Associate Professor, Philadelphia College of Osteopathic Medicine
The inferior incision is through mucosa and muscle only preserving the vessels and developing a mucosal island flap virus 800000cb discount fucidin 10 gm overnight delivery. The flap is mobilised into the neck and transposed to the floor of mouth/tongue via a tunnel created by sectioning the mylohyoid muscle from the lingual mandible antibiotics effect on sperm buy fucidin 10gm online. Anatomical basis and results of the facial artery musculomucosal flap for oral reconstruction virus living or nonliving cheap fucidin online amex. Surgical treatment of non-traumatic lower lip lesions with special reference to the step technique infection 10 buy generic fucidin 10gm. Oncologic aspects of vermilionectomy in microinvasive squamous cell carcinoma of the lower lip. Recreate the muscular commissure with obicularis from the upper and lower lip sutured with a large nonresorbable suture to avoid drooling. Section the lingual periosteum low down to allow better access to the floor of the mouth cancer close to , but not involving, the mandibular lingual plate. Use a haemostatic suture full thickness for bleeding from the palatine artery that retracts into the palatal tissue. Use bone wax for bleeding from the greater palatine artery that has retracted into the bony foramen. Although lateral tongue defects can be closed primarily, when they are close to or involve the floor of the mouth, a flap reconstruction will prevent tethering and allow better function. In the tongue, it is the deep margin which is most deceptive and the worst site to have a recurrence, usually resecting more muscle than you might think is better. A similar approach is required for the resection of bone invaded by malignant salivary tumours, but the points on the patterns of tumour invasion and entry may be different. The principles of the resection techniques may be appropriate to the management of odontogenic tumours, especially if these are recurrent. Resection of the jaws for osteoradionecrosis or osteonecrosis is more of a debridement requiring the resection of bone back to a bleeding base prior to reconstruction. Bone resection for osteosarcoma or primary intraosseous carcinoma requires a more radical removal of bone as the tumour will invade the bone preferentially. It is important to understand the articulation with the rest of the skeleton in tumour resection. Medially, the lateral nasal wall is the least important structure, but care is required in maintaining the lacrimal system. The frontal process of the maxilla and the nasal bones articulate with the frontal bone and immediately behind these structures is the ethmoid sinus and then the sphenoid sinus. The cranium lies directly above these bones and experience in skull base resections is required to safely resect these structures. The lamina papyracea of the medial wall often requires resection and care must be taken to identify the anterior ethmoidal artery in particular. Although there are often attempts to preserve this nerve in the treatment of benign disease, the loss of sensation to the lip and chin is an acceptable morbidity for most patients. The relationship of the teeth to the bone varies with patients and the molars run from a buccal position to a more lingual position posteriorly. The temporomandibular joint articulates with the skull base and in some cases the condylar head may require resection. The inferior alveolar nerve will come to lie on the alveolar ridge and the relationship of the floor of mouth muscle insertions will alter with the loss of bone (Figure 4. In the dentate mandible, this tends to be at the junction of the attached and reflected mucosa and in the edentulous mandible this is more likely at the crest of the ridge due to the lowering of the floor of the mouth due to the loss of teeth. These are important issues if a marginal or more conservative resection of the mandible is being considered. This figure illustrates the method used to enter the floor of the mouth deep to the tumour to obtain a clear margin, even though the bone is not invaded. The more infiltrative pattern is related to deeper invasion in which the connective tissue layer is lost and separate islands of tumour infiltrate in a less favourable manner. It is not possible to predict the pattern of invasion, so the judgement on how much bone to resect remains clinical and based on imaging. Various theories of the route of tumour entry to the mandible have been suggested, but it seems most likely There are multiple papers looking at pre-operative imaging techniques and their accuracy in predicting the presence of tumour invasion of the mandible. A recent review article has summarized the findings which are included in Table 4. This will usually provide 5-mm slices and will include T1, T2 and fat suppression sequences, as well as gadolinium enhancement. The fat suppression sequence is the most sensitive in indicating tumour invasion of the mandible. The only additional image would be an orthopantomogram if there is clear invasion of the mandible or in which the mandible is unlikely to be invaded. The combination of an image with a high specificity with one with a high sensitivity can provide a reasonably accurate prediction of the extent of mandibular invasion and therefore the most appropriate method of resection. As a result, a guide to mandibular resection has been published which relates to the size of the mandible and the results of the investigations predicting bone invasion (Table 4. As in all oncological surgery, the aim is to cure the patient of disease through adequate resection. At the same time, the skilled surgeon should be trying to reduce the morbidity of the operation to a minimum and maintain the best possible function. Good functional results for patients depend more on the tissue left behind than the method of reconstruction. In the marginal or rim resection, the integrity of the lower or upper border of the mandible is kept intact (Figure 4.
The grafted site should be allowed to heal and consolidate for four to six months prior to implant placement antibiotics eye drops purchase fucidin mastercard. Maxillary sinus grafting Maxillary sinus grafting was first described in the 1970s antibiotic long term side effects buy generic fucidin canada, but its success has improved since then antibiotic resistant kennel cough purchase genuine fucidin. The alveolus in the edentulous posterior maxilla is often occupied by a large pneumatized maxillary antrum virus journal 10gm fucidin with mastercard, resulting in a vertical deficiency in bone. Grafting the floor of the sinus increases the vertical dimension of bone available for successful implant placement. Until recently, this has been performed with simultaneous placement of the implants if there was at least 5 mm of native bone height to provide primary stability for the implant, but if there was less than 5 mm of bone height, implant placement was deferred to a second procedure four to six months following the sinus graft. However, recent literature reports successful implant placement in as little as 1 mm of native bone height, provided there is adequate width (8 mm or more). In these situations, some surgeons will use corticocancellous blocks mortized into the floor of the sinus to provide more stability for the implants. Patients with sinusitis or sinus disease should be referred for appropriate management before grafting. Access to the sinus is performed through a Caldwell Luc window in the lateral wall of the sinus. The initial mucosal 92 Adjunctive office-based techniques for bone augmentation in oral implantology: An American perspective incision may be placed in the vestibule, although this may increase the likelihood of oroantral fistula formation in the event of wound dehiscence. This may be avoided by utilizing a crestal or sulcular incision away from the bony window. The superior osteotomy is placed inferior to the infraorbital nerve at the level of the planned graft height, while the inferior osteotomy should lie approximately 3 mm above the floor of the sinus so as to avoid the multiple septations and recesses often encountered along the sinus floor, which make completing the osteotomy and infracturing the bony window problematic. The bony window is created using a diamond bur or a piezosurgery tip to minimize the chance of Schneiderian membrane perforation. Small perforations (less than 3 mm) are inconsequential, but larger perforations should be covered with a resorbable membrane after elevation of the lining and prior to insertion of the graft. Once the bony widow is created and the sinus lining is visible around the periphery, sinus curettes are used to carefully mobilize and elevate the Schneiderian membrane with the oval piece of bone from the window still attached. Once mobilized, the membrane and bony window is turned into the sinus such that the bony segment now becomes the new elevated sinus floor. The space beneath the elevated bony segment and the lining is filled with bone or substitute graft material (Figure 2. The volume of the graft placed should allow for 20 per cent resorption prior to implant placement. Autogenous bone remains the gold standard graft material, but this may be mixed with or even substituted with allogenic bone with good success. To close the site, a resorbable membrane is placed over the bony window and the mucoperiostial flap is sutured with non-resorbable sutures which are left in place for 2 weeks. These are especially important if the sinus lining was perforated, and should include no nose blowing, or sucking through straws for at least 3 weeks. Alveolar bone splitting/spreading Osteotomies along the alveolar crest may be performed in the maxilla and the mandible in order to increase the width of the alveolus (Figure 2. The pre-operative preparation is the same as other grafting procedure outlined above; however, the flap dissection is different. To maintain blood supply to the osteotomized inner and outer segments, the periostium is left attached to the bone. This is achieved by a crestal or vestibular incision as previously described, and a supraperiostial dissection of the labial or buccal mucosal flap. The crestal osteotomy may be made with a saw, a small fissure bur or a piezosurgery tip. The vertical osteotomies may be carried through both inner and outer cortical plates if expansion of both plates is desired. Alternatively, the vertical cut may be through only the buccal/labial cortex if lingual expansion is not required. The vertical osteotomies sinus access window osteotome infractured window bone graft elevated sinus lining greenstick fracture split thickness flap no periosteum 2. Once the osteotomies are made, osteotomes are driven into the crestal cut and the cortical plate(s) are pedicled on the overlying periostium. The intervening space may then be implanted or grafted with bone or substitute graft materials. The segments and intervening graft may be stabilized using miniplates or screws for immobilization during the healing phase. In addition, many surgeons will cover the site with a resorbable membrane prior to suturing with a non-resorbable suture. The principle is osteogenesis as the alveolar segment is gradually moved in a coronal direction, thereby generating greater bone height. Each device has an anchorage and an active component and is operated by a transmucosal element (usually a screw). Therefore, if a 10-mm vertical increase is desired, this can be accomplished in as little as 10 days. The active phase is then followed by a consolidation phase, during which time the distraction is maintained for 12 weeks, allowing the callous to ossify and gain stability. Once adequate bone has been exposed to allow placement of the distraction device, the device is fixated in position using screws, with careful consideration towards the desired vector of movement, and the osteotomies are marked with the device in place. The osteotomies strive to establish a block of alveolus pedicled on the palatal or lingual mucoperiostium, and is free of mechanical interference that may prevent transposition (Figure 2. This is achieved by two vertical osteotomies that are connected by a horizontal apical osteotomy. The osteotomy may be made with a saw, a small fissure bur or a piezosurgery tip, and passes through both inner and outer cortical plates.
This allows no interruption of flow through the artery once this anastomosis is complete bacteria jokes purchase genuine fucidin online. It may be that the heparin prevents fibrin degradation products in the previously ischaemic tissue virus definition best purchase for fucidin, setting off the clotting cascade Division of the pedicle Final dissection of the proximal pedicle should be undertaken and the artery and vein divided and ligated bacteria kingdom classification best 10gm fucidin. The transversalis and parts of the iliacus are sutured into these holes with a round body needled 1 or 1/0 nylon suture antibiotics for bladder infection nitrofurantoin quality fucidin 10 gm. It is recommended to temporarily hold the sutures with an artery clip until all the sutures have been placed before tying the knots. After the flap is running, the internal oblique muscle is sutured into the intraoral defect. Some muscle trimming may be required but, although the flap may appear very bulky at this stage, it is likely to shrink back in a matter of weeks and certainly after radiotherapy. Violation of the thin transversalis muscle to produce herniation of pre-peritoneal fat is always a possibility but can be closed. Snagging of the pedicle with a rotary instrument is possible and potentially disastrous; use of these instruments should be minimized in this operation! For venous monitoring, the colour of the flap, which will obviously appear dark if engorged, is useful. Stabbing the muscle may be useful, bright red blood should flow rapidly and if individual muscle fibres can be seen it probably signifies the flap is not working. A Doppler probe sutured around the flap side of the venous anastomosis may also be helpful. None of these methods is 100 per cent reliable, and it is fair to say this is a difficult flap to monitor. Local anaesthetic can be infused through the epidural catheter to aid in analgesia. A very good aesthetic result can be achieved with this method of reconstruction (Figures 3. Note multiple osteotomies and internal oblique muscle prior to suturing into position. Further reading 241 Top tips Always ensure enough muscle is harvested in mandibular defects. Where pedicle length is likely to be an issue (usually maxillary cases) use the smallest amount of bone harvested as far back along the iliac crest as possible, to lengthen the pedicle. Do not underestimate the time, complex nature and importance of carefully closing the donor site defect. In some quarters, this flap has acquired a reputation for medium- and long-term morbidity, both of which can nearly always be avoided by attention to detail! Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate reconstruction of maxillectomy defect. The free vascularised iliac crest tissue transfer: donor site complications associated with 82 cases. Deep Circumflex iliac perforator flap with iliac crest for mandibular reconstruction. The free iliac crest and fibula flaps in vascularized oromandibular reconstruction: comparison and long term evaluation. The internal oblique-iliac crest osseomyocutaneous microvascular free flap in head and neck reconstruction. Post-operative Loss of flap perfusion and venous drainage are particular problems in maxillary reconstruction. Partial necrosis of the internal oblique muscle may occur, but is not usually a problem as granulation over vital bone will resolve this. Partial bone necrosis can be more of a problem and is of course more likely to occur with small distal segments of osteotomized bone. Seromas may occur, probably as a result of damage to the external iliac lymphatics. Post-operative infection, particularly associated with the internal oblique mesh, can be very troublesome and may even require removal of the mesh. It is advisable to handle this material carefully and apply topical antiseptics to the mesh bed and mesh itself to reduce this. Incisional hernia is always possible if the layers of the donor site are not closed with care. Numbness to the anterior thigh due to damage to the lateral cutaneous nerve may be troublesome to some patients. Acquired long standing facial paralysis most frequently results from neurosurgical or otolaryngological interventions for intracranial tumours as central palsy, but may as well occur after ablation of malignant parotid tumours as peripheral palsy. Facial reanimation encompasses surgical measures that support or restore facial movement in cases of facial nerve palsies. In contrast to static reconstructions, such as suspension plasties to raise the oral commissure or lateral canthopexy to alleviate the sequelae of orbicularis oculi muscle palsy, these procedures allow for active movement of facial muscles either by supporting existing muscular activity or by transferring neuromuscular units from adjacent or distant sites to the deficient area. As voluntary and involuntary facial movement is accomplished by 18 separate muscles that are unique in the way they produce individual facial expression, even dynamic functional reconstruction using revascularized transfer of neuromuscular units cannot fully restore symmetry in unilateral facial palsy. However, functionally and aesthetically most disturbing deficits, such as the inability to raise the oral commissure to achieve oral continence or to close the eyelids to protect the globe, can be repaired. As the facial nerve is the only cranial nerve that spontaneously produces impulses during facial expression, it is considered as the source of choice for neurotization. The hypoglossal nerve and the motor nerve supply to the masseter muscle have also been used as a source of innervation to a muscle graft, but could not achieve the degree of symmetry that the facial nerve provides.
Individualization of exenteration cases should take into account the location bacteria are examples of buy fucidin cheap online, size and aggressiveness of the pathology antibiotics with pseudomonas coverage discount fucidin master card, as well as the reconstruction plan antibiotic with a c order fucidin with a visa. If the bones of the orbit are involved with malignancy antibiotics to treat sinus infection generic 10gm fucidin amex, bone resection should be performed at the time of initial orbitotomy, even if that procedure is not an exenteration. If the entire eyelid anatomy is to be preserved, the operation is similar to an extended enucleation in which the eye with the bulbar conjunctival lining and the other orbital tissues are removed en bloc (Figure 4. The intraocular extension of the tumour produces proptosis and conjuctival ecchemosis. Medially, it lies on the anterior lacrimal crest and laterally it passes close to the outer canthus. On the nasal wall of the orbit, the periosteum must be raised gently, because the orbital plate of the ethmoid is very fragile and a sinus may result if the ethmoid air cells are opened. When the underlying soft tissues have been reached the incision is continued, usually with the use of unipolar cautery with a fine needle tip (a Colorado tip). The periorbita is best incised a few millimetres outside the orbit, rather than on the orbital margin, as the blade of the knife can then be used perpendicularly to the bone (Figure 4. Although the periorbita here is firmly adhered to the bone, it is thick and does not tear when raised. When the periosteum of the orbital rim is reached, it is elevated and the dissection is swiftly continued beyond the rim into the orbit, to complete the procedure as quickly as possible (Figure 4. In the region of the anterior lacrimal crest, the lacrimal sac is reflected laterally with the orbital contents when the periosteum is separated from the nasal wall. The nasolacrimal duct is identified as the dissection proceeds from the nasal wall to the floor of the orbit. Ligation of the duct prevents ascending infection from the nose and prevents blood running down into the nasopharynx. During dissection, bleeding is ignored unless haemorrhage is so profuse that it interferes with the view of the surgical field. Laterally, the temporal and malar branches of the lacrimal artery enter the malar bone and medially the anterior ethmoidal artery passes from the orbit into the anterior ethmoidal foramen. These vessels are exposed and are clamped and coagulated with diathermy to avoid bleeding in the depths of the wound. When the soft tissue dissection is complete, haemostasis with cautery is achieved (Figure 4. When the dissection toward the apex is completed, the apical bundle of soft tissues, including extraocular muscles, blood vessels and nerves, is reached. The bundle is approached from its nasal aspect, a strong curved haemostat Extended exenteration with resection of the osseous orbit 331 is placed and the pedicle is cut with unipolar cautery or a curved pair of scissors above the haemostat. The same manoeuvre is repeated laterally and inferiorly to free the apex from orbital soft tissues. The bleeding sources of the apex (ophthalmic artery and vein) should be identified, clamped and tied after the removal of the bulk of the soft tissues (Figure 4. Excessive application of electrocautery at the apex may create damage in the proximal portion of the optic nerve, which may extend into the optic chiasm. During orbital exenteration, most of the bleeding originates from the supraorbital and infraorbital vessels, the anterior and posterior ethmoidal arteries and the ophthalmic artery when the dissection reaches the apex. Although the posterior bleeding is the most significant, it is easier to control, since by the time the apex of the orbit is reached, all soft tissues have been freed and there is better visibility (Figure 4. After removal of the orbital contents it may be possible to apply clamps behind those previously used to reduce the size of the stump by the removal of more tissue. If there is any diseased bone it is chiselled away, cutting (a) periorbital trochlea (b) orbital contents (c) (d) continued 4. In most areas of the orbit, it is preferable to score the bone with an oscillating saw along the predetermined limits of resection and then fracture the bone en bloc with a strong rongeur. In some sites, a sharp osteotome and a mallet may be needed to remove pathologic bone (Figure 4. The conventional treatment of the sinonasal malignancies with orbital extension is maxillectomy with orbital exenteration. The anatomy of the area and the separation of the orbital cavity from the ethmoids by the lamina papyracea favours the invasion of tumour into the orbit (see also Chapter 4. There are four grades of orbital involvement through the paranasal sinuses: (1) tumour adjacent to the orbit, without infiltration of the orbital wall; (2) tumour eroding the orbital wall without ocular bulb displacement; (3) tumour eroding and infiltrating the orbital wall, displacing the orbital content, without periorbital involvement; (4) tumour invading the orbit with periorbital invasion. In cases of obvious bony orbital tumour involvement, the orbit with the adjacent An essential part of the decision-making process is reconstruction and rehabilitation of the exenterated orbital socket. A decision should be made pre-operatively whether the patient will wear a patch or a prosthesis. Primary surgical closure of the orbital cavity is advantageous with respect to both function and aesthetic outcome, and makes early post-operative radiotherapy possible. The primary goal of reconstruction is the restoration of boundaries between the orbit and surrounding cavities and an acceptable aesthetic outcome. When the eyelids are entirely removed, the free skin margin is tacked to the orbital rim with interrupted silk sutures and the socket is lined with antibiotic-soaked vaseline or Xeroform gauze. By the time granulation is complete, the orbit is covered with a very thin epithelium, which has the advantage of allowing the detection of recurrent tumour at an early stage. The resulting cavity is deep, but can be fitted with a silicone oculofacial prosthesis. The need for regular dressing changes must be weighed against the potential benefits of healing by secondary intention.
