The use of acellular dermis in the prevention of Frey's syndrome.

EDUCATIONAL OBJECTIVE: At the conclusion of this presentation, the participant should be able to discuss the indications and advantages of using acellular dermis in the prevention of post-parotidectomy gustatory sweating (Frey's Syndrome). INTRODUCTION: Gustatory sweating is a common postoperative problem and a challenge to treat. The purpose of this study was to evaluate the role of acellular dermis in preventing post-parotidectomy gustatory sweating. METHODS: Sixty-four patients were randomly assigned to two groups. Group I consisted of 32 patients who underwent a superficial lobe parotidectomy. Group II consisted of 32 patients who underwent a superficial lobe parotidectomy and underwent intraoperative placement of acellular dermis within the parotid bed, between the skin flap and the remaining parotid tissue. The implanted volume of acellular dermis was determined by the amount required to aesthetically restore lateral facial contour. All 64 patients were evaluated for gustatory sweating by identical phone and mail questionnaires. Thirty randomly chosen patients (group I = 15, group II = 15) were evaluated using a modified Minor's Starch-Iodine Test (MSIT). In all 30 patients, the MSIT was administered to both sides of the face. RESULTS: The responses to questionnaires (N = 64) demonstrated the subjective presence of gustatory sweating in 3 of 32 patients (9.3%) in group I, whereas group II demonstrated a subjective incidence in 1 of 32 patients (3.1%). The objective incidence determined by those who underwent the MSIT (n = 30) revealed a 40% (6) and 0% incidence of Frey's Syndrome in groups I and II, respectively. The complication rate in group I was 9% (3 seromas) and in group II it was 25% (7 seromas and 1 wound infection). CONCLUSIONS: Acellular dermis appears to be an effective method for preventing post-parotidectomy gustatory sweating, despite its higher complication rate.

Reconstruction of the pediatric maxilla and mandible.

BACKGROUND: The creation of osseous defects in the upper and lower jaws in children is an uncommon occurrence. It is therefore likely that a head and neck reconstructive surgeon will accumulate only limited experience in restoring such defects. We have reviewed 7 pediatric bone-containing microvascular free flap reconstructions in 6 patients for reconstruction of the upper or lower jaws. Three patients were available for long-term follow-up to evaluate the effect of osseous free flap reconstruction on function and growth and development of the donor site. DESIGN: Retrospective review. SETTING: Academic tertiary referral center for otolaryngology. PATIENTS AND METHODS: Six pediatric patients ranging in age from 8 to 16 years underwent 2 fibular, 4 scapular, and 1 iliac free flap procedure for restoration of 2 maxillary and 5 mandibular defects from 1992 to 1997. Three of the 6 patients were available for long-term follow-up to assess the postoperative donor site function in an effort to determine the effect of this surgery on long-term donor site morbidity and development. RESULTS: Two patients were lost to follow-up, and 1 died secondary to complications related to distant metastatic disease. Three of 6 patients were observed for 2 years 6 months, 4 years, and 4 years 2 months, respectively. Two of the 3 patients who were observed long term have undergone full dental rehabilitation and currently maintain a regular diet and deny pain with mastication or deglutition. One patient did not require dental rehabilitation. All 3 patients demonstrate gross facial symmetry and normal dental occlusion. Assessment of the fibular donor site demonstrated normal limb length and circumference. The patients denied pain or restriction to recreational activity. Scapular donor sites demonstrated normal range of motion, strength, and shoulder stability. CONCLUSIONS: Free flap reconstruction of the pediatric maxilla and mandible requires harvesting bone from actively growing donor sites. We have found no evidence of functional deficit after bone harvest from the fibular or scapular donor sites. Patients demonstrate normal growth at the donor sites, and symmetry of the mandible and maxilla is preserved.

Iliac crest internal oblique osteomusculocutaneous free flap reconstruction of the postablative palatomaxillary defect.

BACKGROUND: Traditionally, restoration of extensive palatomaxillary defects have been achieved by prosthetic restoration, often with suboptimal functional results. More recently, vascularized bone-containing free flaps have been used for this purpose. OBJECTIVE: To describe 6 patients who underwent palatomaxillary reconstruction using the composite iliac crest-internal oblique osteomusculocutaneous free flap. METHODS: Six cases of iliac crest osteomusculocutaneous free flap reconstruction of extensive postablative palatomaxillary defects were retrospectively reviewed with clinical follow-up. We reviewed these cases for pathologic findings, defect size, dental restoration, oral rehabilitation, and speech. RESULTS: Pathologic findings included squamous cell carcinoma (n = 4), osteogenic sarcoma (n = 1), and sinonasal hemangiopericytoma (n = 1). Mean follow-up was 14.5 months (range, 10-25 months). Four patients underwent resection and reconstruction primarily and 2 underwent reconstruction secondarily. Two patients required reconstruction of a cutaneous defect using the iliac skin paddle. The hard palate and lateral nasal wall were reconstructed in all 6 patients, and the orbital rim and zygomatic body were reconstructed in 4. One patient underwent reconstruction with an orbital prosthesis supported by osseointegrated implants. There was 1 donor site complication and 1 recipient site infection, which was treated successfully with oral antibiotics. Four patients were rehabilitated with osseointegrated implants, and all 6 patients maintain an unrestricted oral diet. All 6 patients have normal speech without velopharyngeal or oronasal insufficiency. CONCLUSION: For extensive palatomaxillary defects, the iliac crest-internal oblique osteomusculocutaneous free flap offers a reliable method of primary reconstruction, allowing for complete orodental rehabilitation without the use of a prosthetic obturator.

The scapular osteofasciocutaneous flap: a 12-year experience.

OBJECTIVE: To elucidate the factors that play a role in the decision-making process to use the scapular donor site, we have reviewed our 15-year experience with 57 clinical cases, to our knowledge the largest case series to date. DESIGN: Retrospective, single-surgeon medical record review. PATIENTS AND METHODS: Retrospective review of 57 consecutive cases (53 patients) involving mandibular and maxillary reconstruction using bone-containing scapular free flaps over a 15-year period. Composite flap composition as well as donor and recipient site complications were recorded. RESULTS: Forty-one reconstructions were performed for mandibular defects, 11 were performed for maxillary defects, and 5 for combined defects involving the mandible and maxilla. Seven flaps were composed of 2 separate bone flaps using the angular branch and the circumflex scapular artery. A total of 6 flaps were failures in 5 patients, giving an overall success rate of 89%. CONCLUSIONS: The subscapular system of flaps is a versatile donor site that offers distinct advantages in the older patient population as well as in patients with a preexisting gait disturbance. It is particularly advantageous in patients requiring a large surface area of soft tissue to restore their defect.