A computed tomography-based analysis of the structure of the mandible according to age and sex

Background@#The primary objectives of mandibular surgery are to achieve optimal occlusion, low sensory disturbance, and adequate fixation with early movement. In-depth knowledge of the mandibular structure is required to achieve these goals. This study used computed tomography (CT) to evaluate the mandibular cortical thickness and cancellous space according to age and sex. @*Methods@#We enrolled 230 consecutive patients, aged 20 to 50 years, who underwent CT scanning. The cortex and cancellous space centered around the inferior alveolar nerve (IAN) canal were measured at two specific locations: the lingula and second molar region. Statistical analysis of differences according to increasing age and sex was performed. @*Results@#The t-test revealed that the cancellous space and cortical thickness differed significantly with respect to the threshold of 35 years of age. Both cortical thickness and cancellous space in the molar region were negatively correlated with age. Meanwhile, both cortical thickness and cancellous space in the lingula region showed a positive correlation with age. With respect to sex, significant differences in the cancellous space at the molar region and the cortical thickness at the lingula were observed. However, no further statistically significant differences were observed in other variables with respect to sex. The sum of each measurement on the mandibular body reflected the safe distance from the surface of the outer cortex to the IAN canal. The safe distances also showed statistically significant differences between those above and below 35 years of age. @*Conclusion@#Knowledge of the anatomical structure of the mandible and of changes in bone structure is crucial to ensure optimal surgical outcomes and avoid damage to the IAN. CT examination is useful to identify changes in the bone structure, and these should be taken into account in the planning of surgery for older patients.

Head and neck reconstruction using free flaps: a 30-year medical record review

Background@#The free flap surgical method is useful for the reconstruction of head and neck defects. This study retrospectively analyzed the results of head and neck reconstructions using various types of free flaps over the past 30 years. @*Methods@#Between 1989 and 2018, a total of 866 free flap procedures were performed on 859 patients with head and neck defects, including 7 double free flaps. The causes of vascular crisis and salvage rate were analyzed, and the total flap survival rate calculated among these patients. Additionally, the survival and complication rates for each flap type were compared. @*Results@#The 866 cases included 557 radial forearm flaps, 200 anterolateral thigh flaps, 39 fibular osteocutaneous flaps, and 70 of various other flaps. The incidence of the vascular crisis was 5.1%; its most common cause was venous thrombosis (52.3%). Salvage surgery was successful in 52.3% of patients, and the total flap survival rate was 97.6%. The success rate of the radial forearm flap was higher than of the anterolateral flap (p< 0.01), and the primary sites of malignancy were the tongue, tonsils, and hypopharynx, respectively. @*Conclusion@#The free flap technique is the most reliable method for head and neck reconstruction; however, the radial forearm free flap showed the highest success rate (98.9%). In patients with malignancy, flap failure was more common in the anterolateral thigh (5.5%) and fibular (5.1%) flaps.

Free-flap reconstruction in recurrent head and neck cancer: A retrospective review of 124 cases

Background@#Free-flap reconstruction for recurrent head and neck cancer may be challenging depending on the previous treatments, those are, chemotherapy, radiotherapy, and surgery, including neck dissection or free tissue transfer. Specifically, the previous treatment could compromise the neck vessels, thereby making free-flap reconstruction more difficult. This study aimed to investigate the correlation between previous treatments and vascular compromise of the free flap. @*Methods@#In this retrospective study, 124 free-flap reconstructions in 116 patients for recurrent head and neck cancer between 1993 and 2017 were investigated. The demographic characteristics, previous treatments, flap choices, infections, recipient vessels, and vascular crises were evaluated. @*Results@#Of the 124 reconstruction cases, 10 had vascular crises. There were six revisions, totaling six flap failures. The success rate of free-flap reconstruction for recurrent cancer was 95.2%, which significantly differed from that for primary cancer (98.8%, p= 0.006). Moreover, in the recurrent cancer group, no correlation was found between previous treatments and vascular crises (p> 0.05). Increased rates of contralateral or uncommon anastomoses were found following neck dissection (p< 0.05). @*Conclusion@#Previous neck dissection or radiotherapy could lead to scarring and tissue damage, which could in turn make microvascular reconstruction more challenging; however, the effect was not definite in this study. Approximately 60% of patients with previous neck dissection had compromised ipsilateral recipient vessels, which resulted in contralateral or uncommon anastomoses. In this study, free-flap reconstruction seems to be quite safe and preferable in patients with recurrent head and neck cancer based on the overall survival rate.

Klebsiella pneumoniae necrotizing fasciitis on theupper lip in a patient with uncontrolled diabetes

A 60-year-old woman with a history of diabetes mellitus and chronic renal failure was admitted tothe hospital with severe pain in the upper lip, which began 4 days prior to admission, accompaniedby a bullous lesion and suspected cellulitis in the upper lip. Immediately after admission, asthe patient´s general condition worsened, tests revealed a non-ST elevated myocardial infarction,septic embolism of the lung, as well as septic shock. Her upper lip suddenly presented a gangrenousand necrotic change, which the tissue and blood culture confirmed to be a Klebsiella pneumoniaeinfection. After a quick response, the patient’s general condition improved. Subsequently,serial debridement was performed to effectively clear away the purulent discharge. While undergeneral anesthesia, the process confirmed full-layer necrosis of the upper lip including the orbicularisoris muscle. Almost half of the entire upper lip sustained a full-layer skin and soft tissue defect,with scar contracture. Six months later, to correct the drooling and lip sealing following thedefects, a scar release and an Abbe flap coverage were performed considering both functionaland aesthetic aspects. The follow-up revealed a favorable corrective result of the upper lip drooling,and the patient was satisfied from a functional perspective.

Safety and efficacy of polycaprolactone copolymer nanosphere hydrogel injected into the scalp dermal tissue of rats

BACKGROUND: Currently, dermal fillers need to be 25 µm or larger to reduce in vivo degradation by macrophages. However, the large size of fillers may cause side effects, including interruption of blood flow and nodule formation. Therefore, using rats, we tested a polycaprolactone copolymer hydrogel with nanoscale particles that could maintain a low in vivo degradation rate. METHODS: Thirty-six 6-week-old Sprague-Dawley rats were divided into group A (normal saline), group B (polycaprolactone microsphere filler), and group C (polycaprolactone copolymer nanosphere hydrogel). The corresponding materials were injected into the dermal layer of the scalp of the rats. At 4, 8, and 12 weeks after injection, blood biochemical and kidney and liver histological analyses were performed. Tissues were examined using hematoxylin-eosin staining to observe tissue infiltration of materials. Collagen formation in the dermal tissue of the scalp was observed with Masson trichrome staining and the collagen content was quantified using a soluble collagen assay kit. RESULTS: The histologic examination for organ infiltration showed no abnormal findings. All blood test results were within the normal ranges. The amount of collagen at 12 weeks increased by 1.22 mg/g in group C and by 0.6 mg/g in group B. CONCLUSIONS: The results reveal that the nanosphere complex near the injection site induced collagen formation. Regardless of the sphere size, aggregation of the copolymer prevented macrophage phagocytosis. The polycaprolactone copolymer nanosphere hydrogel was effective for more than 3 months when injected in the scalp dermal tissue of Sprague-Dawley rats and can be used safely.

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.

Occurrence and Surgical Treatment of Massive Morel-Lavallée Lesion after Large-Volume Liposuction: A Rare Clinical Case

A soft tissue injury can cause the formation of a pseudocyst in the subcutaneous tissue due to a hematoma, seroma, or liquefied fat. These cysts are Morel-Lavallée lesion. A 30-year-old male patient had previously received a large-volume Liposuction. After a couple of years, Morel-Lavallée lesion has formed on the abdomen. So after the two communicating massive sacs were resected, we advanced the upper flap inferiorly and resected a margin of the redundant tissue.

Risk Factors of and Treatments for Pharyngocutaneous Fistula Occurring after Oropharynx and Hypopharynx Reconstruction

BACKGROUND: A pharyngocutaneous fistula is a common and difficult-to-manage complication after head and neck reconstruction. It can lead to serious complications such as flap failure, carotid artery rupture, and pharyngeal stricture, and may require additional surgery. Previous radiotherapy, a low serum albumin level, and a higher T stage have been proposed as contributing factors. We aimed to clarify the risk factors for pharyngocutaneous fistula in patients who underwent flap reconstruction and to describe our experiences in treating pharyngocutaneous fistula. METHODS: Squamous cell carcinoma cases that underwent flap reconstruction after cancer resection from 1995 to 2013 were analyzed retrospectively. We investigated several significant clinical risk factors. The treatment modality was selected according to the size of the fistula and the state of the surrounding tissue, with options including conservative management, direct closure, flap surgery, and pharyngostoma formation. RESULTS: A total of 127 cases (18 with fistulae) were analyzed. A higher T stage (P=0.048) and tube-type reconstruction (P=0.007) increased fistula incidence; other factors did not show statistical significance (P>0.05). Two cases were treated with conservative management, 1 case with direct closure, 4 cases with immediate reconstruction using a pectoralis major musculocutaneous flap, and 11 cases with direct closure (4 cases) or additional flap surgery (7 cases) after pharyngostoma formation. CONCLUSIONS: Pharyngocutaneous fistula requires global management from prevention to treatment. In cases of advanced-stage cancer and tube-type reconstruction, a more cautious approach should be employed. Once it occurs, an accurate diagnosis of the fistula and a thorough assessment of the surrounding tissue are necessary, and aggressive treatment should be implemented in order to ensure satisfactory long-term results.

Hand Reconstruction Using Medialis Pedis and Medial Plantar Chimeric Free Flap

It is not easy to decide whether covering soft tissue defect occurred in multiple adjacent fingers with a single, large flap and later secondary division of fingers or cover each digits independently in hand reconstruction. The authors reconstructed soft tissue defect of left second and third finger with medial plantar artery based medialis pedis and medial plantar chimeric free flap and it enabled early rehabilitation without secondary surgery to divide each fingers and get satisfactory result.

Reconstruction of the Hand Using Fabricated Great Toe Pulp and Anterolateral Thigh Chimeric Free Flap

In the treatment of large hand soft tissue defect including pulp defect, it has been recommended to reconstruct pulp defect separately by glabrous skin flap such as toe pulp free flap or thenar free flap considering of skin texture, color and sensation. But sometimes we may not use recipient digital artery which is required for microanastomosis because of the injury of digital artery. To solve this problem, the authors reconstructed thumb pulp and hand palmar area soft tissue defect with fabricated flow-through chimeric free flap connecting distal part of descending branch of lateral circumflex femoral artery which distributes perforators of anterolateral thigh free flap and pedicle of great toe pulp free flap and met with good results.

Heterotopic Ossification in Post-Burn Scar Contracture of the Wrist

Heterotopic ossification is one of the well known complications related to burn and mainly involves major joints and lower extremity, but heterotopic ossification of the hand has been rarely reported. The authors experienced treatment of heterotopic ossification in post-burn scar contracture of the wrist by wide excision with full thickness skin graft and there was no complication such as recurrence. As heterotopic ossification with ulceration is hard to cure with conservative treatment, it must be removed completely by surgical treatment. If ulceration in burn scar of the hand doesn't heal with the conservative treatment, differential diagnosis of heterotopic ossification will be made first.

Clinical Experiences with the Scapular Fascial Free Flap

BACKGROUND: The goal of reconstruction is to provide coverage of exposed vital structures with well-vascularized tissue for optimal restoration of form and function. Here, we present our clinical experience with the use of the scapular fascial free flap to correct facial asymmetry and to reconstruct soft tissue defects of the extremities. METHODS: We used a scapular fascial free flap in 12 cases for soft tissue coverage of the extremities or facial soft tissue augmentation. RESULTS: The flaps ranged in size from 3×12 to 13×23 cm. No cases of total loss of the flap occurred. Partial loss of the flap occurred in 1 patient, who was treated with a turnover flap using the adjacent scapular fascial flap and a skin graft. Partial loss of the skin graft occurred in 4 patients due to infection or hematoma beneath the graft, and these patients underwent another skin graft. Four cases of seroma at the donor site occurred, and these cases were treated with conservative management or capsulectomy and quilting sutures. CONCLUSIONS: The scapular fascial free flap has many advantages, including a durable surface for restoration of form and contours, a large size with a constant pedicle, adequate surface for tendon gliding, and minimal donor-site scarring. We conclude that despite the occurrence of a small number of complications, the scapular fascial free flap should be considered to be a viable option for soft tissue coverage of the extremities and facial soft tissue augmentation.

Reconstruction of the Lower Extremity Using Free Flaps

BACKGROUND: The aim of lower-extremity reconstruction has focused on wound coverage and functional recovery. However, there are limitations in the use of a local flap in cases of extensive defects of the lower-extremities. Therefore, free flap is a useful option in lower-extremity reconstruction. METHODS: We performed a retrospective review of 49 patients (52 cases) who underwent lower-extremity reconstruction at our institution during a 10-year period. In these patients, we evaluated causes and sites of defects, types of flaps, recipient vessels, types of anastomosis, survival rate, and complications. RESULTS: There were 42 men and 10 women with a mean age of 32.7 years (range, 3-72 years). The sites of defects included the dorsum of the foot (19), pretibial area (17), ankle (7), heel (5) and other sites (4). The types of free flap included latissimus dorsi muscle flap (10), scapular fascial flap (6), anterolateral thigh flap (6), and other flaps (30). There were four cases of vascular complications, out of which two flaps survived after intervention. The overall survival of the flaps was 96.2% (50/52). There were 19 cases of other complications at recipient sites such as partial graft loss (8), partial flap necrosis (6) and infection (5). However, these complications were not notable and were resolved with skin grafts. CONCLUSIONS: The free flap is an effective method of lower-extremity reconstruction. Good outcomes can be achieved with complete debridement and the selection of appropriate recipient vessels and flaps according to the recipient site.

Analysis of 120 Pectoralis Major Flaps for Head and Neck Reconstruction

BACKGROUND: A pectoralis major flap is one of the standard tools for the reconstruction of defects of the head and neck. Despite the technical advancement in free tissue transfer in head and neck reconstruction, the benefits of a pectoralis major flap should not be overlooked. The purpose of this study is to evaluate our 17 years of experience in reconstructing defects of the head and neck region using the pectoralis major flap. METHODS: We retrospectively reviewed the medical records of 112 patients (120 cases) who underwent pectoralis major flap operations for head and neck reconstruction during a period ranging from 1994 to 2010. RESULTS: In our series, no total necrosis of the flap occurred. Of the total cases, 30.8% presented with flap-related complications. Major complications occurred in 20% of all of the cases but were then all successfully treated. The male sex was correlated with the occurrence of overall complications (P=0.020) and major complications (P=0.007). Preoperative albumin levels of <3.8 g/dL were correlated with the formation of fistula (P=0.030). Defects of the hypopharynx were correlated with the occurrence of major complications (P=0.019) and the formation of fistula (P=0.012). Secondary reconstructions were correlated with the occurrence of overall complications (P=0.013) and the formation of fistula (P=0.030). CONCLUSIONS: A pectoralis major flap is still considered to be a safe, versatile one-stage reconstruction procedure in the management of the defects of head and neck and the protection of the carotid artery.

V-Y Latissimus Dorsi Musculocutaneous Flap for Reconstruction of Radiation-induced Skin Injuries on the Back

PURPOSE: Cardiac radiofrequency catheter ablation procedures using fluoroscopy were performed for the treatment of supraventricular and selected ventricular tachyarrhythmia. Fluoroscopy is used to localize the position of the intracardiac catheter. Fluoroscopically- guided procedures often involve high radiation doses to patient's skin, but the incidence of serious radiation injuries in these patients is rare. We reported two cases of severe postradiation skin injury on the back treated with the V-Y latissimus dorsi musculocutaneous flap. METHODS: These two patients underwent radiofrequency catheter ablation under the diagnosis of Woff Parkinson White syndrome(WPW syndrome). They had radiation- induced skin injuries on the subscapular area and these lesions represented chronic ulceration, surrounding induration, hardness, and dyspigmentation. We treated these lesions with complete excision and coverage with V-Y latissimus dorsi musculocutaneous flap. RESULTS: These two patients had no recurrence and no special complications during 20 months and 12 months follow-up periods and were satisfied aesthetically and functionally. CONCLUSION: V-Y latissimus dorsi musculocutaneous flap obtained better results functionally and aesthetically compared with conservative management and skin graft in severe radiation-induced skin injuries after cardiac radiofrequency catheter ablation procedure.

Reconstruction of Midfacial Defects with Free Flaps after Maxillectomy

PURPOSE: Maxillectomy for malignant tumor resection often leads to functional and aesthetic sequalae. Reconstruction following maxillectomy has been a challenging problem in the field of head and neck cancer surgery. In this article, we described three dimensional midface reconstructions using free flaps and their functional and aesthetic outcomes. METHODS: We reconstructed 35 cases of maxillectomy defects using 9 radial forearm free flaps, 7 lattisimus dorsi musculocutaneous free flaps, 6 rectus abdominis musculocutaneous free flaps, 4 fibular osteocutaneous free flaps, and 9 anterolateral thigh free flaps, respectively. We classified post-maxillectomy defects by Brown's classification.1 Articulation clarity was measured with picture consonant articulation test. Swallowing function was evaluated with the University of Washington quality-of-life Head and Neck questionnaire by 4 steps. Aesthetic outcomes were checked to compare preoperative with postoperative full face photographs by 5 medical doctors who did not involve in our operation. RESULTS: The average articulation clarity was 92.4% (100-41.9%). 27 (81.9%) patients were able to eat an unrestricted diet. Aesthetic results were considered excellent in 18 patients (51.4%). Functional results were best in the group reconstructed with fibular osteocutaneous free flap. Considering the range of wide excision, aesthetic results is best in the group reconstructed with anterolateral thigh free flap. CONCLUSION: The free flap is a useful technique for the reconstruction of the midface leading to good results, both functionally and aesthetically. Especially, because osteocutaneous flap such as fibular osteocutaneous free flap offered bone source for osteointegrated implant, It produces the best functional results. And perforator flap like as anterolateral thigh free flap reliably provides the best aesthetic results, because it provides sufficient volume and has no postoperative volume diminution.

A Case Report of Hypospadias Repaired by Radial Forearm Free Flap

PURPOSE: Urethral reconstruction following failed hypospadias repair is difficult because of a severe shortage of the skin on ventral surface of the penis. We experienced a successful reconstruction of a failed hypospadias repair using the radial forearm free flap. So we present our case. METHODS: A 16-year-old boy had a proximal shaft hypospadias and had been taken a transverse preputial island flap but it completely broke down. There was no spare skin on the shaft of the penis. So we reconstructed a neo-urethra and the ventral skin of the penis with the radial forearm free flap. RESULTS: Postoperatively he made relatively good process. The urethral catheter was maintained for 10 days and self-voiding was started. The suprapubic catheter was removed on the postoperative 30th day after control of cystitis. The postoperative appearance of the penis is acceptable and a straight erection is achieved. CONCLUSION: In the scarred penis with hypospadias, the radial forearm free flap transfer is a reliable reconstructive method for the neo-urethra and the ventral skin of the penis.

Emergent Exploration after Free Tissue Transfer in Head and Neck Cancer

PURPOSE: Microvascular reconstructive surgery has become an integral part of the treatment of head and neck cancer patients. This review of 121 free flaps for head and neck cancer patients performed over the last 11 years was done to evaluate circulatory crisis, salvage, and secondary reconstruction and to investigate which factors may contribute to these rates. METHOD: Nine emergent explorations among 121 head and neck reconstruction with free flaps were reviewed to analyze detection of vascular crisis, the time interval from detection of circulatory crisis to exploration, operation procedures and results, and secondary reconstructions. Emergent exploration was done with our protocol. RESULT: Nine free flaps exhibited signs of vascular problems between 1 day and 6 days postoperatively. The emergent exploration rate of this series was 7.4% (9/121). The salvage rate was 55.6% (5/9), giving an overall flap viability of 96.7% (117/121). In our study, preoperative radiation therapy, positive smoking history, alcohol consumption history, combined disease such as diabetes mellitus and hypertension, recipient vessels and types of vascular anastomosis were not related to the causes of circulatory crisis. The mean time interval between the onset of clinical recognition of impaired flap perfusion and re-exploration of the salvaged 5 flaps was 3.2 hours, that of failed 4 flaps was 11.25 hours. CONCLUSION: Despite high overall success rate, relatively low salvage rate may be attributed to late detection of circulatory crisis and in long time interval between detection and exploration. We conclude that early detection of circulatory crisis and expeditious re-exploration are a matter of great importance for the success of salvage operation.

Reconstruction of Regions Below the Knee Using Island Flaps

PURPOSE: The lower leg often has poor vascularity, proximity to bone, and insufficient soft tissue. The island flaps offer a feasible one stage reconstruction and has a remarkable vascularization and high quality results for soft tissue defect with or without bony problems to occur on regions below the knee. So we reported our experience of island flaps with review of the literatures. METHODS: We reconstructed 29 cases of soft tissue and 2 cases of bony defect on regions below the knee by using various island flaps at our hospital from December, 1991 to January, 2006. We used 2 fibular osteocutaneous island flaps, 15 reverse sural island flaps, 6 extensor digitorum brevis muscular island flaps, 2 medial plantar island flaps, 5 saphenous island flaps, and a dorsalis pedis island flap. RESULTS: Partial necrosis was developed in 4 out of 15 reverse sural island flaps and 1 out of 5 saphenous island flaps, but they were healed with secondary skin graft. There was partial loss of skin graft on the donor sites in 2 cases. CONCLUSION: Island flaps are very useful for reconstruction of regions below the knee because island flaps have good vascularity and less risk of infection. Generous flap size, easy operative technique, lower cost, shorter operative time, and minimal morbidity at the donor site are other advantages. We attained satisfactory results.

Clinical Analysis of Pharyngocutaneous Fistula after Total Laryngectomy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Pharyngocutaneous fistula after total laryngectomy is one of the most common complication in the immediate postoperative period. The objective of this study is to evaluate the variable predisposing factors after total laryngectomy and to investigate the management of pharyngocutaneous fistula. SUBJECTS AND METHOD: One hundred fifty cases who had been performed total laryngectomy were investigated retrospectively. Fifteen of 150 cases (10.0%) developed pharyngocutaneous fistula after total laryngectomy. We analyzed clinical parameters such as age, sex, smoking, alcohol intake, DM (diabetes mellitus), hypertension, liver disease, postoperative hemoglobin, albumin etc. RESULTS: Smoking, DM, hypertension, postoperative hemoglobin, postoperative albumin were significant factors associated with pharyngocutaneous fistula. Nine patients were managed with conservative treatment and six patients underwent surgical reconstruction by using pectoralis major myocutaneous flap. The average duration of oral feeding was 30 postoperative days in conservative treatment group and 83 postoperative days in surgical intervention group. CONCLUSION: Pharyngocutaneous fistula may be preventable by correcting the predisposing factors. We must consider the initial size of fistula and the response of conservative treatment to determine methodology and timing of surgical management.