The folded radial forearm flap in soft-palate and tonsillary fossa reconstruction: technical note.

Excision of the tonsillary fossa and soft palate leaves functional sequelae unless followed by a well-planned reconstruction phase. This must aim at restoring the pharyngeo-palatal structure, covering the dissected surfaces, and restoring continuity to the lingual and inferior alveolar nerves when these are sectioned. A reconstruction model of this complex three-dimensional anatomical area is proposed that uses a microvascular fasciocutaneous forearm flap adapted to the individual patient. Twelve patients were operated on, following this model. All flaps survived intact. Velopharyngeal function was optimal in 11 cases (92%), suboptimal in 1 case. Patients also achieved good functional recovery (speech, swallowing and chewing). Careful three-dimensional planning of reconstruction for the tonsillary and soft-palate area makes it possible to restore velopharyngeal function to levels close to the preoperative situation.

Surgical approaches to cavernous haemangiomas of the orbit.

Cavernous haemangiomas are the most common orbital masses and the second most common cause of unilateral proptosis after thyroid ophthalmopathy. We retrospectively analysed 19 patients with retrobulbar cavernous haemangiomas, 9 of whom had lateral orbitotomy to remove retrobulbar cavernous haemangiomas located superior (n=4), inferior (n=2) or lateral (n=3) to the optic nerve. Seven patients had lateral orbitotomy together with an anterior medial approach to gain access to retrobulbar cavernous haemangiomas located medially to the optic nerve in the posterior half of the orbit. An anterior approach was used in 3 patient with an anteriorly located cavernous haemangioma. We describe here the planning of surgical treatment based on the site of the lesion.

The free fibula flap for treating benign mandibular lesions.

UNLABELLED: A variety of benign lesions that are typically treated conservatively can affect the mandible. The treatment must be radical when these lesions are locally aggressive and involve the perimandibular soft tissues or involve most of the thickness of the mandible. The main treatment is mandibular resection and reconstruction with bone grafts, mainly iliac crest bone grafts for segmental mandibulectomy or a calvaria bone graft for resection without interruption of the mandible body. These grafts are limited due to the possibility of infection and the unpredictable long-term resorption. Free flap surgery, particularly with fibula free flaps, represents a new era in mandibular reconstruction. This technique has similar donor site morbidity, while the transferred bone resists infection and bone resorption. These advantages are achieved at the cost of a procedure that is about 1 h longer when performed by an experienced microsurgical team. We report our experience with mandibular reconstruction following the surgical resection of benign lesions in 7 patients. All the reconstructions had good RESULTS: After reconstruction, the facial morphology showed restored symmetry of the lower third profile in all patients. The functional results were satisfactory, with restored mandibular function in all cases. No signs of recurrence have appeared in any patient after a mean follow-up of 24 months.

Losses of heterozygosity in oral and oropharyngeal epithelial carcinomas.

We analyzed 25 oral and oropharyngeal epithelial carcinomas for loss of heterozygosity (LOH) and microsatellite instability by using 55 oligonucleotide repeat markers located in 45 chromosomal regions. The aim was to identify which chromosomal regions and tumor-suppressor genes (TSGs) are preferentially lost in these tumors and to relate LOH at specific loci to clinicopathologic data. The analysis was performed on tumor tissue and on a corresponding normal tissue (blood lymphocytes) with the use of the polymerase chain reaction technique followed by microsatellite allele separation with denaturing gel electrophoresis. Thirty-two of 45 chromosomal regions demonstrated a significant (>/=20%) incidence of LOH. An allelic loss of >/=50% was found in 9p21 (77.8%), 8p22-23 (70%), 3p12 (61.5%), 1p36.1 and 12q22 (60%), 3q28 (57.1%), 5q23.3 (54.5%), 3p25-26, 3p24, and 7q35 (50%). We did not find any microsatellite instability. Our results suggest that in addition to a group of TSGs, pleiotropic for several tumor types, other suppressor genes are specifically involved in oral and oropharyngeal carcinogenesis.

Maxillo-malar osteotomy as an approach to the clivus.

Among various approaches to the clivus and upper cervical spine, transmaxillary access gives the neurosurgeon optimal visibility. Maxillo-malar osteotomy permitting the reflection of the osteotomized segment pedicled to the cheek after a Weber-Fergusson type cutaneous incision is the method that for the authors gives the best visibility. A wide operating field from upper clivus to C4 can be obtained by performing a maxillo-malar osteotomy associated with a midline splitting of hard and soft palate. The authors have performed this kind of access in five cases for neurosurgical purposes. Healing was always uneventful and no complications were observed. Occlusion was always restored without intermaxillary fixation, facial scars were of good quality and the only drawback was the section of infraorbital nerve.

Repair of the cleft palate without lateral release incisions: results concerning 124 cases.

The authors report their experience in the treatment of cleft palate patients, with or without cleft lip, carried out without lateral release incisions. The surgical approach was as follows: the cleft palate only was closed in one step at the age of 10 to 12 months, while the cleft of lip and palate was closed in two steps: at 6 months of age the soft palate together with lip and nose repair and at 18 to 24 months the hard palate with gingivo-alveoloplasty. Out of the 147 patients treated from 1984 until 1992, 124 (73 cleft palate, 51 cleft lip and palate) were treated without lateral release incisions, allowing first intention healing in 122 cases. The failures observed involved 2 cases: in the first (a bilateral case with a wide cleft) an almost total dehiscence of the suture at the level of the hard palate occurred, while in the second (a cleft palate case) a small oronasal fistula developed (healed spontaneously in 2 weeks). Our results confirm that by performing the described surgical technique without lateral release incisions, a 98% success rate for closure of a cleft palate could be obtained. Of course, in very large clefts the lateral release incision should be considered however.

Facial nerve injury secondary to lateral displacement of the mandibular ramus.

We describe two cases of facial nerve injury after lateral external dislocation of the mandibular ramus, an event not found in the reviewed literature. We discuss the possible pathogenesis and outline the therapy.

On the feasibility of intraoral maxillo-malar osteotomy.

The maxillo-malar osteotomy is one of the osteotomies developed over the years to correct the deformities of the midface without modifying the nasal projection. After having for many years approached the osteotomy through the classic double access, intraoral and subciliary, we verified the feasibility of this osteotomy via an intraoral route only. For this purpose we modified slightly the classic osteotomy lines, however still including in the mobilized fragment the most prominent and therefore the most aesthetically important portion of the zygoma. At the lower orbital rim the medial osteotomy cut is performed with a fissure bur, the lateral one with an oscillating saw. Both the osteotomies are extended posteriorly in the orbital floor with a fine osteotome. Then, after having performed all other osteotomy cuts, the maxillo-malar complex is down-fractured. The residual thin bone structures which connect the maxillo-malar complex to the cranio-facial skeleton are broken during a careful downfracture, avoiding fracture between the maxilla and zygoma. The complex is advanced and stabilized with intermaxillary fixation, osteosynthesis and bone grafts. A bone graft to the orbital floor is unnecessary.

Facial nerve and parotid surgery.

A series of 100 surgical procedures on the parotid gland affected by tumours is reported, with a detailed analysis of facial nerve function after parotid surgery. A low percentage of temporary lesions (28%) affecting only one branch of the facial nerve, all of which regressed in a short time, and only one case of a permanent lesion affecting the whole nerve, anatomically intact, however, was observed. The authors confirm the safety of parotidectomy, if correctly performed.

The temporalis muscle flap in temporo-mandibular joint surgery.

In the treatment of the severely damaged TMJ structural components (ankylosis, arthrosis, tumour, perforation or degeneration of the disc), it is advisable to insert a biological interposition between bony articular surfaces. The temporal muscle, due to its anatomical, topographical, and functional properties, can be successfully employed for this purpose. Based on the experience of Tessier, Delaire and Rowe, a temporalis muscle flap, inferiorly based, is rotated downwards and medially to the zygomatic arch, interposed and then fixed to condyle and capsule. Using this surgical technique, 12 patients and 13 temporo-mandibular joints were treated with good functional results and without any complication.

Technical refinements in surgical treatment of benign parotid tumours.

Over the last 15 years, a number of techniques have been developed that make it possible to treat benign parotid tumours surgically with virtually no morphofunctional sequelae. Given that the main objectives of the intervention are the complete removal of the lesion as well as isolation and preservation of the facial nerve and its branches, the authors recommend the following procedure: a face-lifting type of incision in order to disguise the cutaneous scar better; preservation of the posterior branch of the great auricular nerve, in order to maintain the sensitivity of the ear lobe; coverage of the residual defect by means of a flap composed of superficial and deep temporalis fascia in order to reduce the postoperative depression in the parotid region and the onset of Frey's syndrome.

The pectoralis major myocutaneous flap. Experience in 100 consecutive cases.

The authors have made a study of 100 consecutive cases in whom a pectoralis major myocutaneous flap was employed for reconstruction after surgical ablation of advanced malignant tumours in the head and neck. The results obtained show that primary healing took place in 74% of cases with a relatively low incidence of complications. The authors therefore confirm the reliability of the pectoralis major myocutaneous flap, which, owing to its rich blood supply, offers the possibility of providing large cutaneous islands, and its proximity to the site of ablation provides a simple and reliable method which may be used in the majority of cases of immediate or delayed reconstruction of the cervico-maxillo-facial area.

Analysis on photographs of the growth of the cleft lip following a rotation-advancement flap repair: preliminary report.

A preliminary report is submitted on the growth of the lip after repair of a unilateral complete cleft (with a modified rotation-advancement flap) in 20 patients. In half of these cases an additional small Z-plasty was performed. The patients were photographed by a standardized method immediately after surgery and again after 18 months. Lip length on the operated side was measured and compared with the opposite side; possible results were: equal, long and short. After 18 months, 65% of all cases remained unchanged, 25% had lengthened and 10% shortened. Among cases treated with an additional small Z-plasty, unchanged and lengthened cases had an almost equal distribution, while the majority (8 out of 10) of the cases treated without Z-plasty remained unchanged. Consequently, the authors emphasize the benefits of reconstructing the cleft lip as symmetrical to the opposite side as possible or, at the most, moderately shorter only in cases treated with an additional Z-plasty.

Recovery of infraorbital nerve function after zygomaticomaxillary cheek pedicled flap.

The zygomaticomaxillary cheek pedicled flap (ZMCF) involves the intentional section of the infraorbital nerve to reflect the flap laterally in order to give access to the rhinopharynx, clivus and upper cervical spine. The aim of this trial was to examine the recovery of sensation of the infraorbital nerve, both quantitatively (touch sensation, localisation test, two-point discrimination) and qualitatively (sharp/blunt test, temperature sensation, pain sensitivity, dental sensitivity) in 7 patients, at least 12 months after surgery. In each patient, four cutaneous areas (lower eyelid, nose ala, upper lip, cheek) and the upper vestibulum were tested. Results of each test in all the examined areas were evaluated and compared with the data obtained on the nonoperated side (control side). Results of neurosensory tests indicated good recovery of sensation with little difference in comparison with the control side, showing that the functional consequence of ZMCF should actually be considered only as a transitory event.

Resection of endonasal neoplasm by means of modified maxillo-zygomatic cheek flap.

To remove an endonasal tumour an access osteotomy has been designed which can be used for tumours of the nasal cavity. This approach allows for a safe and adequate tumour resection without appreciable morphological and functional consequences for the patient.

Jaeger's jugal extended incision to approach the pterygomaxillary region.

In oncological surgery of the pterygomaxillary fossa it is essential to achieve a wide access. For this purpose we have employed the old Jaeger's incision extended posteriorly in association with access osteotomies (zygoma and coronoid). In our experience (9 cases) the jugal access has provided good results without noticeable cutaneous scars. The technique is described with the presentation of 2 cases.

Conservative treatment of arteriovenous malformations of the mandible.

A modified technique is reported on the treatment of arteriovenous malformations in the mandibular body. The technique consists of highly selected embolization and piecemeal removal of the lesion through burred holes made in the cortex. This way the mandible and the teeth may be saved in selected patients.

Reconstruction of the orbital walls in surgery of the skull base for benign neoplasms.

Surgery for benign neoplasm extending into the orbital roof requires immediate reconstruction to avoid complications, which include transmission of the cerebral pulse to the globe, bulbar dystopia, diplopia, and fibrosis of the oculomotor muscles. Many alloplastic materials have been employed for such reconstruction, but currently most authors agree that autologous bone graft is the best option. Using calvarial bone in adults and split ribs in children, we have operated on eight patients for fibrous dysplasia (five cases), neurofibroma (two cases), or meningioma (one case). After a median follow-up period of two years and six months, good morphology of the orbit was maintained with no ocular symptoms.

The early gingivoalveoloplasty. Preliminary results.

To try and achieve good alveolar structure without the need for later bone grafting, we have carried out secondary gingivoalveoloplasties in 19 consecutive patients with cleft lip and palate at a mean age of 36 months (range 19-68). The lip and soft palate had been repaired at a mean age of 6 months. Preliminary results suggest that simultaneous closure of the hard palate and reconstruction of the alveolomaxillary cleft results in good formation of new bone and good or reasonable alveolar structure, so obviating the necessity for bone grafting at the age of 9-10 years. Long term follow up is needed to confirm these results.

[Mouth oepning limitations due to coronoid-zygomatic-malar interference]. / Le limitazioni di apertura della bocca da interferenza coronoido-zigomatico-malare

Interferences between coronoid process and bone walls of the zygomatic arch should always be considered among the causes of extra-ankylotic mouth-opening limitation. With the exception of traumatic cases, the event is rare and once correct diagnosis has been made there are excellent opportunities for treatment, largely of surgical nature. The zygomatic-malar area or coronoid process will be operated on depending on the case. When surgery has involved the coronoid process it is advisable to follow up with an adequate period of mechanotherapy.