Temporalis myofascial flap in maxillofacial reconstruction: clinical and histological studies of the oral healing process

Immediate Reconstruction of Large Full-Thickness Segmental Anterior Maxillary Defect with Bone Transport

Maxillary segmental defects are a reconstructive challenge particularly when the anterior arch is involved. Missing bone, mucosa, and teeth should be replaced; fistulae closure should be guaranteed by bone and mucosa continuity; stable functional occlusion should be achieved; and facial aesthetics restored. These defects resulting from tumor excisions, if left untreated, will cause additional problems related to interposed scar and collapse of lip and nose. Immediate reconstruction should avoid these problems and should be considered when safe tumor-free margins are obtained. This study describes the treatment of such a defect resulting from a myxoma excision, with trifocal distraction requiring only one additional surgery. Internal distractors were fixed bilaterally for transport of two segmental discs created by inverted L osteotomies at the same surgical time of tumor excision. A second surgery was performed after central contact between transport discs was achieved, for device removal and creation of a dynamic system to regenerate molding and compression-focus development. This was accomplished by internal fixation of one side and central fixation of a full-open distractor to act as compression device when reversely activated. Central perfect adaptation between transported segments and good-quality attached mucosa lining the alveolar crest were determinant to obtain a stable functional and aesthetic result.

Comprehensive treatment and rehabilitation of a patient with maxillary arteriovenous malformation

Arteriovenous malformations (AVMs) of the maxilla are rare and potentially life-threatening conditions that can pose a therapeutic dilemma. We reported the first case of maxillary AVM in a 15-year-old girl who was treated by marginal hemimaxillectomy including overlying palatal mucosa and immediate replantation of the segment after removing the AVM tissues and teeth and covering by a full-thickness pedicled temporal muscle flap rotated into the mouth. Then, this preserved bone underwent distraction osteogenesis and dental implant rehabilitation successfully. This method was previously used for the definitive treatment of mandibular AVMs, and in this case, we applied this method for the first time in maxillary AVMs. In conclusion, this surgical method may be considered as a safe, convenient, and effective treatment and reconstructive modality for such vascular malformations in the maxilla and restores function and symmetry of the jaws while obviating the need for bone harvesting and future major reconstructive operations.

Maxillary reconstruction: Current concepts and controversies

Maxillary reconstruction is still an evolving art when compared to the reconstruction of the mandible. The defects of maxilla apart from affecting the functions of the speech, swallowing and mastication also cause cosmetic disfigurement. Rehabilitation of the form and function in patients with maxillary defects is either by using an obturator prosthesis or by a surgical reconstruction. Literature is abundant with a variety of reconstructive methods. The classification systems are also varied, with no universal acceptance of any one of them. The oncologic safety of these procedures is still debated, and conclusive evidence in this regard has not emerged yet. Management of the orbit is also not yet addressed properly. Tissue engineering, that has been hyped to be one of the possible solutions for this vexing reconstructive problem, has not come out with reliable and reproducible results so far. This review article discusses the rationale and oncological safety of the reconstructing the maxillary defects, critically analyzes the classification systems, offers the different reconstructive methods and touches upon the controversies in this subject. The management of the retained and exenterated orbit associated with maxillectomy is reviewed. The surgical morbidity, complications and the recent advances in this field are also looked into. An algorithm, based on our experience, is presented.

Submental flap in intraoral reconstruction after pathologic resections: indications and limitations

INTRODUCTION

Submental flap is used to reconstruct intraoral and facial soft tissue defects. Submental flap is used for intraoral reconstruction in eighteen patients. Complications of this flap that includes local recurrence, remaining metastatic lymph node in the field of neck dissection, wound dehiscence at donor site and probability of transferring metastatic tissue are evaluated.

MATERIALS AND METHODS

This flap is used as an alternative to free tissue transfer, and this article presents 18 cases after pathologic lesion resections, such as verrocous carcinoma (2 patients), odontogenic myxoma (1 patient), oral squamous cell carcinoma (SCC) (10 patients), adenoid cystic carcinoma (2 patients), leukoplakia (2 patients) as well as osteosarcoma in one patient.

RESULTS

There was no case of local recurrence and remaining metastatic lymph node in the field of neck dissection. A case of metastatic lymph node involvement in posterior triangle of the neck, 2 years after surgery was occurred. One case of metastatic tissue transfer and a case of wound dehiscence in submental region are reported.

CONCLUSION

Submental flap is an useful aid for reconstruction of oral cavity mucosal defects. Its use in oral SCC reconstruction should be done in carefully selected cases.

Complication following reconstruction of orbital floor with temporalis-coronoid flap after subtotal maxillectomy

A 33-year-old lady was referred to the Department of Oral and Maxillofacial Surgery of Taleghani hospital in 2008. She complained of firm swelling on the left side of her face with toothache, lacrimation, and nasal stiffness. There was a large mass in the left maxillary sinus with extension to the orbital floor, nasal bone, ethmoid sinus, and infratemporal fossa. The incisional biopsy revealed a neurofibroma of the maxilla. She underwent hemimaxillectomy and simultaneous reconstruction with temporalis-coronoid flap for orbital floor reconstruction. After 2 months' follow-up with no complication, she complained of left globe upward movement during gum chewing. The orbital and visual examinations were otherwise normal. This unusual complication has continued for 4 years with no resolution, although the patient does not worry about it any more.

Functional outcomes and suitability of the temporalis myofascial flap for palatal and maxillary reconstruction after oncologic resection

OBJECTIVES/HYPOTHESIS

The temporalis myofascial flap (TMF) is a method of palatal reconstruction that offers a single-stage, reliable, and functional technique to repair oncologic defects involving the oral cavity following tumor removal. It is hypothesized that both speech and swallowing function are preserved following TMF.

STUDY DESIGN

In a retrospective and prospective case series, this study evaluated the surgical outcomes of 72 patients undergoing surgical resection and reconstruction of the hard and soft palate using a TMF. Of this series, 25 patients underwent nasalence and swallowing quality-of-life testing to determine speech and swallowing function following this procedure.

METHODS

Reliability, safety, and effectiveness data endpoints on TMF reconstruction were collected and analyzed. Instrumental measures of nasalence (KayPentax Nasometer, Lincoln Park, NJ) and swallowing quality of life measures (MD Anderson Dysphagia Inventory [MDADI] were acquired.

RESULTS

All TMF's were successfully transferred with complete healing of the oncologic defect. The group mean nasalence for connected speech tasks were within normal limits for connected speech--high- and low-pressure tasks (M = 21% and M = 17%). The group mean nasalence scores for sustained vowels were mildly affected (M = 26%). The group mean MDADI score was 79 (SD = 16), indicating good to mildly affected swallowing quality of life. Neither nasalence nor MDADI scores appeared to vary as a function of defect region.

CONCLUSIONS

The TMF is an oncologically safe and effective method of palate reconstruction that affords excellent quality of life to appropriately selected patients without reliance on other reconstructive techniques.

Reconstruction of full-thickness cheek defects with combined temporalis myofacial and facial-cervico-pectoral flaps

OBJECTIVE

The objective of this study was to assess using the temporal myofacial flaps (TMFF) and the facial-cervico-pectoral flap (FCPF) to provide both inner and outer linings for large full-thickness cheek defects following ablative oral cancer surgery.

STUDY DESIGN

Twelve patients with malignant tumors in the buccal region were treated by extensive surgical dissection, and the cheek mucosa defects were repaired with the TMFF and the cheek skin defects were reconstructed with the FCPF. There were 9 male and 3 female patients, age range from 18 to 70 years (mean 52.8). The full-thickness cheek defects ranged from 7 x 6 cm to 10 x 8 cm in size.

RESULTS

No patient had complete loss of flap; 3 patients had minor complications (TMFF and FCPF partial necrosis and FCPF distal dehiscence) all of which settled with conservative management. Mouth opening was normal in 10 patients, and facial contour was satisfactory in 8 patients. The follow-up period varied from 6 to 26 months (mean 15.2); 3 tumors had local recurrences and 2 patients died from tumor metastasis.

CONCLUSION

We found the technique to be anatomically sound, technically easy and reliable, and believe it is a useful method for the reconstruction of large full-thickness cheek defects.

Reconstructive techniques for the repair of oral and maxillofacial oncological procedures: what are they, how do they work and what do they look like?

BACKGROUND

There are many different ways to reconstruct the oral and maxillofacial region post tumour ablation. In the past, the resection of oral tumours had been associated with significant disfigurement and loss of function. Modern techniques aim to restore function and improve cosmetics. This paper aims to describe the techniques used in patients treated at the Austin and Repatriation Medical Centre and to answer the more common questions associated with reconstructive techniques.

METHODS

A review of techniques of oral reconstruction used by our unit over the last nine years and a review of the literature.

RESULTS

Various techniques of reconstruction gained from our experience in treating patients with oral cancer are documented. There are a variety of techniques including grafts, local flaps, regional flaps and free vascularized flaps. Metallic implants such as osseointegrated dental implants may also be used for dental rehabilitation.

CONCLUSIONS

There are many different methods of reconstruction in patients who have had resection for oral tumours. It is important for general dental practitioners who may be involved with the care of such patients to have an understanding of the modern techniques of reconstruction that may be used.

The prefabricated scapula flap consists of syngeneic bone, connective tissue, and a self-assembled epithelial coating

The reconstruction of maxillary defects is a challenge in plastic surgery. The so-called prefabricated scapula flap consists of syngeneic bone covered with syngeneic dermis and is used to reconstruct maxillary defects. After placing these flaps into the oral cavity, they are reepithelialized within a short time period, raising the question of the cellular origin of the "neomucosa." We therefore obtained sequential biopsy samples of the prefabricated flap and of the flap after being placed into the oral cavity and analyzed the keratin expression profile of epithelial cells. We expected that after placing the prefabricated flap into the oral cavity, keratinocytes from adnexal structures of the dermal component of the graft would migrate onto the surface and reepithelialize the flap. Unexpectedly, reepithelialization occurred earlier. The flap had acquired a mucosa-like epithelium at the interface between the Gore-Tex coating and the dermis while still being positioned within the scapular region. The keratin expression profile of this epithelium was very similar to that of mucosal epithelium. Thus, the prefabricated scapula flap not only consisted of bone covered with connective tissue, but was also covered with epithelial cells derived from adnexal structures of the dermal graft. This seems to be the reason for the rapid restoration of an intact mucosa and the excellent outcome achieved with this surgical technique.