Sinking skin flap syndrome with delayed dysautonomic syndrome - An atypical presentation

INTRODUCTION Sinking skin flap syndrome or syndrome of the trephined is a rare complication after a large craniectomy, with a sunken skin above the bone defect with neurological symptoms such as severe headache, mental changes, focal deficits, or seizures. PRESENTATION OF CASE We report a case of 21 years old man with trefinated syndrome showing delayed dysautonomic changes. DISCUSSION Our patient had a large bone flap defect and a VP shunt that constitute risk factors to develop this syndrome. Also, there is reabsorption of bone tissue while it is placed in subcutaneous tissue. The principal symptoms of sinking skin flap syndrome are severe headache, mental changes, focal deficits, or seizures. Our patient presented with a delayed dysautonomic syndrome, with signs and symptoms very characteristics. Only few cases of this syndrome were related in literature and none were presented with dysautonomic syndrome. CONCLUSION We reported here a very uncommon case of sinking skill flap syndrome that causes a severe dysautonomic syndrome and worsening the patient condition. © 2013 The Authors.

Implantes do sistema T. F. (Tissue functional) em alvéolos imediatamente após exodontia com e sem membrana de osso bovino: estudo histológico em cães

Pós-graduação em Odontologia - FOA

Open-Flap Versus Flapless Esthetic Crown Lengthening: 12-Month Clinical Outcomes of a Randomized Controlled Clinical Trial

Background: Excessive gingival display (EGD) has a negative impact on a pleasant smile. Minimally invasive therapeutic modalities have become the standard treatment in many dentistry fields. Therefore, the aim of this study is to compare the clinical outcomes of open-flap (OF) and minimally invasive flapless (FL) esthetic crown lengthening (ECL) for the treatment of EGD.Methods: A split-mouth randomized controlled trial was conducted in 28 patients presenting with EGD. Contralateral quadrants received ECL using OF or FL techniques. Clinical parameters were evaluated at baseline and 3, 6, and 12 months post-surgery. The local levels of receptor activator of nuclear factor-kappa B ligand (RANKL) and osteoprotegerin (OPG) were assessed by enzyme-linked immunosorbent assay at baseline and 3 months. Patients' perceptions regarding morbidity and esthetic appearance were also evaluated. Periodontal tissue dimensions were obtained by computed tomography at baseline and correlated with the changes in the gingival margin (GM).Results: Patients reported low morbidity and high satisfaction with esthetic appearance for both procedures (P > 0.05). RANKL and OPG concentrations were increased in the OF group at 3 months (P < 0.05). Probing depths were reduced for both groups at all time points, compared with baseline (P < 0.05). There were no differences between groups for GM reduction at any time point (P > 0.05).Conclusions: FL and OF surgeries produced stable and similar clinical results up to 12 months. FL ECL may be a predictable alternative approach for the treatment of EGD.

Subepithelial connective tissue graft: a case report

Introduction and objective: Marginal tissue recession represents a common condition in Periodontology. Miller's Classes I and II recessions, in which the etiological factors are well diagnosed and eliminated, show great predictability of total coverage when the technique of subepithelial connective tissue graft is used. This technique success has been mainly attributed to the double blood supply for graft's nutrition, originating from the connective tissue of both the periosteum and flap. Case report and conclusion: The authors reported a clinical case in which a Miller's Class I recession was treated by the surgical technique of subepithelial connective tissue graft, obtaining total coverage, eliminating the aesthetic deficiency and the dentin hypersensitivity complained by patient.

Synchronous reconstruction of bilateral osteoradionecrosis of the mandible using a single fibular osteocutaneous flap in patients with nasopharyngeal carcinoma

The reconstruction of bilateral osteoradionecrosis (ORN) of mandibular defects using a single free bone flap is rarely performed because extensively radiated neck tissue with severe fibrosis is usually unsuitable for vascularized reconstruction. Thirty-one patients with nasopharyngeal carcinoma (NPC) underwent bilateral reconstruction of advanced ORN in the mandible using a single fibular osteocutaneous flap. Clinical factors associated with the operation were assessed, including classification of mandible defects, types of recipient vessels, perioperative complications, and postoperative outcomes. All of the fibular osteocutaneous flaps survived completely, with the exception of 1 inner skin paddle that presented partial necrosis in a reconstruction of through-and-through defects. All patients experienced an improvement in cosmetic results 6 months after the reconstruction, whereas 23 patients experienced improved mouth opening compared to the preoperative condition. Advanced bilateral ORN in patients with NPC could be synchronously reconstructed with a single fibular osteocutaneous flap. © 2015 Wiley Periodicals, Inc. Head Neck, 2015.

A bayesian network meta-analysis on comparisons of enamel matrix derivatives, guided tissue regeneration and their combination therapies

Aims: Guided tissue regeneration (GTR) and enamel matrix derivatives (EMD) are two popular regenerative treatments for periodontal infrabony lesions. Both have been used in conjunction with other regenerative materials. We conducted a Bayesian network meta-analysis of randomized controlled trials on treatment effects of GTR, EMD and their combination therapies. Material and Methods: A systematic literature search was conducted using the Medline, EMBASE, LILACS and CENTRAL databases up to and including June 2011. Treatment outcomes were changes in probing pocket depth (PPD), clinical attachment level (CAL) and infrabony defect depth. Different types of bone grafts were treated as one group and so were barrier membranes. Results: A total of 53 studies were included in this review, and we found small differences between regenerative therapies which were non-significant statistically and clinically. GTR and GTR-related combination therapies achieved greater PPD reduction than EMD and EMD-related combination therapies. Combination therapies achieved slightly greater CAL gain than the use of EMD or GTR alone. GTR with BG achieved greatest defect fill. Conclusion: Combination therapies performed better than single therapies, but the additional benefits were small. Bayesian network meta-analysis is a promising technique to compare multiple treatments. Further analysis of methodological characteristics will be required prior to clinical recommendations.

A clinical experience of the supraclavicular flap used to reconstruct head and neck defects in late-stage cancer patients

The supraclavicular island flap has been widely used in head and neck reconstruction, providing an alternative to the traditional techniques like regional or free flaps, mainly because of its thin skin island tissue and reliable vascularity. Head and neck patients who require large reconstructions usually present poor clinical and healing conditions. An early experience using this flap for late-stage head and neck tumour treatment is reported. Forty-seven supraclavicular artery flaps were used to treat head and neck oncologic defects after cutaneous, intraoral and pharyngeal tumour resections. Dissection time, complications, donor and reconstructed area outcomes were assessed. The mean time for harvesting the flaps was 50 min by the senior author. All donor sites were closed primarily. Three cases of laryngopharyngectomy reconstruction developed a small controlled (salivary) leak that was resolved with conservative measures. Small or no strictures were detected on radiologic swallowing examinations and all patients regained normal swallowing function. Five patients developed donor site dehiscence. These wounds were treated with regular dressing until healing was complete. There were four distal flap necroses in this series. These necroses were debrided and closed primarily. The supraclavicular flap is pliable for head and neck oncologic reconstruction in late-stage patients. High-risk patients and modified radical neck dissection are not contraindications for its use. The absence of the need to isolate the pedicle offers quick and reliable harvesting. The arc of rotation on the base of the neck provides adequate length for pharyngeal, oral lining and to reconstruct the middle and superior third of the face. (C) 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Reconstructive Microsurgery and Tissue Engineering in Musculo-Skeletal Oncology - Innovative Techniques

Tumors involving bone and soft tissues are extremely challenging situations. With the recent advances of multi-modal treatment, not only the type of surgery has moved from amputation to limb-sparing procedures, but also the survivorship has improved considerably and reconstructive techniques have the goal to allow a considerably higher quality of life. In bone reconstruction, tissue engineering strategies are the main area of research. Re-vascularization and re-vitalisation of a massive allograft would considerably improve the outcome of biological reconstructions. Using a rabbit animal model, in this study we showed that, by implanting a vascular pedicle inside a weight bearing massive cortical allograft, the bone regeneration inside the allograft was higher compared to the non-vascularized implants, given the patency of the vascular pedicle. Improvement in the animal model and the addition of Stem Cells and Growth factors will allow a further improvement in the results. In soft tissue tumors, free and pedicled flaps have been proven to be of great help as reconstruction strategies. In this study we analyzed the functional and overall outcome of 14 patients who received a re-innervated vascularized flap. We have demonstrated that the use of the innovative technique of motor re-innervated muscular flaps is effective when the resection involves important functional compartments of the upper or lower limb, with no increase of post-operative complications. Although there was no direct comparison between this type of reconstruction and the standard non-innervated reconstruction, we underlined the remarkable high overall functional scores and patient satisfaction following this procedure.

The choice of anesthesia influences oxidative energy metabolism and tissue survival in critically ischemic murine skin

In surgical animal studies anesthesia is used regularly. Several reports in the literature demonstrate respiratory and cardiovascular side effects of anesthesiologic agents. The aim of this study was to compare two frequently used anesthesia cocktails (ketamine/xylazine [KX] versus medetomidine/climazolam/fentanyl [MCF]) in skin flap mouse models. Systemic blood values, local metabolic parameters, and surgical outcome should be analyzed in critical ischemic skin flap models. Systemic hypoxia was found in the animals undergoing KX anesthesia compared with normoxia in the MCF group (sO(2): 89.2% +/- 2.4% versus 98.5% +/- 1.2%, P < 0.01). Analysis of tissue metabolism revealed impaired anaerobic oxygen metabolism and increased cellular damage in critical ischemic flap tissue under KX anesthesia (lactate/pyruvate ratio: KX 349.86 +/- 282.38 versus MCF 64.53 +/- 18.63; P < 0.01 and glycerol: KX 333.50 +/- 83.91 micromol/L versus MCF 195.83 +/- 29.49 micromol/L; P < 0.01). After 6 d, different rates of flap tissue necrosis could be detected (MCF 57% +/- 6% versus KX 68% +/- 6%, P < 0.01). In summary we want to point out that the type of anesthesia, the animal model and the goal of the study have to be well correlated. Comparing the effects of KX and MCF anesthesia in mice on surgical outcome was a novel aspect of our study.

Long-term results after muscle-rib flap transfer for reconstruction of composite limb defects

The authors present the long-term results in a series of 44 cases with post-traumatic bone defects solved with muscle-rib flaps, between March 1997 and December 2007. In these cases, we performed 21 serratus anterior-rib flaps (SA-R), 10 latissimus dorsi-rib flaps (LD-R), and 13 LD-SA-R. The flaps were used in upper limb in 18 cases and in lower limb in 26 cases. With an overall immediate success rate of 95.4% (42 of 44 cases) and a primary bone union rate of 97.7% (43 of 44 cases), and despite the few partisans of this method, we consider that this procedure still remains very usefully for small and medium bone defects accompanied by large soft tissue defects.

Anatomic study of the superficial sural artery and its implication in the neurocutaneous vascularized sural nerve free flap

Combined extended nerve and soft tissue defects of the upper extremity require nerve reconstruction and adequate soft tissue coverage. This study focuses on the reliability of the free vascularized sural nerve graft combined with a fasciocutaneous posterior calf flap within this indication. An anatomical study was performed on 26 cadaveric lower extremities that had been Thiel fixated and color silicone injected. Dissection of the fasciocutaneous posterior calf flap involved the medial sural nerve and superficial sural artery (SSA) with its septocutaneous perforators, extended laterally to include the lateral cutaneous branch of the sural nerve and continued to the popliteal origin of the vascular pedicle and the nerves. The vessel and nerves diameter were measured with an eyepiece reticle at 4.5× magnification. Length and diameter of the nerves and vessels were carefully assessed and reported in the dissection book. A total of 26 flaps were dissected. The SSA originated from the medial sural artery (13 cases), the popliteal artery (12 cases), or the lateral sural artery (one case). The average size of the SSA was 1.4 ± 0.4 mm. The mean pedicle length before the artery joined the sural nerve was 4.5 ± 1.9 cm. A comitant vein was present in 21 cases with an average diameter of 2.0 ± 0.8 mm, in 5 cases a separate vein needed to be dissected with an average diameter of 3.5 ± 0.4 mm. The mean medial vascularized sural nerve length was 21.2 ± 8.9 cm. Because of inclusion of the vascularized part of the lateral branch of the sural nerve (mean length of 16.7 ± 4.8 cm), a total of 35.0 ± 9.6 cm mean length of vascularized nerve could be gained from each extremity. The free vascularized sural nerve graft combined with a fasciocutaneous posterior calf flap pedicled on the SSA offers a reliable solution for complex tissue and nerve defect. Clin. Anat. 2012. © 2012 Wiley Periodicals, Inc.

Patient-centered outcomes after subepithelial connective tissue grafts and coronally advanced flaps

The use of a coronally advanced flap (CAF) and connective tissue graft (CTG) is a well-established procedure to cover single and multiple recessions and improve soft tissue esthetics. However, until now, there are still limited data evaluating patient morbidity, the fear of imminent tooth loss, and modification of sensitivity in surgical areas. The aim of the present study was to evaluate the patient-centered outcomes associated with CAF + CTG.

Treatment of soft tissue recessions at titanium implants using a resorbable collagen matrix: a pilot study

OBJECTIVES: To histologically assess the effectiveness of a porcine-derived collagen matrix (CM) and a subepithelial connective tissue graft (CTG) for the coverage of single mucosal recessions at osseointegrated dental implants. MATERIALS AND METHODS: Chronic-type mucosal Miller Class I-like recessions (mean clinical defect height: 0.67 ± 0.33-1.16 ± 0.19 mm) were established at the buccal aspect of titanium implants with platform switch in six beagle dogs. The defects were randomly allocated to either (1) coronally advanced flap surgery (CAF) + CM, (2) CAF + CTG or (3) CAF alone. At 12 weeks, histomorphometrical measurements were made (e.g.) between the implant shoulder (IS) and the mucosal margin (PM) and IS and the outer contour of the adjacent soft tissue (mucosal thickness [MT]). RESULTS: All treatment procedures investigated were associated with an almost complete soft tissue coverage of the defect area (i.e. coronal positioning of PM relative to IS). Mean IS-PM and MT values tended to be increased in both CAF + CM (1.04 ± 0.74 mm/0.71 ± 0.55 mm) and CAF + CTG (0.88 ± 1.23 mm/0.62 ± 0.66 mm) groups when compared with CAF (0.16 ± 0.28 mm/0.34 ± 0.23 mm) alone. These differences, however, did not reach statistical significance. CONCLUSIONS: Within the limits of this pilot study, it was concluded that all treatment procedures investigated were effective in covering soft tissue recessions at titanium implants.

Evaluation of late results in breast reconstruction by latissimus dorsi flap and prosthesis implantation

BACKGROUND: Breast reconstruction by latissimus dorsi myocutaneous flap in combination with a prosthesis is a widely used, well-established procedure. Short- and medium-term evaluation after this procedure is well described in the literature, but there have been no evaluations of the late course (over 10 years) published until now. METHODS: In a retrospective study, 68 patients operated on by means of this technique at the authors' institution from 1981 to 1993 resulting in a minimal follow-up of 10 years were included. Patients were invited to an interrogation, clinical examination, and photographic documentation (n = 51). Incidence of late flap or prosthesis-related complications, number of and indications for corrective procedures, and the correlation of the patients' subjective judgment and objective results in the late course have been the main interest of the authors' survey. RESULTS: The authors found that 50 percent of the patients needed a late reoperation for change or removal of the prosthesis. Seven (10 percent) of 68 patients needed a definitive removal of the implant in the late course. Assessment of the photographic documentation of the late result by four nonprofessionals showed that the objective aesthetic results of a considerable number of the authors' reconstructions were not sufficient. CONCLUSION: The procedure combines two basic techniques of reconstructive surgery, the soft-tissue restoration by a pedicled flap as the autologous reconstructive component and the volume reconstruction by prosthesis. Therefore, these patients are subject to a cumulation of the basic morbidity of the two techniques. The authors conclude that the indication for this procedure should be restricted to patients not qualifying for "pure" reconstructive techniques.