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Poster 080: Pericranial Flap Use in Reconstruction of Traumatic Cranial Injuries
Scientific Poster Session Materials and Methods: Mandibular angle fractures were performed on 22 sheep hemi-mandibles. 11 hemimandibles were fixed with 4 hole straight titanium plates and 2.0 x 7 mm titanium screws (Trimed, Ankara/Turkey) and the other 11 hemi-mandibles were fixed with 4 hole straight resorbable plates and 2.5 x 6 mm resorbable screws (Inion CPS system, Tampere, Finland) in Champy technique. Subsequently with a fixation apparatus, all hemi-mandibles were mounted in a servohydraulic testing unit (Instron 8874, Warwick, England) to perform a compressive test. Displacement values were recorded digitally by special software (Bluehill Software, Warwick, England). Maximum forces that the model could resist before breakage (Newton (N)), maximum displacements of the model and the displacement values under 20,60, 100, 120, 150, 200 N were compared using the Mann–Whitney U-test. Results: A statistically significant difference between the resorbable and titanium plates and screws was observed up to applied forces (20, 60, 100, 120, 150 and 200 N) (P⬍0.05). It was also observed that the scale of displacement was less for titanium plate and screws. Conclusion: In this in vitro study stability of mandibular angle fractures fixed with resorbable and titanium miniplates according to Champy’s principles showed significant difference. Based on this finding, metallic and resorbable fixation systems cannot be used interchangeably for the treatment of mandibular angle fractures under similar loading conditions. References Chacon GE, Dillard FM, Clelland N, Rashid R. Comparison of strains produced by titanium and poly D, L-lactide acid plating systems to in vitro forces. J Oral Maxillofac Surg. 2005 Jul;63(7):968-72 Alkan A, Celebi N, Ozden B, Ba B, Inal S. Biomechanical comparison of different plating techniques in repair of mandibular angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Dec;104(6): 752-6
POSTER 080 Pericranial Flap Use in Reconstruction of Traumatic Cranial Injuries M. Juliana DiPasquale, DMD, University of Florida Jacksonville, Oral and Maxillofacial Surgery, 653-1 West 8 Street, Jacksonville, FL 32209 (Fattahi T) Background: The use of pericranial flaps in reconstructive surgery goes as far back as the 1800s. Due to its reliable vascular supply and low morbidity it has been used in a vast number of specialties including Oral and Maxillofacial Surgery, Otorhinolaryngology, Plastic Surgery, Craniofacial Surgery, Ophthalmology, and Neurosurgery. Published uses of the pericranial flap include facial soft tissue augmentation, reconstruction of soft tissue defects, reconstruction of nasal septum and audi116
tory canal defects, coverage of bone grafts, reconstruction of defects due to cancer ablation of the head and neck, reconstruction of the cranial base secondary to trauma or cancer surgery and repair of CSF leaks. The pericranial flap has a rich vascular blood supply which is based on the deep branches of the supraorbital artery and supratrochlear artery. The flap is composed of pericranium and loose areolar tissue, which are the two deepest layers of the soft tissue scalp and directly overly the skull. Complication rates associated with the pericranial flap are low and published cases include flap necrosis (secondary to radiation therapy) and flap hypertrophy leading to mass effect and neurological deficits (3 reported cases). Methods: Patients who suffered face and head trauma resulting in fracture of the frontal sinus who met criteria for surgical intervention underwent repair of the dural tear (if present) and obliteration of the frontal sinus using a pericranial flap. A bi-temporal scalp flap is elevated in a sub-galeal plane and maintained 1cm superior to the supraorbital ridge in order to protect the vascular supply. The pericranial flap is then designed and elevated free from the cranium. If desired, the pericranial flap can be divided at the midline between the vascular pedicles for ease of manipulation and adaptation. Results: From December 2002 until December 2007 at UF/Shands Jacksonville, 9 patients underwent repair of frontal sinus fractures and obliteration with pericranial flap. The mean age of the subjects was 38 years of age (range 23-65). Eight patients were males and one was a female. Mechanism of injury involved 2 GSW, 2 assaults with a baseball bat, 3 MVC, 1 MCC, and 1 fall. Mean follow up period was 78 days (range 9 to 160 days). Three patients required concomitant neurosurgical intervention for repair of dural tears. Of those three subjects, two experienced CSF leak pre-operatively. Only one patient required additional surgical intervention due to presence of CSF leak one month post-operatively. This patient was found to have a dural tear extending into the middle cranial fossa and decision was made to allow the tear to heal secondarily due to difficult access. The patient developed chronic CSF leak and was later taken to the operating room for endoscopic transsphenoidal dural repair, which was successful. One patient experienced minor complications such as stitch abscess and temporary temporal branch weakness, which resolved with minimal intervention. No complications were directly related to the use of the pericranial flap (flap necrosis, flap hypertrophy). Complications such as mucoceles, mucopyeloceles, cosmetic defect, meningitis, dural or brain abscesses did not occur. Conclusions: The use of the pericranial flap in trauma surgery for reconstruction of the cranial base and frontal sinus, and repair of CSF leaks is very efficacious, associated with no additional morbidity and low complication rate. An additional donor site is not necessary and the AAOMS • 2008
Scientific Poster Session risk of increased complications associated with alloplastic materials is avoided. References Yoshioka N, Rhoton AL. Vascular Anatomy Of The Anteriorly Based Pericranial Flap. Operative Neurosurgery. 57:11-15, 2005 Price JC, Loury M, Carson B, Johns ME. The pericranial flap for reconstruction of anterior skull base defects. Laryngoscope. 98:11591164, 1988 Kiyokawa K, Tai Y, Tanabe HY, Inoue Y, Hayakawa K, Shigemori M, tokudomi T. A surgical method for treating anterior skull base injuries. Journal of Cranio-Maxillofacial Surgery. 27:11-19, 1999
POSTER 081 Surgical Treatment of Mandibular Angle Fractures Using Intraoral Approach and Fixation With 1 Noncompression Miniplate: Clinical and Radiographic Study Idelmo R. Garcia Junior, DDS, MDS, PhD, Avenida da Saudade, 200, Aracatuba-SP, 16025-140, Brazil (MagroErnica N; Magro-Filho O) The aim of this study was to evaluate the results in patients treated for mandibular angle fractures with a single miniplate. Twenty one patients with 22 mandibular angle fractures were treated by open reduction and internal fixation using one noncompression miniplate positioned along the mandible oblique line with 2.0 mm self-threading screws placed through an intraoral incision. No patient was placed into postoperative intermaxilar fixation. All patients were operated by the Oral and Maxillofacial Surgery Division from the School of Dentistry of Aracatuba, Sao Paulo State University – UNESP, Brazil, during a 31 months period. The study had the UNESP Ethical Committee of Research approval and every patient was given a participation explanation and a consent form to sign for being part of the study group. They were prospectively studied for complications by clinical and radiographic evaluation by the same oral surgeon. Follow-up ranged from 6 to 44 months, with a mean of 15 months and 1 day. Complications occurred in 3 patients (14.3%). One patient (4.8%) presented postoperative infection, one (4.8%) malocclusion, and one (4.8%) sensory disturbance – hyperesthesia in the region of the retained miniplate. The only case requiring a further surgical intervention under general anesthesia was the infection case. Thus, results allowed concluding that the fixation method was suitable for treatment of simple mandibular angle fractures, the presence of only one noncompression miniplate did not interfere on the post-operative complication rate, and the method avoided postoperative intermaxillary fixation. AAOMS • 2008
References Ellis III E: Treatment methods for fractures of mandibular angle. Int J Oral Maxillofac Surg 28:243, 1999 Ellis III E, Walker LR: Treatment of mandibular angle fractures using one noncompression miniplate. J Oral Maxillofac Surg 54:864, 1996 Potter J, Ellis III E: Treatment of mandibular angle fractures with a malleable noncompression miniplate. J Oral Maxillofac Surg 57:88, 1999
POSTER 082 Management of Complex Avulsive Scalp Injuries With Vacuum-Assisted Skin Grafting Shannon K. O’Keefe, DDS, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MSc 7908, San Antonio, TX 78229 (Gutta R) Purpose: Management of extensive traumatic avulsive scalp defects is challenging. These injuries could be partial thickness or full thickness along with involvement of the outer cranial cortex. These defects might also result from cancer resection. Scalp defects are usually treated by local tissue transfer, rotational flaps, distant flaps, vascularized free flaps, and healing by secondary intention. Occasionally these defects are also treated with skin grafting as a primary modality or as a secondary procedure to cover residual defects. Skin grafting to the scalp often poses unique challenges. The shape of the head might cause dependent edema. Occasional shearing forces with prolonged supine positioning could jeopardize the survival of the graft as seen in the multisystem trauma patient. This study describes a series of patients with complex scalp injuries treated with rotational advancement flaps and negative pressure assisted skin grafting. The literature is replete with articles describing the efficacy of negative pressure dressings to treat wounds and assist in the survivability of skin grafts. The articles described wounds of the extremities, chest, abdominal, and other regions. Treatment of scalp defects with negative pressure dressing, however, has not been reported, and this study is the first of its kind. Materials and Methods: This is a retrospective review of all the patients treated from 2007 to 2008 for extensive scalp injuries. The patients were treated with advancement rotational flaps and skin grafting. A negative pressure dressing was used in all the patients to help in decreasing the size of the defect and immobilize the skin grafts. All the patients were monitored closely for wound infection, dehiscence, and graft survival. Results: All the patients had excellent graft intake with 100% survival. There were no major complications associated with this technique. However, in one patient, a small pressure leak was noted during the early postoperative period and was addressed by additional reinforcement. 117
POSTER 080 Pericranial Flap Use in Reconstruction of Traumatic Cranial Injuries M. Juliana DiPasquale, DMD, University of Florida Jacksonville, Oral and Maxillofacial Surgery, 653-1 West 8 Street, Jacksonville, FL 32209 (Fattahi T) Background: The use of pericranial flaps in reconstructive surgery goes as far back as the 1800s. Due to its reliable vascular supply and low morbidity it has been used in a vast number of specialties including Oral and Maxillofacial Surgery, Otorhinolaryngology, Plastic Surgery, Craniofacial Surgery, Ophthalmology, and Neurosurgery. Published uses of the pericranial flap include facial soft tissue augmentation, reconstruction of soft tissue defects, reconstruction of nasal septum and audi116
tory canal defects, coverage of bone grafts, reconstruction of defects due to cancer ablation of the head and neck, reconstruction of the cranial base secondary to trauma or cancer surgery and repair of CSF leaks. The pericranial flap has a rich vascular blood supply which is based on the deep branches of the supraorbital artery and supratrochlear artery. The flap is composed of pericranium and loose areolar tissue, which are the two deepest layers of the soft tissue scalp and directly overly the skull. Complication rates associated with the pericranial flap are low and published cases include flap necrosis (secondary to radiation therapy) and flap hypertrophy leading to mass effect and neurological deficits (3 reported cases). Methods: Patients who suffered face and head trauma resulting in fracture of the frontal sinus who met criteria for surgical intervention underwent repair of the dural tear (if present) and obliteration of the frontal sinus using a pericranial flap. A bi-temporal scalp flap is elevated in a sub-galeal plane and maintained 1cm superior to the supraorbital ridge in order to protect the vascular supply. The pericranial flap is then designed and elevated free from the cranium. If desired, the pericranial flap can be divided at the midline between the vascular pedicles for ease of manipulation and adaptation. Results: From December 2002 until December 2007 at UF/Shands Jacksonville, 9 patients underwent repair of frontal sinus fractures and obliteration with pericranial flap. The mean age of the subjects was 38 years of age (range 23-65). Eight patients were males and one was a female. Mechanism of injury involved 2 GSW, 2 assaults with a baseball bat, 3 MVC, 1 MCC, and 1 fall. Mean follow up period was 78 days (range 9 to 160 days). Three patients required concomitant neurosurgical intervention for repair of dural tears. Of those three subjects, two experienced CSF leak pre-operatively. Only one patient required additional surgical intervention due to presence of CSF leak one month post-operatively. This patient was found to have a dural tear extending into the middle cranial fossa and decision was made to allow the tear to heal secondarily due to difficult access. The patient developed chronic CSF leak and was later taken to the operating room for endoscopic transsphenoidal dural repair, which was successful. One patient experienced minor complications such as stitch abscess and temporary temporal branch weakness, which resolved with minimal intervention. No complications were directly related to the use of the pericranial flap (flap necrosis, flap hypertrophy). Complications such as mucoceles, mucopyeloceles, cosmetic defect, meningitis, dural or brain abscesses did not occur. Conclusions: The use of the pericranial flap in trauma surgery for reconstruction of the cranial base and frontal sinus, and repair of CSF leaks is very efficacious, associated with no additional morbidity and low complication rate. An additional donor site is not necessary and the AAOMS • 2008
Scientific Poster Session risk of increased complications associated with alloplastic materials is avoided. References Yoshioka N, Rhoton AL. Vascular Anatomy Of The Anteriorly Based Pericranial Flap. Operative Neurosurgery. 57:11-15, 2005 Price JC, Loury M, Carson B, Johns ME. The pericranial flap for reconstruction of anterior skull base defects. Laryngoscope. 98:11591164, 1988 Kiyokawa K, Tai Y, Tanabe HY, Inoue Y, Hayakawa K, Shigemori M, tokudomi T. A surgical method for treating anterior skull base injuries. Journal of Cranio-Maxillofacial Surgery. 27:11-19, 1999
POSTER 081 Surgical Treatment of Mandibular Angle Fractures Using Intraoral Approach and Fixation With 1 Noncompression Miniplate: Clinical and Radiographic Study Idelmo R. Garcia Junior, DDS, MDS, PhD, Avenida da Saudade, 200, Aracatuba-SP, 16025-140, Brazil (MagroErnica N; Magro-Filho O) The aim of this study was to evaluate the results in patients treated for mandibular angle fractures with a single miniplate. Twenty one patients with 22 mandibular angle fractures were treated by open reduction and internal fixation using one noncompression miniplate positioned along the mandible oblique line with 2.0 mm self-threading screws placed through an intraoral incision. No patient was placed into postoperative intermaxilar fixation. All patients were operated by the Oral and Maxillofacial Surgery Division from the School of Dentistry of Aracatuba, Sao Paulo State University – UNESP, Brazil, during a 31 months period. The study had the UNESP Ethical Committee of Research approval and every patient was given a participation explanation and a consent form to sign for being part of the study group. They were prospectively studied for complications by clinical and radiographic evaluation by the same oral surgeon. Follow-up ranged from 6 to 44 months, with a mean of 15 months and 1 day. Complications occurred in 3 patients (14.3%). One patient (4.8%) presented postoperative infection, one (4.8%) malocclusion, and one (4.8%) sensory disturbance – hyperesthesia in the region of the retained miniplate. The only case requiring a further surgical intervention under general anesthesia was the infection case. Thus, results allowed concluding that the fixation method was suitable for treatment of simple mandibular angle fractures, the presence of only one noncompression miniplate did not interfere on the post-operative complication rate, and the method avoided postoperative intermaxillary fixation. AAOMS • 2008
References Ellis III E: Treatment methods for fractures of mandibular angle. Int J Oral Maxillofac Surg 28:243, 1999 Ellis III E, Walker LR: Treatment of mandibular angle fractures using one noncompression miniplate. J Oral Maxillofac Surg 54:864, 1996 Potter J, Ellis III E: Treatment of mandibular angle fractures with a malleable noncompression miniplate. J Oral Maxillofac Surg 57:88, 1999
POSTER 082 Management of Complex Avulsive Scalp Injuries With Vacuum-Assisted Skin Grafting Shannon K. O’Keefe, DDS, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MSc 7908, San Antonio, TX 78229 (Gutta R) Purpose: Management of extensive traumatic avulsive scalp defects is challenging. These injuries could be partial thickness or full thickness along with involvement of the outer cranial cortex. These defects might also result from cancer resection. Scalp defects are usually treated by local tissue transfer, rotational flaps, distant flaps, vascularized free flaps, and healing by secondary intention. Occasionally these defects are also treated with skin grafting as a primary modality or as a secondary procedure to cover residual defects. Skin grafting to the scalp often poses unique challenges. The shape of the head might cause dependent edema. Occasional shearing forces with prolonged supine positioning could jeopardize the survival of the graft as seen in the multisystem trauma patient. This study describes a series of patients with complex scalp injuries treated with rotational advancement flaps and negative pressure assisted skin grafting. The literature is replete with articles describing the efficacy of negative pressure dressings to treat wounds and assist in the survivability of skin grafts. The articles described wounds of the extremities, chest, abdominal, and other regions. Treatment of scalp defects with negative pressure dressing, however, has not been reported, and this study is the first of its kind. Materials and Methods: This is a retrospective review of all the patients treated from 2007 to 2008 for extensive scalp injuries. The patients were treated with advancement rotational flaps and skin grafting. A negative pressure dressing was used in all the patients to help in decreasing the size of the defect and immobilize the skin grafts. All the patients were monitored closely for wound infection, dehiscence, and graft survival. Results: All the patients had excellent graft intake with 100% survival. There were no major complications associated with this technique. However, in one patient, a small pressure leak was noted during the early postoperative period and was addressed by additional reinforcement. 117