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PubMed1997

Stability of the mandibular position in occlusion of mandibulectomy patients with lateral discontinuity defect.

In mandibulectomy patients with lateral discontinuity defect, the mandible is severely deviated and the occlusion is considered to be unstable. A thorough understanding of the mandibular occlusal position of these patients is important to achieve desirable results in their occlusal rehabilitation. This study compared the stability of the mandibular positions in occlusion, when the opening distance or the biting force was changed during mandibular movements, by simultaneously measuring four points on the mandible three-dimensionally. This study indicated that the mandibular positions in occlusion of these patients were extremely unstable as compared with those of the normal subjects and were considerably different from each other when the opening distance or the biting force was changed during mandibular movements.

Bite Force↗

PubMed2000

The free vascularized flap and the flap plate options: comparative results of reconstruction of lateral mandibular defects.

OBJECTIVES/HYPOTHESIS: Reconstruction of the mandible and oral cavity after segmental resection is a challenging surgical problem. Although osteocutaneous free flaps are generally accepted to be optimal for reconstruction of anterior defects, the need for bony reconstruction for a pure lateral mandibular defect remains controversial. STUDY DESIGN: A retrospective study. METHODS: A retrospective comparative study of short- and long-term outcomes of three different reconstruction techniques for lateral defects was performed. In total, 57 patients were included, of whom 27 had a plate and pedicled pectoralis major myocutaneous flap (PMMF group), 16 had a plate and free radial forearm flap (FRFF group), and 14 had an osteocutaneous free flap. Functionality, flap failure, and complications were scored. RESULTS: Plates had to be removed in 7 of the 27 patients in the PMMF group and 2 of the 16 in the FRFF group; none of the 14 osteocutaneous free flaps failed. The difference was of borderline statistical significance (P = .055). Longterm functional outcome revealed no statistically significant difference in oral deglutition (P = .76) or in facial contour (P = .36). Oral continence was significantly better in patients in the FRFF group (88%) as compared with the PMMF group (52%) or the osteocutaneous free flap group (43%) (P = .02). On the other hand, the results for speech favored the osteocutaneous free flap group; 13 of 14 patients (92.9%) had a normal score compared with 12 of 16 patients (75%) in the FRFF group and 17 of 27 (63%) in the PMMF group. However, this represented a borderline statistically significant result (P = .06). CONCLUSIONS: For lateral mandibular defects, the osteocutaneous free flap is reliable and durable in the long term. However, in a selected group of patients either of the two flap-plate options is a viable reconstructive option.

Carcinoma, Squamous Cell↗

PubMed2006

A novel flap to repair medial and lateral malleolar defects: anterior tibial artery perforator-based adipofascial flap.

Soft tissue coverage of the ankle is a difficult challenge. The adipofascial flap based on perforators of the anterior tibial artery was harvested from the dorsum of the foot and used for repairing of soft tissue defects either on the lateral or medial malleolar region in 7 patients. Two medial and 5 lateral malleolar defects were covered using the flap described. The size of flaps varied from 3.5 x 10 cm to 4.5 x 12 cm. All flaps had good perfusion and survived completely. Donor-site morbidity was minimal in all cases. Both functional and esthetical results were satisfactory. Because of thin and pliable features, this flap is suitable for repair of defects around the ankle region. In addition, donor-site morbidity of this flap is minimal, with an acceptable scar hidden in the shoe-wearing area.

Adipose Tissue↗

PubMed2001

Evidence for the "midline" hypothesis in associated defects of laterality formation and multiple midline anomalies.

A male infant was liveborn at 38 weeks of gestation to a G4P1AB2, 22-year-old, mother. Polyhydramnios and multiple congenital anomalies were noted by ultrasonography; the infant died 5 min after birth. At autopsy, the infant had multiple defects of blastogenesis including midline anomalies with asplenia and abnormalities of laterality formation. The laterality defects were unusual in that they combined asplenia with hypoplastic, symmetrically unilobate lungs and bilateral hyparterial bronchi more consistent with polysplenia, abdominal situs inversus with midline stomach, symmetric liver, and left gallbladder. No intracardiac abnormalities were present, but there was azygous continuation of the inferior vena cava. Additional multiple midline defects included bronchoesophageal fistula, duodenal atresia, absence of posterior leaf of diaphragm; horseshoe adrenal gland; microcephaly; Dandy-Walker anomaly with agenesis of cerebellar vermis and occipital encephalocele; holoprosencephaly with orbital encephalocele, midline defect of the orbital plate of the skull, bilateral anophthalmia, double proboscis with bilateral choanal atresia, midline upper lip and palatal cleft; single-lobed thyroid; hypoplastic external genitalia with midline cleft of scrotum, long tapering fingers, and defects of the cranium at the sites of orbital and occipital encephaloceles. Defects of laterality frequently are associated with other complex midline anomalies, which both result from a disturbance of pattern formation during blastogenesis, i.e., the induction of the progenitor fields. The latter are the result of the establishment of upstream expression domains of growth and transcription factors and other morphogens. Many of these and other genetic systems, expressed asymmetrically around the midline, are responsible for laterality formation and are the result of upstream and subsequent downstream gene expression cascades through the expression of genes such as HOX genes; bFGF; transforming growth factor beta/activins/BMP4; WNT-1,8; and SHH.

Abnormalities, Multiple↗

PubMed2002

Reconstruction of lateral mandibular defects with dynamic bridging plates.

The principle of mandibular reconstruction by dynamic bridging plates in association with a bone graft is based on the double bridge reconstruction method. However, the plate can be used alone. Our aim was to report the long-term results of this treatment for mandibular lateral defects in fragile patients. From 1993 to 1999, 38 consecutive patients had primary reconstructions with bridging plate for lateral mandibular defects. Their mean age was 58.4 years (26-86) and the mean follow-up was 50 months (6-89). Excluding removal of plates for local recurrences, the overall success rate was 78%. Plates were removed after a mean of 20.4 months (1-66). No plates fractured. Dynamic bridging plates allow an immediate and efficient reconstruction with reduced operating time and compare favourably with conventional plates. They can also be used as a stand-by for patients who are to have a delayed free flap reconstruction.

Adult↗

PubMed1995

Fryns syndrome: two further cases without lateral diaphragmatic defects.

We report on two unrelated infants with Fryns syndrome but without lateral diaphragmatic defects. In case 1, a female stillborn, pertinent findings included a coarse facies, cleft palate, short neck with a broad pterygium, heart defect, lung hypoplasia, omphalocele, urogenital malformations, anal atresia, and distal digital hypoplasia. Case 2 showed a coarse facies with cleft lip and palate, para-oesophageal hernia with herniation of the stomach into the thoracic cavity, malrotation of the intestine, hydronephrosis, and anal atresia. At age 14 months she was developmentally severely retarded. These observations represent the 11th and 12th reports of probable Fryns syndrome without lateral diaphragmatic defect.

Abdomen↗

PubMed1981

Reconstruction of lateral nasal defects.

In planning reconstruction of a lateral nasal soft tissue defect, the surgeon should be aware of alternative methods and select the one most appropriate for the patient. Variables to be considered include the extent, depth, and location of the defect, the age, sex, and tissue laxity of the patient, and the availability of donor tissue. Surface defects are often best corrected with full-thickness skin grafts: upper eyelid, preauricular, postauricular, or supraclavicular, depending on which portion of the nose is being treated. Anterior superior helix composite grafts serve quite nicely to restore full-thickness alar losses, and other such defects are better reconstructed with a nasolabial flap. The midline forehead flap is quite useful but in certain situations has drawbacks. For larger skin and soft tissue defects, a transverse forehead flap based on the superficial temporal vessel provides appropriate reconstruction.

Ear Cartilage↗

PubMed2004

A reconstructive algorithm for plastic surgery following extensive chest wall resection.

Chest wall reconstruction following extensive resection is greatly facilitated by the use of vascularised flaps and prosthetic material. Plastic surgeons are often asked to assist with coverage of large chest wall defects. However, in addition to soft tissue coverage, we need to address other important issues such as the status of the pleural cavity, and the requirement for skeletal support. The purpose of this report is to analyse our experience, provide a reconstructive algorithm following the ablative procedure and review the literature. Two hundred chest wall resections were performed from 1975 to 2000. Defect location was divided into anterior (n = 73) lateral (n = 36) anterior-lateral (n = 36) posterior-lateral (n = 19) posterior (n = 22) and forequarter (n = 14) Average number of ribs resected was four. One hundred and fifty-eight patients (79%) required chest wall reconstruction with either prosthetic material and/or flap closure. Mesh closure was required in 85 cases (43%), being highest for lateral defects (61%), and lowest for anterior defects (31%). Vascularised flaps were needed in 112 patients (56%), more common in anterior defects (79%), and less common for the posterior-lateral defects (26%). Inpatient complication rate was 27% (43/158) following reconstruction, with a mortality of 6% (10/158). Chest wall reconstruction is common following extensive resection. This includes management of the pleural cavity, skeletal support and soft tissue coverage. A better understanding of the respiratory mechanics and local thoracoabdominal anatomy is crucial for managing these complex defects. The need for skeletal support was more prevalent in lateral and posterior-lateral defects. Flap reconstruction was required more often to cover large anterior defects, with regional flaps predominating.

Adolescent↗

PubMed2002

[Transferring of the pedicled second metatarsal base for repairing bone defect of lateral malleolus].

OBJECTIVE: To study the method and effect of transferring the pedicled second metatarsal base for repairing bone defect of lateral malleolus. METHODS: Thirty lower limb specimens were anatomized to observe the morphology, structure and blood supply of the second metatarsal bone. Then transferring of the pedicled second metatarsal base was designed and used in 6 patients clinically. All cases were male, aged from 24 to 48 years old, and the area of bone defect was 3-4 cm. RESULTS: Followed up for 3-11 months, all patients healed primarily both in donor and recipient sites. There were excellent results in 4 cases and good results in 2 cases. The morphology and function of the malleoli were satisfactory. CONCLUSION: Transferring of the pedicled second metatarsal base for repairing bone defect of lateral malleolus is an effective and reliable operative method.

Adult↗

PubMed2001

Persistent site-specific defects after reconstructive pelvic surgery.

Our objective was to determine the persistence rates of site-specific defects after reconstructive pelvic surgery. We conducted a retrospective analysis of the post-operative outcome for 77 patients with pelvic support defects. Forty-five patients in the abdominal group underwent a Burch procedure, paravaginal repair and sacral colpopexy when indicated; 32 patients in the vaginal group had a sacrospinous vault fixation with or without colporrhaphy. A chi2 test, Wilcoxon's two-sample test. Wilcoxon's signed-rank test and multivariate logistic regression model were used for data analysis. The two groups were similar in age, weight, parity and menopausal status. There was significant improvement of all defects except in the vaginal group, which showed a higher rate of persistent paravaginal defects (68.7 vs. 13.3%, P = 0.001). After adjusting for potential confounders, there was no difference in the rates of apical and anterior wall defects between the two groups. The odds ratio for persistent paravaginal defects in the vaginal group was 8.9 (95% CI: 2.3-34). The choice of surgical procedure is the most important factor determining the rate of persistent pelvic support defects. Lateral wall defects must be addressed at the time of reconstructive surgery.

Adult↗

PubMed1987

Mandibular reconstruction using AO plates.

The AO plate represents an acceptable reconstructive choice for mandibular defects, with an 86.7 percent success rate demonstrated in this series. Because this method utilizes an alloplast which is precisely and quickly applied, virtually all patients requiring mandibular resection can be considered candidates for reconstruction. Adequate vascularized soft tissue coverage is essential to prevent plate extrusion and fistula formation. This is even more important for radiated patients. The pectoralis major myocutaneous flap provides muscle and skin for large anterior defects. Frequently, lateral defects can be closed primarily without using regional flaps. We suggest bone reconstruction to avoid potential plate fracture and to allow placement of functional dentures. Resections in elderly patients and for palliation will result in ideal cosmetic and functional results with the plate alone. If we exclude the four patients reconstructed with calcium hydroxyapatite and the AO plate, the morbidity rate is quite acceptable. With this group excluded, only four fistulas and eight plate exposures occurred. Only four plate removals were required to achieve wound closure. Evaluation of the titanium plate is in progress. It is hoped that better osseous and soft tissue integration will help to decrease wound complications. A large prospective review of postoperative radiotherapy patients using the new titanium plate has been designed to address this issue. The therapeutic choice between the AO plate and free vascularized bone graft reconstruction remains. The decision process is dependent on the technical skills of the surgeon, the treatment plan, the survival characteristics of the tumor, and the physiologic condition of the patient.

Bone Plates↗

PubMed1991

The frontonasal flap: utility for lateral nasal defects and technical refinements.

This report details the experience with 27 patients over a 5-year period who had nasal reconstruction using a frontonasal flap. The frontonasal flap procedure is a useful method for the repair of relatively large post-Mohs micrographic surgery defects of the lower, upper, lateral and central nose. Our modified method has been extended (1) to resurface lateral as well as central defects of the caudal one-third of the nose; (2) the scar can be shortened so it does not extend into the forehead; (3) the flap can be combined with the island nasalis flap, or nasolabial flaps to resurface large (3-4 cm) defects; (4) early dermabrasion has improved the scars in sebaceous skin.

Adult↗

PubMed1993

Classification of mandibular defects.

A classification of mandibular defects based on functional as well as aesthetic factors is presented. By taking into account the difficulties in restoring form and function and not simply relying on traditional anatomic landmarks, it is hoped that this method will allow different types of reconstructions to be fairly evaluated. It also should help surgeons to tailor individual reconstructive techniques to specific clinical situations. Major difficulties in mandibular reconstruction arise when a condyle requires replacement, when there is a mucosal and/or skin component to the defect, and when the area to be reconstructed involves the anterior arch. The classification is based on three upper-case and three lower-case characters: H, C, L and o, m, s. H defects are lateral defects of any length, including the condyle but not significantly crossing the midline; L defects are the same only without the condyle; C defects consist of the entire central segment containing the four incisors and the two canines. Combinations of these letters are possible (an angle-to-angle defect, for example, is represented as LCL). Thus H and L defects may reach or even extend slightly beyond the midline but are not referred to as LC or HC unless they contain the entire central segment. The letters o (neither a skin nor a mucosal component), s (skin), m (mucosa), and sm (skin plus mucosa) are added to denote the epithelial requirement.

Bone Plates↗

PubMed1999

Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: an outcome analysis of primary bony union and endosseous implant success.

BACKGROUND: Functional restoration following resection or traumatic injury to the mandible depends on the reliability of the bony reconstruction to heal primarily and support endosseous implants. Although vascularized bone flaps (VBF) and nonvascularized bone grafts (NVBG) are both widely used to reconstruct the mandible, indications for each remain ill-defined. The purpose of this study was to compare bone graft/flap healing and success of implant placement in patients reconstructed with VBF versus NVBG. METHODS: Over the past 10 years, 75 consecutive mandibular reconstructions were performed (26 free bone grafts, 49 vascularized bone flaps). Etiology of the defect, history of irradiation, bone defect size, number of operations, graft/flap success, and dental implant success rates were determined and compared. Bone graft/flap success was defined as complete bony union. Implant success was defined as complete osseointegration. Mean follow-up was 3 years. RESULTS: Free flaps were used primarily for malignant disease (78%, 38/49). Bone grafts were used primarily for benign disease (88%, 23/26). History of prior irradiation: 11% (3/26) NVBG versus 45% (22/49) VBF. Length of bony defect (mean): 8.1 cm NVBG versus 9.4 cm VBF. Successful bony union, any size defect: 69% (18/26) NVBG versus 96% (47/49) VBF (p < .0005); lateral defects only: 75% (15/20) NVBG versus 100% (17/17) VBF (p < .05). Number of operations to achieve bony union (mean), any size defect: 2.3 NVBG versus 1.1 VBF (p < .001); lateral defects only: 1.9 NVBG versus 1.0 VBF (p < .005). Twenty-two patients (29%) had a total of 104 endosseous implants placed (NVBG: 8 patients, 33 implants; VBF: 14 patients, 71 implants). Immediate implants placed: 0/33 NVBG versus 54% (38/71) VBF. Overall implant success: 82% (27/33) NVBG versus 99% (70/71) VBF (p < .0001). Implant success in VBF patients with a history of RT: 100% (15/15). CONCLUSIONS: Despite the fact that patients reconstructed with VBFs were older, had larger defects, and were treated primarily for malignant disease and therefore had a higher incidence of irradiation to the affected mandible than in patients treated with NVBGs, the incidence of bony union was higher, requiring fewer operations to achieve union, and the implant success rate was significantly greater than for NVBG patients. Results were similar when considering lateral defects only. Based on these results, VBFs are indicated in most cases of mandibular reconstruction; NVBGs are effective for short bone defects (<5-6 cm), in nonirradiated tissue, and/or in patients determined to be too medically compromised to tolerate the additional operative time required for a free-flap reconstruction.

Adolescent↗

PubMed2002

Nasalis myocutaneous island pedicle flap with bilevel undermining for repair of lateral nasal defects.

BACKGROUND: The superiorly based nasalis myocutaneous island pedicle flap with bilevel undermining is a recently described bipedicled flap used for repair of nasal tip and supratip defects. This flap was used for the repair of small to medium-size defects of the nasal tip and supratip regions. OBJECTIVE: To describe a single-pedicled modification of this flap for the reconstruction of lateral nasal defects at or above the alar groove. METHODS: With the use of diagrams and fresh cadaver dissection, we demonstrate the method of preparing, raising, and placement of this new flap. We further elucidate in an illustrative way the efficacy of bilevel undermining as it is used for achieving greater flap mobility. Finally, we show representative cases with pre- and postoperative results. RESULTS: We describe the senior author's 4-year experience in the development of this flap. CONCLUSION: The nasalis myocutaneous island pedicle flap with bilevel undermining, a new method for repair of lateral nasal defects at or above the alar groove, yields excellent functional and cosmetic results. Bilevel undermining is a new and valuable method of achieving greater tissue mobility in muscle-based flaps.

Female↗

PubMed1997

Fibular free flap reconstruction of the "true" lateral mandibular defect.

The purpose of this study was to determine the role of the fibular free flap in reconstructing lateral segmental defects of the mandible. Over the past 5 1/2 years, 17 consecutive patients underwent reconstruction of their lateral mandible with the fibular free flap. Patients included 12 men and 5 women, the mean age was 54 years (range, 29-76 years), and the mean length of the mandibular defect was 6.3 cm (range, 2.5-9 cm). The majority of patients with tumors (54%) were treated for recurrence and 92% received radiation to the operative field. The mean operative time to perform the microsurgery and bone plating was 4 hours. Postoperative morbidity occurred in 3 patients (18%) (plate fracture, malocclusion, orocutaneous fistula). Five patients (29%) required leg donor site skin grafting. Donor site morbidity included a minor cellulitis, a transient neuropraxia, and one case of leg swelling. None required additional surgery for donor complications. Thus far, 71% of the patients have received dental rehabilitation and 35% had osseointegrated implants placed in their bone flap. Eighty-two percent of the patients achieved both good or excellent aesthetic and functional results. Sixteen patients (94%) tolerate at least a soft diet and 65% are on a regular diet. Five patients developed tumor recurrence an average of 9 months postoperatively with a mean survival of 21 months. This study demonstrates that the fibular free flap is highly reliable for reconstructing the lateral mandible in a single stage, with low overall morbidity, and provides for excellent dental and speech rehabilitation. For most patients, the fibular free flap should be considered for lateral mandibular reconstruction even in those patients with a limited life expectancy.

Adult↗

PubMed2005

[Repair of anterior tibial, dorsal pedal and calcaneal soft-tissue defects with lateral crural flaps].

OBJECTIVE: To report the methods and clinical effect of the lateral crural flaps in repairing anterior tibial, dorsal and calcaneal soft-tissue defects. METHODS: From August 1999 to December 2004, 18 cases of defects were repaired with lateral crural flap, including 15 cases of anterior tibial, dorsal and calcaneal soft-tissue defects with vascular pedicled island lateral crural flaps and 3 cases of dorsal pedal soft-tissue defects with free vascular lateral crural flaps. RESULTS: All flaps survived after operation. Insufficient arterial supply of the flap occurred in 2 cases after operation, the pedicled incision sewing thread was removed and lidocaine was injected around vascular pedicle, then the flap ischemia was released. Inadequate venous return and venous hyperemia occurred in 1 case because peroneal vein was injured during operation. The flap edge skin was cut and heparin was locally dripped for one week, the flap vascular cycle was resumed. All patients were followed up two months to one year, the flaps were not fat, and the elasticity was good. CONCLUSION: It is safe and reliable to use lateral crural flap to repair anterior tibial, dorsal pedal and calcaneal soft-tissue defects.

Adolescent↗

PubMed1998

Residual lateral wall defects following sinus grafting with recombinant human osteogenic protein-1 or Bio-Oss in the chimpanzee.

Sinus grafting procedures are a viable means of ensuring adequate bone for the placement of dental implants in the posterior maxilla. In the quest to improve predictability and accelerate the time line toward receiving a final prosthesis, researchers have turned to recombinant human proteins like osteogenic protein-1 for the potential to therapeutically enhance bone formation. Bilateral sinus augmentations were performed in 15 adults chimpanzees to evaluate treatment with different doses of the osteogenic protein-1 device or natural bone mineral (Bio-Oss). Methods of evaluation included soft tissue healing, radiography (computed tomographic scan), histology, residual lateral wall defect surface area at 7.5 months, and the extent of soft tissue encleftation at 7.5 months. Findings revealed radiographic and histologic evidence of bone formation with all treatment groups and a statistically significant reduction in the depth of soft tissue encleftation and the residual lateral wall defect surface area for both the Bio-Oss and the 2.5-mg osteogenic protein-1 per gram collagen matrix treatments when compared to collagen matrix alone. These results suggest that Bio-Oss and the 2.5-mg osteogenic protein-1 per gram collagen matrix effectively stimulate bone formation in the maxillary sinus.

Analysis of Variance↗