Two stage reconstruction with revascularized grafts after resection of retromolar and oropharyngeal carcinoma

The clinical outcome of two stage reconstruction with revascularized grafts after resection of extensive retromolar and oropharyngeal squamous cell carcinoma in 17 patients is presented. In the first operation, the intraoral soft tissue defect was covered by a revascularized jejunal flap, and the mandibular defect was bridged by a reconstruction plate. After a period of 5-28 months, mandibular reconstruction was performed with a microsurgically revascularized iliac crest graft that was positioned under the jejunal graft. Clinical follow up included tumour recurrence rate, the form of nutrition, speech disorders and mouth opening restrictions. Quality of life was analysed by the EORTC questionnaires. Fifteen patients were free of recurrence and alive. Twelve patients were able to swallow food. The jejunal flap provided perfect lining of the soft palate, the pharynx and the base of the tongue, thus supporting functional restoration. Despite the gravity of disease and invasiveness of therapy, the two stage procedure leads to satisfying functional and aesthetic results thus obtaining appropriate QOL.

The use of implant-supported prostheses in the functional and psychosocial rehabilitation of tumor patients

PURPOSE

The present study investigated the residual functional constraints as well as the psychosocial rehabilitation of tumor patients following prosthetic treatment with implant-supported dentures.

MATERIALS AND METHODS

A clinical examination and semistructured interview were performed in 66 of 132 consecutive patients who underwent tumor resection and subsequent implant-supported restoration between 1985 and 1997.

RESULTS

Functional and psychosocial constraints were improved by between 91% (general comfort) and 47% (social reintegration) of all cases, but these constraints were never fully compensated for. Restrictions in tongue mobility, loss of sensation, and radiotherapy-induced hyposalivation led to problems in chewing and swallowing, which were hardly improved by prosthetic rehabilitation. The best subjective assessments referred to appearance, followed by masticatory improvement and denture retention.

CONCLUSION

Functional impairment cannot be fully compensated by implant-supported prosthodontic reconstructions, but such treatment contributes essentially to general well-being and relief of disease-related social restrictions.

[Nasolabial flap reconstruction of the columella]

We report three cases of squamous cell carcinoma of the columella invading the sub-partitions. Wide resection raised the problem of several nasal esthetics sub-units. A chronological review of columella reconstruction procedures explained why the nasolabial fragment rarely used for partial rhinopoiesis, was appropriate in these three patients.

Efficacy of dental implants placed into fibula-free flaps for orofacial reconstruction

OBJECTIVES

The transfer of the osseofasciocutaneus fibula-free flap has become a routine procedure in the reconstruction of comprehensive orofacial defects. Besides its length, major advantages of the fibula-free flap include the trigonal diameter of the fibular bone, which usually allows the placement of dental implants.

PATIENTS AND METHODS

In a prospective study, 16 consecutive patients who received free fibula grafts and in total 51 dental implants between 1999 and 2001 were examined. All implants were inserted secondary after bone grafting and loaded after 3 months of submerged healing. The observation period extended 2.5 years on average. The implant success was controlled clinically, radiographically and by resonance frequency analysis.

RESULTS

One implant that was located at the interface between the fibula graft and the mandible was lost due to dehiscence and local infection during the healing period. In two other patients, one implant had to remain unexposed as 'sleeper' due to an unfavourable soft tissue situation. The success rate calculated by Kaplan-Meier analysis was 96.1% after an observation period of 1400 days. Resonance frequency analysis (ISQ-values) revealed significant differences related to the orientation (vestibulo-oral/mesio-distal; vo/md) of the transducer unit (P < 0.01). In general, a high primary stability for implants placed in free fibula grafts could be achieved (vo/md 66/74.1), which on average increased slightly during the healing period (vo/md 67.4/75.4) and within 12 month of functional loading (vo/md 72.1/79.9). Additional augmentation with iliac bone grafts or reconstructions with a double barred fibula resulted in an improved reconstruction of the alveolar process, thus allowing superior individual implant positions or angulations, but no elevation of the ISQ-values.

CONCLUSION

The fibula-free flap provides a consistent bone graft that allows a reliable and predictable restoration with dental implants.

The inverted temporalis muscle flap for intraoral reconstruction: its rationale and the results of its application

PURPOSE

The purpose of this article was to show the discrepancies among the different parts of the temporalis muscle flap (TMF), to introduce a new rotational arc for the TMF based on these findings, and to examine the outcomes associated with the use of this modified method.

MATERIALS AND METHODS

Two models were established on 5 human skulls to mimic the situations with the usual dissection technique or the extended dissection technique for the TMF. The lengths of the anterior part, the middle part, and the posterior part of the flap were measured and analyzed for statistical significance. A new rotational arc for the TMF was introduced, in which the flap was inverted beneath the zygomatic arch, placing the temporalis fascia away from the oral side. Seventeen consecutive oral cancer cases treated with either the traditional method or the inverted method of flap transposition were reviewed and divided into 2 groups dictated by the rotational arcs of their flaps. The traditional TMF was used in 11 cases and the inverted TMF was used in 6 cases. Clinical examination and imaging studies were used for assessment of outcome, and the results from the 2 patient groups were compared.

RESULTS

The middle and posterior parts of the temporalis muscle were significantly longer than the anterior part on the skull models. However, the middle and posterior parts did not differ greatly in length. The extended dissection technique increased the flap length except for the anterior part. Both flaps were successful in closing the defects in all cases and healed well. No muscle necrosis was observed. However, the patients receiving the traditional TMF developed noticeable cheek fullness in 4 instances, sialocele in 3, significant reduction of range of mouth opening in 2, and distinct velopharyngeal insufficiency in 2, whereas only 1 case in which the inverted TMF was used developed cheek fullness.

CONCLUSIONS

The middle or posterior part of the temporalis flap is preferred over the anterior part for covering distant defects because of its extra length. The inverted TMF is simple and safe to apply. It can extend farther in the posterior oral cavity and has fewer complications than the traditional TMF.

Rehabilitation of an irradiated mandible after mandibular resection using implant/tooth-supported fixed prosthesis: a clinical report

Patients undergoing mandibular resection often have facial asymmetry and cosmetic disfigurement, which include a retruded, deviated mandible, motor and sensory deficiencies, and abnormal intermaxillary relationship and occlusion. An implant-supported fixed prosthesis can be an optimal treatment modality. However, there is a problem in creating a repeatable, stable plane of occlusion and maxillomandibular relationship. This report describes the treatment sequence and considerations to rehabilitate a patient undergoing mandibular resection and radiotherapy with an implant-supported fixed prosthesis.

Survival of a free flap after arterial disconnection at six days

We know of no definition of how long it takes for a free flap to develop its own independent blood supply from its recipient bed. In this case report, we describe survival of a free flap after loss of the arterial anastomosis at 6 days.

Mandibular reconstruction using the titanium functionally dynamic bridging plate system: a retrospective study of 34 cases

PURPOSE

We sought to examine the use of the Titanium Functionally Dynamic Bridging Plate System (Howmedica Leibinger, Freiburg, Germany) for mandibular reconstruction after oncologic resection in 34 patients.

PATIENTS AND METHODS

A retrospective study of 34 patients who had mandibular reconstruction using the titanium dynamic bridging plate system for mandibular reconstruction after oncologic resection were evaluated. The indications and postoperative outcomes were studied. Our evaluation focuses on the tolerance and aesthetic and functional results of this system.

RESULTS

The follow-up ranged from 1 to 4 years. At the end of the study, 18 of the 34 patients (53%) still had the plate in place. One plate fracture and 1 plate exposure requiring surgical management were found. Surgical results were satisfying, particularly when looking at healing delay or long-term tolerance. Aesthetic (79% rated the results as good or acceptable) and functional results of this reconstruction material were satisfying.

CONCLUSION

This reconstruction system provides a solution for a safe and rapid mandibular reconstruction for patients with a poor prognosis or poor general condition. This method also preserves the possibility of secondary reconstruction.

The radial forearm flap as a carrier for the osteocutaneous fibula graft in mandibular reconstruction

According to the concept of a free flap carrier we transferred an osteocutaneous fibula graft after microanastomosis to a pedicled radial forearm flap for reconstruction of the lower face in a patient with a total occlusion of the left and a subtotal occlusion of the right common carotid artery. The fibula was osteotomized in three segments to form the new mandible, and the skin paddle was placed extraorally. An external fixation device was connected to the radial bone, and a halo frame was fixed to the skull, and the forearm was thus stabilized rigidly in a suitable position. After 2 weeks, serial occlusion of the pedicle was begun twice daily. Blood flow and haemoglobin oxygenation of the skin paddle were measured by laser Doppler flowmetry and photometry. At the 14th day of ischaemic preconditioning, the flap could tolerate 3h of occlusion. Then the carrier vessels and the forearm flap were excised. The flap survived completely based on neovascularization from the recipient site.

Successful Free Osteocutaneous Scapular Flap Transfer for Mandibular Reconstruction in a 93-Year-Old Patient

With the extension of the average life span and the development of surgical technique, anesthesia, and pre- and postoperative management, operations for elderly patients have become more widely accepted. In the field of plastic surgery, free-flap transfers using microvascular techniques have become a common surgical procedure in reconstruction of the head and neck region after surgical removal of a cancer. There have been several reports of free-flap transfer in patients older than 90 years, but the authors know of no reports of free osteocutaneous flap transfer for mandibular reconstruction, which is a very invasive free-flap surgery, for such patients. The mandible plays a significant role in various kinds of dynamic functions, such as mastication, deglutition, and articulation. Disorder of these functions causes a deterioration in the patient's quality of life. The authors have performed a mandibular reconstruction using an osteocutaneous scapular free flap after resection of a gingival cancer invading the mandibular bone in a 93-year-old Japanese woman. In our case, an osteocutaneous scapular free flap, which permits the patient rapid rehabilitation of the lower leg, is thought to be a good choice because it allows the patient to get out of bed as quickly as possible in the postoperative period to minimize additional complications.

Use of Magnetic Abutments for Short Endosseous Implants Following a Fibula Bone Graft in an Oral Cancer Patient: A Case Report

Dental implant treatment is an indispensable portion of oral rehabilitation in patients who are to undergo reconstructive surgery following the removal of an oral cancerous lesion. However, ideal dental implant treatment cannot be achieved easily in patients who have undergone mandibular reconstruction with a free vascularized flap, usually because of the limited length, height, and width of the bone graft. Shorter implants (< 10 mm in length) therefore are occasionally used in vascularized fibula graft sites. In such cases, however, shorter implants tend to be overloaded, thereby endangering its longevity. In this article, we discuss how a magnetic abutment system was introduced for such a patient. This was designed to discourage overloading of the mandatory short implants. The outcome was successful without overloading 1.5 years after the placing of the mandibular overdenture.

The temporal fasciocutaneous island flap for oncologic oral and facial reconstruction

PURPOSE

This study reports the anatomy, operative technique, and postoperative results of the temporal fasciocutaneous island flap (TFCIF), as used for facial and intraoral reconstruction.

MATERIALS AND METHODS

Retrospective study of 15 patients who underwent TFCIF reconstruction. The anatomic basis and surgical technique are described. The flap was used for mucosal reconstruction after cheek or maxillary resection. It was used for facial tissue loss in 2 cases: orbital osteoradionecrosis and exposure of a mandibular reconstruction plate.

RESULTS

This technique provides a safe and rapid solution for intraoral reconstruction; however, it cannot be used for the anterior floor of the mouth. The best indication that we have found is the reconstruction of hemimaxillectomy, allowing closure of buccosinusonasal communication and prosthetic rehabilitation. The main disavantage is that hair regrowth limits its use to patients who need postoperative radiotherapy. Donor site morbidity is minimal. Only a partial failure was observed.

CONCLUSION

The TFCIF is a rapid, safe, and useful flap for oral and facial reconstruction after oncologic resection. Its arc of rotation limits, however, its use to the posterior part of the oral cavity.

Sternocleidomastoid myocutaneous flap for intraoral reconstruction after resection of oral squamous cell carcinoma

PURPOSE

The sternocleidomastoid (SCM) myocutaneous flap remains an important tool in head and neck reconstruction. This article retrospectively reviews 40 consecutive SCM myocutaneous flaps used for the reconstruction after resection of oral squamous cell carcinoma with respect to reliability and complications.

PATIENTS

From 1987 to 1997, 40 patients underwent SCM myocutaneous flap reconstruction of the oral cavity. The age and gender of the patients, site of primary tumor TNM stage, type of associated operation, and clinical course were analyzed.

RESULTS

In 8 cases, partial epithelial loss over the skin paddle occurred with survival of the muscle and at least some of the dermis. Unilateral supraomohyoid neck dissection (SND) was performed in 11 cases, and unilateral functional neck dissection, which preserves SCM and/or internal jugular vein and/or accessory nerve, in 16 cases. Pathologically positive nodes were recognized in 14 of these 27 neck dissection cases; in 11 of these 14 cases, the neck lesion was controlled.

CONCLUSION

The SCM myocutaneous flap appears to be simple to use and useful for reconstruction of the defect after resection of oral carcinoma, and the indications for this flap will be extended in accordance with the recent increases in the number of supraomohyoid and functional neck dissection cases.

Central resorption in an iliac crest transplant with microvascular anastomosis--report of 2 cases

INTRODUCTION

The microvascular iliac crest flap is preferred for repair of segmental mandibular defects. Its viability and constant size are regarded as a great advantage for oral rehabilitation.

PATIENTS

Two patients with oral cancer and recurrent keratocyst underwent mandibular reconstruction with an iliac crest transplant. Wound healing was uneventful.

RESULTS

Several years after reconstruction we noticed complete absence of cancellous bone in the transplants. The cortical aspect consisted of vital bone.

CONCLUSION

Secondary to changes in the blood supply after tissue transfer, microvascular bone transplants may develop complete medullary resorption. Substitution of this central bone is variable and may not happen at all.

[Preservative surgery of T3 glottic cancer: 75 cases report]

OBJECTIVE

To explore the methods of surgery and evaluate the long-term results of preservative surgery for T3 glottic cancer.

METHOD

Seventy-five cases with T3 glottic cancer were treated surgically from 1989 to 1999. The lesions were removed entirely, the epiglottis, bi-pedicled myoperichondral flap, platysma myocutaneous flap, sternohyoid myofascial flap, platysma myofascial flap, thyroid perichondral flap were utilized to restore the defects of larynx and reconstruct the laryngeal functions.

RESULT

The 3- and 5-year survival rates were 83.2% and 73.6% in all cases, 82.7% had all laryngeal functions (voice, respiration and deglutition) restored and 17.3% partially restored(voice and deglutition).

CONCLUSION

Preservative surgery can be carried out for T3 glottic cancer with the lesions entirely removed. Choosing and following what is optimum from multiple feasible surgical methods is a prerequisite for better laryngeal functions.

The face of cancer

Two voices tell the story of an evolving doctor-patient relationship. Seizures are the first indication of squamous cell lung cancer metastatic to the brain. Both doctor and patient describe the course of the illness, treatment, and remarkable recovery, each from his own perspective. The patient describes how the cancer became a creative as well as a destructive force, expressed in his painting and new approach to life. The essay concludes by discussing limitations of the biomedical model of disease in this case and the complex two-way nature of the healing relationship between doctor and patient.

Total lower lip reconstruction using sensate composite radial forearm flap

In modern plastic and reconstructive surgery, shape and function must be considered together. These are the most important goals of any operation. There are a lot of techniques that have been reported for total lower lip reconstruction. It is believed that the radial forearm flap is the most suitable technique for lower lip and chin reconstruction after tumor excision so as to achieve better shape and functional results. The sensate radial forearm-palmaris longus free flap was used for total lower lip reconstruction in 17 patients with lower lip carcinoma with a mean age of 51 years. Two of the patients were female, and 15 were male. All the patients had squamous cell carcinoma. The patients were followed up for 1 to 3 years. Complications of these operations were partial superficial flap loss in 1 patient, partial graft loss in the donor areas of two flaps, and infection in only 1 patient. Wound dehiscence, fistula formation, suture abscesses, or sialocele was not seen in any patient. In this study, the aim was to demonstrate that the sensate radial forearm flap could produce acceptable esthetic results, good sphincteric function, and sensation in the early period after surgery.

Functional rehabilitation following resection of the floor of the mouth: the nasolabial flap revisited

INTRODUCTION

The aim of this study was to analyse the results of treatment following reconstruction of intraoral soft tissue using a nasolabial flap, with particular consideration of functional aspects.

MATERIAL AND METHODS

In 26 patients (over a period of 10 years), the intraoral repair of the defect was carried out in the anterior floor of the mouth, 19 have received a unilateral and seven a bilateral nasolabial flap. The defects were caused by resection of squamous cell carcinomas (T1-T2) of the intraoral mucosa in 24 cases and osteoradionecrosis with soft tissue loss in two cases.

RESULTS

Complications of local wound healing were observed in three cases. In 23 patients the subsequent prosthetic rehabilitation was successful and allowed a return of masticatory function. In the other three cases, a secondary operation for flap remodelling would have been preferred, but the patients declined these operations.

CONCLUSION

The nasolabial flap for replacement of soft tissue in the floor of the mouth represents a functional and aesthetically satisfactory alternative to reconstruction by microsurgically anastomosed flaps in cases with defects of up to 5 x 5 cm in size, especially in older, medically compromised patients who are therefore of poorer surgical risk.

The posteriorly based platysma flap in oral and facial reconstruction: A case series

PURPOSE

The purpose of this study was to assess the reliability and use of the posteriorly based platysma flap for oral and facial reconstruction.

PATIENTS AND METHODS

This case series consists of 7 patients who were reconstructed with a posteriorly based platysma flap for various tumor resection defects of the oral and facial region. The flaps were monitored for complications, including skin loss and ischemia in the postoperative period.

RESULTS

Three of the patients (43%) in this study had no complications. Three patients (43%) had some skin sloughing, but the underlying muscle remained viable and mucosalized normally. One patient (14%) had 40% flap loss of the distal end, possibly due to vascular compromise that occurred during a concomitant neck dissection.

CONCLUSION

The posteriorly based platysma flap is a reliable reconstruction option for defects in the facial and oral region. If skin sloughing occurs, it is usually inconsequential for intraoral reconstruction as the underlying muscle remains viable and undergoes epithelialization.

[Application of prosthetic replacement for bilateral maxillectomy defect]

A 59-year-old woman with large hard palate cancer underwent surgical resection. We constructed a maxillary prosthesis to be connected to the patient's mandibular denture. Bilateral maxillectomy resulted in total loss of the hard palate and bilateral alveolar and partial loss of the soft palate. A obturator prosthesis was prepared beforehand to fit the surgical cavity. The patient recovered functional speech and swallowing at a relatively early stage, achieving satisfactory cosmetic results.

Vertical distraction osteogenesis of fibula transplants for mandibular reconstruction--a preliminary study

INTRODUCTION

When reconstructing the mandible after tumour resection with a fibular graft, the mandible is often vertically deficient, making placement of dental implants impossible.

PATIENTS

Segmental vertical distraction of the reconstructed mandible was performed in nine patients following tumour surgery between February 1998 and 2001. Their age was 14-65 years (average 46.3); all underwent radiotherapy with a dose of up to 55.6 Gy prior to tumour resection. Mandibular discontinuity was repaired with a microvascular fibular bone graft. All grafts had a vertical bone deficit ranging from 9 to 12 mm when compared with the non-resected part of the mandibles.

METHODS

All patients underwent segmental vertical distraction of the transplants. The distraction devices were applied intraorally. Distraction of 1.0 mm/day was performed using a Martin distractor (TRACK 1.5) followed by 12 weeks retention time.

RESULTS

The increase of vertical bone height was stable and enabled placement of dental implants without any complications.

CONCLUSION

Vertical distraction osteogenesis may become a common procedure in the treatment of alveolar ridge deficiency resulting from transplanting fibulae for mandibular reconstruction following tumour surgery.

Defect-related variations in mandibular reconstruction using fibula grafts. A review of 96 cases

Despite the popularity of the donor region 'laterodorsal calf' with the fibula, the flexor muscles and the overlying skin for microsurgical bone and soft tissue transfer some limitations and possible pitfalls have to be considered. We report on 93 patients who had 96 reconstructions, 65 with and 31 without soft tissue transfer in 8 years using microvascular fibular grafts for mandibular replacement and oromandibular reconstruction. Six patients died within 4 weeks and eight flaps were lost. Necrosis of the skin paddle occurred in 7 (11%) of 61 cases with uncomplicated bony healing.

Anterolateral thigh flap

A 64-year-old Japanese male had a squamous cell carcinoma (T4N1M0) in the left gingival and buccal mucosa, so a radical wide resection involving left radical neck dissection was performed. An anterolateral thigh flap measuring 15 x 8 cm was raised from the left thigh and transferred to the defect. The postoperative course was eventful. There was no postoperative flap necrosis, infection, not even a cervical fistula.