J.M. López-Arcas

The Fibula Osteomyocutaneous Flap for Mandible Reconstruction: A 15-Year Experience

PURPOSE This report documents our experience over the previous 15 years using free vascularized fibular flaps for comprehensive reconstruction of large defects in the mandible, after combined resections of aggressive, malignant odontogenic tumors or for post-traumatic defects. PATIENTS AND METHODS Charts were reviewed retrospectively for 117 consecutive patients who underwent microsurgical reconstruction of the oromandibular complex with a fibula osteocutaneous or osteomyocutaneous free flap over a 15-year period, with an average follow-up of 4 years. All charts were reviewed retrospectively for tumor type, stage and location, surgical procedure performed (including type of plate used), dental restoration if done, the use of pre- or postoperative radiotherapy, length of follow-up, and evidence of complications. RESULTS Fibula osteocutaneous free flaps were used for reconstruction in 117 patients, of whom 60% were men (mean age, 57.1 years) and 40% were women (mean age, 56.6 years). Most cases (61.1%) were secondary to oral malignancies (89.1% of these were squamous cell carcinoma). Thirty-one patients (26.5%) developed postoperative complications, including hardware failure or intolerance in 16 patients (13.7%), total or partial flap failure in 10 patients (8.5%), wound infection in 3 patients (2.6%), and peroneal nerve damage in 2 patients (1.7%). Regarding donor site morbidity, calf paresthesias were recorded in 21% of cases. Similar rates of claw-toe deformity were also observed. CONCLUSIONS In our opinion, the free fibula osteocutaneous flap is the most versatile and reliable option for microsurgical reconstruction of large mandibular defects. It provides a large quantity of bone, which is easily shaped to passively adapt to the remaining mandible. The bone height is suitable for an implant-based prosthetic restoration. Preoperative mapping of the cutaneous perforators of the skin paddle improves the versatility of the flap design and decreases the morbidity at the donor site. In selected cases, other options (iliac crest or scapular free flap) may also be considered.

Fibroscopic findings in patients following maxillary osteotomies in orthognathic surgery

OBJECTIVE To evaluate the intranasal complications in patients submitted to maxillary Le Fort osteotomy within the orthognathic evaluation through flexible fibroscope, method which is safety, reliable and minimally invasive. MATERIALS AND METHODS A prospective, systematic non-randomized study is presented with a series of 47 patients who underwent a Le Fort I maxillary osteotomy due to dentofacial deformity between January 2008 and December 2008. The patients who were included underwent an evaluation of nasal respiratory function using a questionnaire designed for this objective, after which a fibroscopic examination was carried out. RESULTS With regards to the results of the NOSE questionnaire, 4/47 patients had Grade 2 nasal obstruction before the surgery. After the intervention, three improved to a 0-1 grade. 3/47 patients reported snoring during sleep without OSAS that was not modified as a result of the surgery. 2/47 patients presented with sequelae regarding the deviation of the septum, and 1/47 had a luxation of the anterior nasal spine that had not been recorded before the orthognathic surgery. The presence of synechiae was observed in 3/47 cases. A septal perforated mucosa was found in the IV area of the nasal septum. Hypertrophy of the lower turbinate was observed in 4/47 cases. CONCLUSION The fibroscope procedure is minimally invasive and it does not require local anesthesia or sedation, and it allows the surgeon to carry out an immediate and exhaustive evaluation, on an outpatient basis, of possible septal and nasal sequelae in patients undergoing orthognathic surgery.

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.

Carcinoma cutáneo de células de Merkel: Presentación de un caso y revisión de la literatura

espanolEl carcinoma de celulas de Merkel, constituye una variedad infrecuente de cancer cutaneo, de origen neuroendocrino, que clasicamente se describe, como la malignidad cutanea de peor pronostico. Se origina a partir de las celulas de Merkel o receptores cutaneos de presion. Presenta un patron infiltrativo dermo-linfatico asi como extension linfatica nodal y diseminacion hematogena. Presenta numerosas similitudes con el carcinoma pulmonar de celulas pequenas, con una sensibilidad intrinseca a la quimio-radioterapia y un gran potencial metastatico. Los mejores resultados se obtienen cuando se combina un diagnostico precoz y el tratamiento combinado con cirugia-radio y quimioterapia. La principal dificultad que presentan estos tumores es la avanzada edad de la poblacion en que se presentan y la localizacion de los mismos, que en ocasiones limitan las opciones terapeuticas disponibles. Presentamos un caso de carcinoma de celulas de Merkel facial, tratado con cirugia y radioterapia. Se realiza una revision de la literatura. EnglishMerkel-cell carcinoma is a rare skin cancer of neuroendocrine origin, which has been described as the most aggressive skin malignancy. The tumor arises from the Merkel cells, or skin pressure receptors. It has an infiltrative growth pattern and spreads by the lymphatic vessels and blood. It is similar to small cell lung carcinoma, with an intrinsic sensitivity to chemo-radiotherapy and a remarkable tendency to metastasize. The best treatment outcomes are obtained with early diagnosis and a combination of surgery, chemotherapy, and radiotherapy. A clinical case of Merkel cell carcinoma of the face treated with surgery and radiotherapy is reported and the literature is reviewed.