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Total upper lip reconstruction using a free radial forearm flap incorporating the brachioradialis muscle: Report of a case
J Oral Maxillofac 45:959-962,
Surg
1987
Total Upper Lip Reconstruction Using a Free Radial Forearm Flap Incorporating the Brachioradialis Muscle: Report of a Case KAZUAKI TAKADA,
DDS,* TATSUMI SUGATA, DDS,* KOJI YOSHIGA, YOSHIHIRO MIYAMOTO, MDt
reconstructed by a free radial forearm flap incorporating the brachioradialis muscle to focus its advan-
Full-thickness defects of the upper lip can be closed by suturing the wound edges together, transposition of a local flap, or use of a cross-lip or fanshaped flap from the immediate area. In extensive defects when regional flaps are not applicable, flaps from distant parts can be used. Classic distant flaps give poor cosmetic and functional results because of the unfavorable match of color and texture, bulkiness of the reconstructed lip, and lack of muscle function as a sphincter. We report a case of an extensive upper lip defect
tages.
Report of a Case A 60-year-old female visited our clinic with a complaint of a tumor in the upper lip mucosa. She has been treated for rheumatoid arthritis for over 20 years. The tumor had invaded the entire upper lip and the anterior part of maxilla (Fig. 1). An enlarged right submandibular lymph node fixed to the surrounding tissue was palpable. Radiographs showed a poorly demarcated radiolucency of the maxilla extending from the right second premolar to the left first premolar (Fig. 2). A biopsy revealed the lesion to be a mucoepidermoid tumor of high grade malignacy; stage IV (T,N,M,). Systemic chemotherapy (bleomycin; total 75 mg) and Yo irradiation (total 30 Gy) were given in advance of surgery. Wide resection of the tumor, including the whole upper lip, the lower parts of collumela and ala. the nasal floor, and the anterior part of the maxilla extending from the right second premolar to the left first premolar was car-
Received from the *Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, and the ‘Department of Orthopedic Surgery, Faculty of Medicine, Hiroshima University, Hiroshima, Japan. Address correspondence and reprint requests to Dr. Takada: Hiroshima University School of Dentistry, Department of Oral and Maxillofacial Surgery I, Hiroshima 734, Japan. 0278-2391167 $0.00 + .25
FIGURE I : Preoperative ance; B, oral view.
photographs
DDS,* AND
of a 60-year-old female with mucoepidermoid
959
tumor of the upper lip mucosa. A, frontal appear-
960
UPPERLIPRECONSTRUCTION
FIGURE 2 (?op kfi).Preoperative to the left first premolar.
radiograph shows a poorly demarcated radiolucency
of the maxilla from the right second premolar
FIGURE 3 (fop right). Defect following wide resection of the tumor, including the whole upper lip, lower parts of collumela and ala, the anterior part of the maxilla, and the nasal floor. FIGURE 4 (bottom). A, the 7.5 x 9 cm skin paddle of the radial forearm flap outlined on the right forearm. B, the flap at time of transfer. The vascular pedicle consists of the radial artery, the commitant veins, and the cephalic vein. The length of the vascular pedicles is 5 cm long proximally and 7 cm long distally. The flap was elevated incorporating the brachioradialis muscle. ried out. A right radical
neck dissection was done with the sublingual artery and external jugular vein preserved as recipient vessels (Fig. 3). A 7.5 x 9 cm radial forearm flap was designed on the right forearm (Fig. 4A). The vascular pedicle consisted of the radial artery, the commitant
veins, and the cephalic vein. The flap was elevated, incorporating the brachioradialis muscle. The vascular pedicle was 5 cm long proximally and 7 cm long distally (Fig. 4B). The donor defect in the forearm was closed with a free skin graft. The flap was folded along the long axis of
Ea&ial artery ngual artery xt6mnial juqlar vein
FIGURE 5. procedure.
A, the flap grafted to the upper lip defect with the vascular anastomoses
carried out. B, Schematic representation
of the
961
TAKADA ET AL.
”
Upper lip
25QF.iV -_I lsec FIGURE 6. (I&). Patient holding a glass syringe with her reconstructed illustrate function of the reconstructed sphincter.
lip to
FIGURE 7. (right). Electromyographic study two years after surgery shows the synchronized movement of the reconstructed upper lip and the lower lip when they were pursed. The amplitude and frequency of the muscle action potentials indicate a good functional recovery.
the vascular pedicle and grafted over the upper lip defect and the anterior maxilla. The base of columella, the remaining ala, and the nasal septum were sutured to the partially de-epithelized flap. Both ends of brachioradialis muscle were sutured to the inferior orbicularis oris muscle. The proximal end of radial artery of flap was anastomosed to the right sublingual artery (Fig. 5). The veinae comitantes of the radial artery and cephalic vein
were connected to the external jugular vein, using a 9 cm long Y-shaped vein graft, as the vein length was inadequate. The nerve branch to the brachioradialis muscle was sutured to the right buccal branch of the facial nerve. The flap survived without any problem. Deep sensation was felt in its margin three months after surgery and in the entire flap after four months. At follow-up after
FIGURE 8. Postoperative appearances of patient.
years, electromyographic study showed the synchronizing movement of the reconstructed upper lip and the lower lip when the lips were pursed (Fig. 6). The amplitude and frequency of the muscle action potentials indicated a good functional recovery (Fig. 7). Speech was nearly normal and the patient did not have any problem eating. There were no signs of local reccurence or metastasis (Fig. 8).
two
Discussion The forearm flap was developed in China in 1978 by Yang et al. and first reported by Yang and Gao’ and Shaw* in 1981. This flap has been reported
962
MIDDLE EAR INJURY FROM TMJ ARTHROSCOPY
useful in head and neck reconstruction.3-6 Because the venae comitantes are too small to secure proper venous drainage, drainage of the flap was achieved by using both the venae comitantes of the radial artery and the cephalic vein. These vascular pedicles are constant in their size and position. The long vascular pedicle and constant large vascular caliber make anastomosis easy to the recipient vessels of the neck (e.g., the sublingual or the suprathyroid artery and the external jugular vein). The skin and subcutaneous tissue of the forearm flap are thin and pliable. The brachioradialis muscle is nourished by many muscle branches from the radial artery, and the volume is suitable for reconstruction of the orbicularis oris muscle. These anatomic characteristics provide much advantage in using the forearm flap for one-stage reconstruction of the upper lip as a sphincter.
with excellent functional and cosmetic results. The free radial forearm flap, including the vascularized and innervated brachioradialis muscle, has a very wide potential for reconstruction of the lip defects due to carcinoma.
References 1. Yang G, Gao Y: Forearm free skin flap transplantation. Chin Med Assoc 61: 139, 1981
J
2. Shaw WWL: Microvascular reconstruction of the nose. Clin Plast Surg 8:471, 1981 3. Miihlbauer W, Herndl E, Stock W: The forearm flap. Plast Reconstr Surg 70:336, 1982 4. Soutar DS, Scheker LR, Tanner NSB, et al: The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 36:1, 1983
Summary
5. Soutar DS, MacGregor IA: The radial forearm flap in intraoral reconstruction: the experience of 60 consecutive cases. Plast Reconstr Surg 78: 1, 1986
One-stage reconstruction of the upper lip using a free radial forearm flap was successfully performed
6. Harii K, Ebihara S, Ono I, et al: Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg 75:463, 1985
J Oral Maxillofac 45:962-965,
Surg
1987
Middle Ear Injury Resulting from Temporomandibular Joint Arthroscopy JOSEPH E. VAN SICKELS, DDS,* GARY J. NISHIOKA, DMD,t MARK D. HEGEWALD, MD,+ AND G. DAVID NEAL, MD5
Arthroscopy of the temporomandibular joint (TMJ) for diagnosis and treatment of TM disorders is a relatively new addition to the armamentarium of the oral and maxillofacial surgeon. As with any new surgical procedure, complications may arise. After initially being described by Ohnishi’ in 1975, Received from the Department of Oral and Maxillofacial Surgery and the Department of Otorhinolaryngology, University of Texas Health Sciences Center, San Antonio, Texas. * Associate Professor, Department of Oral and Maxillofacial Surgery. t Resident, Department of Oral and Maxillofacial Surgery. $ Resident, Department of Otorhinolaryngology. B Assistant Professor, Department of Otorhinolaryngology. Address correspondence and reprint requests to Dr. Van Sickels: Department of Oral and Maxillofacial Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78284-7908. 0278-2391187 $0.00 + .25
an increasing number of articles on TMJ arthroscopy have been published;2-23 however, few have addressed complications. The purpose of this report is two-fold: 1) to review the literature on complications associated with TMJ arthroscopy, and 2) to describe an unusual complication in which the tympanic membrane was lacerated and ossicular disruption in the middle ear occurred with subsequent hearing loss. A discussion of the prevention and management of this complication is also presented. Anatomy and Review of Literature Based on the regional anatomy of the TMJ, a number of potential complications could occur with TMJ arthroscopy. These include infection; bleeding from injury to the superficial temporal vessels, in-
Surg
1987
Total Upper Lip Reconstruction Using a Free Radial Forearm Flap Incorporating the Brachioradialis Muscle: Report of a Case KAZUAKI TAKADA,
DDS,* TATSUMI SUGATA, DDS,* KOJI YOSHIGA, YOSHIHIRO MIYAMOTO, MDt
reconstructed by a free radial forearm flap incorporating the brachioradialis muscle to focus its advan-
Full-thickness defects of the upper lip can be closed by suturing the wound edges together, transposition of a local flap, or use of a cross-lip or fanshaped flap from the immediate area. In extensive defects when regional flaps are not applicable, flaps from distant parts can be used. Classic distant flaps give poor cosmetic and functional results because of the unfavorable match of color and texture, bulkiness of the reconstructed lip, and lack of muscle function as a sphincter. We report a case of an extensive upper lip defect
tages.
Report of a Case A 60-year-old female visited our clinic with a complaint of a tumor in the upper lip mucosa. She has been treated for rheumatoid arthritis for over 20 years. The tumor had invaded the entire upper lip and the anterior part of maxilla (Fig. 1). An enlarged right submandibular lymph node fixed to the surrounding tissue was palpable. Radiographs showed a poorly demarcated radiolucency of the maxilla extending from the right second premolar to the left first premolar (Fig. 2). A biopsy revealed the lesion to be a mucoepidermoid tumor of high grade malignacy; stage IV (T,N,M,). Systemic chemotherapy (bleomycin; total 75 mg) and Yo irradiation (total 30 Gy) were given in advance of surgery. Wide resection of the tumor, including the whole upper lip, the lower parts of collumela and ala. the nasal floor, and the anterior part of the maxilla extending from the right second premolar to the left first premolar was car-
Received from the *Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, and the ‘Department of Orthopedic Surgery, Faculty of Medicine, Hiroshima University, Hiroshima, Japan. Address correspondence and reprint requests to Dr. Takada: Hiroshima University School of Dentistry, Department of Oral and Maxillofacial Surgery I, Hiroshima 734, Japan. 0278-2391167 $0.00 + .25
FIGURE I : Preoperative ance; B, oral view.
photographs
DDS,* AND
of a 60-year-old female with mucoepidermoid
959
tumor of the upper lip mucosa. A, frontal appear-
960
UPPERLIPRECONSTRUCTION
FIGURE 2 (?op kfi).Preoperative to the left first premolar.
radiograph shows a poorly demarcated radiolucency
of the maxilla from the right second premolar
FIGURE 3 (fop right). Defect following wide resection of the tumor, including the whole upper lip, lower parts of collumela and ala, the anterior part of the maxilla, and the nasal floor. FIGURE 4 (bottom). A, the 7.5 x 9 cm skin paddle of the radial forearm flap outlined on the right forearm. B, the flap at time of transfer. The vascular pedicle consists of the radial artery, the commitant veins, and the cephalic vein. The length of the vascular pedicles is 5 cm long proximally and 7 cm long distally. The flap was elevated incorporating the brachioradialis muscle. ried out. A right radical
neck dissection was done with the sublingual artery and external jugular vein preserved as recipient vessels (Fig. 3). A 7.5 x 9 cm radial forearm flap was designed on the right forearm (Fig. 4A). The vascular pedicle consisted of the radial artery, the commitant
veins, and the cephalic vein. The flap was elevated, incorporating the brachioradialis muscle. The vascular pedicle was 5 cm long proximally and 7 cm long distally (Fig. 4B). The donor defect in the forearm was closed with a free skin graft. The flap was folded along the long axis of
Ea&ial artery ngual artery xt6mnial juqlar vein
FIGURE 5. procedure.
A, the flap grafted to the upper lip defect with the vascular anastomoses
carried out. B, Schematic representation
of the
961
TAKADA ET AL.
”
Upper lip
25QF.iV -_I lsec FIGURE 6. (I&). Patient holding a glass syringe with her reconstructed illustrate function of the reconstructed sphincter.
lip to
FIGURE 7. (right). Electromyographic study two years after surgery shows the synchronized movement of the reconstructed upper lip and the lower lip when they were pursed. The amplitude and frequency of the muscle action potentials indicate a good functional recovery.
the vascular pedicle and grafted over the upper lip defect and the anterior maxilla. The base of columella, the remaining ala, and the nasal septum were sutured to the partially de-epithelized flap. Both ends of brachioradialis muscle were sutured to the inferior orbicularis oris muscle. The proximal end of radial artery of flap was anastomosed to the right sublingual artery (Fig. 5). The veinae comitantes of the radial artery and cephalic vein
were connected to the external jugular vein, using a 9 cm long Y-shaped vein graft, as the vein length was inadequate. The nerve branch to the brachioradialis muscle was sutured to the right buccal branch of the facial nerve. The flap survived without any problem. Deep sensation was felt in its margin three months after surgery and in the entire flap after four months. At follow-up after
FIGURE 8. Postoperative appearances of patient.
years, electromyographic study showed the synchronizing movement of the reconstructed upper lip and the lower lip when the lips were pursed (Fig. 6). The amplitude and frequency of the muscle action potentials indicated a good functional recovery (Fig. 7). Speech was nearly normal and the patient did not have any problem eating. There were no signs of local reccurence or metastasis (Fig. 8).
two
Discussion The forearm flap was developed in China in 1978 by Yang et al. and first reported by Yang and Gao’ and Shaw* in 1981. This flap has been reported
962
MIDDLE EAR INJURY FROM TMJ ARTHROSCOPY
useful in head and neck reconstruction.3-6 Because the venae comitantes are too small to secure proper venous drainage, drainage of the flap was achieved by using both the venae comitantes of the radial artery and the cephalic vein. These vascular pedicles are constant in their size and position. The long vascular pedicle and constant large vascular caliber make anastomosis easy to the recipient vessels of the neck (e.g., the sublingual or the suprathyroid artery and the external jugular vein). The skin and subcutaneous tissue of the forearm flap are thin and pliable. The brachioradialis muscle is nourished by many muscle branches from the radial artery, and the volume is suitable for reconstruction of the orbicularis oris muscle. These anatomic characteristics provide much advantage in using the forearm flap for one-stage reconstruction of the upper lip as a sphincter.
with excellent functional and cosmetic results. The free radial forearm flap, including the vascularized and innervated brachioradialis muscle, has a very wide potential for reconstruction of the lip defects due to carcinoma.
References 1. Yang G, Gao Y: Forearm free skin flap transplantation. Chin Med Assoc 61: 139, 1981
J
2. Shaw WWL: Microvascular reconstruction of the nose. Clin Plast Surg 8:471, 1981 3. Miihlbauer W, Herndl E, Stock W: The forearm flap. Plast Reconstr Surg 70:336, 1982 4. Soutar DS, Scheker LR, Tanner NSB, et al: The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 36:1, 1983
Summary
5. Soutar DS, MacGregor IA: The radial forearm flap in intraoral reconstruction: the experience of 60 consecutive cases. Plast Reconstr Surg 78: 1, 1986
One-stage reconstruction of the upper lip using a free radial forearm flap was successfully performed
6. Harii K, Ebihara S, Ono I, et al: Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg 75:463, 1985
J Oral Maxillofac 45:962-965,
Surg
1987
Middle Ear Injury Resulting from Temporomandibular Joint Arthroscopy JOSEPH E. VAN SICKELS, DDS,* GARY J. NISHIOKA, DMD,t MARK D. HEGEWALD, MD,+ AND G. DAVID NEAL, MD5
Arthroscopy of the temporomandibular joint (TMJ) for diagnosis and treatment of TM disorders is a relatively new addition to the armamentarium of the oral and maxillofacial surgeon. As with any new surgical procedure, complications may arise. After initially being described by Ohnishi’ in 1975, Received from the Department of Oral and Maxillofacial Surgery and the Department of Otorhinolaryngology, University of Texas Health Sciences Center, San Antonio, Texas. * Associate Professor, Department of Oral and Maxillofacial Surgery. t Resident, Department of Oral and Maxillofacial Surgery. $ Resident, Department of Otorhinolaryngology. B Assistant Professor, Department of Otorhinolaryngology. Address correspondence and reprint requests to Dr. Van Sickels: Department of Oral and Maxillofacial Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78284-7908. 0278-2391187 $0.00 + .25
an increasing number of articles on TMJ arthroscopy have been published;2-23 however, few have addressed complications. The purpose of this report is two-fold: 1) to review the literature on complications associated with TMJ arthroscopy, and 2) to describe an unusual complication in which the tympanic membrane was lacerated and ossicular disruption in the middle ear occurred with subsequent hearing loss. A discussion of the prevention and management of this complication is also presented. Anatomy and Review of Literature Based on the regional anatomy of the TMJ, a number of potential complications could occur with TMJ arthroscopy. These include infection; bleeding from injury to the superficial temporal vessels, in-