Dermal Matrix for Intraoral Lining Following Composite Mandibular Defect Reconstruction With Chimeric Fibular Osseocutaneous Flap.

BACKGROUND: This report aims to first present Integra as an adjunct to complex mandibular reconstruction for intraoral lining resurfacing, and to review the literature on the use of dermal matrices for mucosal resurfacing of the floor of the mouth. CLINICAL REPORT: A 62-year-old female patient with previous ablation surgery for squamous cell carcinoma of the floor of the mouth, presented with extrusion of the mandibular plate through the chin skin and serious tongue tethering. The patient was managed with a chimeric osseocutaneous free fibula flap to restore the mandibular bone and chin skin defect, followed by a second-stage reconstruction of the intraoral defect with bilayer Integra. Complete release of tongue tethering was achieved enabling normal speech and deglutition and allowing for dental rehabilitation. CONCLUSIONS: Integra was safely used as an alternative for intraoral lining, in composite mandibular reconstruction, downgrading reconstructive demands and offering optimal functional results.

Recurrent giant mandibular ameloblastoma in young adults.

BACKGROUND: The purpose of the study was to define the most appropriate management of the giant mandibular ameloblastoma (GMA) in young adults. METHODS: A retrospective study was performed on patients with GMA <30 years old. The data collected included initial treatment, tumor margins, reconstruction, and follow-up. Patients evaluated speech, chewing, swallowing, and facial appearance after definitive treatment. RESULTS: Thirteen patients were identified with recurrent solid/multicystic disease requiring further treatment. Definitive treatment involved segmental mandibulectomy and reconstruction with free fibular flap in all patients. Seven patients had immediate reconstruction (group A) and 6 had secondary (group B). Mandibular resection was planned at least 2 cm beyond the radiological limit, free margins were achieved in all patients, and all flaps were transplanted successfully. In group A, functional score was 13.7 ± 0.45 and facial appearance score was 4.5 ± 0.49, whereas in group B were 11.16 ± 0.37 and 3.3 ± 0.5, respectively (both p < .05). CONCLUSION: Aggressive resection of the GMA and immediate reconstruction is strongly advised. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1947-E1954, 2016.

Aesthetic and anatomic subunit reconstruction of composite mandibular gunshot wound.

BACKGROUND: Gunshot facial traumas involving the mandible and surrounding soft tissues are represented by the potential for loss of relationships between the functional and the aesthetic subunits of the head. METHODS: A patient presented with an 8-cm composite mandibular defect, resulting from a self-inflicted gunshot injury. Taking into account the anatomic/aesthetic subunits involved, a fibular osseoseptocutaneous flap was transferred to reconstruct the left lateral mandibular segment and the floor of the mouth, whereas a preexpanded temporal scalp flap was transferred to restore the hair-bearing skin of the left buccomandibular subunit. A review of the literature is also presented. RESULTS: A satisfactory functional and aesthetic outcome was achieved. Although current literature supports the value of aesthetic subunit face reconstruction and the use of double flaps for the reconstruction of through-and-through oromandibular defects, there is no previous report of the combined use of temporal scalp flap and fibular osseocutaneous flap. CONCLUSIONS: The combined use of hair-bearing skin and osseocutaneous flap may achieve optimal results in through-and-through oromandibular defects.

Impact of portable duplex ultrasonography in head and neck reconstruction.

We have reviewed the use of portable duplex ultrasonography (PDU) in 12 patients who underwent soft tissue/bone head and neck reconstruction, aiming to determine its role in the design and management of such complex cases. According to our data, there were modifications either of the surgical plan or of patient's management, based on PDU findings, in 9 (75%) of 12 patients. The use of ultrasound directed to subtle modifications in 3 patients (25%) but to significant changes of the surgical plan in the other 3 patients (25%). Also, the use of duplex ultrasound impacted significantly the postoperative management in 4 patients (33.33%). Thus, significant impact of PDU in patient's treatment was recorded in 58.33% of cases. Portable ultrasound represents generally available method for preoperative, intraoperative, and postoperative diagnosis and decision making in free tissue transfer, hence could replace in the future the unidirectional Doppler in the hands of head and neck surgeons.

Portable duplex ultrasonography: A diagnostic and decision-making tool in reconstructive microsurgery.

Unidirectional Doppler is a common diagnostic tool by the Reconstructive Microsurgeons; however, it may generate false signals and surely provides less imaging data as compared to duplex ultrasonography. We have reviewed the use of Portable Duplex Ultrasonography (PDU) in 16 patients who underwent complex soft-tissue/bone reconstruction, aiming to determine its role in the design and management of free tissue transfer. According to our data, there were modifications either of the surgical plan and/or of patient's management, based on PDU findings, in 10 out of 16 patients (62.5%). The use of ultrasound directed to subtle modifications in three patients (19%), but to significant changes of the surgical plan in four patients (25%). Also, the use of ultrasound improved significantly the postoperative management in three patients (19%). Thus, significant impact of PDU in patient's treatment was recorded in 44% of cases. Portable ultrasound represents generally available method for preoperative, intraoperative, and postoperative diagnosis and decision-making in free tissue transfer, hence could replace in the near future the unidirectional Doppler in the hands of Microsurgeons.

Microvascular anastomotic aneurysms in the clinical setting: case report and review of the literature.

Microvascular anastomotic aneurysms are an uncommon complication in reconstructive surgery, which can lead to free flap failure or even threaten the life of the patient. The literature referring to microvascular anastomotic aneurysms was reviewed in order to highlight their clinical presentation, diagnostic work-up, and therapeutic management. Also, a case of a ruptured aneurysm following free transfer of a fibula flap to the lower face is presented. No prospective studies were found. Only few case reports and some sporadic cases in retrospective studies referring to free flap complications were identified. All the aneurysms were false, the main etiologic factor was assumed to be infection, and the presenting signs were either arterial bleeding, as a result of rupture, or the presence of a pulsating mass. No widely accepted therapeutic guidelines were found, and the treatment was tailored to the specific clinical presentation of each case. Regarding the reported case, excision of the ruptured aneurysm and restoration of vascular continuity with a vein graft ensured complete survival of the flap. In conclusion, microvascular anastomotic aneurysms, although uncommon, represent a complication that every reconstructive surgeon should be aware of. Early diagnosis and proper treatment are crucial for a successful outcome. Selection of the appropriate treatment should be based on the presenting sign, the location, the degree of flap neovascularization as well as the condition and quality of the recipient bed; and comprises either ligation of the nutrient artery or excision of the aneurysm and restoration of arterial continuity.