OBJECTIVE: To compare the postoperative complications of the fibular free flap (FFF), scapula free flap (SFF), and osteocutaneous radial forearm free flap (OCRFFF) following osseous reconstruction in the head and neck.
METHODS: PUBMED, EMBASE, Cochrane.
METHODS: A literature search and systematic review were performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. A meta-analysis of proportions was conducted using a random effects model to compare operative time and postoperative complications.
RESULTS: The systematic review identified 26 studies comparing at least 1 variable of interest. The odds ratio estimates favored reduced rates of flap failure with the OCRFFF when compared to FFF (0.7, confidence interval [CI]: 0.29-1.11, P < .001), while FFF and SFF were similar. The mean difference estimates for operative time significantly favored FFF over SFF (-51.04 minutes, CI: -92.73 to -9.35, P = .016) and OCRFFF over FFF (66.77 minutes, CI: 52.74-80.8, P < .001). The FFF was more prone to hardware exposure, longer hospital stays, and donor site complications. Recipient wound complications and fistula rates were similar for all flap types.
CONCLUSIONS: Depending on the clinical context, the OCRFFF, FFF, and SFF are all robust options for reconstruction in the head and neck. The OCRFFF is associated with a reduced rate of flap failure and shorter operative times. The SFF requires longer operative times, although significant variation was observed between institutions. The FFF has broad reconstructive indications but is associated with more perioperative and long-term complications.

Bone defects following resections for head and neck tumours can cause significant functional and aesthetic defects. The choice of the optimal reconstructive method depends on several factors such as the size of the defect, location of the tumour, patient’s health and surgeon’s experience. The reconstructive gold standard is today represented by revascularised osteo-myocutaneous or osteomuscular flaps with osteosynthesis using titanium plates. Commonly used donor sites are the fibula, iliac crest, and lateral scapula/scapular angle. In recent years, computer-aided design (CAD)/computer assisted manufacturing (CAM) systems have revolutionised the reconstructive field, with the introduction of stereolithographic models, followed by virtual planning software and 3D printing of plates and prostheses. This technology has demonstrated excellent reliability in terms of accuracy, precision and predictability, leading to better operative outcomes, reduced surgical times and decreased complication rates. Among the disadvantages are high costs, implementation times and poor planning adaptability. These problems are finding a partial solution in the development of “in house” laboratories for planning and 3D printing. Strong indications for the use of CAD/CAM technologies today are the reconstruction of total or subtotal mandibular or maxillary defects and secondary bone reconstructions.

Giant congenital nevi, especially on the head and neck, pose a challenge for plastic surgeons. This requires extensive experience in detailed planning, combining different techniques, and selecting appropriate materials for reconstruction. There have been reports of using a tissue expander, serial resection method, and full-thickness skin grafts for this type of nevus. However, the best way to completely remove a giant congenital nevus is endless. In this article, we would like to present a case of a left hemifacial giant congenital nevus in which we used multiple tissue expansion to fully replace the nevus, along with some of our modification techniques.

BACKGROUND: The medial arm flap (MAF) has been used as a pedicle flap and free flap to reconstruct various deformities, including those of the head and neck, axilla, elbow, chest, and hand. This study reviews the anatomy of the flap, the technique of flap harvest, its clinical applications, and a systematic review of the current published literature.
METHODS: An online systematic review of MEDLINE, EMBASE, PubMed, and The Cochrane Library from inception to September 30, 2023, was completed. Studies that investigate the anatomy, technique or clinical outcomes of medial arm flaps were included. Clinical data extracted includes patient, defect, flap characteristics, complications, and take-back procedures. Anatomic data extracted includes anatomical variations, and vascular characteristics and patterns.
RESULTS: Between 1980 and 2023, 50 papers were published outlining the medial arm flap. Anatomic studies detail the anatomy of 384 medial arms, and outcomes are reported for 283 MAFs (75 free flaps and 208 pedicle flaps). The superior ulnar collateral artery is most commonly cited as the dominant arterial supply to the middle third of the medial arm. The majority of patients required reconstruction post-burn (39.2%), trauma (17.7%), and tumor excision (12.4%). MAFs were mostly used to reconstruct defects of the head and neck (41.7%), the hand and wrist (21.9%), and the elbow (16.3%). Eleven flaps (4.1%) suffered partial flap failure, and two flaps (0.7%) suffered total flap failure.
CONCLUSIONS: This manuscript demonstrates that the MAF is a reliable and underutilized flap option with a well-hidden donor scar and a low complication rate.

BACKGROUND: Limited data exist regarding the effect of adjuvant radiochemotherapy on free flap volume in head and neck reconstruction. However, an adequate free flap volume is an important predictor of functional and patient-reported outcomes in head and neck reconstruction.
METHODS: A systematic review of Medline, Embase, and the Cochrane Central Register of Controlled Trials was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. A total of 6710 abstracts were screened, and 36 full-text papers were reviewed. Nineteen studies met the inclusion criteria and were used to extract data for this analysis.
RESULTS: A meta-analysis of 14 two-arm studies comparing the impact of adjuvant radiotherapy versus no adjuvant radiotherapy was performed. The main analysis revealed that 6 months postoperatively, irradiated flaps showed a significant reduction of volume (average, 9.4%) compared to nonirradiated flaps. The average interpolated pooled flap volumes 6 months postoperatively were 76.4% in irradiated flaps and 81.8% in nonirradiated flaps. After a median postoperative follow-up of 12 months, the total flap volume was 62.6% for irradiated flaps and 76% for nonirradiated flaps. Four studies reported that chemotherapy had no significant impact on free flap volume.
CONCLUSIONS: Compared to nonirradiated flaps, irradiated flaps were significantly reduced in volume (range, 5% to 15.5%). Clinicians should take this into account when planning the surgical reconstruction of head and neck defects. Conducting large-scale prospective studies with standardized protocols and well-defined follow-up measurements could contribute to defining the ideal, personalized free flap volume for optimal function and patient-reported outcomes.

Supermicrosurgery is an evolving approach in the reconstruction of head and neck (HN) and craniofacial (CF) defects. This systematic review aims to evaluate the use of supermicrosurgery for arterial or combined arterial and venous anastomoses in the reconstruction of HN and CF soft tissue defects, and the associated success, total complication, and reoperation rates. A literature search was conducted on PubMed, Dynamed, DARE, EMBASE, Cochrane, and British Medical Journal (BMJ) electronic databases (PROSPERO ID: CRD42023476825). Nine studies fulfilled the inclusion criteria with 35 patients who underwent soft tissue reconstructive procedures using supermicrosurgery. Twenty-one flaps were performed on 20 patients (57.1%) with the remaining 15 patients (42.9%) undergoing supermicrosurgical replantation. The most common pathology requiring reconstruction was HN trauma (n = 16, 45.7%) followed by malignancy (n = 15, 42.9%). The pooled success rate for supermicrosurgery was 98% (95% CI 90 to 100, p = 1.00; I2 = 0%). The cumulative complication rate across all the studies was 46% (95% CI 13 to 80, p < 0.01; I2 = 0%), and the pooled rate of reoperation was 1% (95% CI 0 to 8, p = 0.23; I2 = 24%). The use of supermicrosurgery for HN and CF soft tissue reconstruction has an overall success rate of 98%, which is commensurate with traditional microsurgery for HN reconstruction. Complication and reoperation rates are comparable to previous literature. This study confirms the feasibility of supermicrosurgery as a safe and reliable reconstructive option for HN and CF defects.

BACKGROUND: The thoracodorsal artery perforator (TDAP) flap has gained interest as a option for reconstruction of head and neck defects while minimizing donor site morbidity as compared to traditional workhorse flaps. The primary aim of this systematic review is to assess the postoperative outcomes and efficacy of this flap.
METHODS: Several databases were screened for relevant citations. The quality of studies and risk of bias were evaluated using the MINORS scoring system.
RESULTS: Twenty articles containing 168 patients undergoing at least one TDAP flap reconstruction met the inclusion criteria. There were no incidences of total flap failure and only 10 incidences of partial flap failure (5.95 %). Flap complications and donor site morbidity was low. The average MINORS score of the studies suggested a moderately high amount of bias.
CONCLUSIONS: Based on limited quality evidence, this review suggests that TDAP flap is a safe and feasible option for head and neck reconstruction with comparable success rates as other commonly used flaps, with low complication rate and donor site morbidity. Further large-scale studies are warranted.

In this study, we aimed to appraise the quality and psychometric properties of quality of life (QOL) assessment tools used after microsurgical reconstruction for head and neck cancers. A systematic review of QOL assessment tools used in head and neck cancer patients after microsurgical reconstruction was performed; emphasis was placed on psychometric properties and validity. Fifty-four studies published between January 2010 and February 2023 fulfilled the criteria; in these, twenty-three different QOL assessment tools were identified. The most commonly used instrument was the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck version (EORTC-H&N). No assessment tool fulfilled all the quality criteria; no single tool presented evidence from all the components of validity. Almost all reported reliability coefficients were above 0.7; most papers reported an internal consistency coefficient (Cronbach\'s alpha) for the global score. The array of available tools allows for the choice of the most appropriate one depending on the context faced by the clinician or researcher.

OBJECTIVE: Defects resulting from open resection of anterior skull base neoplasms are difficult to reconstruct. Our objective was to review the literature and describe an evidence-based algorithm that can guide surgeons reconstructing anterior skull base defects.
METHODS: A research librarian designed database search strategies. Two investigators independently reviewed the resulting abstracts and full text articles. Studies on reconstruction after open anterior skull base resection were included. Studies of lateral and posterior skull base reconstruction, endoscopic endonasal surgery, traumatic and congenital reconstruction were excluded. Based on the review, a reconstructive algorithm was proposed.
RESULTS: The search strategy identified 603 unique abstracts. 53 articles were included. Adjacent subsites resected, defect size, radiotherapy history, and contraindications to free tissue transfer were identified as key factors influencing decision making and were used to develop the algorithm. Discussion of the reconstructive ladder as it applies to skull base reconstruction and consideration of patient specific factors are reviewed. Patients with a prior history of radiotherapy or with simultaneous resection of multiple anatomic subsites adjacent to the anterior skull base will likely benefit from free tissue transfer.
CONCLUSIONS: Reconstruction of anterior skull base defects requires knowledge of the available reconstructive techniques and consideration of defect-specific and patient-specific factors.

Head and neck osteosarcomas (HNOS) account for less than 1% of all head and neck cancers and makeup 6-10% of all primary osteosarcomas. Mandibular osteosarcomas are the second most common subtype of HNOS. They demonstrate higher recurrence rates; however, are amenable to surgery. An 18-year-old male presented with a 2 cm x 3 cm x 2 cm intraoral mass for two months. Biopsy revealed chondroblastic osteosarcoma. Computed tomography revealed extension into the left internal jugular vein. Composite resection of the left mandible, floor of the mouth, ventral tongue, submandibular gland, and modified radical neck dissection with fibular flap repair was performed. Adjuvant chemotherapy and palliative radiotherapy were added. Unfortunately, progressive metastasis to the contralateral mandible and entire spinal cord ensued. We report the first case of head and neck osteosarcoma with intravascular invasion into the internal jugular vein.