Versatility of temporalis myofascial flap in maxillofacial reconstruction--analysis of 30 cases

Advances in Tissue Engineering of the Temporomandibular Joint Disc: An Overview of Current Status and Future Directions

Advances in tissue engineering have progressed to potentially offer a solution to temporomandibular joint disc (TMJ) disorders not amenable to conservative therapies. Conclusive treatment options for patients with end-stage disc disorders requires discectomy and reconstruction of the articular disc with various materials. Tissue engineering TMJ disc is a promising alternative to the limited and sometimes inadequate clinical options in the management of such disorders. However, tissue engineering is far from completion for the TMJ disc regeneration. This review briefly discusses the properties of native disc, the mechanism by which TMJ disorders manifest, and how a tissue engineered disc could assuage the problems inherent in the management of such disorders. Furthermore, the review addresses and provides updates to relevant themes of tissue engineering in regards to the TMJ disc, namely, the scaffolds, cells and biomarkers, hurdles in tissue engineering of the disc, and its application in translation to the clinical practice and future directions.

Temporal Flaps in Head and Neck Reconstructive Surgery: A Systematic Review of Surgical Techniques

The temporal region is a great source of vascularized flap, providing extremely variable and versatile options for reconstruction in head and neck surgery. Its popularity has led to the conception of a large variety of different flaps, in terms of contents and design. Temporal flaps are highly pliable and flexible, providing adequate bulk to obliterate dead spaces and improving engraftment, thus facilitating wound healing. The need to access different anatomical compartments, often far from the original flap anatomical site, has led surgeons to develop techniques to enlarge pedicles and bulk, by reverting and splitting flaps' contents, as well as through partial mandibular and zygomatic resection. To further increase versatility, a multilayered combination of different regional tissues and muscle segmentation techniques has been described. Historically, each flap has had its own proponents and opponents, but a pointy review systematizing techniques and comparatively analyzing different flaps was still missing in the literature. The field of use of some flaps has been progressively limited by the increasing relevance of free tissue transfers, which nowadays may provide success rates up to 95% with a constrained morbidity, thus offering an effective alternative, when available. Given the wide range of reconstructive strategies based on temporal flaps, there is still a great debate on nomenclature and surgical techniques. The present study systematizes the topic, classifying regional flaps according to contents and indications. Harvesting techniques are described stepwise and schematically illustrated, thus offering an indispensable tool to the armamentarium of reconstructive surgeons.

The branching pattern of the middle temporal artery and the relation with the temporal fascia

PURPOSE

Although the middle temporal artery is used for maxillofacial and otological flap surgeries, the anatomical knowledge of the artery is insufficient to corroborate its usage. This study has investigated the interrelationship between the artery and the temporal fascia to enhance its availability.

METHODS

The middle temporal artery was dissected in ten cadavers, and its spatial relations with the temporal fascia and muscle and the adjacent structures were examined.

RESULTS

The middle temporal artery arose behind the mandibular head or neck and in front of the external acoustic meatus. It penetrated the temporal fascia external to the junction between the zygomatic process and the supramastoid crest. The artery gave off a thin branch in the space between the superficial and the deep layers of the fascia and is divided into two branches piercing the deep layer to supply the temporalis. The anterior branch anastomosed with the deep temporal artery; furthermore, it gave off the slender ramus coursing on the base of the zygomatic process to communicate with the masseteric artery. The posterior branch passed along the supramastoid crest, gave off a slender ramus and ascended in the groove of the temporal bone.

CONCLUSION

The branching pattern of the middle temporal artery and its positions relative to the temporal fascia and the landmark structures are helpful in identifying the artery, designing favourable flaps and avoiding unfavourable bleeding during surgery. They are also beneficial in developing the clinical usage of the artery.

Functional and aesthetic outcomes of pedicled temporalis muscle flap for mesostructure reconstruction

The purpose of this work is to analyse the soundness of the Temporalis Muscle Flap as a safe and reliable flap to restore the aesthetic and functions of the facial mesostructure after its partial resection. Subjects were selected retrospectively and were invited to come to our outpatient clinic. Here, subjects completed a clinical evaluation in which the medical examiners evaluated the aesthetic outcome, the phonation, the ocular motility and the swallowing. Twenty-two subjects were enrolled in this study and completed the clinical evaluation. The mean value of the score obtained for the aesthetic outcome was 2.91 ± 0.92, slightly less than good. The VHI-30 questionnaire for voice evaluation obtained a mean score of 22.5 ± 11.5, pointing out minor voice problems. The mean value of the P-score evaluated during Fiberoptic Endoscopic Evaluation of Swallowing was 4.64 ± 0.95, highlighting the near absence of endoscopic signs of dysphagia. On the evaluation of ocular function, only one subject showed an inferior displacement of his right eyeball without vertical diplopia. The Temporalis Muscle Flap is a safe and reliable flap that can be used to reconstruct numerous surgical defects of the maxilla, giving an excellent recovery of physical aspect, phonation, and swallowing.

A Review of and Algorithmic Approach to Soft Palate Reconstruction

Importance

The soft palate contributes to deglutition, articulation, and respiration. Current reconstructive techniques focus on restoration of both form and function. The unique challenges of soft palate reconstruction include maintenance of complex upper aerodigestive tract function, with minimal local or donor site morbidity.

Objective

To review the literature on soft palate reconstruction and present an algorithm on how to approach soft palate defects based on this review.

Evidence Review

A review of the literature for articles reporting studies on and that described concepts related to soft palate reconstruction was conducted in March 2017. In all, 1804 candidate titles and abstracts were independently reviewed. English-language articles that discussed acquired soft palate defect reconstruction were included. Non-English language studies without available translations, studies on primary soft palate defect reconstruction (ie, cleft palate repair) and primary cleft palate repair, studies in which the soft palate was not the focus of the article, and studies involving animals were excluded.

Findings

The following observations were made from the review of 92 included articles. Soft palate anatomy is a complex interplay of multiple structures working in a 3-dimensional area. Three of the authors created an initial algorithmic framework based on the selected studies. After this, a round table discussion among 3 authors considered experts was used to refine the algorithm based on their expert opinion. The 4 most important factors were determined to be defect size, defect extension to other subsites, defect thickness, and history of radiotherapy or planned radiotherapy. This algorithm includes both surgical and nonsurgical options. Defects in the soft palate not only affect the size and shape of the organ but, more critically, the function. The reconstructive ladder is used to help maximize the remaining soft palate functional tissue and minimize the effect of nonfunctional implanted tissue. Partial-thickness defects or defects less than one-fourth of the soft palate may not require locoregional tissue transfer. Patients with a history of radiotherapy or defects of up to 75% of the soft palate may require locoregional tissue transfer. Defects greater than 75% of the soft palate, defects that include exposure of the neck vasculature, or defects that include significant portions of the hard palate or adjacent oropharyngeal subsites may require free tissue transfer. Obturation should be considered a second-line option in most cases.

Conclusions and Relevance

Ideal reconstruction of the soft palate relies on a comprehensive understanding of soft palate anatomy, a full consideration of the armamentarium of surgical techniques, consideration for adjacent subsite deficits, and a detailed knowledge of various intrinsic and extrinsic patient factors to optimize speech, swallowing, and airway outcomes. The included algorithm may serve as a useful starting point for the surgeon when considering reconstruction.

True bony TMJ ankylosis in children: Case report

INTRODUCTION

The clinical importance of ankylosis in children is concerning with its massive effect and disturbance on the mandibular future growth causing gross deformity apart from the limited mouth opening. Trauma is the most common cause of bony and fibrous ankylosis. History, physical examination and radiographical examination of each patient with ankylosis of TMJ is mandatory in arriving to a final diagnosis, severity, involvement of adjacent structures and ultimately to plan the treatment.

CASE PRESENTATION

Ten years old girl presented with her family seeking solution for a severely limited mouth opening. From the history, the child has suffered from height fall at the age of 4 years. She had complained from swelling and pain near the ear, treated by analgesics, gradually subsided and neglected. This limitation affects on feeding and had an impact on the child's health, seeking for management for the condition became mandatory. Clinical examination, radiographical examination is prepared in beside that ethical approval with full discussion with the parents done. Blind nasal intubation done.

DISCUSSION

Patients with true bilateral ankylosis are considered as the aggressive type. It's not just because of ankylosis. Surgeons should keep in their minds that well experienced anesthetist is important; also extension of the ankylosed bone with amount of cutting is important and re ankylosis as a complication must be avoided.

CONCLUSION

The surgeons agree with the statement that success in the preventing reankylosis after TMJ gap arthroplasty. Its primarily refers to the early postoperative physiotherapy, maintained on a long term.

Burr Hole Surgery for Chronic Subdural Hematoma with Extensive Scalp Burn

BACKGROUND

Neurosurgical intervention for a patient with an extensive scalp burn is rare, but it may be associated with a high risk of surgical site infection.

CASE DESCRIPTION

An 80-year-old man had a severe and extensive scalp burn. A chronic subdural hematoma (CSDH) was observed on a computed tomographic view of the head, performed for the assessment of bacteremia during treatment in the intensive care unit. To evaluate whether the CSDH might underlie the patient's prolonged fever and sepsis, we urgently evacuated the hematoma using 1 burr hole. The surgery was uneventful. We made a skin incision through the deep burn wounds covering the right temporal muscle. We removed necrotic tissue from scalp burns continuously to avoid wound complications and intracranial infection.

CONCLUSIONS

Temporal muscle with a constant blood supply served as an effective tissue for surgical wound closure. By use of this multidisciplinary approach, the CSDH resolved completely, and surgical wound complications were avoided.

Continuous Validity of Temporalis Muscle Flap in Reconstruction of Postablative Palatomaxillary Defects

INTRODUCTION

Postablative palatomaxillary defects (PAPMDs) represent a challenging reconstructive problem. Temporalis muscle flap (TMF) has been widely used for reconstruction of these defects with minimal morbidity and satisfactory outcome.

AIM OF THE STUDY

To presents the authors' experience in the reconstruction of PAPMDs with TMF and to evaluate the validity of TMF in the reconstruction of such defects.

METHODS

This prospective study was conducted between July 2011 and July 2016 on selected patients for primary reconstruction of PAPMDs with TMF. Temporalis muscle flaps were assessed during surgery and postoperatively. Patients were followed up to evaluate functional and esthetic outcomes and detect complications.

RESULTS

This study included 32 patients with mean age 48.3 years. The pathology was squamous cell carcinoma in 15 patients (46.9%). Twenty-one patients (65.6%) had type II maxillectomy. Mean time of flap harvesting was 43 minutes. Zygomatic arch osteotomy was done in 3 patients while Coronoid osteotomy in 4 patients. Postoperatively, flaps were viable in 31 patients (96.9%) with good healing of recipient site. Flap epithelization completed within 28 to 59 days. Follow-up period was 13 to 55 months. Satisfactory functional and esthetic outcomes were reported in most of patients with no recurrence. Transient temporal nerve palsy occurred in 2 patients, limited mouth opening in 5 patients. One patient had Transient diplopia with enopthalmos and hypophthalmos. Flap failure occurred in another patient.

CONCLUSIONS

Temporalis muscle flap is still a valid reliable and versatile reconstructive tool in palatomaxillary reconstruction after ablative surgery. It has a good cosmetic and functional outcomes and minimal morbidity.

Maxillary artery based flaps for oral cavity reconstruction, a review

BACKGROUND

There are different flaps based on the branches of the maxillary artery. Flaps based on the maxillary artery branches can be used for oral cavity reconstruction in selected cases, but there is lack of comprehensive review in this topic.

METHODS

A literature review was performed on Medline for maxillary artery based flaps and oral cavity reconstruction. Surgical techniques for each possible variant of maxillary artery based flaps and an example of each situation for oral cavity reconstruction is explained.

RESULT

Five variants of soft tissue flaps based on maxillary artery branches are presented. Some of them such as temporal flap, superiorly based masseter flap, palatal flap and posteriorly based buccinator myomucosal flap are famous flaps, while posteriorly based inferior turbinate flap is less noticed for oral cavity reconstruction. Nasoseptal and infraorbital based flaps are two other maxillary artery based flaps but have no role in oral cavity reconstruction.

CONCLUSION

Maxillary artery based flaps should be considered as an option especially in previously radiotherapy/surgically operated patients with facial vessels sacrifice.

Interpositional Gap Arthroplasty by Versatile Pedicled Temporalis Myofascial Flap in the Management of Temporomandibular Joint Ankylosis- A Case Series Study

Temporomandibular Joint (TMJ) ankylosis is a situation in which the mandibular condyle is fused to the glenoid fossa by bone or fibrous tissue. The management of TMJ ankylosis has a complicated chore and it is challenging for the maxillofacial surgeon because of technical hitches and high rate of re-ankylosis. Interpositional gap arthroplasty is one of the modalities for its management. A range of inter-positional materials have been used to avert recurrence after gap arthroplasty in TMJ ankylosis. The aim of this series was to evaluate the effectiveness of the temporomyofacial flap in the treatment of TMJ ankylosis as an interpositional gap arthroplasty. A total of 10 cases with unilateral TMJ ankylosis were treated by interpositional gap arthroplasty by pedicled temporalis myofacial flap and evaluated with a follow-up of 6 months to 5 years (Mean 3.3 years) for the functional stability of TMJ. All the patients were successfully treated. There were no signs of recurrence in any patients up to last follow up visit. The result showed that temporalis myofascial flap is a preferable choice for inter-positional gap arthroplasty which proves its versatility as an inter-positional material.

Immediate reconstruction of palato-maxillary defect following tumor ablation using temporalis myofascial flap

The resection of oral cavity tumor and malignancies often causes functional disabilities like deglutition and articulation. Maxillectomy is a very common surgical procedure carried out for the management of benign and malignant tumors of maxilla. Irrespective of the procedure, there is a common end result that is the defect. Several soft tissue flaps can be used for reconstruction of maxillectomy defect. Keeping the parameters of reconstruction in mind it is ideal to reconstruct the maxillary defect with either the free flaps or the regional flaps. Of all regional flaps, the temporalis myofascial flap (TMF) provides a high degree of reliability, vascularity, adequate bulk, and proximity to the defect in the oral and maxillofacial region.

Reconstruction of composite oral cavity defects with temporalis flaps after prior treatment

BACKGROUND

Reconstruction of composite oral cavity defects in the setting of prior surgery and radiotherapy presents a significant challenge. Although free tissue transfer has shown success in such situations, it is not without considerable risk. Regional pedicled flaps may provide a more suitable alternative. In certain patients, however, severe soft tissue fibrosis makes more conventional regional flaps impractical or impossible. In these situations, temporalis flaps (temporalis muscle and temporoparietal fascia flaps) are versatile options for coverage of complex defects.

OBJECTIVE

To report our experience using pedicled temporalis flaps for reconstruction of composite oral cavity defects in patients with significant co-morbidities and prior treatment.

METHODS

Three patients were identified and their medical records were reviewed. Their clinical courses and functional outcomes are described. We include a discussion of the operative technique and relevant literature.

RESULTS

All patients had previously undergone extensive treatment. One patient needed reconstruction after resection of a third head and neck malignancy and two patients presented for treatment of osteoradionecrosis. A temporalis muscle flap was used to reconstruct composite oral cavity defects in two patients and a combined temporalis muscle and temporoparietal fascia flap was used for independent defects in one patient. All flaps survived. Functional status and pain improved or stabilized in all patients. There were no major or minor complications.

CONCLUSION

In previously treated fields, where more conventional flaps are impractical, temporalis flaps are a suitable alternative to achieve a stable healing wound and prevent worsening of functional status.

Prosthodontic rehabilitation after myofascial flap surgery of hemimaxillectomy defects in the edentulous patient: a clinical report

OBJECTIVE

The aims of this clinical report were to present and discuss the clinical procedure and the treatment considerations of prosthetic rehabilitation after myofascial flap surgery.

DESIGN

A 78-year-old edentulous woman with a squamous cell carcinoma underwent hemimaxillectomy. A temporalis myofascial flap surgery combined with implant-supported prosthesis is one successful approach to the restoration of oral function after hemimaxillectomy.

CONCLUSIONS

Although the bulky and mobile nature of a temporalis myofascial flap prevented the retention of a tissue-borne denture, an appropriate impression technique and the fabrication of implant-supported prosthesis using an implant attachment system enhanced the overall satisfaction by the patient.

Polymorphous low-grade adenocarcinoma--management and reconstruction with temporalis myofacial flap

Polymorphous low-grade adenocarcinoma is a rare, malignant salivary gland tumor, which is found almost exclusively in minor salivary glands. It is more frequent in the third-seventh decade of life, with a clear female predilection in a 2:1 ratio. It is usually located in the hard or soft palate, although it may be found in the rest of the oral cavity too. It is rare in major salivary glands. In general it has good prognosis, with recurrence rates in the range of 17-24%. Although rare, metastasis to regional lymph nodes has been reported. We report a case of 38 year old female patient who reported with recurrent low grade polymorphous adenocarcinoma in the hard palate, who has been treated with wide excision of the lesion, with reconstruction of the defect using temporalis myofacial flap.

Complication following reconstruction of orbital floor with temporalis-coronoid flap after subtotal maxillectomy

A 33-year-old lady was referred to the Department of Oral and Maxillofacial Surgery of Taleghani hospital in 2008. She complained of firm swelling on the left side of her face with toothache, lacrimation, and nasal stiffness. There was a large mass in the left maxillary sinus with extension to the orbital floor, nasal bone, ethmoid sinus, and infratemporal fossa. The incisional biopsy revealed a neurofibroma of the maxilla. She underwent hemimaxillectomy and simultaneous reconstruction with temporalis-coronoid flap for orbital floor reconstruction. After 2 months' follow-up with no complication, she complained of left globe upward movement during gum chewing. The orbital and visual examinations were otherwise normal. This unusual complication has continued for 4 years with no resolution, although the patient does not worry about it any more.

Is aggressive gap arthroplasty essential in the management of temporomandibular joint ankylosis?-a prospective clinical study of 15 cases

The purpose of this three-year, prospective, follow-up study was to evaluate whether aggressive gap arthroplasty is essential in the management of ankylosis of the temporomandibular joint (TMJ). Fifteen patients were treated by the creation of a minimal gap of 5-8mm and insertion of an interpositional gap arthroplasty using the temporalis fascia. Eleven patients had unilateral coronoidectomy and 4 bilateral coronoidectomy based on Kaban's protocol. Preoperative assessment included recording of history, clinical and radiological examinations, personal variables, the aetiology of the ankylosis, the side affected, and any other relevant findings. Patients were assessed postoperatively by a surgeon unaware of the treatment given for a minimum of 3 years, which included measurement of the maximal incisal opening, presence of facial nerve paralysis, recurrence, and any other relevant findings. Of the 15 patients (17 joints), 12 had unilateral and three had bilateral involvement, with trauma being the most common cause. The patients were aged between 7 and 29 years (mean (SD) age 20 (8) years). Preoperative maximal incisal opening was 0-2mm in 8 cases and 2-9mm in 9. Postoperatively adequate mouth opening of 30-40mm was achieved in all cases, with no recurrence or relevant malocclusion during 3-year follow up. However, patients will be followed up for 10 years. Aggressive gap arthroplasty is not essential in the management of ankylosis of the TMJ. Minimal gap interpositional arthroplasty with complete removal of the mediolateral ankylotic mass is a feasible and effective method of preventing recurrence.

Temporal muscle flap in reconstruction of maxillo-facial tissues

Aim of the study

Presents our experience in reconstruction of postsurgical defects with use of temporal muscle flap.

Material and methods

In the years 1996–2010 we treated 10 patients with malignant neoplasms of maxillo-facial region. Following tumor removal the fascia-muscle flaps of temporal muscle were used for reconstruction. Temporal muscle flaps were applied in 5 cases for reconstructing the defect of eye socket tissue after extensive resections and in the other 5 patients was used for reconstructing the defect of palate following maxillary resections.

Results

All the flaps of temporal muscle that were used for reconstructing eye sockets incorporated with no local reaction. In one case of flap applied into the oral cavity for tightly separate from nasal, partial necrosis of flap's edge and oro-nasal fistula occurred.

Conclusions

Fascia-muscular flap of temporal muscle is a simple, easy and effective method of tissue reconstruction in maxillo-facial region following extensive oncologic procedures.

Retrospective analysis of use of buccal fat pad as an interpositional graft in temporomandibular joint ankylosis: preliminary study

PURPOSE

To evaluate the feasibility and usefulness of buccal fat pad as an interpositional graft in the treatment of temporomandibular joint (TMJ) ankylosis.

MATERIALS AND METHODS

A retrospective study of 10 patients with TMJ ankylosis (9 unilateral and 1 bilateral) was performed with follow-up of 6 months to 2 years.

RESULTS

In the present study, patients had a maximum interincisal opening of 32 to 41 mm (mean, 35.1 mm) at the latest follow-up. Mean deviation to the affected side on mouth opening was 1.6 mm (range, 0 to 4 mm), but chewing function was good and all the patients were satisfied. No major occlusal changes were observed and all the patients had satisfactory occlusion at the follow-up periods. No facial paresis of temporal and zygomatic branch of facial nerve was observed in any case. Periodic panoramic radiographs showed well-maintained intra-articular space because of the interposed tissue, with no signs of relapse.

CONCLUSION

The findings of this study showed the short-term successful management of TMJ ankylosis using buccal fat pad as an interpositional graft.

Functional outcomes and suitability of the temporalis myofascial flap for palatal and maxillary reconstruction after oncologic resection

OBJECTIVES/HYPOTHESIS

The temporalis myofascial flap (TMF) is a method of palatal reconstruction that offers a single-stage, reliable, and functional technique to repair oncologic defects involving the oral cavity following tumor removal. It is hypothesized that both speech and swallowing function are preserved following TMF.

STUDY DESIGN

In a retrospective and prospective case series, this study evaluated the surgical outcomes of 72 patients undergoing surgical resection and reconstruction of the hard and soft palate using a TMF. Of this series, 25 patients underwent nasalence and swallowing quality-of-life testing to determine speech and swallowing function following this procedure.

METHODS

Reliability, safety, and effectiveness data endpoints on TMF reconstruction were collected and analyzed. Instrumental measures of nasalence (KayPentax Nasometer, Lincoln Park, NJ) and swallowing quality of life measures (MD Anderson Dysphagia Inventory [MDADI] were acquired.

RESULTS

All TMF's were successfully transferred with complete healing of the oncologic defect. The group mean nasalence for connected speech tasks were within normal limits for connected speech--high- and low-pressure tasks (M = 21% and M = 17%). The group mean nasalence scores for sustained vowels were mildly affected (M = 26%). The group mean MDADI score was 79 (SD = 16), indicating good to mildly affected swallowing quality of life. Neither nasalence nor MDADI scores appeared to vary as a function of defect region.

CONCLUSIONS

The TMF is an oncologically safe and effective method of palate reconstruction that affords excellent quality of life to appropriately selected patients without reliance on other reconstructive techniques.

The versatility of temporalis myofascial flap in maxillo-facial reconstruction: a clinical study

OBJECTIVES

This clinical study was conducted in the department of Oral & Maxillofacial Surgery, at our institute, to study the versatility of temporalis myofascial flap in maxillofacial reconstruction.

METHODS

The study group comprised of 20 patients, both male and female patients between the age group of 6 years and 60 years underwent surgery under general anesthesia and temporalis myofascial flap was used for reconstruction of various types of maxillofacial defects including maxillectomy defects arising as a result of ablative surgery for tumors and treatment of aggressive cysts, as an interposing material in TMJ ankylosis surgery and facial reanimation in cases of long standing facial nerve paralysis. Following surgery the cases were evaluated for clinical parameters weekly for first post-operative month followed by monthly review for a minimum period of one and maximum of three years from January 2003 to June 2006.

RESULTS

Temporalis myofascial flap fared well in 16 out of 20 cases (80%), in remaining four cases (20%) three reported back with reankylosis, and in one case of facial reanimation flap breakdown occurred due to infection leading to failure of the procedure.

CONCLUSION

The temporalis myofascial flap is a versatile option for reconstruction of moderate to large sized maxillofacial defects, the muscle can provide abundant viable and vascular tissue, with minimal to no functional morbidity or esthetic deformity at the donor site.

A Retrospective Study of Temporalis Muscle and Fascia Flap in Treatment of TMJ Ankylosis

BACKGROUND

This study sought to determine the efficacy of interpositional arthroplasty with temporalis muscle and fascia flap in the treatment of unilateral temporomandibular joint (TMJ) ankylosis in adults.

METHODS

This retrospective study of nine cases evaluated the postoperative results of interpositional arthroplasty on temporalis muscle and fascia flap in adults. The operative protocol for unilateral TMJ ankylosis entailed (1) resection of ankylotic mass, (2) intraoral ipsilateral coronoidectomy, (3) contralateral coronoidectomy when necessary, (4) interpositional tissue transfer to the TMJ with temporalis muscle, fascia flap, and (5) early mobilization, aggressive physiotherapy.

RESULTS

The study evaluated nine patients with follow-up checks from 13 to 31 months (mean 18.3 months). Patients had a preoperative maximal interincisal opening of 9-19 mm (mean 11.7 mm). During the last follow-up observation after surgery, the patients had a maximal interincisal opening of 35-40 mm (mean 38.3 mm).The results of this protocol were encouraging, the functional results of interpositional arthroplasty on temporalis muscle and fascia flap were also satisfactory.

CONCLUSION

The findings of this study support the use of temporalis muscle and fascia flap in adult patients with unilateral TMJ ankylosis. Early postoperative initial exercise, physiotherapy and strict follow-up play an important role in preventing postoperative recurrences.

Interpositional arthroplasty using autogenous costal cartilage graft for temporomandibular joint ankylosis in adults

This retrospective study evaluated 11 adult patients with TMJ ankylosis treated by interpositional arthroplasty using autogenous costal cartilage grafts between 1985 and 2003. Minimum follow-up was 2 years. Basic personal data, function of TMJ and complications of operation were recorded. Mouth opening increased during operation by a mean of 25.5mm and postoperatively by a mean of 26.2mm. The procedure failed in one case with recurrent ankylosis. The remaining 10 cases had final opening ranges in excess of 30mm. Complications included one numb lower lip. There were no instances of a facial nerve or internal maxillary artery injury. Consideration is given to the width and level of gap arthroplasty, fixation of the grafts, complications at both donor and recipient sites, postoperative physical therapy, occlusal change, and the need for coronoidectomy. This study demonstrated that autogenous costal cartilage is a suitable material for interpositional arthroplasty in adults. Complications were low. The intraoral approach and the role of postoperative physical therapy appear key elements in the success of this procedure.

Reconstruction of full-thickness cheek defects with combined temporalis myofacial and facial-cervico-pectoral flaps

OBJECTIVE

The objective of this study was to assess using the temporal myofacial flaps (TMFF) and the facial-cervico-pectoral flap (FCPF) to provide both inner and outer linings for large full-thickness cheek defects following ablative oral cancer surgery.

STUDY DESIGN

Twelve patients with malignant tumors in the buccal region were treated by extensive surgical dissection, and the cheek mucosa defects were repaired with the TMFF and the cheek skin defects were reconstructed with the FCPF. There were 9 male and 3 female patients, age range from 18 to 70 years (mean 52.8). The full-thickness cheek defects ranged from 7 x 6 cm to 10 x 8 cm in size.

RESULTS

No patient had complete loss of flap; 3 patients had minor complications (TMFF and FCPF partial necrosis and FCPF distal dehiscence) all of which settled with conservative management. Mouth opening was normal in 10 patients, and facial contour was satisfactory in 8 patients. The follow-up period varied from 6 to 26 months (mean 15.2); 3 tumors had local recurrences and 2 patients died from tumor metastasis.

CONCLUSION

We found the technique to be anatomically sound, technically easy and reliable, and believe it is a useful method for the reconstruction of large full-thickness cheek defects.

Functional reconstruction of maxilla with pedicled buccal fat pad flap, prefabricated titanium mesh and autologous bone grafts

The aim of this study was to evaluate the use of pedicled buccal fat pad flap (PBFPF), prefabricated titanium mesh and autologous bone graft in maxillary reconstruction. Seventeen patients with a unilateral class I-III maxillary defect were involved. Preoperatively, a solid model was manufactured based on virtual maxillectomy and reconstruction of the abnormal maxilla. Intraoperatively, PBFPF was applied to repair the soft-tissue defect, serving as nasal lining and the receiving bed for bone grafts. Titanium mesh was prefabricated on the solid model and then, together with bone grafts from iliac crest, fixed to residual bones to reconstruct the hard-tissue defect. Postoperative aesthetic appearance and function were followed up. No exposure of titanium mesh, leakage or oronasal regurgitation occurred. Of the patients with a class I or II defect 91% (10/11) and of those with a class III defect 50% (3/6) gained a good appearance. Fifteen patients were articulate. Eleven patients received dental rehabilitation and had a normal diet. PBFPF with prefabricated titanium mesh and autologous bone grafts is a reliable option for reconstruction of unilateral maxillary defects of class I and II, but this method alone should be used cautiously in defects of class III and beyond.

The arterial supply of the temporalis muscle

Owing to the diverse applications of the temporalis muscle in reconstructive surgery, the study of its arterial supply is becoming an issue of great importance nowadays. The material of the present study consisted of 44 specimens, four obtained from two stillbirths and 40 dissected from 20 embalmed cadavers after injecting the external carotid artery with lead oxide solution. Direct branches from the second part of the maxillary artery and the middle temporal artery proved to be constantly furnishing the muscle from its superficial and deep surfaces. The muscular branch of the middle temporal artery supplied the middle and posterior thirds of the superficial surface and the posterior third of the medial surface of the muscle. The superficial temporal artery participated in supplying the muscle from its lateral surface, while the anterior and posterior deep temporal arteries lay deep to the anterior and the middle thirds of the muscle, respectively. The temporal branches of the middle meningeal artery anastomosed with the deep temporal arteries, thereby contributing to the supply of the temporalis muscle. An arterial pedicle arising from the third part of the maxillary artery constituted an additional supply in 9.1% of the specimens, providing an additional arterial pedicle for temporalis-muscle-flap elevation.