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Wound healing considerations in chemotherapy and radiation therapy
J Oral MaxillofacSurg 53:857-863, 1995
Abstracts The Sandwich Zygomatic Osteotomy: Technique, Indications and Clinical Results. Mommaerts MY, Abeloos JVS,
blood supply. Alternatives for management of the condyle include, auto transplantation, replication by shaping the free flap, and creation of a gap. Osseointegrated implants can help to further refine the reconstruction.--R.H. HAUG
De Clercq CAS, et al. J Craniomaxillofac Surg 23:12, 1995 The classical approach to lateral midface hypoplasia is reconstruction with onlays. This article describes an osteottroy technique whereby the zygomatic body is luxated laterally and ventrally, with stabilization achieved by the wiring of an interpositional hydroxylapatite block, via the intraoral approach. Twenty patients treated between September 1990 and December 1992 were studied to assess outcome and complication rates. Follow-up with clinical assessment, photographs, and three-plane cephalograms varied from 12 to 37 months postoperatively. Case selection was based on the presence of anterolateral malar deficiency, although 17 patients required other surgical techniques to correct their facial deformity. Clinical results were deemed excellent. Complications included fractured hydroxylapatite block leading to acute sinusitis, infraorbital nerve hypoesthesia and orbital ecchymosis. No masticatory or mimetic problems were encountered. Superiority of the zygomatic osteotomy technique is emphasised where problems of donor site morbidity of autografts and asymmetry, malpositioning and extrusion of allografts were avoided.--M. MAN/SALt
Reprint request to Dr Cordeiro: Plastic and Reconstructive Surgery Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, C-1189, New York, N Y 10021.
Wound Healing Considerations in Chemotherapy and Radiation Therapy. Drake DB, Oishi SN. Clin Plast Surg 22:31, 1995 The process by which wounds heal has been the subject of research for several centuries, and various factors have been implicated in retarding the organism's ability to heal. Wounds heal in three phases: inflammation, proliferation, and maturation. At the microscopic level, radiation injury causes both stasis and occlusion of small blood vessels. Fibroblasts are altered permanently, collagen production becomes deficient, and the cellular response to wounding becomes inadequate. Keratinocytes, melanocytes, epithelial appendages, and hair follicles may be damaged. The safe dose for preoperative radiotherapy has not been determined. Too much radiation retards healing. Radiation therapy given 1 week postoperatively has no detectable clinical effects on wound healing or tensile strength. Chronically irradiated tissues have impaired proliferative capabilities of the endothelial, mesenchymal, and epithelial cells. In addition, decreased vascularity, hypoxia, and increased susceptibility to bacterial invasion result. Surgery in previously irradiated tissues must be planned carefully. Brachytherapy initiated 5 or more days after surgery seems to reduce the incidence of complications associated with wound healing. Various classes of chemotherapy have different effects on individual cells, although most are active at the DNA level. In general, the drug dose correlates directly with the effect on wound healing. These agents should not be given in the 2 weeks preceding surgery or 'within 1 week postsurgery. The administration of chemotherapy causes neutropenia and affects wound healing by reducing the monocyte count and thus collagen production control over fibroplasia.--R.H. HAUG
Reprint requests to Dr Mommaerts: Division of Maxillo-Facial Surgery, A Z. St.-Jan, Ruddershove 10, Belgium-8000, Brugge.
Conceptual Considerations in Mandibular Reconstruction. Cordeiro PG, Hidalgo DA. Clin Plast Surg 22:61, 1995 The ability to reliably transfer well-vascularized skin, muscle, and bone to re-establish mandibular contour at the time of resection has made immediate reconstruction the preferred approach. If the resected ends are allowed to float free after resection, then soft tissue scarfing, fibrosis, and contractures develop which create esthetic deformities and functional deficits. The primary goals of mandibular reconstruction are to achieve primary wound closure and restore form and function. Careful preoperative planning is the key to a successful mandibular reconstruction after oncologic resection. The clinical examination, imaging evaluation, stage of the disease, and status of the vasculature are important to assess preoperatively. Intraoperatively, the twoteam concept permits resection, harvesting, and reconstruction in a timely fashion. Nonvascularized bone grafts and reconstruction plates, with and without soft tissue coverage, are less than ideal. The development of rnicrovascular surgery into a highly reliable technique for transferring tissue has revolutionized the approach to mandibular reconstruction. The vascularized osteocutaneous flap is the best reconstructive option for the majority of mandibular defects. Because of the small amount of bone available, the radial forearm fasciocutaneous is rarely indicated for mandibular reconstruction. The free ilium, although capable of providing quality and quantity of bone, is difficult to shape. The free scapula tends to be too thin to accept osseointegrated implants. The free fibula appears to be best suited for mandibular reconstruction because of its uniform shape, capabilities for precision shaping, quantity of bone available, and profuse
Reprint requests to Dr Drake: Division of Plastic Surgery, Kentucky Clinic, Suite K454, 740 South Limestone, Lexington, KY 405360284.
The Difficult Scalp and Skull Wound. Oishi SN, Luce EA. Clin Plast Surg 22:51, 1995. In the management of scalp and skull defects, an interplay of a number of circumstances often pose unique and challenging problems for the reconstructive surgeon. These defects can be divided into two groups: immediate reconstruction after extirpation, and wound closure of complications caused by tumor treatment. The entire scalp is attached to the skull by loose areolar tissue, except at the neurovascular pedicles. Yet, it is taut with little flexibility and redundancy. The principle layers of the scalp include the skin, galea, and loose avascular plane above the adherent periosteum. The
857
Abstracts The Sandwich Zygomatic Osteotomy: Technique, Indications and Clinical Results. Mommaerts MY, Abeloos JVS,
blood supply. Alternatives for management of the condyle include, auto transplantation, replication by shaping the free flap, and creation of a gap. Osseointegrated implants can help to further refine the reconstruction.--R.H. HAUG
De Clercq CAS, et al. J Craniomaxillofac Surg 23:12, 1995 The classical approach to lateral midface hypoplasia is reconstruction with onlays. This article describes an osteottroy technique whereby the zygomatic body is luxated laterally and ventrally, with stabilization achieved by the wiring of an interpositional hydroxylapatite block, via the intraoral approach. Twenty patients treated between September 1990 and December 1992 were studied to assess outcome and complication rates. Follow-up with clinical assessment, photographs, and three-plane cephalograms varied from 12 to 37 months postoperatively. Case selection was based on the presence of anterolateral malar deficiency, although 17 patients required other surgical techniques to correct their facial deformity. Clinical results were deemed excellent. Complications included fractured hydroxylapatite block leading to acute sinusitis, infraorbital nerve hypoesthesia and orbital ecchymosis. No masticatory or mimetic problems were encountered. Superiority of the zygomatic osteotomy technique is emphasised where problems of donor site morbidity of autografts and asymmetry, malpositioning and extrusion of allografts were avoided.--M. MAN/SALt
Reprint request to Dr Cordeiro: Plastic and Reconstructive Surgery Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, C-1189, New York, N Y 10021.
Wound Healing Considerations in Chemotherapy and Radiation Therapy. Drake DB, Oishi SN. Clin Plast Surg 22:31, 1995 The process by which wounds heal has been the subject of research for several centuries, and various factors have been implicated in retarding the organism's ability to heal. Wounds heal in three phases: inflammation, proliferation, and maturation. At the microscopic level, radiation injury causes both stasis and occlusion of small blood vessels. Fibroblasts are altered permanently, collagen production becomes deficient, and the cellular response to wounding becomes inadequate. Keratinocytes, melanocytes, epithelial appendages, and hair follicles may be damaged. The safe dose for preoperative radiotherapy has not been determined. Too much radiation retards healing. Radiation therapy given 1 week postoperatively has no detectable clinical effects on wound healing or tensile strength. Chronically irradiated tissues have impaired proliferative capabilities of the endothelial, mesenchymal, and epithelial cells. In addition, decreased vascularity, hypoxia, and increased susceptibility to bacterial invasion result. Surgery in previously irradiated tissues must be planned carefully. Brachytherapy initiated 5 or more days after surgery seems to reduce the incidence of complications associated with wound healing. Various classes of chemotherapy have different effects on individual cells, although most are active at the DNA level. In general, the drug dose correlates directly with the effect on wound healing. These agents should not be given in the 2 weeks preceding surgery or 'within 1 week postsurgery. The administration of chemotherapy causes neutropenia and affects wound healing by reducing the monocyte count and thus collagen production control over fibroplasia.--R.H. HAUG
Reprint requests to Dr Mommaerts: Division of Maxillo-Facial Surgery, A Z. St.-Jan, Ruddershove 10, Belgium-8000, Brugge.
Conceptual Considerations in Mandibular Reconstruction. Cordeiro PG, Hidalgo DA. Clin Plast Surg 22:61, 1995 The ability to reliably transfer well-vascularized skin, muscle, and bone to re-establish mandibular contour at the time of resection has made immediate reconstruction the preferred approach. If the resected ends are allowed to float free after resection, then soft tissue scarfing, fibrosis, and contractures develop which create esthetic deformities and functional deficits. The primary goals of mandibular reconstruction are to achieve primary wound closure and restore form and function. Careful preoperative planning is the key to a successful mandibular reconstruction after oncologic resection. The clinical examination, imaging evaluation, stage of the disease, and status of the vasculature are important to assess preoperatively. Intraoperatively, the twoteam concept permits resection, harvesting, and reconstruction in a timely fashion. Nonvascularized bone grafts and reconstruction plates, with and without soft tissue coverage, are less than ideal. The development of rnicrovascular surgery into a highly reliable technique for transferring tissue has revolutionized the approach to mandibular reconstruction. The vascularized osteocutaneous flap is the best reconstructive option for the majority of mandibular defects. Because of the small amount of bone available, the radial forearm fasciocutaneous is rarely indicated for mandibular reconstruction. The free ilium, although capable of providing quality and quantity of bone, is difficult to shape. The free scapula tends to be too thin to accept osseointegrated implants. The free fibula appears to be best suited for mandibular reconstruction because of its uniform shape, capabilities for precision shaping, quantity of bone available, and profuse
Reprint requests to Dr Drake: Division of Plastic Surgery, Kentucky Clinic, Suite K454, 740 South Limestone, Lexington, KY 405360284.
The Difficult Scalp and Skull Wound. Oishi SN, Luce EA. Clin Plast Surg 22:51, 1995. In the management of scalp and skull defects, an interplay of a number of circumstances often pose unique and challenging problems for the reconstructive surgeon. These defects can be divided into two groups: immediate reconstruction after extirpation, and wound closure of complications caused by tumor treatment. The entire scalp is attached to the skull by loose areolar tissue, except at the neurovascular pedicles. Yet, it is taut with little flexibility and redundancy. The principle layers of the scalp include the skin, galea, and loose avascular plane above the adherent periosteum. The
857