Immediate Reconstruction Of Defects Research Articles

Immediate reconstruction of defects after a partial maxillectomy with a digitally planned, prefabricated, 3-dimensionally printed, esthetic obturator prosthesis.

A digital workflow was used to design and prefabricate a 3-dimensionally printed, esthetic obturator prosthesis for immediate placement after a partial maxillectomy. The approach involved simultaneous reciprocation and support of the maxillary defect during the surgery and minimized the incidence of cicatricial contracture of the soft tissue, preventing permanent facial deformity and dysfunction.

Vertical Rectus Abdominis Myocutaneous-Pedicled Island Flap for Covering Defect of the Suprapubic Area: A Case Report

Immediate reconstruction of defects in the lower abdomen is challenging. We present a successful reconstruction case using a vertical rectus abdominis myocutaneous (VRAM) flap for a radiation ulcer on the suprapubic area following radiation therapy for recurred malignant melanoma. Before flap elevation, we conducted sufficient debridement until pliable healthy tissue was revealed. Afterwards, a 15×9 cm VRAM flap was elevated. We then inserted the flap through a suprafascial tunnel. At 6 months postoperatively, a completely healed aesthetic flap was achieved. This case is meaningful in that it involves a successful reconstruction of a sizable abdominal wall defect of the suprapubic area with unhealthy and unviable adjacent tissue following repeated surgery and chemoradiotherapy.

Bilateral Alar Cartilage Reduction Rhinoplasty Allows Primary Repair of Alar Defects in the Bulbous Nose

Plastic surgeons have many reconstructive options for lower nasal skin defects, but given the unique aesthetic features of nasal skin the best source for reconstruction is nasal skin itself, when sufficient quantity exists. The purpose of this study is to determine the outcome of bilateral alar cartilage reduction rhinoplasty in combination with a nasal flap to facilitate immediate reconstruction of defects of the nasal tip, soft triangle and alar margin. This prospective study analyzed the aesthetic outcome after reconstruction with bilateral alar cartilage reduction rhinoplasty to reduce the nasal rim and create an excess of skin sufficient to facilitate immediate reconstruction of defects of the nasal tip, soft triangle and alar margin. All wounds healed primarily and patient satisfaction was achieved. Bilateral alar cartilage reduction rhinoplasty allows single-stage reconstruction of defects of the nasal tip, soft triangle, and medial alar rim in the bulbous nose. By placing incisions along the borders of the aesthetic subunits, this novel approach to primary reconstruction of the nasal tip, soft triangle, and medial alar rim provides skin with a superior color and texture match, maintains a satisfactory contour of the nasal rim, and optimizes the likelihood of good scar quality.

Lower gluteal muscle flap and buttock fascio-cutaneous rotation flap for reconstruction of perineal defects after abdomino-perineal resections

Abdomino-perineal resection (APR) in the treatment of anal and low rectal cancers is associated with perineal wound problems, especially after pre-operative radiotherapy. Immediate reconstruction of defects after APR with flaps has been shown to reduce post-operative morbidity. The combined gluteal muscle and buttock fascio-cutaneous rotation flap is useful for this purpose. The dual blood supply of the gluteus maximus muscle allowed it to be split into superior and inferior halves. The inferior fibres were used to fill the pelvic cavity, whilst the superior fibres were preserved to maintain hip function. The buttock rotation flap was used for skin closure. Eight patients who underwent APR for low rectal (n=5) and anal (n=3) carcinomas had immediate reconstruction with the gluteal muscle and buttock fascio-cutaneous rotation flap. The size of the perineal defects ranged from 5×7 to 13×9cm. The indications for reconstruction were: skin defects too large for primary closure (n=7) and previous failed flaps (n=1). All the flaps survived without major complications. The minor complications were superficial wound dehiscence (n=1) and seroma (n=1). Both wounds healed with conservative treatment. All patients were ambulating well within 1 month with full range of active and passive motion at the hips, and completed post-operative radiotherapy without perineal wound complications. The gluteus maximus muscle and fascio-cutaneous buttock rotation flap was useful for reconstructing perineal defects after abdomino-perineal resection.

Surgical Outcomes of VRAM versus Thigh Flaps for Immediate Reconstruction of Pelvic and Perineal Cancer Resection Defects

Reconstruction following abdominoperineal resection or pelvic exenteration is commonly performed with regional flaps from the thigh or abdomen. This study compared the surgical outcomes and complications in cancer patients who underwent immediate reconstruction of these defects with vertical rectus abdominis myocutaneous (VRAM) versus thigh flaps. One hundred thirty-three patients who underwent abdominoperineal resection or pelvic exenteration for cancer resection and immediate VRAM (n = 114) or thigh flap (n = 19) reconstruction of the perineal/pelvic defect were studied. Patient, tumor, and treatment characteristics; surgical outcomes; and postoperative donor- and recipient-site complications were compared between the two groups. Multivariate logistic regression analysis was used to identify predictive/protective factors for complications. The thigh flap group had a significantly greater incidence of major complications (42 percent versus 15 percent) than the VRAM flap group. They also had significantly higher rates of donor-site cellulitis (26 percent versus 6 percent) and recipient-site complications, including cellulitis (21 percent versus 4 percent), pelvic abscess (32 percent versus 6 percent), and major wound dehiscence (21 percent versus 5 percent). Abdominal wall complications were not increased in the VRAM group despite flap harvest from the abdominal wall. Obesity was an independent predictor of any donor-site complication (odds ratio, 3.3) and previous abdominal surgery was a predictor of any complication (odds ratio, 3.6), any recipient-site complication (odds ratio, 3.5), and any major complication (odds ratio, 3.6). Immediate VRAM flaps result in fewer major complications than thigh flaps without increased early abdominal wall morbidity when used to repair abdominoperineal resection and pelvic exenteration defects.

Hair transplantation and micrografting for the oral and maxillofacial surgeon

ciated with an improved survival and better quality of life. The specter of “cancer” is an emotional upheaval in a patient’s life and approaches to the patient with a potentially malignant lesion need to be carefully thought out. Developing strategies for managing this situation enhances patient care, and provides a pathway for guiding the patient through the maze of the health care system targeted to cancer patients. This lecture will cover the current statistics regarding oral cancer incidence, mortality, and trends. When suspicious lesions are detected, a strategy will be outlined to include pre-biopsy counseling, biopsy techniques (including the role for incisional biopsy and brush biopsy), communication biopsy results, psychological responses to a cancer diagnosis, dealing with negative or equivocal results, managing pre-malignant lesions, and recommendations for follow-up. Following a confirmed diagnosis, the role of staging, appropriate test ordering and referral will be covered with an emphasis on current treatment schemes for the variations of oral cancer. The management of these cancers, including the major modalities and management of the neck will be discussed. Oral rehabilitation of the oral cancer patient will be covered including immediate reconstruction of defects, prostheses, and restorative options. The OMS has expertise in these areas that can be critical to quality of life for oral cancer patients. Many patients, especially those with more advanced disease will be treated with multimodality therapy radiation therapy and the role of adjunctive treatments such as hyperbaric oxygen therapy in managing problems in the irradiated jaws will be covered. Once treated for oral cancer the patient will require surveillance not only for recurrence or persistence of disease, but also for the sequelae of treatment that includes mucositis, xerostomia, osteoradionecrosis, radiation caries, speech and swallowing problems, and other maladies. Current literature regarding the use of endosseous implants in these patients will be covered. The comprehensive care of oral cancer patients involves many areas that OMS’ have a significant role to contribute. Knowledge of these areas enhances that care that we give to this special population of patients.

Myocardial infarction after microvascular head and neck reconstruction.

Microvascular flap transfer is a popular method for immediate reconstruction of defects in the head and neck resulting after the treatment of head and neck cancer. Head and neck cancer occurs most commonly in elderly patients with a high prevalence of heavy smoking. Surgery in this patient population is frequently prolonged and is associated with significant intraoperative blood loss. The present study seeks to identify factors contributing to perioperative myocardial infarction and to determine the best course of management. Retrospective analysis of 193 consecutive free flap surgeries. METHODS A series of 193 microvascular free flaps performed over a 5-year period for reconstruction of defects in the head and neck was retrospectively analyzed to identify the incidence, management, and outcome of perioperative myocardial infarction in this patient population. Myocardial infarctions occurred in seven patients, for an overall incidence of 3.6%. Statistical analysis using logistic regression failed to demonstrate any significant relationship between age, sex, total operative time, operative blood loss, net intraoperative fluid shifts, tumor stage, American Society of Anesthesiology (ASA) preoperative classification, type of free flap, and the occurrence of perioperative myocardial infarction. Hemodynamic instability manifested by hypotension occurred in four patients who had perioperative myocardial infarction. Three of these patients underwent urgent coronary artery bypass surgery, whereas one patient underwent urgent endovascular therapy with subsequent stabilization of the hemodynamic instability. All free flaps survived despite myocardial infarction and hemodynamic instability. Two patients (29%) died after postoperative intervals of 74 and 99 days, never having left the hospital. Systemic hypotension is a well-recognized risk factor for free flap failure. Our experience suggests that aggressive intervention to reverse coronary ischemia associated with hemodynamic instability has a favorable outcome on free flap survival, and free flap thrombosis is not an inevitable outcome of the low-flow state associated with perioperative cardiopulmonary bypass. Although the overall incidence of perioperative myocardial infarction in patients undergoing microvascular head and neck reconstruction is low, patient mortality is high, so emphasis should be placed on preoperative identification of patients with coronary artery disease.

Segmental Resection of the Anterior Mandibular Arch With Fibular Microvascular Reconstruction

Segmental mandibular resection should be undertaken if there is a demonstrable invasion by cancer or if such invasion is suspected. Before the advent of microvascular free flaps, immediate osseous reconstruction of the anterior mandible was technically demanding and unreliable. Mandibular reconstruction with microvascular free flaps is no longer a novelty, nor is it reserved for unusually large resections. It has become the method of choice for the immediate reconstruction of defects resulting from mandibular cancer. This technique is particularly well-suited for defects of the anterior mandibular arch.

Clinical features and management of ameloblastoma of the mandible in children and adolescents

Thirty cases of ameloblastoma of the mandible in children and adolescents were reviewed. During the period of evaluation, 206 patients with ameloblastoma in the craniofacial region were seen of which 14.6% were in children (under 18 years). The tumour was more prevalent in male (1.5: 1). Enucleation with curettage of the surrounding bones appears adequate for unicystic lesions. Multicystic lesions were managed by radical resection of the mandible with or without immediate reconstruction of defect with bone graft or by resection of the lesion with the dentoalveolar structure and preservation of the lower border of the mandible. Uninvolved periosteum should be preserved because of its osteogenic potential.

大胸筋皮弁の血行形態に関する研究

The pectoralis major musculocutaneous flap (PMMC-flap) has been used for the immediate reconstruction of defects in thc head and neck region. This technique is highly valued because it can transplant a large amount of well-vascularized tissue, but its vascular pattern seems to have been characterized by a simple axial pattern without adequate investigation.Recently, the vascular anatomy has been clarified gradually as many authors have reported on it in detail. The purpose of this study was to define the vascular pattern of the PMMCflap by dye injection, angiography and cadaver dissection.Materials and methods:Dye injection: Fresh cadavers (3 males, 2 females), were used and different color inks were injected in to the internal thoracic artery and thoracoacrominal artery. Then the colored skin areas on the chest were observed and recorded. Angiography: Fresh cadavers (3 males, 7 females) were also used into which a contrast medium was infused via the femoral artery, and the pectoralis major muscle and overlying skin with adjacent vessels were resected. After taking X-ray photographs and making the angiograms, the vascular patterns in the muscle and cutaneous layer were analysed. Subsequently the PMMC-flap on the cadavers was evaluated and the vascular pattern was analysed from the angiograms.Cadaver dissection: The vascular anatomy was studied by cadaver dissection.Results:1) The pectoralis major muscle and the overlying skin were found to receive their blood supply from separate blood vessels.2) The musculocutaneous perforators directly airisng from the dominant artery appeared in certain limited areas only and not observed in the area where the skin island is usually designed.3) The blood supply of the PMMC-flap was supported by a communicating circulatory system from the muscle to cutaneous layer, which was formed by the pectoral branch anastomosing with the anterior perforators in the muscle and fascial layer.4) It seems that the vascular pattern of the PMMC-flap is not of axial pattern directly sustained by musculocutaneous perforators arising from the pectoral branch but is of extended axial pattern which is spreaded in three dimensions by anastomosis to adjacent vessels.5) The concept of this vascular pattern is very important and the author thinks that with this knowledge we can reduce the risk of partial and/or marginal necrosis in the skin island on the PMMC-flap.

悪性腫よう切除後の口腔領域即時再建手術に関する検討 大胸筋皮弁による４０症例

Forty patients who underwent transposition of pectoralis major myocutaneous flapfor the immediate reconstruction of defects after resection of head and neck cancer were reviewed. In our series, 18 patients experienced 30 complications related to flap usage. Those were 2 partial flap necrosis, 9 marginal flap necrosis, 6 suture line separations and 13 orocutaneous fistulas. Although most complications were minor and healed with local wound care, 5 orocutaneous fistulas associated with infection around the mandibular bone required removal of reconstruction plate, wire and grafted bone to achieve healing of fistulas. There were 30 patients that resulted in acceptable disability. However, 6 patients could not take peroral feedings and 4 patients could not successfully take an adequate amount of oral feedings as a result of persistent aspiration.There is no question that the pectoralis major myocutaneous flap has various advantages as a one-stage reconstructive technique. However, recent reports have suggested that the incidence of complications is far greater than previously considered. In our series, overall incidence (45%) was also high as described above.Of 40 patients, 27 received preoperative irradiation which ranged from 40 to 250 Gy and 30 patients received preoperative chemotherapy. Based on our experiences, we concluded that pathological changes of mandibular bone induced by irradiation was, at least in part, related to the postoperative infections which preceded the formation of orocutaneous fistulas.Recent analysis on the vascular system of the skin has revealed that there are few cutaneous branches derived from thracoacrominal artery in the chest skin. Thus, we believe this anatomical character is closely related to the high incidence of complications.10 patients were treated with salvage operation combined with planned perioperative irradiationand chemotherapy, It seemed likely that the immediate reconstruction with pectoralis major myocutaneous flap contributed to the development of such a combination therapy in the management of advanced head and neck cancer.

The pectoralis major myocutaneous flap in head and neck reconstruction: Analysis of complications

Sixty-seven patients underwent 73 pectoralis major myocutaneous flap procedures for the immediate reconstruction of defects after resection of head and neck cancers. Thirty-six patients experienced a total of 50 complications for an overall complication rate of 54 percent. There were 3 instances of total flap necrosis, 9 of partial flap necrosis, 12 orocutaneous fistulas, 9 suture line separations, 8 neck wound complications, 1 donor site complication, and 8 mandibular replacement complications. Most complications were minor and did not require a second procedure for correction; however, 36 percent did require a second operation. Eight of 10 patients in whom a metal appliance was placed to restore mandibular continuity required the removal of that appliance due to either flap necrosis, fistula formation, or exposure. Based on our experience, we conclude that attention to flap design, operative technique, and postoperative management were useful in reducing the incidence of complications. We also conclude that a metal appliance was an unsatisfactory means of restoring mandibular continuity when utilized beneath a pectoralis major myocutaneous flap. Although the overall incidence of complications was high, the actual incidence of flaps failing to accomplish their intended purpose and requiring secondary repair was acceptable. The pectoralis major myocutaneous flap was reliable in the reconstruction of defects in the head and neck region.

Immediate reconstruction of oral cavity and oropharyngeal defects using microvascular free flaps

Eighteen patients underwent immediate reconstruction of defects involving the oral cavity and oropharynx with free groin and dorsalis pedis flaps. One partial and four complete failures occurred. In the successfully reconstructed patients, the functional results were equal to conventional flaps while the cosmetic improvements were dramatic.