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P43 The use of Polyetheretherketone (PEEK) in zygomatico-orbital reconstruction
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Posters / British Journal of Oral and Maxillofacial Surgery 48 (2010) S25–S55
P42 The DCIA perforator flap – an option to reconstruct the large composite glossomandibular defect B. Bisase, P.M. Norris, A.E. Brown. Queen Victoria Hospital, East Grinstead, UK The deep circumflex iliac artery (DCIA) osteomusculocutaneous flap with iliac crest is one of the most frequently used free transfer grafts for mandibular reconstruction. Limitations of this graft include its bulkiness and added donor-site morbidity because of the inclusion of an “obligatory muscle cuff” of abdominal muscle. Occasionally segmental mandibular resections also include large amounts of adjacent soft tissue involving the floor of mouth and a subtotal glossectomy. Reconstruction for such defects has often required two free transfer grafts addressing the bone and soft tissue component separately. Although the scapula free flap is known to confer some chimeric characteristics, it offers poorer bone quantity and quality for mandibular rehabilitation. This flap also obviates two teams operating simultaneously and requires turning the patient which often increases the operative time. Perforator flaps are increasingly used because of advantages such as the super-selection of the soft tissues with reduced bulk and less donor-site morbidity. When such flaps are combined with bone they are more chimeric with increased mobility of the components. Early results at designing a DCIA perforator flap to circumvent this problem have been varied. Although concerns relate to the location, number, and reliability of DCIA musculocutaneous perforators, Bergeron et al. present their anatomical study in favour of such a flap. We present 2 cases which required segmental mandibular resection and subtotal glossectomy that were subsequently reconstructed with a single free flap. Reference(s) Bergeron L et al, The anatomical basis of the DCIA perforator flap with iliac crest. Plast Reconstr Surg 2007 Jul; 120(1): 252–8. P43 The use of Polyetheretherketone (PEEK) in zygomatico-orbital reconstruction. C. Pace, D. Holt. Rotherham Foundation NHS Trust, UK We describe the use of Polyetheretherketone (or PEEK) as an example of an alloplastic, custom-made prosthetic reconstructive solution following resection of a bony arterio-venous malformation in the zygomatico-orbital region. We outline an interesting case of a resection of the zygomatic body, orbital floor and lateral wall for a large, long standing but slowly increasing in size arterio-venous malformation. A 58year old female patient presented with a one year history of slowly increasing right sided facial swelling over the zygomatic prominence. Following biopsy, a pre-operative angiogram was arranged which showed no treatable feeding vessels. Coil embolisation of the vascular lesion was undertaken to reduce the risk of significant intra-operative bleeding. One week following embolisation, bicoronal and Weber-Ferguson were used to gain access to the lesion. Resection was followed by reconstruction using sterile prefabricated custom made PEEK prosthesis with an excellent cosmetic outcome. We will outline a description of this patient specific implant, including the properties and handling of the material, advantages over other reconstructive techniques, materials and cost. A number of clinical photographs and radiographs will be presented.
P44 A new type of neck incision for neck dissection procedures G. Gillan, S. Westley, P. Hardee. Whipps Cross University Hospital NHS Trust, UK Introduction: There are several different, well recognised, types of incisions used in order to access the neck during a neck dissection procedure. The main concerns when choosing an incision are: • access • vital structures • wound closure • aesthetic outcome The incisions will vary in their ability to satisfy the above. Material: This paper proposes a new type of incision for neck dissection access. A series of cases are discussed and photographic illustration of the new incision technique is used to demonstrate how it fulfils all the above requirements in a uniformly superior manner to the well recognised currently used incisions. The incision is a ‘hemi-visor’ incision. It starts at the mastoid process and proceeds caudaly over the sternocleidomastoid (SCM) muscle parallel to its fibres. The incision is then curved slightly in an anterior direction where the lower 1/3 of the SCM joins the upper 2/3. Results: Photographic records demonstrated that this incision fulfilled all the above requirements. The access to levels I–V was more than ample. The thoracic duct was adequately visualised at level IV after delineation using enteral mix of methylene blue and olive oil which was administered via NG tube after anaesthetic induction. The post-operative aesthetic outcome was good in that the scar healed quickly with minimal lymphoedema. There was virtually no problems with webbing of the scar. Conclusion: The case series demonstrates enough benefits of the technique for it to be investigated further with a view to its adoption as a standard procedure. P45 A conservative method for removal of osseointegrated dental implants – the bony lid technique N.J. Perkins1 , F. Khoury2,3 . 1 St. Helen’s Dental Practice, Cumbria, UK; 2 Privatklinik Schloss Schellenstein, Olsberg; 3 Department of Oral & Maxillofacial Surgery, University of Muenster, Germany The removal of osseointegrated dental implants may become necessary following implant failure – for example due to implant fracture – or in patients who have psychological problems with dental implants. The bony lid technique was originally developed in the 1980s as a bone-saving method for surgical endodontic treatment of mandibular molars. It involves the removal of a lid of buccal bone using a MicroSaw, accomplishment of the desired surgical procedure (e.g. apicectomy), and then replantation of the bony lid with primary closure of the surgical site. This technique has evolved over time and has many applications in oral surgery including: cystectomies; removal of deeply buried roots and deeply impacted teeth; retrieval of foreign bodies; and explantation of fractured or failed osseointegrated dental implants. Conventional approaches to implant removal – such as trephination – can result in a significant bony defect requiring subsequent bone augmentation procedures, which can increase the risk of significant post-operative morbidity for the patient. Several studies have shown the bony lid approach to be very successful with minimal post-operative complications. The purpose of this poster is to present two cases which demonstrate an alternative approach to removal of failed dental
Posters / British Journal of Oral and Maxillofacial Surgery 48 (2010) S25–S55
P42 The DCIA perforator flap – an option to reconstruct the large composite glossomandibular defect B. Bisase, P.M. Norris, A.E. Brown. Queen Victoria Hospital, East Grinstead, UK The deep circumflex iliac artery (DCIA) osteomusculocutaneous flap with iliac crest is one of the most frequently used free transfer grafts for mandibular reconstruction. Limitations of this graft include its bulkiness and added donor-site morbidity because of the inclusion of an “obligatory muscle cuff” of abdominal muscle. Occasionally segmental mandibular resections also include large amounts of adjacent soft tissue involving the floor of mouth and a subtotal glossectomy. Reconstruction for such defects has often required two free transfer grafts addressing the bone and soft tissue component separately. Although the scapula free flap is known to confer some chimeric characteristics, it offers poorer bone quantity and quality for mandibular rehabilitation. This flap also obviates two teams operating simultaneously and requires turning the patient which often increases the operative time. Perforator flaps are increasingly used because of advantages such as the super-selection of the soft tissues with reduced bulk and less donor-site morbidity. When such flaps are combined with bone they are more chimeric with increased mobility of the components. Early results at designing a DCIA perforator flap to circumvent this problem have been varied. Although concerns relate to the location, number, and reliability of DCIA musculocutaneous perforators, Bergeron et al. present their anatomical study in favour of such a flap. We present 2 cases which required segmental mandibular resection and subtotal glossectomy that were subsequently reconstructed with a single free flap. Reference(s) Bergeron L et al, The anatomical basis of the DCIA perforator flap with iliac crest. Plast Reconstr Surg 2007 Jul; 120(1): 252–8. P43 The use of Polyetheretherketone (PEEK) in zygomatico-orbital reconstruction. C. Pace, D. Holt. Rotherham Foundation NHS Trust, UK We describe the use of Polyetheretherketone (or PEEK) as an example of an alloplastic, custom-made prosthetic reconstructive solution following resection of a bony arterio-venous malformation in the zygomatico-orbital region. We outline an interesting case of a resection of the zygomatic body, orbital floor and lateral wall for a large, long standing but slowly increasing in size arterio-venous malformation. A 58year old female patient presented with a one year history of slowly increasing right sided facial swelling over the zygomatic prominence. Following biopsy, a pre-operative angiogram was arranged which showed no treatable feeding vessels. Coil embolisation of the vascular lesion was undertaken to reduce the risk of significant intra-operative bleeding. One week following embolisation, bicoronal and Weber-Ferguson were used to gain access to the lesion. Resection was followed by reconstruction using sterile prefabricated custom made PEEK prosthesis with an excellent cosmetic outcome. We will outline a description of this patient specific implant, including the properties and handling of the material, advantages over other reconstructive techniques, materials and cost. A number of clinical photographs and radiographs will be presented.
P44 A new type of neck incision for neck dissection procedures G. Gillan, S. Westley, P. Hardee. Whipps Cross University Hospital NHS Trust, UK Introduction: There are several different, well recognised, types of incisions used in order to access the neck during a neck dissection procedure. The main concerns when choosing an incision are: • access • vital structures • wound closure • aesthetic outcome The incisions will vary in their ability to satisfy the above. Material: This paper proposes a new type of incision for neck dissection access. A series of cases are discussed and photographic illustration of the new incision technique is used to demonstrate how it fulfils all the above requirements in a uniformly superior manner to the well recognised currently used incisions. The incision is a ‘hemi-visor’ incision. It starts at the mastoid process and proceeds caudaly over the sternocleidomastoid (SCM) muscle parallel to its fibres. The incision is then curved slightly in an anterior direction where the lower 1/3 of the SCM joins the upper 2/3. Results: Photographic records demonstrated that this incision fulfilled all the above requirements. The access to levels I–V was more than ample. The thoracic duct was adequately visualised at level IV after delineation using enteral mix of methylene blue and olive oil which was administered via NG tube after anaesthetic induction. The post-operative aesthetic outcome was good in that the scar healed quickly with minimal lymphoedema. There was virtually no problems with webbing of the scar. Conclusion: The case series demonstrates enough benefits of the technique for it to be investigated further with a view to its adoption as a standard procedure. P45 A conservative method for removal of osseointegrated dental implants – the bony lid technique N.J. Perkins1 , F. Khoury2,3 . 1 St. Helen’s Dental Practice, Cumbria, UK; 2 Privatklinik Schloss Schellenstein, Olsberg; 3 Department of Oral & Maxillofacial Surgery, University of Muenster, Germany The removal of osseointegrated dental implants may become necessary following implant failure – for example due to implant fracture – or in patients who have psychological problems with dental implants. The bony lid technique was originally developed in the 1980s as a bone-saving method for surgical endodontic treatment of mandibular molars. It involves the removal of a lid of buccal bone using a MicroSaw, accomplishment of the desired surgical procedure (e.g. apicectomy), and then replantation of the bony lid with primary closure of the surgical site. This technique has evolved over time and has many applications in oral surgery including: cystectomies; removal of deeply buried roots and deeply impacted teeth; retrieval of foreign bodies; and explantation of fractured or failed osseointegrated dental implants. Conventional approaches to implant removal – such as trephination – can result in a significant bony defect requiring subsequent bone augmentation procedures, which can increase the risk of significant post-operative morbidity for the patient. Several studies have shown the bony lid approach to be very successful with minimal post-operative complications. The purpose of this poster is to present two cases which demonstrate an alternative approach to removal of failed dental