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Suture anchors to fix free flaps in oral and oropharyngeal reconstruction
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British Journal of Oral and Maxillofacial Surgery 54 (2016) e5–e6
Technical note
Suture anchors to fix free flaps in oral and oropharyngeal reconstruction Zoran Marij Arneˇz a , Vittorio Ramella a , Margherita Tofanelli b,∗ , Giancarlo Tirelli b a b
Department of Plastic and Reconstructive Surgery, Cattinara Hospital, University of Trieste, Strada di Fiume 447, I-34149, Trieste, Italy Department of Otorhinolaryngology, Head and Neck Surgery, Cattinara Hospital, Strada di Fiume 447, I-34149 Trieste, Italy
Accepted 25 September 2015 Available online 21 October 2015 Keywords: Free flap; Oral and oropharyngeal cancer; Oral and oropharyngeal reconstruction; Mini-Mitek®
The use of suture anchors has been widely described in orthopaedic, oculoplastic, temporomandibular, and aesthetic surgery,1,2 and they have also been used to fix pedicle flaps in cases of ulcers or post-traumatic deficiency.3 Other authors have described their use in oncological head and neck surgery, but only when a free flap was not needed.4 We have recently tested the use of the anchors for fixing free flaps to reconstruct both the oral cavity and the oropharynx after resections for cancer.5 The Mitek® suture anchors (Depuy Mitek Surgical Products, Inc. Raynham, Massachusetts) are produced in a number of different sizes (micro, mini, GII, and Super) but we use the mini. It is composed of a body and two wings, the body being made of titanium alloy, and the wings of nickel-titanium alloy, which benefits from superelasticity and its memory of shape. The packaging includes both the anchor and the insertion device, in which the anchor is already preloaded. The bottom of the anchor has a loop that contains the suture, which is charged on to the insertion device (Fig. 1). The first step is the exposure of the bone. A calibrated hole is then drilled with the drill bit supplied in the package that corresponds to the size of the anchor. The drilling is done slowly, perpendicular to the bone, and under abundant irrigation (Fig. 2). It is important to realise that the drill is not required to pierce the entire thickness of the bone, because the anchor has to be positioned within the cortical bone to minimise the risk of overpenetration. Once the pilot hole has
∗
Corresponding author. Fax: +390403994180. E-mail address: [email protected] (M. Tofanelli).
Fig. 1. The mini Mitek® anchor. The body is 1.8 mm wide and 5.0 mm long, and is provided with a pair of superelastic nickel-titanium wings.
been drilled, the anchor is positioned using the insertion tool that keeps the wings collapsed. After the extrusion of the anchor, the wings spread out to the wide resting position, and fix the anchor into the bony hole (Fig. 3). The insertion tool
http://dx.doi.org/10.1016/j.bjoms.2015.09.031 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
e6
Z.M. Arneˇz et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) e5–e6
Fig. 2. The drilling of the pilot hole in the bare bone.
Fig. 4. The 2.0, double-armed, non-absorbable suture anchored to the bone ready for the flap to be fixed.
also prevent dehiscence of the suture flap, and avoid the onset of a salivary fistula.
Conflict of Interest We have no conflict of interest.
Ethics statement/confirmation of patients’ permission Written informed consent was obtained from all patients. Fig. 3. The positioning and release of the anchor.
is then removed, which releases the suture, and this is used to fix the free flap to the recipient site (Fig. 4). We routinely use these devices to fix free flaps after different surgical interventions in head and neck surgery - transoral, submandibular, and transmandibular - without complications. In our experience the anchors become completely integrated into the bone, and the effects of radiotherapy are well tolerated. The anchors are also suitable for use in irradiated bone, such as in the treatment of osteoradionecrosis. We have found the fastening process quick, easy, precise, and reliable, and we think that the main advantage of this device is that it allows us to fix not only the periphery of the flap but also its central portion to the underlying bare bone, which facilitates its taking root. This has the potential to avoid the “sagging” of the flap that is more likely to happen when the oropharynx or the hard palate has to be reconstructed. It might
References 1. Antonyshyn OM, Weinberg MJ, Dagum AB. Use of a new anchoring device for tendon reinsertion in medial canthopexy. Plast Reconstr Surg 1996;98:520–3. 2. Fields Jr RT, Cardenas LE, Wolford LM. The pullout force for Mitek mini and micro suture anchor systems in human mandibular condyles. J Oral Maxillofac Surg 1997;55:483–8. 3. Yamamoto Y, Tsutsumida A, Murazumi M, Sugihara T. Long-term outcome of pressure sores treated with flap coverage. Plast Reconstr Surg 1997;100:1212–7. 4. Dean A, Alamillos F, García-López A, Sánchez J, Pe˜nalba M. The use of Mitek pins in the mandibular lingual releasing approach to oral and/or oropharyngeal carcinomas: a technical note. J Craniomaxillofac Surg 2000;28:308–11. 5. Arneˇz ZM, Novati FC, Ramella V, et al. How we fix free flaps to the bone in oral and oropharyngeal reconstructions. Am J Otolaryngol 2015;36:166–72.
British Journal of Oral and Maxillofacial Surgery 54 (2016) e5–e6
Technical note
Suture anchors to fix free flaps in oral and oropharyngeal reconstruction Zoran Marij Arneˇz a , Vittorio Ramella a , Margherita Tofanelli b,∗ , Giancarlo Tirelli b a b
Department of Plastic and Reconstructive Surgery, Cattinara Hospital, University of Trieste, Strada di Fiume 447, I-34149, Trieste, Italy Department of Otorhinolaryngology, Head and Neck Surgery, Cattinara Hospital, Strada di Fiume 447, I-34149 Trieste, Italy
Accepted 25 September 2015 Available online 21 October 2015 Keywords: Free flap; Oral and oropharyngeal cancer; Oral and oropharyngeal reconstruction; Mini-Mitek®
The use of suture anchors has been widely described in orthopaedic, oculoplastic, temporomandibular, and aesthetic surgery,1,2 and they have also been used to fix pedicle flaps in cases of ulcers or post-traumatic deficiency.3 Other authors have described their use in oncological head and neck surgery, but only when a free flap was not needed.4 We have recently tested the use of the anchors for fixing free flaps to reconstruct both the oral cavity and the oropharynx after resections for cancer.5 The Mitek® suture anchors (Depuy Mitek Surgical Products, Inc. Raynham, Massachusetts) are produced in a number of different sizes (micro, mini, GII, and Super) but we use the mini. It is composed of a body and two wings, the body being made of titanium alloy, and the wings of nickel-titanium alloy, which benefits from superelasticity and its memory of shape. The packaging includes both the anchor and the insertion device, in which the anchor is already preloaded. The bottom of the anchor has a loop that contains the suture, which is charged on to the insertion device (Fig. 1). The first step is the exposure of the bone. A calibrated hole is then drilled with the drill bit supplied in the package that corresponds to the size of the anchor. The drilling is done slowly, perpendicular to the bone, and under abundant irrigation (Fig. 2). It is important to realise that the drill is not required to pierce the entire thickness of the bone, because the anchor has to be positioned within the cortical bone to minimise the risk of overpenetration. Once the pilot hole has
∗
Corresponding author. Fax: +390403994180. E-mail address: [email protected] (M. Tofanelli).
Fig. 1. The mini Mitek® anchor. The body is 1.8 mm wide and 5.0 mm long, and is provided with a pair of superelastic nickel-titanium wings.
been drilled, the anchor is positioned using the insertion tool that keeps the wings collapsed. After the extrusion of the anchor, the wings spread out to the wide resting position, and fix the anchor into the bony hole (Fig. 3). The insertion tool
http://dx.doi.org/10.1016/j.bjoms.2015.09.031 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
e6
Z.M. Arneˇz et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) e5–e6
Fig. 2. The drilling of the pilot hole in the bare bone.
Fig. 4. The 2.0, double-armed, non-absorbable suture anchored to the bone ready for the flap to be fixed.
also prevent dehiscence of the suture flap, and avoid the onset of a salivary fistula.
Conflict of Interest We have no conflict of interest.
Ethics statement/confirmation of patients’ permission Written informed consent was obtained from all patients. Fig. 3. The positioning and release of the anchor.
is then removed, which releases the suture, and this is used to fix the free flap to the recipient site (Fig. 4). We routinely use these devices to fix free flaps after different surgical interventions in head and neck surgery - transoral, submandibular, and transmandibular - without complications. In our experience the anchors become completely integrated into the bone, and the effects of radiotherapy are well tolerated. The anchors are also suitable for use in irradiated bone, such as in the treatment of osteoradionecrosis. We have found the fastening process quick, easy, precise, and reliable, and we think that the main advantage of this device is that it allows us to fix not only the periphery of the flap but also its central portion to the underlying bare bone, which facilitates its taking root. This has the potential to avoid the “sagging” of the flap that is more likely to happen when the oropharynx or the hard palate has to be reconstructed. It might
References 1. Antonyshyn OM, Weinberg MJ, Dagum AB. Use of a new anchoring device for tendon reinsertion in medial canthopexy. Plast Reconstr Surg 1996;98:520–3. 2. Fields Jr RT, Cardenas LE, Wolford LM. The pullout force for Mitek mini and micro suture anchor systems in human mandibular condyles. J Oral Maxillofac Surg 1997;55:483–8. 3. Yamamoto Y, Tsutsumida A, Murazumi M, Sugihara T. Long-term outcome of pressure sores treated with flap coverage. Plast Reconstr Surg 1997;100:1212–7. 4. Dean A, Alamillos F, García-López A, Sánchez J, Pe˜nalba M. The use of Mitek pins in the mandibular lingual releasing approach to oral and/or oropharyngeal carcinomas: a technical note. J Craniomaxillofac Surg 2000;28:308–11. 5. Arneˇz ZM, Novati FC, Ramella V, et al. How we fix free flaps to the bone in oral and oropharyngeal reconstructions. Am J Otolaryngol 2015;36:166–72.