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O.234 A few remarks about bones inclusion in facial allotransplantation
Oral Presentations
Microsurgery I
S59
Conclusions: The use of the OPTP is not routine in the UK and adverse incidents occasionally occur when used. It would also appear that in some areas, theatre teams may be at variance as regards to who is responsible for its removal when used and a unified practice and policy at trust level should probably be adopted.
Dissections of fresh cadavers have been done with selective injection (with and without X-ray product). The results of this dissection are presented. From that, we deduce and suggest a pattern for the mandible inclusion. We discuss also the technical feasibility of the approach of maxillary internal carotid, and we try to extrapolate these anatomical works into in vivo conditions.
Tuesday, 9 September 2008, 08.30–10.30
O.235 Carrier flaps as a solution in vessel depleted necks K. Wolff, M. Kesting, D. Loeffelbein, T. Muecke, F. Hoelzle. Klinikum rechts der Isar, M¨unchen, Germany
Sala Bianca
Microsurgery I O.233 28 cases of perforator flaps in maxillofacial surgery L.J. Arias-Gallo, M.-J. Morin-Soto, T. Gonzaez-Otero, V. Martorell-Martinez, J. Gonzalez-Martin-Moro, G. DemariaMartinez, J.M. Lopez-Arcas-Calleja, M. Burgueio-Garcia. Hospital Universitario La Paz, Madrid, Spain Flaps based on perforator vessels are been increasingly used in head and neck reconstruction. Their main advantages are a low morbidity of the donor site and an increased flexibility of the reconstruction. Standard perforator flaps are composed mainly of skin and fat, tissues adequate for the reconstruction of most of the defects in the head and neck, excluding facial reanimation. Since oct 2005 we have performed 17 anterolateral thigh flaps (ALT flap) and 11 deep inferior epigastric artery perforator flaps (DIEAP flap). In this period we have just made 3 antebraquial flaps and none rectus abdominis flap. 16 patients were operated for malignant tumors, having the remaining patient sequelae of neonatal traumatic soft tissue loss. Distribution of recipient sites among the 17 ALT-reconstructed patients was as follows: total glosectomy (6), partial glosectomy (4), floor of the mouth (3), maxillectomy (1), skin tumor (2), and cheek defect (1). Among the 11 DIEAP-reconstructed patients, distribution was: total glosectomy (8), and partial glosectomy (3). Number of perforating vessels ranged between one and four. In no case there was a complete failure of a flap. Partial necrosis was observed in 2 cases. Donor site morbidity was unremarkable. Harvesting of the flap did not extend the operating time because a two team approach was used. Hospital stay ranged between 9 and 32 days. Perforator flaps are advocated as the standard microvascular procedure for soft tissue reconstruction. O.234 A few remarks about bones inclusion in facial allotransplantation A. Lemaire, C. Moure, B. Lengele, S. Testelin, B. Devauchelle. Departement of Maxillofacial Surgery, Hˆopital Nord, Amiens, France Today, three facial transplantations have been achieved all over the world. They have all been a success, even if they still need to be studied in the coming months and even years. Enlightened by this experience, we can easily imagine some patterns of graft based on aesthetic and functional units, and vascularized by well-known pedicles. Nevertheless, to include some bone in facial transplantations it is necessary to modify the approaches and perhaps the technique of harvesting. In that prupose, we have not only to consider a surface area or region with cutaneous, subcutaneous and muscular vascular territories, but also a volume. Thanks to anatomical studies, we suggest several possibilities of bone inclusion in the ransplant. The goal concerns essentially the vascularization of the bone part. The originality of this presentation is to formulate if the necessity or not to include the internal maxillary artery. In fact we tried to determine the necessity and the relative part between the internal maxillary artery and the other branches of the external carotid artery such as the facial artery.
Background: In irradiated and vessel depleted necks, flaps can mostly only be anastomosed using loops or interponates. We present the wrist carrier technique to provide flap perfusion until autonomisation takes place. Methods: In three patients, an osteocutaneous fibular flap was anastomosed to the radial artery and cephalic vein for reconstruction of the mandible. In one case, an anterolateral thigh flap was additionally chain linked to the fibular flap to provide suffient soft tissue to the lower face. To speed up autonomisation, periodical pedicle occlusion started immediately after surgery. Cutaneous blood flow and hemoglobin oxygenation were continuously determinated. Results: All flaps were autonomously perfused after occlusion of the pedicle on day 16. Although cutaneous blood flow and oxygenation were still reduced significantly, wound healing was uneventful in all three patients after removal of the pedicle at day 20. Conclusion: Although long time integrity of the vascular pedicle is reported to be decisive for flap survival in irradiated patients, systematic ischemic preconditioning can lead to reliable flap autonomisation. Microvascular reconstruction can thus be performed completely independent from the vascular status of the neck, by using the radial forearm flap as a carrier. O.236 Chimera-flaps for covering complex facial defects A. Gaggl, H. Buerger, F.M. Chiari. Landeskrankenhaus, Klagenfurt, Austria Objectives: The main indication for microvascular reconstruction of the face is the best possible functional and aesthetic outcome. Here every special kind of missing tissue is to be substituted. By using the Chimera-flap technique a combination of different transplants for individual defect coverage is possible. Material and Methods: In 23 patients with extended or penetrating defects of the face reconstruction was performed with a double flap technique. A combination of microvascular iliac crest or microvascular femur transplants for bone reconstruction and a soft tissue flap from the thigh region was performed after ablative tumour surgery. All patients had radiotherapy 6 weeks after surgery. Results: All patients had good functional and aesthetic results and have been successfully treated with implant retained prostheses. There were no severe postoperative complications. There was only one tumour relapse within 14 to 42 months postoperatively. Conclusions: The Chimera-technique makes good aesthetic and functional outcome possible. The iliac crest transplant is of a good dimension for reconstruction of non-high atrophic mandibles or maxillas after complete resection. The microvascular femur is well suited for covering partial defects of the mandible. Implant placement is possible in both transplant types. The soft tissue flaps from the thigh have a low incidence of complications and donor site morbidity and can be shaped adequately to a soft tissue defect of the face.
Microsurgery I
S59
Conclusions: The use of the OPTP is not routine in the UK and adverse incidents occasionally occur when used. It would also appear that in some areas, theatre teams may be at variance as regards to who is responsible for its removal when used and a unified practice and policy at trust level should probably be adopted.
Dissections of fresh cadavers have been done with selective injection (with and without X-ray product). The results of this dissection are presented. From that, we deduce and suggest a pattern for the mandible inclusion. We discuss also the technical feasibility of the approach of maxillary internal carotid, and we try to extrapolate these anatomical works into in vivo conditions.
Tuesday, 9 September 2008, 08.30–10.30
O.235 Carrier flaps as a solution in vessel depleted necks K. Wolff, M. Kesting, D. Loeffelbein, T. Muecke, F. Hoelzle. Klinikum rechts der Isar, M¨unchen, Germany
Sala Bianca
Microsurgery I O.233 28 cases of perforator flaps in maxillofacial surgery L.J. Arias-Gallo, M.-J. Morin-Soto, T. Gonzaez-Otero, V. Martorell-Martinez, J. Gonzalez-Martin-Moro, G. DemariaMartinez, J.M. Lopez-Arcas-Calleja, M. Burgueio-Garcia. Hospital Universitario La Paz, Madrid, Spain Flaps based on perforator vessels are been increasingly used in head and neck reconstruction. Their main advantages are a low morbidity of the donor site and an increased flexibility of the reconstruction. Standard perforator flaps are composed mainly of skin and fat, tissues adequate for the reconstruction of most of the defects in the head and neck, excluding facial reanimation. Since oct 2005 we have performed 17 anterolateral thigh flaps (ALT flap) and 11 deep inferior epigastric artery perforator flaps (DIEAP flap). In this period we have just made 3 antebraquial flaps and none rectus abdominis flap. 16 patients were operated for malignant tumors, having the remaining patient sequelae of neonatal traumatic soft tissue loss. Distribution of recipient sites among the 17 ALT-reconstructed patients was as follows: total glosectomy (6), partial glosectomy (4), floor of the mouth (3), maxillectomy (1), skin tumor (2), and cheek defect (1). Among the 11 DIEAP-reconstructed patients, distribution was: total glosectomy (8), and partial glosectomy (3). Number of perforating vessels ranged between one and four. In no case there was a complete failure of a flap. Partial necrosis was observed in 2 cases. Donor site morbidity was unremarkable. Harvesting of the flap did not extend the operating time because a two team approach was used. Hospital stay ranged between 9 and 32 days. Perforator flaps are advocated as the standard microvascular procedure for soft tissue reconstruction. O.234 A few remarks about bones inclusion in facial allotransplantation A. Lemaire, C. Moure, B. Lengele, S. Testelin, B. Devauchelle. Departement of Maxillofacial Surgery, Hˆopital Nord, Amiens, France Today, three facial transplantations have been achieved all over the world. They have all been a success, even if they still need to be studied in the coming months and even years. Enlightened by this experience, we can easily imagine some patterns of graft based on aesthetic and functional units, and vascularized by well-known pedicles. Nevertheless, to include some bone in facial transplantations it is necessary to modify the approaches and perhaps the technique of harvesting. In that prupose, we have not only to consider a surface area or region with cutaneous, subcutaneous and muscular vascular territories, but also a volume. Thanks to anatomical studies, we suggest several possibilities of bone inclusion in the ransplant. The goal concerns essentially the vascularization of the bone part. The originality of this presentation is to formulate if the necessity or not to include the internal maxillary artery. In fact we tried to determine the necessity and the relative part between the internal maxillary artery and the other branches of the external carotid artery such as the facial artery.
Background: In irradiated and vessel depleted necks, flaps can mostly only be anastomosed using loops or interponates. We present the wrist carrier technique to provide flap perfusion until autonomisation takes place. Methods: In three patients, an osteocutaneous fibular flap was anastomosed to the radial artery and cephalic vein for reconstruction of the mandible. In one case, an anterolateral thigh flap was additionally chain linked to the fibular flap to provide suffient soft tissue to the lower face. To speed up autonomisation, periodical pedicle occlusion started immediately after surgery. Cutaneous blood flow and hemoglobin oxygenation were continuously determinated. Results: All flaps were autonomously perfused after occlusion of the pedicle on day 16. Although cutaneous blood flow and oxygenation were still reduced significantly, wound healing was uneventful in all three patients after removal of the pedicle at day 20. Conclusion: Although long time integrity of the vascular pedicle is reported to be decisive for flap survival in irradiated patients, systematic ischemic preconditioning can lead to reliable flap autonomisation. Microvascular reconstruction can thus be performed completely independent from the vascular status of the neck, by using the radial forearm flap as a carrier. O.236 Chimera-flaps for covering complex facial defects A. Gaggl, H. Buerger, F.M. Chiari. Landeskrankenhaus, Klagenfurt, Austria Objectives: The main indication for microvascular reconstruction of the face is the best possible functional and aesthetic outcome. Here every special kind of missing tissue is to be substituted. By using the Chimera-flap technique a combination of different transplants for individual defect coverage is possible. Material and Methods: In 23 patients with extended or penetrating defects of the face reconstruction was performed with a double flap technique. A combination of microvascular iliac crest or microvascular femur transplants for bone reconstruction and a soft tissue flap from the thigh region was performed after ablative tumour surgery. All patients had radiotherapy 6 weeks after surgery. Results: All patients had good functional and aesthetic results and have been successfully treated with implant retained prostheses. There were no severe postoperative complications. There was only one tumour relapse within 14 to 42 months postoperatively. Conclusions: The Chimera-technique makes good aesthetic and functional outcome possible. The iliac crest transplant is of a good dimension for reconstruction of non-high atrophic mandibles or maxillas after complete resection. The microvascular femur is well suited for covering partial defects of the mandible. Implant placement is possible in both transplant types. The soft tissue flaps from the thigh have a low incidence of complications and donor site morbidity and can be shaped adequately to a soft tissue defect of the face.