Challenging the Orthodoxy of Mandibular Reconstructions Comparing Functional Outcomes in Osseous versus Soft Tissue Reconstructions of the Posterolateral Mandible.

BACKGROUND: Appropriate reconstruction of the posterolateral mandible remains controversial. Both osseous and soft tissues are vital components for an overall successful outcome and are often combined in complex defects. Their respective effect on oromandibular function in the reconstruction of different degrees of mandibular defects has been less evaluated. This study aimed to compare patient-perceived oromandibular function in osseous and soft tissue-only reconstructions following posterolateral mandibular defects, defined as limited or extended. PATIENTS AND METHODS: A 10-year retrospective review of consecutive patients undergoing mandibular reconstructions of the posterolateral mandible were identified. Limited defects were defined as reaching from the ipsilateral parasymphysis to anterior of the coronoid (sparing insertion of muscles of mastication). Extended defects were defined as reaching from the ipsilateral parasymphysis to posterior of the coronoid (sacrificing the muscle insertions). Functional outcomes were assessed using the University of Washington Quality of Life questionnaire, version 4. RESULTS: A total of 163 patients were identified, of which 41 patients had the particular posterolateral mandibular resections sought after. In 23 limited resections, there was no difference in functional outcome between osseous and soft tissue-only reconstructions. In 18 patients undergoing extended resections, osseous reconstructions demonstrated significantly better outcomes (p = 0.011). There were no significant differences in patient demographics between the groups. CONCLUSION: Our study highlights the interest of soft tissue-only reconstructions of the posterolateral mandible. Limited resections seem not to benefit from complex osseous reconstruction for adequate function. Conversely, there is a noteworthy positive impact on functional outcomes in extended posterolateral mandibulectomies reconstructed with osseous tissue, compared with soft tissue only. Although a larger study is needed to identify a stronger relationship, these preliminary results could aid reconstructive decisions, particularly when considering patient morbidity.

Surgical treatment of severe hidradenitis suppurativa of the axilla: thoracodorsal artery perforator (TDAP) flap versus split skin graft.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic, inflammatory disease affecting the apocrine glands of the axillary, groin and mammary regions with significant physical and psychosocial sequelae. Surgical excision of the affected tissue is the gold standard treatment. Severe axillary HS is associated with high rates of recurrence and requires extensive surgical resection with challenging reconstruction associated with risk of post-operative complications. The most effective method for reconstruction of the axilla after excision of HS is yet to be identified. We present a prospective observational study comparing thoraco-dorsal artery perforator (TDAP) flap and split-skin graft (SSG). METHODS: Over 4 years, we enrolled 27 consecutive patients with Hurley's Stage III HS of the axilla who underwent surgical excision with reconstruction using either SSG (n=12) or TDAP flap reconstruction (n=15). We evaluated and compared intraoperative and post-operative data, quality of life (dermatology life quality index questionnaire) and pain/discomfort (visual analogue scale) before and after surgery. RESULTS: Patients who underwent TDAP flap reconstruction had significantly faster recovery, fewer complications and fewer overall number of procedures than those who underwent SSG reconstruction. All patients reported an improved quality of life (QOL) after their operation and the TDAP group showed significantly more improvement than the SSG group. All patients reported a reduction in pain/discomfort but there was no significant difference between groups. CONCLUSION: TDAP flap and SSG both improve QOL for patients with severe axillary HS. The TDAP flap showed greater benefits in terms of QOL, recovery, rate of complications and number of overall procedures.

A comparison between free gracilis muscle flap and pedicled pectoralis major flap reconstructions following salvage laryngectomy.

INTRODUCTION: Muscle flaps are often used in the prevention and treatment of pharyngocutaneous fistula following total salvage laryngectomy in the setting of chemo-radiated neck for laryngeal carcinomas. We report our experience with the gracilis free muscle flap compared to the pedicled pectoralis major for the prophylaxis of fistula formation. METHODS: Forty-nine patients with radio-recurrent laryngeal carcinoma over ten years who underwent salvage laryngectomy and either immediate free gracilis (22 patients) or pedicled pectoralis major muscle flap (27 patients) reconstruction were reviewed. RESULTS: There were 12 complications in pectoralis major flap group and eight in gracilis flap group. Most of these occurred early in the post-operative period. These were related to poor wound healing with the pectoralis major flap reconstructions. Fistulation rates were similar in the two groups (Pectoralis major: 6/27, gracilis: 5/22). CONCLUSIONS: In our experience, the gracilis free muscle flap is a good reconstructive option in the prevention of pharyngocutaneous fistula formation following salvage laryngectomies. It is at least equivalent to a pectoralis muscle flap in the prevention of fistulae, but we prefer the gracilis for many reasons, including ease of harvest and preservation of the pectoralis major flap for future reconstructions.

"Globus symptoms": a rare case of giant osteochondroma of the axis treated with high cervical extrapharyngeal approach.

Background Osteochondroma is the most common primary bone tumor, composing 35% of benign bone tumors and 9% of all bone tumors; 1.3 to 4.1% of all osteochondromas originate from the spine. A rare differential diagnosis for globus symptoms is an osteochondroma originating from the anterior surface of the axis. We describe a rare case of osteochondroma of the dens resulting in "globus symptoms" (the subjective sensation of a mass in the throat) treated with excision via the high cervical extrapharyngeal approach. Purpose To discuss the surgical management of this problem, with an emphasis on surgical approach used. The clinical history, examination, and investigations are presented and illustrated, along with clinical patient outcome. Study Design/Setting This article is a case report of a patient treated at the Department of Trauma and Orthopaedics in an active university teaching hospital. Methods Case presentation. For the discussion, we used handpicked articles, as well as MEDLINE and PubMed database searches with the keywords "C2," "dens," "osteochondroma," "globus," "extrapharyngeal approach." Results Uncomplicated procedure. Histological analysis confirmed a benign osteochondroma with no evidence of malignancy. The patient underwent an uncomplicated postoperative recovery and was discharged 24 hours after surgery, fully ambulatory and eating and drinking well. Conclusions The high cervical retropharyngeal approach is safe and reproducible for the excision of osteochondromas or osteophytes of the upper cervical spine.