The caudal-lateral inserted transposition flap in reconstructive tumor surgery on the nasal ala.

The nasal region represents an important three-dimensional esthetic unit where minimal distortion will be obvious and disturbing. In this regard the reconstruction of the nasal ala in dermatologic tumor surgery may be challenging. We propose the reconstructive option of a caudal-lateral inserted transposition flap for this indication. The principle of this surgical alternative and the long-term outcome is demonstrated in representative cases. The various indications and modifications of this reconstructive principle are discussed and compared to other remodeling alternatives.

Reconstruction of large defects on the scalp and forehead as an interdisciplinary challenge: experience in the management of 39 cases.

AIMS: To describe options and indications for different surgical reconstruction techniques after resection of large skin tumours on the scalp taking into account an interdisciplinary approach of cranio-maxillofacial surgeon, dermatologist, and neurosurgeon, and to evaluate complications and postoperative outcome. PATIENTS AND METHODS: From a total of 39 patients with large skin tumour resections on the scalp and/or the forehead, treated between January 01, 1995 and June 30, 2005, a number of 42 surgical reconstructions were performed. The medical histories, the surgical treatment, postoperative complications, follow-up and outcome were evaluated. RESULTS: The excision defects measured 146 cm(2) (range: 80.6-546 cm(2)) on average. The most common methods for defect closure were multiple rotation-advancement flaps (n=19). Six patients were treated with split-thickness skin grafts after bone drilling for inducing granulation tissue to grow. Free latissimus dorsi muscle flaps were used in 8 patients and radial forearm flaps in 4 cases. Postoperative complications were rare. An algorithm for the surgical approach to large scalp defects was developed. CONCLUSION: For reconstruction of large defects on the scalp and forehead, various reliable methods may be used with regard to individual patient-specific parameters in cooperation with different medical specialties involved.

Surgical reconstruction after subtotal ear resection in malignant melanoma of the ear.

Surgery in malignant melanoma of the external ear often leads to substantial defects where reconstruction poses a difficult challenge. We describe an option of a one-step ear reconstruction after subtotal ear resection in malignant melanoma surgery. In a patient with a high-risk melanoma of the helical rim, a wide local excision was performed. Because of a metastasis-suspect lymph node in the parotid gland, surgery included asservation of the sentinel lymph node, neck dissection and parotidectomy. A complete reconstruction of the ear was achieved using a bilobed flap from the retroauricular and neck region with acceptable cosmetic and functional results by one-step surgery. One micrometastasis was detected in the nuchal region but not in the marked sentinel lymph node. An adequate one-step ear reconstruction as described may also be performed to the benefit of patients with high-risk melanomas, allowing early adjuvant therapy.

Principles of bone formation driven by biophysical forces in craniofacial surgery.

Biophysical forces, particularly mechanical loading and electromagnetic signals, are important regulators of bone formation. Indeed, the regenerative capacity of bony tissue is largely the result of the bone's capacity to recognise the functional environment required for the emergence and maintenance of a structurally intact bone. Biophysical methods of stimulation have therefore been introduced and have proved successful in clinical practice with craniofacial bones. Distraction osteogenesis, application of ultrasound, calculated transfer of stresses, and exposure to an electromagnetic field are some examples of biophysically driven approaches to influencing bone formation. The purpose of this review is to provide an insight into cellular and tissue models that are used to study the effects of biophysical stimuli on bone.

[Aggressive fibromatosis in the jaw and facial region with bone involvement. A review]. / Aggressive Fibromatose im Kiefer-Gesichts-Bereich mit ossärer Beteiligung. Eine Ubersicht.

BACKGROUND: Aggressive fibromatosis (AF) involving bones of the head is rare and surgery is often complicated by a high recurrence rate. Interdisciplinary treatment is of the utmost importance to avoid extensive, mutilating resection. Two cases emphasize the difficulties in the management. CASE REPORTS: A 67-year-old woman was referred to our unit with a blepharochalasis of the left upper palpebra and a palsy of the face on the left side. Her medical history included 12 operations over the previous 4 years for an extensive AF. MATERIAL AND METHODS: Our review includes all case reports of AF involving bones of the head published between 1960 and 2004. Additionally, our two cases are presented. Signs, symptoms and outcome were analyzed in relation to different treatment options. CONCLUSION: According to the literature, surgery is the most common treatment for AF in the head and neck region. Alternative modes of therapy must be considered because of the high recurrence rate and to avoid mutilating operations.

Score system for elective tracheotomy in major head and neck tumour surgery.

BACKGROUND: This study was designed to evaluate prognostic parameters for respiratory failure after major oropharyngeal resections in head and neck cancer surgery, focusing on a score system to identify patients requiring an elective tracheotomy and to avoid tracheotomy under emergency conditions. METHODS: One hundred and fifty-two out of 928 patients with oropharyngeal cancers, treated between January 1993 and June 2000 at our hospital, fulfilled the inclusion criteria for a retrospective analysis. This collective underwent tumour resection in different regions of the oropharynx combined with bony resection of the mandible and neck dissection without primary tracheotomy. The reconstruction was accomplished using radial forearm flaps (n1 = 59) or local flaps (n2 = 93). These two groups were subdivided into patients treated post-operatively by tracheotomy due to respiratory failure (n1 = 26; n2 = 12) and those without such treatment (n1 = 33; n2 = 81). The database comprising tumour localization and size, staging, general medical condition, smoking and alcohol consumption was evaluated by logistic regression. RESULTS: We developed a score system which predicts the likelihood of post-operative respiratory failure. For indication of tracheotomy, tumour size and localization, multimorbidity, alcohol consumption and pathologic chest X-ray findings were identified as significant parameters with different weightings. The predictive value for tracheotomy (yes/no) using the score system was 96.7% for the total collective. CONCLUSION: The decision on whether or not an elective tracheotomy in major head and neck tumour surgery is necessary can be facilitated using this score system which is based on objective facts. It may reduce post-operative complications and contribute to safer treatment.

Internet-capable publication database system.

Scientific databases are generally accessible to the public via the Internet. Reports of most peer-reviewed (quotable) research is thus available to researchers and others. However, other reports and information of interest to researchers and teachers such as poster presentations at congresses, articles describing techniques and teaching material, and details of vocational and continuing education courses (nonquotable literature) generally do not appear in such databases. This nonquotable literature is often of great use to teachers. A project was therefore initiated at the Münster Dental Clinic which aimed to address the problem by developing a database of all publications and other printed material produced by the staff (faculty). After a systematic search, all such publications (quotable and nonquotable) were entered in the database which is partially accessible via the Internet and fully accessible via the Münster Dental Clinic's Intranet. The complete list can be found in the protected Intranet areas, which can be accessed by all the Dental Clinic's staff members. The database also permits Münster Clinic staff to access the Internet and locate those publications that are on the Internet by year of publication and topic.

[Odontogenic foci--possible etiology of urticaria?]. / Odontogene Foci-mögliche Ursache einer Urtikaria?

Recent studies have shown that chronic odontogenic infections could pose a risk for myocardial infarction, cerebral ischemia, and arteriosclerosis. However, the correlation between urticaria and dental infections has rarely been examined so far. Therefore, we performed a case-control study using a standardized questionnaire and examination. We investigated 66 patients suffering from an acute or chronic urticaria and 65 age- and sex-matched healthy patients as a control group. Dental status was determined by a so-called total dental index (TDI) which primarily reflects caries, periodontitis, periapical lesions, and nonvital and missing teeth. All 66 patients were referred from the department of dermatology. After their treatment in hospital, all patients received a questionnaire with questions on intensity and localization of the urticaria. The TDI of the urticaria patients was slightly better ( n=66; 2.6+/-1.98) than that of the control group ( n=65, TDI=3.3+/-1.86). Subsequently, it was determined if the urticaria had receded after dental treatment. In conclusion, chronic dental infections do not seem to correlate with an increased risk for urticaria.

Influence of distraction rates on the temporomandibular joint position and cartilage morphology in a rabbit model of mandibular lengthening.

PURPOSE: Although various aspects of bone formation during distraction osteogenesis have been studied extensively, there are only limited experimental data concerning the influence of mandibular distraction rates on structural alterations in the temporomandibular joint (TMJ). In this study, a rabbit model of unilateral mandibular distraction was used to test the effects of various strain schedules on the position and morphology of the TMJ. MATERIAL AND METHODS: Fifty-two immature white female rabbits were used. The distraction procedure was performed using physiologic (2,000 microstrains, 1 per day) and elevated strain magnitudes (20,000 microstrains, 1 per day), as well as high strain magnitudes (200,000 and 300,000 microstrains, 1 per day). The investigation of the TMJ included clinical, radiologic, and histologic aspects. RESULTS: Clinical and radiologic examinations at the end of the distraction period showed no evidence of joint luxation even at maximal distraction rates. Histologic and ultrastructural analyses revealed a positive correlation between the degree of mechanical loading and the development of degenerative alterations in the cartilage. In samples distracted at hyperphysiologic strain magnitudes, all cartilaginous layers were reduced in the regions of the TMJ that had been exposed to the higher pressure forces. The fibrous layer became nearly completely destroyed. CONCLUSIONS: These experimental data show that distraction schedules with single but hyperphysiologic loads may lead to degenerative or even early arthrotic changes in the condyle. These data support the principle that distraction protocols should be performed without extensive mechanical loading on the TMJ.

Microstructural investigations of strain-related collagen mineralization.

Distraction osteogenesis in rabbit mandibles after osteotomy can be used as an experimental model to study the microstructural features of mineralization of callus under defined mechanical loads. Our aim was to study the relation between the micromotions in the gap and the resulting features of mineralization of the matrix. We found that assembly of collagen and formation of crystals depended on the magnitude of the mechanical stress applied. At physiological bone strains (2000 microstrains), the callus had collagen type I in a mature bone-like extracellular arrangement, whereas at 20000 microstrains bundles were orientated predominantly towards the tension vector. Maximum loads (200000 microstrains) resulted in disorganized assembly of the collagen. Quantitative energy-dispersive analysis by X-rays confirmed that high strains were associated with substantially lower concentrations of calcium and phosphate. In contrast to bone-like apatitic formation of crystals at physiological strains, significantly fewer but larger crystals were detected by electron diffraction analysis in samples exposed to high strains. We suggest that mechanical stress regulates the assembly and mineralization of collagen during distraction osteogenesis.

Late effects of radiotherapy on oral mucosa in humans.

In order to gain further understanding of the late effects of radiotherapy on oral mucosa, we analysed the histomorphological alterations, the cell populations in the subepithelial tissue, and the endothelial expression pattern of different adhesion molecules. Biopsies were taken from patients before irradiation, directly after 60 Gy, and 6-12 months after radiotherapy. Besides the histomorphological evaluation of the vessels, the endothelial expression of ICAM-1, VCAM-1 and E-selectin was determined as well as the distribution of LFA-1-, Mac-1-, VLA-4-, RM3/1-, 27E10- and 25F9-bearing cells in the subepithelial tissue. The expression of ICAM-1 was downregulated after radiotherapy, whereas the percentage of LFA-1- and VLA-4-bearing cells increased. VCAM-1 remained at low levels. The subepithelial infiltration was still dominated by RM3/1-positive macrophages. The number of vessels decreased, while the lumen of the remaining vessels increased. In conclusion, the late effects of radiotherapy are characterized by a decreased number of blood vessels and by significantly different expression patterns of the adhesion molecules studied, and of integrins and macrophage subpopulations, compared to the conditions before irradiation and directly after irradiation with 60 Gy.

Increase of RM3/1-positive macrophages in radiation-induced oral mucositis.

The purpose of this study was to describe the distribution patterns of various leukocyte subpopulations in the oral mucosa during the course of radiotherapy and to determine whether there are dose-dependent alterations, or any correlation between the clinical stages and the population density of specific leukocytes. The distribution and density of various leukocytes in oral mucosa in 13 head and neck cancer patients were immunohistochemically analysed before radiotherapy at 30 and 60 Gy and compared with the clinical degree of oral mucositis. Antibodies were used which characterized different subtypes of macrophages (27E10, 25F9, RM3/1) and recognized epitopes of granulocytes (CD15) and T cells (CD3, CD4, CD8). The study showed that whereas macrophages reactive with RM3/1 increased significantly at 30 Gy (p<0.01) and showed a further increase at 60 Gy (p<0.01), no significant alterations could be detected in the density of macrophages which stained positively for 27E10 or 25F9. Moreover, the percentage of macrophages reactive with RM3/1 showed a non-linear correlation with the clinical mucositis score (p<0.05). No significant alterations were detected in the percentage of T cells and granulocytes, compared with the values before radiotherapy. In conclusion, radiation-induced mucositis is characterized by features of an intermediate stage of an inflammatory response, suggesting active involvement of down-regulatory macrophages in its pathogenesis.

Mechanical tension in distraction osteogenesis regulates chondrocytic differentiation.

Differentiation of chondrocytes to cells of osteoblastic phenotype occurs during an interim period of bone development, fracture repair and distraction osteogenesis. To study the relationship between tension-stress and chondrogenesis, uniaxial strains (0 microstrains, 2000 microstrains, 20000 microstrains, 200000 microstrains, 300000 microstrains) were applied in a rabbit model of mandibular distraction osteogenesis. The results demonstrated that cell differentiation, apoptosis and tissue development in the newly formed gap tissue showed a correlation to the applied strain magnitudes. Only strains of 20000 microstrains resulted in a statistically significant (P<0.05) formation of cartilage struts with embedded chondrocyte-like cells. However, chondrocyte-like cells were rarely detected in samples distracted at lower or higher strain magnitudes. Osteoblasts appeared to replace cartilaginous matrix by mineralized bone matrix. The phenotypic change from chondrocytes to osteoblasts was accompanied by a decreased proteoglycan synthesis. a change in the expression from type II collagen towards type I and involved asymmetric cell divisions and apoptotic cell death. Therefore, we suggest that mechanical strain is an external stimulus responsible for phenotypic cell alterations.

Oral findings in three different groups of immunocompromised patients.

The objective of this study was to determine the frequency of oral, dental and periodontal findings in three different groups of immunocompromised patients and in a healthy control group, to evaluate whether there is a correlation between manifestations of disease and immunologic parameters. The survey included 46 patients with a diagnosis of systemic lupus erythematosus, 48 heart transplant recipients, and 53 adult patients suffering from acute leukemias. Fifty matched healthy subjects were used as a control group. Each patient had to answer questions on medical and dental health and underwent a thorough oral, dental and serological investigation. Oral mucosal lesions were found in nearly half of all immunocompromised patients (49.6%), but in only 26% of control patients. No significant associations were found between different types of oral lesions and the underlying cause of immunosuppression. Leukemia patients showed age-unrelated higher scores in periodontal indices (P<0.05). Laboratory parameters failed to be significant in the assessment of oral health.

The effect of magnitude and frequency of interfragmentary strain on the tissue response to distraction osteogenesis.

PURPOSE: Bone regeneration is believed to be partially controlled by the applied local mechanical strain. To test whether the magnitude or frequency of discontinuous traction regulates the tissue response, defined daily strains were applied on mandibular osteotomies using an implanted mechanical distractor. MATERIALS AND METHODS: Unilateral mandibular osteotomies were performed in skeletally immature rabbits (n = 36). and distraction was done by applying 2,000, 20,000, 200,000, or 300,000 microstrains once or 10 times (2,000, 20,000 microstrains) per day, respectively. Sham-operated animals (n = 6), serving as controls, underwent frame application and osteotomy without distraction. At the end of the distraction process, the newly formed tissue was evaluated histomorphometrically by the use of a well-defined scoring system of bone-forming indices. RESULTS: The highest bone-forming indices were detected in the osteotomized, nondistracted group and in samples exposed to a physiologic strain (2,000 microstrains). Application of hyperphysiologic strains (200,000 and 300,000 microstrains) resulted in the formation of fibrous tissue and decreased bone-forming indices. Using Kruskal-Wallis tests, a statistically significant relationship was found between the bone-forming indices and the applied strain magnitudes. Scanning and transmission electron microscopic examinations showed osteoblastic differentiation and early mineral deposition in samples distracted up to 20,000 microstrains, whereas higher strain magnitudes led to the formation of fibroblast-like cells surrounded by collagen fibrils and only slight mineralization. Multiple strain applications (10 cycles/d vs 1 cycle/d) did not alter the histomorphometric indices or ultrastructural morphology significantly but increased the amount of newly formed tissue. CONCLUSIONS: These results suggest that the magnitude and not the frequency of mechanical loading controls the differentiation of bone cells and the subsequent formation of bone tissue.

[Proliferating trichilemmal cyst with focal segments of metastatic squamous epithelial carcinoma]. / Proliferierende Trichilemmalzysten mit Anteilen eines metastasierenden Plattenepithelkarzinoms.

A large ulcerated tumor covered the right hemisphere of the scalp of a 77 year old woman. By histological, immunohistological, and electronmicroscopical examination, a proliferating trichilemmal cyst with focal areas of a poorly differentiated squamous cell carcinoma was identified. Six months after extirpation of the entire tumor and dissection of supraomohyoidal lymph nodes, metastases in nuchal and supraclavicular lymph nodes and soft tissue of the neck became apparent. The present case underlines the necessity of a preoperative diagnostic evaluation and of radical surgical treatment for proliferating trichilemmal cysts.

Strain-related bone remodeling in distraction osteogenesis of the mandible.

Distraction osteogenesis has become a mainstay in craniofacial surgery. However, there are several unresolved problems concerning the biology of bone regeneration. We investigated the biomechanical effects of mandibular lengthening in 32 rabbits on a cellular and histologic level. The mandible was subjected to a corticotomy, held in a neutral position for 4 days, and then lengthened at various strain rates and frequencies for 10 days. Radiographic, histologic, and electron microscopic examinations showed a strain-related bone regeneration. Application of physiologic strain rates (2000 microstrains or 0.2 percent) led to a bridging of the artificial fracture exhibiting woven ossification, whereas at 20,000 microstrains trabecular bone formation was demonstrated. In contrast, hyperphysiologic strain magnitudes (200,000 microstrains and 300,000 microstrains) showed a fibrous tissue formation. Multiple strain applications (10 cycles/day versus 1 cycle/day) increased the width of the distraction gap without changing the stage of bone regeneration. The gradual distraction of bone in physiologic magnitudes at higher frequencies seems to be desirable for a bony differentiation and may help to improve clinical applications.

[Gigantic proliferating trichilemmal cyst of the scalp with central carcinoma and lymph node metastasis]. / Gigantische proliferierende Trichilemmalzyste der Kopfhaut mit zentralem Karzinom und Lymphknotenmetastasierung.

We report the case of a 77 year old woman with a giant proliferating trichilemmal cyst of the scalp and a central squamous-cell carcinoma. Six months after radical tumor-excision and dissection of the locoregionary lymph nodes the patient developed retroclavicular lymph node metastases. The tumor develops from cells of the hair matrix and tends to recur after excision; in rare cases malignant transformation may occur. We suggest radical excision and complete histological examination of the tumor. In cases of malignancy, lymph node-dissection is sometimes necessary. In these cases close postoperative follow-up of the patient is mandatory.

[Risk of myocardial infarct in 40 to 60-year-old males in relation to potential risk factors of atherosclerosis. Intermediate evaluation of the Göttingen risk, incidence and prevalence study following a 5-year observation period]. / Myokardinfarktrisiko bei 40- bis 60jährigen Männern in Abhängigkeit von potentiellen Risikofaktoren der Atherosklerose. Zwischenauswertungen der Göttinger Risiko-, Inzidenz- und Prävalenzstudie (GRIPS) nach einem 5jährigen Beobachtungszeitraum.

The main part of the Göttingen risk, incidence and prevalence study (GRIPS) is a prospective cohort-study (GRIPS-project B). In 1982 about 6,000 male subjects aged 40-60 years underwent an extensive, baseline examination. The incidences of death and disease are being recorded in this collective by regular follow-up investigations. A five-year observation period has now been completed for more than 95% of the original study participants. During this period 107 subjects, who had no symptoms of atherosclerotic diseases in 1982, developed fatal or non fatal myocardial infarction (MI). In the present evaluation this incidence group is compared to those study participants, who remained free of atherosclerotic diseases until December 1986 (reference group: n = 5160). The results indicate that LDL-cholesterol is the predominant predictor of MI-risk among all variables investigated. Additional risk factors of significance were as follows (in the rank order of their importance): positive family history of MI, hyperglycemia, low HDL-cholesterol, increased levels of triglyceride-rich-lipoproteins, hypertension, cigarette-smoking. For the most important risk-factor, LDL-cholesterol, 190 mg/dl seem to be a useful threshold value for therapeutic intervention according to the present data from GRIPS-project B. However, if additional risk-factors or definitive coronary artery disease are present, LDL-cholesterol levels below 140 mg/dl should be the therapeutic aim.