Learning Objectives: After studying this article, the participant should be able to: (1) Have a broad understanding of the oncological principles relating to cancers involving the maxilla. (2) Define anatomically the various types of maxillectomy defects and their associated morbidity. (3) Understand the goals and principles of maxillary reconstruction. (4) Demonstrate an understanding of the strengths, limitations, and alternative reconstructive options for the various types of maxillectomy defects. Summary: Reconstruction of the maxilla following cancer resection has evolved over the past decade. Underpinned by advances in virtual surgery technology and an increased focus on dental rehabilitation, more sophisticated workflows using free bone flaps have become more commonplace. There are few reconstructions anywhere in the body that require the restoration of similarly intricate bone and soft-tissue relations with implications for both form and function, like the maxilla. Success demands careful anatomical definition of the defect, an understanding of the goals and principles of reconstruction, and the understanding of relative strengths and limitations of the various reconstructive options. Equally, as no one technique is without shortcomings and maxillary surgery can be associated with a significant complication profile, it is just as important to match the patient and oncologic context to the reconstruction. This article is intended to provide the reader with a broad overview of these core factors.

What are the reconstructive challenges of the lumbosacral area?What are the goals and principles of reconstructing the lumbosacral defect?What are propeller flaps?How are propeller flaps used in the lumbosacral region?

PURPOSE: Immediate dental implant placement (IDIP) is a technique that places dental implants into the bony reconstructions of maxillomandibular defects at the time of oncologic surgery. FACE-Q is a patient reported outcome measure (PROM) that has two scales: function and distress. This study describes short- and long-term PROMs in patients undergoing IDIP during free fibula flap reconstruction of their maxillomandibular defects. METHODS: Postoperative FACE-Q scores for patients who underwent IDIP were prospectively collected between November 2017 and January 2022. Converted scores (0 to 100) were analyzed at three timepoints: perioperative (0-90 days), short-term (90-365 days), and long-term (1+ years). Patient demographics, surgical characteristics and complications were also assessed. RESULTS: 70 patients underwent IDIP and completed FACE-Q postoperatively. We found no significant difference in scores between timepoints, although many domains, including eating/drinking and speaking function as well as speaking and drooling distress, showed an upward trend over time points. IDIP patients with short-term complications reported significantly worse function in eating/drinking (p=0.002), oral competence (p=0.018) and swallowing (p=0.012) as well as distress in eating/drinking (p=0.005) and speaking (p=0.024) compared to those without complications. Patients with long-term complications reported worse function in eating/drinking (p=0.028), oral competence (p=0.015), and swallowing (p<0.001) than those without long-term complications. CONCLUSION: Patient satisfaction following IDIP placement is stable through one year. As expected, complications adversely affect PROMs in this complicated patient population. Future studies are needed to evaluate patients undergoing IDIP to those who do not as it relates to patient satisfaction and quality of life.

PURPOSE: Immediate dental implant placement (IDIP) at the time of ablative/reconstructive surgery for maxillomandibular cancer is a novel technique that has yet to be evaluated for its long-term clinical outcomes. This study describes long-term clinical outcomes with IDIP in free fibula flaps (FFF) for oncologic head and neck reconstruction. METHODS: A retrospective review for patients who underwent oncologic FFF reconstruction of mandibular or maxillary defects with and without IDIP was performed. Average length of follow-up and complication rates over two time periods (1-2 years and 2+ years) were analyzed. The number of patients who achieved dental rehabilitation in the IDIP cohort was also examined. RESULTS: 99 patients received FFF reconstruction with IDIP, and 120 historical patients received FFF reconstruction alone. The average length of follow-up was significantly longer in the historical group (1498.9±1700.6 days vs. 565.4±397.9 days, p=0.0005). 63/99 IDIP patients achieved dental rehabilitation. There was no significant difference in the complication rates between the IDIP and historical cohorts in either 1-2 year or 2+ year time period. CONCLUSION: IDIP is an effective method for rapidly achieving dental rehabilitation in patients undergoing maxillomandibular reconstruction with FFF. Long-term complications in IDIP patients were not significantly different from the historical cohort. Further studies investigating patient satisfaction and quality of life scores with IDIP are warranted to elucidate the full benefits of this treatment.

SUMMARY:Oncologic maxillectomy defects requiring bony reconstruction are among the most challenging head and neck cases because of the complex three-dimensional geometry of the midface. Virtual surgical planning technology is advantageous in these cases because it provides superior positional precision and accuracy compared with traditional techniques and facilitates prosthodontic rehabilitation. Maxillary cancer recurrence after an initial fibula flap reconstruction presents a unique challenge. The authors report the first two cases of sequential fibula flaps after second or recurrent cancer of the maxilla. Virtual surgical planning facilitated resection with adequate tumor margins, optimized anatomic positioning of the fibula construct with three-dimensional printed plates, and enabled immediate functional dental implant placement.

Background: The implications on the choice of donor side when using the free fibula flap for reconstruction of unilateral maxillectomy defects has not been discussed in the literature so far. Methods: A unilateral maxillectomy reconstruction was replicated using a 3D-printed skull model and fresh cadaveric dissections of left and right osteomyocutaneous fibula flaps for comparison. Detailed photo documentation was conducted to analyze and illustrate the anatomical differences of performing a reconstruction using the ipsilateral or contralateral sides and their relative benefits and risks. Results: A more favorable lie of the septum and skin paddle and flexor hallucis longus muscle is attainable depending on which donor side is used and the planned direction of the pedicle. Conclusion: This study demonstrates why it is preferable to use the ipsilateral fibula if anastomosis is to the ipsilateral facial or neck recipient vessels, or the contralateral fibula where the contralateral recipient vessels are preferred.

Necrotising soft tissue infection (NSTI) is a rapidly progressing disease that presents a surgical emergency. Timely antibiotics, radical debridement of infected tissues and adjuvant hyperbaric oxygen therapy are the foundations of its treatment. Split-skin graft (SSG) is the main reconstruction technique due to its simplicity and dependability. Dermal substitutes, as well as creating a suitable wound bed for grafting, aim to recreate the inherent thickness and pliability of skin. One innovation, Novosorb™ (produced by PolyNovo Ltd, Port Melbourne, Australia), is a biodegradable temporising matrix (BTM) that is an entirely synthetic implantable dermal matrix that creates a neo-dermis in complex wounds.

Flap surgery is the essence of plastic surgery. It has a rich history underpinned by innovative endeavour. In principle, its basis is the understanding of the blood supply of the soft tissues, and compliance and mobility. The art and craft of plastic surgery requires an aesthetic sense and above all experience. This chapter attempts to provide an overview of these fundamental concepts.

Myelomeningocele, also known as spina bifida, is the commonest form of neural tube defect in which both meninges and spinal cord herniate through a large vertebral defect. It may be located at any spinal level; however; lumbosacral involvement is most common. After birth, the closure of spinal lesion is preferably undertaken in the first 48 hours to minimize the risk of injury and central nervous system infection. Relatively small skin defects overlying the dural repair may be directly closed. However, larger defects require reconstructive closure. Numerous methods of reconstruction have been described, such as split skin graft, local flaps or lumbosacral fasciocutaneous flaps, muscle flaps using latissimus dorsi, gluteal or paraspinous muscles, and perforator flaps namely superior gluteal artery perforators, and dorsal intercostal artery perforator flaps. At Monash Health, Victoria, we have used the keystone perforator island flaps to reconstruct lumbosacral myelomeningocele defects on 5 newborns between January 2008 and January 2014. This article evaluates the short-term and long-term outcomes of these patients who were followed up for 10 to 66 months.

Summary: Abdominoperineal resections have evolved to the point where increasing amounts of skin and pelvic floor are removed, resulting in extensive defects. Many patients receive neoadjuvant chemoradiotherapy and may require adjuvant treatment; thus, primary wound healing is essential. Existing reconstructive techniques may be inadequate and predispose to postoperative complications including wound breakdown and perineal herniation. The authors have developed a novel innervated gluteal flap reconstruction with significant advantages, including preservation of abdominal wall integrity, prone harvest, reliable vascularity, bulky volume, and tailored inset. This robust technique addresses all components required for successful perineal reconstruction comprising dead space obliteration, reconstruction and maintenance of perineal floor integrity, and importation of nonirradiated skin to facilitate primary wound healing. Indications can be extended to include reconstruction of the posterior vaginal wall and large sarcoma/sacrectomy defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.