. In some cases it covered two sites concurrently. CONCLUSIONS: The BFP pedicled rotational flap is a potential alternate flap following EEA in select cases. LEVEL OF EVIDENCE: NA

PURPOSE OF REVIEW: Free tissue transfer is a versatile and valuable method for reconstructing select head and neck defects following trauma or oncologic resection. Microvascular reconstructive cases are among the longest, most technically challenging, and most labor-intensive operations performed by departments of otolaryngology/head and neck surgery. However, technical advances, increased experience, and robust training programs have permitted realization of microvascular success rates in excess of 97% at most high-volume centers. Given this unprecedented degree of success, research emphasis has shifted to advancing techniques, expanding indications, and increasing efficiencies. RECENT FINDINGS: Although numerous topics are important for discussion, this update focuses on recent notable advances in reconstruction. These include expanding utility of the anterolateral thigh free flap in soft tissue reconstruction, prefabricated plating for fibula free flap mandibular reconstruction, use of venous couplers, and postoperative free tissue monitoring techniques. SUMMARY: Improvements in technique, technology, and monitoring continue to improve success rates, reduce operative time and associated morbidity, improve overall functional outcomes, and improve patient-specific quality of life. These highlighted recent advances, amongst others, promote further advancement and simplification of reconstructive capabilities.

PURPOSE: Patients having suffered severe nasal trauma or having undergone prior septal surgery present particular problems during open structure septorhinoplasty. Septal cartilage deficient noses often require costal or conchal cartilage grafting or the use of allograft material, resulting in secondary donor site morbidity, longer operative times and variable results. The present study evaluated the utility of cyanoacrylate-based adhesives (CBA) in creating layered septal cartilage grafts from remnant septal cartilage for L-strut reconstruction during open septorhinoplasty. STUDY DESIGN: A retrospective clinical review was performed at a university-based facial plastic and reconstructive surgical practice, identifying patients undergoing open structure septorhinoplasty performed by the senior authors. Procedures involved construction of a layered caudal or dorsal L-strut graft from at least two smaller autologous septal cartilage grafts. The grafts were adhered together with CBA with 5-0 polydioxanone suture (Ethicon, Somerville, NJ) used for reinforcement. Stability of the final construct was assessed postoperatively. RESULTS: Fifteen patients were included with mean age of thirty-nine years (range: 15-65). Fifty-three percent of the patients had undergone prior nasal surgery: Seven had undergone at least one prior external septorhinoplasty and one had undergone prior endonasal septoplasty. Median follow-up was 144 days (range: 45-405). Postoperatively, one local infection was noted and two patients complained of post-operative columellar deviation. No other complications were encountered. CONCLUSION: CBAs provide a safe technique in the crafting of layered grafts to provide reliable tip/dorsal support when performing open structure septorhinoplasty among patients with cartilage deficient or severely traumatized septa.

IMPORTANCE: Minimizing morbidity when performing free flap reconstruction of the head and neck is important in the overall reconstructive paradigm. OBJECTIVE: To examine the indications and success rates of free tissue transfer using small-caliber facial recipient vessels and minimal access incisions. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review of patients with head and neck defects undergoing free tissue transfer from May 2010 to June 2013 at 2 tertiary care academic medical centers. INTERVENTIONS: Free tissue transfer using small-caliber recipient vessels and minimal access approaches. MAIN OUTCOMES AND MEASURES: Postoperative complications, including flap failure, requirement for revision surgery, and nerve dysfunction. RESULTS: Eighty-nine flaps in 86 patients met inclusion criteria. Fifty flaps used the facial artery and vein distal to the facial notch, and 33 flaps used the superficial temporal vascular system. Six flaps used the angular artery and vein. A variety of flap donor sites were included. In most cases, free tissue transfer was indicated for the reconstruction of defects secondary to extirpation of malignant neoplasia. Overall success rate was 97.7% with 2 instances of total flap loss and 1 partial loss. One patient had transient nerve weakness (frontal branch), which resolved during a follow-up of 9 months. CONCLUSIONS AND RELEVANCE: Free tissue reconstruction of head and neck defects can be safely and reliably accomplished using small-caliber recipient vessels, such as the superficial temporal, distal facial, and angular vessels. Minimal access approaches for microvascular anastomosis may be performed with excellent cosmesis and minimal morbidity. LEVEL OF EVIDENCE: 4.

IMPORTANCE: Limited donor and recipient site complications support the osteocutaneous radial forearm free flap (OCRFFF) for mandibular reconstruction as a useful option for single-stage mandibular reconstruction. OBJECTIVE: To examine and report long-term outcomes and complications at the donor and recipient sites for patients undergoing the OCRFFF for mandibular reconstruction. DESIGN: Retrospective review. SETTING: Academic, tertiary care medical center. PATIENTS: The study population comprised 167 consecutive patients who underwent single-staged mandibular reconstruction with an OCRFFF. MEAN OUTCOME MEASURES: Rates of complications at the donor and recipient sites. RESULTS: The mean patient age was 61 years (range, 20-93 years). Men compromised 68% of the population. Follow-up interval ranged from 2 to 99 months (mean, 25.9 months). The median length of bone harvested was 7 cm (range, 2.5-12.0 cm). Prophylactic plating was completed for each of the radii at the time of harvest. Donor site complications included radial fracture (1 patient [0.5%]), tendon exposure (47 patients [28%]), and donor hand weakness or numbness (13 patients [9%]). Recipient site complications included mandible hardware exposure (29 patients [17%]), mandible nonunion or malunion (4 patients [2%]), and mandible bone or hardware fracture (4 patients [2%]). Using regression analysis, we found that patients were 1.3 times more likely to have plate exposure for every increase of 1 cm of bone harvest length; this was statistically significant (P = .04). CONCLUSIONS AND RELEVANCE: This is the largest single study reporting outcomes and complications for patients undergoing OCRFFF for mandibular reconstruction. Prophylactic plating of the donor radius has nearly eliminated the risk of pathologic radial bone fractures. Limited long-term donor and recipient site complications support the use of this flap for single-stage mandibular reconstruction.