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Purpose: The aim of this study was to review and describe techniques for the reconstruction of large, complex perioral defects after resection of oral squamous cell carcinoma with emphasis on cosmetic and functional outcome., Patients and Methods: A review of techniques and selected case presentations using different flap designs for the reconstruction of large perioral defects following resection of squamous cell carcinoma was performed. The Bernard and Karapandzic flaps were used for large lower lip defects. A Zisser flap technique was used to reconstruct a large commissure defect., Results: All reconstructed patients had acceptable functional results and healed without complication. The large lower lip defects were easily closed with the Bernard and Karapandzic flaps. The commissure defect was reconstructed using the Zisser technique. While cosmesis was acceptable in all cases, the commissure was the most difficult region to reconstruct with a favorable appearance. There were no flap failures. The Karapandzic flap led to greater rounding of the commissure area and the composite resection resulted in a lack of lower lip support that was improved with prosthesis. Function was noted to be excellent in the Bernard and Karapandzic flaps, with the patients able to purse lips and blow up balloon-type devices., Conclusion: The Bernard, Karapandzic, and Zisser flaps provide a predictable method to reconstruct large perioral defects following resection for oral cancer. Subsequent fabrication of a prosthesis can aid in lip support for the resected area.

Purpose: Lingual nerve damage following lower third molar surgery remains a clinical problem. The traditional approach in the United States has been a buccal approach avoiding exposure or surgery on the lingual side of the crest of the ridge. An alternative technique is to deliberately expose the lingual tissues and retract the lingual nerve lingually before tooth removal. This study reports a trial of this technique., Materials and Methods: Patients had removal of their lower third molars carried out using a technique that raises a lingual flap in addition to a buccal flap and places a specially designed lingual retractor to ensure that the lingual nerve is held out of the surgical field. This technique was used in cases where the crown of the tooth had to be sectioned or when distal bone needed to be removed., Results: Two hundred fifty patients were treated by this method. There were 4 cases of transient lingual paresthesia, presumably caused by traction pressure from the retractor. Three of these cases were mild and resolved within 3 weeks. The fourth case had more profound paresthesia, but still resolved within 2 months. There were no cases of permanent nerve damage, and in many cases removal of the third molar was simplified by the superior access., Conclusion: Lingual retraction for third molar removal improves access to the surgical site and can simplify third molar removal. In this prospective study there were no cases of permanent lingual nerve injury.

Background: Functional restoration following resection or traumatic injury to the mandible depends on the reliability of the bony reconstruction to heal primarily and support endosseous implants. Although vascularized bone flaps (VBF) and nonvascularized bone grafts (NVBG) are both widely used to reconstruct the mandible, indications for each remain ill-defined. The purpose of this study was to compare bone graft/flap healing and success of implant placement in patients reconstructed with VBF versus NVBG., Methods: Over the past 10 years, 75 consecutive mandibular reconstructions were performed (26 free bone grafts, 49 vascularized bone flaps). Etiology of the defect, history of irradiation, bone defect size, number of operations, graft/flap success, and dental implant success rates were determined and compared. Bone graft/flap success was defined as complete bony union. Implant success was defined as complete osseointegration. Mean follow-up was 3 years., Results: Free flaps were used primarily for malignant disease (78%, 38/49). Bone grafts were used primarily for benign disease (88%, 23/26). History of prior irradiation: 11% (3/26) NVBG versus 45% (22/49) VBF. Length of bony defect (mean): 8.1 cm NVBG versus 9.4 cm VBF. Successful bony union, any size defect: 69% (18/26) NVBG versus 96% (47/49) VBF (p < .0005); lateral defects only: 75% (15/20) NVBG versus 100% (17/17) VBF (p < .05). Number of operations to achieve bony union (mean), any size defect: 2.3 NVBG versus 1.1 VBF (p < .001); lateral defects only: 1.9 NVBG versus 1.0 VBF (p < .005). Twenty-two patients (29%) had a total of 104 endosseous implants placed (NVBG: 8 patients, 33 implants; VBF: 14 patients, 71 implants). Immediate implants placed: 0/33 NVBG versus 54% (38/71) VBF. Overall implant success: 82% (27/33) NVBG versus 99% (70/71) VBF (p < .0001). Implant success in VBF patients with a history of RT: 100% (15/15)., Conclusions: Despite the fact that patients reconstructed with VBFs were older, had larger defects, and were treated primarily for malignant disease and therefore had a higher incidence of irradiation to the affected mandible than in patients treated with NVBGs, the incidence of bony union was higher, requiring fewer operations to achieve union, and the implant success rate was significantly greater than for NVBG patients. Results were similar when considering lateral defects only. Based on these results, VBFs are indicated in most cases of mandibular reconstruction; NVBGs are effective for short bone defects (<5-6 cm), in nonirradiated tissue, and/or in patients determined to be too medically compromised to tolerate the additional operative time required for a free-flap reconstruction.

Purpose: The purpose of this study was to determine the efficacy of vascularized free fibula bone grafts for mandibular salvage reconstruction., Patients and Methods: Seven patients had fibula grafts after failed attempts at mandibular reconstruction. The prior attempts involved 20 operative procedures. Four of the seven patients (57%) had a history of radiation to the affected mandible. Bony defects averaged 10.2 cm (range, 4.5 to 24 cm), and the associated soft tissue defects averaged 6 x 12 cm. Average follow-up was 16 months. Cosmetic (facial symmetry) and functional (speech quality, oral continence, deglutition, donor site morbidity, dental rehabilitation) results were evaluated by questionnaire and clinical examinations., Results: Soft tissue coverage and mandibular restoration were successful in all patients, and flap survival was 100%. Five of the seven patients (70%) achieved good or excellent functional results, and five of seven (70%) achieved good or excellent esthetic results. Complications were minimal, and the average hospital stay was 14 days., Conclusions: When the initial attempt at mandibular reconstruction is unsuccessful, mandibular function and esthetics can be salvaged with reliable vascularized soft tissue and bone flaps. As long as appropriate flap options are considered and the patient is medically stable, successful mandibular reconstruction should be achievable despite the number or cause of prior failed attempts.

Modern treatment of complex midfacial defects has evolved over the past 5 years, primarily with the advent of reliable vascularized bone flaps and osseointegrated implants. To determine the effectiveness of these advances, 26 consecutive patients with complex midfacial defects treated from 1991 through 1995 with immediate muscle-flap coverage were evaluated. The etiology of the defect included neoplasm (n = 23) and trauma (n = 3). Seventy-eight percent of the patients received adjuvant radiation therapy. Follow-up ranged from 3 months to 4 years, with a mean of 18 months. Twenty-three patients (88 percent) were reconstructed with a single major procedure. All patients had free-flap reconstruction, and 100 percent of the flaps survived. Late tumor recurrence was seen in 5 of 23 patients (22 percent) and was detected promptly. Aesthetic and functional results were rated good or excellent in 77 and 88 percent of the patients, respectively, as determined by patient questionnaires and physical examinations. Fourteen of 18 patients (78 percent) undergoing partial or complete alveolar ridge resection received dental rehabilitation, 43 percent of whom received osseointegrated implants into either a bone flap or remaining native bone. Osseointegrated implants were inset during the initial reconstruction 50 percent of the time. A treatment algorithm for free-flap selection based on the size of the defect and the bony requirement for reconstruction is presented. Bony restoration is only required in those areas where osseointegrated implants need to be placed. In such cases, the fibula osteocutaneous free flap is the flap of choice. Otherwise, soft-tissue flaps are selected based on wound size. Immediate free-flap coverage provides effective, single-stage treatment, both aesthetically and functionally, for complex midfacial defects.

The purpose of this study was to determine the role of the fibular free flap in reconstructing lateral segmental defects of the mandible. Over the past 5 1/2 years, 17 consecutive patients underwent reconstruction of their lateral mandible with the fibular free flap. Patients included 12 men and 5 women, the mean age was 54 years (range, 29-76 years), and the mean length of the mandibular defect was 6.3 cm (range, 2.5-9 cm). The majority of patients with tumors (54%) were treated for recurrence and 92% received radiation to the operative field. The mean operative time to perform the microsurgery and bone plating was 4 hours. Postoperative morbidity occurred in 3 patients (18%) (plate fracture, malocclusion, orocutaneous fistula). Five patients (29%) required leg donor site skin grafting. Donor site morbidity included a minor cellulitis, a transient neuropraxia, and one case of leg swelling. None required additional surgery for donor complications. Thus far, 71% of the patients have received dental rehabilitation and 35% had osseointegrated implants placed in their bone flap. Eighty-two percent of the patients achieved both good or excellent aesthetic and functional results. Sixteen patients (94%) tolerate at least a soft diet and 65% are on a regular diet. Five patients developed tumor recurrence an average of 9 months postoperatively with a mean survival of 21 months. This study demonstrates that the fibular free flap is highly reliable for reconstructing the lateral mandible in a single stage, with low overall morbidity, and provides for excellent dental and speech rehabilitation. For most patients, the fibular free flap should be considered for lateral mandibular reconstruction even in those patients with a limited life expectancy.

Objective: To establish a treatment algorithm for reconstructing complex midfacial defects., Design: Retrospective case series., Setting: University-based teaching hospital., Patients: Thirty-one consecutive patients were treated from 1991 through 1995. The 18 males and 13 females were aged 15 to 90 years (mean age, 58 years). The cause of the defect included neoplasm (n = 27) and trauma (n = 4). Reconstruction consisted of 1 of 4 free flaps: rectus abdominis, radial forearm, fibula, or latissimus dorsi. Aesthetic and functional results were determined by patient questionnaires and physical examinations., Main Outcome Measures: Length of stay, postoperative morbidity and mortality, degree of aesthetic and functional restoration, and detection of tumor recurrence., Results: Twenty-seven (87%) of the 31 patients underwent reconstruction with a single major procedure. All of the flaps survived. Postoperative hospital stays averaged 14 days. Late tumor recurrence occurred in 7 (23%) of the 31 patients and was promptly detected. Aesthetic and functional results were rated good or excellent in 77% (24/31) and 87% (27/31) of patients, respectively. Of the 20 patients who underwent alveolar ridge resection, 16 (80%) received dental rehabilitation, 44% of whom received osseointegrated implants into either a bone flap or remaining native bone. Osseointegrated implants were inset during the initial reconstruction 57% (4/7 patients) of the time., Conclusions: For complex midfacial defects, free-flap transfer can be performed with a high degree of success, restoring both appearance and function in most patients. The only instance in which bone is necessary to reconstruct the midface involves those areas in which osseointegrated implants are needed, ie, alveolar ridge (dental implant) and/or orbit (ocular prosthesis). In such cases, the fibula osteocutaneous free flap is the flap of choice. Otherwise, soft-tissue flaps are selected based on wound size.

Refinements in microsurgical techniques, plate fixation, and osseointegration have changed the conceptual approach to midface reconstruction. Free tissue transfer has emerged as the ideal method of reconstructing complex midfacial defects. Single-stage bony restoration of the palate and orbital rim using the folded fibular osteocutaneous free flap is described. The fibular free flap is our first choice for reconstructing complex midfacial defects. The thin, soft, pliable tissue is ideal for intraoral and palatal reconstructions. The bone can be tailored precisely to fit any desired shape, and forms a sturdy support for both orbital and dental prostheses. With a single flap, rapid and reliable restoration of midfacial appearance, orbital support, and palatal function can be achieved.

Temporalis muscle/fascia axial flaps (TFs) were used in 115 temporomandibular joints (TMJs) in 81 patients to correct ankylosis (n = 25 joints), traumatic defects (n = 8), congenital anomalies (n = 4), defects resulting from tumor resection (n = 2), degenerative joint disease (n = 52), autoimmune arthritides (n = 21), and lateral capsule flaccidity (n = 3). The follow-up period ranged from 6 months to 5.5 years. Seven patients (8.6% of the group; 10 TMJs) were reevaluated for recurrent symptoms (pain and decreased motion), with a mean of 1.7 years (range = 1 to 3 years) postoperatively. Four of these patients (seven TMJs) had magnetic resonance imaging (MRI) as part of their diagnostic workup and four patients (five TMJs) required a second operative procedure. This study reports the results of the MRI, intraoperative, and histologic evaluations of the TFs in these seven patients. The MRIs showed vascularized tissue between the condyle and roof of the glenoid fossa in all seven joints examined. The signal was consistent with muscle and/or fat as opposed to scar tissue. All flaps examined at the time of surgery (arthroscopy, n = 1; arthrotomy, n = 4) were in place and had the gross appearance of normal muscle. Histologic examination of biopsies of four flaps indicated the presence of viable muscle with normal-appearing nuclei. The results of this study indicate that the TF does survive when it is carefully dissected and inferiorly based to preserve blood supply.

The bicoronal scalp flap provides an excellent approach to the temporomandibular joint, particularly in cases where bilateral operation is required. It is also indicated when wide exposure is required and when previous surgery may make more conventional techniques difficult. In this report, the anatomy and indications for this approach are reviewed, the operative technique is described and complications are discussed.

Temporalis fascia, with a varying thickness of temporalis muscle, may be harvested as an axial flap based on the middle and deep temporal arteries and veins. The dependable blood supply, the proximity to the temporomandibular joint, and the ability to alter the arc of rotation by basing the flap inferiorly or posteriorly make this a versatile flap for lining the temporomandibular joint. In this report, the anatomy is reviewed, the harvesting technique is described, and multiple uses of the temporalis muscle-fascia flap in temporomandibular joint surgery are described.