Reconstruction of the nose with a new double flap technique: microvascular osteocutaneous femur and microvascular chondrocutaneous ear flap--first clinical results.

This study describes a new microvascular flap combination from the medial femur and ear to reconstruct the nose after subtotal resection and presents the first clinical results. In four patients a squamous cell carcinoma of the nose was registered. In three patients this was diagnosed for the first time while in the fourth patient it was the second relapse after two resections and local flap surgery. In every case, tumour resection ended up in an extended defect of the nose, cheek and upper lip region. For skeletal reconstruction and the inner lining of the nose, a microvascular osteocutaneous femur flap was used. After reconstructing the nasal skeleton, the remaining defect was covered by a microvascular composite flap from the left ear and preauricular region. Both flap pedicles were anastomosed to the facial vein and artery. In every case, the flaps healed without complications. There was no tumour relapse. 12 months after reconstruction, minor surgical corrections were made. The patients showed a satisfying functional and aesthetic result. The combination of a microvascular osteocutaneous femur flap and a microvascular ear flap can be used successfully for reconstructing the nose after subtotal resection.

A combined superficial inferior epigastric artery flap and vascularized iliac crest flap in the reconstruction of extended composite defects of the posterior mandible and adjacent soft tissue: first clinical results.

The technique of posterior facial reconstruction using a combination of a superficial inferior epigastric artery (SIEA) flap and a microvascular iliac crest flap (deep circumflex iliac artery (DCIA) flap) is described. 12 cases are reported. The patients had unilateral squamous cell carcinoma of the posterior mandible affecting parts of the soft palate and tonsil region or the posterior cheek. In all patients unilateral neck dissection, resection of the posterior and lateral mandible, was performed. Reconstruction was carried out during primary surgical therapy, followed by postoperative radiotherapy. A flap combination of a SIEA and a DCIA flap was used. There were no problems with pedicle length or anastomoses. There was no flap loss or severe postoperative complications. All patients had good aesthetic and functional results. One patient had distant metastases 2 years postoperatively. All other patients were free of tumour relapse or metastases within 12-58 months of follow up. The SIEA flap and vascularized iliac bone flap combination is useful in reconstructing the posterior face. The iliac bone flap is well suited for posterior mandible reconstruction and the SIEA flap for reconstruction of the soft palate, lateral pharyngeal wall and cheek. Both flaps are harvested from the same donor site.

An intraoral anastomosing technique for microvascular bone flaps in alveolar ridge reconstruction: first clinical results.

The main indication for microvascular reconstruction of the face is to achieve the best possible functional and aesthetic outcome. In several cases of reconstruction of the alveolar ridges of the mandible or maxilla, extraoral scars might have been avoided if microvascular anastomoses had been performed without using the extraoral approach. In 9 patients with severe defects of the alveolar ridge of the mandible or maxilla caused by trauma, tumour resection, atrophy or partial loss of premaxilla, reconstruction was performed using six microvascular corticocancellous femur flaps, two iliac crest flaps and one osteoperiosteal fibula flap. In every case, an intraoral approach was used to prepare the transplant bed and the facial vessels. The anastomoses were carried out via this intraoral approach between the donor vessels and the facial vessels. The patients were followed up radiologically and clinically for 6-24 months postoperatively. There was no flap loss or severe complication postoperatively. All patients had good functional and aesthetic results, were treated successfully with dental implants 4-6 months after microvascular reconstruction, and were subsequently fitted with implant-retained prostheses. Intraoral anastomosing of microvascular bone flaps is a reliable technique for microvascular reconstruction of the alveolar ridge. Extraoral scars can be avoided.

[Comparison of the peripheral and central effects of opiates after iliac crest transplants. Reconstruction of severely atrophied maxilla]. / Vergleich der peripheren und zentralen Opiatwirkung bei Beckenkammtransplantaten. Rekonstruktion eines hoch atrophen Oberkiefers.

PURPOSE: Severe pain is one of the main problems after harvesting iliac crest transplants. In this randomized double-blind study differences in the peripheral and central effects of opiates for pain treatment in the iliac crest region after augmentation of the severely resorbed maxilla were examined. MATERIALS AND METHODS: In 20 consecutive patients with severe atrophy of the edentulous maxilla, augmentation was performed with the use of iliac crest transplants. In 10 patients a gelatine sponge soaked with a 10 mg morphine hydrochloride solution was placed in the iliac region after harvesting the transplant ipsilaterally for local opiate therapy. In the control group the same opiate was injected into the contralateral glutaeus maximus muscle for systemic therapy. Both groups were followed up for pain intensity every 2 h during the first 48 h and 3 times a day from postoperative days 3-10. Thereafter the patients were followed up 1, 3, 6 and 12 months postoperatively. At each time of control the VAS score, as well as the quality of pain with and without movement and the consumption of NSAIDs were registered. RESULTS: Lower pain values were registered in the control group within the early postoperative period, whereas the mean VAS score was less from postoperative days 3-10 in the study group (2.3 compared to 1.3 VAS). The consumption of NSAIDs corresponded to the pain scores in both groups during the control periods. There were no statistically significant differences for long term results at 1, 3, 6 and 12 months postoperatively. CONCLUSIONS: The effect of centrally given opiates is more effective in the early postoperative period. In the early rehabilitation period the effect of intraoperatively local peripherally placed opiates is superior to intraoperatively centrally administered opiates.

[Positron-emission tomography (PET) and PET/CT in head and neck cancer - recommendations of an interdisciplinary consensus conference]. / Positronen-Emissionstomografie (PET) und PET/CT bei Kopf-Hals-Tumoren - ein Vorschlag für einen interdisziplinären Konsensus.

BACKGROUND: Today's available therapeutic options in head and neck cancer patients have led to better treatment modalities tailored to the individually clinical staging of the patients towards a risk adapted tumour management. This, however, is only possible with an accurately pretherapeutic diagnostic regimen and closely posttherapeutic follow-up. METHODS: These issues were discussed by nuclear medicine experts, otorhinolaryngologists, oral surgeons, radiologists, radio-oncologists and oncologists in a meeting that took place in Pörtschach, Austria, on 05 May 2006. The aim was to discuss the impact and indications of performing FDG PET/CT in patients with head and neck cancer and to outline possible future perspectives. RESULTS: FDG PET/CT is recommended for a better pretherapeutic staging in stage IV according to UICC and should be the method of choice in CUP with lymph node metastases. FDG PET/CT should be performed 3 - 4 months after radiation-/radiochemotherapy to diagnose viable tumour and to avoid false positive results. To evaluate the position and effectiveness of FDG PET/CT in therapy-monitoring further studies are needed. In case of radiation therapy FDG PET/CT allows a tailored treatment of patients with an accurate design of the target volume to reduce damage to the surrounding tissues. CONCLUSIONS: The interdisciplinary consensus reached by the experts is not intended to recommend standard guidelines in the management of head and neck cancer but to summarise and stress the impact of FDG PET/CT on the basis of the present literature and current clinical practise.

A combined anterolateral thigh flap and vascularized iliac crest flap in the reconstruction of extended composite defects of the anterior mandible.

The technique of lower anterior facial reconstruction using a combination of an anterolateral thigh flap (ALTF) and a microvascular iliac crest flap is described and the results of 18 cases are reported. Eleven patients suffered recurrence after surgery and radiotherapy of oral squamous cell carcinoma of the lower face. These patients underwent a second surgery and reconstruction. In seven patients reconstruction was performed during primary surgical therapy, followed by postoperative radiotherapy. The pedicle of the ALTF was used for elongation of the iliac crest pedicle. There were no problems with the pedicle length and anastomoses even in patients who had received previous surgery and irradiation of the neck. There was no flap loss. There were no severe postoperative complications. One patient had distant metastases 18 months postoperatively. In all other patients there was no tumour recurrence or metastasis within 10-43 months of follow-up. The ALTF and vascularized iliac bone flap combination is useful in reconstruction of the lower face. The main advantage is the elongation of the iliac flap pedicle by the ALTF pedicle in patients with previous surgery in the neck.

Horizontal distraction of the anterior maxilla in combination with bilateral sinuslift operation--preliminary report.

In many cases alveolar ridge atrophy causes severe alveolar ridge deficiency in horizontal and vertical direction. In cases of severe atrophy of the edentulous maxilla a maxillary retrognathism results. In this article, a new technique of solving this problem prior to implant placement is described. In six patients with severe atrophy of the edentulous maxilla a sinuslift operation and placement of dental implants were carried out in the posterior maxilla. In the anterior part of the maxilla a segmental split osteotomy and placement of two miniplate distractors were performed. One week after surgery distraction started with a distraction speed of 0.5 mm a day until a clinical correct position of the anterior maxilla resulted. Then, the stabilisation period of 12 weeks followed before the distractors were removed and two to four implants were placed in the anterior distracted maxilla. After a second healing period of 4 months the implants were used for loading by a fixed prosthetic superstructure. Six patients were treated by this regime and 58 implants were placed. All implants were loaded by a fixed prosthesis. Distraction was performed without disturbances. Three months after healing new bone was formed in the distraction gap. There was no implant loss. An aesthetic satisfying superstructure with good red and white aesthetics was achieved together with a correct interalveolar relation. Distraction of the anterior part of the maxilla in combination with sinuslift operation is an alternative technique for correction of interalveolar incongruences in the edentulous maxilla and augmentation prior to implant placement.

Efficacy of peripheral morphine analgesia in inflamed, non-inflamed and perineural tissue of dental surgery patients.

In a clinical model of dental pain, the analgesic efficacy of local morphine treatment was examined under three different conditions. Patients undergoing dental surgery were randomly assigned to an injection of local anesthetic (articaine) plus 1 mg morphine either into inflamed (n = 14; trial 1) or non-inflamed (n = 24; trial 2) submucous tissue or perineurally n = 19; trial 3). Patients in the control group for each condition (n = 13, trial 1; n = 26, trial 2; n = 16, trial 3) received articaine plus saline. Postoperative pain intensity was assessed by the visual analog scale (VAS) and numeric rating scale (NRS) at 0, 2, 4, 6, 8, 10, 12, 16, 20, and 24 h. In addition, patients recorded the occurrence of side effects and the supplemental consumption of diclofenac. Immediately after the operation, pain scores were reduced to a similar extent in all groups, most likely due to the local anesthetic effect. Thereafter, pain scores and supplemental consumption of diclofenac were significantly lower in patients receiving 1 mg morphine into inflamed submucous tissue than in the control group for up to 24 h. Patients receiving 1 mg morphine into non-inflamed tissue or perineurally did not show any further reduction in pain scores compared to each control group. Our results show in patients undergoing dental surgery that injection of 1 mg of morphine into inflamed tissue results in significant and prolonged postoperative analgesia, whereas administration into non-inflamed tissue or perineurally is not effective. Thus, consistent with experimental studies, the requirement of an inflammatory process for the occurrence of peripheral opioid effects is also found in the clinical setting.

The fixed combination of collagen with components of fibrin adhesive-a new hemostypic agent in skull base procedures.

CSF leak still is one of the major sources of morbidity after extensive skull base procedures. Of the various standard closure techniques of traumatic or iatrogenic dural defects, none provides a really waterlight, persistent closure. Even the supplementary use of fluid fibrin glue did not substantially improve the rate of postoperative CSF leaks. The application of a collagen sheet covered with a fixed layer of solid components of a fibrin tissue glue (TachoComb(R)) overcomes the major drawbacks of dural sealing in skull base surgery. The dural defects of 58 patients undergoing extensive skull base procedures were sealed with this new hemostyptic agent. The series includes 44 patients undergoing primary surgery, 6 patients with traumatic or iatrogenic tears of venous sinuses, and 8 patients with postoperative leaks after previous skull base procedures in which other sealing methods were previously used. In the group of primary surgery, none of the patients had postoperative CSF leakage or venous rebleeding. One patient developed a delayed pneumatocephalus. All cases of patent CSF fistulas were resolved without any adjuvant therapy. Preliminary experience shows that the good sealing and hemostyptic performance of this new agent will considerably reduce the risk of postoperative CSF leak and infection after skull base procedures.

[Treatment of lip, jaw and palatal clefts at the Klagenfurt Regional Hospital]. / Die Behandlung von Lippen-, Kiefer- und Gaumenspalten am Landeskrankenhaus Klagenfurt.

Description of a new way in the treatment of cleft lip and/or palate at the Landeskrankenhaus Klagenfurt since 1986. Important is the schedule of periodically observations starting in the first weeks of the new born kid up to the age of about 6 years. Then 90% of the skullcap-expansion is completed and surgeries of bone-deformities of palate can be done. Orthodontic therapy almost goes over a longer period of time. Sufficient functional and cosmetic results always need a perfect cooperation between obstetricians, child specialists, oto-rhino-laryngologists, dental- and facial-plastic-surgeons as well as orthodontic-specialists.