Ayman Amin

The submental flap for oral cavity reconstruction: Extended indications and technical refinements

Background and purposeThe submental flap is gaining popularity as a simple technique for reconstruction of small to moderate size defects of the oral cavity. However, its role in composite defects involving the jaw is not clearly defined. Indeed, controversy exists about the flaps interference with an oncologically sound neck dissectionPatients and MethodsA total of 21 patients with oral cavity cancers over a three year period were included. All patients underwent surgical resection and immediate reconstruction with submental flap except one patient who had delayed reconstruction with reversed flap. The flap was used for reconstruction of intra-oral soft tissue defect in 13 patients and composite defects in 8 patients.ResultsOf 21 patients 12 were males and 9 were females, age ranged from 32 to 83 years. The primary tumor sites included buccal mucosa (7), tongue (4), alveolar margin (3), floor of mouth (5) and lip (2). Eventually in this study, we adopted completing the neck dissection first before flap harvest. Complete flap loss occurred in 2 whereas 3 patients had partial flap loss. Follow up ranged from 3 to 44 months, one patient died from metastatic disease. Four patients developed neck recurrences.ConclusionThe submental flap is a valid option for reconstruction of intra-oral soft tissue as well as composite oral defects particularly in elderly patients. However, oncologically sound neck dissection should be assured.

Crucial issues of hepatic artery reconstruction in living donor liver transplantation: our experience with 133 cases at Dar El-Fouad Hospital, Egypt.

Hepatic artery (HA) reconstruction is a crucial step in living donor liver transplantation (LDLT). However, many important aspects specific to this challenging step are still inadequately documented. From August 2001 through March 2007, we performed a total of 133 cases of LDLT at Dar El-Fouad Hospital. The magnifying loupe was used for performing microanastomoses in the first 31 cases, and the operating microscope was used for 98 cases. There were 128 adult and five pediatric patients. One hundred twenty-five patients received right lobe grafts, and seven patients received left lobe grafts. One patient died intraoperatively and was excluded from analysis. Arterial complications occurred in four patients of the first group (4/30, 13%) in the form of early thrombosis. One patient underwent successful interventional thromboembolectomy, two patients underwent surgical reexploration with revision of anastomoses; these three patients survived. The fourth patient died from fulminant liver failure. Regarding the second group, all arterial anastomoses were patent after reconstruction. Signal problems occurred in the form of intraoperative intermittent flow and postoperative no diastole phenomenon. Our overall arterial complication rate was 4.5%; however, we lost only one patient due to HA thrombosis (0.8%). Microsurgical reconstruction of the HA carries its own challenges. The use of operating microscope reduces the risk of complications, and aggressive interference including salvage surgery maximizes the success of HA reconstruction.

Transaxillary thoracodorsal artery perforator flap: a versatile new technique for hypopharyngeal reconstruction.

INTRODUCTION  Reconstruction of the hypopharynx and cervical esophagus after tumor resection remains a challenging problem. Different techniques of reconstruction have been described for such defects. Although free flap reconstruction, including jejunum and fasciocutaneous flaps, has gained popularity for this complex defect, regional flaps are still in use worldwide. PATIENTS AND METHODS  We present our experience using the pedicled thoracodorsal artery perforator (TDAP) flap whereby only a small cuff of latissimus dorsi muscle around the perforators is harvested. The remaining muscle with its nerve supply is preserved. The flap is delivered to the neck through the cervicoaxillary tunnel. It was used as a complete tube in six patients and with an additional attached skin island for reconstruction of the neck skin in another four patients. RESULTS  A total of 11 TDAP flaps were used for reconstruction in 10 patients. All flaps survived except in one patient who suffered from a complete flap loss. This was salvaged by another TDAP flap from the contralateral side. Partial sloughing of the outer part of the pedicled TDAP occurred in one other patient. Pharyngeal fistulas developed in another two patients and eventually healed spontaneously. All patients resumed an oral diet within 2 weeks except two with fistulas. All patients resumed their shoulder active range of motion within 3 weeks. CONCLUSION  The transaxillary TDAP flap is an ideal technique for hypopharyngeal reconstruction. It offers the advantages of free fasciocutaneous flaps, has a wide arc of rotation, a relatively larger flap dimension, a reliable vascular pedicle, and acceptable donor site morbidity.

Living related hemi-face skin transplant using radial forearm free flap for a xeroderma pigmentosa patient: early outcome

IntroductionXeroderma pigmentosa (XP) is a hereditary disease characterized by deficient repair of DNA damage that occurred on exposure of the skin to ultraviolet irradiation. The affected children have a propensity to develop multiple skin cancers mainly in the face and eventually die before the age of 20.HypothesisAllograft replacement of facial skin by a healthy skin from normal person might decrease the incidence of skin cancer development, the number of surgical procedures, and eventually might improve the survival of these miserable patients.MethodsAs Cadaveric organs are unavailable in our country. After approval from the ethical committee, confirmed agreement of the donor and the patients guardian, a radial forearm free flap was transplanted from an ABO compatible mother to her 5 year old daughter with XP. The mother had an older daughter died from the same disease at the age of 14. The flap replaced skin of the hemi face that developed precancerous lesions. The girl was kept on adjusted doses of immunosuppressive drugs.ResultsThe flap survived, wounds healed uneventfully. The flap developed a reddish spot one and half month following transplant where baseline skin biopsy was taken. In the fifth months the girl presented with bad non salvageable rejection that ended up loosing the flap. On long term follow up, the girl started to develop skin lesion on the virgin half of the face. Our early cosmetic result replacing half of the facial skin was very promising. In addition the girl did not develop skin lesions in the operated site.ConclusionOur early cosmetic result was very promising. In addition to this, the girl did not develop skin lesions in the operated side of the face

Hybrid Microsurgical Reconstruction and Percutaneous Endovascular Stent Placement for Management of Dissected Graft Hepatic Artery during Living Donor Liver Transplantation

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Temporal bone resection for patients with head and neck cancer: surgical modalities and techniques of reconstruction

Objective The aim of this article is to present authors’ experience of using different modalities of temporal bone resection (TBR) and methods of reconstruction in malignant tumor involving temporal bone. Patients and methods For 27 patients scheduled for TBR, computed tomography was done for all patients, whereas complementary MRI for 13 patients. Different indications, TBR types, reconstruction technique, complications, and outcome were documented and analyzed. Results This study included 27 patients who had malignancy of or extend to temporal bone, including 11 (40.7%) external auditory canal, eight (29.6%) parotid gland, seven (26%) middle ears, and one (3.7%) lateral skull base tumors. The mean age of the patients was 57±10.4 years. Final histopathology was proved to be squamous cell carcinoma in 15 patients, adenoid cystic carcinoma in eight patients, and adenocarcinoma in four patients. Types of TBR were Lewis en-block technique in seven (26%) cases, lateral TBR in eight (29.6%) cases, modified lateral TBR in eight (29.6%) cases, and subtotal TBR in four cases (14.8%). Neck dissection (ND) was performed in all patients in the form of modified radical neck dissection (13 cases), radical neck dissection (five cases), supraomohyoid (three cases), and upper neck dissection (six cases). All preoperative clinicoradiological staging was upstaged postoperatively. Reconstruction of resulting defects was done using temporalis muscle flap (55.5%), pectoralis major myocutaneous flap (26%), latissimus dorsi myocutaneous flap (3.7%), trapezius myocutaneous flap (3.7%), and free flaps (14.8%). Reported complications were dural tears (22.2%), internal jugular vein injury (3.7%), transient vertigo (55.5%), complete facial nerve paralysis (33.3%), and hearing loss (14.8%). Postoperative adjuvant radiotherapy was given to 17 (62.9%) patients. The overall 3-year survival was 73%. Conclusion Commonest temporal bone involving malignancy was squamous cell carcinoma. TBR is integral part of radical resection for certain cancers involving temporal bone. Postoperative radiotherapy is usually needed. Operative tumor staging is more advanced than preoperative.