María José Morán

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.

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®

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.

Página del residente¿Cuál es su diagnóstico?What would your diagnosis be?☆

con hipertensión arterial en tratamiento y EPOC severo con oxigenoterapia domiciliaria y corticoterapia como antecedentes importantes de interés. Es remitido por su odontólogo a urgencias del Hospital Universitario La Paz, al presentar en encía mandibular edéntula una tumoración de aspecto úlcero-necrótico de 1 cm de diámetro de 4 semanas de evolución. En la anamnesis, el paciente refiere haber sido tratado por su odontólogo con antibioterapia y antiinflamatorios, dado el diagnóstico de presunción de absceso odontogénico, sin mejorìa del cuadro (Fig. 1). Como síntoma principal presenta intenso dolor en encía afecta y mandíbula subyacente con hipoestesia en territorio del nervio dentario inferior izquierdo. No aqueja disfagia ni odinofagia. A la exploración física, no drena material purulento, ni espontáneamente ni a la compresión de la lesión, así como tampoco presenta sangrado activo. Ausencia de trismus, apreciando a la palpación, abombamiento de la cortical vestibular mandibular. Ausencia de otras lesiones en cavidad oral ni se palpan adenopatías cervicales. En el estudio radiológico, la ortopantomografía muestra una imagen osteolítica en sector edéntulo del tercer cuadrante mandibular correspondiente a piezas 35-37. La imagen se extiende a los 2/3 superiores de la altura del cuerpo mandibular (Fig. 2). La TC corrobora la presencia de lesión osteolítica mandibular de patrón difuso y afectación de la cortical vestibular mandibular. Destaca la existencia de lesión de 2x1 cm con centro necrótico, en partes blandas correspondiente a encía suprayacente (Fig. 3). Se realiza biopsia de la lesión con curetaje de hueso alveolar. El análisis anatomopatológico e inmunohistoquímico es informado de células linfoproliferativas monoclonales tipo B de fenotipo CD 20+, CD 79a+. La serología es negativa para VIH, citomegalovirus, VHB y VHC. Male, 82 years old, non smoker being treated for hypertension and severe COPD, he has a history of in home oxygen therapy and cortical therapy. His dentist sent him to the emergency room at University Hospital of La Paz because of a tumor on the gum “mandibular edentia” the tumor has an ulcer-necrotic appearance and is 1 cm in diameter and 4 weeks progressed. During anamnesis the patient reports that his dentist treated him with antibiotherapy and anti-inflammatory, given the presumed diagnosis as a dental abscess, without improvement of the square (Fig. 1). The main symptoms are intense pain in the affected gum and subjacent mandible, and hypoesthesia in the area surrounding the left inferior dental nerve. It doesn’t cause dysphagia or odynophagia. Upon physical exploration there is no purulent material drained. Nor is there active bleeding even when pressure is applied to the lesion. There was no trismus, perceived upon ballooning palpation of the mandible cortical vestibular. There were no other lesions of adeonpathies felt in the oral cavity. In a radiological study the ortopantomography shows the osteolytic image of the edentulous sector of the third mandible quadrant which corresponds to teeth 35-37. The image extends to the 2/3 superiors and to the height of the mandible body (Fig. 2). The CT verifies the presence of an osteolytic mandible lesion with a vague pattern and cortical vestibular mandible affectation. It highlights the existence of a 2x1 cm lesion with a necrotic center in soft parts of the corresponding super adjacent gum (Fig. 3). A biopsy of the lesion is carried out with alveolar bone curettage. The anatomopatological and inmunohistochemistry analyses are informed about the lympho proliferative monoclonal cells type B and phenotype CD 20+, CD 79 a+. The serology is negative for HIV, cytomegalovirus, HBV, and HCV. Página del Residente Rev Esp Cir Oral Maxilofac 2009;31,4 (julio-agosto):271-275

Trastornos hidroelectrolíticos en el postoperatorio de cirugía ortognática

espanolObjetivo. El objetivo de este trabajo es analizar los cuadros de poliuria precoz encontrados en un alto porcentaje de nuestros pacientes sometidos a procedimientos de cirugia ortognatica. Material y metodo. Hemos realizado un estudio descriptivo retrospectivo, a partir de la revision de las historias clinicas de los 172 pacientes sometidos a cirugia ortognatica entre los anos 1997 y 2002, con el fin de recoger datos analiticos y de diuresis referentes tanto a la cirugia como al periodo de estancia en Reanimacion. Resultados. Un 55% de los pacientes que ingresaron en la unidad de reanimacion postoperatoria presentaron poliurias precoces autolimitadas. Todas fueron tratadas con exito con un correcto manejo hidroelectrolitico, salvo un caso que necesito desmopresina intranasal. Dos pacientes presentaron alteraciones ionicas: un caso de hipopotasemia y otro de hiponatremia. Ambos respondieron adecuadamente a la reposicion hidroelectrolitica. Discusion y conclusiones. Casi el 50% de los pacientes tratados de deformidades dentofaciales mediante cirugia ortognatica desarrolla poliuria en el postoperatorio inmediato. Las tres hipotesis etiologicas que barajamos fueron: una intoxicacion hidrica producida en el quirofano, una inhibicion de la produccion hipofisaria de hormona antidiuretica tras las osteotomias faciales y un sindrome de gasto de sal relacionado con excrecion inadecuada del peptido atrial natriuretico. En nuestros casos lo mas probable es que se trate de una intoxicacion hidrica producida durante la cirugia, que haga replantearse el manejo de liquidos en el periodo perioperatorio. EnglishIntroduction. The aim of this article is to analize the early polyuria cases that we found among our patients that have undergone a orthognatic procedure. Materials and methods. We reviewed data from 172 patients that have undergone an orthognatic surgycal procedures between 1997 and 2002. We collected data during the intraoperatory period, and the first 24 postoperatory hours. Results. 55% of the patients that staid for more than 24 hours in Reanimation showed early autolimited polyuria. All of them were successfully treated with a proper hidroelectrolitic treatment. One needed intranasal desmopresin. However hypopotasemy in one case and hyponatremy in another were resolved with hidroelectrolitic treatment. Disscusion and conclusions. Almost 50% of patients surgically treated of dentofacial deformities present polyuria in the early postoperatory period. There are three main etiologic hypotesis: hydric intoxication during surgery, inhibition of ADH liberation due to facial osteotomies, and salt wasting syndrome. The most probable in our serie is an hydric intoxication during surgery.