Buccal Mucosal Flap Research Articles

In this issue – May 2014

A case report describes an attack of a mare and newborn foal by a swarm of bees, resulting in hundred of stings.1 After initial symptomatic treatment, both developed diffuse swelling of the head and were reported to be very agitated, which I think seems to be a surprisingly calm description of how they must have been feeling. The authors give details of the mechanisms of bee envenomation and suggest that in the rare fatal cases, IgE-mediated anaphylaxis is the most likely cause of death rather than toxicity. They give details of the clinical outcome of these and the rational basis of any treatments, especially as no direct scientific studies will be possible. A prospective study assessed three easily performed methods of skin surface sampling for bacterial culture of Staphylococcus isolates obtained from 27 dogs with superficial bacterial pyoderma (SBP).2 Confirmed lesions were sampled using a dry cotton swab, a saline-moistened cotton swab and a skin surface scraping. Staphylococcus spp. were isolated from lesions in all dogs. The isolates were susceptible to common empirical antimicrobials and all three of the sampling techniques gave similar results for culture. A surgical case report of two dogs describes the complication of distal flap necrosis associated with surgical reconstruction of hard palate defects with a buccal mucosal flap based on the angularis oris artery and vein.3 The authors show that the flaps were successfully salvaged by dividing the original flap pedicle and rotating the tissue to fill the remaining defect, after a vascular supply had been established from adjacent tissue. They note that the surgical outcome can be improved by removing any teeth that are likely to cause trauma to the flap's pedicle. Corynebacterium urealyticum is an uncommon cause of urinary tract infections in small animals and is difficult to treat because it is resistant to most antibacterial agents. A case report describes the outcome of a female speyed dog that had had surgery for bilateral ectopic ureters 14 weeks before presentation.4 The authors show the radiographic and ultrasound features of the tract and the carbonate apetite uroliths that were voided after linezolid treatment and change to urine-acidifying diet. The authors discuss the problems of treating a resistant organism and the possible choices for treatment. Feed intake in the first week is critical for cattle that are newly arrived in a feedlot, as they are often in negative energy and protein balance and they may have abnormal rumen function because of their time without feed during transport. This has an effect on the immune system and may lead to increases in diseases such as bovine respiratory disease (BRD) and cattle may need to be fed for longer to reach a marketable weight. In this report of a randomised trial of 4643 beef cattle given a urea-molasses supplement or left untreated, results showed that BRD incidence and production were not improved by the treatment.5 Morbidity from BRD was higher when cattle without permanent incisors were supplemented with urea-molasses compared with unsupplemented cattle, and the authors note that more research is needed in this area to work out the cause of this. They also found that BRD was higher in steers than heifers, as shown previously, and incidence was double in cattle bought from saleyards than off farms. An extensive case report describes the outcome of a domestic pigeon that developed a sterile recurring granuloma after vaccination with an oil-adjuvant, inactivated La Sota strain of Newcastle's disease.6 This was given off-label as protection against pigeon paramyxovirus-1 (PPMV-1). The authors describe the extensive management of the granuloma, which included surgical removal of foreign material, control of the pain and inflammation and protection against antimicrobial contamination. PPMV-1 is now considered endemic in Australia and vaccination is important, but the authors stress that the risks of adverse reaction, including sterile granuloma, must be considered. A retrospective review of case records of ultrasonography and necropsy outcomes of 62 koalas was used to investigate the accuracy of ultrasonography in assessing koala urogenital tract structural disease.7 The results showed high concordance, indicating that ultrasonography is an effective tool for evaluating structural disease of the koala urogenital tract, which is mainly chlamydiosis. The authors also stress the animal welfare benefits that can be made by wildlife carer groups through a scientific, evidence-based approach. A case report of an adult female koala was referred for assessment of buphthalmos and keratitis of the right eye, which was severe enough to obstruct examination of intraocular structures.8 Enucleation of the affected eye was performed and the histopathological diagnosis was anterior chamber collapse syndrome and secondary glaucoma. There is little information on ocular diseases in koalas. Anterior chamber collapse syndrome occurs in various species and is associated with early-life ocular disease or trauma. It is important to differentiate this acquired condition from a congenital malformation.

RECURRENT PALATAL FISTULA AND NASAL REGURGITATION;

Background: Post Palatoplasty fistulas are the common complications seen after cleft palate repair. This produce varioussymptoms including regurgitation of fluids into nasal cavity, interference with normal speech and middle ear problems . Although smallfistulas can be successfully treated with local flaps such as palatal or buccal mucosal flaps, large fistulas are difficult to treat. Because ofrich blood supply, tongue is a suitable and convenient source of large flap. The anteriorly based dorsal tongue flap is a safe and effectivemethod for closure of relatively large recurrent palatal fistula without any functional impairment of donor site. Objective: To determine thesuccess rate of Tongue flap in correction of the nasal regurgitation in recurrent palatal fistulas Duration of study: 12 months from 16thJuly 2010 to 15th July 2011. Study design: It was descriptive case series. Settings: This study was carried out in the department ofplastic surgery Services institute of medical sciences, Services Hospital Lahore. Methods: Forty patients who were having recurrentpalatal fistula included in this study. All underwent palatal fistula repair by dorsal tongue flap. Each patient was followed after one month ofoperation for fistula closure and correction of nasal regurgitation. Results: In this study 65 percent of the patients were male, while 35percent of them were female. 21 (52.5%) of the patients belonged to age group 10-15 years, while 14 (35.0%) of the respondents had 16-20 years of age and remaining 5 (12.5%) of them had 21-30 years of age. The 90 percent (out of 40) of the patients had complete fistulaclosure, while only 10.0 percent of them had not complete fistula closure. Nasal regurgitation was corrected in 38 (95 %) of the patientsand remaining 2 ( 5%) patients had un-corrected nasal regurgitation. Conclusions: Tongue flap is a effective and reliable method oftreatment, not only for palatal fistula closure but also treating nasal regurgitation which is a social stigma for patients in recalcitrant palatalfistula.

Personal Technique for Primary Repair of Alveolar Clefts

From 1969, the senior author (H.B.) has developed a technique for the repair of alveolar clefts during primary cheiloplasty at patient age of 3 months. The operation used palatally hinged mucoperiosteal flaps from the edges of the cleft to reconstruct the posterior and inferior walls of the alveolar box. The roof was reconstructed by repairing the nasal floor, and the anterior wall was reconstructed using a buccal mucosal flap from the undersurface of the lateral lip segment. Fourteen operated patients were selected to scientifically follow the long-term results of the technique. The results indicated restoration of the arch form, varying degrees of ossification in the repaired alveolar box, and eruption of canines through the repaired alveolus. One case of anterior cross-bite was observed in these selected cases. However, a limited cross-bite was present at the site of the repaired cleft in many cases.

Reconstruction of a Defect on the Buccal Mucosa and Prolabium

We describe the procedure for reconstruction of a defect on the buccal mucosa and the prolabium with a buccal mucosal transposition flap and an artificial dermis graft. The preparation of the flap started with an incision extending from the border of the defect to the corner of the mouth. The pivot point of the flap was near the stump of the excised prolabium. Only the buccal mucosa was elevated from the buccal surface. It was transposed onto the defect of the prolabium and sutured to the edges of the defect. After reconstruction of the prolabium, the artificial dermis was trimmed and sutured to the mucosal and skin edges of the surgical defect. This is an easy and minimally invasive procedure to cover a defect of the buccal mucosa and the prolabium. In our experience, the wound healed with good, functional, and cosmetic results.

Single layer closure of palatal fistula using anteriorly based dorsal tongue flap

Palatal fistulas are the common complications seen after cleft palate repair. Small fistula may be asymptomatic, the large ones produce various symptoms including regurgitation of fluids into nasal cavity and interference with normal speech. Although small fistulas can be successfully treated with local flaps such as palatal or buccal mucosal flaps, large fistulas pose difficulty. Because of rich blood supply, tongue is a suitable and convenient source of large flap. The anterior based dorsal tongue flap is a safe and effective method for closure of relatively large recurrent palatal fistula with out any functional impairment of donor site. This article describes one such case treated by single layer closure using anteriorly based tongue flap with excellent outcome.

Reconstruction of the urethra with a Surgisis® onlay patch in urethral reconstructive surgery: two case reports

IntroductionWe present two case reports of patients with recurrent stricture of the urethra. We used Surgisis® for reconstruction.Case presentationIn these two case reports, we show the positive results of reconstructive surgery with Surgisis® as an alternative surgical approach to common onlay patch surgery of the urethra performed on two Caucasian patients: a 48-year-old man and a 55-year-old man.ConclusionCompared to buccal mucosa flap or foreskin graft surgeries for urethral reconstruction, reconstructive surgery with Surgisis® is considered a relevant therapeutic alternative because of the shorter operation time and the preventable surgery of the buccal cavity or foreskin.

Reconstruction of the urethra with a Surgisis® onlay patch in urethral reconstructive surgery: two case reports

IntroductionWe present two case reports of patients with recurrent stricture of the urethra. We used Surgisis® for reconstruction.Case presentationIn these two case reports, we show the positive results of reconstructive surgery with Surgisis® as an alternative surgical approach to common onlay patch surgery of the urethra performed on two Caucasian patients: a 48-year-old man and a 55-year-old man.ConclusionCompared to buccal mucosa flap or foreskin graft surgeries for urethral reconstruction, reconstructive surgery with Surgisis® is considered a relevant therapeutic alternative because of the shorter operation time and the preventable surgery of the buccal cavity or foreskin.

Reconstruction of Traumatically Avulsed Parotid Duct Using Buccal Mucosa Flap: Report of a New Technique

Injury to parotid duct is frequently overlooked especially in multiple injuries settings. Consequently they are rarely reported in the literature. Treatment of these injuries is highly controversial. Short series and anecdotal case studies claim success with various approaches such as nonsurgical management, simple ligation of the proximal duct with or without antisialagogues, microsurgical primary repair, creation of sialodocho-oral fistula, and vein-graft replacement. A novel technique of sialodochoplasty using buccal-mucosa pedicle flap is described in this report. Short-term result of this method in a 4-year-old boy with traumatic loss of right parotid duct was encouraging. Hypothetical advantages of this new operation are reviewed in the background of alternative procedures. It is concluded that buccal-mucosa flap technique appears to be a promising alternative in the management of parotid duct injuries.

Keratoprosthesis Surgery for End-Stage Corneal Blindness in Asian Eyes

To establish a multidisciplinary surgical program for osteo-odonto-keratoprosthesis (OOKP) surgery in Asia and to evaluate efficacy and preliminary safety of this keratoprosthesis in end-stage corneal and ocular surface disease. Prospective noncomparative case series. Sixteen adults of Asian ethnic origin, bilaterally blind with end-stage corneal blindness from Stevens-Johnson syndrome, or severe chemical or thermal burns. Osteo-odonto-keratoprosthesis surgery involves 2 procedures-in stage 1, an autologous canine tooth is removed, modified to receive an optical polymethyl methacrylate cylinder, and implanted into the cheek. The ocular surface is denuded and replaced with full-thickness buccal mucosa. Stage 2 surgery, performed 2 to 4 months later, involves retrieval of the tooth-cylinder complex and implanting it into the cornea, after reflection of the buccal mucosal flap, corneal trephination, iris and lens removal, and anterior vitrectomy. Concurrent glaucoma and vitreoretinal procedures are also performed at either stage, as required. Visual acuity (VA), field of vision, anatomical integrity and stability, and ocular and oral complications related or unrelated to the OOKP device. Osteo-odonto-keratoprosthesis surgery was performed on 15 patients, with a mean follow-up of 19.1 months (range, 5-31). Intraoperative complications included expulsive hemorrhage (keratoprosthesis device not implanted), tooth fracture (n = 1), oronasal fistula (n = 1), and mild inferior optic tilt (n = 1). Anatomical stability and keratoprosthesis retention has been maintained in all eyes, with no dislocation, extrusion, retroprosthetic membrane formation, or keratoprosthesis-related infection. Other complications not directly related to device insertion included retinal detachment (RD) related to silicone oil removal (n = 1) and endophthalmitis related to endoscopic cyclophotocoagulation performed 1 year after OOKP surgery (n = 1). Eleven patients (73.3%) attained a stable best spectacle-corrected VA of at least 20/40 or better, whereas 9 (60%) attained stable 20/20 vision. Four patients achieved their best visual potential, ranging from 20/100 to counting fingers vision, related to preexisting glaucomatous optic neuropathy or previous RD. Establishment of our OOKP program suggests that OOKP surgery has the potential to restore good vision to the most severe cases of corneal blindness in an Asian setting, with minimal device-related complications. Longer follow-up of these cases is currently underway.

OOKP ‐ the Singapore Experience

Abstract Purpose: The management of severe ocular surface diseases and end‐stage dry eye disorders such as Stevens Johnson syndrome, ocular cicatricial pemphigoid and chemical burns with conventional keratoplasty or keratolimbal allografting remains unsatisfactory. The Osteo‐Odonto Keratoprosthesis (OOKP) is a form of keratoprosthesis (artificial cornea) surgery designed to treat the most severe of these cases, and good outcomes with long‐term retention have been reported. We present the moderate‐term clinical results of Asian patients who have had this device implanted within our Singapore OOKP Program. Methods: OOKP surgery involves a radical two‐stage procedure – in stage 1, an autologous canine tooth is removed, modified to receive an optical PMMA cylinder, and implanted into the cheek. The entire ocular surface is denuded and replaced with a full thickness buccal mucosal graft. Stage 2 surgery, performed 2‐4 months later, involves retrieval of the tooth‐cylinder complex and implanting it into the cornea, after lifting of the buccal mucosal flap, corneal trephination, iris and lens removal and anterior vitrectomy. Concurrent glaucoma and vitreo‐retinal procedures may also be performed at either stage, if required. Indications for OOKP surgery include bilateral severe blindness, not amenable to keratoplasty or ocular surface transplantation or with previous failed attempts. Results: In February 2004, the Singapore National Eye Centre embarked on its OOKP program, in collaboration with the National Dental Centre. We have now performed OOKP surgery on 22 patients, with the longest follow‐up being 39 months. Of 16 patients with a mean of 19.1 months follow‐up (range 5‐39 months), no major keratoprosthesis‐related complications have occurred, with full anatomical stability and retention in all cases. 73.3% of patients attained at least 6/12 or better vision, while 90% attained 6/6 vision, and remaining patients have attained, and retained their best visual potential with the exception of one patient who lost vision unrelated to the KPro device (endophthalmitis following glaucoma surgery occurred 1 year after KPro surgery). Conclusions: OOKP surgery appears to be a highly promising procedure which has the potential to restore excellent vision to the most severe cases of end‐stage corneal disease, when all else has failed. Longer follow‐up of these cases is currently underway.

本文掲載論文内容訂正の公示

本文掲載論文内容訂正の公示

犬の咬傷による口角および上唇欠損に対して頬粘膜 advance flap により再建した1例

犬の咬傷による口角および上唇欠損に対して頬粘膜 advance flap により再建した1例

Suitability of DNA Extracts from Peripheral Blood, Oral Mucosa, Dental Pulp, and Split Tooth for Genetic Analysis

Objective: To assess the suitability of DNA extracted from peripheral blood, oral mucosal tissue, dental pulp, and split tooth for genetic analysis.Patients and Methods: DNA was isolated and extracted from the blood, oral mucosal tissue, dental pulp, and split tooth of 5 patients undergoing surgical removal of an impacted third molar. Six millilitres of peripheral blood was collected in an ethylenediamine tetra-acetic acid tube and frozen immediately. A piece of tissue from the buccal mucosal flap was removed following surgery. The pulp was harvested by cutting the extracted molar in half and scraping with a curette. DNA was extracted from both halves of the tooth. All samples were extracted in Tris-ethylenediamine tetra-acetic acid (pH 8) using sodium dodecyl sulphate and proteinase K, and digested overnight at 37°C. DNA was purified using phenol-chloroform-isoamyl alcohol, precipitated in 4 M sodium acetate with ethanol, and assessed by amplification of the variable number of tandem repeat locus DIS80 using polymerase chain reaction. The presence of contaminating bacteria in the samples was analysed by detection of the bacterial 16S ribosomal gene.Results: The DNA purity in 90% of the samples was 1.5 to 1.7, which indicated good purity with minimal protein contamination. Amplification of the extracted DNA at the variable number of tandem repeat locus DIS80 produced distinct bands in DNA extracted from the 4 different samples. Individuals homozygous for the DIS80 locus in chromosome 1 produced equal numbers of repeats from both homologues of chromosome 1. DNA from heterozygous individuals produced 2 bands as a result of amplification of a different number of repeats in the 2 chromosomes.Conclusion: This preliminary study indicates that pure and amplifiable DNA can be successfully extracted from blood, oral mucosal tissue, dental pulp, and split tooth.

Reconstruction of intraoral defects using facial artery musculomucosal flap

The facial artery musculomucosal flap, technically a combination of the nasolabial flap and the buccal mucosal flap, has been a reliable, versatile flap, either superiorly or inferiorly based for reconstruction of a wide variety of postcancer excision intraoral mucosal defects including defects of the palate, alveolus, lips and floor of mouth. We have used it 17 times in 16 patients with no failures and one flap with terminal necrosis. Almost all flaps developed venous congestion which settled on its own by conservative management.

Postoperative Evaluation of Palatoplasty Using the Modified Kaplan Method

Bilateral buccal mucosal flaps were used for a pushback operation of the nasal mucosa as well as the oral mucosa. Two flaps from the buccal mucosal areas were inserted into the nasal mucosal raw surface at the hard and soft palatal border to achieve nasal mucosal pushback. Forty-four children with cleft palates were retrospectively studied to investigate the velopharyngeal function, articulation, and craniofacial morphology following primary palatoplasty using the modified Kaplan method. 72.7% showed good velopharyngeal function. Articulation disorders were found in 26 of the 44 subjects (59.1%). A craniofacial morphological analysis revealed no major changes in the SNA (sella-nasion point A angle) and SNB (sella-nasion point B angle) and no cases of a marked loss of maxillary mandibular balance. In addition, no significant differences were observed in the maxillary length and width. The results of these palatoplasties by the modified Kaplan method indicated that the use of bilateral buccal mucosal flaps for the pushback of the nasal mucosa was effective in preventing the contraction of the maxillary and mandibular corpal lengths.

Komplizierte Harnröhrenrekonstruktionen bei Erwachsenen und Kindern

The urethral reconstruction is a challenge in the adult, but even more in infant and young male patients. Good knowledge of the anatomy of the penis (blood supply and the course of the nerve fibers) with the availability of microsurgery suturing and instruments improved the outcome significantly. The growing knowledge opened the possibility to reconstruct complicate strictures with grafts. The buccal mucosa flap is one of those improvements, which made a tremendous impact to have a successful outcome. Recently we looked into the outcome of urethral reconstruction of long urethral strictures by using a buccal mucosa only flap. We used a modified technique for hypospadias repair to reconstruct coronar or subcoronar defects by meatal mobilization (MEMO). In cases with a long urethral stricture the success rate was over 90% with a mean follow up of 16 months. In all children the outcome with the MEMO-technique was successful without any major complication with a mean follow-up of 12.5 months.

Buccal mucosal transposition flap for reconstruction of oropharyngeal–oral cavity defects: An analysis of six cases

Operation on tumors situated in the posterior part of the oral cavity is a challenging aspect of head and neck surgery. Both the approach and the postablative reconstruction of the remaining defect require special procedures. An arsenal of reconstructive methods are available depending on the size and complexity of the defect. The goal should be to employ the simplest surgical reconstructive method, resulting in the best functional result and allowing for later complex oncotherapy. To study the outcomes of patients treated using buccal mucosal transposition flaps for reconstruction of posterior oral cavity and oropharyngeal border defects. A total of 6 patients with defects of the posterior oral cavity and mesopharynx were treated with buccal mucosal transposition flaps. The patients were followed for up to 24 months. Defects ranging from 12 to 27 cm 2 were reconstructed with the buccal mucosal transposition flap. One patient developed an orocutaneous fistula and 1 had some trismus requiring a Z-plasty scar reorientation. One patient suffered from nasal regurgitation. Five of the 6 patients lived past 24 months, the time of follow-up of this study. The buccal mucosal transposition flap, with its random pattern of circulation, used alone proved to be a safe method to reconstruct soft tissue defects or line exposed hard tissues located in the posterior oral cavity and oropharynx.

Chirurgie reconstructrice des paupières

Eyelid reconstruction must provide a good protection of the eye, but also a normal visual field and a nice appearance of the face. To achieve this result in difficult cases, anatomy and physiology of the eyelids must be well known by the surgeon. In most cases, the defect involves only the skin, and simple techniques of plastic surgery are sufficient to provide satisfactory results. In cases of important defect, numerous techniques have been proposed; the two main groups are: the techniques that use eyelid tissues (tarso conjunctival flaps or grafts, and full thickness eyelid flaps), and the techniques that use buccal mucosal graft and skin flaps from the surrounding areas. These techniques are described with advantages and disadvantages referring to author’s experience. Each surgeon will choose the technique which seems the most convenient for him, depending on his experience and training.

62: Management of the Complex Rectourinary Fistula with Buccal Mucosal Patch Graft and Muscle Flap Support

62: Management of the Complex Rectourinary Fistula with Buccal Mucosal Patch Graft and Muscle Flap Support

The buccal flap--a useful technique in cleft palate repair?

To evaluate speech quality and oronasal fistula after primary palate repair using a buccal mucosal flap. Retrospective study cohort of patients with cleft palate. Primary care center for treatment of craniofacial congenital anomalies. One hundred fifty-six nonsyndromic patients underwent palatoplasty with the buccal myomucosal flap by the senior surgeon between 1989 and 2002. The preoperative workup, surgical technique, and other factors that might affect the outcome were identical in every case. Oronasal fistula and variables affecting speech quality were analyzed. The most common type of cleft was unilateral cleft lip and palate (43.5%). The median follow-up was 5.8 years (0.4 to 21 years), and the median age at repair was 6.2 months. The overall fistula formation was 3.6%, decreasing progressively: 1989 to 1994: 2.9%, 1995 to 2002: 0.7% (p <.05). Velopharyngeal incompetence (VPI) occurred in 8.8% of the patients, decreasing from 5.3% to 3.5% in the last years. VPI and oronasal fistulae were observed mainly in unilateral and bilateral clefts of the lip and palate. Velopharyngeal adequacy occurred in 91.1% of the children, and resonance was normal in 91.1 %. None of the patients had severe hypernasality or hyponasality. Articulation was normal in 97.9% of the children. Speech quality was good in 89% of the patients. The technique presented has been effective, with the advantages of palatal closure without tension, good muscular reconstruction, lengthening of the nasal layer, and palatal closure without raw areas. The technique, early repair, and surgeon's skills were the most important variables for good outcomes regarding speech and fistula formation.