Tommaso Agostini

Background: The subclavicular pedicled flap is based on the thoracic branch of the supraclavicular artery, and it represents a versatile reconstructive option for low‐middle third face defects. Since its use in head and neck surgical oncology has not been popularized yet, we propose its application for oral cavity reconstruction after cancer resection by showing favorable results.Methods: Eighteen subclavicular pedicled flaps were used to treat intraoral defects after oral squamous‐cell cancer resection between June 2015 and December 2018. Tumor dissection type, complications, donor and reconstructed area results, and functional and aesthetic outcomes were assessed.Results: No major complications were observed and all of the flaps survived. Adjuvant therapy was administered without delay when needed, and all of the patients had normal functional outcomes and good aesthetic results.Conclusions: The subclavicular flap is an excellent choice for the reconstruction of oral cavity defects. Selection of patients should exclude positive lower‐third neck node and include appropriate informed consent for women due to the possibility of deformity of the breast. In our opinion, this flap has the potential for common application given its consistent anatomy and donor site advantages, including long pedicle, high pivot point, and relatively unlimited flap width.

The sagittal split osteotomy (SSO) is an indispensable tool in the correction of dentofacial abnormalities. In elective orthognathic surgery, it is important that surgeons inform patients about the risk of complications related to inferior alveolar nerve damage and unfavorable split. The purpose of this article is to describe a novel, hybrid technique to SSO by combining a reciprocating saw and piezoelectric devices with several advantages over traditional “pure” methods (osteotomies performed by reciprocating saw or piezoelectric devices only) in terms of precision, rapidity, easier splitting, and decreased complications related to inferior alveolar nerve damage and bad split with reduced overall morbidity. The level of evidence was Level IV, therapeutic study.

The purpose of the present study was to assess the safety and efficacy of both functional intranasal procedures and cosmetic rhinoplasty combined with bimaxillary surgery.

Background and Objectives: Reconstruction of tongue cancer defects is challenging due to the complex anatomy and physiology of the tongue. Here, we classify patterns of tongue tissue loss and describe a treatment algorithm for achieving good functional and oncologic outcomes.Methods: We retrospectively reviewed 50 tongue squamous‐cell carcinomas surgically treated between January 2010‐June 2015. Cancer resection and tongue reconstruction were stratified according to the missing anatomical subunits.Results: A type 1 defect is a unilateral and marginal defect, not crossing the midline, and not extending to the posterior‐third of the tongue. Type 2 involves the two‐anterior‐thirds of the mobile body, not crossing the midline, without posterior‐third evolvement. Type 3 involves the two‐anterior‐thirds of the mobile body of the tongue with contralateral extension. Type 4 extends to the tongue base. Type 5 defect comprises any of the previous defects along with involvement of the floor of the mouth. Type 2 and 3 defects were the most common. Microvascular reconstruction was performed in 23 out of 50 patients. Complications included infection, partial necrosis, dehiscence, and microvascular thrombosis.Conclusions: Our classification system and treatment algorithm represent a reliable method of addressing management of tongue defects.

Agostini T, et al. Arch Craniofac Surg. 2017 Jun;18(2):105-111. https://doi.org/10.7181/acfs.2017.18.2.105

It was with extreme pleasure that we read the article titled “Suprafascial Anterolateral Thigh Flap Harvest: A Better Way to Minimize Donor-Site Morbidity in Head and Neck Reconstruction,” published in the September issue of Plastic and Reconstructive Surgery, where Chen et al. report their experience with anterolateral thigh flaps harvested with preservation of the deep fascia and applied to head and neck reconstruction.1 We would like to take the opportunity to further discuss this topic of interest to reconstructive plastic surgeons. Our point of discussion is pertinent both to the donor site and to the recipient site. Indeed, in a particular area such as the head and neck and specifically the oral cavity, the need for a thin flap can limit the long-term results of reconstruction. Flap sagging and atrophy are the main factors responsible of soft-tissue deviation toward the reconstructed side and bolus stagnation. Advantages of anterolateral thigh flaps of proper thickness include volume preservation over time, thus maintaining the palatal contact and the propulsive properties of a neotongue, enhancing the residual mobility and recreation of the hyoid mandibular tension arch with improved stability of the larynx/hyoid bone complex.2–4 Furthermore, more patients who undergo oral cavity reconstruction over time may develop gradual worsening of dysarthria, dysphagia, and swallowing secondary to flap sagging, physiologic atrophy, and adjuvant radiotherapy.2,3 These issues can be indications for a further onlay free flap with improved results in other centers, and for the same reasons, the anterolateral thigh flap has overcome the radial forearm flap in oral cavity reconstruction.3 Certainly, one of the advantages of the anterolateral thigh flap remains the possibility of choice of thickness at a certain body mass index. The second point of discussion is inherent in the recipient site: (1) preservation of the deep fascia is questionable because it can be a key point of the successful long-lasting reconstruction because of a stable anchoring (lower lip, floor of the mouth, oropharynx, through-and-through defects)4–6; (2) suprafascial dissection of the anterolateral thigh flap does not avoid skin graft on the donor site, which is responsible for increased thigh morbidity7 (in this regard, a users’ guide to anterolateral thigh flap donor-site closure has been published6); and (3) lower limb weakness following anterolateral thigh flap harvest is not influenced by the suprafascial dissection, although muscle damage occurs deriving from intramuscular dissection of the vascular pedicle.7 Because several studies suggest that musculocutaneous perforators are present in up to 80 percent of cases, intramuscular dissection can damage the vastus lateralis muscle to a certain degree, and in cases where two or more consecutive perforators are included in the flap, the muscle damage can be extensive.8 It is our opinion that the flap should be harvested to better replace the defect and not to minimize donor-site morbidity, with consequent indication for harvest of a suprafascial anterolateral thigh flap (1) to restore lower and upper limbs where the necessary thickness is usually limited; (2) to reconstruct defects in patients with increased body mass index; (3) to reconstruct very few cases into the oral cavity requiring limited thickness; and (4) in nononcologic patients in general, where the defect is obviously limited and is not further influenced by fresh frozen margin analysis, which would require surgical widening. Thus, to conclude, the true advantages of a suprafascial dissection of the anterolateral thigh flap rely on the prevention of compartment syndrome, muscle herniation, or muscle bulging and improved abnormal sensation of the skin of the thigh, in terms of dysesthesia, paresthesia, numbness, and itching as Chen et al. emphasize.

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