The partial-thickness cross-lip flap for correction of postoncologic surgical defects.

PURPOSE: Abbe and Estlander cross-lip flaps have been described and designed as a full-thickness flap to reconstruct a full-thickness excisional defect. Some Mohs surgical excisions and other serial excisions leave partial-thickness defects. This article reviews a series of partial-thickness cross-lip flaps, which included some orbicularis oris muscle in the vermilion region but otherwise was a subcutaneous flap. PATIENTS AND METHODS: In the last 7 years, 110 patients with lip cancer had their postsurgical defects reconstructed 24 to 72 hours after the resection. In all cases, negative margins were established by histologic evaluation or Mohs micrographic surgery. Twenty of 29 patients had Abbe- and Estlander- (lip-switch) type flaps, which were composed of a musculomucosal pedicle of 1.25 to 1.50 cm and an attached skin/subcutaneous flap trimmed to fit the defect. The remainder had full-thickness lip-switch flaps. RESULTS: There were no vascular complications in either group. Four patients had notching or trapdoor- type bulking, which were revised after 3 to 6 months. CONCLUSION: The partial-thickness cross-lip flap has the same viability as the full-thickness flap within 1 cm from the inferior border of the mandible.

Reconstruction of superficial skin cancer defects of the nose.

PURPOSE: This article reviewed the results of reconstruction of surface nasal defects after removal of skin cancer. PATIENTS AND METHODS: One hundred patients with 103 surface defects involving various locations on the nose were treated. Management included direct closure, secondary epithelization, full-thickness skin grafts, and local flaps using 1 or 2 stages. RESULTS: Ten nasal defects were treated by direct closure, 8 defects healed by secondary epithelization, and 30 patients were treated with a full-thickness skin graft. Fifty-five defects were reconstructed with local flaps including 30 one-stage and 25 two-stage flaps. CONCLUSION: Many options are available for reconstructing nasal defects that can lead to acceptable aesthetic results. Among the factors that need to be addressed before choosing a procedure for reconstruction of surface nasal defects resulting from skin cancer are size and location of the defect, aesthetic concerns, and the medical status of the patient.

Autogenous bone harvest and bone compacting for dental implants.

The long-term success of a dental implant depends on having or creating an adequate amount of autogenous bone. An instrument is described that conserves the drilled bone during implant preparation, as well as during bone-block graft preparation. Compression of the autogenous bone is performed within the instrument. Also, a simple particulate bone harvest technique from the anterior mandible is offered. The value of a compacted cake of corticocancellous autogenous bone is discussed for dehiscence/fenestration defects as well as for sinus lift bone grafting.

Delayed repair of skin cancer defects.

PURPOSE: A review of surgical outcomes in 280 patients who underwent in-office excision of skin lesions, open wound therapy, and delayed reconstruction is presented. Advantages of open wound therapy and delayed reconstruction are discussed. PATIENTS AND METHODS: The surgical records of all patients treated between January 1, 1994 and December 31, 1996 were evaluated for outcome and complications. RESULTS: One hundred seventeen patients presented with biopsy-confirmed malignant skin lesions of the head and neck. After surgical excision of the malignancy, the wounds were treated with a semiocclusive dressing while waiting for the results of the biopsy report and reconstruction (open wound therapy). Eighty-nine percent of the residual skin defects were repaired within 10 days. The remaining 11% were closed within 35 days. Except for one allergic reaction to neomycin and slight blood oozing from the wound in two patients, no other complications occurred. CONCLUSIONS: Open wound therapy is an effective method for managing skin defects after excision of malignant lesions. It is cost-effective and can be done quickly as an in-office procedure under local anesthesia without complications.

Freehand full-thickness grafting for facial defects: a review of methods.

PURPOSE: This article reviews the use of full-thickness skin grafts for closure of facial defects. PATIENTS AND METHODS: In almost 3 years, 30 patients had full-thickness skin grafting after removal of premalignant or malignant facial skin lesions. The most common graft harvest sites included the preauricular and postauricular, neck, and supraclavicular areas. RESULTS: Few complications were seen except for rare surface necrosis and depression of the grafted site, and the esthetic results were generally satisfactory. CONCLUSION: Full-thickness skin grafts offer a reliable alternative to the use of flaps in selected cases.

Lower lip cancer: Mohs micrographic surgery and reconstruction as a multidisciplinary effort.

Lower lip cancer treated as a multidisciplinary effort has advantages in cost savings, conservation of tissue, and tumor elimination. This article discusses the technique of eradication of the lesion by the Mohs micrographic surgeon and secondary reconstruction by the oral and maxillofacial surgeon, and illustrates the results of this cooperative effort.

Scar revision with hypereversion.

PURPOSE: Scar revision techniques rarely describe methods of deep tissue closure. This article reinvestigates an often-forgotten method of deep wound closure that produces wide eversion. CONCLUSION: The process may be used alone, with subcutaneous closure, or as an adjunct to W and Z-plasty techniques. Advantages are discussed, and representative cases are presented.

Pexing and presuturing for closure of traumatic soft tissue injuries.

The technical values of pexing and presuturing have been confirmed for tumor surgery. Extrapolation of these techniques to the trauma patient has proven worthwhile. This article reviews these methods and presents cases as examples.

An alternate elective neck incision.

The classic submandibular incision parallels the inferior border of the mandible and does not follow the resting skin tension lines of the neck. A modified approach is described that initially follows these lines but, as the midbody region is approached, a zigzag incision with legs of 1 to 3 cm and tip angles of approximately 70 to 90 degrees is made. This zigzag skin incision is adjusted for the intended surgery. Subjectively, the results are much more esthetic.

The placement of screws above the zygomaticofrontal suture.

The use of plates in the zygomaticofrontal (ZF) region for stabilization of zygoma fractures necessitates use of screw holes. This anatomic study was done to assess where these holes can be safely placed. A study of 20 adult skulls showed that when drilling perpendicular to the bone above the ZF suture, the cranial cavity can be entered as low as 12 mm above it (average, 15 mm). Therefore, when drilling more than 12 mm over the ZF suture, the surgeon should angle the drill at an acute angle to the forehead to prevent cranial encroachment. In addition there is great variability of depth of bone around the ZF suture. When drilling perpendicularly on the frontal bone in the first centimeter above the ZF suture, the orbital cavity will always be entered.

Open reduction of mandibular condyle fractures. Indications and technique.

The traditional approach of closed reduction for condylar fractures has proved to be effective in an overwhelming majority of patients, but not in all. Some authors have proposed open reduction in selected cases. At present, there are no long-term data supporting open reduction to prevent future joint problems. In view of this, I believe that the best overall indication for open reduction is the surgical need to place the face or jaws in the proper functional position.

Hydroxylapatite cranioplasty directly over dura.

Seven patients who had noticeable defects of their frontal bone were reconstructed with dense hydroxylapatite (HA) particles with or without autogenous bone placed directly over the dura. The results indicate that HA is well tolerated over dura; no meningitis occurred with follow-up of one to 3 1/2 years. The clinical response was excellent and complications were minor, generally related to particle control and settling.

Hydroxylapatite blocks and particles as bone graft substitutes in orthognathic and reconstructive surgery.

A three-year clinical evaluation of 98 patients in whom dense hydroxylapatite in particle and block form had been placed in facial contour defects and osteotomy sites, and in cystic and reconstructive defects, alone or with autogenous bone, was conducted. The results indicate that the implants were effective in reducing operating time and potential for infection and relapse, as well as in reducing or eliminating the necessity of a donor site. The clinical response was excellent, and complications with both forms were minor, generally related to lack of initial fixation or failure to use autogenous bone in specific situations.

Rheumatoid disease and related arthropathies. II. Surgical rehabilitation of the temporomandibular joint.

A new classification of four types of TMJ involvement is proposed to help orient and direct the medical and surgical treatment of patients with rheumatoid disease and related arthropathies. Clinical symptoms, radiographic findings, facial deformity features, treatment planning, and results are discussed, with case reports that illustrate each type. Interpositional polymer laminates, a new glenoid fossa prosthesis, and a metallic condyle are introduced for use in selected cases where erosion and destruction of the condyle, meniscus, and fossa area have produced significant TMJ dysfunction and occlusal-facial deformity.

Excision of sclerosing osteomyelitis and reconstruction with particulate hydroxylapatite.

A new technique for treating diffuse sclerosing osteomyelitis is described. The entire lesion is eliminated and the ridge bulk and form are immediately reconstructed by implantation of hydroxylapatite. Three cases are described.