Primary insertion of osseointegrated dental implants into fibula osteoseptocutaneous free flap for mandible reconstruction

Twelve patients with segmental mandibular defects were reconstructed with fibula osteoseptocutaneous flaps and simultaneous placement of osseointegrated implants. Decision to perform this procedure was based on the facts that all patients had benign diseases, did not require postoperative radiotherapy, were in good general and oral conditions, and were psychologically motivated. A total of 34 fixtures was inserted in the first stage. Eight patients underwent second stage surgery, which consisted of connection of the implant abutments to the fixtures and the use of palatal mucosal grafts around the implants. Final dental prostheses were fixed 1 month later in seven patients, at this time. All flaps survived after surgery, and no implant failure was observed after a mean follow-up period of 25 months. Only one fixture was not used during the subsequent stage and was left as a sleeper. Fixed dental prostheses were used in five patients and removable overlay prostheses in the other two. Chewing function was recovered between 4 and 6 weeks after the start using the definitive dental prosthesis. In contrast to previous results, we conclude that excellent results can be achieved when this combined procedure is used in carefully selected patients. In addition, it is confirmed that the fibula osteoseptocutaneous flap is a versatile, reliable composite tissue that facilitates primary placement of osseointegrated dental implants during mandible reconstruction, thus allowing full oral rehabilitation in a shorter period of time.     

Fibrous dysplasia of the maxillofacial bones. Clinical considerations

OBJECTIVE: After a wide survey of the literature, the results of a clinical-statistic study carried out on twelve cases of maxillo-facial bones fibrous dysplasia, diagnosed and treated at the Oral and Maxillo-Facial Surgery Department of the II University of Naples, are reported. EXPERIMENTAL ASSAY: Retrospective study. MATERIALS AND METHODS: All the patients examined showed fibro-osseus lesions involving the mandible in eight cases, the maxilla in three cases and the frontal bone in one case. Seven patients were females and five males, aged between nine and seventy-two years. The surgical treatment was carried out on eleven patients: four cases were treated by complete surgical excision of the fibro-osseous lesions and seven cases by a conservative removal of the portion of the lesion contributing to the bone deformity. RESULTS AND CONCLUSIONS: All cases examined involved maxillo-facial skeleton structures as a sole localization, confirming that the polyostotic forms are more infrequent than the maxillary monostotic ones. The distribution of the cases according to age classes and lesion localization showed a higher incidence of fibrous dysplasia in the third decade of life and a clear predilection for the mandible. The observation of active lesions in old age shows that the disease may evolve also after the growth. The cases treated by radical excision of the lesions have not been followed from relapse; on the contrary three of the seven cases treated by conservative excision relapsed after a few years.     

Overview of quality measurement and improvement

BACKGROUND: Oro-mandibular reconstruction using vascularized bone-containing free-flaps can be accomplished with flap survival rates in the range of 95%. Primary reconstruction offers the best opportunity to achieve the optimal aesthetic and functional results. Patients presenting for secondary oro-mandibular reconstruction have a unique set of problems; these include the presence of soft tissue contracture displacing the mandibular segments in malposition and soft tissue deficiencies, that makes surgical correction more difficult and potentially more hazardous. Vascularized bone-containing free-flaps are indicated in secondary oro-mandibular reconstruction where both hard and soft tissues replacement is needed or when the recipient bed is unfavourable due to previous surgery and/or radiation. METHODS: Authors presents personal experience in ten cases of secondary oro-mandibular reconstruction treated at Maxillofacial Department of Parma from September 1995 to September 1996 with secondary oro-mandibular reconstruction using bone containing free flaps. Two different donor sites were used to harvest bone-containing free flaps: iliac crest in 2 cases and fibula in the others. In 4 cases the flap was only osseous while in the other 6 cases it was osteocutaneous. RESULTS: All flaps were transplanted successfully; in 1 case necrosis of the skin component of the flap was observed. CONCLUSIONS: The introduction of vascularized bone containing free flaps transferred from distant sites by microvascular techniques has changed mandibular reconstruction. Vascularized bone transferred into tissue beds compromised by salivary contamination and previous irradiation and the rational use of the soft tissutal components of the flap permit also the restoration of articulation, deglutition and mastication with quality of life better than non-vascularized alternatives.     

Reconstruction of compound tibial and soft tissue loss using a traction histogenesis technique

We used simultaneous bone and soft tissue transport for reconstruction of large compound tissue loss in the lower leg. We report the results and complications of a 12-patient series. The average age of the patients was 31.2 years (range 20 to 48 years). Seven patients had grade IIIB open tibial fractures, three had complications after grade II or IIIA, and two had an en-bloc resection of bone, muscle, and skin for a malignant bone tumor. Arteriography was routinely performed, and demonstrated at least one patent tibial artery. Every patient had normal sensibility of the sole. The first stage of the reconstruction was an aggressive excision of the all necrotic skin, muscle, and bone. The Ilizarov external fixator was applied and wires were secured under a tension of 100 kg, using a dynamometric tensioner. Cutaneous tissue loss was not replaced in 10 patients, when the bone was not exposed. A medial gastrocnemius flap was performed in two patients and lengthened with the bone. Corticotomy was performed 15 days after the first stage with careful respect for the periosteum. Distraction was initiated 15 days after the corticotomy. The average bone defect was 12.5 cm after initial excision. An average of 9 operative procedures and 18 months of treatment were required before bony union. The mean duration of bone transport was 6.5 months, and the mean duration of external fixation was 12 months. The final functional results were fair and only two patients returned to work. One patient had a below-knee amputation after 10 months of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap

This is the first series of total penile reconstructions with the free sensate osteocutaneous fibula flap. The main advantages of this flap lie in its intrinsic rigidity, its superior donor-site location, and its long vascular pedicle. The fibula flap provides better bone volume than does the radial forearm flap, which commonly results in a floppy phallus in the absence of bone. Penile prostheses in other flaps have enjoyed limited success. Forearm donor-site complications can be avoided. The donor site in the lower extremity can be readily covered with a sock. The vascular pedicle of the fibula flap is of sufficient length to allow end-to-side anastomosis of the flap to the femoral artery. Interpositional vein grafts are unnecessary, and dissection of the inferior epigastric artery system to serve as a donor artery may be avoided. The appearance of the neophallus is excellent. We present only the first four continuous cases of the six we have performed because sufficient follow-up data are available only for these four. The advantages and disadvantages of fibula and forearm donor sites, the long-term fate of the bony component, the importance of sensation, and the vascularized urethral reconstruction are discussed. High patient satisfaction and the advantages of the technique convince us that the fibula osteocutaneous flap is superior for total penile reconstruction.     

Obliterative vesicourethral strictures following radical prostatectomy for prostate cancer: reconstructive armamentarium

PURPOSE: We report the reconstructive techniques used to correct obliterative vesicourethral strictures related to prostate cancer surgery. MATERIALS AND METHODS: Four men with anastomotic obliteration after radical prostatectomy underwent primary excision with end-to-end anastomosis, penile fasciocutaneous flap, free-graft urethroplasty with rectus muscle flap or anterior bladder tube with omental pedicle flap procedure. RESULTS: At mean followup of 33.8 months all patients had urethral patency but none was continent. CONCLUSIONS: Single stage reconstruction of the obliterated vesicourethral anastomosis after prostatectomy successfully restored urethral patency. No technique was applicable in all cases. Sphincteric function is likely to be compromised after the primary procedure, resulting in incontinence after successful urethral reconstruction. Subsequent artificial sphincter placement appears to be safe and helpful in restoring continence.     

Reconstruction of the long bones of the legs in children via free vascularized transplant of the fibula after resection for sarcoma

Nineteen children were operated on between 1985 and 1994. All the patients presented a sarcoma of long bones: osteosarcoma: 12 and Ewing's sarcoma: 7. They were operated on: resection and reconstruction of the long bones with a free vascularised fibula. Pre and post-operative chemotherapy was used. The average follow-up was 3 years (between 10 years and 1 year). The mean bone defect was 20 cm (between 32 and 11 cm). Boys were more frequently encountered [12]. Average age was 9.5 years. The pathological bone was: femur: 14, tibia: 4, humerus 1. The approach needs usually two incisions for femoral bone: the internal incision allows us to prepare the recipient vessels: deep femoral vessels in 11 cases. In 18 cases, union occurred in less than 14 months. One case of pseudarthrosis occurred. Immediate follow-up was simple in 17 cases. Infection was observed in 2 cases. Secondly, the most frequent complications were: fracture of the fibula: 6 cases, vicious cal: 2 cases; delayed union: 6 cases; stiffness: 2 cases. One patient died later from pulmonary metastasis. Solid osteosynthesis of the member and of the free vascularised fibula permit to shorten these delays. Success depends on two criteria: the graft thickening of the fibula and union of the fibula at both ends. The micro vascular anastomoses must be excellent. Twelve children had bone union with only one operation. In the 6 cases of delayed union, secondary bone grafts give consolidation. The comparison of this technique with standard treatment showed an evident superiority of the free vascularised fibula transplant in extensive defects of bone. The fibula is a life bone which permits rapid union with a short hospitalization, a quick recovery and an early return to school. Free vascularised fibula permit to ameliorate the quality of survival.     

A historical review of mental health services in Hong Kong (1841 to 1995)

OBJECTIVE: To review the experience of 1 microvascular surgeon during an 11-year period in performing 210 vascularized bone-containing free flaps for oromandibular reconstruction. DESIGN: Retrospective medical records review of patients who underwent primary and secondary oromandibular reconstruction with the use of vascularized bone free flaps. SETTING: Academic medical center. PATIENTS: A total of 201 patients underwent 210 composite free-flap reconstructions of the mandible for various disorders and with a range of bony and soft tissue defects. INTERVENTION: All patients underwent the microvascular transfer of vascularized bone flaps from the ilium, fibula, or scapula. In selected cases, 2 simultaneous free flaps were transferred to achieve an optimal bone and soft tissue reconstruction. Endosteal dental implants were used in 81 patients, with a total of 360 fixtures placed during these 11 years. MAIN OUTCOME MEASURES: The success of microvascular free tissue transfer, dental implant extrusion, and short- and long-term complications at the recipient and donor sites. RESULTS: Of the 210 mandibular reconstructions that were performed, 202 were successful in reestablishing mandibular continuity. Reexploration for vascular-related complications was done in 16 patients, 8 of whom were successfully treated, yielding an overall success rate of 96%. The overall success rate for endosteal dental implants was 92%. The implant success rate was 86% when the bone in which the fixtures were placed was irradiated postoperatively. The success rate was 64% in the 14 fixtures that were placed into previously irradiated bone. CONCLUSIONS: The success of the use of vascularized bone free flaps in restoring continuity to the mandible is clearly demonstrated in this series. There was an acceptable incidence of donor- and recipient-site complications that resulted in minimal long-term morbidity. The careful selection of a donor site(s) for oromandibular reconstruction allows for an optimal restoration of bony and soft tissue defects. Dental implants can be safely used in oromandibular reconstruction with a high level of success. Placing these implants during the initial surgery shortens the duration for achieving dental rehabilitation and enhances the success of the implants when postoperative radiotherapy is administered.     

Reconstruction of total maxillectomy defects with preservation of the orbital contents

Reconstruction after total maxillectomy with preservation of the orbital contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. Reconstruction of such defects should (1) provide support to the orbital contents, (2) obliterate any communication between the orbit and nasopharynx, (3) reconstruct the palatal surface, and (4) achieve facial symmetry and a good aesthetic result. We report our experience in performing reconstructive surgery on 14 patients who had a total maxillectomy and preservation of the orbital contents using nonvascularized bone grafts for reconstruction of the orbital floor and maxilla, in conjunction with a soft-tissue free flap or pedicled muscle flap. The orbital floor was reconstructed using split ribs in six cases (42.9 percent), split calvaria in six cases (42.9 percent), and iliac crest graft in two cases (14.3 percent). A myocutaneous rectus abdominis free flap was used for soft-tissue reconstruction and resurfacing of the palatal mucosa in twelve patients (85.7 percent), and a temporalis muscle transposition was used in two elderly patients (14.3 percent). One patient died 2 days after surgery. Mean follow-up and aesthetic and functional results were assessed in the remaining 13 patients a minimum of 6 months postoperatively. In 9 of these 13 patients (69.2 percent), postoperative radiotherapy was administered. No reexplorations or free flap failures were observed. One rectus flap developed partial necrosis of the skin island intraorally without affecting the final result. All patients had adequate functional vision. One patient had a mild vertical dystopia; there were no cases of enophthalmos. Ectropion was the most common undesirable result and was present in 10 of 13 cases (76.9 percent). It was graded as mild in four cases (40.0 percent), moderate in four cases (40.0 percent), and severe in the remaining two cases (20.0 percent). Speech was considered normal in six cases (46.2 percent), near normal in six cases (46.2 percent), and intelligible in one case (7.7 percent). Chewing function was considered good (soft to unrestricted diet) in all cases except for one patient who was only able to eat a pureed diet. Aesthetic results after immediate reconstruction were considered good in nine cases (69.2 percent) and fair in four cases (30.8 percent). Primary reconstruction of total maxillectomy defects with orbital content preservation remains a complex problem without a perfect solution. The combination of nonvascularized bone grafts for orbital/maxillary reconstruction with a soft-tissue free flap is a safe, reliable, and effective method of maximizing postoperative functional and aesthetic results.     

Repair of bone defect of distal end of radius and its functional restoration

The treatment of the bone defect of the distal part of the radius included repair of the bone defect and restoration of the function of the wrist joint. Since 1979, three operative methods were used to treat 13 cases, and they were grafting of the vascularized fibula by anastomrsis fibular vessels, grafting of upper part of fibular with lateral inferior genicular artery and grafting vascularized scapula flap. Follow-up had been carried out from 1 to 10 years. The result was satisfactory. The discussion included the repair of the defect of the middle or distal part of the radius, the operative methods, main attentions and indications. It was considered that it should be based on the length of bone defect while the operative method was considered.     

Retrograde intra-arterial infusion of prostaglandin E1 and heparin for the no-reflow phenomenon after oromandibular reconstruction with a free fibular flap

The authors encountered a patient with a tumor of the floor of the mouth in whom the no-reflow phenomenon occurred after excision of the lesion and the mandible, followed by reconstruction using a free fibular flap. A catheter was inserted retrogradely from the point where the peroneal artery had been ligated at the time of flap preparation. Continuous intra-arterial infusion of prostaglandin E1 and heparin was performed, and the flap survived. This method salvaged free flaps subject to the no-reflow phenomenon.     

Electron paramagnetic resonance studies of cobalt-substituted angiotensin I-converting enzyme

The traditional treatment of high-flow vascular malformations consists of selective embolization, surgical removal, or a combination of both. Recurrence of the lesion and bleeding control are still the main problems, and the result of treatment is sometimes disappointing. We suggest treatment of these lesions with surgical ligation of the distal major feeding arteries followed by intravascular injection of a sclerosing agent (3% tetradecyl sulfate), and surgical excision and reconstruction when indicated. We have found this to be an effective treatment regimen. We present 14 cases of high-flow vascular malformations of the head and neck area treated with this approach, of which 4 cases developed skin necrosis. Three of these 4 cases of skin necrosis were later treated with skin grafting and, in 1 case, an upper arm skin tube flap was used for nasal tip reconstruction. Three cases underwent delayed reconstruction using tissue expanders. From a symptomatic and aesthetic point of view, preliminary satisfactory results were obtained. We feel that this approach is a good option for treating difficult, high-flow vascular malformations.     

Clinical morphology of pneumoconiosis]

Different methods of primary mandibular reconstruction carried out at the Tata Memorial Cancer Hospital range from the pectoralis major myocutaneous or osteomyocutaneous composite flap, which is the most frequently performed procedure, to a free vascularised composite tissue transfer with microvascular anastomosis, including, iliac crest free vascularised bone grafts or radial artery forearm flap free vascularised radius bone grafts, free vascularised fibular bone grafts and silastic mandibular implants. The clinical results of immediate mandibular reconstruction with a silastic mandibular implant (SMI) in 69 patients is presented. Out of the 69 cases, 2 patients died in the early post-operative period. Twenty (30%) SMI were retained for a period of 1 year to 5 years. Forty seven (70%) SMI were retained for a period of less than 1 year. These implants have been used in a variety of cases, with or without major flap reconstruction, where a skeletal support was indicated, especially after mandibular arch resection. The results of this series indicates the importance of these implants as a short term spacer, even in advanced, fungating lesions of head and neck cancer where the risk of infection, haematoma and salivary leak is very high. Bone replacements were undertaken at a later date in suitable cases. The effects of preoperative chemotherapy and radiotherapy on the retention of these implants has also been studied.     

Mandibular reconstruction using a microvascular method in the transplantation of a fibular flap

The best results in mandibular reconstruction are achieved by transplantation of vascularised bone. This transplant has an own blood supply therefore its surviving is not influenced by the non-sterile environment of the oral cavity and the insufficient blood supply of the operated area (caused by scar or radiation). A new promising method for reconstruction of a wide segmented defect of the mandible is vascularised fibular flap transplantation. Eight consecutive patients treated with fibular flap transplantation in 1993 and 1994 were reviewed. Osteo- and osteo-cutan flaps were used for reconstruction of the composite tissue defects. The authors report on the surgical technique and their first experiences. The authors consider the application of the fibular flap the most successful procedure of all types of reconstruction of segmented mandibular defect.     

Myocutaneous flap as reliable defect coverage in high grade pelvic decubitus ulcers. Classification, therapeutic concept and presentation of personal patient sample of 16 years

Infected pelvic pressure sores of Campbell stages IV-VII require soft tissue reconstruction, which means stable, multi-layered filling cover of the defect and reliable prophylaxis of relapse. Myocutaneous flaps meet these conditions well. Depending on the extent and the area of the sore, with predilection for the sacrum, the ischial tuberosity and the femoral trochanter, the gluteus maximus, biceps femoris and tensor fasciae latae muscles are most often used for myocutaneous flaps. Primary sutures, split skin grafts or local fasciocutaneous flaps are often sufficient treatment for smaller, superficial defects. Between 1981 and 1996, 133 patients (average age 50 years) with 212 pelvic pressure sores of all stages were treated in our clinic. After radical decubitus excision with pseudotumor technique and resection of the osseous prominences, one-stage reconstruction of solitary as well as multiple defects was performed with myocutaneous flaps in 135 cases. The postoperative general complication rate for all treatments was about 10-30%. With regard to the muscle flaps, one third healed without any problems, partial flap necrosis occurred in 6% and there was total loss of flap in 2% of all myocutaneous flaps. According to present knowledge, myocutaneous flaps seem to be the most reliable method for definitive covering of deep pelvic pressure sores, independent of the cause of the ulcer.     

Reconstruction of the jaw and oral cavity with free vascularized grafts

59 microvascular graft transfers performed in 50 patients in our department since 1985 have been studied retrospectively. The indications for microvascular reconstruction were sequelae after tumour surgery in 38 patients, gunshot injury in seven, chronic osteomyelitis of the mandible in three, complication after jaw fracture in one patient, and atrophy of the alveolar ridge also in one patient. Transplants from the iliac crest, fibula, radius, radial forearm skin and jejunum were used. Three transplants were lost because of arterial thrombosis, giving a success rate of 94.9%. Complications were registered in 19 cases, the largest group being wound infections. 21 of the 50 patients have been treated with dental implants for total rehabilitation of masticatory function. Transfer of free vascularized bone and soft tissue grafts has greatly improved the functional and cosmetic results obtained in reconstructive surgery of the orofacial region.     

Failure of hypertrophy in revascularised fibula grafts due to stress protection

Three cases of long bone reconstruction with vascularised fibula grafts are described. Hypertrophy of the graft did not occur after a follow-up of 3-5 years. Three different kinds of stress shielding appeared to prevent transformation of the graft.     

Autonomous thyroid adenoma, papillary thyroid carcinoma, and ectopic parathyroid adenoma in a patient with primary hyperparathyroidism and a nontoxic multinodular goiter

OBJECTIVE: To discuss the method for nipple-areola preserved mastectomy with one-stage breast reconstruction in cancer surgery. METHODS: Because of the merits of sufficient blood supply and plasticity of rectus abdominis musculocutaneous flap, we used one-stage breast reconstruction after modified radical mastectomy. The incision line was covered and the nipple-areola was preserved. The reconstructed breast was naturally in contour. RESULTS: 21 cases were treated from 1990 to 1995, and 18 of them received horizontal-rhombus shaped rectus abdominis musculocutaneous flaps and 3 longitudinal-rhombus flaps for breast reconstruction. Nipple-areola was preserved in 16 cases. Objective evaluation after operation showed that the excellent and satisfied rate reached to 90.5%; and subjective evaluation showed that the excellent and satisfied rate reached to 95.2%. Thirteen cases have been followed up for 3 years, and 9 for 5 years. Three-year survival rate was 100% (13/13), and 5-year 88.9% (8/9). CONCLUSION: The method is recommendable for the treatment of stage I-II breast cancer.     

Remnant-like particle cholesterol levels in patients with dysbetalipoproteinemia or coronary artery disease

Fibula osteocutaneous free tissue transfer to reconstruct the oromandibular complex is a widely recommended technique following oncologic resection. Preoperative determination of adequate perfusion to the donor extremity is necessary to assure lower extremity viability after flap harvest. Vascular variations and/or peripheral arterial occlusive disease (PAOD) may exist whereby sacrifice of peroneal vessels can cause ischemia to the lower leg and foot. Additionally, variability of cutaneous perforators can make the fibula skin paddle viability unpredictable. Color flow Doppler (CFD) is a reliable modality to preoperatively assess the lower extremity in fibula osteocutaneous free tissue transfer patients. Prospective CFD examination of 38 consecutive patients (76 legs) considered for fibula free flap reconstruction was performed. A standard protocol was designed to evaluate the lower extremity vasculature and identify cutaneous perforators with CFD. Findings were studied with respect to flap choice, operative findings, and reconstruction outcomes. Number of cutaneous perforators and their impact on skin paddle design were also recorded. Color flow Doppler's ability to image peroneal vessels as well as determine collateral and distal perfusion were effective. CFD accurately identified bilateral vascular anomalies in one patient (2.6%), and significant arterial disease in three patients (7.9%). Cutaneous perforators were also accurately mapped and confirmed intraoperatively in 31 patients. In several instances, the information provided by the CFD examination altered flap selection, 4/38 patients (10.5%), or skin paddle design, 5/32 patients (15.6%). Color flow Doppler allowed successful fibula transfer in all the free flap candidates with normal exams. It has the advantages of low cost and no morbidity. CFD allows for accurate mapping of fibula cutaneous perforators which facilitates skin paddle design. We recommended the use of preoperative CFD in all patients being considered for fibular free flap surgery.     

Primary pterygium surgery using the inferior conjunctival transposition flap

The authors investigated a surgical method for primary pterygium without adjunctive therapy and devised a technique called the inferior conjunctival transposition flap. The procedure was performed by making a flap of the inferior conjunctiva after excision of the pterygium, and transpositioning it to make a covering for the bare sclera and donor site and a barrier to pterygium tissue. This method has been used on 54 eyes of 50 patients (mean age 47 years, range 18 to 69 years) with primary pterygium. All of these patients were treated by one surgeon. During a follow-up period of 12 to 26 months (mean 20 months), the pterygium recurred in 3 (5.6%) of the 54 eyes. In all other cases good anatomic and cosmetic results were achieved without any serious complications. The authors concluded that the inferior conjunctival transposition flap is an encouraging technique for the treatment of primary pterygium.