The Arterialized Facial Artery Musculo-Mucosal Island Flap for Post-Oncological Tongue Reconstruction.

BACKGROUND: In 1992, Pribaz described the facial artery musculomucosal flap (FAMM), an axial musculomucosal flap based on the facial artery. The FAMM flap, a modification of the nasolabial and buccal mucosal flaps, is widely used in the reconstruction of defects in the oral cavity. Many modifications of this flap have been described in the literature. Here we aimed to explore the use of an arterialized tunnelized FAMM island flap (a-FAMMIF) for the reconstruction tongue defects after tumor resection. METHOD: From January 2015 to December 2016, five cases of tongue cancer were selected for the use of arterialized FAMMIF flap to reconstruct defects after tumor resection. RESULTS: Reconstruction was successful in all cases, except one case of total flap necrosis; partial necrosis of the flap occurred in two patients, which were solved with medications. CONCLUSION: The authors consider the a-FAMMIF an unreliable flap in the reconstruction of tongue defects.The authors recommend avoiding tunneling and island modification when the vein is not included in the pedicle.

The Use of a Superiorly Based Melolabial Interpolated Flap for Reconstruction of Anterior Oronasal Fistulas: An Easy and Practical Solution.

PURPOSE: This study aimed to propose the use of a superiorly based melolabial interpolated flap for reconstruction of anteriorly located oronasal fistulas maxillary defects. MATERIALS AND METHODS: Using a prospective study design, we evaluated indications and outcomes of the reconstructive technique using the interpolated melolabial flap in 6 patients affected by anteriorly located maxillary defects with naso-sinonasal communication. The cases differed in demographic characteristics and etiology of the defect. The outcome variables were flap vitality/failure and persistent/recurrent oronasal fistula. Both the outcomes were clinically evaluated. RESULTS: No partial or total flap failures were recorded. Two patients experienced recurrent oronasal fistula after previous attempts of correction that required second surgery repair; in both cases, the melolabial flap was available and functional for the secondary procedure. CONCLUSIONS: In selected cases, the superiorly based interpolated melolabial flap could represent a valuable choice for repairing of anteriorly located maxillary defects with oronasal fistulas.

Anterior retrograde approach to the myofascial temporalis muscle for orbital reconstruction: series of 9 consecutive cases.

BACKGROUND: Among the reconstructive options after orbital exenteration, the temporalis myofascial flap (TMF) has been widely recognized as the one of the best available solutions. We think that the hemicoronal approach to harvest the TMF represents a disadvantage so we adopted a modified approach that we named the anterior retrograde approach to the TMF. METHODS: Nine patients with malignant orbital tumors underwent orbital exenteration and primary reconstruction with TMF harvested with the anterior retrograde approach. The temporalis muscle was widely exposed through the anterior incision used to perform the orbital exenteration. The harvested flap was then rotated and insetted to fill the orbital cavity. RESULTS: Neither cases of total/partial flap failure nor local/regional recurrence of tumor were recorded. The technique showed a significant reduction of morbidity, surgical time, and blood loss compared with the traditional technique. CONCLUSIONS: We think that the anterior retrograde approach should be considered as a valid alternative to the traditional hemicoronal approach.

Mandibular reconstruction with different techniques.

Traumas, malformative or dysplastic pathologies, atrophy, osteoradionecrosis, and benign or malignant neoplasm can cause bone deficits in the mandible. Consequent mandibular defects can determine aesthetic and functional problems; therefore, being able to perform a good reconstruction is of critical importance.Several techniques have been proposed for mandibular reconstruction over the years. In this article, we present and discuss the evolution during the time of the methods of mandible reconstruction as well as pros and cons of each procedure on the basis of experience of 10 years in the maxillofacial department of the Catholic University of Sacred Heart of Rome.Free flaps represent the gold standard method of reconstruction of large mandibular defects: the fibula bone flap represents the best choice for large defects involving the arch and the mandibular ramus, whereas the deep circumflex iliac artery represents a valid alternative for mandibular defects involving the posterior region.In cases where free flap reconstructions are contraindicated, the use of regional pedicle flap combined with autologous bone grafts still represents a valid choice. Patients who are not deemed suitable for long and demanding surgery can still be treated using alloplastic materials in association with regional pedicle flap or, when adjuvant radiation therapy is needed, by simple locoregional pedicle flap. Finally, in selected cases, the bone transporting technique should be considered as a valid alternative to the more "traditional" reconstructive methods because of the extraordinary potential and its favorable cost-benefit ratio.

Equine pericardium membrane to prevent dorsal irregularities in rhinoplasty.

Even after a well-executed rhinoplasty, small dorsal irregularities are not uncommon. Many materials have been used for camouflage, including autologous, homologous, and alloplastic materials. We used an equine pericardium membrane in 33 postrhinoplasty patients to prevent or correct nasal dorsal irregularities. The membrane promotes a local fibrous reaction, which leaves a uniform connective layer. In our hands, equine pericardium membrane seems to be a useful material for rhinoplasty refinements.

The Resting Angle Suture.

SUMMARY: The goal of every rhinoplasty surgeon is to create a functional and aesthetically pleasing nose. The lateral crura resting angle, a recently described key concept, should be taken into consideration to achieve a satisfactory result. In this article, the authors describe the resting-angle suture, a novel technique derived from the inversion suture used to correct ectropion deformity in lower eyelid surgery.

Vertical distraction osteogenesis combined with bilateral 2-step osteotomy for preprosthetic rehabilitation of edentulous mandible.

The aim of the current study was to appraise the effectiveness of distraction osteogenesis combined with bilateral 2-step osteotomy for the vertical augmentation of atrophic edentulous mandibles. To verify the predictability of this technique, we evaluated bone density and vertical bone gain of a cohort of 27 patients. The intraoral alveolar distractor was placed in the symphyseal area; then, it was left in situ for 2 months after surgery to consolidate the newly formed bone. A total of 189 implants were inserted. The main complications' issue was tied up to the neurosensory disturbances of the inferior alveolar nerve, which disappeared few months after the surgery.At the end of the distraction osteogenesis, a mean vertical bone gain of 10.5 mm evaluated by comparing preoperative and postoperative computed tomography was reached. Three months after the surgery, the radiologic data indicated that the difference in the mean bone density, recorded in Hounsfield units (HU), between the distracted bone and the preexisting mandibular bone was not statistically significant (P > 0.05). The last measurements done showed that the osseous density in the distraction chamber was higher than the original medullary bone density: the regenerated bones were more dense (876.8 [205.9] HU) than the preexisting medullary bone (312.1 [142.3] HU) and less dense than the preexisting cortical bone (1721.1 [170.4] HU) at the ninth month.In conclusion, this approach appeared to be a viable solution for the improvement of vertical volume in atrophic mandibles.

Evaluation of obstructive sleep apnea in pediatric patients with facio-craniostenosis: a brief communication.

PURPOSE: This study aimed to evaluate our experience in treating cranio-maxillo-mandibular malformations with hypoplasia of the upper and middle third of the face. We wished to determine a new diagnostic path involving a new clinical questionnaire for obstructive sleep apnea (OSA) evaluation, which we have developed by merging existing tests, literature findings, and our clinical experience to obtain a high level of information with minimal cost. This questionnaire is an improvement of the other anamnestic tests in the literature. METHODS: The study was carried out on 17 pediatric patients affected by syndromic craniofacial malformations and treated with surgical advancement of the middle third of the face, associated with or without upper third advancement, through osteodistraction. We used the obstructive airway child test (OACT) for clinical evaluation. The OACT is an OSA assessment test based on questions proposed to the patient's relatives. All patients underwent polysomnography for instrumental assessment of OSA. These patients were also required to have a computed tomography scan for surgical planning. At the start of the treatment, 11 patients had severe OSA, 4 patients had moderate OSA, and 2 patients had slight OSA. RESULTS: At the end of the treatment, 6 patients had slight OSA and 11 patients had no OSA; these data were confirmed with OACT and polysomnography. CONCLUSIONS: Based on our results, we suggest the following flowchart: OACT for OSA clinical evaluation; CT scan for evaluation of the volume of the rhinoropharyngeal air column, anatomical obstruction detection, and surgical planning; and polysomnography for diagnostic confirmation.

Giant neglected desmoplastic ameloblastoma: reconstruction with free fibula flap.

The desmoplastic ameloblastoma (DA) is a rare variant of the conventional ameloblastoma. It accounts for only 4% to 13% of all ameloblastomas. In this article, we describe the case of a young child affected by a giant neglected DA of the jaw. Preoperative biopsy demonstrated the extremely rare osteoplastic variant of DA. The patient was submitted to segmental mandibulectomy and immediate reconstruction with a free fibula osseous flap. The postoperative period was uneventful. The patient was very satisfied with the functional and aesthetic results of the procedure. In case of such rare variants of ameloblastoma, it is mandatory to preoperatively recognize them to allow the adequate treatment modality to be provided.

Clinical evaluation of obstructive sleep apnea in children.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is often found in children affected by congenital or acquired craniomaxillomandibular malformations. This disease carries different levels of risk, ranging from attention problems at school to growth problems and serious disorders, such as cor pulmonale or sudden infant death. The examination that is most commonly used to evaluate the severity of OSAS is polysomnography, and the therapeutic course is often determined by the disease state. Considering the discrepancy between clinical history and polysomnographic findings, we felt the need to identify an instrument for evaluating OSA to be used as a support for polysomnography. MATERIALS AND METHODS: This study was carried out on pediatric patients affected by congenital or acquired craniomaxillofacial malformations. We selected 34 pediatric patients, including 15 boys and 19 girls, aged between 1 and 16 years, with a mean age of 7.3 years. The study consisted of individuation of common clinical history data obtained from each patient and associating those data with the level of OSA severity identified by polysomnography. We were able to isolate certain symptoms and signs that can be predictive of OSA from research in the literature and our clinical experience with pediatric patients. In the clinic, we have found that the clinical history, given by the parents, often differs significantly from the instrumental findings obtained with polysomnography. From the previously expressed considerations and comparison of clinical history data and questionnaires, we have extracted the most significant questions for our questionnaire, which are present in the literature but formulated for adults. RESULTS AND CONCLUSIONS: The obstructive airway child test was found to be a very efficient method to evaluate and diagnose OSA. In all patients, it consistently revealed the pathology and never underestimated OSA severity. The examination focuses on clinical signs and symptoms because, in our opinion, clinical history, reported by the parents, can be more accurate than any instrumental examination.

Total or subtotal glossectomy with microsurgical reconstruction: functional and oncological results.

INTRODUCTION: Management of patients after total or subtotal glossectomy presents challenging reconstruction of complex three-dimensional defects. Such defects can have a dramatic effect on respiration, speech, and nutrition, and may significantly impact quality of life. PATIENTS AND METHODS: We present our experience with 39 patients submitted to total or subtotal glossectomy and reconstruction with microsurgical flaps. Functional results are reported in term of swallowing ability, decannulation, and intelligible speech. Oncological outcomes are described in terms of local disease control and overall survival rate. RESULTS: We carried out 24 total glossectomies and 15 subtotal glossectomies. Total glossectomy was associated with a total laryngectomy in eight patients. Reconstruction was performed using Taylor's myocutaneous extended deep inferior epigastric flap in 33 patients, and an anterolateral thigh perforator flap in six patients. A fibula osteocutaneous free flap was raised in two patients with an anterior segmental mandibulectomy. A second free flap was needed in three cases. Wound complications occurred in 17 patients: an orocutaneous fistula in eight patients and a dehiscence of the suture without fistulization in nine patients. Oral feeding was resumed in 33 patients (85%). In nonlaryngectomized patients, decannulation was achieved in 28 (90%) and speech was good or acceptable in 27 (87%). The 5-year adjusted survival for patients treated with total or subtotal glossectomy was 47%. CONCLUSION: Our results in a relatively large sample of patients who underwent total or subtotal glossectomy followed by reconstruction with microsurgical free flaps support the efficacy of this surgery as treatment for advanced oral and oral pharyngeal cancers.

Retrobulbar lipofilling to correct the enophthalmos.

In this article, we describe an alternative procedure to restore the retrobulbar volume in enophthalmic patients. We report the case of a patient with a late enophthalmos we submitted to retrobulbar lipofilling to correct the defect. The preoperative assessment and the surgical technique are described in detail. The volume of fat injected was 3.2 mL, with a satisfying increase in exophthalmometry measurements. The procedure was well tolerated without complications. Retrobulbar lipofilling for enophthalmos appears to be a safe alternative technique for orbital volume enhancement. It avoids the use of alloplastic materials and allows to obtain good cosmetic results with an easy technique and minimal donor-site morbidity.

Nasal and ethmoidal alterations in anterior synostotic plagiocephaly.

BACKGROUND: Nasal deviation plays an important role in plagiocephaly nosography, and it is frequent in plagiocephaly and objectivable both in early treated patients and in those patients who did not undergo any surgical correction. PATIENTS AND METHODS: The group analyzed consisted of 12 patients affected by anterior synostotic plagiocephaly. All of them had reached the end of growth. A morphological analysis was made by using anthropometry. All patients were asked to undergo computed tomography, and all the scans were then reconstructed into three-dimensional models using a dedicated software. We made two-dimensional assessments on coronal and axial slices, and three-dimensional reconstruction was used to evaluate the volumetry of ethmoidal cells. RESULTS AND DISCUSSION: From anthropometry, we realized that, in all patients, not only that the tip of the nose is deviated to the not affected side but also that the root itself does not lie on the midline and it is tilted to the synostotic side. Analysis of the computed tomographic scan results shows that the ethmoid bone, as much as the vomer and the upper maxilla, is deeply involved in these nasal abnormalities, presenting a deviated position and an altered development. CONCLUSIONS: We concluded that nasal morphology in plagiocephaly is strictly related to basicranium dysmorphism.

Three-dimensional analysis and treatment planning of hemimandibular hyperplasia.

INTRODUCTION: The advent of computed tomography (CT) provided a useful instrument for diagnosis and surgical treatment of patients with craniofacial malformations. The development of software for three-dimensional graphic simulation applied to CT scan has made possible the three-dimensional computerized analysis, surgical planning, and simulation. This kind of analysis is particularly useful in case of complex facial malformations, making reliable a surgical treatment in 1 step. The purpose of this report was to present the diagnosis and treatment planning on a patient with hemimandibular hyperplasia by three-dimensional cephalometric analysis. METHODS: A 20-year-old young woman who presented with hemimandibular hyperplasia was investigated with CT scan and plaster cast mounted on an articulator; a two-dimensional manual and computerized cephalometric analysis was also developed on frontal and lateral cephalograms. Images in DICOM format were processed on a PC by means of commercial software, thus obtaining the three-dimensional reconstruction of the skeletal structures. RESULTS: Three-dimensional CT permits to program skeletal corrections and to foresee surgical outcomes with adequate realism. Surgical planning based on three-dimensional CT makes it easy and reliable to achieve the correction of the malformation in a single surgical intervention. CONCLUSIONS: The virtual three-dimensional CT model, a versatile diagnostic aid, has proven to be effective in the exact reproduction of bone and soft tissue anatomy, thus helping in the diagnosis, surgical planning, and simulations. Three-dimensional analysis is particularly indicated in case of complex asymmetric malformations, in which the more accurate reproduction of the individual anatomy can be very useful in implementing surgical results.

Hilotherm efficacy in controlling postoperative facial edema in patients treated for maxillomandibular malformations.

BACKGROUND: A cooling system based on polyurethane preshaped masks for postoperative cryotherapy, named Hilotherm, has been recently introduced. The purpose of this study was to evaluate the effectiveness of this equipment in controlling postoperative edema and compare the results with those obtained with a group treated with conventional cryotherapy and a group not treated with cryotherapy. METHODS: Ninety patients were included in this randomized controlled trial. The 90 patients were divided into 3 groups. Group A was treated with Hilotherm. Group B was treated with conventional cryotherapy. Group C was not treated with cryotherapy. Using a tape measure, we measured for both sides of the face the distances in centimeters between point 0 and external canthus ([alpha]), most lateral point on the ala of the nose ([beta]), commissura labialis ([gamma]), and Pos ([delta]). We performed a Kruskal-Wallis test comparing the average variation of edema on the right and left sides of the face for each facial segment of patients of the 3 groups from time 0 to time 24 hours. RESULTS: No cryotherapy is the worst treatment for every segment studied. In anatomic regions defined [beta], [gamma], and [delta], Hilotherm was more effective in containing edema than the ice pack 24 hours after the first measurement. Opposite results were seen on district [alpha], the site not completely enclosed in the mask. CONCLUSIONS: The substantial difference between different treatments probably consisted in the greater reliability of the Hilotherm system, which is characterized by easy handling, constant temperature control, comfort, and practicality of the masks.

Zygomatic sagittal split osteotomy: a novel and simple surgical technique for use in midface corrections.

BACKGROUND: The correction of many craniofacial malformations requires the improvement and stabilization of the midface area. In this article, we present a simple surgical technique for improving and correcting the orbitozygomatic area. This technique is called zygomatic sagittal split osteotomy (ZSSO). METHODS: Between September 2003 and June 2008, we performed ZSSO on 12 patients. The technique is described in the article. We performed a clinical evaluation of the technique using the following criteria: postsurgical complications, loss of stability, and sagittal prominence. In addition, a radiologic evaluation was performed on axial computed tomographic images. We considered a 1-year follow-up. RESULTS: We performed 15 ZSSO procedures. No evidence of postsurgical complications, loss of stability, or sagittal prominence was reported during the 1-year follow-up. CONCLUSIONS: Zygomatic sagittal split osteotomy is a simple surgical technique to be used in the correction and stabilization of the midface area. It can be performed without using graft or osteodistraction device.

Autofluorescence and early detection of mucosal lesions in patients at risk for oral cancer.

Loss of autofluorescence as an early phenomenon associated with tissue degeneration seems to be promising for the diagnosis of oral cancer. The method seems to make visible early structural and biochemical alterations of the oral mucosa not always evident under direct inspection of the oral cavity. For this reason, the margins of the mucosal lesions usually appear wider compared with direct visualization. Actual extension of the potentially malignant lesions must be precisely perceived to avoid any underestimation of the tumor. In this study, 32 patients at risk for oral cancer underwent autofluorescence test. Of these patients, 12 (group A) experienced potentially malignant diseases. The other 20 patients (group B) were previously operated on for oral cancer. In addition, 13 patients showed loss of autofluorescence (8 patients from group A and 5 patients from group B). Among these 13 patients, 12 were affected with lesions of relevance (in group A, 6 had squamocellular carcinoma and 2 had low-grade dysplasia; in group B, 2 patients had high-grade dysplasia, 2 had low-grade dysplasia, and 1 had an epithelial hypertrophy with inflammatory cells). Preliminary results seem to indicate that autofluorescence is a high-performing test for the individuation of oral cancer in populations at risk (sensibility up to 100% and specificity up to 93% in this study).

In search of the ideal method in perforator mapping: noncontrast magnetic resonance imaging.

A reliable method for precise identification of the dominant perforator would be extremely valuable in perforator flap surgery. During the past 5 years, multidetector-row computed tomography has demonstrated excellent results in preoperative planning of abdominal free flap breast reconstruction, significantly reducing operative time and complications. The main drawbacks of computed tomography are unnecessary radiation to the patient and possible allergic reactions to intravenous contrast material. To circumvent these limitations, we performed noncontrast magnetic resonance imaging for abdominal perforator mapping. The aim of our study was to assess the accuracy and reliability of this technique in preoperative planning of breast reconstruction with deep inferior epigastric artery perforator flaps. From October 2007 to February 2009, noncontrast magnetic resonance preoperative mapping was performed in 56 female patients who underwent breast reconstruction after mastectomy with deep inferior epigastric artery perforator flaps. Imaging results were compared with the intraoperative clinical findings in all patients. Preoperative magnetic resonance imaging without the contrast showed no false-positive or false-negative results. In all cases, the perforator chosen as dominant according to magnetic resonance images corresponded with the perforator chosen intraoperatively (100% predictive value). Preoperative imaging techniques make perforator flap surgery safer for the patient. Noncontrast magnetic resonance imaging provides reliable information on the vascular anatomy of the abdominal wall, facilitating selection of the most appropriate deep inferior epigastric artery dominant perforator. It avoids radiation to the patient and also the need for intravenous contrast medium as required for the multidetector-row computed tomography. In our opinion, noncontrast magnetic resonance imaging is an ideal method for preoperative planning of breast reconstruction with deep inferior epigastric artery perforator flaps.