En bloc resection and trapezius island flap reconstruction of giant extracranial Schobinger stage III/Yakes type IV arteriovenous malformations involving the orbital region.

Background: Extensive head and neck arteriovenous malformations (AVMs) associated with severe hemorrhage are potentially life-threatening and present substantial challenges for head and neck surgeons. Methods: We evaluated a 33-year-old man (Patient 1) and a 38-year-old woman (Patient 2) with life-threatening, extensive Schobinger stage III/Yakes type IV AVMs of the head and neck. Both patients underwent en bloc resection, and the resulting large craniofacial defects were reconstructed using an extended vertical trapezius myocutaneous island flap (eTMF). In Patient 2, simultaneous radical neck dissection was performed because of a concomitant primary T4a squamous cell carcinoma of the maxilla. Results: The extensive head and neck AVMs, including those with orbital involvement, were completely and safely resected, and the foldable eTMF reconstructed the resulting large defects. No surgical complications occurred, and postoperative appearance was acceptable. Swallowing, mastication, and speech were restored to preoperative levels. Quality-of-life scores improved by 40 percentage points, reaching 80% in Patient 1 and 60% in Patient 2. Patient 1 remained disease-free after 36 months of follow-up, whereas Patient 2 died of local recurrence 8 months after surgery. Conclusions: En bloc resection or radical surgery is an effective treatment approach for patients with life-threatening extracranial Schobinger stage III/Yakes type IV AVMs involving the orbital region, even when accompanied by T4a-stage SCC of the maxilla. The foldable eTMF is a large, highly reliable option for reconstruction of extensive head and neck defects, including full-thickness cheek defects.