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Background: The scapular free flap has increasingly gained popularity as an alternative to the fibular free flap in osseous head and neck reconstruction. The authors evaluated its use in maxillomandibular reconstruction and examined surgical and patient outcomes.

Methods: Osseous head and neck defects reconstructed with an angular artery-based scapular flap or fibular flap from 2016 to 2022 at 2 Swedish university hospitals were evaluated for their intraoperative execution (osseous and soft-tissue combinations) and postoperative outcomes. Facial quality of life (QoL) was assessed using the FACE-Q Head and Neck Cancer module. Donor-site morbidity was assessed using the Disabilities of the Arm, Hand, and Shoulder (DASH) and Self-Evaluated Foot and Ankle Score (SEFAS) questionnaires for scapular- and fibular-reconstructed cases, respectively.

Results: A total of 120 patients were recruited, 86 with mandibular reconstructions (26 scapulas, 60 fibulas) and 34 with maxillary reconstructions (32 scapulas, 2 fibulas). The concave scapula facilitated fewer osteotomies for curved reconstructions, particularly for lateral mandibular defects (P = 0.039). Intraoral lining was primarily achieved with muscle accompanying the scapula and skin accompanying the fibula. Using the latissimus dorsi muscle instead of only teres major decreased fistulas, plate/bone exposure, and nonunions (P = 0.039) in scapular reconstructions. Both flaps demonstrated comparable facial QoL, but the scapula presented superior donor-site outcomes (P = 0.001). Donor limb outcomes were unaffected by harvesting the latissimus dorsi with the scapula (P = 0.64) or by resuturing the detached muscles to the remaining scapula (P = 0.35).

Conclusion: The scapular free flap can be advantageous in osseous head and neck reconstructions, enabling nonosteotomized and chimeric reconstructions without compromising surgical outcomes or QoL.

Background: Reconstruction of the marginal mandibular nerve (MMN) is important for achieving optimal outcomes in the treatment of facial paralysis. However, the heterogeneity of injuries, ranging from extensive proximal facial nerve injuries to isolated distal MMN injuries, complicates meaningful outcome comparisons. This study assessed a new anatomical classification system for stratifying facial nerve injuries by injury location. The aim was to study MMN outcomes in proximal versus distal injuries and determine whether this system could provide a more reliable way to compare surgical results.

Methods: A retrospective, single-center study of MMN reconstructions (either independent MMN reconstructions or as part of a broader facial nerve reconstruction) was conducted over a 12-year period. Clinical outcomes were assessed using a classification system for facial nerve injuries (Levels 1-3, based on facial nerve injury location: Level 1 = proximal, Level 2 = parotid area, Level 3 = distal). Outcome measures included the Terzis' Lower Lip Grading Scale, photogrammetry, Sunnybrook, and quality-of-life assessments (Facial Disability Index, Facial Clinimetric Evaluation Scale).

Results: Sixteen patients (7 female; mean age 46.5 ± 20.6 years) underwent MMN reconstruction. Across all outcome measures, distal Level 3 injuries yielded the best outcomes, followed by Level 2, with proximal Level 1 injuries showing the least favourable results.

Conclusions: Proximal facial nerve injuries demonstrated inferior MMN outcomes compared with distal injuries, highlighting the importance of considering injury location when comparing results. The proposed classification system may provide a practical method for grouping patients according to anatomical injury location, enabling more meaningful and standardized comparisons of surgical outcomes among patients with similar characteristics and treatment protocols.

Introduction

As breast cancer survival rates improve, the long-term quality of life (QoL) has become increasingly important. With a significant number of patients still undergoing mastectomy and experiencing its well-known negative impacts on QoL, breast reconstruction aims to mitigate this by restoring body integrity. This study aimed to evaluate the changes in QoL and satisfaction in patients after breast reconstruction and influence of various patient-related factors.

Methods

Patients who underwent delayed unilateral deep inferior epigastric perforator (DIEP) breast reconstruction at a single institution between January 2016 and April 2019 were surveyed. QoL was assessed using the BREAST-Q questionnaire preoperatively and one year postoperatively. Scores were compared between the time points, and regression analysis was conducted to identify the influence of age, body mass index, economic status, education level, and relationship status on QoL.

Results

Among the 93 patients, 55 completed the preoperative and one-year postoperative BREAST-Q questionnaires (response rate: 59%). Postoperative QoL scores significantly increased for the domains “satisfaction with breasts,” physical well-being chest,” “sexual well-being,” and “psychosocial well-being” (p<0.001). The scores for the domain “physical well-being abdomen” remained unchanged one year postoperatively. Higher education correlated with greater satisfaction with the breasts. Lack of an intimate partnership was identified as a significant negative factor for poorer psychosocial well-being.

Conclusions

Delayed unilateral DIEP breast reconstruction significantly enhances QoL and breast satisfaction one year postoperatively without causing long-term physical discomfort at the donor site. Education level and relationship status significantly affect the postoperative outcomes. Tailored preoperative counseling and psychosocial support are essential to maximize patient satisfaction and well-being following reconstruction.

Background: Perioperative management in autologous breast reconstruction has gained focus in recent years. This study compares two pain management protocols in patients undergoing abdominal-based free flap breast reconstruction: a past protocol (PP) and a current protocol (CP)-both intended to reduce opioid consumption postoperatively. The PP entails use of a pain catheter in the abdominal wound and the CP consists of an intraoperative nerve block in addition to refinements in the oral pain management. We hypothesize that the CP reduces opioid consumption compared to PP.

Methods: From December 2017 to January 2020, 102 patients underwent breast reconstruction with an abdominal-based free flap. Two postoperative pain management strategies were used during the period; from December 2017 to September 2018, the PP was used which entailed the use of a pain catheter with ropivacaine applied in the abdominal wound with continuous distribution postoperatively in addition to paracetamol orally and oxycodone orally pro re nata (PRN). From October 2018 to January 2020, the CP was used. This protocol included a combination of intraoperative subfascial nerve block and a postoperative oral pain management regime that consisted of paracetamol, celecoxib, and gabapentin as well as oxycodone PRN.

Results: The CP group ( n = 63) had lower opioid consumption compared to the PP group ( n = 39) when examining all aspects of opioid consumption, including daily opioid usage in morphine milligram equivalents and total opioid usage during the stay ( p < 0.001). The CP group had shorter length of hospital stay (LOS).

Conclusion: Introduction of the CP reduced opioid use and LOS was shorter.

Introduction:

The inevitable sacrifice of the inferior alveolar nerve during oncologic resections results in substantial sensory impairment, impacting crucial functions such as speech, saliva retention, and mastication. This study investigated the feasibility of sensory restoration through cross-face reconstruction of the mental nerve via a contralateral mental nerve branch.

Methods:

The cross-face reconstruction procedure was simulated in five formalin-fixed cadavers in both sides to evaluate the anatomic fundamentals and the nerve gap between the mental nerve main trunk and transferred contralateral mental nerve branch. Furthermore, a histomorphometric analysis was performed to assess the cross-sectional area and axon counts.

Results:

The mean gap distance between the main mental nerve trunk and transferred contralateral branch was 15.3 mm. End-to-end coaptation was achieved in nine out of ten simulations. The mean cross-sectional area was 0.996 mm(2) at the main mental nerve trunk and 0.253 mm(2) at the coaptation site of the nerve branch. The mean donor-to-recipient axon ratio was found to be 0.3:1.

Conclusion:

The cadaveric simulation demonstrates the feasibility of a cross-face reconstruction of the mental nerve with only minimal gapping. Advantages of the proposed technique include the use of shorter nerve grafts, to minimize donor site morbidity and enable fast reinnervation. This technique may offer a promising method to enhance the quality of life in patients by increasing survival rates and life expectancy. (c) 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons.

Background: Myectomies of the lower lip depressor muscles have unexplained high failure rates. This study aimed to examine the depressor anguli oris (DAO) muscle using high-resolution ultrasound to identify potential anatomical explanations for surgical failures and to determine the accuracy of utilizing preoperative ultrasound assessment to improve myectomies.

Methods: Anatomical features of DAO and the surrounding anatomy were examined in 38 hemifaces of human body donors using high-resolution ultrasound and dissection.

Results: The ultrasound and dissection measurements showed the DAO muscle width to be 16.2 ± 2.9 versus 14.5 ± 2.5 mm, respectively, and the location of the lateral muscle border 54.4 ± 5.7 versus 52.3 ± 5.4 mm lateral to the midline. In 60% of the cases, the facial artery was either completely covered by lateral DAO muscle fibers or was found to be in direct contact with the lateral border. Significant muscle fiber continuity was present between the DAO and surrounding muscles in 5% of cases, whereas continuity between the depressor labii inferioris and surrounding muscles was considerably more common and pronounced.

Conclusions: High-resolution ultrasound can accurately reveal important preoperative anatomical information in myectomies. Two potential explanations for the surgical failures were discovered: an overlap of lateral DAO muscle fibers over the facial artery could lead to inadequate resections and continuity with the surrounding muscles might lead to muscle function takeover despite adequate resections. Both can be uncovered preoperatively by the surgeon through a brief, directed ultrasound examination, which may allow for modification of the surgical plan to reduce surgical failure.

Early facial nerve reconstruction should be offered in every patient with oncological resections of the facial nerve due to the debilitating functional and psychosocial consequences of facial nerve palsy. Oncologic pathology or oncologic resection accounts for the second most common cause of facial nerve palsy. In the case of these acute injuries, selecting an adequate method for reconstruction to optimize functional and psychosocial well-being is paramount. Authors advocate consideration of the level of injury as a framework for approaching the viable options of reconstruction systematically. Authors breakdown oncologic injuries to the facial nerve in three levels in relation to their nerve reconstruction methods and strategies: Level I (intracranial to intratemporal), Level II (intratemporal to extratemporal and intraparotid), and Level III (extratemporal and extraparotid). Clinical features, common clinical scenarios, donor nerves available, recipient nerve, and reconstruction priorities will be present at each level. Additionally, examples of clinical cases will be shared to illustrate the utility of framing acute facial nerve injuries within injury levels. Selecting donor nerves is critical in successful facial nerve reconstruction in oncological patients. Usually, a combination of facial and nonfacial donor nerves (hybrid) is necessary to achieve maximal reinnervation of the mimetic muscles. Our proposed classification of three levels of facial nerve injuries provides a selection guide, which prioritizes methods for function nerve reconstruction in relation of the injury level in oncologic patients while prioritizing functional outcomes.

The use of virtual surgical planning (VSP) and computer-aided design and manufacturing to assist in osseous reconstruction has become the standard of care in head and neck reconstruction. The use of the free fibula flap with VSP remains the most common flap for osseous reconstruction, and as such, it is well described in the published literature. The scapular free flap (SFF) based on the angular branch has not yet garnered the same attention. The popularity of the SFF osseus head and neck reconstruction is increasing due to the flaps' inherently different properties and indications it can fulfill; the natural curvature of the bone, the reduced incidence of atheroscelerosis in the donor vessels and the earlier postoperative mobilization of the patient. In the preoperative planning process, the SFF presents several unique challenges and considerations that differ from the free fibula flap. It is important for surgeons already using, or considering using the SFF, that VSP is used correctly to achieve optimal outcomes. The authors aim to describe and clarify aspects of VSP use in SFF reconstruction in the head and neck area with a specific focus on: (1) The perforator-like vascular anatomy of the scapula; (2) How to maximize the shape of the scapula to minimize osteotomies; (3) Fine-tuning of scapula osteotomies on side table; (4) How to plan cutting guide placement and fit on the scapula. The authors hope that this article will help reconstructive microsurgeons plan and perform the SFF in conjunction with VSP.