Dylan J. Murray

Functional outcomes and donor site morbidity following circumferential pharyngoesophageal reconstruction using an anterolateral thigh flap and salivary bypass tube

This study reports our experience with fasciocutaneous reconstruction of circumferential pharyngoesophageal defects using an anterolateral thigh flap wrapped around a salivary bypass tube.

The internal mammary artery perforator flap: an anatomical study and a case report.

The anatomic basis for the internal artery mammary perforator (IMAP) flap is described in this cadaveric study, together with a clinical case report. The IMAP flap is based on a single or double perforator of the internal mammary artery that is included in the pedicle for added length. It provides a very useful source of local tissue with skin of good texture and color for head and neck reconstruction and, being muscle free, is thin. With preservation of the anterior cutaneous branch of the intercostal nerve, the flap has the potential to be sensate. A large area can be covered, particularly if bilateral flaps are raised. The donor site can be closed directly. In selected patients, it offers an excellent option for use in head and neck reconstruction and should be considered as an alternative to the deltopectoral and pectoralis major flaps.

Advanced technology in the management of fibrous dysplasia.

BACKGROUND The aim of this paper is to describe the applications of advanced imaging technology in optimising the surgical management of complex craniofacial fibrous dysplasia (FD). METHODS Preoperative planning involved a number of advanced technologies. Haptic modelling was used to simulate tumour excision and the design of the osteotomies, on a virtual 3D computerised tomographic (CT) scan. Rapid prototyping was employed in fabricating a physical prototype of the skull, featuring the ideal, symmetrical reconstruction. Tumour extirpation was carried out with the aid of stereotactic navigation. Intraoperatively, resorbable mesh is moulded precisely to the shape of the skull prototype, thereby transferring the surgical simulation to the patient in the operating room. The resorbable mesh serves as a template which guides the shape and spatial orientation of an autologous bone graft reconstruction. Pre- and postoperative volumetric differences were assessed to determine the accuracy of the final results. RESULTS Short and long term follow-up examinations show excellent cosmetic outcome, with significant restoration of volumetric symmetry. CONCLUSIONS The added complexity of using the new technologies increases preoperative planning time, but we believe that this is offset by the improved safety during the resection of the tumours as well as the excellent aesthetic outcomes.

Optimizing Craniofacial Osteotomies: Applications of Haptic and Rapid Prototyping Technology

Craniofacial reconstruction frequently relies on the osteotomy and transposition of skeletal segments. Preplanning of the osteotomies has been greatly simplified with the development of more accurate imaging techniques including 3-dimensional (3D) computed tomographic (CT) scans. More recently the use of rapid prototyping (RP) and the construction of a physical prototype with stereolithography (SL) has allowed the craniofacial surgeon to remotely plan the osteotomy site and position. 1-6 Despite the increased sophistication of preoperative planning, accurate intraoperative implementation of the osteotomy design remains problematic. Precise determination of the optimal spatial position and orientation of the osteotomy segment is difficult, particularly when visualization is restricted or when adjacent anatomical landmarks are unreliable. This problem is addressed very effectively in orthognathic surgery by the use of intraoral splints, which provide a means of transferring the preoperative plan from the dental models to the patient and in guiding osteotomy segment positioning. There is no analogous technique in the zygoma or upper face. This report introduces a simple, reliable system to guide the intraoperative positioning and fixation of osteotomy segments in the upper craniofacial skeleton. It requires initial haptic simulation of the desired reconstruction based on 3D CT images, followed by the fabrication of a custom made resorbable polylactic-co-glycolic acid (PLGA) (Stryker Leibinger Co, Kalamazoo, MI) template to guide osteotomy segment transfer and positioning. This template is constructed on a physical model produced by RP using a 3D printing system.

A Cephalometric Analysis of Maxillary and Mandibular Parameters in Treacher Collins Syndrome

Background: Treacher Collins syndrome is an autosomal dominant condition of varying severity, affecting the tissues of the first and second branchial arches. The aim of this article is to present a cephalometric analysis of the craniofacial skeleton in Treacher Collins syndrome and provide an age- and sex-matched comparison as a standard control sample. Methods: Twenty-four Treacher Collins syndrome patients (11 male patients and 13 female patients; mean age, 17.99 ± 1.96 years) underwent cephalometric studies, including orthopantomography and lateral and anteroposterior cephalography, as part of their preparation for bimaxillary surgery. Cephalometric parameters assessing the relationships of the skull base, maxilla, and mandible were analyzed and compared with age- and sex-matched control data (mean age, 17.75 ± 1.95 years). Results: Cephalometric analysis before orthognathic surgery documented that the Treacher Collins syndrome mandible and midface are expectedly short in the anteroposterior plane; however, the ratio of maxillomandibular deficiency is particularly significant in the female patient. The mandibular plane angle is obtuse, affecting female patients in particular, in whom there is also a posteriorly placed chin point. Affected individuals have a high antegonial notch height. Although the parameters of anterior lower facial height proportion in control and syndrome individuals are similar, posterior face height in Treacher Collins syndrome is reduced. Conclusions: This study quantifies the cephalometric dysmorphology of patients with Treacher Collins syndrome and compares it to that of age-matched controls. These cephalometric characteristics have clinical significance in Treacher Collins syndrome and in the planning of bimaxillary advancement and genioplasty in syndrome patients.

Free tissue transfer and deep vein thrombosis

Reconstruction of the post-oncologic defect of the lower limb frequently requires free tissue transfer and these often extensive bone and soft tissue resections can occasionally be compounded by the presence of a deep venous thrombosis (DVT). We describe two patients in whom free tissue transfer was attempted, following extensive resection of a sarcoma in the thigh. Both patients had been diagnosed with DVT prior to surgery and received therapeutic low molecular weight heparin preoperatively. In the first patient, flap failure occurred due to venous congestion initially resulting from poor flow in the reconstructed femoral vein and then thrombosis and failure of the vascular reconstruction. In the second patient the superficial venous system was used for successful microvascular anastomosis leading to survival of the flap. Therefore, patients undergoing lower extremity free tissue transfer who are at high risk of DVT, or when there is a clinical suspicion of DVT, thorough preoperative assessment of the deep and superficial venous system is warranted for reconstruction planning.