Search

Summary: Reconstructive requirements of medium to large sized oral mucosal defects following oncological resection include restoration of mucosal continuity with prevention of salivary leak and fistula formation, predictable soft tissue healing, and ensuring optimal oral function and cosmetic restoration. Such defects frequently mandate the use of microvascular free tissue transfer of fasciocutaneous flaps such as the radial forearm or anterolateral thigh flaps, or, for larger defects incorporating significant dead-space, muscle flaps such as rectus abdominis or latissimus dorsi. Commonly described techniques for re-establishing continuity of the epithelial component include using native mucosa, split skin graft, or a myocutaneous flap skin paddle. Few case series reports exist of non-epithelial reconstructive approaches. Here, the authors report a large series of muscle only flaps for oral defect reconstruction following oncologic resection. The current study demonstrates that mucosalised muscle is an effective additional method for intra-oral mucosal defect reconstruction. [Copyright &y& Elsevier]

Summary: Small-medium pharyngo-oesophageal or peri-tracheostoma defects represent a difficult reconstructive problem. Previous solutions included locoregional options such as the deltopectoral flap, or microvascular free tissue transfer. The authors present a novel application of the internal mammary artery perforator (IMAP) flap for reconstructing such defects. The IMAP flap may be mapped using pre-operative Doppler or CTA, and is raised on a single perforator. The relatively quick and simple flap raise provides robust fasciocutaneous tissue, may be tunneled subcutaneously to reach the neck and yields an inconspicuous donor site. The authors provide several cases demonstrating applications of the IMAP flap for reconstructing small-medium sized defects following release of annular pharyngoesophageal stricture, and studies documenting post-operative swallow. Overall, the pedicled IMAP fasciocutaneous flap is a useful technique to provide excellent composite tissue to reconstruct defects resulting from release of annular pharyngeal strictures. It is technically simple, and yields an inconspicuous anterior chest donor site. [Copyright &y& Elsevier]

Background: Autologous reconstruction with the deep inferior epigastric artery (DIEA) perforator (DIEP) flap is increasingly utilized for breast reconstruction. However, situations arise in which the DIEP flap is not an appropriate option, including the presence of a midline abdominal scar or an inadequate volume of abdominal tissue. While other donor sites may be considered, the stacked DIEP flap, in which the perforators of both hemi-abdominal walls are utilized in a single vascular pedicle, provides a safe technique to utilize the integument of both hemi-abdominal walls. Methods: Five consecutive patients underwent a stacked DIEP flap for breast reconstruction. Preoperative imaging with computed tomographic angiography (CTA) of the abdominal wall was undertaken, with each DIEA, its branching pattern, and all musculocutaneous perforating branches mapped using three-dimensional software reconstructions. The anatomical basis, operative technique and outcomes are discussed. Results: In all cases, CTA was able to demonstrate individual vascular anatomy, and guide planning for a stacked DIEP flap. Unique anatomy between individuals required a range of variations in flap anatomy, with the contralateral DIEA, SIEA, or perforators each used to perfuse the contralateral hemi-abdominal wall. There was a 100% flap survival, with no donor site morbidity reported. Conclusion: The stacked DIEP flap is a safe and reliable technique for augmenting the perfusion of the abdominal wall in cases where the single pedicle DIEP flap is limited. The anatomical basis of the flap can be planned preoperatively with CTA, facilitating faster operating times and good outcomes. [ABSTRACT FROM AUTHOR]

Background: While autologous breast reconstruction is frequently sought, donor sites providing versatility in volume with low donor site morbidity other than the abdominal wall are limited. Gluteal artery perforator flaps have been described in this role, however variations in individual vascular anatomy have resulted in the difficult planning of flaps, and particularly selection of whether superior or inferior gluteal artery perforators should be utilized. Methods: Five consecutive patients underwent a gluteal artery perforator flap for breast reconstruction. Preoperative imaging of the gluteal artery vasculature was undertaken with computed tomographic angiography (CTA). Both superior and inferior gluteal artery perforators were mapped on imaging, and the dominant system selected preoperatively. The anatomical basis, operative technique and outcomes are discussed. Results: In all cases, CTA was able to demonstrate individual vascular anatomy, and select the optimal perforators supplying the gluteal integument. Either a superior gluteal artery perforator (SGAP) or inferior gluteal artery perforator (IGAP) flap was planned, and undertaken successfully in each case. There was a 100% flap survival, with low donor site morbidity. Conclusion: With the use of preoperative planning, selection of either an SGAP or IGAP flap can be reliably made based on individual vascular anatomy. With low donor site morbidity and good aesthetic outcomes, gluteal artery perforator flaps are a good option in cases where the abdominal wall is not appropriate. [ABSTRACT FROM AUTHOR]

Purpose: The nerve to masseter has long been used as a recipient to innervate free muscle flaps for facial nerve reconstruction in adults and children alike. This presentation demonstrates the effectiveness and utility of the masseter nerve to directly re-innervate the native muscles forming a natural smile in an elderly population. Methodology: Twelve patients aged 40 to 92 years underwent facial nerve resection for malignant disease. There were 11 immediate and one delayed reconstructions utilising the masseter nerve for reconstruction of the smile. The nerve to masseter was dissected and transposed to achieve a direct neurorrhaphy to the nerve to zygomaticus major without the necessity of a nerve graft. Results: The earliest movement of the commissure of the mouth was detected at 10 weeks postoperatively. All patients reviewed at 6 months showed dynamic movement and were graded cosmetically as either good or excellent. Conclusion: This is a fast, simple and reliable technique which achieves good cosmetic outcomes for facial reanimation in an elderly population and dispels the myth that dynamic reanimation of the smile is not achievable in patients over 50 years old. [ABSTRACT FROM AUTHOR]

Purpose: Free muscle microvascular transfer has been the preferred procedure for reanimation of the face in young patients with facial palsy. Historically, the use of the contralateral facial nerve via a cross facial nerve graft has been the chosen method for innervation. However, this usually involves a two-stage procedure, precludes treatment of patients with bilateral facial paralysis and has had variable results with symmetry, tone and strength of voluntary movements. The unreliability of result has been greater in older patients. The nerve to masseter has been successfully shown to provide a reliable alternative for use in facial reanimation with both free muscle transfer and direct nerve transfer to the facial nerve. We present the results of cases using the nerve to masseter in both middle-aged adult and paediatric free gracilis transfer and also with direct innervation with the facial nerve in the elderly. Methodology: Nine patients with facial nerve paralysis underwent reanimation surgery utilising the nerve to masseter. Three adult and three paediatric patients received free gracilis muscle transfer. Three other elderly patients underwent transfer of the ipsilateral masseteric nerve to facial nerve through direct coaptation. Results: All patients have been able to good movement post-operatively with the earliest contractions noted at one month post surgery. All patients had significant movement by three months post surgery. A number of patients have also been able to achieve some amount of spontaneous movement. Conclusions: The nerve to masseter provides a highly reliable source of innervation for free muscle transfers and direct nerve transfer in older adults and children. [ABSTRACT FROM AUTHOR]