Secondary maxillofacial reconstruction with the radial forearm free flap: a standard operating procedure for the venous microanastomoses.

BACKGROUND: The radial forearm free flap (RFFF) is commonly used in reconstructive surgery. With respect to the maxillofacial region, several venous anastomotic techniques (e.g., single or double anastomoses) have been described, but the debate as to which alternative is preferable is ongoing. A complicating factor is the unpredictable anatomical situation in patients undergoing secondary operation. No recommendations are available for the surgical strategy in such cases. We present a standard operating procedure (SOP) applicable for secondary reconstructions, postulating double anastomoses as the method of choice, and evaluate its efficacy. METHODS: The following parameters were retrospectively analyzed for 120 patients with secondary (41; 34.2%) or primary (79; 65.8%) reconstruction following the instructions of SOP and compared between the study groups: age; sex; history of radiotherapy; side of the donor arm; flap size; preparation and use of the cephalic vein and reasons for its non-inclusion; included venae comitantes; recipient veins; arterial anastomoses; revisions, flap survival, and mortality within thirty days after operation. RESULTS: The method of choice was applicable in 26 (63.4%) secondary and 52 (65.8%) primary reconstructions (no difference; P = 0.841), resulting in 100% flap viability in both groups. In the remaining cases, single venous anastomoses were performed, resulting in 73.3% flap viability in secondary and 100% in primary reconstructions. Flap survival in secondary reconstructions was significantly higher when double anastomoses were conducted (P = 0.012). CONCLUSIONS: The results suggest the necessity of double venous anastomoses in secondary maxillofacial reconstructions with RFFF.

Expression of host defence peptides in the lip vermilion mucosa during early infancy.

Emerging resistance to antibiotics has become a major problem. Host defence peptides (HDPs), which are effector molecules of the innate immune system, show broad antimicrobial activity. Synthetic derivates are currently being investigated as new anti-infectious agents. In infants, the use of conventional antibiotics is limited to a few substances because of adverse reactions. The new HDP substances might become alternatives to conventional antibiotics, but knowledge of the physiological quantities of the HDPs in infants is essential because of a narrow therapeutic index of currently available derivates. This study compares the mRNA levels of five major HDPs between infants and adults to test the hypothesis that HDP gene expression differs between these groups. Expression profiles of human beta-defensin (hBD)-1, hBD-2 and hBD-3, psoriasin and RNase 7 were assessed in the lip vermilion mucosa of infants (n = 15) and adult controls (n = 15) using real-time polymerase chain reaction. A significantly lower expression of hBD-2 (P = 0.043), hBD-3 (P = 0.014) and psoriasin (P = 0.018) was found in infants. No difference between the groups was noted with respect to transcript levels of hBD-1 and RNase 7. In conclusion, several HDPs are expressed at lower levels in infants, but not all. The results emphasize the need to adjust the dose of agents based on the specific HDP level for the treatment of infantile infections.

Use of microvascular flap technique in older adults with head and neck cancer: a persisting dilemma in reconstructive surgery?

OBJECTIVES: To compare perioperative problems and outcomes of reconstructive surgery with microvascular flaps of a group of older (≥ 70) and younger adults (20-69). DESIGN: Prospective clinical cohort study. SETTING: Maxillofacial surgical unit of a university teaching hospital in Munich, Germany. PARTICIPANTS: Two hundred fifteen people with head and neck carcinoma (older: n = 54, mean age 75.8, range 70-96; younger: n = 161, mean age 55.5, range 20-69) who underwent surgery between 2007 and 2009. MEASUREMENTS: Participant characteristics: age, sex, American Society of Anesthesiologists (ASA) status, tumor type, preoperative radiation or chemotherapy, medical comorbidities. Surgical variables: flap type, type of reconstruction (primary/secondary), length of operation (minutes). Postoperative variables: length of stay (minutes) on intensive care unit (ICU), reasons for ICU stay longer than 1,500 minutes (surgical or medical), length of hospitalization (days), and reasons for hospitalization longer than 20 days (surgical or /medical). Short-term outcome within 30 days: revisions, flap success, overall complication rate, mortality. RESULTS: Older adults had a higher ASA class (P < .001) and shorter duration of surgery (P = .02). Age as an independent factor prolonged stay on ICU (P = .008) and was associated with a higher complication rate (P = .003) but had no influence on length of hospitalization, flap success, need for revisions, or mortality. CONCLUSION: Although higher rates of peri- and postoperative difficulties must be expected when microvascular reconstructive surgery is considered for older adults, careful surgical technique, adequate postoperative surveillance, and immediate management of complications can facilitate outcomes comparable with those for younger adults.