M. Burgueño

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.

Polyetheretherketone custom-made implants for craniofacial defects: Report of 14 cases and review of the literature

BACKGROUND Craniofacial defects tend to carry functional and esthetic consequences for the patient. The complex shapes in this region make such reconstructions a challenging procedure and the most suitable material to be used remains controversial. METHODS We report a series of 14 patients whose craniofacial defects were reconstructed using a computer designed PEEK-PSI (Polyetheretherketone- Patient Specific Implant). We analyzed the complications and outcomes of PEEK custom-made implants and compared our results with those of other case series reported in the current literature. RESULTS Fourteen patients underwent craniofacial reconstruction using a PEEK-PSI. Three cases involved a one-step primary reconstruction and the rest of cases underwent a delayed reconstruction. Two cases (14.3 %) presented infection and only in one case was the implant definitively removed. Esthetic results were considered to be highly satisfactory. CONCLUSION With CAD-CAM techniques, it is possible to prefabricate an individual implant. The ideal material for reconstructing maxillofacial defects does not exist, but PEEK has demonstrated good outcomes. When autologous bone is not available or, in selected cases with large or complex defects in the maxillofacial area, PEEK is one of the best options to reconstruct these defects. However, further studies are needed to determine the long-term results.

I Conferencia Nacional de Consenso sobre el Injerto Óseo del Seno Maxilar

Resumen Objetivo El objetivo de la I Conferencia Espanola de Consenso sobre el Injerto Oseo Sinusal era intentar llegar a puntos de acuerdo sobre las principales controversias de esta tecnica, aplicada de forma muy variada y con el empleo de materiales muy diversos, y conseguir plasmar los mismos en un documento resumen consensuado por todos los autores. Material y metodo Durante los dias 17 y 18 de octubre de 2008 se celebro en Oviedo la citada conferencia, auspiciada por la Sociedad Espanola de Cirugia Oral y Maxilofacial. En ella se dieron cita un total de 50 ponentes de reconocido prestigio nacional e internacional que repasaron en 6 mesas de trabajo las principales controversias sobre los injertos oseos sinusales. Tras las conferencias de los ponentes, los moderadores establecian las principales conclusiones de cada mesa y se abria un turno de debate donde participaban todos los asistentes. Resultado Este documento y sus conclusiones emanan de las presentaciones realizadas por los ponentes y de las deliberaciones y acuerdos de cada mesa de trabajo. Ambos han sido aprobados tras varias correcciones por todos los autores antes de ser enviados para su publicacion. Ademas, han obtenido el reconocimiento cientifico oficial de la Sociedad Espanola de Cirugia Oral y Maxilofacial y deben servir como base para futuros estudios y reuniones cientificas. Conclusiones El objetivo fundamental cuando se realiza un injerto oseo sinusal es la formacion de hueso vital en el seno maxilar, para conseguir la supervivencia a largo plazo de los implantes tras su carga protesica. Para ello, la tecnica y la secuencia de tratamiento deben orientarse a conseguir resultados predecibles y estables en el tiempo, aunque esto suponga un mayor tiempo de espera hasta la colocacion de la protesis. La estabilidad inicial del implante es el factor clave para la osteointegracion y debe ser el principal criterio para indicar implantes simultaneos o diferidos en el seno maxilar.

Parotid gland solitary fibrous tumor with mandibular bone destruction and aggressive behavior

Introduction: Solitary fibrous tumor is associated with serosal surfaces. Location in the salivary glands is extremely unusual. Extrathoracic tumors have an excellent prognosis associated with their benign clinical behavior. We report an aggressive and recurrent case of this tumor. We review the clinical presentation, inmunohistochemical profiles and therapeutic approaches. Case Report: A 73-years-old woman presented a mass in her right parotid gland. She had a past history of right superficial parotidectomy due to a neurilemoma. FNAB and magnetic resonance were non-specific. After a tumor resection, microscopic findings were spindled tumor cells with reactivity to CD34, bcl-2 and CD99 and the tumor was diagnosed as Solitary Fibrous Tumor. The patient suffered two recurrences and the tumor had a histological aggressive behavior and a destruction of the cortical bone of the mandible adjacent to the mass. A marginal mandibulectomy with an alveolar inferior nerve lateralization was performed. Conclusions: Solitary fibrous tumor is a very rare tumor. Usually, they are benign, but occasionally they can be aggressive. Complete resection is the most important prognostic factor and no evidence supports the efficacy of any therapy different to surgery. Due to the unknown prognosis and to the small number of cases reported, a long-term follow-up is guaranteed. Key words:Solitary fibrous tumor, parotid mass, parotid gland, salivary gland, rare tumors.

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.

Use of a three-way stopcock in grafting of autologous fat: technical note

Fig. 1. Conventional hospital 3-way stopcock. The 3 systems are connected. utologous fatty tissue is used routinely to treat conditions s varied as syndromic defects, post-traumatic and postperative complications, velopharyngeal insufficiency, and esthetic disorders. Fat has been transferred by injection since he beginning of the last century, although the technique has ecome more popular in the last 25 years.1 Many different aspects have been reported and cover the onor site, methods of aspiration, local anaesthesia, processng of fatty tissue,2 reinjection, and stability of the graft. ne such technique is that proposed by Coleman,2 in which he Luer-Lok® syringe system is necessary throughout the rocedure. A 10 ml Luer-Lok® syringe attached to a 2-holed cannula s used to harvest autologous fat. Care should be taken not to amage the fatty parcels. The graft can be processed using entrifugation: the syringes are spun at 3000 rpm for 3 min, fter which time the oil and aqueous layers are decanted and rained.3 The next step is injection of the fat using a 1 ml Luerok® syringe. However, transferring fatty tissue from the 0 ml syringe to the 1 ml syringe can be difficult. Coleman laced the 10 ml syringe in the open barrel of a 1 ml syringe rom which the plunger had been removed and held the 1 ml yringe upwards and obliquely to minimise the introduction 4 f air bubbles. However, this position could cause the tisue to spill. An alternative could be to use a Luer-Lok®

Orthodontically guided bone transport in the treatment of alveolar cleft: A case report

Introduction Conventional treatments are sometimes not possible in certain alveolar cleft cases due to the severity of the gap which separates the fragments. Various management strategies have been proposed, including sequential surgical interventions or delaying treatment until adulthood to then carry out maxillary osteotomies. A further alternative approach has also been proposed, involving the application of bone transport techniques to mobilise the osseous fragments and thereby reduce the gap between lateral fragments and the premaxilla. Case Report We introduce the case of a 10-year-old patient who presented with a bilateral alveolar cleft and a severe gap. Stable occlusion between the premaxilla and the mandible was achieved following orthodontic treatment, making it inadvisable to perform a retrusive osteotomy of the premaxilla in order to close the alveolar clefts. Faced with this situation, it was decided we would employ a bone transport technique under orthodontic guidance using a dental splint. This would enable an osseous disc to be displaced towards the medial area and reduce the interfragmentary distance. During a second surgical intervention, closure of the soft tissues was performed and the gap was filled in using autogenous bone. Conclusions The use of bone transport techniques in selected cases allows closure of the osseous defect, whilst also preserving soft tissues and reducing the amount of bone autograft required. In our case, we were able to respect the position of the premaxilla and, at the same time, generate new tissues at both an alveolar bone and soft tissue level with results which have remained stable over the course of time. Key words:Alveolar cleft, bone transport, graft.

Fístula arteriovenosa postraumática: tratamiento endovascular. Revisión de la literatura y presentación de un caso clínico

Traumatic arteriovenous fistulas of the head and neck region are uncommon. The majority are due to penetration of blunt injury. We describe a successful endovascular treatment of a posttraumatic fistula between the left maxillary artery and the external jugular vein due to a penetration injury. This case and a review of the literature illustrate the causes, manifestations, image studies and treatment for a posttraumatic fistula between the maxillary artery and the external jugular vein. This case demonstrate the utility of endovascular treatment of head and neck injuries complications.

Fibula free flap splitting for mandible reconstruction: A technical note

Conformation of the fibula flap to passively adapt to the remaining mandible may be indeed challenging. A review of the ‘axial splitting’ technique for fibula free flaps is presented with a novel method of osteosynthesis. Adequate mandibular angle shape is achieved by performing this type of osteotomy with a minimal use of titanium hardware for flap insetting.

Rescate con sanguijuelas de un injerto libre lateral del muslo

espanolResumen: La tasa de exito total de los injertos libres microvascularizados se situa actualmente por encima del 95% en la mayoria de los Servicios. Los intentos de rescate en distintas series son exitosos en un 28-87,5% de los casos. La insuficiencia venosa es responsable de la mayor parte de los fracasos iniciales. Presentamos un caso clinico en el que se detecto trombosis venosa del injerto que finalmente fue rescatado con el empleo coadyuvante de sanguijuelas. EnglishAbstract: The overall success rates using free flaps is nowadays over 95% in the majority of services. Salvage attempts successfully rescue from 28-87,5% of the cases in different series. Venous insufficienency is responsible for most initial flap failures We report a case in which a venous trombosis of the free flap was detected and it was finally successfully rescued with leeches.