Free flaps and literature review.

BACKGROUND: Microvascular free flaps are a reliable and efficient method for restoring head and neck defects. Here we describe 169 free flap procedures, and determine the success rate of these reconstructions. METHODS: This study included data from all patients who underwent microsurgical reconstruction for head and neck defects at St. John's Hospital in Bruges between 1994 and 2012. We analysed sex, age, American Society of Anaesthesiologists (ASA) score, smoking, prior radiotherapy, and deep circumflex iliac artery (DCIA) harvesting technique to determine their influences on flap complications and overall complications. RESULTS: Our study included 169 free flap procedures, with a flap success rate of 92%. The rate of systemic complications was 21%. The DCIA split harvesting technique was associated with a significantly higher incidence of flap complications. Increased age (357 years) was associated with a higher incidence of overall complications. CONCLUSION: In our present series, the DCIA split harvesting technique was associated with a significantly higher frequency of total flap failure. This increased failure rate was attributed to important haematomas that compromised venous circulation. We also found that patient age was a significant factor for the development of postoperative complications.

The effect of mandibular nerve block on opioid consumption, nausea and vomiting in bilateral mandibular osteotomies.

UNLABELLED: The purpose of this study was to compare the efficacy of a mandibular nerve block to placebo, in patients undergoing mandibular osteotomy surgery, regarding opioid consumption and adverse opioid induced side effects. Forty healthy individuals with a mean age of 19.7 years participated in the study. All subjects received lidocaïn 2% + adrenaline 1/80,000 versus placebo for mandibular nerve block in a randomized double-blind manner. Opioid consumption and opioid related side effect such as postoperative nausea and vomiting (PONV), and respiratory depression were assessed. RESULTS: The placebo group received significantly more sufentanil during the surgical procedure than the lidocaïngroup. There were no significant differences in adverse opioid induced side effects. In the postoperative phase there was no difference in additional pain intervention between the two groups. CONCLUSION: The mandibular block during mandibular osteotomy reduces intra-operative opioid consumption but does not alternate the opioid related side-effects in the postoperative phase.

Intraoral transmental suction lipectomy.

Intraoral transmental suction lipectomy (TMSL) is performed by entering the suction canula through the chin osteotomy/ostectomy gap into the sub- and/or supraplatysmal fat tissue layers. The aim of the study was to know patients' and operators' satisfaction with the procedure, and to know the kind and frequency of the complications. Twenty patients were consecutively treated and reviewed after a minimum of 5 years. All were satisfied with the overall results. It proved difficult to differentiate between the results of the liposuction and those of the genioplasty and/or orthognathic profile correction. From a surgeon's point of view, 11 showed excellent, nine good and one moderate results. Complications included one local subcutaneous infection, four transient neurosensory disturbances at the lower lip and two marginal branch weaknesses. All complications were resolved by the time of the long-term follow-up appointment. TMSL offers the psychological advantage of being performed without skin incision. Cosmetic results and complications are similar to those obtained with the transcutaneous liposuction techniques.

Nasal profile changes after maxillary impaction and advancement surgery.

PURPOSE: The profile changes in the nasal tip and columello-labial region that occur after maxillary advancement and impaction surgery were measured to test the hypothesis that a subspinal osteotomy would induce less nasal tip change and would result in a more acute columello-labial angle than a conventional Le Fort I-type osteotomy. PATIENTS AND METHODS: The lateral cephalograms of 2 matched groups of 23 advancement/impaction cases with and without subspinal osteotomy were analyzed electronically. RESULTS: There was no difference in nasal tip elevation and change in nasal tip projection between the 2 groups. The columello-labial angle was, on average, unchanged by the surgery. A linear correlation with a weak clinical relevance could be demonstrated between nasal tip projection and maxillary advancement in the group that was treated without subspinal osteotomy. Such a correlation was not detected for nasal tip elevation in either of the groups. Palatal plane rotation had a significant influence on nasal tip projection but not on tip elevation in both groups. The correlation was strongest in the group treated conventionally. The multiple regression equation with maxillary advancement and rotation as predictors had a r2 of .6071 (nasal tip projection = 0.9 + 0.19 maxillary advancement + 0.18 palatal plane inclination) in this group. CONCLUSION: The results indicate that the advancing piriform aperture pushing on the alae, and not the nasal spine, is responsible for the increase in nasal tip projection. The subspinal osteotomy is not superior to the conventional Le Fort I-type osteotomy in regard to minimizing nasal tip changes and obtaining control over the columello-labial angle.

Six year's experience with the zygomatic "sandwich" osteotomy for correction of malar deficiency.

PURPOSE: This study discusses the rationale, modifications, and complications of an osteotomy technique used to increase malar projection. PATIENTS AND METHODS: Seventy "sandwich" zygomatic osteotomies were performed in a 6-year period. Hydroxyapatite (HA) blocks were used to stabilize the anterolateral rotation of the zygomatic body in 44 osteotomies, calcium carbonate blocks were used in 23, calvarial bone grafts in three, a piece of bovine cartilage in one, and a bone graft from a chin ostectomy procedure combined with mesh osteosynthesis in one procedure. Fifty-six zygomatic osteotomies were combined with Le Fort I-type osteotomies (eight with a midline split). Nineteen zygomatic osteotomies were performed simultaneously with a Le Fort I-type osteotomy and a rhinoplasty with lateral osteotomies. RESULTS: The increase of malar projection and the stability of the procedure could not be measured on conventional three-plane cephalograms. However, patient's and surgeon's satisfaction were high and remained so during the follow-up period (maximum, 6.5 years; minimum, 6 months). Three patients developed maxillary sinusitis. In two of them, this was clearly related to fragmentation of an HA block. A Treacher-Collins patient developed a chronic fistula in the upper vestibule, caused by leakage of infraorbitally placed HA granules. In two cases, a fracture of the zygomatic arch occurred. Osteosynthesis was performed in one of them. CONCLUSION: With proper technique and care not to fracture the interpositional HA block, complications are rare. The procedure is expedient and provides predictable and stable correction of malar deficiency.

Proximal segment position after distraction with the MD-DOS device.

We investigated cephalometrically the movement of the proximal segment in the sagittal plane in patients treated with distraction (MD-DOS device) for mandibular lengthening. The proximal segment was anteriorly rotated, whilst the distal segment was posteriorly rotated after the lengthening procedure. Thus the angle of the jaw was advanced half the distance of the advancement of the distal segment. One possible reason for the anterior rotation of 3.3 degrees on average is the repositioning of the proximal segment during application of the anterior fixation unit in the cases where mobilization was complete. Another more plausible reason is the anterior pull by the masticatory muscles and elastic bands being greater than the reactive distraction vector component in concert with a flexible telescopic distraction module and a single posterior screw anchorage. The positional movements of both distal and proximal segments were similar to those observed after mandibular advancement with bilateral sagittal split osteotomies.

The nasal frame osteotomy: technical note.

In the practice of orthognathic surgery, a patient presenting with a gummy smile and lip incompetence is readily diagnosed as having vertical maxillary excess, and a maxillary impaction osteotomy is usually the proposed treatment. If a short nose, an arched and upwardly displaced upper lip, and a broad face accompany these 2 features, nasal lengthening and caudal repositioning of the central portion of the upper lip by a nasal frame osteotomy should be considered instead. The technique of the nasal "frame" osteotomy, which was used in 1 patient with a 4-year follow-up, is described.

Prediction of mandibular autorotation.

PURPOSE: The purpose of this investigation was to test the hypothesis that the mandible rotates around the same point during maxillary impaction surgery as during initial jaw opening. This point, called the center of mandibular autorotation (CAR), could then be used to predict mandibular position and to decide whether only maxillary impaction would be needed to correct the occlusion and the facial profile. PATIENTS AND METHODS: Preoperatively, two lateral cephalograms were obtained from a consecutive series of 20 patients who underwent maxillary impaction without concomitant mandibular ramus osteotomy. One cephalogram was taken with the mandible in centric relation using a wax bite wafer and another with a jaw opening of 10 mm using a fabricated acrylic bite block with the mandible manipulated to its most retruded position. The CAR was calculated before and after jaw opening using the Rouleaux method on the lower incisor and gonion point. A third lateral cephalogram was taken within 2 days postoperatively. The postoperative lower incisal point was then transferred to the first cephalogram using cranial base superimposition. RESULTS: When the preoperative and postoperative distances between CAR and incisal point were compared, there was no significant difference between these distances, proving the hypothesis. CONCLUSIONS: The method used is a practical and precise way to determine the center of mandibular autorotation on an individual basis. The center of rotation during initial jaw opening is the same as during impaction surgery.

Reconstruction of the severely resorbed maxilla with a combination of sinus augmentation, onlay bone grafting, and implants.

PURPOSE: A new method of reconstruction of the atrophic maxilla by combining a bilateral sinus floor elevation and cancellous bone graft with buccal and labial onlay graft using L-shaped corticocancellous blocks from the posterior iliac crest is presented. PATIENTS AND METHODS: Seventeen patients were treated with this procedure. One hundred one IMZ implants were placed in 14 patients, and 22 Brånemark implants were placed in three patients. Patients were observed for 6 months after prosthetic rehabilitation. RESULTS: All patients were fully rehabilitated with fixed bridges except one, who preferred an overdenture. Only two implants were lost at the time of the abutment connection. Some bone resorption was seen around six implants. The success rate with this procedure was 92.7% 6 months after prosthetic rehabilitation if implants with bone resorption were considered failures. CONCLUSIONS: These preliminary results indicate that this surgical procedure is suitable for reconstruction of most atrophic maxillas.

An intra-operative technical aid to miniplating of mandibular fractures by fracture segment apposition.

Internal plate osteosynthesis and lag-screw osteosynthesis are currently the preferred methods of fixation in the treatment of mandibular fractures. Rigid internal fixation (RIF) provides for functionally stable immobilization of the segments, avoiding the need for postoperative intermaxillary fixation (IMF) by "dental wiring" in the majority of cases. Reduction and fixation can be provided by so-called compression plates (type AO/ASIF). Non compressive mini-plates are more extensively used, however, because their size and malleability facilitate their transoral application. Peroperative problems may arise with the anatomical reduction of the fragments. We present a simple fracture reduction-compression technique that can be used in combination with either compression and non-compression mini-plate fixation. Its use can be extended to reduction and fixation in selected areas of difficult surgical access.

The effect of the subspinal Le Fort I-type osteotomy on interalar rim width.

The postoperative increase in interalar rim width was measured in two groups undergoing Le Fort I impaction or advancement. In the control group, 19 patients with a conventional osteotomy, an absorbable alar cinch suture, and V-Y closure were followed for 20 months on average. In the experimental group, 12 patients with a "subspinal" Le Fort I osteotomy (without alar cinch or V-Y closure) were followed for 15 months on average. Interalar rim width was measured with a slide gauge preoperatively, at several times during surgery, and at the 6-month and late follow-up appointments. At surgery, the alar cinch suture decreased the interalar rim width by 50% in the control group. Still, after extubation, there was no statistical difference between groups. At the 6-month follow-up measurement, the interalar rim width was significantly (1.92 mm) smaller in the subspinal group. At the late follow-up, this difference had decreased by a mean of 0.61 mm.

High labial incisions for genioplasty.

Clinical experience in genioplasty has shown that high labial incisions heal with fewer scar bands than conventional deep labial incisions. In a prospective randomized trial, we compared 18 high labial curvilinear incisions with 27 high labial W-shaped ('royal') incisions for access and visibility during chin osteotomy. Both incisions were 3 cm wide. Maximal incision lengthening between two skin hooks was recorded with a ruler before closure, and there was no significant difference between the two. The maximum wound area between three skin hooks was photographed and computed, and showed a mean difference of 188.75 mm2 (t-test, P < 0.001), which corroborated the clinical findings that access and visibility were superior in the W-shaped incision group. Complications were few in both groups. We now use the high labial royal incision about 3.5 cm wide, with 90 degrees limb angle for complicated chin osteotomies and ostectomies. A smaller curvilinear high labial incision is used for simple advancement osteotomies.

The 'sandwich' zygomatic osteotomy: technique, indications and clinical results.

The classical approach to lateral midface hypoplasia is reconstruction with onlays. Dislocation and asymmetry, early and late infection, and extrusion are possible complications with alloplastic implant materials. Unpredictable resorption, irregular contours and asymmetry are problems that can arise with autogenous, homogenous and hetergenous onlay grafts. We describe a technique by which the zygomatic body is luxated laterally and ventrally after a combined oblique-horizontal and vertical osteotomy. The resultant greenstick fracture at the temporo-zygomatic suture together with minimal lateral degloving causes the malar body to return to its former position. An interpositional porous hydroxyapatite block acts as a space maintainer until the osteotomy sites are ossified. The restoration of contour is performed by the zygomatic body itself, not by the implants. The indications are discussed and the results of three year follow-up are illustrated.

Condylar resorption in orthognathic surgery: a retrospective study.

A retrospective study was performed to examine the occurrence of condylar atrophy in connection with orthognathic surgery. Patients with high-angle mandibular deficiency (n = 29) were selected from among those who underwent bimaxillary osteotomy (n = 93) during the period from January 1987 through December 1990. This group of 29 was examined for shortening of the ascending ramus of the mandible because of condylar resorption. In 9 of these 29 (31%), the ramus had resorbed more than 2 mm, or more than 6% of the total length of the ramus. All 9 of these patients were female. There was no correlation between resorption and age, the amount of retrognathism, or the presence of preoperative temporomandibular joint dysfunction. Female patients with high-angle retrognathism should be informed of the possibility of postoperative condylar resorption and should be followed with radiographic controls for at least 2 years after surgery.

The use of skull bone in maxillofacial reconstruction and its potential use in orthopedic surgery.

The calvarium provides a source of bone grafts that are widely applied in maxillofacial surgery, with minimal donor-site morbidity and less resorption than endochondral grafts. A technique of harvesting monocortical bone is described and possible indications in orthopedic surgery are proposed. Thus, we suggest that skull bone can be used in orthopedic surgery in some instances, resulting in less donor-site morbidity than when autogenous bone from other sources is used.