Bin Nakayama

New reconstruction for total maxillectomy defect with a fibula osteocutaneous free flap

The osteocutaneous fibula free transfer with three segments of bone and the peroneal flap was used to reconstruct a total unilateral maxillectomy defect. Satisfactory restoration of three-dimensional facial structure, orbital support, and prosthesis wearing was achieved. The fibula osteocutaneous free flap is a very useful alternative for reconstructing a maxillectomy defect.

Intraoral ultrasonography is useful to evaluate tumor thickness in tongue carcinoma

BACKGROUND A number of studies have reported that tumor thickness (the depth of invasion) is a valuable prognostic factor in oral cancers, especially as a predictor of cervical lymph node metastasis. Accurate preoperative assessment of the tumor thickness of tongue cancer would provide useful information for targeting those patients for whom elective treatment of the neck is appropriate when the primary tumor is resected. No studies have been done measuring the tumor thickness of tongue cancer preoperatively. The present study was undertaken in order to evaluate the clinical usefulness of intraoral ultrasonography as a tool to delineate tumor extent and measure the thickness of tongue carcinomas. MATERIALS AND METHODS Twenty-four patients with tongue carcinoma were preoperatively evaluated with intraoral ultrasonography. The tumor thickness measured by ultrasonography was compared with the measurements by histological sections. RESULTS High-quality ultrasonic images were obtained, and the tumor thicknesses were measurable within 1 mm. There was a significant correlation (P <0.001) between measurements by ultrasonography and histological sections. CONCLUSION Our results demonstrated that intraoral ultrasonography is an excellent method to delineate tumor extent and measure tumor thickness in tongue carcinomas.

Functional reconstruction of a bilateral maxillectomy defect using a fibula osteocutaneous flap with osseointegrated Implants

We have achieved functional reconstruction for a bilateral upper alveolar bone, gingival, and palatal defect that has various problems originating from instability of the prosthesis using the fibula osteocutaneous flap with osseointegrated implants. The flap had three bone segments and two skin paddles. The combined bone segments created the upper alveolar arch, and the skin paddles closed the palatal defect. Nine months later, prosthodontic treatment was performed successfully. Our procedure restored the patient to masticatory function of the upper jaw, intelligible speech, and natural facial appearance. As a result, quality of life of the patient was extremely improved.

The Relationship of Shape of Tumor Invasion to Depth of Invasion and Cervical Lymph Node Metastasis in Squamous Cell Carcinoma of the Tongue

Several investigators have suggested that there is a strong correlation between tumor depth and lymph node involvement in tongue carcinoma. The purpose of this study was to investigate the relationship between the shape of tumor, tumor depth, and lymph node metastasis in tongue carcinoma. Fifty-four patients with T1 abd T2 tongue carcinomas who underwent surgical treatment were included in this study. Tumors were divided into four categories according to their shape of invasion: superficial, exophytic, endophytic, and a combination of endophytic and exophytic. Forty cases of endophytic and combination types were divided into two groups according to the shape of invasion: (1) reductive bottom of invasion (n = 17) and (2) expansive bottom of invasion (n = 23). Tumors with a reductive bottom of invasion showed a variety of tumor depths and had low lymph node involvement (4/17, 23.5%). However, tumors with an expansive bottom of invasion showed deeper invasion and a high incidence of lymph node metastasis (16/23, 69.6%). These results suggested that the macroscopic shape of invasion is a feature that may provide important information about the prognosis of the primary tumor especially in relation to cervical lymph node involvement.

Reconstruction using a three-dimensional orbitozygomatic skeletal model of titanium mesh plate and soft-tissue free flap transfer following total maxillectomy.

The surgical strategy for maxillary reconstruction after maxillectomy has yet to be standardized. The authors developed a technique using a three-dimensional orbitozygomatic skeletal model of a titanium mesh for skeletal reconstruction after maxillectomy. From May of 1996 to September of 2000, 18 patients underwent reconstruction using the titanium mesh model in conjunction with a soft-tissue free flap following total maxillectomy for a maxillary malignancy. The soft-tissue free flap was conventional and consisted of two skin paddles to the maxillary defect. One skin paddle became the lateral nasal wall and the other was used to close the palatal defect. After modeling, the titanium mesh plate was implanted between the orbital contents and the upper edge of the free flap to lie over the front of the flap. The model was fixed to the residual zygoma laterally and to the nasal or frontal bone medially. The palatal skin paddle was anchored by three or four dermal stitches to the bottom edge of the titanium mesh to create a concave neopalate that allowed the patient to wear a denture. Thirteen of 18 patients who underwent implantation had good facial appearance and oral function. This procedure prevented lagophthalmos, facial deformity, and sagging of the palatal skin paddle caused by gravitational force. Five patients (27.8 percent) developed exposure or infection of the implant and lost the benefit of having the prosthesis. However, treatment did not require total removal of the implant. Maintaining adequate tissue volume during soft-tissue transfer on either side of the mesh plate may minimize the complication rate. Titanium mesh implantation for skeletal reconstruction after maxillectomy avoids the need for bone grafting and may be especially beneficial in fragile or aged patients.

usefulness of a First Transferred Free Flap Vascular Pedicle for Secondary Microvascular Reconstruction in the Head and Neck

&NA; The authors found that a previously transferred free flap vascular pedicle, distal to the first microvascular anastomosis, can be used as a recipient vessel for an additional free flap transfer. Free flap transfers were performed by using the standard procedure in patients with head and neck cancer. The mean age of the patients was 62 years. Five patients were men and three were women. A second free flap was transferred for secondary primary head and neck cancer in two cases, facial deformity in two cases, osteomyelitis of the skull in two cases, recurrent cancer in one case, and exposure of a mandibular reconstruction plate in one case. The interval between the two operations was from 4 months to 12 years (median, 21 months). All secondary free flaps were performed successfully. In two cases, the external jugular vein proximal to the previously anastomosed site was used for venous drainage. In another case, additional venous anastomosis was performed for flap congestion. It became clear that a previously transferred free flap vascular pedicle could be used as a recipient vessel for microvascular anastomosis. This is an excellent procedure for additional free flap transfers. (Plast. Reconstr. Surg. 109: 1246, 2002.)

Autoperipheral blood mononuclear cell transplantation improved giant ulcers due to chronic arteriosclerosis obliterans

We report the case of a 74-year-old man with Fontaine stage IV chronic arteriosclerosis obliterans who had been suffering from inveterate giant skin ulcers on the dorsum and heel of the right foot. As conventional medical treatments had not improved these ulcers and surgical treatment was considered unfeasible, amputation of the right lower limb below the knee appeared to represent the only option. The patient was admitted to Tottori University Hospital to attempt a new angiogenic therapy using auto-mononuclear cell transplantation to avoid amputation. On admission, neither right ankle blood pressure nor transcutaneous partial pressure of oxygen at the right toe were detectable. The patient had a history of multiple cerebral infarctions, and collection of mononuclear cells from bone marrow was considered too difficult, so collection of peripheral blood mononuclear cells was selected. Transcutaneous partial pressure of oxygen and skin temperature in the treated limb started to improve from 2 weeks after implantation. Ulcer size was recognizably reduced by 1 month after treatment. Partial auto-skin implantation on the right heel was performed 2 months after treatment, and the giant skin ulcer was finally completely covered. No adverse effects were noted during follow-up lasting 1 year. These results suggest that peripheral blood mononuclear cell implantation may offer a suitable alternative rescue therapy for patients with critical limb ischemia whose general condition is not good.

Analysis of Salvage Operation in Head and Neck Microsurgical Reconstruction

In this study, we examined salvage operations after reexploration in head and neck reconstruction and analyzed ways to solve problems. Free flap reconstruction of the head and neck lesion was carried out for 513 cases in our hospital over the past 12 years. Twenty‐one cases of reexploration were caused by postoperative thrombosis (4.1%). We could only salvage seven cases (33.3%) of 21 cases from flap thrombosis. All seven cases were included in the category of venous thrombosis, and they were undertaken within 3 days postoperatively. Our results have shown that once thrombosis occurs, there is little possibility of flap salvage, particularly 3 days after operation and in infectious cases. When no flow phenomena are observed and no flap salvage is deemed possible, aggressive treatment such as a second free flap or next pedicle flap should be chosen as soon as possible to avoid any delay in postoperative treatment.

Combined fibular osteocutaneous and omental flaps

Background: The free vascularized fibular bone graft, first described in 1975, has become one of the most commonly used bone grafts. It is useful for reconstructing mandibular and traumatic long bone defects and defects following tumor resection. This flap, however, does not have a long pedicle and does not have very much volume. The authors report a solution to these problems through the use of an omental flap as a bridge. Methods: Over a 3-year period, nine patients were treated by means of a free fibular osteocutaneous flap with an omental flap. These cases required bone reconstruction without suitable recipient vessels that existed near the defect. The nine patients had the following disorders: two femoral pseudoarthrosis, two tibial pseudoarthrosis, two malignant femoral tumors, one maxillary defect after tumor resection, and one femoral and tibial osteomyelitis. Results: All flaps were transferred successfully. In one case, an additional skin graft was performed because of partial omental necrosis that occurred within 2 weeks. Fibular synostosis developed in eight cases, but amputation was performed in one case because of failed fibular synostosis. In one case, femoral amputation was performed because the femoral artery became obstructed 3 months postoperatively. Conclusions: An omental flap has a long pedicle for use as a bridge flap. It is useful as a vascular flap. A combined fibular osteocutaneous and omental flap is useful for bone reconstruction without satisfactory recipient vessels that exist near the defect. Furthermore, the flap is useful for infected wounds.

Free fibula bone wedge technique for mandible reconstruction using fibula osteocutaneous flaps.

Mandibular reconstruction using a fibula osteocutaneous flap is a reliable procedure that provides good cosmetic and functional outcomes.1– 4 Wedge osteotomy is the most conventional technique for reconstructing a massive defect of the mandible using a fibula free flap.5–9 Modeling of the neomandible requires a meticulous technique and extreme care so as not to damage the vascular pedicle during wedge osteotomy. The template technique of the procedure can achieve very precise approximation of vascularized fibula bone.8 However, it cannot be used in a secondary case of mandibular defect. Another technique, an axial split osteotomy, was presented to overcome these drawbacks.10 However, its advantages have been limited to reconstruction of the mandibular angle. We propose a practical technique using a free fibula bone wedge between vascularized fibula bone segments to construct a neomandible. This method minimizes the amount of manipulation around the vascular pedicle and is relatively easy to perform. We present the procedure and the successful results. OPERATIVE TECHNIQUE Simultaneous with fibular flap harvesting, mandibular resection for cancer or osteoradionecrosis was performed, and the distance of the mandibular defect at the inferior and internal border of the mandible was measured. In cases of secondary mandibular reconstruction, the distance between both ends of residual mandibular bone was measured along the section of mandibular defect. The fibula bone was harvested 5 cm proximal to the lateral malleolus to the upper one-third of the fibula, and the peroneal vessels were ligated at the bifurcation of the posterior tibial vessels (Fig. 1). After harvesting the osseous free flap, the required vascularized fibula bone was outlined to a length equal to the measured or estimated mandibular defect. With the exception of the part of the fibula necessary for the mandibular reconstruction, the excess fibular bone was abraded from the fibular periosteum by raspatorium, and the free fibular bone piece was preserved in saline solution. The vascularized fibular bone section was cut into several bone segments by axial osteotomies for insertion of free fibular wedges. The axial osteotomy was performed by using the following procedure. At the osteotomy site, the periosteum was cut and abraded minimally by means of a raspatorium, a narrow malleable retractor was inserted between the fibular bone and the dissected periosteum, and axial split of the bone was performed so as not to damage the adjacent peroneal vessels (Fig. 2). The axial splitting site was chosen according to the curved shape of the original mandible. Each vascularized fibular bone piece was at least 3 cm in length, to maintain the blood supply for each bone piece (Fig. 3). The next step was rebuilding the neomandible using a prefabricated fibular osseous flap. Both ends of the fibular osseous flap were fixed with the From the Departments of Plastic and Reconstructive Surgery and Otolaryngology, Head and Neck Surgery, Tottori University Faculty of Medicine; Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine; and Department of Head and Neck Surgery, Aichi Cancer Center Hospital. Received for publication January 6, 2005; revised June 8, 2005. Presented at the 43rd Annual Meeting of the Japan Society of Plastic and Reconstructive Surgery, in Sapporo, Japan, May 25, 2000. Copyright ©2006 by the American Society of Plastic Surgeons