Restoration of the mandible by full-thickness calvarial bone flap.

Two patients with reconstruction of a massive mandibular defect with vascularized full-thickness calvarial bone flaps are reported. In Patient 1, the mandibular body developed osteomyelitis and once was replaced with a metallic prosthesis. The prosthesis later perforated the skin and was removed. Full-thickness calvarial bone flaps were elevated bilaterally to reconstruct the mandibular body. In Patient 2, the mandible was totally destroyed by invasion of squamous cell carcinoma. The lower one-half of the face was resected and replaced with a large island scalp flap with full-thickness calvarial bone.     

Reconstruction of Achilles tendon using vascularised fascia lata with free lateral thigh flap

A case of Achilles tendon reconstruction using free vascularised fascia lata joined to a lateral thigh flap is reported. This is a simple one-stage reconstruction and a sufficiently strong tendon can be obtained.     

Reconstruction of skull base and dura using rectus abdominis muscle combined with a vascularised fascial perforator flap.

The goal of reconstruction of the skull base is to repair dural defects with a watertight seal and separate it from the nasopharynx and the exterior environment with well vascularised tissue. This prevents cerebro-spinal fluid leakage and secondary contamination leading to the potentially life threatening complications of meningitis or extradural abscess. Following large composite resections, traditional techniques to repair the dura involve the use of an autologous fascial graft or a pericranial flap, whilst a regional pedicled or free muscle flap is used to close the dead space defect. We describe a technique performed in two cases, whereby a single flap, the rectus abdominis muscle free flap, can be used to provide vascularised reconstruction both of the dura and the skull base. The anterior rectus sheath, islanded on a single perforator vessel, is used as a vascularised layer to reconstruct dura, whilst the supporting rectus abdominis muscle provides bulk to obliterate dead space. We show that this flap is suitable for reconstruction even in the presence of chronic infection. Advantages of a vascularised reconstruction are the rapid healing of the wound, even after radiotherapy, the delivery of systemic antibiotics to the site of the operation, and that it may allow early postoperative radiotherapy to be planned.     

新型三维钛网在眶底缺损重建整形手术中的应用

目的:介绍三维钛网在眶底缺损整复中的应用.方法:对4例因上颌骨鳞癌行上颌骨全切或扩大切除的患者以三维钛网行眶底及眶下缘的重建,评价术后眶部外形及眼的功能.结果:4例手术均获得满意效果,眶部外形恢复好,眶下区无明显塌陷,眼球运动好,无复视、感染等并发症.结论:采用新型三维钛网重建上颌骨肿瘤术后眶底及眶下缘缺损畸形能获得满意的眶部外形;防止术后复视;利于术后观察和复诊;术式简单、创伤小.三维钛网具有易成形、可塑性强、组织相容性好等特点.是理想的眶底重建整复材料,值得在临床推广.     

Cranioplasty with autogenous autoclaved calvarial bone flap in the cases of tumoural invasion

Summary When a bone flap is raised in the course of a craniotomy, the ideal is to replace it at the end of the procedure. When it is invaded by tumoural cells, it cannot be replaced due to the risk of tumoural recurrence. In these cases we have autoclaved the bone flap to be able to replace it with no fear of tumoural recurrence.Between October 1989 and October 1995 sixty-two patients required autoclaving of the bone flap in the course of a craniotomy due to tumoural invasion (thirty-five meningiomas, sixteen bone tumours, five metastases, and eight scalp tumours).The infiltrated bone flaps were removed, cleaned, autoclaved for 20 minutes at 134 °C and 1 kg/cm² and re-implanted.Patients were followed-up for 10 to 58 months (average 41 months). At every follow-up visit skull x-ray studies, clinical examination, and photographs were done. When needed a CT scan was performed to assess the thickness of the bone flap.On follow-up roentgenograms partial resorption was observed in twelve cases (19.3%). CT scan studies showed loss of thickness in another thirty-five cases (56.4%). Meanwhile the external aspect remained unchanged.In six cases (3.2%) biopsies of the bone flaps were taken at a second surgical procedure. They showed newly formed bone partly re-populated by osteocytes but retaining areas of sequestered bone.We conclude that autoclaved bone, if replaced with direct contact with living bone, it is gradually repopulated with osteocytes. Cranial vault autoclaved autologous bone flap is a good alternative when the original bone flap is invaded but not destroyed by tumoural cells.     

Reconstruction of the orbital region with the “blepharoplasty flap”

A modified technique of unipedicled orbicularis oculi myocutaneous flap raised along an upper or lower blepharoplasty incision line for reconstruction of the orbital region is described. This procedure provides excellent aesthetic improvement in older patients with a standard blepharoplasty being performed on the other eyelid.     

Reconstruction of the anophthalmic orbit by orbital osteotomy and free flap transfer.

It is challenging to perform an adequate reconstruction of the post enucleation irradiated orbit of patients with rentinoblastoma. Rebuilding of the orbital structure, reconstruction of the eye socket and restoration of periorbital volume are required. We reviewed 12 patients with hypoplastic orbital deformities, who have undergone orbital osteotomy and free flap transfer. Reconstruction of the orbital cavity was achieved using 'C' osteotomy of the lateral portion of the orbit in mild and moderate cases or transverse 'U' osteotomy of lateral wall, roof, and floor by intra-cranial approach in severe cases. Socket reconstruction and periorbital volume restoration was achieved using dorsalis pedis free flap transfer. From our experience the combination of orbital osteotomy and free flap transfer could meet the multi-requirements for the anophthalmic orbital reconstruction, including both orbital bony enlargement and soft tissue restoration.     

The pedicled vascularised scapular bone flap for proximal humerus reconstruction and short humeral stump lengthening.

The vascularised scapular bone free flap is popular in mandible reconstruction, but it is less commonly used as a pedicled flap to reconstruct the upper humerus. We analysed our experience with pedicled scapular crest flaps in humerus reconstruction and compared our results with cases reported in the literature. We considered the age at surgery, the time elapsed before reconstruction, the time required to obtain solid bony union, the operative indication, the osteosynthesis procedure used and whether circumflex scapular vessels or angular vessels were used. There were eight patients (seven men and one woman, mean age=33): four humerus stump lengthenings, two upper-third humerus bone and soft tissue defects and two multioperated established humerus non-unions. Flaps were pedicled either on circumflex scapular vessels (three) or angular vessels (five). The mean size of the scapular bone used was 9.4 cm (range 7-11 cm). We associated a covering flap for seven patients. All the flaps survived and bone healed in a 3.75 month mean delay (range three to six months), and there was one accidental secondary fracture one year after reconstruction. For a vascularised reconstruction of the upper humerus, the pedicled scapular bone flap is a valuable option especially if a composite reconstruction is needed. For short humerus stump lengthening, this flap seems to provide a very satisfactory solution.     

岛状皮瓣一期修复眼睑分裂痣的设计与技巧

目的 探讨应用邻位及远位岛状皮瓣一期修复眼睑分裂痣的设计与技巧.方法 切除眼睑分裂痣上、下睑病变后,根据缺损的部位、形态及面积,选择应用眼轮匝肌蒂岛状皮瓣、耳后SMAS蒂岛状皮瓣或逆行颞浅动脉岛状皮瓣一期修复上、下睑皮肤缺损,供区均直接缝合.结果 2003年以来,共收治患者16例,其中应用眼轮匝肌肌皮瓣10例,耳后SMAS筋膜蒂皮瓣3例及逆行颞浅动脉岛状皮瓣3例.切除痣体的最大面积上睑为2.5 cm ×2.0 cm,下睑为4.0 cm×3.0 cm.1例耳后SMAS筋膜蒂皮瓣及1例逆行颞浅动脉岛状皮瓣术后出现皮瓣远端静脉回流障碍、部分表皮坏死,经换药后自行愈合,其余14例皮瓣全部成活良好.结论 根据病变的部位、形态和面积等选择合适的邻位或远位岛状皮瓣修复眼睑分裂痣切除术后皮肤缺损,效果满意,且供区隐蔽、无继发畸形.     

Reconstruction of post-traumatic long bone defect with vascularised free fibula: A series of 28 cases

Introduction:

The severe long bone defects usually follow high-energy trauma and are often associated with a significant soft-tissue injury. The goal of management of these open long bone defects is to provide stable fixation with maintenance of limb length and soft-tissue coverage. The purpose of this article is to present the clinic-radiological outcome, complications and treatment of post-traumatic long bone defect with vascularised fibula transfer.

Materials and Methods:

Retrospective records of 28 patients were analysed who presented with post-traumatic long bone defects and in whom reconstruction with vascularised free fibula was done. Demographic data were recorded and clinical and radiological assessment was done.

Results:

Out of 28 patients in whom vascularised free fibula transfer was carried out three flaps were lost while non-union occur in three patients. Three patients developed a stress fracture of transferred free fibula in the post-operative period. Few of the patients experienced some problems in the donor leg; however, all of them improved in subsequent follow-up.

Discussion:

It is clearly evident from this study that timing of surgery plays an important role in the micro-vascular reconstruction in trauma cases. All the complication like flap loss, non-union or delayed union occur in patients in whom reconstruction was delayed.

Conclusion:

The free vascularised fibula graft is a viable method for the reconstruction of skeletal defects of more than 6 cm, especially in cases of scarred and avascular recipient sites or in patients with combined bone and soft-tissue defects. Results are best when the reconstruction is done within 1 week of trauma.KEY WORDS: Long bone defect, post-traumatic, vascularised free fibula     

Reconstruction of the sella floor using vascularized pedicled mucosal flap

The efficacy and uses of a vascularized pedicled sphenoid sinus mucosal flap in reconstruction of the sella floor after trans-sphenoidal surgery for sellar lesions is studied. The method was successfully performed in 31 cases over a period of 7 years. The ease of harvesting, high vascularity and local availability of the flap are the principal advantages.     

颅眶截骨前移结合游离皮瓣整复放疗后眶畸形

目的探讨经颅眶截骨前移结合足背游离皮瓣串联胫前筋膜瓣整复放疗后眼眶凹陷及结膜囊狭窄畸形的临床疗效。方法自2004年以来,共收治5例视网膜母细胞瘤手术及放疗后眼眶及结膜囊严重凹陷畸形,应用冠状切口经颅眶前部截骨前移,钛钉钛板坚强固定后,复原头皮瓣,再在狭窄的结膜囊中部切开向四周分离,根据结膜囊缺损的大小及颞部的凹陷范围设计足背游离皮瓣串联胫前筋膜瓣,分别移植于结膜囊及颞部凹陷部位,血管蒂与颞浅动静脉或面动脉及颈外静脉吻合。结果皮瓣全部成活,经3-6个月随访,眶外形满意,颞部凹陷明显改善。结膜囊内义眼模固定3个月后3例配戴义眼外形良好;2例较差,其中1例眼窝凹陷仍较明显,二期行义眼座置入术,另1例结膜囊挛缩,术后下穹隆过浅,二期行自体硬腭黏膜移植。上述2例经二期修整后1个月安戴义眼,外形也达到满意效果。足部供区4例愈合良好,1例延期愈合。结论经颅眶截骨前移结合游离足背皮瓣串联胫前筋膜瓣转移整复放疗后眼眶及颞区凹陷及结膜囊狭窄畸形具有可行性,一期手术即可完成。