JAMA Facial Plastic Surgery
Journal Club Slides:
Free Tissue Transfer
Cannady SB, Rosenthal EL, Knott PD, Fritz M, Wax MK.
Free tissue transfer for head and neck reconstruction: a
contemporary review. JAMA Facial Plast Surg. Published
online July 3, 2014. doi:10.1001/jamafacial.2014.323.
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Introduction
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Reconstruction in the head and neck follows a well-defined reconstructive
ladder.
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Microvascular free tissue transfer is usually reserved for problems at the
apex of the ladder.
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Numerous advances have been made both technically and from a tissue
selection perspective.
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Where free tissue transfer fits in the armamentarium of the facial plastic
surgeon is a process in evolution.
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Purpose
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Objectives:
– To provide a comprehensive review of the role of free tissue transfer in
the management and rehabilitation of patients with maxillary and scalp
defects.
– To discuss the role of virtual surgical planning in head and neck
reconstruction.
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Relevance to Clinical Practice
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Defects of the maxilla can be debilitating to the patient from cosmetic and
functional perspectives. The ideal reconstruction will need to address
osseous contour restoration, long-term soft-tissue volume restoration,
separation of the oral and nasal cavities, and support of the eye.
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Reconstruction of the bony contours of the mandible or maxilla can be difficult
in the ablative setting. Virtual planning allows for determination of the best
reconstructive plan in complex settings prior to the surgical extirpation.
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Most lesions of the scalp can be closed primarily or with local tissue
rearrangement. Occasionally one encounters a massive lesion or a lesion in
a patient that has seen other treatments and local tissues are not available
for reconstruction. In these patients, free tissue transfer may be the only
option.
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Description of Evidence
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A comprehensive review of the literature was performed. Selected articles
were reviewed and discussed. The authors’ personal extensive experience
was used.
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For maxillary reconstruction, there are many options available in the
reconstructive paradigm.
– If the infraorbital rim and orbital contents are left intact, then obturation
should be considered.
– While muscle flaps provide soft-tissue bulk, this bulk disappears over
time. When combined with lack of a bony platform, the long-term results
do not stand up.
– The fibula flap is an excellent option for bony reconstruction as well as
soft-tissue reconstruction. It also allows for dental rehabilitation.
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Description of Evidence
This patient has had maxillectomy that was reconstructed with a fibula
free flap. Implants were placed later in the reconstruction.
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Description of Evidence
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Skin cancer is one of the most common forms of cancer in the head and
neck. It is usually easily reconstructed with local flaps.
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Patients with previous or anticipated radiation, very tight scalps, previous
attempts at reconstruction with local flaps, or calvarial defects (full or partial
thickness) may benefit from free tissue transfer in their reconstructive
paradigm.
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The latissimus dorsi myogenous flap with a split-thickness skin graft is the
most commonly used flap in this scenario.
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Cranial reconstruction can occur contemporaneously with the soft-tissue
reconstruction.
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Description of Evidence
This patient has had a large scalp resection that was reconstructed with
a latissimus dorsi myogenous free flap with a split-thickness skin graft.
It has healed well and has an acceptable cosmetic outcome.
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Description of Evidence
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Mandibular reconstruction with composite bony flaps has been accepted as
the reconstructive method of choice.
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Preoperative virtual surgical planning is a technique that uses 3-dimensional
computed tomographic scans with an interface over the Internet to plan the
bony ablation and the bony reconstruction.
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The planning allows for determination of the osteotomies and the
manufacturing of surgical guides.
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This in turn leads to a decrease in surgical time and better approximation of
the segments.
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In cases where a plate cannot be bent to the native mandible, the
preoperative planning allows for the generation of a computer-designed
reconstruction that facilitates oral rehabilitation.
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Description of Evidence
This patient will have a mandibular resection. The scans demonstrate
the creation of the defect and how the bone will fit in the defect. The
cutting jigs are also demonstrated.
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Controversies and Consensus
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Free tissue transfer is accepted as the best method of reconstructing
composite tissue defects.
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While obturators can be used in some maxillectomy defects, the use of free
flaps allows for bony reconstruction.
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Virtual modeling has improved the ability to preoperatively plan the
reconstruction. However, the benefits on a cost basis are unknown. Also, it
is unknown how this translates into functional benefits.
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Comment/Conclusions
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The role of free tissue transfer in head and neck reconstruction is well
defined. Refinements in the use of this composite tissue to replace defects
are an ongoing process.
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The need to continue to improve the rehabilitation of patients with defects
in the head and neck is clearly understood.
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Using improved computer modeling may allow for less operative time.
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The next advance may be the universal use of implants in the rehabilitation
of these patients.
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Whether the reconstruction with composite tissue translates into
improvements in quality of life is unknown and deserves further study. The
patient population that benefits from these advances also needs to be
defined.
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Contact Information
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If you have questions, please contact the corresponding author:
– Mark K. Wax, MD, Microvascular Reconstruction Program, Departments
of Otolaryngology–Head and Neck Surgery and Oral Maxillofacial
Surgery, Oregon Health and Sciences University, 3181 SW Sam
Jackson Park Rd, PV-01, Portland, OR 97239 (waxm@ohsu.edu).
Conflict of Interest Disclosures
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None reported.
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