Mucosal Reconstruction Research Articles

Remodeling of Buccal Mucosa by Bladder Microenvironment

The optimal cell source for bladder mucosa reconstruction is in question. This study explored the feasibility of phenotype transformation of oral mucosa towards bladder urothelium by transplanting the oral mucosa into bladder local microenvironment. Porcine oral mucosa grafts were transplanted into autologous bladder mucosa defects, and the specific marker expressions of both oral epithelium and bladder urothelium were examined by immunohistochemistry and RT-PCR at 3, 6, and 12 months to detect a potential phenotype transformation. The grafts could retain the phenotype and structure of oral mucosa within 3 months with positive expression of cytokeratin 14 (CK 14, a specific marker of oral epithelium) and negative expression of uroplakin II (UPII, a urothelium-specific marker). However, after 6 months of transplantation, the grafts expressed UPII at both protein and mRNA levels and the phenotype persisted at 12 months postsurgery. All the grafts continuously retained the positive expression of CK 14 at all time points. These findings, for the first time, revealed the transdifferential potential of oral keratinocytes toward urothelial cells and the important role of bladder local microenvironment for remodeling oral mucosa epithelium. These results support the hypothesis that oral keratinocytes can serve as a potential cell source for reconstructing bladder mucosa.

Le corps adipeux de la joue dans la reconstruction des pertes de substances postérieures de la cavité buccale

Some losses of matter in the posterior area of the oral cavity require reconstruction with vascularized tissue to prevent retraction and a limited mouth opening. Bichat's fat pad or Bichat's fat ball is rarely used for oral mucosal reconstruction despite its proximity, easy availability, plasticity and simple use as a flap. Bichat's fat pad is resistant to lipolysis even in case of major weight-loss. It usually herniates in the exeresis site of a jugal tumor or intermaxillary commissure. When this is not the case, it can be obtained by a horizontal vestibular incision. The fat pad is unfolded and sutured without tension to the margin of the defect. The flap may be protected by a Bourdonnet dressing. Epithelialization begins 8 to 10 days after surgery. It is completed in the second or third week. The fat volume is variable, thus filling can only be applied to areas with loss of matter under 6cm. The technique is simple and quick. Postoperative evolution is usually uneventful; healing is quick as well as recovery of normal feeding function.

Free Fibula Osteocutaneous Flap for Primary Reconstruction of T3-T4 Gingival Carcinoma

Lower gingival squamous cell carcinoma (SCC) frequently invades the mandibular bone and buccal or lingual oral mucosa. In the concept of en bloc surgery of malignant tumors, it is advisable to prefer segmental mandibulectomy for T3-T4 lower gingival carcinoma that had radiologic bone involvement and resection of soft tissue on the buccal or lingual side with negative border of margin. Consequential defects of oral mucosa and mandible need immediate reconstruction to provide the maximum probability of cure and quality of life with minimal donor site morbidity. The aim of this study was to evaluate the fibula osteocutaneous flap with skin island as a means to meet both hard and soft tissue reconstructions needed in a one-stage procedure of gingival SCC. Data of 17 patients, with gingival SCC pathologically and who underwent en bloc operations including segmental mandibulectomy and reconstruction of mandible and intraoral mucosa with fibular flap, were retrospectively analyzed. The segmental mandibular defects ranged from 8 to 17 cm, and intraoral soft tissue defects ranged from 4 degrees at 2.5 cm to 8.5 degrees at 4 cm. The flaps survived in all 17 patients including 9 patients who received postoperative radiotherapy with good final function of the lower leg. Of 17 patients, 11 had with no evidence of disease with a mean follow-up period of 25 months. Our study results, together with literature findings, revealed that the fibula that had a long length of good-quality bone and sufficient blood supply were suitable for stable osteosynthesis, with the overlying skin suitable in thickness and without limitation of skin flap size for intraoral reconstruction especially after ablative surgery. This method provides oral and maxillofacial surgeons with a means to meet both hard and soft tissue needs in a one-stage procedure for extensive resection of gingival SCC.

Tissue engineering by transplantation of oral epithelial sheets cultivated on amniotic membrane for oral mucosal reconstruction

Human amniotic membrane (AM), a thin intrauterine placental membrane is highly biocompatible, and possesses anti-inflammatory and anti-scarring properties. Using AM, we developed a novel method for cultivating oral mucosal epithelial cell sheets. We evaluated autologous transplantation of oral mucosal epithelial cells on AM in patients undergoing oral surgeries. Specimens of AM were obtained from women undergoing Caesarean section. Using oral mucosal biopsy specimens obtained from the patients, oral epithelial cells were cultivated on an AM carrier. The resultant sheet was transplanted on the oral mucosal defect. After 2-3 weeks of culture, the cultivated epithelial cells seemed well differentiated and showed stratification into 5-7 layers on AM. Immunohistochemistry demonstrated that the cultivated cells expressed highly specific mucosal epithelial cell markers and basement membrane proteins. After the surgical procedure, the reconstructed sites did not show infection, bleeding, rejection, or sheet detachment, and the sites achieved a new oral mucous membrane. The cultivated epithelial sheets maintained the properties of a mucous membrane and expressed basement membrane proteins. Autologous transplantation of cultivated oral epithelial sheets was performed, and the transplanted tissue showed adherence to the oral mucosal defect. A long-term follow-up of more than 12 months revealed absence of postoperative recurrence, and the postoperative courses were excellent. These findings showed that this novel epithelial sheet is a useful biomaterial for mucosal reconstruction.

Immunohistochemical study of oral epithelial sheets cultured on amniotic membrane for oral mucosal reconstruction

We immunohistochemically evaluated whether oral epithelial cells grown on amniotic membrane (AM) would be an effective biomaterial for reconstructing oral mucosal defects. Oral mucosal epithelial cells from albino rabbits were grown for 2-3 weeks on an AM carrier in a co-culture with 3T3 fibroblasts. The rabbits' oral mucosal defects were reconstructed by autologous transplantation of the oral epithelial sheets. The oral epithelial sheets and reconstructed tissues were then examined histologically and immunohistochemically. After 2-3 weeks of culture, the rabbit oral mucosal epithelial cells developed 5-7 layers of stratification on the AM. Immunohistochemistry revealed that they expressed keratins 4/13, integrin alpha 6, alpha 5 chain and collagen type III, but not keratins 1/10. The transplanted sheets attached to the mucosal defects, and AM fragments disappeared from the transplant area. Immunohistochemical patterns revealed properties of the mucous membrane and basement membrane components in the reconstructed epithelia. The results of this experiment showed that the AM-cultured oral epithelial sheets resulted in mucosa-like differentiation, and adhered to the mucosal defects. Therefore, AM-cultured oral epithelial sheets might be a useful biomaterial for oral mucosal reconstruction.

UP-1.054: Preliminary Study of Tissue-Engineered Lingual Mucosa Reconstruction

UP-1.054: Preliminary Study of Tissue-Engineered Lingual Mucosa Reconstruction

Two small flaps from one anterolateral thigh donor site for bilateral buccal mucosa reconstruction after release of submucous fibrosis and/or contracture

Oral submucous fibrosis causes health-related and social problems for affected patients. Free flap reconstruction has proved effective for maintaining mouth opening after release of fibrosis. Two independent free flaps from separate donor sites, such as bilateral forearm flaps or bilateral anterolateral thigh (ALT) flaps, were traditionally required for reconstruction. The former option sacrifices one of the two major arteries in the forearm. Both options are time consuming and required two donor sites. To eliminate these disadvantages, we developed a technical modification that allows harvesting of two independent flaps from one ALT thigh based on one descending branch of the lateral circumflex femoral artery (d-LCFA). Eighteen flaps from nine donor sites were harvested for post-release reconstruction of oral submucous fibrosis. Mean flap size was 4.1 x 7.5 cm, mean pedicle length was 7.6 cm, mean ischaemia time was 104 min and mean total operation time was 13 h and 19 min. All donor sites were closed primarily, with one exception. One flap failed and was replaced with a contralateral ALT flap. One patient developed a wound infection and another developed a seroma at the recipient site. Four flaps required secondary de-bulking in three patients. The improvement in mouth opening was evaluated by inter-incisor distance (IID): mean preoperative IID was 9.6mm (range: 0-20mm), mean follow-up time was 16.2 months (range: 10-33 months); mean postoperative IID was 23.8mm and mean improvement in IID was 15.3mm (range: 10-27 mm). In conclusion, two independent flaps can be harvested from d-LCFA of the same thigh, instead of from both thighs, to reconstruct bilateral buccal defects after release of submucous fibrosis and/or contracture.

Free Radial Forearm Flap Lip Reconstruction

Lip reconstruction is best suited to the dictum of replacement of like tissue with like. The use of the remaining lip in the use of the lip reconstruction becomes more difficult as the size of the defect increases. The use of local tissue for subtotal lower lip loss problems like microstomia and facial and commissure distortion are real risks. The use of free tissue transfer becomes especially an attractive option when in addition to the lip there is associated loss of other aesthetic units and/or mandibular bone loss. The potential value of local perioral tissue is more likely to maintain dynamic and sensory function of the lip.Five patients were included in the clinical series during a period of 3 1/2 years since January 2002. All 5 patients were men. The age ranged from 15 to 67 years. Four patients underwent reconstruction by composite radial forearm flaps including both the cutaneous nerve of the forearm and the palmaris longus tendon. A single patient in this group had a partial brachioradialis muscle flap raised as chimeric component to the composite radial forearm flap. In the fifth patient, 2 simultaneous free radial forearm flaps were used for both upper and lower lip and bilateral buccal mucosal reconstruction. All patients achieved the goals of providing an adequate mouth opening with competence. The refinement of dynamic palmaris sling attachment to the perioral muscle provided for very good oral competence and support. In the single patient, adding bulk with the brachioradialis muscle to the neo lower lip most likely served to improve both aesthetics and lip function. With the use of free flaps an adequate labial sulcus, near dynamic sphincter control and sensation can be restored. The major drawback, however, is aesthetics of the lip. Further refinements like vermillion tattooing, fat injections or defatting by liposuction, and secondary mucosal flap surgery to provide the neolip with a vermillion are beneficial.

Minimizing Microstomia While Maximizing Esthetics in the Reconstruction of Acquired Lip Defects: The Evolution of the Bilateral Paramedian Cross-Lip Flap

Mutilating trauma and malignancy can create devastating lip defects. After insult or ablation, it is essential to strike a workable balance between esthetics and preservation of oral sphincter competence, which is fundamental for articulation, deglutition, and social and personal acceptance. Perioral local flaps are often the best source of combined vermilion, orbicularis oris, and mucosal reconstruction. Numerous techniques exist for reconstructing acquired lip defects including lateral and inferior cheek advancements, gate flaps, and fan techniques.

Long-term study of male rabbit urethral mucosa reconstruction using epidermal cell

To investigate the transformation of characteristics of epidermal cells from foreskin which were used to reconstruct male rabbit anterior urethra in combination with acellular collagen matrices. In three rabbits, autologous foreskin epidermal cells were isolated, expanded in vitro, and seeded (inoculated) onto a tubular acellular collagen matrix, acquired from allogeneic rabbit bladder submucosa. A urethral mucosal defect was created, and urethral reconstruction was performed with the tubular acellular collagen matrix seeded with epidermal cells. On gross examination at 12 months following the procedure, the mucosa of the urethral grafts appeared lubricous and smooth. Urethrography showed that a wide urethral caliber had been maintained without any sign of strictures. Histological examination showed a transitional cell layer in the graft without evidence of a margin between the graft and the host tissue at 12 months postoperatively. Epidermal cells seeded onto acellular collagen matrices can be successfully used to reconstruct urethras that have defects and are transformed to transitional epithelial cells.

A Modification of Technique to Cover a Large Posterior Thigh Defect Using an Anterolateral Thigh Flap

Anterolateral thigh (ALT) flap is one of the popular flaps for soft-tissue reconstruction. It is a versatile flap which commonly used to resurface external skin defect and internal mucosal lining. In addition if raised as musculocutaneous flap, the muscle portion provides bulk to fill up any potential space. With increase knowledge on the vascular anatomy of this flap, it is possible to harvest 2 skin paddles base on more than one branches of the supplying vessel. This technique is commonly employed to provide coverage of more than one epithelial surfaces such as the complex facial defect after maxillectomy where both the cheek skin and oral mucosa reconstruction are required. Using similar concept, we report a case in which a large external skin defect was successfully covered with an ALT flap and the donor site could be closed primarily without skin grafting.

Myodermal Flap for Reconstruction of Oral Mucosa

Myocutaneous flaps are commonly used to repair the mucosal defect that results from ablative tumor surgery. However, skin is not a perfect substitute for the oral mucosa because it can lead to poor hygiene due to hair growth and desquamation. A muscle-only flap has been used for reconstruction of the oral cavity because it heals with secondary epithelialization, mimicking the oral mucosa.1-3 However, cicatricial contraction remains an issue for the muscle-only flap.4,5 In a previous study, we showed that fascial flaps heal with secondary epithelialization with mild contraction.

Standards for Gastroenterologists for Performing and Interpreting Diagnostic Computed Tomographic Colonography

Standards for Gastroenterologists for Performing and Interpreting Diagnostic Computed Tomographic Colonography

Bilobed fibula flap for reconstruction of through‐and‐through oromandibular defects

The role of fibula free flaps for reconstruction of through-and-through oromandibular defects is examined. Thirty-four patients underwent reconstruction of through-and-through oromandibular defects using fibula free flaps that contain large, bilobed skin paddles for simultaneous reconstruction of intraoral mucosa and external skin. We examined the incidence of wound healing complications, the need for revision reconstructive surgery, and factors affecting the incidence of complications. Wound healing complications occurred in 50% of patients. There was a relatively high incidence of partial flap necrosis (26%) and revision surgery (41%). The area of the flap skin paddle was significantly associated with the risk of partial flap necrosis and the need for revision surgery. Many through-and-through oromandibular defects can be successfully reconstructed using a fibula free flap that contains a large, bilobed skin paddle. However, wound healing complications are increased when the flap skin paddle area exceeds 300 cm2.

Spontaneous sensory recovery in non-innervated radial forearm flaps used for head and neck reconstruction

Although several studies have reported the use of reinnervated microvascular free flaps for oro-pharyngeal reconstruction, it has been known for some time that non-innervated flaps demonstrate spontaneous sensory recovery. This study sought to evaluate the degree of such spontaneous recovery in 50 radial forearm flaps used for mucosal reconstruction of head and neck ablative defects. The recovery of sensation to pinprick, light touch and temperature was tested a mean of 38 months (range 15–71) after surgical insetting. Two-point discrimination was also sought. Although 18 flaps (36%) remained anaesthetic, partial recovery in one or more modalities was present in 28 patients (56%). A recovery in all modalities of sensation in at least two-thirds of the flap area was recorded in 4 patients (8%). The mean 2-point static discrimination for fascio-cutaneous flaps was 18.9 mm.

Stent fabrication for graft immobilization following wide surgical excision of myofibroblastic sarcoma of the buccal mucosa: A clinical report

Sarcomas of the head and neck are rare tumors derived from cells of mesenchymal origin. This article briefly discusses the epidemiology, etiology, and classification of head and neck sarcomas. Emphasis is placed on myofibrosarcoma, a malignant tumor of the myofibroblasts. Histologic criteria, prognostic factors, and the multidisciplinary management of these tumors are reviewed. A situation of a surgically excised myofibrosarcoma of the buccal mucosa is reported. In this patient, a stent was fabricated to stabilize a split-thickness skin graft used for the buccal mucosa reconstruction.

Poster 8: Development and characterization of tissue-engineered oral mucosa using cryopreserved oral keratinocytes

Poster 8: Development and characterization of tissue-engineered oral mucosa using cryopreserved oral keratinocytes

Utilización simultánea de colgajo libre microvascular y colgajo pediculado en la reparación de defectos de espesor total

IntroductionIn great surgical defects due to radical oncological head and neck surgery, sometimes, a unique flap reconstruction is not suitable to restore local anatomy. In those cases, it is suitable to do both, a free flap and a pectoralis mayor flap simultaneously Material and methodsWe introduce a sample of 6 patients with local advanced head and neck cancer who underwent cervical surgery reconstruction with free foearm flap and pectoralis mayor myocutaneous flap simultaneously ResultsIn great surgical defects due to radical oncological head and neck surgery, sometimes, a unique flap reconstruction is not suitable to restore local anatomy. In those cases, it is suitable to do both, a free flap and a pectoralis mayor flap. Through and through defects (after oncological surgery), should need simultaneous skin and mucosa reconstruction thus cervical tissue contribution to cover the surgical defect ConclusionSimultaneous free flap and local flap reconstruction on one step surgery it is a reasonable option as we and other authors have done

The temporal fasciocutaneous island flap for oncologic oral and facial reconstruction

Purpose: This study reports the anatomy, operative technique, and postoperative results of the temporal fasciocutaneous island flap (TFCIF), as used for facial and intraoral reconstruction. Materials and Methods: Retrospective study of 15 patients who underwent TFCIF reconstruction. The anatomic basis and surgical technique are described. The flap was used for mucosal reconstruction after cheek or maxillary resection. It was used for facial tissue loss in 2 cases: orbital osteoradionecrosis and exposure of a mandibular reconstruction plate. Results: This technique provides a safe and rapid solution for intraoral reconstruction; however, it cannot be used for the anterior floor of the mouth. The best indication that we have found is the reconstruction of hemimaxillectomy, allowing closure of buccosinusonasal communication and prosthetic rehabilitation. The main disavantage is that hair regrowth limits its use to patients who need postoperative radiotherapy. Donor site morbidity is minimal. Only a partial failure was observed. Conclusion: The TFCIF is a rapid, safe, and useful flap for oral and facial reconstruction after oncologic resection. Its arc of rotation limits, however, its use to the posterior part of the oral cavity.

Total oral reconstruction for cancers associated with advanced oral submucous fibrosis.

The progression of submucous fibrosis to oral cancer is well established. This condition in an advanced stage causes progressive trismus. Oral cancers associated with severe submucous fibrosis (interincisor distance [IID] < or = 1.5 cm) require bilateral buccal mucosal reconstruction after tumor excision. After wide excision of the tumor, a regional flap is used to reconstruct the buccal mucosal loss on that side. The opposite buccal mucosa, afflicted by advanced submucous fibrosis, is released at the same time to open the mouth and is resurfaced by an ipsilateral, inferiorly based nasolabial flap. This helps to rehabilitate the oral cavity completely and to prevent the recurrence of trismus. In 18 months, 12 patients underwent total reconstruction of intraoral tumors associated with submucous fibrosis. The average preoperative IID was 0.875 cm. All patients had inferiorly based, two-stage nasolabial flaps for submucous fibrosis reconstruction. The average pain-free postoperative IID was 3.13 cm.