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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">One-Stage Reconstruction for Midfacial Defect after Radical Tumor Resection</title><author><name sortKey="Kim, Hyun Jik" sort="Kim, Hyun Jik" uniqKey="Kim H" first="Hyun Jik" last="Kim">Hyun Jik Kim</name><affiliation><nlm:aff id="A1">Department of Otolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author><author><name sortKey="Lee, Kwang Ho" sort="Lee, Kwang Ho" uniqKey="Lee K" first="Kwang Ho" last="Lee">Kwang Ho Lee</name><affiliation><nlm:aff id="A1">Department of Otolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author><author><name sortKey="Park, Sang Yong" sort="Park, Sang Yong" uniqKey="Park S" first="Sang Yong" last="Park">Sang Yong Park</name><affiliation><nlm:aff id="A1">Department of Otolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author><author><name sortKey="Kim, Han Koo" sort="Kim, Han Koo" uniqKey="Kim H" first="Han Koo" last="Kim">Han Koo Kim</name><affiliation><nlm:aff id="A2">Department of Plastic and Reconstructive Surgery, Chung-Ang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">22468204</idno><idno type="pmc">3314807</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3314807</idno><idno type="RBID">PMC:3314807</idno><idno type="doi">10.3342/ceo.2012.5.1.53</idno><date when="2011">2011</date><idno type="wicri:Area/Pmc/Corpus">001B84</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001B84</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">One-Stage Reconstruction for Midfacial Defect after Radical Tumor Resection</title><author><name sortKey="Kim, Hyun Jik" sort="Kim, Hyun Jik" uniqKey="Kim H" first="Hyun Jik" last="Kim">Hyun Jik Kim</name><affiliation><nlm:aff id="A1">Department of Otolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author><author><name sortKey="Lee, Kwang Ho" sort="Lee, Kwang Ho" uniqKey="Lee K" first="Kwang Ho" last="Lee">Kwang Ho Lee</name><affiliation><nlm:aff id="A1">Department of Otolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author><author><name sortKey="Park, Sang Yong" sort="Park, Sang Yong" uniqKey="Park S" first="Sang Yong" last="Park">Sang Yong Park</name><affiliation><nlm:aff id="A1">Department of Otolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author><author><name sortKey="Kim, Han Koo" sort="Kim, Han Koo" uniqKey="Kim H" first="Han Koo" last="Kim">Han Koo Kim</name><affiliation><nlm:aff id="A2">Department of Plastic and Reconstructive Surgery, Chung-Ang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author></analytic><series><title level="j">Clinical and Experimental Otorhinolaryngology</title><idno type="ISSN">1976-8710</idno><idno type="eISSN">2005-0720</idno><imprint><date when="2011">2011</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>A serious midface defect involving resection of squamous cell carcinoma originating from the hard palate was treated by an unusual reconstructive strategy. After tumor resection, surgical reconstruction was accomplished in one stage using one free flap with one distant and local flap: a radial forearm flap to reconstruct the upper lip, a forehead flap to reconstruct the external nose, a cantilever calvarial bone graft to replace the nasal skeleton and a nasolabial flap and split thickness skin graft to cover the internal nasal lining. The rationale for this one-stage reconstruction and the problems associated with midfacial reconstruction after wide tumor excision are discussed.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Choung, Ph" uniqKey="Choung P">PH Choung</name></author><author><name sortKey="Nam, Iw" uniqKey="Nam I">IW Nam</name></author><author><name sortKey="Kim, Ks" uniqKey="Kim K">KS Kim</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Clauser, L" uniqKey="Clauser L">L Clauser</name></author><author><name sortKey="Curioni, C" uniqKey="Curioni C">C Curioni</name></author><author><name sortKey="Spanio, S" uniqKey="Spanio S">S Spanio</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Muzaffar, Ar" uniqKey="Muzaffar A">AR Muzaffar</name></author><author><name sortKey="Adams, Wp" uniqKey="Adams W">WP Adams</name></author><author><name sortKey="Hartog, Jm" uniqKey="Hartog J">JM Hartog</name></author><author><name sortKey="Rohrich, Rj" uniqKey="Rohrich R">RJ Rohrich</name></author><author><name sortKey="Byrd, Hs" uniqKey="Byrd H">HS Byrd</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Smolka, W" uniqKey="Smolka W">W Smolka</name></author><author><name sortKey="Iizuka, T" uniqKey="Iizuka T">T Iizuka</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Reece, Gp" uniqKey="Reece G">GP Reece</name></author><author><name sortKey="Lemon, Jc" uniqKey="Lemon J">JC Lemon</name></author><author><name sortKey="Jacob, Rf" uniqKey="Jacob R">RF Jacob</name></author><author><name sortKey="Taylor, Td" uniqKey="Taylor T">TD Taylor</name></author><author><name sortKey="Weber, Rs" uniqKey="Weber R">RS Weber</name></author><author><name sortKey="Garden, As" uniqKey="Garden A">AS Garden</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nisanci, M" uniqKey="Nisanci M">M Nisanci</name></author><author><name sortKey="Turegun, M" uniqKey="Turegun M">M Turegun</name></author><author><name sortKey="Er, E" uniqKey="Er E">E Er</name></author><author><name sortKey="Sengezer, M" uniqKey="Sengezer M">M Sengezer</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Terz, Jj" uniqKey="Terz J">JJ Terz</name></author><author><name sortKey="Young, Hf" uniqKey="Young H">HF Young</name></author><author><name sortKey="Lawrence, W" uniqKey="Lawrence W">W Lawrence</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Martin, Jw" uniqKey="Martin J">JW Martin</name></author><author><name sortKey="Lemon, Jc" uniqKey="Lemon J">JC Lemon</name></author><author><name sortKey="King, Ge" uniqKey="King G">GE King</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Thomas, Wo" uniqKey="Thomas W">WO Thomas</name></author><author><name sortKey="Harris, Cn" uniqKey="Harris C">CN Harris</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nothdurft, Fp" uniqKey="Nothdurft F">FP Nothdurft</name></author><author><name sortKey="Propson, M" uniqKey="Propson M">M Propson</name></author><author><name sortKey="Spitzer, Wj" uniqKey="Spitzer W">WJ Spitzer</name></author><author><name sortKey="Pospiech, Pr" uniqKey="Pospiech P">PR Pospiech</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Clin Exp Otorhinolaryngol</journal-id><journal-id journal-id-type="iso-abbrev">Clin Exp Otorhinolaryngol</journal-id><journal-id journal-id-type="publisher-id">CEO</journal-id><journal-title-group><journal-title>Clinical and Experimental Otorhinolaryngology</journal-title></journal-title-group><issn pub-type="ppub">1976-8710</issn><issn pub-type="epub">2005-0720</issn><publisher><publisher-name>Korean Society of Otorhinolaryngology-Head and Neck Surgery</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">22468204</article-id><article-id pub-id-type="pmc">3314807</article-id><article-id pub-id-type="doi">10.3342/ceo.2012.5.1.53</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>One-Stage Reconstruction for Midfacial Defect after Radical Tumor Resection</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Kim</surname><given-names>Hyun Jik</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="A1"></xref></contrib><contrib contrib-type="author"><name><surname>Lee</surname><given-names>Kwang Ho</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="A1"></xref></contrib><contrib contrib-type="author"><name><surname>Park</surname><given-names>Sang Yong</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="A1"></xref></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Kim</surname><given-names>Han Koo</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="A2">1</xref></contrib></contrib-group><aff id="A1">Department of Otolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea.</aff><aff id="A2"><label>1</label>Department of Plastic and Reconstructive Surgery, Chung-Ang University College of Medicine, Seoul, Korea.</aff><author-notes><corresp>Corresponding author: Han Koo Kim, MD. Department of Plastic and Reconstructive Surgery, Chung-Ang University College of Medicine, 224-1 Heukseok-dong, Dongjak-gu, Seoul 156-756, Korea. Tel: +82-2-6299-1615, Fax: +82-2-825-9880, <email>hkkiim@cau.ac.kr</email></corresp></author-notes><pub-date pub-type="ppub"><month>3</month><year>2012</year></pub-date><pub-date pub-type="epub"><day>07</day><month>2</month><year>2011</year></pub-date><volume>5</volume><issue>1</issue><fpage>53</fpage><lpage>56</lpage><history><date date-type="received"><day>18</day><month>8</month><year>2009</year></date><date date-type="rev-recd"><day>27</day><month>10</month><year>2009</year></date><date date-type="accepted"><day>01</day><month>11</month><year>2009</year></date></history><permissions><copyright-statement>Copyright © 2012 by Korean Society of Otorhinolaryngology-Head and Neck Surgery.</copyright-statement><copyright-year>2012</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/3.0"><license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/3.0">http://creativecommons.org/licenses/by-nc/3.0</ext-link>) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p>A serious midface defect involving resection of squamous cell carcinoma originating from the hard palate was treated by an unusual reconstructive strategy. After tumor resection, surgical reconstruction was accomplished in one stage using one free flap with one distant and local flap: a radial forearm flap to reconstruct the upper lip, a forehead flap to reconstruct the external nose, a cantilever calvarial bone graft to replace the nasal skeleton and a nasolabial flap and split thickness skin graft to cover the internal nasal lining. The rationale for this one-stage reconstruction and the problems associated with midfacial reconstruction after wide tumor excision are discussed.</p></abstract><kwd-group><kwd>Surgical flaps</kwd><kwd>Midface</kwd><kwd>Radical tumor resection</kwd></kwd-group></article-meta></front><body><sec><title>INTRODUCTION</title><p>Midfacial defects caused by radical tumor surgery or trauma involve various structures, such as the palate, teeth, nasal cavity and maxillary sinus (<xref ref-type="bibr" rid="B1">1</xref>). The unique anatomy of the midface with its aesthetic and functional importance makes its reconstruction challenging. How it should be done remains a matter of debate. Although the reconstructive option depends on the extent of the bony and soft tissue defect, various pedicled and free tissue transfer techniques with and without bone grafts have been used (<xref ref-type="bibr" rid="B2">2</xref>-<xref ref-type="bibr" rid="B5">5</xref>). Midfacial reconstruction using multiple free flaps has more advantages than a prosthesis or osseointegrated implants, and staged reconstruction has been recommended (<xref ref-type="bibr" rid="B5">5</xref>). However, vascularized or local flaps are not always viable options due to the amount of missing tissue and nasomaxillary defects need prosthetical reconstruction to enhance their oral function and aesthetics (<xref ref-type="bibr" rid="B6">6</xref>). This report presents a case of surgical reconstruction in a patient with a large midfacial defect after radical tumor resection. The problems associated with midfacial and oral cavity reconstruction are discussed.</p></sec><sec><title>CASE REPORT</title><p>A 54-year-old man was referred to the Otolaryngology Department of Chung-Ang University College of Medicine due to nasal obstruction and a known intranasal mass. A huge necrotic mass protruded to the upper gingiva and the mucosal surface of the upper lip. Tumor invasion to the hard palate and upper teeth from right third molar to left first molar was observed (<xref ref-type="fig" rid="F1">Fig. 1A</xref>). Paranasal sinus computed tomography (CT) revealed that the primary mass arose in the right hard palate and invaded across the opposite palate, and extended into the bilateral upper gingiva, nasal cavity and nasal septum. The destruction of the anterior side of right maxilla was also detected and the tumor protruded onto the subcutaneous tissue of the anterior maxillary wall (<xref ref-type="fig" rid="F1">Fig. 1B, C</xref>). Posterior portions of the right inferior turbinate and nasal septum were intact. An intranasal biopsy was performed and the pathologic report revealed squamous cell carcinoma. There was no evidence of distant metastasis or enlargement of the cervical lymph node.</p><sec><title>Surgical technique and clinical sourse</title><p>Radical tumor resection (clinical stage T<sub>4a</sub>N<sub>0</sub>M<sub>0</sub>), including composite bilateral infrastructure maxillectomy, total rhinectomy, near total upper lip resection and total hard palatectomy was performed (<xref ref-type="fig" rid="F2">Fig. 2</xref>). After tumor resection, surgical reconstruction was accomplished by the plastic and reconstructive surgeon. The operative plan was based on the simultaneous transfer of one free flap with one distant and local flap, and immediate placement of a temporary palatal surgical obturator in one stage: a radial forearm flap to reconstruct the upper lip, a forehead flap to reconstruct the external nose, a cantilever calvarial bone graft to replace the nasal skeleton, a nasolabial flap and split thickness skin graft to cover the internal nasal lining and a palatal surgical obturator to substitute the hard palate temporarily. The surgical procedures were as follows. Firstly, a temporary obturator, which was made preoperatively by a dentist, was secured with stainless steel wires to both sides of the pterygoid plates for palatal reconstruction. Secondly, a 6×6 cm radial forearm free flap was harvested and transferred to the missing upper lip area. The proximal ends of the radial artery and two venae commitantes were anastomosed to the facial artery, submental and facial vein. Thirdly, a 6×1 cm calvarial bone was harvested from the left parietal bone and anchored with two screws to the remnant nasal bone as a cantilever bone graft. The inner side of the calvarial bone graft was covered with a single nasolabial flap from the left cheek. Lastly, a forehead gull-wing flap was elevated for total nasal coverage and the inner side was covered with split-thickness skin graft. Then, the forehead gull-wing flap was inserted to the reconstructed upper lip and palatal obturator (<xref ref-type="fig" rid="F3">Fig. 3</xref>). Pedicle division and final revisions, including a full-thickness skin graft to the forehead flap donor site, were performed 4 weeks later (<xref ref-type="fig" rid="F4">Fig. 4A</xref>) Postoperative radiotherapy was carried out with 7,000 cGY on the primary lesion and the patient made an uncomplicated recovery (<xref ref-type="fig" rid="F4">Fig. 4B</xref>). Two years following surgery, the patient had no evidence of recurrent disease.</p></sec></sec><sec><title>DISCUSSION</title><p>Complex head and neck defects are seen in patients having oncologic resection or trauma and often demand composite reconstruction of mucosal lining, skeletal support, soft tissue and skin coverage (<xref ref-type="bibr" rid="B7">7</xref>-<xref ref-type="bibr" rid="B9">9</xref>). Furthermore, midfacial defects, including both the perioral and nasomaxillar areas are not common and are more difficult to reconstruct because of complex multidimensional characteristics of the area. There are several options that can be applied to those extensive defects, such as prosthetic devices, osseointegrated implants, pedicled flaps with the aid of autologous or alloplastic grafts and microvascular free flaps (<xref ref-type="bibr" rid="B8">8</xref>, <xref ref-type="bibr" rid="B9">9</xref>). Staged procedures have been more useful for midfacial reconstruction using a prosthetic device, distant flap, and one or multiple autologous free flaps (<xref ref-type="bibr" rid="B5">5</xref>, <xref ref-type="bibr" rid="B9">9</xref>). However, these staged techniques require a prolonged operation time and may cause serious problems, such as wound infection, psychiatric problems, scarring from a nonfunctional upper lip, contraction of free flaps and weak support of palate. In one report, three free flaps were used to reconstruct the middle and lower facial defect in one-stage, which provided better aesthetic and functional outcomes, resulting in prevention of contraction of the remaining facial soft tissues (<xref ref-type="bibr" rid="B6">6</xref>).</p><p>In the present case, we decided on a one-stage surgical reconstruction after en-bloc tumor resection and performed the combined reconstructive method in our patient with a massive midfacial defect. For the large nasal defect, we used a full-thickness forehead rotational flap including a calvarial bone graft for the caudal portion of nasal skeleton. For the defect in both upper cheeks, we used the radial forearm free flap. For the defect of the hard palate, we planned to use a composite graft. However, we could not find an adequate donor site for graft with a good blood supply due to the patient's long history of smoking. Lastly, we applied a temporary prosthesis instead of a composite graft. We intended to replace the temporary obturator by a permanent one, but a long-term follow-up of the patient did not occur. Nevertheless, we found that temporary obturator preserved its structural support during the available follow-up period, even after radiotherapy. The maintenance of structural support by a temporary prosthesis during a long-lasting step-wise therapy after large maxillectomy has been reported (<xref ref-type="bibr" rid="B10">10</xref>). We found that both the microvascular and pedicled flaps associated with the prosthetic device were resistant to radiotherapy and that a one-stage midfacial defect reconstruction including the nose, hard palate, and upper lip, using those flaps was versatile, comparing with multiple microsurgical free flaps or staged surgical reconstruction.</p><p>The presently-reported reconstructive procedure using a distant free flap, local flap and obturator is not an absolute operative option for reconstruction of extensive midfacial defects. In particular, a viable flap may be preferable to an obturator, considering the postoperative function of the oropharynx. 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position="float"><label>Fig. 1</label><caption><p>Preoperative view and paranasal sinus computed tomography (CT) of the patient with squamous cell carcinoma, originated from hard palate. (A) Endoscopic findings showing the mass destroying the hard palate and protruding into the oral cavity. Axial (B) and coronal CT (C) scans showing the lesion arising from the hard palate, filling the anterior nasal cavity and extending into both maxilla and gingiva.</p></caption><graphic xlink:href="ceo-5-53-g001"></graphic></fig><fig id="F2" position="float"><label>Fig. 2</label><caption><p>Intraoperative view of the surgical procedure. (A) Operative view of midfacial defect after composite bilateral infrastructure maxillectomy, total rhinectomy, near total upper lip resection and total hard palatectomy. (B) A photograph showing the specimen, including primary tumor after surgical resection.</p></caption><graphic xlink:href="ceo-5-53-g002"></graphic></fig><fig id="F3" position="float"><label>Fig. 3</label><caption><p>Immediate postoperative view of patient. The midface defect was reconstructed with a radial forearm free flap to reconstruct the upper lip, a forehead flap to reconstruct the external nose, a cantilever calvarial bone graft to replace the nasal skeleton and a nasolabial flap and split thickness skin graft to cover the internal nasal lining.</p></caption><graphic xlink:href="ceo-5-53-g003"></graphic></fig><fig id="F4" position="float"><label>Fig. 4</label><caption><p>Postoperative views of the patient. (A) Postoperative view at 4 weeks after reconstruction. (B) Postoperative view at 9 weeks after reconstruction.</p></caption><graphic xlink:href="ceo-5-53-g004"></graphic></fig></floats-group></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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