Algorithm for the treatment of oral and peri-oral defects through local flaps

Purpose

Local flaps are currently considered the main reconstructive option for medium-size oral and peri-oral defects; however, their indications are sometimes challenging to select. The aim of this study was to critically analyse their selection and to propose a therapeutic algorithm.

Use of Nasolabial Flap in Intra and Extraoral Reconstruction: Our Experience with 40 Cases

Purpose

This article represents the use of inferiorly based nasolabial flap in reconstruction of various intraoral and extraoral defects.

Patients and Methods

Nasolabial flaps were performed in 40 patients, for reconstruction of buccal mucosa, gingivobuccal sulcus, commissure, lower lip, floor of mouth, upper lip and lower alveolar defects.

Results

The most common defect site in the oral cavity was the buccal mucosa. Partial flap necrosis occurred in five patients. Out of 40 cases of carcinoma of lip, commissure and floor of the mouth, all the patients had good speech after complete healing of the wound. None of the patients who had lip or commissure reconstruction developed drooling of saliva due to lip incompetence.

Conclusion

The inferiorly based nasolabial flap provides reliable coverage of intermediate-sized oral cavity defects when used alone. Minimal donor morbidity is associated with its use. It is especially useful in elderly patients with facial skin laxity and where esthetics is not a major concern.     

Reconstruction of Nasal Cleft Deformities Using Expanded Forehead Flaps: A Case Series

Introduction

Reconstruction of the nasal clefts is a challenging task considering the nasal anatomic complexity and their possible association with craniofacial defects. The reconstruction of these defects needs extensive amounts of soft tissue that warrant the use of forehead flaps. Often presence of cranial defects and low hairline compromise the amount of tissue available for reconstruction warrenting tissue expansion.

Aim

To evaluate the efficacy of tissue expansion in reconstruction of congenital nasal clefts.

Subjects and Methods

9 patients with congenital nasal clefts involving multiple sub units were taken up for nasal reconstruction with expanded forehead flaps. The average amount of expansion needed was 200 ml. The reconstruction was performed in 3 stages.

Results

Expanded forehead flaps proved to be best modality for reconstruction providing the skin cover needed for ala, columella and dorsum with minimal scarring at the donor site.

Conclusion

Expansion of the forehead flap is a viable option for multiple sub unit reconstruction in congenital nasal cleft deformities.     

Functional assessment: Free thin anterolateral thigh flap versus free radial forearm reconstruction for hemiglossectomy defects

Background

To compare free thin anterolateral thigh (ALT) flap with free radial forearm (FRF) flap in the reconstruction of hemiglossectomy defects, and to introduce our methods and experience in the tongue reconstruction with free thin ALT flap.

Material and Methods

The clinicopathologic data of 46 tongue carcinoma cases hospitalized from December 2009 to April 2014 were obtained from Nangjing Stomatological Hospital, Medical School of Nanjing University. All the subjects were evaluated for the articulation and the swallowing function 3 months after the surgery.

Results

Among these 46 patients, 12 patients underwent tongue reconstruction after hemiglossectomy with ALT flap; 34 patients underwent tongue reconstruction with FRF flap. The differences in the incidence of vascular crisis, the speech and the swallowing function between two groups were not significant (P>0.05).

Conclusions

Thin ALT flap could be one of the ideal flaps for hemiglossectomy defect reconstruction with its versatility in design, long pedicle with a suitable vessel diameter, and the neglectable donor site morbidity. Key words:Free thin anterolateral thigh flap, free radial forearm flap, hemiglossectomy, reconstruction, morbidity.     

Kapetansky-Juri Technique to Correct the Whistlers Lip in the Multiple Operated Cleft Patient

Purpose

One of the common sequels of a cleft lip repair may be “whistling lip deformity” but other deformities are also seen particularly in failed or multiple resurgery cases. This retrospective study was carried out to evaluate the usefulness of “Kapetansky-Juri” advancement flap technique to correct such deformities.

Methods

Ten patients of bilateral cleft lip with history of minimum five failed cleft lip surgeries and having residual lip deformity were operated using “Kapetansky-Juri” advancement flap technique and were followed up to minimum 36 months.

Results

All patients showed good tissue fullness and complete correction of the deformity. There was no contracture of surrounding skin or vermilion during follow-up period. In eight patients minimal scar formation was seen while two showed midline scar formation.

Conclusion

No tissue loss due to vascular insufficiency was observed. The technique gives good tissue distribution and minimal surface scar formation.     

Rational and simplified nomenclature for buccinator myomucosal flaps

Background

Reconstruction of moderate-sized mucosal defects of the oral cavity or oropharynx represents a surgical challenge. Buccinator myomucosal flaps seem to provide “ideal reconstruction” of oral/oropharyngeal defects because they carry a thin, mobile, well-vascularized, and sensitive tissue, like that excised or lost. Nevertheless, these flaps are not immediately popular because of confusion surrounding the complex terminology used to name them.

Methods

After a retrospective study on our experience and a literature review, the authors propose a new rational and simplified nomenclature for the classification of buccinator myomucosal flaps, which clarifies the source vessel, the composition of the flap, and the type of transfer.

Results

According to this nomenclature, six types of buccinator myomucosal flaps are described.

Conclusions

This proposed nomenclature may bring a consensus on the classification of buccinator myomucosal flaps and can help their spread.

     

Incidence and types of complications after ablative oral cancer surgery with primary microvascular free flap reconstruction

Background

The aims of the study were 1) to evaluate the incidence and types of postoperative complications after ablative oral cancer surgery with primary free flap reconstruction and 2) identify prognostic variables for postoperative complications.

Material and Methods

Desired data was retrieved from a computer database at the department of Oral and Maxillofacial Department, Queen Elisabeth hospital Birmingham, United Kingdom, between June 2007 and October 2012. Logistic regression was used to study relationships between preoperative variables and postoperative outcomes.

Results

The study population consisted 184 patients, comprising 189 composite resections with reconstruction. Complications developed in 40.2% of the patients. Three patients (1.6%) died, 11.1% returned to the operating room, 5.3% developed donor site complications and 6.9% flap complications of which 3.2% total flap failure. In the multivariable analysis systemic complications were associated with anaesthesia time and hospital stay with red cell transfusion.

Conclusions

A significant proportion of the patients with primary free flap reconstructions after oral cancer surgery develops postoperative complications. Prolonged anaesthesia time and red cell transfusion are possible predictors for systemic complications and hospital stay respectively. Preoperative screening for risk factors is advocated for patient selection and to have realistic information and expectations. Key words:Free flap, complications, oral cancer, risk factors, reconstruction.     

Survival of dental implants placed in vascularised fibula free flaps after jaw reconstruction

Purpose

Ablative oncological surgery to treat head-and-neck cancer often triggers a requirement for jaw reconstruction. Modern surgical procedures using free microvascular flaps afford acceptable outcomes in terms of restoration of bony and soft tissue defects. A fibula free flap is often the preferred flap, as the bone length is considerable and a two-surgeon approach is possible. Dental implants play important roles in functional rehabilitation. Our aim was to evaluate the survival of dental implants placed in reconstructed areas after transfer of fibula tissue to the jaw.

Platysma Flap: An Alternative to Free Flaps

Objective

The objective of this paper is to show that platysma flaps have good results and should be an alternative in reconstructive surgery for oral tumors when microsurgery is not possible. It is a versatile, portable, and thin flap, is easy to perform, and can be obtained during neck dissection, with a primary closure of the donor site.

Methods

Five cases are presented, three men and two women, 51 and 71 years old, with medium size (2–4 cm) defects of oral cavity after the excision of squamous cell carcinomas. All of them were reconstructed with a platysma flap after neck dissection. This reconstruction technique was chosen because of the poor conditions of these patients to allow a microsurgical reconstruction.

Results

Non-local complications occurred with this technique. Overall aesthetic results were acceptable in all the patients. There were no cases of total necrosis flap, dehiscence, fistula or fibrosis. Only one case of partial necrosis occurred in one end of the flap, which was resolved with excision of necrotic tissue and closure by secondary intention.

Conclusion

The platysma flap is a good method to reconstruct small and medium sized defects of oral cavity, especially in patients where a microsurgery reconstruction is not possible.     

Goldenhar syndrome: clinical features with orofacial emphasis

Objectives

Goldenhar syndrome (GS) is a relatively common developmental disorder characterized by craniofacial anomalies in association with vertebral, cardiac, renal, and central nervous system defects. This paper describes GS features with special emphasis on oral characteristics.

Material and methods

The clinical features of 6 patients with GS aged 3 months to 12 years are described, and a brief review of the literature about this genetic disorder is presented.

Results

All patients demonstrated the classical triad of GS, including mandibular hypoplasia resulting in facial asymmetry, ear and/or eye malformation, and vertebral anomalies. In addition, renal and gastrointestinal abnormalities were observed in 2 patients. Regarding the oral involvement, 2 patients presented cleft lip and palate, and 1 patient had temporomandibular joint malformation. Malocclusion was found in all patients.

Conclusion

Our orofacial findings correlate with the reported cases in the literature, and point out that after diagnosis GS patients need to be examined for systemic abnormalities.     

Facial reconstruction with vascularised serratus anterior muscle flap in patients with Parry–Romberg syndrome

Objective

Parry–Romberg syndrome, popularly known as progressive hemifacial atrophy, is a rare and complicated craniofacial deformity characterized by idiopathic and progressive atrophy of patient's face with compromised facial aesthetics and functions. In the present study, we performed a retrospective review on the vascularised serratus anterior muscle flap transfer for the treatment of the hemifacial atrophy in 4 consecutive Chinese patients with Parry–Romberg syndrome.

Methods

The serratus anterior muscle flaps were harvested and transferred to correct the facial defects together with simultaneous nerve anastomosis between the long thoracic nerve and the ipsilateral cervical branch of facial nerve in the patients with Parry–Romberg syndrome. The postoperative results from patients’ own perception of improvement of facial profile and symmetry were also evaluated.

Results

In this patient series, both of the vessels and nerves of all flaps were anastomosed successfully in the recipient facial regions without any microvascular failures. Satisfactory facial contour and favorable symmetry were achieved with minimal donor-site morbidity, complications, recurrence and little resorption in surgical reconstruction of hemifacial atrophy during our follow-up period.

Conclusions

Our results suggested that vascularised serratus anterior muscle flap transfer combined with simultaneous nerve anastomosis is a reliable and effective treatment of choice that offers satisfactory results in the surgical correction of facial atrophy associated with Parry–Romberg syndrome.     

Perforator Peroneal Artery Flap for Tongue Reconstruction

Introduction

Reconstruction has evolved long way from primary closure to flaps. As time evolved, better understanding of vascularity of flap has led to the development of innovative reconstructive techniques. These flaps can be raised from various parts of the body for reconstruction and have shown least donor site morbidity. We use one such peroneal artery perforator flap for tongue reconstruction with advantage of thin pliable flap, minimal donor site morbidity and hidden scar.

Materials and Methods

Our patient 57yrs old lady underwent wide local excision with selective neck dissection. Perforators are marked about 10 and 15 cm inferiorly from the fibular head using hand held Doppler. Leg is positioned in such a way to give better exposure during dissection of the flap and flap is harvested under a tourniquet with pressure kept 350 mm Hg. The perforator is kept at the eccentric location, so as to gain length of the pedicle. Skin incison is placed over the peroneal muscle and deepened unto the deep facia, then the dissection is continued over the muscle and the perforator arising from the lateral septum. The proximal perforator about 10 cm from the fibular head is a constant perforator and bigger one, which is traced up to the peroneal vessel. We could get a 6 cm of pedicle length. Finally the flap is islanded on this perforator and the pedicle is ligated and flap harvested. Anastamosis was done to the ipsilateral side to facial vessels. The donor site is closed primarily and in the upper half one can harvest 5 cm width flap without requiring a skin graft along with a length of 8 to 12 cm.

Discussion

Various local and free flap has been used for reconstruction of partial tongue defects with its obvious donor site problems, like less pliable skin and not so adequate tissue from local flaps and sacrificing a important artery as in radial forearm flap serves as the work horse in reconstruction of partial tongue defects, Concept of super microsurgery was popularized by Japanese in 1980s and the concept of angiosome proposed by Taylor paved the way for development of new flaps. True perforator flaps are those where the source vessel is left undisturbed and overlying skin flap is raised. Yoshimura proposed cutaneous flap could be raised from peroneal artery (Br J Plast Surg 42:715–718, 1989). Wolff et al. (Plast Reconstr Surg 113:107–113, 2004) first used perforator based peroneal artery flap for oral reconstruction. Location of perforators vary, hence pre operative localisation can be done by ultrasound doppler, CT angio or MR angiography. Disadvantages over radial flap include varying anatomic location of perforators, need for imaging and difficult dissection of delicate vessels through muscles and hence a learning curve. Our patient had an arterial thrombus within few hours post-operatively which was successfully salvaged with immediate re-exploration and re-anastomosis of artery. Post-operative healing was uneventful and donor site was closed primarily without the need for graft.

Conclusions

Perforator peroneal flap serves as a useful armamentarium for reconstruction of moderate size defects of tongue, buccal mucosa and floor of mouth with advantages of thin pliable flap, minimal donor site morbidity and hidden scar.

     

Bilateral interdigitated Pacman flap for round and oval facial defects

Background

Skin texture and color are important considerations during the reconstruction of facial defects, and anatomical borders should be preserved. Therefore, a local flap is a better option. In these cases, the authors repaired facial defects using a bilateral interdigitated VY flap.

Utility of superiorly based platysma myocutaneous flap for reconstruction of intraoral surgical defects: our experience

Purpose

Various surgical modalities have been advocated for the soft tissue reconstruction of oral cavity with variable results. This prospective study evaluates the utility of platysma myocutaneous flap (PMF) in the reconstruction of surgical defects followed by treatment of oral submucous fibrosis (OSMF) and oral squamous cell carcinoma (OSCC) in terms of healing and functional outcomes.

Methods

In this prospective study, 47 patients with OSMF and 15 of OSCC were evaluated and selected for PMF reconstruction. OSCC was selected under T₁N₀M₀ category only. Patients were operated under general anaesthesia followed by PMF grafting. In OSCC, ipsilateral and for OSMF, bilateral PMF was used.

Results

In 47 patients treated for OSMF, 46 were male and 1 female while 15 cases of OSCC, 10 were male and 5 females aged between 18 and 44 years. Intraoperative mouth opening was achieved up to 48 mm in OSMF followed by 42.5 mm postoperatively after 2 years. However, uneventful healing and acceptable scar on cervical region was noted in all the cases including OSCC. In OSMF, three cases of dehiscence, four partial necrosis at end of flap and in OSCC one case shows skin loss at flap and two partial necrosis at tip of flap and extraoral localised abscess at ipsilateral donor site in one case was noted. An uneventful healing, anatomical form and functional results were restored with acceptable scarring at donor site without any evidence of difficulty in neck movements were observed.

Conclusion

The PMF is simple, versatile and could be valued as a reconstructive alternative, with interesting visual qualities. It is a good therapeutic alternative tool for reconstruction of the buccal mucosa, especially for small- and medium-sized defects between 2 and 4 cm² of the oral cavity.

     

Effect of the suture technique on postoperative pain,swelling and trismus after removal of lower third molars: A randomized clinical trial

Background

To evaluate the intensity of pain, swelling and trismus after the removal of impacted lower third molars comparing two different suture techniques of the triangular flap: the complete suture of the distal incision and relieving incision and the partial suture with only one suture knot for closure of the corner of the flap and the closure of the distal incision, without suturing the relieving incision.

Material and Methods

A prospective, randomized, crossover clinical trial was conducted in 40 patients aged from 18 to 45 years who underwent surgical extraction of impacted lower third molars at the Department of Oral Surgery in the Odontological Hospital of the University of Barcelona during the year 2011. Patients were randomly divided in 2 groups. Two different techniques (hermetical closure and partial closure of the wound) were performed separated by a one month washout period in each patient. Postoperative pain, swelling and trismus were evaluated prior to the surgical procedure and also at 2 and 7 days post operatively.

Results

No statistically significant differences were observed for pain (p<0.06), trismus (p<0.71) and swelling (p<0.05) between the test and the control group. However, the values of the three parameters related to the test group were lower than those for the control group.

Conclusions

Partial closure of the flap without suturing the relieving incision after surgical extraction of lower third molars reduces operating time and it does not produce any postoperative complications compared with complete closure of the wound. Key words: Third molar, surgical flaps, suture techniques, postoperative pain, swelling, trismus.     

Development of a novel resection and cutting guide for mandibular reconstruction using free fibula flap

Introduction

The authors developed a semi-standardised resection and cutting guide for mandibular reconstruction with free fibula flap based on data of mandible sizes and angles.

Perforator flaps from the lower leg for intraoral reconstruction: Experience of 131 flaps

Background

During the last decade, perforator flaps have become popular for defect cover in the head and neck because they increase the choice of reconstructive possibilities and can lead to minimal donor site morbidity. In particular, the lower leg is considered a suitable option, as it provides thin and pliable skin for intraoral lining. Having gained experience with 131 flaps raised from four different donor sites at the lower leg, the aim of this paper is to evaluate success rates and patient satisfaction, but also difficulties and pitfalls during flap transfer.

Evaluation of Non-vascular Fibula Graft for Mandibular Reconstruction

Introduction

Functional and cosmetic defects in maxillofacial region are caused by various ailments like trauma, neoplasm, developmental, infections and iatrogenic causes. Reconstruction of these defects with free flaps remains the gold standard but demerits like need for surgical expertise and equipment, prolonged duration of surgery, compliance of the patient and increased cost are associated with microvascular reconstruction. Hence reconstruction with nonvascular bone grafts can be considered when defect is nonirradiated and <9 cm and with sufficient soft tissue cover available.

Purpose

To retrospectively evaluate clinical, radiological outcome and complications encountered with mandibular reconstruction using non vascular fibula graft.

Patients and Methods

This retrospective study included 7 patients who were treated in the Department of Oral and Maxillofacial Surgery, Narayana Dental College and Hospital, Nellore, AP between 2011 and 2013 with histologically proven benign osteolytic lesions of mandible that require a segmental mandibulectomy and primary reconstruction using autogenous non-vascularised fibular graft. The clinical case records of the patients and personal patient assessment forms (Quality of Life Assessment Forms) were analysed. They were recalled every 3rd, 6th and 9th month after surgery for evaluation of clinical, radiological outcome of the graft and complications occurring at recipient and donor sites.

Results

In all the 7 patients, the lower border continuity was maintained except in one where the graft was dislodged. Tongue movements in all the patients were unrestricted. Jaw movements were affected in cases of ramus defects with slight deviation to operated side and reduced mouth opening. Radiological observations revealed no significant changes in 3 months except for slight reduction in graft height. The radioopaque bridging with continuity of lower border of mandible was noticed in 6th month indicating the take of the graft. This was achieved in every case except in one where the graft was lost due to dislodged reconstruction plate. In 9th month the edges of the graft i.e., graft to native mandible junction showed more resorption (3 mm) especially where there is >2 mm of gap. Whereas increase in height of graft in other areas especially in graft to graft junction was seen. Significant graft resorption was seen in two cases. There were no major complications associated with the donor site.

Conclusion

Avascular fibula graft although a second choice to vascularised fibula, is a favourable option for mandible defects of 6–10 cm under optimum conditions especially in developing countries where financial and/or surgical resources are limited. An attempt for primary reconstruction with this is never futile as it prevents aesthetic deformity even in the event of failure and thus makes secondary reconstruction easy. However in order to confirm the results a prospective study with large scale of patients is necessary.

Electronic supplementary material

The online version of this article (doi:10.1007/s12663-014-0657-1) contains supplementary material, which is available to authorized users.     

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目的探讨游离皮瓣在全下唇及颏部大范围缺损修复重建中的应用价值及临床效果。方法 2007年7月至2013年3月,对中国医科大学口腔医学院口腔颌面外科收治的12例下唇癌根治术后及2例外伤造成的全下唇及颏部缺损患者,应用前臂皮瓣和股前外侧皮瓣同期修复。术后随访6个月至3年,并对患者修复后下唇外观和功能进行评价。结果 14例皮瓣全部成活,成活率100%。术后随访下唇癌患者肿瘤未见复发,14例患者均可进行基本正常的语言交流;12例可进普食,2例进软食;1例流涎,均无小口畸形。下唇及颏部外观患者均能接受。结论应用游离皮瓣修复全下唇及颏部缺损,方法安全可靠且成功率较高,根据下唇及颏部缺损范围选择合适修复方式可获得较好的口腔功能和外观。     

A Protocol for Management of the Hairs Problem in Oral Cavity Reconstruction by Submental Flap

Background

Submental flap is a useful aid in maxillofacial reconstruction. For intraoral usage the hairs in male patients will create some problems.

Materials and Methods

In a retrospective study, patients in whom submental flap had been used for reconstruction of orofacial region between 2007 and 2013, in the Mashhad University, Ghaem Hospital, were included. The ways in which the problem of hairs was solved in male patients were evaluated.

Results

There were 42 patients in whom submental flap was used for orofacial reconstruction. Sixty percent were males. Three ways had been used for management of intraoral hairs: radiotherapy (9 patients), second surgery (2 patients) and flap de-epithelialization (13 patients).

Conclusion

Deepithelialized variant of submental flap is the best option when submental flap is used for oral cavity reconstruction in male patients. Flap thickness, age, race and postoperative radiotherapy can have strong influence on this strategy.