The deep inferior epigastric artery perforator (DIEAP) flap for total glossectomy reconstruction.

PURPOSE: Total or subtotal glossectomy following the resection of intraoral tumors causes significant morbidity. However, which reconstructive technique is the most successful remains controversial. PATIENTS AND METHODS: After approval by the Ethics Committee, charts were reviewed retrospectively for patients treated at the Oral and Maxillofacial Surgery Department, University Hospital La Paz (Madrid, Spain), during a 3-year period (2005-2008). All were reconstructed with a deep inferior epigastric artery perforator (DIEAP) flap after total glossectomy. Data collected included affiliation data, extent of extirpation, type of reconstruction, and surgical outcome, including donor-site morbidity, complications, and functional results. RESULTS: Seven patients (5 men, 71.4%; 2 women, 28.6%) with primary squamous cell carcinoma of the tongue underwent total glossectomy and simultaneous microsurgical reconstruction with a DIEAP flap. In all cases, the flap was harvested with a fusiform shape oriented craniocaudally and limited to zone 1. The average size of the flap was 16.7 × 7.2 cm. Functional outcome related to swallowing was poor; 57.1% of the patients required a permanent gastrostomy. Speech was considered intelligible in 85.7% of cases by 2 independent observers. The surgical outcome was uneventful in most of the cases, with only 1 case of local dehiscence at the mouth floor. None of the cases developed abdominal wall dehiscence or an abdominal hernia at mid- or long-term follow-up. CONCLUSIONS: The DIEAP flap is a reliable alternative for tongue reconstruction. It provides a large volume of soft tissue for transfer and is predictable and stable over time with low donor-site morbidity.

Oral rehabilitation with osseointegrated implants in oncologic patients.

PURPOSE: The esthetic and functional rehabilitation of oncologic patients subjected to major resection surgery constitutes one of the greatest challenges for the head and neck surgeon. Immediate bone reconstruction with microsurgical free tissue transfer and dental implants has constituted a genuine revolution in the management of such patients. MATERIALS AND METHODS: We present a series of 111 oncologic patients, involving a total of 706 implants, who underwent reconstruction with pedicled or free microsurgical flaps. RESULTS: The osseointegration success rate was 92.9%, with a global failure rate (malpositioning or failed osseointegration or loading) of 15%. Failure particularly affected the group of irradiated patients and those subjected to lateral osseomyocutaneous trapezial pedicled flap reconstruction. Excellent results were obtained with the fibular and iliac crest free flaps and osseointegrated dental implants. CONCLUSIONS: The difficulties of prosthetic rehabilitation are discussed, along with the individualized solutions applied, the repercussions on the temporomandibular joint, and the management protocol adopted by our service.

Microvascular approach to function and appearance of large orbital maxillary defects.

Forty-three patients with major three-dimensional orbitomaxillary defects underwent 48 free-tissue transfers for defects arising from resection of a neoplasm or trauma. Defects were complex, involving the malar skin, mandible, lateral nasal wall, orbit, palate, and brain. A three-dimensional approach attempting to recreate the midface by folding the flaps was the usual method, with subsequent revisions if necessary. Ten patients had simultaneous free bone grafts and 6 had vascularized bone grafts. There were three flap failures and four perioperative deaths. Excluding the 4 deaths, the results were assessed as excellent in 25 patients, good in 12, and poor in 2. Free-tissue transfer is a reliable method of providing enough tissue at one initial operation to satisfy complex three-dimensional defects of the orbitomaxillary region. Followed by minor revision, it provides a means of restoring function and appearance without multiple staged procedures with a high risk of failure.

Malignant neoplasms of the hard palate and upper alveolar ridge.

Malignant neoplasms of the hard palate and upper alveolar ridge can arise from the epithelial (mucosal), salivary, hematopoietic, or mesenchymal tissues in this region. Unlike other regions in the head and neck, only about two thirds of malignant neoplasms of the hard palate are squamous cell carcinomas, and few large series have reported treatment protocols and outcomes for patients with these tumors. In this review, we will describe our series of 51 patients with malignant neoplasms of the hard palate and upper alveolar ridge. This review will emphasize the surgical treatment program and rehabilitative techniques developed at the University of Pittsburgh.

Intraoral adenoid cystic carcinoma.

A case report of adenoid cytic carcinoma of the palate is presented. The clinical manifestations, diagnostic criteria, surgical resection, and prosthetic reconstruction of the patient are discussed.

An alternative method for fabricating a closed hollow obturator: a clinical report.

This article describes a procedure in which the fabrication of a closed hollow obturator can be made with three sections of a denture flask by using silicone. Ease of fabrication while controlling the thickness of the hollow portion and eliminating leakage and discoloration are major advantages of this technique while minimizing laboratory and clinical appointment time.

Use of osteomuscular free flaps after extended maxillectomy and craniofacial resection. About two cases.

A composite free flap with the lower part of the scapula and the serratus muscle has been used in two clinical cases for reconstruction after extensive maxillectomy and craniofacial resection. The palatal defect was reconstructed with the lower part of the scapular bone and the bone and the serratus muscle was used to restore facial contour. This type of osteomuscular free flap based on the thoracodorsal artery and veins provides a one-stage reconstruction of complex facial defects, including bone and soft tissue. The main advantages of this flap are the configuration of its bony component that closely matches the hard palate and its versatility that allows other regional flaps such as the latissimus dorsi and/or the serratus to be raised on the same vascular pedicle.

Microvascular free tissue transfer in oral and maxillofacial reconstruction.

Forty-two patients with head and neck cancer were submitted to microvascular reconstructive procedures. We divided patients in three groups; a first group of 30 patients, in whom the oral floor (8 patients), the part of tongue (14 patients), the lower gingiva (6 patients) and the oropharynx (2 patients) were reconstructed using various sizes of forearm flaps; a second group of 7 patients who underwent buccal mucosa reconstructions with the forearm flaps; and a third group of 5 patients who received rectus abdominis flaps for total tongue reconstruction. Three illustrative cases, one from each group, are presented in detail. Good results were obtained in 39 patients (94%), with both functional and morphological rehabilitation. There were three flap losses due to thrombosis of the microvascular anastomoses. There was no surgical mortality. The average operating time was about 10 hours in total. We concluded that there is a place for these complex procedures in the treatment of selected cases of head and neck tumors.

Prosthetic rehabilitation of a patient with adenoid cystic carcinoma with continuous orbital-maxillary defect.

Extensive head and neck surgical procedures severely affect vital functions, physical appearance and lead to huge psychological trauma in the patients. Well-constructed maxillofacial prosthesis will help them lead a normal social life for the remaining precious time. This case report explains the prosthetic rehabilitation of continuous orbital-maxillary surgical defect in a patient with adenoid cystic carcinoma with restricted mouth opening. Maxillofacial prosthesis needs individual modification to a treatment plan according to the defect and existing clinical conditions. In this case, magnetically retained three-piece prosthesis was designed because of high recurrence rate of the adenoid cystic carcinoma, lack of adequate bone for implants and limited mouth opening in the patient. The prosthesis restored the phonetics, aesthetics and deglutition of the patient by re-establishing the separation of oral-nasal-orbital cavities.

Comparison of obturator design for acquired maxillary defect in completely edentulous patients.

The most challenging and appreciated area in the field of Prosthodontics is the rehabilitation of maxillary defects. Tumors of the head and neck are the common cause for acquired maxillofacial defects. Surgical consequences predispose the patient to hypernasal speech, fluid leakage into nasal cavity, impaired masticatory function, and cosmetic deformity. The Prosthodontists play a significant role in the intervention and improve the quality of life of such patients. The current article describes two clinical case reports of completely edentulous patients with acquired maxillary defects.

Orofacial rehabilitation of patients with post-cancer treatment--an overview and report of three cases.

According to World Health Organisation statistics, individuals of the Indian subcontinent have the highest prevalence of orofacial cancer. Surgery, radiation, chemotherapy or combination therapies are commonly administered treatment modalities for treatment of oral cancer. Surgical resection can be mutilating, disfiguring and may deeply affect self-image of patients. Orofacial defects have unique limitations and challenges. A coordinated effort from the surgeon, oral physician and the maxillofacial prosthodontist to treat such patients is the need of the hour. This article presents an overview of the orofacial rehabilitation of postcancer treatments along with case reports.

A maxillary lip prosthesis retained by an obturator with attachments: A clinical report.

This article describes the prosthetic rehabilitation of small maxillary lip and maxilla defects with a lip prosthesis attached to an obturator. The definitive obturator prosthesis was designed with 3 plastic ball attachments on the labial surface that provided adequate retention for the lip prosthesis. The thin margin of the lip prosthesis ensured that it adapted well to functional movements.

Prosthetic replacement of bilateral maxillectomy.

A patient had an adenocystic carcinoma that involved both maxillary sinuses, the entire hard palate, and the lower third of both nasal chambers. Treatment consisted of bilateral maxillectomy and a split-thickness skin graft applied to the inside of the cheeks. A dental obturator constructed to fit undercuts in the surgical cavity allowed speech and swallowing. Because the patient objected to the sunken appearance of the upper lip, she obtained the central incisor portion of her late husband's upper denture and bonded this segment to the dental appliance. This achieved satisfactory cosmesis.

The inverted temporalis muscle flap for intraoral reconstruction: its rationale and the results of its application.

PURPOSE: The purpose of this article was to show the discrepancies among the different parts of the temporalis muscle flap (TMF), to introduce a new rotational arc for the TMF based on these findings, and to examine the outcomes associated with the use of this modified method. MATERIALS AND METHODS: Two models were established on 5 human skulls to mimic the situations with the usual dissection technique or the extended dissection technique for the TMF. The lengths of the anterior part, the middle part, and the posterior part of the flap were measured and analyzed for statistical significance. A new rotational arc for the TMF was introduced, in which the flap was inverted beneath the zygomatic arch, placing the temporalis fascia away from the oral side. Seventeen consecutive oral cancer cases treated with either the traditional method or the inverted method of flap transposition were reviewed and divided into 2 groups dictated by the rotational arcs of their flaps. The traditional TMF was used in 11 cases and the inverted TMF was used in 6 cases. Clinical examination and imaging studies were used for assessment of outcome, and the results from the 2 patient groups were compared. RESULTS: The middle and posterior parts of the temporalis muscle were significantly longer than the anterior part on the skull models. However, the middle and posterior parts did not differ greatly in length. The extended dissection technique increased the flap length except for the anterior part. Both flaps were successful in closing the defects in all cases and healed well. No muscle necrosis was observed. However, the patients receiving the traditional TMF developed noticeable cheek fullness in 4 instances, sialocele in 3, significant reduction of range of mouth opening in 2, and distinct velopharyngeal insufficiency in 2, whereas only 1 case in which the inverted TMF was used developed cheek fullness. CONCLUSIONS: The middle or posterior part of the temporalis flap is preferred over the anterior part for covering distant defects because of its extra length. The inverted TMF is simple and safe to apply. It can extend farther in the posterior oral cavity and has fewer complications than the traditional TMF.