published_or_final_version / Dental Surgery / Master / Master of Dental Surgery

published_or_final_version / Dental Surgery / Master / Master of Dental Surgery

Background Maxillary defects subsequent to hemimaxillectomy have long been restored with a pedicled temporalis flap. Recently,the trend towards maxillary reconstruction using vascularized bone free flaps and soft tissue free flaps has been gaining popularity. However, the value in terms of functional rehabilitation of these surgical modalities remains unconclusive. Objective To ascertain and compare masticatory performance and quality-of-life in patients with surgically reconstructed maxillectomy Class 2 (subtype A) defects by vascularized bone free flaps, vascularized soft tissue free flaps and pedicled soft tissue flaps. Methods Eighteen patients divided into 3 groups (4 vascularized bone flap, 5 vascularized soft tissue flap, 9 pedicled soft tissue flaps) were evaluated for functional outcome and qualityof-life (QoL). All patients were objectively assessed using masticatory comminution test. Subjective evaluation was conducted using functional outcomes questionnaire and patient reported speech perception. Self image and body perception were assessed using Body Esteem Scale. Overall quality-of-life was assessed using University of Washington QoL questionnaires. Results Patients reconstructed with vascularized bone flaps and vascularized soft tissue flaps showed superior masticatory performance compared to patients reconstructed with pedicled soft tissue flaps. Speech, facial attractiveness and overall QoL were similar for all three groups. Conclusions Maxillectomy class 2 (subtype A) patients show comparable speech, facial attractiveness and quality-of-life levels after reconstruction with vascularized bone flaps, vascularized soft tissue flaps and pedicled soft tissue flaps. However, those reconstructed with pedicled soft tissue flaps achieved lowest masticatory performances amongst the three surgical reconstruction modalities. Thus, the choice of recontruction for maxillectomy class 2 (subtype A) defects should be guided by minimizing surgical time and long term morbidity given the apparent similarity in functional outcomes. / published_or_final_version / Dental Surgery / Master / Master of Dental Surgery

Vinte e seis pacientes com paralisia facial unilateral de longa duração foram submetidos à reanimação facial em único estágio com transplante do músculo grácil inervado pelo ramo massetérico do nervo trigêmeo. Foram divididos em 2 grupos não-randomizados de acordo com a técnica de fixação: Grupo I (19 pacientes), fixação do músculo com uso do tendão palmar longo inserido no músculo orbicular nos lábios superior e inferior do lado não paralisado (além da linha média); Grupo II (7 pacientes), fixação do retalho apenas com pontos separados no músculo orbicular dos lábios superior e inferior no lado paralisado. A avaliação qualitativa demonstrou melhores resultados no Grupo I (94,1% vs 66,6%). Na comparação do posicionamento do arco de cúpido em repouso, no pré e pós-operatório, observamos melhora estatisticamente significante (p<0,05) em ambos os grupos. Durante o sorriso, entretanto, houve melhora significativamente maior na centralização do arco de cúpido nos pacientes submetidos à fixação com tendão palmar longo (Grupo I) / Twenty-six patients with unilateral long-stading facial palsy underwent 1-stage reanimation with free gracilis muscle transplant innervated by the masseteric branch of the trigeminal nerve. They were divided into 2 nonrandomized groups according to insertion technique: group I (19 patients), palmaris longus tendon graft placed between the gracilis free flap and the orbicularis oris of the upper and lower lip on the nonparalyzed side; group II (7 patients), interrupted suture between the free flap and the orbicularis oris of the upper and lower lip on the paralyzed side. Qualitative evaluation of the smile demonstrated better results in patients from group I (94,1% vs 66,6%). Comparing the position of the Cupid`s bow at rest, pre- and postoperatively in each patient, we observed significant improvement of facial symmetry in both groups. During smile, however, there was significantly higher rate of centralization of the Cupid`s bow in patients submitted to reanimation with the use of the palmaris longus tendon (group I)

Vinte e seis pacientes com paralisia facial unilateral de longa duração foram submetidos à reanimação facial em único estágio com transplante do músculo grácil inervado pelo ramo massetérico do nervo trigêmeo. Foram divididos em 2 grupos não-randomizados de acordo com a técnica de fixação: Grupo I (19 pacientes), fixação do músculo com uso do tendão palmar longo inserido no músculo orbicular nos lábios superior e inferior do lado não paralisado (além da linha média); Grupo II (7 pacientes), fixação do retalho apenas com pontos separados no músculo orbicular dos lábios superior e inferior no lado paralisado. A avaliação qualitativa demonstrou melhores resultados no Grupo I (94,1% vs 66,6%). Na comparação do posicionamento do arco de cúpido em repouso, no pré e pós-operatório, observamos melhora estatisticamente significante (p<0,05) em ambos os grupos. Durante o sorriso, entretanto, houve melhora significativamente maior na centralização do arco de cúpido nos pacientes submetidos à fixação com tendão palmar longo (Grupo I) / Twenty-six patients with unilateral long-stading facial palsy underwent 1-stage reanimation with free gracilis muscle transplant innervated by the masseteric branch of the trigeminal nerve. They were divided into 2 nonrandomized groups according to insertion technique: group I (19 patients), palmaris longus tendon graft placed between the gracilis free flap and the orbicularis oris of the upper and lower lip on the nonparalyzed side; group II (7 patients), interrupted suture between the free flap and the orbicularis oris of the upper and lower lip on the paralyzed side. Qualitative evaluation of the smile demonstrated better results in patients from group I (94,1% vs 66,6%). Comparing the position of the Cupid`s bow at rest, pre- and postoperatively in each patient, we observed significant improvement of facial symmetry in both groups. During smile, however, there was significantly higher rate of centralization of the Cupid`s bow in patients submitted to reanimation with the use of the palmaris longus tendon (group I)

Η μικροχειρουργική τεχνική και η μεταφορά ελεύθερων αγγειούμενων κρημνών για την αποκατάσταση εκτεταμένων και σύνθετων ελλειμμάτων ογκολογικής ή τραυματικής αιτιολογίας της κεφαλής και του τραχήλου αποτελεί μέθοδο επιλογής. Με την τεχνική αυτή επιτυγχάνεται στον ίδιο χρόνο με την εκτομή, η λειτουργική και αισθητική αποκατάσταση με μειωμένο ποσοστό επιπλοκών και επίπτωση από την δότρια περιοχή. Στην παρούσα μελέτη καταγράφουμε και αναλύουμε την εμπειρία μας σε ασθενείς που αντιμετωπίστηκαν με μικροχειρουργική τεχνική και ελεύθερους αγγειούμενους κρημνούς. Την περίοδο 2003 έως 2010, σε 48 ασθενείς πραγματοποιήθηκαν 56 ελεύθεροι αγγειούμενοι κρημνοί. Οι 34 ασθενείς από τους 48 υπεβλήθηκαν συγχρόνως σε ογκολογική εκτομή λόγω Ca και σε αποκατάσταση, ενώ σε 14 από τους 48 ασθενείς αφορούσε έλλειμμα τραυματικής αιτιολογίας. Η τοπογραφία του ελλείμματος αφορούσε το τριχωτό της κεφαλής και του μετώπου σε 12 ασθενείς (25%), το μέσο τριτημόριο του προσώπου και τα παραρίνια σε 9 ασθενείς (18.7%), το κάτω τριτημόριο του προσώπου και τραχήλου σε 27 ασθενείς (56.25%). Σε 7 ασθενείς χρησιμοποιήθηκαν διπλοί ελεύθεροι αγγειούμενοι κρημνοί και σε 41 ασθενείς μονήρεις κρημνοί. Χρησιμοποιήθηκαν συνολικά 56 ελεύθεροι αγγειούμενοι κρημνοί. Σε 16 ασθενείς χρησιμοποιήθηκε φλεβικό μόσχευμα (33.3%). Οι κρημνοί επιλογής ήταν ο κερκιδικός κρημνός 28.5%, ο κρημνός της περόνης 17.8%, ο προσθιοπλάγιος κρημνός του μηρού 14.2%, ο μυοδερματικός κρημνός του ορθού κοιλιακού(VRAM) 12.5% και εγκάρσιος(ΤΡΑΜ) 5.3%, ο κρημνός του πλατέως ραχιαίου 8.9%, ο κρημνός του ισχνού προσαγωγού 7.1% και ο πρόσθιος οδοντωτός 1.7%. Οι μικροαγγειακές αναστομώσεις έγιναν στα αγγεία του τραχήλου σε ποσοστό 96.2%. Η επιβίωση των κρημνών ήταν σε ποσοστό 92.8% (52/56) και 4 κρημνοί απορρίφθηκαν (7.1%) λόγω θρόμβωσης. Ένας ασθενής απεβίωσε στην μετεγχειρητική περίοδο λόγω σοβαρών συστηματικών επιπλοκών. Ο σωστός σχεδιασμός, η επιλογή του κατάλληλου κρημνού, η εμπειρία στην μικροχειρουργική και η συνεργασία των εμπλεκόμενων ιατρικών ομάδων είναι αυτά που διασφαλίζουν το υψηλό ποσοστό επιτυχίας στην επανορθωτική μικροχειρουργική με πολύ καλό λειτουργικό και αισθητικό αποτέλεσμα. / Microsurgical free tissue transfer considered as the best choice for the reconstruction of head and neck extended and complex tissue defects due to tumor resection or trauma. A total of 48 patients underwent free tissue transfer between 2003-2010. There were 34 patients underwent one stage tumor resection and microsurgical free flap reconstruction and 16 patients for free flap reconstruction due to head and neck trauma. The defect in 12 patients 25% was on the scalp and forehead, the middle third in 9 patients 18.7% lower third in neck in 27 patients 56.25%. We used a combination of double free flaps for reconstruction in 7 cases and in 41 patients a single free flap. Vane grafts were used in 16 cases (33.3%). We used in total 56 free flaps with success rate 92.8% (52/56). Four flaps were lost due to anastomotic thromboses. Work horse flaps in our series include the radial forearm 28.5%, fibula 17.8%, ALT 14.2%, VRAM 12.5%, TRAM 5.3%, latissimus dorse 8.9%, gracilis 7.1% and serratus anterior 1.7%. The neck recipient vessels were used in 96.2%. One patient died in post surgical period after systemic complications. Preoperative surgical and reconstruction plan, flaps selection, high microsurgical experience and team collaboration are essential for the good functional and aesthetic results in microsurgery reconstruction of head and neck tissue defects.