Craniofacial Resection and Reconstruction in Patients With Recurrent Cancer Involving the Craniomaxillofacial Region

Accepted Manuscript Craniofacial resection and reconstruction in patients with recurrent cancer involving the cranio-maxillofacial region Wei-liang Chen, DDS, MD, MBA, Zhao-hui Yang, DDS MD, PhD, Zhi-quan Huang, DDS MD, PhD, Song Fan, DDS, PhD, Da-ming Zhang, DDSS, PhD, You-yuan Wang, DDS, PhD PII:

S0278-2391(16)30791-1

DOI:

10.1016/j.joms.2016.08.044

Reference:

YJOMS 57433

To appear in:

Journal of Oral and Maxillofacial Surgery

Received Date: 29 May 2016 Revised Date:

24 August 2016

Accepted Date: 29 August 2016

Please cite this article as: Chen W-l, Yang Z-h, Huang Z-q, Fan S, Zhang D-m, Wang Y-y, Craniofacial resection and reconstruction in patients with recurrent cancer involving the cranio-maxillofacial region, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.08.044. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT

Craniofacial resection and reconstruction in patients with recurrent cancer involving the cranio-maxillofacial region

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Wei-liang Chen, DDS, MD, MBAa,1; Zhao-hui Yang, DDS MD, PhDb,1; Zhi-quan Huang DDS MD, PhDc, Song Fan, DDS, PhDd; Da-ming Zhang, DDSS, PhDe; You-yuan Wang, DDS, PhDf a

1

Shared first authorship.

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Professor and Director, Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China b Assistant Professor c Assistant Professor d Attending e Attending f Assistant Professor

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Correspondence and requests for offprints to: Professor and Director Dr Wei-liang Chen, Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University. 107 Yan-jiang Road, 510120 Guangzhou, China. Tel: +86 020 81332429 Fax: +86 020 81332853 E-mail:[email protected]

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Craniofacial resection and reconstruction in patients with recurrent cancer involving the cranio-maxillofacial region

Abstract

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Purpose

Head and neck tumors that involve the cranio-maxillofacial region are classified as stage IVb disease and are clinically challenging. In this study, the outcomes of

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craniofacial resection and craniofacial reconstruction in patients with recurrent malignant tumors involving the cranio-maxillofacial region were evaluated.

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Patients and Methods:

This retrospective observational study was conducted from January 2008 to August 2015. Data collected for each patient included age, gender, tumor site, initial treatment, craniofacial resection, reconstruction flaps and complications following craniofacial resection, adjuvant treatment and reported the outcomes of craniofacial resection and

Results

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craniofacial reconstruction. The χ2 test in SPSS software was used to analyze the data.

A total of 24 patients with recurrent

malignant tumors

involving the

cranio-maxillofacial region were identified who had undergone craniofacial resection

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at the Center of Cranio-Maxillofacial Surgery of Sun Yat-sen University (Guangzhou, Guangdong, China). The study population comprised 24 patients with recurrent tumors

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(58.3% squamous cell carcinoma, 41.7% sarcoma) involving the cranio-maxillofacial region who underwent craniofacial resection. The 15 males and 9 females ranged in age from 21 to 73 years. Craniofacial resection consisted of orbital exenteration and maxillotomy; anterior skull base surgery, facial resection, and mandibulotomy; or ipsilateral radical neck dissection. The resultant cranio-maxillofacial defects were reconstructed using extended vertical lower trapezius island myocutaneous flaps (TIMFs), temporalis myofascial flaps, or submental flaps. All patients with recurrent malignant tumor involving the cranio-maxillofacial region underwent gross total resection of the tumor; 22 patients underwent craniofacial reconstruction. There were

ACCEPTED MANUSCRIPT no major surgical complications. Minor flap failure and wound dehiscence in the donor site occurred in four patients. The follow-up period ranged from 8 to 36 months. Seven patients in the squamous cell carcinoma (SCC) group and 7 in the sarcoma (SA) group were alive with no evidence of disease (AND), 3 in the SCC group and 2 in the SA

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group were alive with disease (AWD), and 4 in the SCC and 1 in the SA group died of the disease (DOD) following local recurrence or distant metastases at 8-18 months. There were no significant differences between the AND, AWD, and DOD groups. Conclusions

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Craniofacial resection remains an effective salvage treatment for patients with recurrent SCC and SA involving the cranio-maxillofacial region. The extended vertical lower

a craniofacial resection.

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TIMF is a large, simple, and reliable flap for reconstructing the major defects following

Keywords: Salvage surgery, squamous cell carcinoma, sarcoma, head and neck,

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skull base, craniofacial resection, craniofacial reconstruction

Malignant tumors involving the cranio-maxillofacial region may be direct extensions

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of head and neck cancers or recurrences of squamous cell carcinoma (SCC) and sarcoma (SA) involving the cranio-maxillofacial region. The 2010 American Joint

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Committee on Cancer (AJCC) cancer staging guidelines classify malignant head and neck tumors as T4b if they invade the masticator space, pterygoid muscle, pterygoid plate, nasopharynx, carotid artery, or skull base.1 Salvage surgery remains an effective treatment modality for T4b patients with recurrent oral and oropharyngeal squamous cell carcinoma involving the carotid artery and defects can be reconstructed with a trapezius flap.2 However, involvement of the cranio-maxillofacial region is classified as stage IVb disease, which is considered unresectable. Little is known about the outcomes of patients who undergo craniofacial resection and craniofacial reconstruction, and few literature reports exist. Therefore, in this retrospective study,

ACCEPTED MANUSCRIPT we evaluated the feasibility of salvage surgery, including craniofacial resection of the tumor together with craniofacial reconstruction, in patients with recurrent malignant tumors involving the cranio-maxillofacial region.

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Patients and methods This retrospective observational study was conducted from January 2008 to August 2015. Data collected for each patient included age, gender, tumor site, initial treatment, craniofacial resection, reconstruction flaps and complications following craniofacial

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resection, adjuvant treatment and reported the outcomes of craniofacial resection and craniofacial reconstruction. The diagnosis of recurrent malignant tumors involving the

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cranio-maxillofacial region was made based on history, clinical appearance, and CT scanning or magnetic resonance imaging. The main inclusion criteria were patients with recurrent malignant tumors involving the cranio-maxillofacial region, excluding serious blood disorders such as leukemia. The exclusion criteria for treatment were the presence of cachexia, congestive cardiac failure, bradycardia, asthma, or obstructive

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pulmonary disease or no follow-up. The Institutional Review Board of Sun Yat-sen University approved the study. The χ2 test in SPSS software (version12.0; SPSS, Inc., Chicago, IL, USA) was used to analyze the data. Means and standard deviations were

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Results

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calculated. A P value < 0.05 was considered to indicate statistical significance.

A total of 24 patients with recurrent

malignant tumors

involving the

cranio-maxillofacial region were identified who had undergone craniofacial resection at the Center of Cranio-Maxillofacial Surgery of Sun Yat-sen University (Guangzhou, Guangdong, China). Among the 24 patients, 14 (58.3%) had SCC (Table 1) and 10 (41.7%) had SA (Table 2). The age range of the 15 males and 9 females was 21–73 years (median, 46.3 years). The site of the primary tumor was the maxilla in 16 patients (66.7%), the zygoma in four (16.7%), the buccal mucosa in two (8.3%), and the palate in two (8.3%). All patients underwent tumor resection and/or radiotherapy and

ACCEPTED MANUSCRIPT chemotherapy. Biopsy was performed in all patients to confirm recurrence of the tumor. Computed tomography and magnetic imaging studies delineated the extent of the tumors. The most common presenting symptoms were facial swelling, trismus, proptosis, and pain or anesthesia in the maxillary division of the trigeminal nerve.

recurrence (rCS), 1 all patients had rCS stage IVb disease.

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According to the 2010 AJCC cancer guidelines regarding the clinical staging of

Craniofacial resection with orbital exenteration and maxillotomy was performed in all 24 patients. In addition, 18 underwent anterior skull base surgery, including

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resection of the dura mater in 3 patients. In the latter, the resulting dural defect was repaired using Dura-Guard® (Synovis Life Technologies, Inc.). In the other 15 patients

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in this group, extradural dissection in the form of facial resection (11 patients), mandibulotomy (9 patients), and/or ipsilateral radical neck dissection (4 patients) was performed (Tables 1 and 2). Frozen-section assessment of the surgical margins was performed routinely. The resultant cranio-maxillofacial defects were reconstructed using 12 extended vertical lower trapezius island myocutaneous flaps (TIMFs), with a

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skin paddle measuring between 6×10 cm and 10×30 cm (average, 8.5×17.8 cm). The TIMFs included five folded extended vertical lower TIMFs for the reconstruction of through-and-through defects (Fig. 1) and three extended vertical lower TIMFs with part

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of the latissimus dorsi muscle to reconstruct major defects of the skull base (Fig. 2). Among the 12 patients who did not receive a TIMF, a temporalis myofascial flap (Fig. 3) measuring between 5×14 cm and 5×16 cm (average, 5×15 cm) was used in 8 patients

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and a submental flap measuring 3.5×15 cm in 2 patients (Fig. 4); the remaining 2 patients, both of whom had recurrent SA did not undergo any form of repair (Fig. 5). Seven patients who had positive or close margins after craniofacial resection were treated with adjuvant chemotherapy, radiotherapy (median dose of 60 Gy), or both (Tables 1 and 2). There was no significant difference in the sex distribution between the SCC and the SA groups. Patients in the SCC group had an older mean age than that of those in the SA group (53.14 ± 7.11 vs. 36.60 ± 5.21 years, P < 0.05). All 24 patients with recurrent malignant tumors involving the cranio-maxillofacial region underwent gross total

ACCEPTED MANUSCRIPT resection of the tumor; 22 patients also underwent craniofacial reconstruction. There were no operative major complications. Minor flap failure and wound dehiscence in the donor site occurred in four patients (Tables 1 and 2). The patients were followed for 8–36 months (median of 19.9 and 20.3 months in the SCC and SA groups, respectively).

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Seven patients (50.0%) in the SCC group and 7 (70.0%) in the SA group were alive with no evidence of disease (AND), 3 (21.4%) in the SCC group and 2 (20.0%) in the SA group were alive with disease (AWD), and 4 (28.6%) in the SCC group and 1 (10.0%) in the SA group died of the disease (DOD) following local recurrence or

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distant metastases at 8–18 months (Tables 1 and 2). There were no significant

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differences among the three groups.

Discussion

A previous study showed that patients with anterior skull base malignancies can be treated successfully with skull base surgery.3 Although the morbidity and mortality after craniofacial resection for anterior skull base SA are relatively low, these patients

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are at high risk for tumor recurrence, regardless of the tumor grade.4 In a large-scale study of 1307 patients who underwent craniofacial surgery at 17 institutions, postoperative complications were reported in 433 patients (33%), with local wound

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complications being the most common (18%) of the complications. The postoperative mortality rate was 4%.5

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Salvage surgery remains the only curative treatment option for patients with advanced recurrent head and neck SCC after primary radiation and/or surgery. 2,6-8 Involvement of the cranio-maxillofacial region is classified as stage IVb disease, which is considered unresectable. However, the developments in surgical and reconstructive methods have included craniofacial resection and craniofacial reconstruction techniques to treat malignant tumors involving the cranio-maxillofacial region. In this study, 24 patients with advanced recurrent SCC or sarcoma involving the cranio-maxillofacial region underwent

complete

en

bloc

craniofacial

resection.

The

resultant

major

cranio-maxillofacial defects were reconstructed using pedicle flaps. Overall, there was

ACCEPTED MANUSCRIPT no major morbidity or mortality. After 8–36 months follow-up, 50.0% of the patients in the SCC group and 70.0% of those in the SA group were AND. Despite its considerable challenges, craniofacial resection appears to be a safe and reasonably effective treatment modality for patients with malignant tumors involving

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the cranio-maxillofacial region. While there were no significant differences among the AND, AWD, and DOD groups, 28.6% of the SCC patients versus 10.0% of the SA patients died of local recurrence or distant metastases at 8-18 months. Nonetheless, our results suggest that rCS IVb tumors can be removed safely and completely by en bloc

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craniofacial resection, resulting in a good patient survival rate. The higher mortality rate in the SCC group in this study can perhaps be explained by the older age of these

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patients.

Craniofacial reconstruction remains a therapeutic challenge. The main purposes of skull base reconstructions is to create a support for the brain, prevent brain herniation, avoid intracranial infections, diminish the risk of cerebrospinal fluid (CSF) leakage, and avoid pneumocephalus.9 In an earlier report, the incidence of CSF leakage,

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intracranial infection, and tension pneumocephalus was 5.6% following anterior skull base resections of malignant and benign tumors.10 Craniofacial defects can be reconstructed in one stage, using either regional flaps, including temporal flaps,11 island pedicle flaps such as the submental and pectoralis major flaps,12,13,14 and extended

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vertical lower TIMF,6 or vascularized flaps such as the forearm free flap,15 rectus abdominis myocutaneous flap,16 anterolateral thigh flap,17 and osteo-fascio-cutaneous

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fibular flap.18

In this study, the primary treatment for most of the patients was surgery, including

ipsilateral radical neck dissection, radiotherapy alone, or surgery + adjuvant radiotherapy. None of the patients were candidates for microvascular free flaps at the recipient site. Among the 22 patients who underwent one-stage craniofacial reconstruction following craniofacial resection, 12 underwent extended vertical lower TIMFs with a skin paddle measuring 8.5×17.8 cm on average, including folded extended vertical lower TIMFs for reconstructing through-and-through defects in 5 patients and extended vertical lower TIMFs with part of the latissimus dorsi muscle for

ACCEPTED MANUSCRIPT reconstructing major defects of the skull base in 3 patients. The use of Dura-Guard® and these large flaps was adequate for the prevention of CSF fluid leakage, meningitis, tension pneumocephalus, and brain herniation among the three patients who underwent intradural dissection (cases 11 and 12 in Table 1 and case 1 in Table 2). The extended

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vertical lower TIMF provided a straightforward and reliable means for skull base reconstruction after en bloc resection in patients with recurrent malignant tumors involving the cranio-maxillofacial region. Wound dehiscence at the donor site occurred in one patient but was treated successfully with debridement. Because the flaps can be

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raised with technical ease, the duration of the procedure is relatively short. The pedicles of the flaps also help to fill the defect created by the neck dissection and to cover the

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vessels of the neck.2,8 We previously reported that when an extended vertical lower TIMF was used to reconstruct the major defects following wide resection of the tumour oral craniofacial resection, the result in swallowing function, speech function, and the appearance of the face and neck were acceptable. 8

The island pedicle, pectoralis major myocutaneous flap can be rotated up to the orbital

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region. The skin paddle of the TIMF flap is both wider and longer than that of the pectoralis major flap. This longer pedicle flap with a larger skin paddle is valuable for the reconstruction of major defects arising after salvage surgery in patients with advanced recurrent oral and oropharyngeal SCC, and it may be long enough for

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application to the skull base.14 In the present study, all patients had been treated with surgery including ipsilateral radical neck dissection and 7 patients (29.2%) had been

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treated with radiotherapy alone or surgery + adjuvant radiotherapy, and no appropriate condition for the use of microvascular free flaps at the recipient site was evident.

Ten defects following exenteration and maxillotomy were reconstructed using a temporalis myofascial flap or submental flap, measuring on average 5×15 cm and 3.5×15 cm, respectively. Minor flap failure occurred in 2 patients in whom reconstruction was performed using a temporalis myofascial flap and in 1 patient who received a submental flap. The temporoparietal fascial flap can be used to reconstruct composite defects in the orbital, malar, auricular, and cheek areas.11 The reconstruction

ACCEPTED MANUSCRIPT of major cranio-maxillofacial defects using local flaps is usually difficult because of the need for a large flap. In two patients, the defects following exenteration and maxillotomy were not reconstructed, because a temporalis myofascial flap had been used in the primary surgery such that flap repair was not possible.

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Craniofacial resection remains an effective salvage treatment for patients with recurrent SCC and SA involving the cranio-maxillofacial region. The extended vertical lower TIMF is a large, straightforward, and reliable flap for reconstructing the major

Acknowledgment

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Conflict of interest None declared. Ethical Approval: Not required

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defects following a craniofacial resection.

This work was supported by the National Natural Science Foundation of China (No. 81172563) and a research grant from the Guangdong Science and Technology Foundation (no. 2013B021800217).

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References

1. Edge SB, Byrd DR, Compton CC. AJCC cancer staging manual. 7th ed. New York

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(NY): Springer–Verlag; 2010.

2. Chen WL, Yang ZH, Zhou B, Fan S, Zhang DM, Wang YY. Salvage Surgery for Patients with Recurrent Oral and Oropharyngeal Squamous Cell Carcinoma

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Involving the Carotid Artery. J Oral Maxillofac Surg. 2016;74(7):1483-93.

3. Bentz BG, Bilsky MH, Shah JP, Kraus D. Anterior skull base surgery for malignant tumors: a multivariate analysis of 27 years of experience. Head Neck. 2003;25(7):515-520

4. Gil Z, Patel SG, Singh B, Cantu G, Fliss DM, Kowalski LP, Kraus DH, Snyderman C, Shah JP. Analysis of prognostic factors in 146 patients with anterior skull base sarcoma: an international collaborative study. Cancer. 2007;110(5):1033-41. 5. Patel SG, Singh B, Polluri A, Bridger PG, Cantu G, Cheesman AD, deSa GM, Donald P, Fliss D, Gullane P, Janecka I, Kamata SE, Kowalski LP, Kraus DH,

ACCEPTED MANUSCRIPT Levine PA, dos Santos LR, Pradhan S, Schramm V, Snyderman C, Wei WI, Shah JP. Craniofacial surgery for malignant skull base tumors: report of an international collaborative study. Cancer. 2003;98(6):1179-87 6. Chen WL, Li J, Yang Z, Huang Z, Wang J, Zhang B. Extended vertical lower

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trapezius island myocutaneous flap in reconstruction of oral and maxillofacial defects after salvage surgery for recurrent oral carcinoma. J Oral Maxillofac Surg. 2007; 65(2):205-11.

7. Kostrzewa JP, Lancaster WP, Iseli TA, Desmond RA, Carroll WR, Rosenthal EL.

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Outcomes of salvage surgery with free flap reconstruction for recurrent oral and oropharyngeal cancer. Laryngoscope. 2010;120(2):267-72

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8. Chen W, Yang Z, Zhang D, Wang Y, Fan S, Huang Z. Second salvage surgery with extended vertical lower trapezius island myocutaneous flap reconstruction for advanced re-recurrent oral and oropharyngeal squamous cell carcinoma. Int J Oral Maxillofac Surg. 2014;43(5):531-8.

9. Cantù G, Solero CL, Pizzi N, Nardo L, Mattavelli F. Skull base reconstruction after

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anterior craniofacial resection. J Craniomaxillofac Surg. 1999;27(4):228-34. 10. Fliss DM, Gil Z, Spektor S, Leider-Trejo L, Abergel A, Khafif A, Amir A, Gur E, Cohen JT. Skull base reconstruction after anterior subcranial tumor resection.

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Neurosurg Focus. 2002;12(5):e10.

11. Raffaini M, Costa P. The temporoparietal fascial flap in reconstruction of the cranio-maxillofacial area. J Craniomaxillofac Surg. 1994;22(5):261-167

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12. Chen WL, Zhou M, Ye JT, Yang ZH, Zhang DM. Maxillary Functional Reconstruction Using a Reverse Facial Artery-Submental Artery Mandibular Osteomuscular

Flap

With

Dental

Implants.

J

Oral

Maxillofac

Surg.

2011;69(11):2909-14.

13. Resto VA, McKenna MJ, Deschler DG. Pectoralis major flap in composite lateral skull base defect reconstruction. Arch Otolaryngol Head Neck Surg. 2007;133(5):490-4. 14. Chen WL, Wang YY, Zhang DM, Fan S, Lin ZY. Extended vertical lower trapezius island myocutaneous flap versus pectoralis major myocutaneous flap for

ACCEPTED MANUSCRIPT reconstruction in recurrent oral and oropharyngeal cancer. Head Neck. 2016;38(S1):E159-E164. 15. Yeo IS, Kim SH, Park MC, Lim H, Kim JH, Lee IJ. Successful reconstruction of irradiated anterior skull base defect using the dual flap technique involving local

16. Chicarilli

ZN,

reconstruction

Davey

LM.

following

Rectus a

abdominis

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pericranial flap and radial forearm free flap. J Craniofac Surg. 2014;25(4):1376-8. myocutaneous

cranio-orbital-maxillary

free-flap

resection

for

neurofibrosarcoma. Plast Reconstr Surg. 1987;80(5):726-31

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17. Wolff KD, Kesting M, Thurmüller P, Böckmann R, Hölzle F. The anterolateral thigh as a universal donor site for soft tissue reconstruction in maxillofacial surgery.

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J Craniomaxillofac Surg. 2006;34(6):323-31.

18. Lundgren TK, Pignatti M, Halle M, Boscaini G, Docherty Skogh AC, Luigi C, De Santis G. Composite orbital reconstruction using the vascularized segmentalized osteo-fascio-cutaneous

fibula

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2016;69(2):255-61

flap.

Table 1. Tumor origin, initial treatment and craniofacial resection in 14 patients with advanced recurrent squamous cell carcinoma involving the cranio-maxillofacial region Patient no., age, sex 1, 40, M

Initial Tumor site

treatment/rec

Craniofacial resection

onstruction Maxilla

TR+RT+CT

OE, ASBS, Max, Man, FR

Reconstruction flaps (cm) TIMF, 10×(7+18)*

Complications

None

Adjuvant Follow-up treatment (months) -

8

Status

AWD

ACCEPTED MANUSCRIPT Patient no., age, sex

Initial Tumor site

treatment/rec

Craniofacial resection

onstruction

Reconstruction flaps (cm)

Complications

Adjuvant Follow-up treatment (months)

Status

1, 40, M

Maxilla

TR+RT+CT

OE, ASBS, Max, Man, FR

TIMF, 10×(7+18)*

None

-

8

AWD

2, 73, F

Maxilla

TR

OE, Max

TMP, 5 × 15

None

-

36

AND

3, 49, F

Palate

TR

OE, Max

SF, 3.5 × 15

None

CT/RT

20

AND

4, 69,M

Buccal mucosa

TR+ RT

CT

30

AWD

5, 59, M

Maxilla

TR/TMP

None

-

6

AND

6, 69, F

Maxilla

7, 27, M

Maxilla

8,34, M

Wound dehiscence

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OE, ASBS, Max, Man, FR, IND TIMF, 10 × (20+10 )**

at the donor-site

TIMF, 9 × 15

OE, ASBS, Max FR,

TIMF, 10 × (8+7) *

None

-

18

DOD

TR

OE, ASBS, Max, Man, FR, IND

TIMF, 9 × (10+5) *

None

RT

36

AND

Maxilla

RT+TR

OE, ASBS, Max, Man, FR

TIMF, 9 × 12

None

-

8

DOD

9, 61, M

Maxilla

TR

OE, ASBS, Max

TMP, 5 × 15

None

-

8

DOD

10, 38, F

Maxilla

TR

OE, Max, Man, FR, IND

SF, 3.5 × 15

Minor flap failure

-

29

AND

11,69, M

Maxilla

RT + CT

OE, ASBS, Max, FR,

DG, TIMF, 6 × 10

None

-

8

DOD

12,55, F

Maxilla

RT

OE, ASBS, Max, FR,

DG, TIMF,10×(7+12)*

None

-

24

AND

13,53, M

Buccal mucosa

TR + CR

OE, ASBS, Max, Man, FR,

TIMF, 8×(7+10)*

None

-

19

AWD

14,48, M

Palate

TR

OE, Max, IND

TMP, 5 × 15

Minor flap failure

-

29

AND

TR+INDF/S

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OE, ASBS, Max

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Abbreviations: M, male; F, female; tumor resection; RT, radiotherapy; CT, chemotherapy; TMF, temporalis myofascial flap; SF, submental flap; OE, orbital exenteration; Max, maxillotomy; ASBS, anterior skull base surgery; Man, mandibulotomy; FR, facial resection; IND, ipsilateral radical neck dissection; TIMF, trapezius island myocutaneous flap; *folded extended vertical lower TIMF; **extended vertical lower TIMF with the latissimus dorsi muscle; DG, Dura-Guard® used to repair the dural defect; AND, alive with no disease; DOD, died of disease; AWD, alive with disease.

Table 2. Tumor origin, initial treatment and craniofacial resection in 10 patients with advanced recurrent sarcoma involving the cranio-maxillofacial region

ACCEPTED MANUSCRIPT Patient no., age, sex

Tumor site

Initial treatment/ reconstruction

Reconstruction flaps Craniofacial resection

Complications (cm)

Adjuvant

Follow-up

treatment

(months)

Status

Maxilla

TR/TMP

OE, ASBS, Max, Man

DG,TIMF 6 × (12+10 )**

None

-

28

AND

2, 36, M

Maxilla

TR

OE,ASBS, Max

TMP, 5 × 14

None

CT/RT

24

AND

3, 48, M

Zygoma

TR

OE, ASBS, Max

TMP, 5 × 15

None

-

25

AND

4, 24, F

Maxilla

RT+TR+CT

OE, ASBS, Max, FR

TIMF, 8 × (13+6 )**

None

-

13

AND

5,28,M

Maxilla

TR

OE, ASBS, Max, Man

TMP, 5 × 16

RT

12

AWD

6, 48, M

Maxilla

TR

OE, Max

TMP, 5 × 15

CT

8

AND

7,21,F

Maxilla

TR/TMP

OE, Max

-

None

RT

18

DOD

8, 45, M

Zygoma

TR/TMP

OE, ASBS, Max, Man

-

None

-

31

AND

9,38,M

Zygoma

TR

OE, ASBS, Max, FR

TIMF, 7 × 12

None

-

14

AWD

10,36,F

Zygoma

TR

OE, ASBS, Max

TMP, 5 × 15

None

-

30

AND

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1, 43, F

None

Minor flap

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failure

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Abbreviations: M, male; F, female; tumor resection; RT, radiotherapy; CT, chemotherapy; TMF, temporalis myofascial flap; OE, orbital exenteration; Max, maxillotomy; ASBS, anterior skull base surgery; Man, mandibulotomy; FR, facial resection; DG, Dura-Guard® used to repair the dura defect; TIMF, trapezius island myocutaneous flap; *folded extended vertical lower TIMF; **extended vertical lower TIMF with the latissimus dorsi muscle; AND, alive with no disease; DOD, died of disease; AWD, alive with disease.

Figure 1. A 40-year-old male presented with advanced recurrent squamous cell carcinoma of the left maxilla (Table 1, patient no. 1). (A) A major lesion was present in

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the cranio-maxillofacial region. (B) Magnetic resonance imaging scans show that the tumor involves the left infratemporal fossa, orbit, ethmoid sinus, and skull base. (C)

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Design of the extended lower vertical trapezius island myocutaneous flap (TIMF) using a skin paddle measuring 10 × (7+18) cm. (D) The harvested flap. (E) and (F) The folded flap provides both an inner and outer lining for the repair of a through-and-through cranio-maxillofacial defect.

Figure 2. A 43-year-old female presented with advanced recurrent sarcoma involving the cranio-maxillofacial region (Table 2, patient no. 1). (A) The incision line outline for wide excision of the tumor. (B) Design of the extended lower vertical TIMF using a skin paddle and part of the latissimus dorsi muscle measuring 6 × (12+10) cm. (C) The harvested flap. (D) The flap with the latissimus dorsi muscle was used to repair the

ACCEPTED MANUSCRIPT major cranio-maxillofacial defect. (E) and (F) Intraoral view and the appearance of the face 28 months postoperatively.

Figure 3. A 49-year-old female presented with advanced recurrent squamous cell

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carcinoma of the right palate involving the cranio-maxillofacial region (Table 1, patient no. 3). (A) and (B) Appearance of the face and oral cavity 3 months after a repair using a submental flap after craniofacial resection.

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Figure 4. A 28-year-old male presented with advanced recurrent sarcoma involving the cranio-maxillofacial region (Table 2, patient no. 5). Appearance of the face 12 months

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after temporalis myofascial flap repair following craniofacial resection.

Fig. 5. A 45-year-old male presented with advanced recurrent sarcoma involving the cranio-maxillofacial region (Table 2, patient no. 8). Repair was not possible.

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Appearance of the face 31 months after craniofacial resection.

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