Mandibular reconstruction with local live vascularised bone transfer

There are different methods to provide a skeletal support for mandibular reconstruction following the trauma or ablation for tumor in head and neck region. These methods vary from complicated techniques like vascularised free bone grafts to methods like free bone grafts, local vascularised bone grafts, cadaveric irradiated bone grafts and alloplastic material spacers including silastic rubber, polyvinyl plastics, ceramics, hydroxylapatite or metal. The technique employed solely depends upon many factors like expertise available, existing infrastructure, the available time factor and complexity of the defects including the type and extent of tissue loss in the particular patient. The sliding mandibulectomy is a simple method of mandibular reconstruction. This surgical technique is indicated for repairing short mandibular defects up to 9 cm in overall length including the mandibular arch for which extra vertical osteotomies are needed to bend the segment. More so it has its value in patients with poor prognosis and poor general conditions in whom longer and complicated mandibular reconstruction procedures with free vascularised bone flaps are not advisable. This article describes different types of sliding osteotomies used to harvest live bone flaps for rebuilding the mandibular defects including the arch of the mandible for patients who have undergone malignant tumor ablation. Primary reconstruction for the mandibular skeletal support was obtained in 18 cases with vascularised live-bone graft through various sliding osteotomies in different combinations. Complications, failures and success rate of sliding mandibulectomies and osteotomies have been analyzed and discussed in detail.

Total oral reconstruction for cancers associated with advanced oral submucous fibrosis

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

Free jejunal transfer for pharyngo-esophageal reconstruction

During the course of head and neck surgery for cancer the reconstructive surgeon is involved in replacement of pharyngeal mucosal defects. Siedenberg (7) first reported free transplantation in 1959 using a segment of jejunum, Roberts (5) using jejunum, Nakayama (3) using colon and Jurkiewicz (4) using ileum and jejunum. Green (2) in 1966 using microsurgical techniques demonstrated 100% survival of free transfers of jejunum and also patches of jejunum in dogs. We have used free interposing iso-peristaltic jejunal loop transfer in 30 patients to bridge the cervical esophagus defects for advanced cancer of hypopharynx, larynx and cervical esophagus after ablative cancer surgery. The major complication rate was 13% (4/30 cases) including total flap failure and loss of interposed jejunal segment. The minor complication rate was 36% (11/30 cases) including postoperative hypothyroidism in 2 patients. Intra-abdominal hemorrhage or peri-operative mortality was not observed in any of our cases. Total post-operative average hospital stay was 15 days, and median swallowing time was 10 days. Complication rates and success of early functional and social restoration have been analyzed.

The venoneuroadipofascial pedicled distally based sural island myofasciocutaneous flap: case reports

Complex soft-tissue defects of the lower third of the leg, the heel and the ankle still present a challenge for the reconstructive surgeon. In addition to skin replacement, many of these defects require muscle bulk, which promotes the healing of open bone fractures, effectively fills osteomyelitic cavities and deep three-dimensional defects, and helps to reconstruct the Achilles tendon. In an anatomical study, we developed a new flap based on the 'neuromuscular concept'. This flap consists of a paddle of gastrocnemius muscle and a skin paddle based distally on the sural venoneuroadipofascial pedicle supplied by the lower peroneal perforators. Three cases are presented to illustrate the versatile use of this flap.

The venoneuroadipofascial pedicled distally based sural island myofasciocutaneous and muscle flaps: anatomical basis of a new concept

Reconstruction of soft-tissue defects of the lower third of the leg, the heel and the foot remains a challenge. The distally based sural neurocutaneous flap has been used effectively to resurface these defects. However, the paucity of bulk in this flap makes it inadequate for complex post-traumatic or post-ablative soft-tissue reconstruction. We dissected 20 freshly amputated lower limbs after injecting them with a mixture of lead oxide and gelatin. We found muscular branches of the accompanying artery of the sural nerve to the gastrocnemius muscle in all 20 limbs. This led us to conceptualise the distally based venoneuroadipofascial pedicled island sural myofasciocutaneous and muscle flaps. These flaps are useful for the reconstruction of complex soft-tissue defects of the lower third of the leg, the heel and the foot.

A simple, cost effective, innovative method of securing burns dressing

An easy, simple way of securing the burns dressing has been described. This is achieved by using an ordinary office stapler and staple pins. The use of long, encircling gauze bandages for fixation of burns wound dressings around the torso and extremities, is eliminated. This article describes the use of this innovative, cost effective, quick, easy and simple method of fixation of burns wound dressings.

Tumor implantation at the flap donor site: a case report

The genesis of cancer and its variable patterns of spread have been theorized and debated upon for decades. Recurrences, both local and metastatic, are dreaded by both the patient as well as the surgeon. An interesting case of tumor implantation at the flap donor site was noted in a patient who underwent a primary flap reconstruction for cancer of the cheek. The details of the case and theories regarding tumor implantation have been enumerated in this report.

The hemithigh microvascular transfer (combined anterolateral thigh flap and tensor fasciae latae flap) for a full thickness abdominal wall reconstruction: a case report

In large, full thickness upper abdominal wall defects a free microvascular tissue transfer is the only option which will enable reconstruction of the structural integrity of the abdominal wall as well as give a good aesthetic appearance. We present a case in which such a defect was reconstructed by a 29 x 19 cm hemithigh free flap, combining the adjacent vascular territories of the anterolateral thigh flap and the tensor fasciae latae flap based on the lateral circumflex femoral artery.

Primary reconstruction of mandible in head and neck cancer with silastic implant--a review of 69 cases

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.

Prophylactic antibiotics administration head and neck cancer surgery with major flap reconstruction: 1-day cefoperazone versus 5-day cefotaxime

Patients who undergo surgery of the head and neck cancer with major flap reconstruction, benefit from perioperative antibiotic prophylaxis. Head and neck surgery, especially ablative cancer surgery with major flap reconstruction is potentially contaminated iatrogenic wound, and the use of preoperative, perioperative and post operative chemoprophylaxis for infection is mandatory. This study is being done to determine if shorter course of antibiotic administration (Cefoperazone) would be more effective than conventional 5-day antibiotic administration (Cefotaxime). Patients who are identified as requiring major flap reconstruction after extensive ablative surgery for head and neck cancer, are considered as potential candidates for this study. The choice of ideal antibiotics and duration period are still under discussion. Patients were assigned randomly to receive Cefoperazone sodium for either 24 hr. (study group) or Cefotaxime sodium for 120 hr. (control group). A total of fifty patients were studied. The incidence of wound infection, flap death and major complications are evaluated. Out of the fifty patients studied, twenty-eight were assigned to 1-day prophylaxis. Incidence of failure of prophylaxis (F. P.) was 7.1% in this group. Twenty-two patients were assigned to 5-day prophylaxis, in whom F. P. rate was 9.8%. This study suggests that, there is no beneficial effect from administration of antibiotics for more than 24 hr. postoperatively in patients two undergo major flap reconstruction for head and neck cancer after extensive radical ablation surgery.

The submental island flap for reconstruction of facial defects

The procedure of facial resurfacing dictates that there should be an excellent colour and texture match between the facial and the transposed skin. Cervical flaps e.g. platysma flap are commonly used for reconstruction of facial defects but, with disadvantages like limited mobility, unacceptable donor site and unpredictable outcomes. The submental island flap is a new addition to the armamentorium of the Plastic Surgeon. It is an axial pattern flap based on the submental branch of facial artery and the submental tributary of common facial vein. We report the use of this flap for the reconstruction of postexcisional facial defects in two patients having basal cell carcinoma and recurrent parotid tumour. In both patients, the flap provided an excellent colour and texture match. Other advantages of this flap are inconspicuous donor site, wide arc of rotation, simple dissection and a reliable pedicle.

Comparative evaluation of function after surgery for cancer of the alveolobuccal complex

PURPOSE

The current study was undertaken to assess the functional deficit after hemiresection of the mandible and to determine whether lateral segment resection with reconstruction was a functionally superior alternative in the management of patients suffering from alveolobuccal cancer.

PATIENTS AND METHODS

Eighty-three patients were assigned to one of two main groups: Group I, hemiresection of the mandible (n = 47), and group II, lateral segment defects (n = 36). Functional assessment of patients included subjective evaluation of overall well-being, feeding, and cosmesis, as well as objective assessment of mastication, speech, and cosmesis. Mean scores for each of these categories were compared across groups using the Duncan Multiple Range Test with .01 confidence intervals.

RESULTS

Subjective assessment of overall well-being, feeding, and cosmesis did not yield statistically significant differences between groups. Objective evaluation of mastication showed significantly better function after hemiresection in dentate patients as compared with their edentulous counterparts. However, masticatory scores for hemimandibulectomy patients with intact residual dentition were not significantly different from those for patients whose lateral segmental defects had been reconstructed. Although objective cosmetic scores for reconstruction of lateral segment defects were significantly better than those for hemiresection of the mandible, most patients in the latter group accepted the resultant deformity as a consequence of their treatment and did not let it affect their routine activities.

CONCLUSION

Until functional results in patients undergoing lateral segmental resection for alveolobuccal cancer can be improved by better prosthetic techniques, hemiresection of the mandible remains a simple, safe, reliable, and cost-effective option that produces acceptable postoperative function.

Caudal trapezius composite island flap for extensive shoulder defects

The trapezius composite flap was first described by Demergasso in 1979 (2). The caudal trapezius island flap was described by Mathes and Nahai (4), in head and neck cancer reconstruction. Baek and Biller (1) described the descending branch of the transverse cervical artery, as a dominant blood supply. It is an useful flap for the reconstruction of defects around shoulder, neck and cheek regions. The anatomy of the trapezius muscle, its blood supply, vascular territories and its function is described in brief. Use of this flap in the reconstruction of compound extensive tissue defects in shoulder region of our patient is presented.

Folded free radial forearm flap for reconstruction of full-thickness defects of the cheek

BACKGROUND

Full thickness defects of the cheek have been conventionally reconstructed using the folded forehead flap, cervical flap, pectoralis major myocutaneous flap, or deltopectoral flap in various combinations. We report a modified technique of folding the radial forearm flap for reconstruction of full-thickness defects of the cheek.

METHODS

The free radial forearm flap is a type C fasciocutaneous flap based on the radial artery along with its vena commitans and superficial forearm vein. The size and shape of the flap are determined according to the dimensions of the surgical defect. The flap is then lifted off with the fascia of the forearm making it a fasciocutaneous flap, in which the radial artery lies deep to the fascia and gives numerous branches. The flap is disconnected from the donor site only after the recipient vessels have been prepared for anastomosis. Vascular anastomosis is then performed using the operating microscope. This technique was used in 13 patients with carcinoma of the buccal mucosa who underwent fill-thickness excision of the cheek.

RESULTS

Flap edema was observed in 4 patients in the immediate post-operative period. Necrosis of the outer paddle was seen in 1 patient. Donor site morbidity was seen in 4 patients who required dressings on an outpatient basis for up to 3 weeks.

CONCLUSION

Single-stage reconstruction of full-thickness defects of the cheek with the folded free radial forearm flap is reliable and produces excellent cosmesis with minimal donor site morbidity.

Reconstruction of chest wall defects following extirpative surgery

Reconstructive procedures following chest wall resection pose a special surgical challenge. With modern surgical technique, a wide range of reconstructive options are at the surgeon's disposal and, hence it is imperative that the appropriate procedure be selected in a given patient. A total of 64 patients underwent resection of malignant chest wall tumors at the Tata Memorial Hospital. The technique of preference at our institution for reconstruction of full-thickness chest wall defects uses a combination of autogenous fascia lata and Marlex mesh. We present our experience with chest wall reconstruction following extirpative surgery in these patients.

Osteomyocutaneous flap reconstruction for major mandibular defects

Mandibular defects after composite resections for carcinoma of the buccal mucosa require immediate restitution of both form and function with an acceptable cosmetic result. The pectoralis major osteomyocutaneous flap (PM-OMC) provides restoration of bone, soft tissue and skin with minimum morbidity. The procedure is technically simple, and in our series reconstruction using this flap has been performed by consultants, fellows and residents in training. We present a series of 116 PM-OMC flaps with good postoperative mastication in more than 70% of cases, and satisfactory swallowing and intelligible speech in 85% patients.

One stage reconstruction of extensive abdominal wall defect with bilateral tensor fascia lata (TFL) flaps

An extensive anterior abdominal wall defect, measuring 20cm x 20cm following a wide excision for recurrent abdominal wall tumor, was reconstructed with extended bilateral TFL flaps. Minimal sequelae have been observed in three year follow-up. Inspite of both sides TFL used for the reconstruction, patient has no difficulty in walking and day-to-day activities.

Primary reconstruction of head and neck cancer with anterior rib, osteomyocutaneous composite flap

The anterior rib, osteomyocutaneous composite flap (AROCF) incorporating both vessels, supracostal and intercostal, has been harvested for primary reconstruction in advanced head and neck cancer patients. The adequacy of the periosteal circulation alone for the successful free osseous transfer has been well proved. The available length of the internal mammary vessels is sufficient for the successful microvascular anastomosis in the neck. This same AROCF can be used as a pedicled flap based on the pectoralis major musculo-vascular pedicle for successful primary reconstruction in cases in which it is deemed unsuitable for use as a free flap. This is possible because of the unique functional blood supply of the rib.

Folded, bipaddled composite flap in head and neck reconstruction

A series of 34 patients repaired by folded, bipaddled composite flaps for head and neck cancer surgical defects is presented. Pectoralis major composite flap was used in 33 patients on musculovascular pedicle and 1 patient had a latissimus dorsi composite flap free-tissue transfer. The pectoralis major rib, osteomyocutaneous flap was utilized in 6 patients who had lesions of the mouth floor and anterior mandibular arch. The incorporated rib was used as a vascularized bone graft for the stability of mandibular fragments. Thus, one regional composite flap used in bipaddled fashion enabled the reconstruction of mucosal, skin, and mandibular arch defects.

The folded, bipaddled pectoralis major composite flap in oral cancer reconstruction

We report on the pectoralis major composite (musculocutaneous or rib osteomusculocutaneous) flap used in bipaddled fashion for one-stage immediate reconstruction in 53 patients with oral cancer. Of these, 44 patients had lesions of buccal mucosa and lateral lower alveolus, and 9 patients had lesions of floor of mouth and middle third of lower alveolus. In one patient this flap was used as a free composite tissue transfer in bipaddled fashion. The flap can be used either before or after radiotherapy in oral cancer and provides both lining mucosa and skin cover. If necessary, a rib (vascularised bone graft) incorporated with this composite flap can give skeletal support for mandibular arch reconstruction.

Reconstructive surgery in head and neck cancer

In the past 15 years dynamic changes have taken place in primary reconstructive procedures for head and neck cancer. We have here described the latest techniques used at the Tata Memorial Hospital in reconstruction of major defects in head and neck cancer surgery.

Bipaddled, retrograde radial extended forearm flap with microarterial anastomosis for reconstruction in oral cancer

The design of a bipaddled, retrograde, radial artery forearm flap is described. Its utility in providing lining and cover for advanced oral cancer patients in five clinical cases is discussed and evaluated.

Surgery for severe trismus in submucous fibrosis

Bilateral full thickness naso-labial flaps have been used successfully in three patients to give long-term relief of the severe trismus caused by oral submucous fibrosis. The flaps are set into defects created by incision of the oral mucosa. The postoperative rehabilitation compared favourably with other methods and we now advocate the technique for all cases of submucous fibrosis requiring correction of severe trismus.