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A modified technique of sinus-bone-grafting—a new way for a better success
262
British
Journal
of Oral
and Maxillofacial
Surgery
taken to confirm patency of the microanastomoses and palatal perfusion. The reproducibility of the technique was tested by repeating the procedure on a second cadaver. The characteristics of the Le Fort I avulsion injury consisted of partial tearing of the soft palate, leaving some levator palati muscle tissue and nasal mucosal layer in-situ. The average GP pedicle length was 1.9 cm, but this could be increased by a further 1 cm by careful opening up of its canal with a drill. The average diameters of the arteries and venae comitantes were 1.75 mm and 0.9 mm, respectively. The RFF flap measured 20 cm in length enabling the neck to be reached easily from the maxilla. The average diameters of the radial artery and venae comitantes were 4.0 mm and 2.0 mm, respectively. Despite the significant size mismatch between the GP and RFF flap vessels,DSA showed patency of the microanastomoses and palatal perfusion. In conclusion, successful revascularization of an avulsed maxilla can be achieved with the use of a radial forearm free flap as a conduit between the vessels of the greater palatine pedicle and those of the neck. The versatility struction. I.
of subscapular axis free flaps for head & neck reconHutchison & P. Hardee. Department of Oral &
Maxillofacial Surgery, The Whitechapel, London, UK.
Royal
Hospitals
NHS
Trust,
The scapular artery and vein are branches of the axillary vessels. They vary in calibre from 3-6 mm and are minimally affected by peripheral vascular disease. The circumflex scapular vessels usually branch off the subscapular pedicle 2-4 cm from the axillary artery to supply the lateral surface of the scapula and skin overlying the posterior surface of the scapula. Approximately 6 cm distally the subscapular pedicle terminates variably into the thoraco-dorsal vessels supplying the latissimus dorsi muscle and overlying skin, the vessels to the serratus anterior muscle, and further vessels to the lower lateral border of the scapula. Osteocutaneous flaps can be supplied by the circumflex scapular vessels; myo-osseo-cutaneous flaps can be supplied by the thoracodorsal vessels; myo-osseous rib flaps can be raised on the blood supply to serratus anterior; or various combinations of all these flaps can be elevated, transferred and anastomosed on the single artery and vein of the subscapular pedicle. This paper will present 5 cases to illustrate the variety of flaps that can be raised on the subscapular pedicle. Oropharyngeal cal spine. D.
morbidity C. Jones,
following transoral approaches to the cerviJ. P. Hayter & E. D. Vaughan. Regional
Maxillofacial
Unit, Walton Hospital, Liverpool,
UK.
The transoral approach using a midline pharyngeal incision is a well established method of gaining access to the upper anterior cervical spine. We have used this approach, modified by using a superiorly based flap to provide enhanced access, since 1986. In some cases access is further improved by splitting the soft palate. The postoperative oropharyngeal morbidity and function was investigated in this group of patients. Forty-four consecutive patients with a mean age of 55 (range 17-75) were treated between 1986 and 1995. The principal pathology was rheumatoid arthritis with atlanto-occipital subluxation resulting in progressive neurological deficit. The use of the superiorly based flap to improve access resulted in a low incidence of oropharyngeal morbidity. Early complications included dysphagia and later complications included nasal escape and nasal regurgitation. Such complications were more frequent in those cases where the soft palate was split. A modilled technique of sinus-bone-grafting-a success. S. Kiinig, E. Machtens & S. Reinert.
and Maxillofacial Germany.
Surgery, Ruhr-University
new way for a better
Department of Oral of Bochum, Bochum,
We have developed a modified technique of sinus bone grafting using exclusively corticocancellous bone transplants from the pelvic crest. We remove a bony window from the maxillary sinus wall and
fix the bone transplant with cranial location of the cortical surface roughly 2cm above the alveolar ridge using two vertical miniosteosynthesis screws. This produces a space between the bone transplant and the maxillary sinus floor which is tightly filled with cancellous bone chips. Finally the bony window is setback and Iixed with micro-osteosynthesis plates. In this way also a transversal widening of the alveolar ridge can be realized. Using this technique a total of 38 antroplastics in 20 patients with extremely atrophied maxilla has been performed. The postoperative CT controls show, that bone heights up to 20 mm can be gained. The comparison between the postaugmentative CT scans and those 4 months later before insertion of implants reveals virtually no bone resorption, neither a loss of bone height nor internal lacunary bone resorption. Neither CT scans nor transnasal sinus endoscopy demonstrate mucosal thickening or pseudopolyps as signs of chronic sinusitis. Also in the l-year-follow-up CT control there is no change in the radiographic picture of the grafted areas. To date 95 screw type titanium implants are inserted in the transplanted bone without any surgical or prosthetic compromises. 67 of them are loaded by prosthetic rehabilitation.
Assessment of outcome of internal carotid artery ligation using intraoperative hack pressure monitoring. M. A. Kuriakose, Q. Yongja* & T. Ping-zhang*. Sunderland General Hospital, VK, *Beijing Cancer Hospital, China.
Ligation of internal carotid artery has serious sequel, with reported perioperative mortality of 5-20% and neurological deficit of 20-40%. It is therefore paramount to predict the outcome to help in selection of cases and to plan reconstructive procedures. The aim of this paper is to describe the technique of internal carotid artery back pressure monitoring and to report the predictive value of this method. Of the 71 patients who underwent ligation of internal carotid artery at the Head and Neck division of Beijing Cancer hospital, from 1986 to 1994 in 15 patients internal carotid artery back pressure reading and follow-up details were available for analysis. Results are reported on this patient group. The age range of these 15 patients were from 33 to 65 years with mean value of 54 and sex ratio of 4: 1 (M: F). The reasons for carotid ligation were invasion of tumour (S), impending carotid rupture (4), carotid blow-out (4) and carotid aneurysm (2). The carotid back pressure recording showed over 70 mm Hg in 3 patients, between 60 and 69 mmHg in 6 patients and between 50 and 59 mmHg in 4 patients. The postoperative recovery was uneventful in all the above patients. In one patient with 42 mmHg pressure there was a transient hemiplegia which resolved in 4 days. In a patient who underwent emergency ligation of a carotid blow out with back pressure of 35 mmHg resulted in permanent hemiplegia. There was no perioperative mortality in this group. In conclusion, internal carotid artery back pressure monitoring is a simple, reliable and readily available technique. The results from this series has shown that it is safe to ligate the carotid artery if the pressure is more than 50 mmHg.
Provision of a head & neck dermatology surgery service: the North Wales experience. E. B. Larkin & R E. A. Williams. Department
of Oral & Maxillofacial Surgery and Department of Dermatology, Glan Clwyd Hospital, Bodelwyddan, Clwyd, Wales, UK. The appointment 40 years ago of a doubly qualified, surgically trained Consultant allowed North Wales to introduce a dermatological surgery service; an unusual development at that time. This activity, which comprises 19% of the work of the Unit, has never been questioned but is now under increasing scrutiny, as changes within the organisation of the Health Service mean that traditional patterns of referral and activity can no longer be guaranteed. The requirements of an ideal head and neck dermatological surgery service is presented, along with the current service provided in North Wales and an assessment of activity from 1990 to 1995. Its importance in developing relations and referrals from general medical practice and the facilitation of soft tissue surgery including free flaps and more recently Mohs’ Surgery is discussed. Its effect on other referral patterns, particularly with regard to dento-
British
Journal
of Oral
and Maxillofacial
Surgery
taken to confirm patency of the microanastomoses and palatal perfusion. The reproducibility of the technique was tested by repeating the procedure on a second cadaver. The characteristics of the Le Fort I avulsion injury consisted of partial tearing of the soft palate, leaving some levator palati muscle tissue and nasal mucosal layer in-situ. The average GP pedicle length was 1.9 cm, but this could be increased by a further 1 cm by careful opening up of its canal with a drill. The average diameters of the arteries and venae comitantes were 1.75 mm and 0.9 mm, respectively. The RFF flap measured 20 cm in length enabling the neck to be reached easily from the maxilla. The average diameters of the radial artery and venae comitantes were 4.0 mm and 2.0 mm, respectively. Despite the significant size mismatch between the GP and RFF flap vessels,DSA showed patency of the microanastomoses and palatal perfusion. In conclusion, successful revascularization of an avulsed maxilla can be achieved with the use of a radial forearm free flap as a conduit between the vessels of the greater palatine pedicle and those of the neck. The versatility struction. I.
of subscapular axis free flaps for head & neck reconHutchison & P. Hardee. Department of Oral &
Maxillofacial Surgery, The Whitechapel, London, UK.
Royal
Hospitals
NHS
Trust,
The scapular artery and vein are branches of the axillary vessels. They vary in calibre from 3-6 mm and are minimally affected by peripheral vascular disease. The circumflex scapular vessels usually branch off the subscapular pedicle 2-4 cm from the axillary artery to supply the lateral surface of the scapula and skin overlying the posterior surface of the scapula. Approximately 6 cm distally the subscapular pedicle terminates variably into the thoraco-dorsal vessels supplying the latissimus dorsi muscle and overlying skin, the vessels to the serratus anterior muscle, and further vessels to the lower lateral border of the scapula. Osteocutaneous flaps can be supplied by the circumflex scapular vessels; myo-osseo-cutaneous flaps can be supplied by the thoracodorsal vessels; myo-osseous rib flaps can be raised on the blood supply to serratus anterior; or various combinations of all these flaps can be elevated, transferred and anastomosed on the single artery and vein of the subscapular pedicle. This paper will present 5 cases to illustrate the variety of flaps that can be raised on the subscapular pedicle. Oropharyngeal cal spine. D.
morbidity C. Jones,
following transoral approaches to the cerviJ. P. Hayter & E. D. Vaughan. Regional
Maxillofacial
Unit, Walton Hospital, Liverpool,
UK.
The transoral approach using a midline pharyngeal incision is a well established method of gaining access to the upper anterior cervical spine. We have used this approach, modified by using a superiorly based flap to provide enhanced access, since 1986. In some cases access is further improved by splitting the soft palate. The postoperative oropharyngeal morbidity and function was investigated in this group of patients. Forty-four consecutive patients with a mean age of 55 (range 17-75) were treated between 1986 and 1995. The principal pathology was rheumatoid arthritis with atlanto-occipital subluxation resulting in progressive neurological deficit. The use of the superiorly based flap to improve access resulted in a low incidence of oropharyngeal morbidity. Early complications included dysphagia and later complications included nasal escape and nasal regurgitation. Such complications were more frequent in those cases where the soft palate was split. A modilled technique of sinus-bone-grafting-a success. S. Kiinig, E. Machtens & S. Reinert.
and Maxillofacial Germany.
Surgery, Ruhr-University
new way for a better
Department of Oral of Bochum, Bochum,
We have developed a modified technique of sinus bone grafting using exclusively corticocancellous bone transplants from the pelvic crest. We remove a bony window from the maxillary sinus wall and
fix the bone transplant with cranial location of the cortical surface roughly 2cm above the alveolar ridge using two vertical miniosteosynthesis screws. This produces a space between the bone transplant and the maxillary sinus floor which is tightly filled with cancellous bone chips. Finally the bony window is setback and Iixed with micro-osteosynthesis plates. In this way also a transversal widening of the alveolar ridge can be realized. Using this technique a total of 38 antroplastics in 20 patients with extremely atrophied maxilla has been performed. The postoperative CT controls show, that bone heights up to 20 mm can be gained. The comparison between the postaugmentative CT scans and those 4 months later before insertion of implants reveals virtually no bone resorption, neither a loss of bone height nor internal lacunary bone resorption. Neither CT scans nor transnasal sinus endoscopy demonstrate mucosal thickening or pseudopolyps as signs of chronic sinusitis. Also in the l-year-follow-up CT control there is no change in the radiographic picture of the grafted areas. To date 95 screw type titanium implants are inserted in the transplanted bone without any surgical or prosthetic compromises. 67 of them are loaded by prosthetic rehabilitation.
Assessment of outcome of internal carotid artery ligation using intraoperative hack pressure monitoring. M. A. Kuriakose, Q. Yongja* & T. Ping-zhang*. Sunderland General Hospital, VK, *Beijing Cancer Hospital, China.
Ligation of internal carotid artery has serious sequel, with reported perioperative mortality of 5-20% and neurological deficit of 20-40%. It is therefore paramount to predict the outcome to help in selection of cases and to plan reconstructive procedures. The aim of this paper is to describe the technique of internal carotid artery back pressure monitoring and to report the predictive value of this method. Of the 71 patients who underwent ligation of internal carotid artery at the Head and Neck division of Beijing Cancer hospital, from 1986 to 1994 in 15 patients internal carotid artery back pressure reading and follow-up details were available for analysis. Results are reported on this patient group. The age range of these 15 patients were from 33 to 65 years with mean value of 54 and sex ratio of 4: 1 (M: F). The reasons for carotid ligation were invasion of tumour (S), impending carotid rupture (4), carotid blow-out (4) and carotid aneurysm (2). The carotid back pressure recording showed over 70 mm Hg in 3 patients, between 60 and 69 mmHg in 6 patients and between 50 and 59 mmHg in 4 patients. The postoperative recovery was uneventful in all the above patients. In one patient with 42 mmHg pressure there was a transient hemiplegia which resolved in 4 days. In a patient who underwent emergency ligation of a carotid blow out with back pressure of 35 mmHg resulted in permanent hemiplegia. There was no perioperative mortality in this group. In conclusion, internal carotid artery back pressure monitoring is a simple, reliable and readily available technique. The results from this series has shown that it is safe to ligate the carotid artery if the pressure is more than 50 mmHg.
Provision of a head & neck dermatology surgery service: the North Wales experience. E. B. Larkin & R E. A. Williams. Department
of Oral & Maxillofacial Surgery and Department of Dermatology, Glan Clwyd Hospital, Bodelwyddan, Clwyd, Wales, UK. The appointment 40 years ago of a doubly qualified, surgically trained Consultant allowed North Wales to introduce a dermatological surgery service; an unusual development at that time. This activity, which comprises 19% of the work of the Unit, has never been questioned but is now under increasing scrutiny, as changes within the organisation of the Health Service mean that traditional patterns of referral and activity can no longer be guaranteed. The requirements of an ideal head and neck dermatological surgery service is presented, along with the current service provided in North Wales and an assessment of activity from 1990 to 1995. Its importance in developing relations and referrals from general medical practice and the facilitation of soft tissue surgery including free flaps and more recently Mohs’ Surgery is discussed. Its effect on other referral patterns, particularly with regard to dento-