Anterolateral Thigh Fascia Lata Rescue Flap: A New Weapon in the Battle Against <scp>Osteoradionecrosis</scp>

Meleca, Joseph B.; Kerr, Rhorie; Prendes, Brandon; Fritz, Michael A.

doi:10.1002/lary.29709

Cited by 12 publications

(27 citation statements)

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“…In 1983, Marx originally introduced the theory of ORN, wherein RT creates a hypo‐vascular and hypoxic environment that increases the tendency of long‐term tissue breakdown and poor healing, subsequently resulting in chronic pain, bony destruction, and non‐healing wounds 1 . Due to the dense anatomy in the head and neck region, the mandible, maxilla, skull base, and spine are frequently within the RT treatment field and prone to developing ORN 2–11 . Currently, multiple surgical and non‐surgical measures exist in the treatment algorithm of ORN including hyperbaric oxygen, intravenous antibiotics, and the PENTOCLO protocol incorporating tocopherol, pentoxifylline, and clodronate therapy with promising results 12–14 .…”

Section: Introductionmentioning

confidence: 99%

Free Tissue Transfer for Skull Base Osteoradionecrosis: A Novel Approach in the Endoscopic Era

et al. 2022

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Objectives Osteoradionecrosis (ORN) of the skull base and craniovertebral junction is a challenging complication of radiation therapy (RT). Severe cases often require surgical intervention through a multi‐modal approach. With the evolution in endoscopic surgery and advances in skull base reconstruction, there is an increasing role for microvascular free tissue transfer (MFTT). We describe an endoscopic‐assisted approach for the management of ORN of the skull base using fascia lata for MFTT. Study Design Retrospective case series. Methods Between 2017 and 2021, a review of all cases in which fascia lata MFTT was utilized for skull base ORN was performed. Patient demographics, preoperative characteristics, and postoperative outcomes with long‐term follow‐up were reviewed. Results Five patients were identified. Mean duration to onset of ORN was 17 months following RT. A trial of antibiotics, hyperbaric oxygen (HBO), and/or limited debridement was attempted without success. Refractory pain and progressive osteomyelitis were unifying symptoms. All patients underwent endoscopic debridement of the affected region of ORN prior to MFTT. Vascularized fascia lata was inset through a combined endonasal and transoral corridor. There was improvement in chronic pain in the postop setting with no patients requiring continued antibiotics or HBO therapy. Mean post‐op follow‐up was 23 months. Conclusions With continued evolution in endoscopic, minimally invasive approaches, there is an expanding indication for early surgical management in refractory ORN. Fascia lata MFTT is a novel and effective strategy for the management of ORN of the skull base and upper cervical spine with excellent postoperative outcomes and limited patient morbidity. Level of Evidence 4 Laryngoscope, 133:562–568, 2023

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Section: Introductionmentioning

confidence: 99%

Free Tissue Transfer for Skull Base Osteoradionecrosis: A Novel Approach in the Endoscopic Era

et al. 2022

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“…Although this gives the best representation of ultimate outcome, variability in the time that patients were measured limits the reproducibility and predictability of these functional measures. This population is limited to patients undergoing free tissue transfer for mandibular osteoradionecrosis; however, additional studies are needed to compare outcomes and charges associated with other treatments or preventions 14,15,17,39–41 …”

Section: Discussionmentioning

confidence: 99%

“…This population is limited to patients undergoing free tissue transfer for mandibular osteoradionecrosis; however, additional studies are needed to compare outcomes and charges associated with other treatments or preventions. 14,15,17,[39][40][41]…”

Section: Limitationsmentioning

confidence: 99%

“…Early ORN can be managed conservatively with therapies such as oral hygiene, antibiotics, local debridement, and hyperbaric oxygen 14,15 . However, when progression of ORN results in pathologic fracture, fistulization, and/or severe pain, the most common treatment is resection of involved segments of bone and reconstruction with free tissue transfer 16–18 .…”

Section: Introductionmentioning

confidence: 99%

“…3,12,13 Early ORN can be managed conservatively with therapies such as oral hygiene, antibiotics, local debridement, and hyperbaric oxygen. 14,15 However, when progression of ORN results in pathologic fracture, fistulization, and/or severe pain, the most common treatment is resection of involved segments of bone and reconstruction with free tissue transfer. [16][17][18] Despite this intervention serving as the gold standard for definitive treatment, there is a paucity of data evaluating outcomes, including the incidence of recurrent ORN.…”

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Outcomes after definitive surgery for mandibular osteoradionecrosis

et al. 2022

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Objectives To analyze charges, complications, survival, and functional outcomes for definitive surgery of mandibular osteoradionecrosis (ORN). Materials and Methods Retrospective analysis of 76 patients who underwent segmental mandibulectomy with reconstruction from 2000 to 2009. Results Complications occurred in 49 (65%) patients and were associated with preoperative drainage (odds ratio [OR] 4.40, 95% confidence interval [CI] 1.01–19.27). The adjusted median charge was $343 000, and higher charges were associated with double flap reconstruction (OR 8.15, 95% CI 2.19–30.29) and smoking (OR 5.91, 95% CI 1.69–20.72). Improved swallow was associated with age <67 years (OR 3.76, 95% CI 1.16–12.17) and preoperative swallow (OR 3.42, 95% CI 1.23–9.51). Five‐year ORN‐recurrence‐free survival was 93% while overall survival was 63% and associated with pulmonary disease (HR [hazard ratio] 3.57, 95% CI 1.43–8.94). Conclusions Although recurrence of ORN is rare, surgical complications are common and charges are high. Poorer outcomes and higher charges are associated with preoperative factors.

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Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis

Arianpour,

Meleca,

Liu

et al. 2023

JAMA Otolaryngol Head Neck Surg

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ImportanceMandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management requires a morbid segmental resection with osteocutaneous reconstruction. Evidence of the anterolateral thigh fascia lata (ALTFL) rescue flap technique’s safety, effectiveness, and long-term outcomes is needed.ObjectiveTo determine the long-term outcomes of the ALTFL rescue flap procedure for treating patients with mandibular ORN.Design, Settings, and ParticipantsThis was a retrospective medical record review performed at a single tertiary-level academic health care institution with patients who were appropriate candidates for the ALTFL procedure to treat mandibular ORN from March 3, 2011, to December 31, 2022. Data analyses were performed from January 1 to March 26, 2023.Main Outcomes and MeasuresPatient characteristics, preoperative radiographic Notani staging, intraoperative defect size, length of stay, complication rates, and clinical and radiographic findings of progression-free intervals.ResultsThe study population of 43 patients (mean [SD] age, 66.1 [47-80] years; 24 [55.8%] male individuals) included 52 cases of mandibular ORN. The preoperative Notani staging of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%), stage II; and 14 (30.4%), stage III. The mean defect area was 20.9 cm2. Successful arrest of ORN disease progression was noted in the clinical and radiographic findings of 50 of the 52 (96.2%) cases, with only 2 (3.8%) cases subsequently requiring fibular free flap reconstruction. The major complication rate was 1.9% (1 case). Clinical and radiographic progression-free intervals were assessed, and no statistically significant differences were noted between Notani staging groups (log-rank P = .43 and P = .43, respectively); ie, patients with stage III disease had no significant difference in risk of clinical (HR, 0.866; 95% CI, 0.054-13.853) or radiographic (HR, 0.959; 95% CI, 0.059-15.474) progression vs those with stage I disease. Weibull profiling revealed 96.9%, 94.6%, and 93.1% successful mandibular ORN arrest at 1, 3, and 5 years, respectively. The major complication rate was 1.9%. Mean (SD) length of stay was 2.7 (0.0-7.0) days. Mean (SD) radiographic follow-up was 29.3 (30.7) months.Conclusions and RelevanceThe findings of this large retrospective patient case series support the continued success of the ALTFL rescue flap technique, a safe and highly effective long-term treatment for mandibular ORN in carefully selected patients.

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Anterolateral Thigh Fascia Lata Rescue Flap: A New Weapon in the Battle Against Osteoradionecrosis

Cited by 12 publications

References 11 publications

Free Tissue Transfer for Skull Base Osteoradionecrosis: A Novel Approach in the Endoscopic Era

Free Tissue Transfer for Skull Base Osteoradionecrosis: A Novel Approach in the Endoscopic Era

Outcomes after definitive surgery for mandibular osteoradionecrosis

Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis

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