Negative pressure wound therapy in complex cranio-maxillofacial and cervical wounds.

The care and the management of the healing of difficult wounds at the level of the skull-facial face many problems related to patient compliance and the need to perform multiple dressings, with long periods of healing and, occasionally, a very long hospitalisation period. The introduction and evolution of negative pressure wound therapy (NPWT) in the treatment of difficult wounds has resulted in better healing, with a drastic reduction in terms of time and biological costs to the patient and cost to the health care system. The main aim of this study is to describe and discuss, using out our experience, the usefulness of NPWT in the cranial-facial-cervical region. We studied 16 patients with complex wounds of the cranial-facial-cervical region treated with NPWT. We divided clinical cases in four groups: cervicofacial infectious disease, healing complications in oncological-reconstructive surgery, healing complications of injury with exposure of bone and/or internal fixations and healing complications in traumatic injury with loss of substance. We evaluated complete or incomplete wound healing; application time, related also to hospitalisation time; days of intensive care unit (ICU) stay; management of the upper airways; timing of medication renewal; and patient comfort and compliance (on a scale of 1-5). Depression values were always between -75 and -125 mmHg in a continuous aspiration pattern. For every patient, we used the ActiVAC Therapy Unit, derived from the vacuum-assisted closure system (Kinetic Concepts Inc., San Antonio, TX). Medication renewals were performed every 48-72 hours. The NPWT application time ranged from 4 to 22 days (mean of 11·57 day). Therapy was effective to gain a complete restitutio ad integrum in every patient included in the group of cervicofacial infectious disease. Therapy has, however, been well tolerated in our series; this is probably due to the decreased number of applications, the ease of use and the comfort of the system relative to traditional dressing. Results were satisfactory for most of cases treated; faster and more effective wound healing was achieved. The lower number of NPWT applications, relating to standard dressings, led to an increase in patient comfort and compliance and a decrease in the use of medical, and in some cases economic, resources according to international literature.

Orbital Osteoblastoma: Technical Innovations in Resection and Reconstruction Using Virtual Surgery Simulation.

Osteoblastoma is a benign tumor of bone, representing less than 1% of bone tumors. Craniomaxillofacial localizations account for up to 15% of the total and frequently involve the posterior mandible. Endo-orbital localization is very rare, with most occurring in young patients. Very few of these tumors become malignant. Orbital localization requires radical removal of the tumor followed by careful surgical reconstruction of the orbit to avoid subsequent aesthetic or functional problems. Here, we present a clinical case of this condition and describe a surgical protocol that uses and integrates state-of-the art technologies to achieve orbital reconstruction.

Primary Intraosseous Squamous Cell Carcinoma of the Jaws: 6 New Cases, Experience, and Literature Comparison.

PURPOSE: To analyze the clinical, histologic, radiologic, therapeutic, and prognostic aspects of 6 cases of an uncommon head and neck malignancy and compare these results with data in the literature. MATERIALS AND METHODS: The medical histories of all patients treated in the Maxillofacial Surgery Unit in San Gerardo Hospital (Monza, Italy) for primitive intraosseous squamous cell carcinoma (PIOSCC) of the jaw were reviewed. All patients were considered suitable for inclusion in the study, specifically those whose oral mucosa had not been compromised and who did not have distant metastases. RESULTS: Six patients were included (4 male, 2 female). The odontogenic origin was histologically shown in only 2 patients. The male-to-female ratio was 2:1, and the malignancy occurred in the posterior mandible in 50% of cases. The most common symptoms were swelling and pain, but no sensory disturbances were observed. Radiologic findings indicated considerable variation in presentation, including small cystic lesions, which might complicate a pathologic diagnosis. All patients in the study were treated with surgery, and 2 patients received adjuvant radiotherapy. Cervical node metastases were present in 33% of patients. All patients are currently alive and free of disease. CONCLUSION: PIOSCC is a rare malignancy of the head and neck. Diagnosis can be difficult during the early stages of disease owing to a lack of clinical symptoms or radiologic presentation. Treatment is surgical and, like every other cancer, must be adequate to cure the cancer.

The free anterolateral thigh musculocutaneous flap for head and neck reconstruction: one surgeon's experience in 92 cases.

BACKGROUND: Applications of the free anterolateral thigh (ALT) musculocutaneous flap have been largely underestimated compared with indications for fasciocutaneous or perforator flaps. In this article, the authors critically review the experience of a single surgeon with the free ALT musculocutaneous flap for head and neck reconstruction, focusing on its applications in different cephalic areas and on advantages and disadvantages of this technique. PATIENTS AND METHODS: Ninety-two patients were treated using a free ALT musculocutaneous flap. Reconstructed areas included tongue, oropharynx, mandible, maxilla, hypopharynx, cheek, and skull base. RESULTS: Flap survival rate was 97.8%. Donor site morbidity consisted in two cases of partial necrosis of the skin graft used its closure with a final donor site complication rate of 2.2%. Overall results showed an 89% of patients returned to a normal or a soft diet. Speech was good or intelligible in 88% and cosmesis resulted good or acceptable in 89% of cases. CONCLUSION: The free ALT musculocutaneous flap offers unique advantages in head and neck reconstructions including adequate bulk when needed, obliteration of dead space, support for the soft tissues of the face, low donor-site morbidity, and harvesting without needing for perforators dissection, allowing for optimal patient outcome. Excessive bulky and thickness of subcutaneous tissue, especially in occidental population, have to be considered as the main disadvantages of this technique, finally the high incidence of hairy skin in thigh area in male patients and donor site scars associated with the use of skin grafts have to be considered as supplementary minor drawbacks.

Donor site morbidity using the buccinator myomucosal island flap.

OBJECTIVE: The objective of this study was to analyze our experience with donor site morbidity after harvesting a buccinator myomucosal island flap (BUMIF) for reconstructing surgical defects involving the tongue and floor of the mouth after oncological resections in 15 consecutive patients. STUDY DESIGN: Donor site morbidity was evaluated using 5 parameters: mouth opening, oral commissure symmetry, inner vestibule restoration, cheek mucosal lining, and the esthetic result. The clinical evaluation was performed by a blinded panel of 2 clinicians and the patient him- or herself, assessing each parameter with a score ranging from 0 to 3. The 3 scores for each parameter were summed to obtain a score reflecting the overall parameter assessment. RESULTS: The mean mouth opening score was 8.6 out of a maximum of 9 (range, 6-9). The mean commissure symmetry was 8.6 (range, 7-9), the mean inferior vestibule score was 8 (range, 6-9), the mean cheek lining score was 8.2 (range, 7-9), and the mean final esthetic score was 8.5 (range, 6-9). CONCLUSION: The results of this retrospective evaluation demonstrate that when special care is taken in the management of the BUMIF donor site, its morbidity is extremely low, allowing optimal functional and cosmetic results and confirming the major role of this flap in reconstructing moderate-size defects following tongue and floor of the mouth resections.

Fibro-osseous dysplasia localized to the zygomatic arch: case report.

Fibrous dysplasia is an osseous growth disorder, producing immature bone characterized by the replacement of normal bone with fibro-osseous connective tissue. The therapy is surgical, but the diagnosis of fibrous dysplasia of the craniofacial bones is not in itself an indication for treatment. The authors present a rare case of a zygomatic arch localization of fibrous dysplasia causing considerable facial asymmetry and social impairment. The clinical and radiological features are presented, the surgical procedure and indications are then described and the histopathological findings are discussed.

Reconstruction of lateral through and through oro-mandibular defects following oncological resections.

BACKGROUND: Resections of oromandibular squamous cell carcinoma involving lateral mandible, oral cavity, and the skin, lead to composite oromandibular defects that can be approached in several ways depending on the extension of the bone defect, of the soft tissue and cutaneous resection, the patient's general status and the prognosis. Purpose of the study is to evaluate retrospectively functional and esthetic outcome obtained with different reconstructive technique employed. METHODS: A retrospective evaluation of 42 patients has been performed. The study population consisted of 24 males (57.1%) and 18 females (42.9%), ranging in age from 25 to 81 years (mean, 62.6 years). The primary location of the tumor was the mandibular alveolar crest (18 cases), retromolar trigon (9), floor of the mouth (8), cheek (5), and oral commissure (2). For reconstruction a single free flap technique was used eight times; a double free flap technique, seven times; free and locoregional flap association, 25 times; and a single locoregional flap and two associated locoregional flaps, one time each. Postoperative follow-up ranged from 12 to 144 months. Final results were evaluated with regards to deglutition, speech, oral competence, and esthetic outcome. RESULTS: When free bone-containing flaps or two free flaps technique were used, the functional results were better (normal diet, 67%-71%; good oral competence, 100%-71%; good or intelligible speech, 100%-86%). When free and locoregional flap association was chosen, the esthetic results were best (excellent, 76%; acceptable 24%; poor 0%). The worst results were obtained with the use of a single free soft tissue flap and with the use of single or double locoregional flap technique. CONCLUSION: Bone reconstruction of the lateral mandible is indicated whenever possible. In elderly or poor prognosis patients acceptable results can be achieved with free soft tissue flaps techniques. When the defect involves different structures of the oral cavity, the best results are provided by the association of two free flaps. Finally, the association of free and locoregional flaps is a good option for external coverage reconstruction.

Iliac crest free flap for maxillary reconstruction.

PURPOSE: Reconstructing defects after maxillary resections presents a challenge for the reconstructive surgeon because of the critical role played by the maxillary skeleton in facial function and esthetics. Obturation, local or locoregional flaps, and soft tissue free flaps are good options for maxillary reconstruction; however, the lack of bone reconstruction often leads to ptosis of the facial tissues, particularly of the nasal base and columella, under the effects of gravity and makes it impossible to place osseous implants for dental rehabilitation. We present our experience with the iliac crest free flap for maxillary reconstruction, focusing on the advantages of this technique and particularly on flap positioning, which is dependent on defect site and size. Finally, 2 representative cases will be presented. PATIENTS AND METHODS: Between January 1, 1996, and January 1, 2008, 14 patients were treated for maxillary reconstruction with an iliac crest free flap. In 6 patients, the floor of the orbit was included in the resection. In 5 patients, we performed reconstructions using bone grafts harvested from the iliac crest, whereas in the remaining patient a titanium mesh was used. RESULTS: All flaps were harvested and transposed. Minor complications included wound dehiscence in 2 cases, ectropion in 2, and nasal airway obstruction in 1. No major complications or donor site morbidity occurred. No oronasal communication or swallowing impairments developed in any patient. Seven patients completed oral rehabilitation with dental implant placement; the remaining 7 refused the treatment because of financial problems, and 4 patients were rehabilitated with a mobile prosthesis. CONCLUSIONS: The iliac crest free flap is an optimal method for maxillary defect reconstruction. The main advantages of the flap are the large amount of bone provided, its height, and the possibility of including the internal oblique muscle. Flap insetting is the key part of the procedure, and whether to use vertical or horizontal placement of the flap is the main consideration. Finally, the low rate of donor site morbidity reported in our patients, as in the recent literature, makes this flap even more safe and reliable.

Reconstruction of anterior through and through oromandibular defects following oncological resections.

BACKGROUND: Resections of oromandibular squamous cell carcinoma involving anterior mandible, floor of the mouth, and the skin, lead to composite oromandibular defects that can be approached in several ways depending on the extension of the bone defect, of the soft tissue and cutaneous resection, the patient's general status, and the prognosis. METHODS: A retrospective evaluation of 27 patients has been performed. The techniques described included single osseous or soft tissues free flap reconstruction, two free flaps or free and locoregional flap association. RESULTS: Postoperative follow-up ranged from 12 to 120 months. Final results were evaluated with regards to deglutition, speech, oral competence, and esthetic outcome. CONCLUSION: Reconstruction of the anterior mandible is strongly indicated whenever possible. When the defect involves the tongue, the best results are provided by the association of two free flaps. Finally, the association of free and locoregional flaps ia a good option for external coverage reconstruction.