Osteomyocutaneous Flap Research Articles

Maxillary Reconstruction Using Vascularized Fibular Osteomyocutaneous Flap and Iliac Bone Through Modified Lateral Lip-Submandibular Approach

The objective of this study was to demonstrate total maxillary reconstruction using 1 vascularized fibular osteomyocutaneous flap segment alone and nonvascularized iliac crest bone through the modified lateral lip-submandibular approach. At the same time, three-dimensional virtual technology was performed as well. Nine patients suffering from total maxillary defects, who had undergone maxillary reconstruction using 1 vascularized fibular osteomyocutaneous flap segment and nonvascularized iliac bone through the modified lateral lip-submandibular approach, were reviewed for this study. Before the surgery, patients' computed tomography scan data were virtually analyzed using SimPlant Pro software (version 11.04). Healing courses were uneventful in all patients; acceptable maxillomandibular relationship, mouth opening, and speech were assessed as normal in all. There were no long-term functional limitations of the lower limb, even though all complain of dysfunction of the first toe, which developed the deformity of the claw toe in the end. Other complications did not occur such as diplopia, ectropion, flap necrosis, facial paralysis, and sensory numbness in the lower lip. The maxillary reconstruction using 1 vascularized fibular osteomyocutaneous flap segment and nonvascularized iliac crest bone through the modified lateral lip-submandibular approach is a feasible and acceptable technique because of multiple advantages. Combined with the three-dimensional virtual technology, the technique can improve the postoperative outcomes.

PP148: Use of the trapezius flap for reconstruction in head and neck defects

Introduction The trapezius myocutaneous flap is an effective alternative to microsurgical techniques for reconstruction of surgical defects after oncological resection in oral cavity. The extraction technique is simple, being a predictively viable flap. It may be harvested as an osteomyocutaneous flap and can even be used to reconstruct the mandible. As a main drawback, highlights the need for change in posture of the patient during surgery, which stretches, although not overly, the operative time. We present a series of patients operated in our Department, in which we used the trapezius flap for the reconstruction of surgical defects in the head and neck. Materials and methods Nine cases are included in our study. In eight of them the flap was designed as a myocutaneous flap, while in the last patient it was an osteomyocutaneous flap, incorporating the spine of the scapula to reconstruct a segmental mandibular defect created after a tumor excision. Seven cases were oncologic surgical defects (squamous cell carcinomas of the tongue, jaw, retromolar trigone, tonsillar fossa and soft palate). The other two cases were used to temporal fossa reconstruction after a titanium mesh that were used in a previous reconstructive attempt, were removed because of its exposure with a soft tissue defect. The mean time to harvest of the flap was 65 min. Results One patient died of locoregional recurrence of the tumor at 6 months after surgery and another two patients had a flap necrosis by compression of the pedicle. MMSS mobility was recovered in all cases after rehabilitation and physiotherapy. In two cases, surgical wound dehiscence occurred at the back, resolved without the need for skin grafting. Conclusions While at present microsurgical flaps are the first choice for the reconstruction of head and neck cancer defects, regional flaps as the trapezius or pectoralis remain a valid and effective weapon when free flaps can not be considered for some reasons, attributable to the patient or to structural problems in the Surgery Departments. The myocutaneous or osteomyocutaneous trapezius flap is easy to manage, with a constant vascular pedicle. No major complications have been found postoperatively.

OP037: Special considerations in virtual surgical planning for secondary accurate maxillary reconstruction with vascularized fibula osteomyocutaneous flap

This paper describes our special considerations in virtual surgical planning for secondary maxillary reconstruction with vascularized fibular osteomyocutaneous flap and our revised surgical design for maxillary reconstruction. Eleven patients with different maxillary defects according to Brown’s revised classification underwent virtual surgical planning for secondary accurate reconstruction. For different horizontal class defects, the fibular was osteomized to match maxillary alveolar arch by using the mirror image of the contralateral alveolar ridge or the curve of mandibular arch and dentition. Maxillary reconstruction was performed with the guidance of preoperative virtual planning and using fibular osteotomy and reposition guide templates to replicate the virtual planning intraoperatively. Virtual surgical planning was replicated intraoperatively in all patients. The fibulae were osteotomized into four segments in three patients with the horizontal class d2 defect and three segments in eight patients with the horizontal class b ∼ d1 defects, respectively. Overall success rate for 11 flaps was 100%. Good bony unions and wound closure were observed and intelligible speech was achieved in 11 patients. Maximum incisal opening ranged from 3.0 to 4.0 cm. All patients tolerated a regular diet postoperatively. Postoperative mid-facial appearance was good in all patients. We recommend that the horizontal class d defect in Brown’s revised classification of maxilla and mid-face be divided into two subtypes according to whether it involves the contralateral canine or not. Special considerations in virtual surgical planning are helpful to perform accurate secondary maxillary reconstruction with vascularized fibular osteomyocutaneous flap.

Computer-Assisted Orthognathic Surgery Combined With Fibular Osteomyocutaneous Flap Reconstruction to Correct Facial Asymmetry and Maxillary Defects Secondary to Maxillectomy in Childhood

Maxillectomy in childhood not only causes composite primary defects but also secondary malformation of the middle and lower face. In the case presented, we introduced computer-assisted planning and simulation of orthognathic surgery combined with fibular osteomyocutaneous flap reconstruction to correct complex craniofacial deformities. Virtual orthognathic surgery and maxillary reconstruction surgery were undertaken preoperatively. LeFort I osteotomy, with bilateral sagittal split ramus osteotomy and lower border ostectomy, was performed to correct malocclusion and facial asymmetry. Maxillary reconstruction was accomplished using a fibular osteomyocutaneous flap. The patient recovered uneventfully with an adequate aesthetic appearance on 3D computed tomography. Our experience indicates that orthognathic surgery combined with fibular osteomyocutaneous flap reconstruction can used to correct complex facial asymmetry and maxillary defects secondary to maxillectomy. Computer-assisted simulation enables precise execution of the reconstruction. It shortens the free flap ischemia time and reduces the risks associated with microsurgery.

OP032: What can fibula flap do in jaw reconstruction?

Part A 3-D model simulation and reconstruction of composite total maxillectomy defects with fibula osteomyocutaneous flap flow-through from radial forearm flap 3-Dimensional model simulation technique and free fibula osteomyocutaneous flap flow-through from radial forearm flap were used to reconstruct a total maxillectomy defect for a 21-years-old female patient. Preoperatively, the 3-dimensional simulated resin models of skeleton and fibula were used to design. In surgery, a 22-cm length free fibula was divided into four segments to make skeletal framework as surgical planning with a radial forearm flap flow-through for the free fibula flap with the skin paddle to repair the palatal and nasal region. Free fibula and radial forearm flap were alive, and the patient was satisfied with the results both aesthetically and functionally due to dental rehabilitation which was carried out 6 months postoperatively. This preliminarily clinical study and case demonstrated the fibula osteomyocutaneous flap is an ideal donor site in total maxillectomy defect reconstruction; the flow-through forearm radial flap not only serves as the vascular bridge to midface reconstruction, but also provides sufficient soft tissue cover for the intra-oral defect. Part B Double barrel fibula free flap with second-staged dental implants for mandibular reconstruction. The aim of this study was to evaluate the method for segmental mandibular reconstruction using double-barrel fibular flap with second-staged dental implant-supported prosthetic rehabilitation. 5 patients (2 gingival carcinomas, 2 ameloblastomas and 1 keratocyst) had undergone segmental mandibulectomy with 6–9 cm defect length. After tumor resection, double barrel fibula osteomyocutaneous flaps were used to reconstruct the mandible. All the flaps were alive with no complications post-operatively. Follow-up at 6 months showed good osteo-integration in panoramic radiograph and esthetic facial appearance. The patients underwent second-stage implants 8 months after fibula transplantation and implant-supported prosthesis was installed 1–2 months later to complete teeth rehabilitation.

Design of a Modified Monobloc Composite Facial Allograft Technique in Facial Reconstruction

Composite facial allografts have become increasingly popular in the reconstruction of complex facial defects. Good to excellent aesthetic results can be achieved, particularly when a foundation of donor skeleton has been transferred. The authors propose using a conventional craniofacial technique (monobloc osteotomy) to transfer a thin monocortical foundation of bone, even in lieu of a skeletal defect, to improve the recipient periorbital and malar aesthetics. The monobloc osteotomy approach was used to obtain a full facial allograft and modified ex vivo to a thin monocortical layer and transferred to an anatomical facial skeleton. The authors have named this the "masque" flap because of the resemblance of the outline of the foundation of bone to a costume worn in masquerade balls. The masque flap was performed on two fresh-frozen cadavers. The total time to harvest and thin the osteomyocutaneous flap was 155 minutes (30 minutes to modify it ex vivo). The average total surface area was 1060 cm. Periorbital and malar ligaments were maintained, as was the integrity of the canthal tendons. The modified monobloc composite facial allograft technique allows transfer of a full facial allograft and maintains malar projection and excellent shape of the palpebral aperture.

Microsurgical Reconstruction In Pediatric Patients: A Series Of 30 Patients

Free flap surgery in the pediatric population has gained widespread acceptance regarding its technical utility and reliability. Initial concerns as to the feasibility and reliability of the procedure in children were resolved over time. Thirty children (15 boys, 15 girls) were treated in Sisli Etfal Training and Research Hospital, Plastic and Reconstructive Surgery Clinic. Their mean age was 10.8 years. Defects were located on the lower extremity (n=22), head and neck (n=5) and upper extremity (n=3). The etiologies of the defects included vehicle accident, sequelae of burn, traumatic contractures, crush injury, epulis in the maxilla, and gunshot wound. The free flaps performed in our series were latissimus dorsi muscle flap, combined latissimus dorsi and serratus muscle flaps, serratus anterior muscle flap, cross latissimus dorsi muscle flap, scapular osteomyocutaneous flap, parascapular fasciocutaneous flap, fibular osteocutaneous flap, anterolateral thigh flap, medial circumflex femoral artery perforator flap, and crista iliaca osteocutaneous flap. The advantages of free flaps in children, which include better adaptation of the flap growth and better learning capacity of the children, provide the surgeon with more satisfactory functional and aesthetic results.

Simultaneous Bone Marrow and Composite Tissue Transplantation in Rats Treated With Nonmyeloablative Conditioning Promotes Tolerance

Approaches to safely induce tolerance in vascularized composite allotransplantation (VCA) with chimerism through bone marrow transplantation (BMT) are currently being pursued. However, VCA was historically performed sequentially after donor chimerism was established. Delayed VCA is not clinically applicable due to the time constraints associated with procurement from deceased donors. A more clinically relevant approach to perform both BMT and VCA simultaneously was evaluated. Wistar Furth (RT1A) rats were treated with a short course of immunosuppressive therapy (anti-αβ-TCR monoclonal antibody, FK-506, and anti-lymphocyte serum). One day before BMT, rats were treated with varying doses of total body irradiation (TBI) followed by transplantation of heterotopic osteomyocutaneous flaps from hindlimbs of August Copenhagen Irish (RT1A) rats. Eighty percent of rats conditioned with 300 cGy TBI and 40% of rats receiving 400 cGy TBI accepted the VCA. Mixed chimerism was detected in peripheral blood at 1 month after VCA, but chimerism was lost in all transplant recipients by 4 months. Most peripheral donor cells originated from the BMT and not from the VCA. Acceptors of VCA were tolerant of a donor skin graft challenge and no anti-donor antibodies were detectable, suggesting a central deletional mechanism for tolerance. Regulatory T cells (Treg) from spleens of acceptors more potently suppressed lymphocyte proliferation than Treg from rejectors in the presence of donor stimulator cells. These studies suggest that simultaneous BMT and VCA may establish indefinite allograft survival in rats through Treg-mediated suppression and thymic deletion of alloreactive T cells.

Mandibular Reconstruction Using Computer-Aided Design and Computer-Aided Manufacturing: An Analysis of Surgical Results

The purpose of this study was to analyze the accuracy of virtual surgical planning in mandibular reconstruction. This is a retrospective study involving 8 consecutive patients reconstructed with nonvascularized iliac crest bone grafts and free fibula osteomyocutaneous flaps. DICOM data from a maxillofacial skeleton computed tomography (CT) scan were sent to a medical modeling company and used to map the mandibular resection, anatomically place the mandibular reconstruction plate, and create surgical guides. After surgery a postoperative CT compared the virtual plan to the surgical result. Linear measurements [2 transverse and 1 anterior-posterior (A-P)] were performed to determine if the virtual surgical result was achieved. The transverse measurements were made from the condylar head to condylar head and from the gonial angle to gonial angle. The A-P analysis was made by measuring a perpendicular line drawn from the anterior inferior mandibular border to the center point on the condylar head to condylar head measurement. The average surgical error in the A-P dimension for the iliac crest bone grafts and free fibula flap was 0.2 mm (range 0.0 mm to 0.7 mm) and 0.9 mm (range 0.2 mm to 1.9 mm), respectively. In the transverse dimension the average surgical error was 1.6 mm (range 0.7 mm to 2.4 mm) and 2.7 mm (range 1.9 mm to 4.5 mm) from condyle to condyle, and 1.7 mm (range 0.7 mm to 2.7 mm) and 2.5 mm (range 0.4 to 4.8 mm) from gonial angle to gonial angle. The use of CAD-CAM (Medical Modeling, Golden, Colorado) technology for the fabrication of surgical resection guides and mandibular reconstruction plates resulted in an accurate surgical result.

Developing of an Experimental Model for Immunological Studies in VCA

Vascularized composite allotransplantation (VCA) has become a recent therapeutic entity in reconstructive surgery. Long term immunosuppressive therapy ensures graft survival, although, with a risk of serious side effects. Further progress in this field depends on better understanding of basic immunology of composite tissue grafts with the dynamics of rejection and possibilities to induce donor specific-tolerance. Without a vast clinical experience, a possibility for achieving those goals is intensive study in preclinical field. The classical experimental model for VCA is rat hind limb transplantation. We analyzed several microsurgical models in order to determine the most adequate one for immunological studies. We performed both orthotopic and heterotopic hind limb transplantations (we tested different techniques: entire or partial hind limb allotransplantation) and also osteomyocutaneous flaps, noting their advantages and limits. The osteomyocutaneous flap is less morbid and represents a promising experimental model in VCA studies.

Adoptive Transfer of Ex-Vivo Donor Alloantigen-Stimulated Regulatory T Cells Delays Composite Tissue Allotransplantation Rejection

Introduction: Great efforts from teams around the world have made composite tissue allotransplantation (CTA, or vascularized composite allotransplantation, VCA in short) a clinical reality. However, chronic application of immunosuppresants is still critical for long-term survival of the allografts. To circumvent this, major research efforts have been focused on establishing the allograft-specific tolerance. A specific subset of T cells termed regulatory T cells (Treg), with expression of CD4+CD25+Foxp3+, was found to be involved in suppressing the immune response. Tregs have been increasingly documented to suppress alloantigen-driven rejection especially in organ transplantation studies. However, less is known about functions of Tregs in composite tissue allotransplantation. Methods: The hindlimb osteomyocutaneous flap allotransplantation was performed on a rat model with BN donors and LEW recipients. The recipients were conditioned with two doses of antilymphocyte serum (ALS) in addition to daily injection of cyclosporine A for 7 days. CD4+CD25+ splenocytes were collected from the recipients with MACS magnetic microbeads technique in two steps. Firstly, splenic CD4+ cells were sorted out using negative selection by antibodies against non-CD4 cells. Secondly, CD25+ cells were sorted from CD4+ cells using positive selection. The in vitro suppressive potential of sorted CD4+CD25+ cells were assayed with mixed lymphocyte reaction. The in vivo effects were evaluated by adoptive transfer to allotransplantation receipients. Flap appearance was observed daily to monitor the rejection. Blood cell population was characterized with flow cytometry. Results: Two-step sorting greatly increased the purity of CD4+CD25+ cells from 7% to 91%. Out of these CD4+CD25+ cells, 61% expressed Treg marker Foxp3, in contrast to 6% in whole splenocyte population. When added into the coculture of Lewis and BN splenocytes, Tregs suppressed alloantigen-stimulated proliferation of LEW splenocytes in a dose-dependent manner. The in vivo effects of Tregs were evaluated by adoptive transfer to the allotransplantation recipients. Without conditioning by ALS and cyclosporine A, fresh-isolated CD4+CD25+ -infused rats showed signs of rejection sooner than controls. However, after alloantigen-stimulation, via coculture with BN splenocytes for 72 hours prior to infusion, the Tregs greatly delayed the onset of rejection in combination with ALS and cyclosporine A. One third of the allotransplantation recipients with alloantigen-stimulated Treg infusion had the allografts survive longer than 150 days. Conclusion: The protocol to isolate Tregs from rat splenocytes was developed with good purity. Isolated Tregs showed immnunosuppressive function in vitro. In vivo, alloantigen-stimulated Tregs in combination of ALS and cyclosporine A prolonged the survival of allotransplanted grafts.

Reconstruction of metatarsal bone defects with a free fibular osteomyocutaneous flap incorporating soleus muscle

Severe traumatic bone and soft-tissue defects are often treated by lower leg amputation. The amputation level becomes a very important factor with respect to the patient's basic daily activities. We report the case of a 51-year-old man who was referred to us with severe traumatic metatarsal bone and dorsum pedis skin and soft-tissue defects. To avoid amputation, a free fibular osteomyocutaneous flap incorporating the soleus muscle was used to reconstruct the second and third metatarsal bones and the soft-tissue defect, respectively. Now, 2 years after the procedure, the patient is able to walk independently. To the best of our knowledge, this is the first report of use of such a composite transfer for a complex midfoot defect.

Bone flap perfusion assessment using near-infrared fluorescence imaging

BackgroundMicrosurgical vascularized bone flaps are a versatile technique for reconstructing large bone defects. However, the assessment of perfusion is challenging, because clinical examination is difficult intraoperatively and often not possible postoperatively. Therefore, it is important to develop techniques to assess the perfusion of vascularized bone flaps and potentially improve the surgical outcomes. Near-infrared (NIR) fluorescence imaging has previously been shown to provide real-time, intraoperative evaluation of vascular perfusion. The present pilot study investigated the ability of NIR imaging to assess the perfusion of vascularized bone flaps. MethodsVascularized bone flaps were created in female Yorkshire pigs using well-established models for porcine forelimb osteomyocutaneous flap allotransplantation (n = 8) and hindlimb fibula flaps (n = 8). Imaging of the bone flaps was performed during harvest using the FLARE intraoperative fluorescence imaging system after systemic injection of indocyanine green. Perfusion was also assessed using the standard of care by clinical observation and Doppler ultrasonography. NIR fluorescence perfusion assessment was confirmed by intermittent clamping of the vascular pedicle. ResultsNIR fluorescence imaging could identify bone perfusion at the cut end of the osteotomy site. When the vascular pedicle was clamped or ligated, NIR imaging demonstrated no fluorescence when injected with indocyanine green. With clamp removal, the osteotomy site emitted fluorescence, indicating bone perfusion. The results using fluorescence imaging showed 100% agreement with the clinical observation and Doppler findings. ConclusionsVascularized bone transfers have become an important tool in reconstructive surgery; however, no established techniques are available to adequately assess perfusion. The results of our pilot study have indicated that NIR imaging can provide real-time, intraoperative assessment of bone perfusion.

Application of CAD/CAM-assisted technique with surgical treatment in reconstruction of the mandible

ObjectiveThe purpose of this clinical study was to explore the optimal method of reconstruct mandible defects individually and immediately. Study designThree-dimensional model simulation technique and vascularized fibular osteomyocutaneous flap were used to repair 15 cases of mandible defects, which were caused by ameloblastoma. A three-dimensional computed tomography (CT) images were converted to a virtual model using CAD software and the 3-dimensional (3D) simulated resin models of skeleton and fibula were used to design the osteotomies, bone segment replacement and titanium mesh shaping preoperatively. ResultsFibula flaps were alive and no complication occurred. The patients were satisfied with the results both esthetically and functionally. ConclusionsThis preliminarily clinical study and case demonstrated that CAD/CAM-assisted technique with surgical treatment offers an individual anatomical reconstruction of the mandible in ameloblastoma patients. The procedures guarantee intraoperatively an exact placement of the preformed mesh even for precise reconstruction of extensive mandible defects.

Free Tensor Fasciae Latae Flap for Abdominal Wall Reconstruction: Overview and New Innovation

Extensive abdominal wall defects may result from tumor extirpation, traumatic injury, or soft tissue infections. Extensive traumatic injuries can often disrupt the soft tissue content of the abdomen as well as the bony support provided by the pelvis. Reconstruction of the lower abdomen should aim to recreate dynamic stability. Five patients with extensive lower abdominal wall disruption following traumatic injuries or infection were treated using a novel flap for functional reconstruction. We devised a free neurotized osteomyocutaneous tensor fasciae latae (TFL) flap that would restore bony continuity by providing a vascularized bone graft and simultaneously maintain the integrity of the attachment of the tensor fascia latae muscle to the iliac crest, reestablishing musculofascial continuity. A branch of the superior gluteal nerve was harvested with this composite flap and coapted to an intercostal nerve for reinnervation, thereby creating a dynamic muscle in these patients. All patients underwent successful free tissue reconstruction with 100% flap survival. The lower abdominal wall and bony integrity of the pelvis were successfully reconstructed. Reinnervation has shown clinical signs of maintained dynamic stability. The innervated TFL osteomyocutaneous flap is an ideal option for lower abdominal reconstruction in patients with complex abdominoperineal defects with loss of bony integrity.

Special considerations in virtual surgical planning for secondary accurate maxillary reconstruction with vascularised fibula osteomyocutaneous flap

This article describes our special considerations in virtual surgical planning for secondary maxillary reconstruction with vascularised fibular osteomyocutaneous flap and our revised surgical design for maxillary reconstruction. Eleven patients with different maxillary defects according to Brown's revised classification underwent virtual surgical planning for secondary accurate reconstruction. For different horizontal class defects, the fibular was osteomised to match the maxillary alveolar arch by using the mirror image of the contralateral alveolar ridge or the curve of the mandibular arch and dentition. Maxillary reconstruction was performed with the guidance of preoperative virtual planning and using fibular osteotomy and reposition guide templates to replicate the virtual planning intra-operatively. Virtual surgical planning was replicated intra-operatively in all patients. The fibulae were osteotomised into four segments in three patients with the horizontal class d2 defect and three segments in eight patients with the horizontal class b-d1 defects, respectively. The overall success rate for 11 flaps was 100%. Good bony unions and wound closure were observed and intelligible speech was achieved in 11 patients. Maximum incisal opening ranged from 3.0 to 4.0 cm. All patients tolerated a regular diet postoperatively. Postoperative midfacial appearance was good in all patients. We recommend that the horizontal class d defect in Brown's revised classification of maxilla and midface be divided into two sub-types according to whether it involves the contralateral canine or not. Special considerations in virtual surgical planning are helpful to perform accurate secondary maxillary reconstruction with a vascularised fibular osteomyocutaneous flap.

Reconstruction of oncological oro-mandibular defects with double skin paddled-free fibula flap: A prudent alternative to double flaps in resource-constrained centres

The free fibula flap is the choice flap for mandibular reconstruction following extensive tumor resections. While large defects are managed with a second flap [free or pedicle] in advanced centres, a free fibula flap with a large skin paddle that can be de-epithelised to provide outer skin and inner lining is the best alternative in resource- constrained centres. From January 2005 to December 2009 a total of 386 free fibula flaps were used of which 307 flaps had de-epithelised double skin paddle in reconstructing complex oral and mandibular defects after tumor ablative surgeries. Complete flap survival was seen in 282/307 patients. Complete flap loss was seen in 9/307 patients. Partial flap loss was seen in 16 patients. Re - exploration was done in 30 patients and the flap was salvaged in 21 patients. The vascular supply of the free fibula osteo myocutaneous flap is reliable and a flap with a large skin paddle can be used to provide both inner lining and outer cover in resource-constrained centres.

Development of surgical phalloplasty techniques: Is there a gold standard?

Summary Introduction In the field of penile reconstruction surgery there is a range of techniques, including fasciocutaneous, septocutaneous, myocutaneous, osteocutaneous and osteomyocutaneous flaps, taken from the suprapubic, abdominal, inguinal, scapular, deltoid, thoracodorsal, fibular or anterolateral thigh areas or from the forearm or arm. Among this wide variety of techniques, is there a gold standard treatment to identify best practice, and what are the criteria that should be used to define such a standard? The aim of this article is to provide an overview of the main phalloplasty techniques and to show their advantages and drawbacks, in order to answer the ultimate question, of whether a gold standard can be identified or not. Method Literature review using Pubmed and selection of articles about the most common types of phalloplasty, and how these have changed over time. Selection of articles that evaluate the main techniques. Results Six phalloplasty techniques (flaps from the suprapubic, abdominal, inguinal, forearm, fibular and anterolateral thigh areas) are described. There have been few studies that formally evaluate these techniques, other than studies of complications, even though it is suggested that some techniques preserve erogenous sensitivity. Discussion The criteria that an ideal phalloplasty must fulfil are: 1) satisfactory aesthetic appearance; 2) creation of a neourethra which enables urination while standing up; 3) sufficient rigidity to have sexual relations; 4) tactile and erotic sensitivity; 5) surgery carried out in just one stage; 6) low levels of donor site morbidity and site must be easy to hide; 6) density, texture and colour to match the perineum. No technique currently meets all these criteria and thus no gold standard treatment can easily be identified. Any standard, if one is to exist, must stress the need to inform and educate patients in order that their needs be met and in order to reduce unrealistic expectations and postoperative disappointment.

Osteoplastic surgery of the face – state of the art and future aspects

BACKGROUND: The management of facial defects has rapidly changed in the last decade. Functional and esthetic requirements have steadily increased along with the refinements of surgery. METHODS: To achieve excellence, a comprehensive spectrum of osteoplastic surgical methods, in particular in combination with each other, is required to meet this challenge. Osteomyocutaneous flaps, advanced block grafting techniques, especially complex prefabricated composite grafts, and distraction osteogenesis last being the most recent surgical method both in reconstructive and orthognathic face surgery, are in use. RESULTS: Since osseous deficiencies of any kind ranging from aging, malocclusion-related skeletal disfigurement to orofacial defects result in facial deformities and impairment of function, the goal of osteoplastic surgery is the reconstruction of the skeletal architecture to achieve an esthetic and functional musculoskeletal balance of the face. Exemplary are CLP and the complete clinical picture of facial aging. CONCLUSIONS: Against this background plastic-reconstructive face surgery, craniofacial surgery and oral implant surgery still exist in isolated clinical fields although an interdisciplinary approach on new surgical concepts would be able to shift the border of the possible considerably. Because of the complexity of the demonstrated osteoplastic proceedings, oral surgery and its used bone substituted materials will only be marginally reviewed.

Evaluation of oro-mandibular-facial reconstruction using vascularized free fibular osteomyocutaneous flap

Evaluation of oro-mandibular-facial reconstruction using vascularized free fibular osteomyocutaneous flap