Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Introduction: The facial nerve plays an essential role in enabling facial expression and social interaction. Facial nerve paralysis has been associated with reduced quality of life, rendering basic functions such as speaking and eating more challenging, in addition to aesthetic concerns. Preserving the facial nerve during surgery is, therefore, essential. However, this remains a challenge during oncological surgery, where the facial nerve may be sacrificed to achieve negative margins. Several facial reanimation techniques have been previously described, with gracilis muscle transfer being recognized as the gold standard for primary dynamic reanimation. Limitations to this technique in oncological extirpative surgery include short pedicle length, limited soft tissue volume, and less adaptable chimeric muscle properties. Additionally, oncological patients often have limited life expectancy and may undergo adjuvant radiotherapy, foreshowing the need for a one-step procedure.
Methods: Two techniques, the chimeric anterolateral thigh (ALT) flap and vastus lateralis flap, and the serratus anterior free flap (SAFF), show great promise for dynamic facial reanimation by addressing the shortcomings of the gold standard. Here, we present two cases utilizing these techniques, along with a narrative review of the SAFF and chimeric ALT technique.
Results: Our first case is a 72-year-old male patient who underwent a single-stage dynamic reanimation using a chimeric ALT flap following a radical parotidectomy and neck dissection for a T3N0M0 parotid ductal carcinoma. The vastus lateralis motor nerve was coapted to the ipsilateral masseteric nerve, while the descending branch of the lateral circumflex femoral vessels were anastomosed to the facial vessels. The total duration was of 12 hours and 15 minutes, and the patient was discharged after 7 days. 8 months following surgery, the patient's House-Brackmann mid-face score improved from 6 to 4.
In the second case, a 52-year-old male was initially treated for a T4N0M0 alveolar squamous cell carcinoma with a composite mandibular resection and reconstruction with a fibular fascio-osteo-cutaneous free flap. This patient underwent secondary dynamic facial reanimation using a SAFF 10 years following his initial oncological surgery. The subscapular artery was anastomosed to the ipsilateral superior thyroid artery, and the subscapular vein was anastomosed end to end with the internal jugular vein. The long thoracic nerve was coapted to the ipsilateral partially split hypoglossal nerve. This surgery lasted 17 hours and 45 minutes, and the patient was hospitalized for 6 days. 3 months postoperatively, the patient's House-Brackmann mid-face score improved from 6 to 3.
Discussion: A literature review on the SAFF will include variations of the harvest technique, muscle slip thinning, use of superficial subslips, and varying tension across different vectors. A literature review on the chimeric ALT free flap will also be provided, focusing on anatomical variations. Both reviews will explore the use of composite flaps and neurotization. A patient-based algorithm is also provided, to guide the optimal use for dynamic reanimation.
Conclusion: Dynamic facial reanimation is an effective reconstructive approach in head and neck oncologic surgery, and requires a personalized strategy based on patient characteristics and surgical parameters.