Inferior alveolar nerve reconstruction with interpositional sural nerve graft: a sensible addition to one-stage mandibular reconstruction.

BACKGROUND: This study was to evaluate the sensory recovery in the lower lip and chin in patients who underwent segmental mandibulectomy involving inferior alveolar nerve and simultaneous reconstruction with fibular osteoseptocutaneous flap and interposition sural nerve graft. MATERIAL AND METHOD: From 1993 to 2004, a total of 20 patients underwent segmental mandibulectomy, simultaneous fibula osteoseptocutaneous flap reconstruction and interpositional sural nerve graft. Twelve patients were available for the study. There were seven male and five female patients with average age of 35.8 years (16-52 years). The sense at the lower lip and chin was measured by two-point discrimination both at the operated and non-operated side at an average of 64.3 months (12-146 months). RESULT: The operated side revealed an average of 13.7 mm for static (STPD) and 13.3 mm for moving two-point discrimination (MTPD) at the lower lip and 13.7 mm for static and 13.4 mm for MTPD at the chin. Data from the non-operated side averaged 3.4 mm for static and 3.2 mm for MTPD at lower lip and 5.1 mm for static and 4.5 mm for moving discrimination at the chin. All patients recovered better than protective sensation on the operated side, which was sufficient to prevent self-mutilation, preserve comprehensible speech and maintain oral competence. No patient complained of significant donor site morbidity. CONCLUSION: Simultaneous reconstruction of a segmental mandibulectomy involving inferior alveolar nerve with a fibula osteoseptocutaneous flap and interpositional sural nerve graft offers simultaneous replacement of mandibular architecture and restoration of protective perioral sensation.

Single-splint technique in orthognathic surgery: intraoperative checkpoints to control facial symmetry.

BACKGROUND: Despite the most meticulous preoperative planning and execution, intraoperative soft-tissue response to dentoskeletal changes is often different from those statistically predicted, especially when midline asymmetry is present. A "single-splint" technique for bimaxillary surgery, with intraoperative adjustments and checkpoints, was developed in an attempt to overcome these limitations. The purpose of this study was therefore to determine whether this technique can improve the midline symmetry of facial soft tissues. METHODS: Forty-five patients who underwent at least a Le Fort I and a bilateral sagittal split osteotomy of the mandible were identified in the authors' patient database. Standardized frontal photographs were used to measure the change in midfacial, intercommissural, chin to midface, and chin to ideal facial midline angles. The facial midline symmetry index, an overall score of facial symmetry, was also calculated. RESULTS: This study demonstrates that there is a statistically significant improvement of the four angles measured and of the facial midline symmetry index. CONCLUSIONS: These findings demonstrate that the single-splint technique with its intraoperative checkpoints can successfully maintain or improve facial midline symmetry. Thus, the single-splint technique is a useful alternative to the classic two-splint technique for bimaxillary surgery.

Bimaxillary protrusion: an overview of the surgical-orthodontic treatment.

Bimaxillary protrusion is a commonly seen deformity in Asian populations. This condition is characterized by protrusive and proclined upper and lower incisors and an increased procumbency of the lips. It is usually combined with lip incompetence, gummy smile, mentalis strain, and anterior open bite. Facial aesthetics is the primary concern of these patients. Successful treatment depends on a thorough evaluation and understanding of this dentofacial deformity. Typical orthodontic treatment includes retraction and retroclination of maxillary and mandibular incisors after extraction of the four first premolars. Orthognathic surgery is required to correct significant skeletal problems. Anterior subapical osteotomies and extraction of premolars can correct sagittal excess of the jaw bones and relieve dental crowding. Segmental maxillary osteotomies are performed to treat patients with an associated exaggerated curve of Spee and vertical maxillary excess. Differential intrusion of anterior and posterior maxilla/maxillary segments with clockwise rotation of the occlusal plane is a useful technique for treatment of anterior open bite and creation of a consonant smile arc. Le Fort I osteotomy with setback sometimes provides an alternative to segmental maxillary osteotomies. Meticulous planning and execution of osteotomies in accordance with surgical planning are essential for aesthetic and functional outcome.

Surgical approach to the patient with bimaxillary protrusion.

The patient who has bimaxillary protrusion often is treated using a combination of orthodontics and orthognathic surgery, and the general approach is dental extraction with retraction of the incisors. In certain cases, maxillary excess may be corrected solely with LeFort I osteotomy and setback and without dental extraction or anterior segmental osteotomies. This article discusses (1) treatment evaluation and planning and (2) the specific surgical techniques, primarily anterior segmental osteotomies and the technical details for setback of the LeFort I osteotomized segment (more than 5 mm), as they relate to the surgical approach of the patient who has bimaxillary protrusion.

Periodic alterations of jejunal mucosa morphology following free microvascular transfer for pharyngoesophageal reconstruction.

BACKGROUND: Free jejunal flap reconstruction is the treatment of choice for patients after pharyngoesophagectomy. It remains unclear as to how the transplanted jejunal mucosal damage proceeds after the warm ischaemia. The current study aims to assess the relationship between the duration of ischaemia and the damage of jejunal mucosa. PATIENTS AND METHODS: From May 2002 to February 2003, 15 free jejunal flaps in 15 patients were transplanted to the cervical area for the reconstruction after pharyngoesophagectomy. Biopsy specimens were taken from the monitor loop at the time of pedicle ligation, 10 min after reperfusion, every day for 10 days, 14th day, 28th day, and 40th day after operation. Mucosal injury was assessed based on an accepted three-point scale which evaluates oedema, inflammation, mucosal necrosis or exfoliation, shortening of villi, and increase of goblet cells. FINDINGS: All 15 jejunal flaps survived. The mean ischaemia time was 68.7+/-5.2 min (range: 37-116). Serious injury to the mucosa was observed at 10 min after reperfusion, and gradually recovered until the 8th day, when it became normal in all flaps. The degree of damage was not found to be correlated with the length of ischaemia (less than 116 min). Severe ischaemia/reperfusion-induced mucosal damage occurs immediately following reperfusion and gradually recovers with time. The severity of the damage is not related linearly to the ischaemia time within 2h. The mucosa recovers gradually from the 8th day and returns to normal at the 28th day.

Principles for the management of toe-to-hand transfer in reexploration: toe salvage with a tubed groin flap in the last step.

Failure of the transferred toe in toe-to-hand transplantations is a catastrophe and a devastating complication for both the patient and the reconstructive surgeon, as in all microvascular tissue transfers. Management of the toe transfer in the case of reexploration is still a challenging issue, even for experienced microsurgeons. In this report, basic principles for a successful outcome are proposed, based on experience with more than 500 toe-to-hand transfers. Although the requirements for each case may vary, technical details and some basic salvage strategies receive special emphasis. When faced with a problem, the first step should be focused on perceiving the problem differently from under completely normal conditions. The problem may occur at any stage of the procedure. The basic orientations are focused on vasospasm, a thrombus inside the lumen, possible intimal damage that may be caused during the surgery or by a thrombus, or technical failures regarding anastomoses. After all possible revisional procedures have been carried out, if the proper arterial inflow and/or venous outflow are still not provided, or if the general health status of the patient is no longer suitable for additional lengthy procedures, the tubed groin flap can be used to salvage the transferred toe. Between 1996-2004, eight tubed groin flaps were used to salvage transferred toes in the last step of the revisional procedure, with satisfactory results. In conclusion, close follow-up and prompt reexploration when needed are both essential to salvaging transferred toes. Proper surgical strategies and decision-making in reexploration are highly important factors in achieving a successful outcome. In prolonged and recurrent revisional steps, the creation of a tubed flap by means of a reliable flap is an effective procedure as the last step of the salvage procedure.