Value of the preservation of an osseous mandibular rim with a fibula free flap reconstruction

BACKGROUND

Reconstruction of the mandible with microvascularized fibula transplants is actually a well-established procedure, yet the major component is the limited diameter of the diaphysis that can induce oral rehabilitation's failure, especially in dentate patients. In this paper, we report our surgical procedure allowing preservation of the mandibular height. The primary objective was to assess aesthetic and functional improvements of preservation of an osseous mandibular rim with a fibula free flap reconstruction.

PATIENTS AND METHODS

Five patients (all males, mean age of 60 years) were treated with this method. Aetiologies were tumour in 3 cases, and osteoradionecrosis in the two others cases. We described all step of our surgical procedure and the functional, aesthetic and carcinologic results were evaluated. The follow up varies from 6 to 30 months.

RESULTS

One patient died at 12 days from unrelated affection. For the other patients, both the aesthetics and functional outcomes were better than in case of mandibular interruption surgery. In fact, the mandibular contour of the mandibule was preserved and the height of mandible was restored. One patient is in progress of dental rehabilitation with osseous implants. Carcinologically, no local recurrence was observed.

CONCLUSION

This technique is reliable and enables to optimize oral rehabilitation with endosteal implants. Nevertheless, we consider that the 3D scanner is essential before the intervention to evaluate the osseous reach. Moreover, if necessarily the procedure can be modified intraoperatively.

Combined transoral and suprahyoid approach for oropharyngeal cancers: an alternative to mandibulotomy

Surgical treatment of oropharyngeal tumours usually requires mandibular osteotomy. Using this technique allows a better exposure and an easier excision, but this approach often generates complications. Since 1995, we used a less aggressive surgical technique, with a suprahyoid pharyngotomy when the oral approach was not sufficient, thus sparing the mandible.

OBJECTIVE

The purpose of this study is to evaluate this technical evolution, ensuring that mandibular preservation doesn't affect quality of exeresis, local control and survival, while allowing a lower complication rate.

MATERIAL AND METHODS

All patients who have had a surgical treatment for an oropharyngeal carcinoma between 1995 and 2001 in our center were included in this study.

RESULTS

Mandibular sparing was used for 55 patients; 19 patients underwent mandibulotomy. The surgical procedure's quality was classified as clear, close, or insufficient margins. All adjuvant treatments were noted, functional and carcinologic results were evaluated. No significant differences are found for exeresis quality and local control. There are less complications (p = 0.045) and less surgical revisions (p = 0.023) in the preservation group. Survival and functional results are better in the preservation group, but without significant difference. For oropharyngeal tumours, survival is dependent on tumoural aggressivity, on general condition and co-morbidity and on the development of a second tumour. Results in local control rate (83.7% at 1 year) are satisfying compared to literature.

CONCLUSION

Mandibular preservation is an efficient and safe procedure, even for T3/T4 tumours. Most of oropharyngeal tumours can be removed without mandibulotomy. The suprahyoid approach provides a good exposure when oral approach is insufficient, thus avoiding mandibulotomy and its complications.

Navigation in head and neck oncological surgery: an emerging concept

Navigation surgery, initially applied in rhinology, neurosurgery and orthopaedic cases, has been developed over the last twenty years. Surgery based on computed tomography data has become increasingly important in the head and neck region. The technique for hardware fusion between RMI and computed tomography is also becoming more useful. We use such device since 2006 in head and neck carcinologic situation. Navigation allows control of the resection in order to avoid and protect the precise anatomical structures (vessels and nerves). It also guides biopsy and radiofrequency. Therefore, quality of life is much more increased and morbidity is decreased for these patients who undergo major and mutilating head and neck surgery. Here we report the results of 33 navigation procedures performed for 31 patients in our institution.

[Microsurgical reconstruction and full management of patients with head and neck cancer: importance of a quality approach and a patient care team]

MAIN OF STUDY: Management and surgical reconstruction of head and neck cancers remain a challenge. From the first consultation to surgery and radiotherapy it is necessary to gain time to ensure optimum treatment and better survival rates.

OBJECTIVE

To establish a kind of quality approach to the management of patients with head and neck cancers. 54 patients who received microsurgical reconstruction after head and neck cancer were included in this study between 1997 and 2006.

RESULTS

Multiple data were considered: body mass index (BMI), ASA stage, age, existence of a pre-or postoperative radiotherapy, the surgeon's experience and the number of drainage veins. The success rate is superior when more than one draining vein is sutured to the flap for patients with a BMI >20. Radiotherapy does not seem to affect the survival of the flap.

CONCLUSION

According to current literature, the survival rate of these patients is better when the overall time care is less than 100 days. That period is possible with a perfect organization of the medical and paramedical team. Therefore, we propose to include these patients in a circuit protocolisation care, which saves time, to better inform patients and improve survival rates.

Use of the infra hyoid musculo-cutaneous flap in soft palate reconstruction

AIMS

To review a series of 23 consecutive patients with squamous cell carcinomas arising from oropharynx who underwent infra hyoid musculo-cutaneous flap reconstruction including soft palate in alternative to free radial forearm flap or maxillofacial prosthesis. Post operative radiotherapy was performed for all patients.

RESULTS

Every reconstruction healed quickly without major wound complications. The functional results evaluated by speech and swallowing capacities, were good for 17 patients, fair for 4 patients and bad for 2.

CONCLUSIONS

The infra hyoid musculo-cutaneous flap is a versatile, reliable and convenient flap suitable for repairing small and medium sized defects; it can be used in combination with other flaps, and in selected cases obviates the need for a microvascular free radial forearm flap or maxillofacial prosthesis.

Modification of the infra hyoid musculo-cutaneous flap

BACKGROUND

In 1986, Wang described the infra hyoid musculo-cutaneous flap. Here, we report technical adaptations and improvements to this flap.

METHODS

From 1994 to 1996, we performed 61 infrahyoid flaps using the classical procedure. After 5 years of technical evolution, we studied a new series of 91 flaps from January 2000 to June 2002. We reviewed our experience with the infra hyoid flap and described the surgical procedure, its evolution and the impact on the viability of the flap.

RESULTS

In the two series, the main arterial pedicle was usually the superior thyroid artery. Venous drainage was more variable; consequently we always performed a modified neck dissection with preservation of the internal jugular vein. In the first series, the surgical results were good with only seven local complications essentially skin necrosis. The functional and aesthetic results seemed acceptable. In the second series, the results, after technical evolution with better venous drainage and cervical closure, were improved (only one necrosis) and the indications were extended.

CONCLUSION

With experience, the infra hyoid myocutaneous flaps is reliable and appears as a particularly useful flap for oral cavity, oral pharynx and pharyngeolaryngeal reconstruction.

Dental occlusion modifies gaze and posture stabilization in human subjects

Repercussion of dental occlusion was tested upon postural and gaze stabilization, the latter with a visuo-motor task evaluated by shooting performances. Eighteen permit holders shooters and 18 controls were enrolled in this study. Postural control was evaluated in both groups according to four mandibular positions imposed by interocclusal splints: (i) intercuspal occlusion (IO), (ii) centric relation (CR), (iii) physiological side lateral occlusion and (iv) controlateral occlusion, in order to appreciate the impact of the splints upon orthostatism. Postural control and gaze stabilization quality decreased, from the best to the worst, with splints in CR, IO and lateral occlusion. In shooters, the improvement in postural control was parallel to superior shooting performance. A repercussion of dental occlusion upon proprioception and visual stabilization is suggested by these data.