Hemangioma of the mandible in a 12-year-old boy

@#Intraosseous hemangioma is a benign, rare neoplasm that accounts to 0.5 - 1% of all benign tumors of bones.1, 2 While most hemangiomas arise from soft tissues, it is uncommon for it to arise from bones.2 The most common sites of growth are in the vertebral body and the calvarium with frontal bone making up approximately 45% of calvarial cases.2,3 However, they are also encountered in the head and neck with sites such as the skull (53%), mandible (10.7%), nasal bones (9%), and cervical spine (6%).4 In the mandible, the body is mostly affected and 65% are found in the molar and premolar region.1 They are more common in adult females with peaks at the second and fifth decades of life.1-3 Hemangioma of the mandible is difficult to diagnose due to its nonspecific clinical presentation and radiographic features. It mimics various mass lesions in the mandible such as giant cell granuloma, fibrous dysplasia, multiple myeloma, osteosarcoma, ameloblastoma and keratocysts. Therefore, a comprehensive history taking and physical examination plus examination of the imaging studies available and tissue biopsy all play important roles in arriving at the final diagnosis.5 We present the case of an aggressive mandibular hemangioma in a young boy and our management involving a failed fibular free flap reconstruction.

Plastic and reconstruction surgery for non-healing wound after posterior spinal surgery / 北京大学学报(医学版)

OBJECTIVE@#To investigate the clinical significance of different plastic surgeries in the treatment of poor healing wound after posterior spinal internal fixation.@*METHODS@#In this study, 16 patients with poor incision healing after posterior spinal internal fixation were retrospectively included, and dif-ferent plastic surgery treatment plans were determined according to the wound characteristics and defect condition. The measures included debridement, vacuum sealing drainage (VSD), and different tissue flaps according to the location and extent of the defect.@*RESULTS@#A total of 16 patients meeting the criteria were included, of whom 3 were treated with debridement combined with VSD and wound suture directly, 6 were treated with debridement combined with Z-flap for wound repair, 1 was treated with bilateral sacrospinous muscle flap for dural defect repair combined with Z-flap for skin wound repair, 1 was treated with lectus dorsi flap for wound repair, 3 were treated with the fourth lumbar artery perforator flap for wound repair. The wound was repaired with local rotating flap in 1 case and gluteus maximus musculocutaneous flap in 1 case. Among the 16 patients, 7 cases were positive for wound culture, including 3 cases of Staphylococcus aureus, 1 case of Pseudomonas aeruginosa, 1 case of Staphylococcus epidermidis, 1 case of Escherichia coli, 1 case of Klebsiella pneumoniae, and the other 9 cases were negative. After surgery, there were 7 patients with different degrees of poor wound healing, including 3 patients undergoing dressing change, 2 patients undergoing secondary debridement and suture, 1 patient undergoing free scalp skin graft, and 1 patient undergoing local effusion suction treatment. All the above 7 patients were discharged from hospital after improvement, and the remaining 9 patients had good first-stage wound hea-ling after surgery. None of the 16 patients underwent internal fixation.@*CONCLUSION@#Multiple factors could lead to poor wound healing after posterior spinal internal fixation. Early intervention, thorough debridement, removal of necrotic/infected tissue, and selection of suitable skin flap for effective wound fil-ling and covering were important means to ensure wound healing after spinal surgery and reduce removal of internal fixation.

Long-term functional outcomes and quality of life after partial glossectomy for T2 squamous cell carcinomas

Abstract Introduction: Partial glossectomy and reconstruction strategy for malignant tongue tumors influences speech and swallowing. Objective: The aim of this retrospective study was to evaluate long-term functional outcomes after partial glossectomy for pT2 mobile tongue carcinomas with a maximum dimension between 2 and 3 cm. Different reconstruction strategies (with or without pedicled flap) were compared. Methods: Twenty-two patients with at least 12 months followup were included. Clinician-based and self-reported instruments were used to analyze tongue motility, speech intelligibility and articulation, swallowing, and quality of life. Results: Patients with a higher tongue motility had better articulation and lower dysphagia. Avoiding pedicled flap reconstruction seemed to guarantee lower impairment of speech and swallowing. Worse functional outcomes induced a lower quality of life. Conclusion: Partial glossectomy results in tongue motility impairment and consequently alterations of oral functions. Since the type of reconstruction impacts long-term outcomes, it should be adequately planned before surgery.

Clinical analysis of selective tracheostomy necessary for patients undergoing head and neck surgery with free flap reconstruction / 北京大学学报(医学版)

OBJECTIVE@#To discover the factors that may affect the use of selective tracheostomy among patients who have undergone head and neck surgeries with free flap reconstruction, so that the patients will not need tracheostomy nor receive the unnecessary treatment.@*METHODS@#Five hundred and thirty-three patients who had undergone head and neck surgery with free flap reconstruction operated by the same team of surgery at Department of Oral and Maxillofacial Surgery at Peking University School of Stomatology from 2015 to 2016 were reviewed. Three hundred and twenty-one (60.2%) of these patients underwent selective tracheostomy. All the patients' demographic information, operation-related information, prior treatments, comorbidities and complications were recorded and analyzed.@*RESULTS@#The patients with defects of the tongue, mouth floor, oropharynx and bilateral mandible, who underwent neck dissection and with previous radiotherapy and smoking habit were more likely to get selective tracheostomy. Usage of bulky soft tissue flap might also add to the risk of airway obstruction and the need of selective tracheostomy, while other factors were not significantly related to the risk of postoperative airway obstruction and the patients could be kept safe without selective tracheostomy. Most cases without tracheostomy were kept safe except one case, while 8.39% of the patients with tracheostomy suffered from tracheostomy related complications, mainly pneumonia and hemorrhage of the tracheostomy wound, yet none led to serious consequences or even death.@*CONCLUSION@#Selective tracheostomy is not necessary for patients who have undergone head and neck surgeries with free flap reconstruction except that there are defects at the tongue, oropharynx and mandible. Neck dissection, bulky soft tissue flap reconstruction, previous radiotherapy and smoking habit may also add to the risk of postoperative airway obstruction, while a favorable decision would involve a combination of all the above factors to assure the safety of the postoperative airway for the patients undergone head and neck surgeries with free flap reconstruction.

Wounds repaired by flap transfer after total knee arthroplasty / 中国组织工程研究

BACKGROUND: Wound complications probably result in severe soft tissue defects after total knee arthroplasty, which brings orthopedic surgeon a big challenge. Some treatment options, such as frequent sterile dressings changes, persistent drainage, minor or thorough debridement, negative pressure wound therapy and split-thickness skin grafts, fail to help those quite large and deep wounds around the knee, with exposed fascia or prosthesis, bone, joint, tendon, large vessels and nerve, heal by secondary intention. Under these situations, orthopedic surgeon should consult plastic surgery and propose flap re-construction. OBJECTIVE: To introduce some types of flaps for orthopedic surgeon, so as to help orthopedic surgeon understand and chose flaps logically, and reduce severe consequences caused by soft tissue defect wounds. METHODS: The first author retrieved databases of PubMed, Medline, Wanfang and CNKI for the articles concerning wounds repaired by flap transfer after total knee arthroplasty published before 2019. The key words were "flap, knee, wound" in Chinese and English, respectively. Initially 668 articles were retrieved and 45 eligible articles were included in accordance with the inclusion and exclusion criteria for analysis. RESULTS AND CONCLUSION: (1) Flap reconstruction is widely applied in plastic surgery. It is significant for orthopedic surgeon to recognize the characteristics of each flap. (2) Selecting and designing suitable type of flap according to the three-dimensional structure and position of wounds is helpful for repairing soft tissue defect, reducing the risks of prosthesis exposure, periprosthetic infection, prosthesis removal and even amputation after total knee replacement after total knee arthroplasty.

Depression status of 136 patients with adjuvant radiotherapy after reconstruction of the oral cancer flap and analysis of influencing factors / 口腔疾病防治

Objective@#To explore the depression and influencing factors of patients with adjuvant radiotherapy after reconstruction of oral cancer flaps and to provide evidence for postoperative care.@*Methods@#One hundred thirty-six patients with oral cancer who had undergone adjuvant radiotherapy after reconstruction of skin flaps at 4 affiliated hospitals in Harbin Medical University were selected by convenience sampling. The basic information of the patients with adjuvant radiotherapy after reconstruction of skin flaps was collected, a self-rating scale for depression was used to assess depression, and a questionnaire was used to assess symptom distress. Depression and its influencing factors were determined by multiple stepwise regression analysis. @*Results@#The average score of depression in patients with oral cancer after skin flap reconstruction was (52.32±13.11): 33.1% of the patients showed mild depression, 21.3% showed moderate depression, and 2.2% showed severe depression. Postoperatively, the patients had pain, dysphagia, taste disorders, temporomandibular joint and salivary gland dysfunction, as well as marital and financial problems. The results showed that dysphagia (P < 0.001), taste disorder (P < 0.001), marital status (P=0.004) and family income per month (P= 0.011) could be the influencing factors of depression in patients with oral cancer during radiotherapy, and a significant correlation was found between them.@*Conclusion @#Patients with adjuvant radiotherapy after reconstruction of oral cancer flaps have depressive symptoms, which will seriously affect the quality of life. Therefore, the care of such patients should focus on improving the postoperative depression of patients.

Value of the Post-Operative CT in Predicting Delayed Flap Failures Following Head and Neck Cancer Surgery

OBJECTIVE: To identify post-operative computed tomography (CT) findings associated with delayed flap failures following head and neck cancer surgery. MATERIALS AND METHODS: We retrospectively reviewed 60 patients who underwent flap reconstruction after head and neck cancer surgery and post-operative (3–14 days) contrast-enhanced CT scans for suspected complications. Patients were divided into two groups: delayed flap failure patients (patients required flap revision) (n = 18) and flap success patients (n = 42). Clinical data (age, sex, T-stage, type of flap, and time interval between reconstruction surgery and CT) and post-operative CT findings of flap status (maximum dimension of the flap, intra- or peri-flap fluid collection and intra- or peri-flap air collection, fat infiltration within the flap, fistula to adjacent aerodigestive tract or skin, and enhanced vascular pedicle) were assessed and compared between the two groups. RESULTS: CT findings showed that the following flap anomalies were observed more frequently in the delayed flap failure group than in the flap success group: intra- or peri-flap fluid collection > 4 cm (61.1% vs. 23.8%, p 2 cm (61.1% vs. 2.4%, p < 0.001), and fistula to adjacent aerodigestive tract or skin (44.4% vs. 0%, p < 0.001). The maximum dimension of the flap, fat infiltration within the flap, and enhanced vascular pedicle were not associated with delayed flap failures. CONCLUSION: A large amount of fluid or air collection and fistula are the CT findings that were associated with delayed flap failures in patients with suspected post-operative complications after head and neck cancer surgery.

An Anatomical Study of Gracilis Muscle and its Vascular Pedicles.

Background: Gracilis muscle being easily accessible and functionally a weak muscle is suitable for muscle graft to replace the damaged muscle in any part of the body. The length of the muscle, vascular pedicles and limited donor site morbidity helps the surgeon to plan accordingly. The muscle receives a number of vascular pedicles ranging from one to five. The source of these pedicles varies. Material and Methods: The study was conducted on 36 formalin fixed lower limbs of both sexes of unknown age from the department of Anatomy, BMCRI, Bangalore. Results and Discussion: In 75% of limbs two vascular pedicles were seen penetrating the muscle at different levels and in 25% accessory pedicles were seen in the lower 2/3rd of the muscle. Conclusion: The findings suggest that the first vascular pedicle to the muscle is always constant in position accompanied by its venae comitans and branch from obturator nerve and is placed at a distance of 10.5cms±2cms from the pubic tubercle.

An Anatomical study on Dorsalis Pedis Artery.

Background:The study of Dorsalis pedis artery and variations in its branching pattern has been reported sporadically. The purpose of this study was to evaluate the arterial supply on the dorsum of the foot. Materials and Methods: The study was carried out on forty two dissected limbs of unknown sex and age from the department of Anatomy,BMCRI,Bangalore. Results and Discussion:The incidence of classical text book description was found to be very less in the present study. In 16.67% of cases the arcuate artery was completely absent, which was compensated by two large lateral tarsal arteries that provided the dorsal metatarsal arteries. In 9.52% of cases the dorsalis pedis artery was absent. Conclusion:The findings suggest that the lateral aspect of the dorsum of the foot has a poor nourishment.

Anterolateral thigh free flap for the reconstruction of through and through defect of cheek following cancer ablation.

The anterolateral thigh flap is a highly versatile and reliable flap for use in the reconstruction of various soft-tissue defects of the head and neck. This flap has gained great popularity due to its versatility, ability for a two-team approach, and minimal donor site morbidity. However, it has not met the same enthusiasm in the armamentarium of Maxillofacial Surgeons due to its relative difficulty in perforator dissection, reported variations of the vascular anatomy, and the presumed increased thickness of the anterolateral thigh tissue. These obstacles may be overcome by increased surgical experience and by the ability to create a thinner suprafacial flap or thinning the flap after it has been obtained. We have described the versatility of this flap for the reconstruction of the through and through defect of cheek following cancer ablation along with difficulties in raising flap.

Six Cases of Reconstruction with Latissimus Dorsi Pedicled Flap for Head and Neck Defects in the Era of Free Flap Reconstruction / 대한이비인후과학회지

Reconstruction with free flaps has become the choice of reconstruction for most patients with head and neck defects. However, pedicled flaps, such as pectoralis major pedicled flap and latissimus dorsi pedicled flap (LDPF), can also be used instead in selected patients. We performed LDPFs in 6 patients from November 2007 to September 2009. Five of the patients were females with either vascular diseases or large skin defects, or they were highrisk old patients. One male patient received LDPF as a salvage after tongue reconstruction with a free flap failed. Various types of head and neck defects were effectively managed with LDPF without complications. LDPF can be one option for head and neck reconstruction especially in patients who may hve high risk in undergoing free flap reconstruction.

Reconstruction of Soft Tissue Defect of Knee Joint Area Using Anterolateral Thigh Perforator Flap

Reconstruction of soft tissue defect of knee joint area has been remained a challenging task for plastic surgeons. The earlier the normal tissue saved and the necrotic tissue removed, the less the patients had complications and functional disability. But such defects are difficult to manage for its poor vascularity, rigid tissue distensibility, easy infectability and a relatively long healing period. The goal of flap coverage in the knee joint should not only be satisfactory wound coverage, but also acceptable appearance and minimal donor site morbidity. We have treated five cases using the anterolateral thigh perforator flaps for reconstruction successfully. In conclusion, we believe that in cases of knee joint area soft tissue defects, flaps like anterolateral thigh perforator flap should be considered as the first line of treatment.

Reconstruction of Soft Tissue Defect with Free Flap in Pediatric Patients

PURPOSE: Free flap reconstruction in the pediatric population is difficult. However, microsurgery has had remarkable success rates in children. The aim of study is to present our clinical experience using free flap for reconstruction of soft tissue defects in children and to describe long-term follow-up results. METHODS: Between June 2002 and July 2010, 30 cases of pediatric reconstruction were performed with free flap. The authors analyzed several items, such as the kind of flap, associated complications, and growth problems. RESULTS: Among the 30 cases, 21 cases were due to traffic accidents, 5 to cancer, and 4 to falls and other soft tissue defects. The lower leg and foot were the most common sites of the lesion. In the free flap operations we have done, 20 cases involved an anterolateral thigh perforator free flap, 6 a superficial circumflex iliac perforator free flap, and 4 an upper medial thigh perforator free flap. In early postoperative complications, partial necrosis was seen in 2 cases, infection in 1 case, and the hematoma in 1 case. A satisfactory success rate and functional results were achieved. CONCLUSION: Free flap reconstruction in children allows satisfactory function with no significant effect on growth. Free flaps are regarded as the primary choice for selective pediatric reconstructive cases.

Analysis of Free Flap Reconstruction of the Tongue

PURPOSE: Advanced carcinoma of the tongue is a devastating disease which may cause severe speech or swallowing dysfunction. But, none to date has provided all of the complex functions of the tongue. The purpose of this study is to review our experiences with individuals who underwent glossectomy followed by reconstruction using free tissue transfer. METHODS: Between February 1998 and February 2005, twenty-four patients underwent glossectomy followed by free tissue transfer reconstruction. The defects of tongue caused by partial or subtotal glossectomy were reconstructed by means of radial forearm or lateral thigh free flap with nerve innervation. Especially for the patients who underwent total glossectomy, we reconstructed deglutition muscles anatomically with nerve reinnervation, a procedure that allows the grafted muscle to maintain good tongue bulk without obvious atrophy. RESULTS: Patients were reviewed to determine their functional outcome as it related to speech, deglutition, and aspiration. All patients achieved oral intake of a soft diet and acceptable speech. CONCLUSION: Although reconstruction following glossectomy using free tissue transfer is not ideal, this procedure is safe and reliable, and provides predictable results. A future challenge is the development of a surgical procedure for reconstruction of a tongue that maintains mobility and sensation using neurotized flaps.

Head and neck reconstruction using free flaps

BACKGROUND: Free flap reconstruction was first introduced in 1959 and has since been used for reconstruction of various defects in the head and neck. It has been shown to be the most reliable and efficient way of restoring tissue in the head and neck region secondary to surgical or traumatic defects. It has allowed single stage reconstruction of even complex defects with high flap viability rates. Here in the Philippine setting, free flaps have not been the reconstructive option of choice. It is viewed as a special option for selective cases not amenable to pedicled reconstruction. OBJECTIVE: To describe the experience of one microvascular team in head and neck reconstruction using free flaps from 1996 to March 2004. DESIGN AND SETTING: Retrospective chart review of all patients who underwent free flap reconstruction of head and neck defects from 1996 to March 2004 at six tertiary hospitals in Manila. PATIENTS AND METHODS: Atotal of 69 patients who underwent 71 free-flap reconstructions of the head and neck for various pathologies and with a range of bony and soft tissue defects from 1996 to March 2004 were included in the study. All free flap reconstructions were done by only one microvascular team. The success and viability of free tissue transfer, length of hospital stay, length of operation, complications and morbidities encountered and functional outcome based on length of time to removal of the nasogastric tube and decannulation were reviewed. RESULTS: Of the 71 free flap reconstructions that were performed, 64 flaps were viable leading to an overall success rate of 90 percent. The first 36 cases had a success rate of 86 percent while the subsequent 35 cases had a success rate of 94 percent. Average length of hospital stay was 24 days and the average length of operation was 13 hours 40 minutes. There were 6 mortalities secondary to medical problems and 7 patients had major surgical complications. Twenty-one patients (29 percent) did not have any complication post-operation. Average time post-operation to decannulation was 14 days while return to oral diet was noted at 17 days post-operation. There were 8 patients who were discharged with either a nasogastric tube or percutaneous endoscopic gastrostomy. The results are at par with the review of literature reviewed. CONCLUSIONS: The success of the use of free flaps in head and neck reconstruction was demonstrated in this series. There were minimal complications noted. All patients were decannulated with majority able to return to an oral diet. (Author)

Increase of Fat Necrosis after Radiation Therapy Following Mastectomy and Immediate TRAM Flap Reconstruction in High-risk Breast Cancer Patients / 한국유방암학회지

PURPOSE: This study evaluated the benefit of radiation therapy in high-risk breast cancer patients who have received immediate transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. The evaluation involved examining the effect of radiation therapy on postmastectomy flap fat necrosis and tumor recurrence. METHODS: A retrospective review was performed on 102 patients who underwent mastectomy and immediate TRAM flap reconstruction between 1996 and 2001 at the Asan Medical Center (Seoul, Korea). The mean patient age was 41 years, and the median follow-up time was 33 months. Skin-sparing mastectomy was con ducted in 82 patients (80.4%) and classical mastectomy in 20 patients (19.6%). Of the 21 high-risk patients needing postmastectomy radiation therapy, nine received it. RESULTS: Moderate or severe TRAM flap fat necrosis occurred more frequently in patients receiving radiation therapy than those not receiving radiation therapy (55.6% vs. 19.4%, P=0.026). In the group with high-risk patients, two tumor recurrences occurred (one-locoregional and one-systemic). Among the 102 patients, thirteen had recurrences, including only two high-risk patients, with almost of them being systemic recurrences except four locoregional recurrences. CONCLUSION: Our findings showed that radiation therapy increased flap fat necrosis in high-risk patients underwent immediate TRAM flap reconstruction. Such necrosis can result in poor outcomes for reconstruction. We recommend careful consideration prior to using radiation therapy on high-risk breast cancer patients after immediate TRAM flap reconstruction, where clinicians need to balance the possible positive effects on recurrence with the possible negative effects on flap tissue.

Sensory Recovery after Reconstruction of Oral Cavity and Oropharynx using Non-sensate Flap

The ablation surgery of the oral cavity and oropharyngeal carcinoma induced some disturbance in multiple aspects of normal anatomy and physiologic function. Sensation is one of the most important factor for restoration of many disturbed oral function like articulation, swallowing and mastication. Thirteen oral cavity and oropharyngeal carcinoma patients with reconstruction using non- sensate flap including free flap or musculocutaneous pedicled flap were subjects of this study. The sensory recovery was evaluated among the following 5 subjective senses: light touch, deep touch(pressure), pain, warm and cold sense and the two point discriminations were also recorded after postoperative 6 months. For histologic examination, after the flap tissues including the normal mucosa were obtained, H&E and immunohistochemical stains with anti-S-100 protein were performed at the same time. The subjective sensation, especially deep touch(pressure) and pain were almost restored(92%) in the flap and histologic changes, such as loss of keratin, granular layer and hyperkeratosis were observed. But, only 15% of the flap revealed positive reaction in staining with S-100 protein. Our results demonstrates some recovery of sensation in the non-sensate flap and the changes in epidermis of the flap such as mucosalization. However, histologic evidence were lack on the sensory nerve regeneration. Therefore, detailed study should be included electromicroscopic examination and comparison between the sensate and non-sensate flap.

Application of Double Flap Reconstruction to Craniectomy through Transpetrosal-presigmoid Approach for Petroclival Tumor:Report of 14 Cases / 中国微创外科杂志

Objective To evaluate the efficacy of double flap reconstruction after craniectomy through transpetrosal-presigmoid approach in the treatment of petroclival tumor.Methods A total of patients with petroclival tumor were enrolled in this study.Craniectomy was performed on them through the transpetrosal-presigmoid approach,and then double flap reconstruction was carried out.After the temporo-occipotal free osseous flap(retrosigmoid flap)was obtained,the superficial flap of the mastoid process(presigmoid flap)was freed by grinding and drilling.During the operation,partial petrosectomy and mastoidectomy were avoided to protect the semicircular canals and cochlea.Results Among the 14 cases,radical resection of the tumor was performed on 8 patients,subtotal resection on 3,and partial resection on 3.Two patients developed CSF leak through the ear.No subcutaneous hydrops or intracranial infection was found in the patients.The patients were followed up at 3 and 6 months after the operation,during which no complications were detected.Conclusions The rates of CSF leak,subcutaneous hydrops,and intracranial infection are low after applying double flap reconstruction to craniectomy through the transpetrosal-presigmoid approach.The procedure are mini-invasive and safety.

Reconstruction of the Nose with Local Flap ater Mohs Micrographic Surgery of Basal Cell Carcinoma / 대한피부과학회지

BACKGROUND: An aggressive skin cancer on the nose, tends to have poorly defined clinical margins, and has a higher recurrence rate. A small tumor on the nose is usually easily treated by any of the standard methods. However, removal and reconstruction with preserved cosmesis is more laborous in a basal cell carcinoma larger than 10 mm in diameter. This is because the nose has complex contoures, unique skin color and texture, and the limited availability of mobile adjacent skin. When available Mohs micrographic surgery is the preferred treatment for these large tumors. OBJECTIVE: Our purpose was to investigate the preferred reconstruction method(especially, local flap reconstruction) by the cosmetic unit of the nose after Mohs micrographic surgery. METHODS: From March 1991 to February 1997, twenty-one patients were diagnosed with basal cell carcinoma on the nose at our department. All the tumors were removed with Mohs micrographic surgery, and then the defects were reconstructed with a primary closure, skin graft, and local flap.