Microsurgical reconstruction of the skull base and midface after orbitomaxillary resections for malignant tumors

Background. Orbitomaxillary resection includes exenteration of the orbital contents with resection of the inferior orbital and medial walls. The main goals are: reconstruction of soft tissue and bone structure defects, tamponade of the orbital cavity and/or its preparation for further ocular prosthetics, and reconstruction of the skull base defect. The purpose of the study to present the immediate results of orbitomaxillary resections in patients with malignant neoplasms of the skull base and midface. Material and methods. Between 2014 and 2020, 6 patients who previously underwent surgery for primary cancer (n=3) and recurrent cancer (n=3) were treated at the Head and Neck cancer department of N.N. Blokhin National medical Research center of oncology. To reconstruct defects after resection of bone structures (maxilla, frontal and nasal bones) and skin, a musculocutaneous alt-flap was used in 3 (50 %) cases and a fascial skin radial flap in 3 (50 %) cases. Results. The aesthetic result was assessed in 6 patients. In all cases, a satisfactory result was obtained. None of the patients who underwent resection of the dura mater followed by reconstruction had no symptoms of liquorrhea in the postoperative period. Conclusion. Flap selection depends on the defect size. In cases with a small defect size (up to 70 cm3), reconstruction with the radial fascial skin flap can be performed. If the defect size is more than 71 cm3, reconstruction with musculocutaneous alt flap can be the method of choice.

Skin and composite grafts

Skin grafts may be used for coverage of facial defects in situations in which alternative methods of reconstruction, such as local flaps, are not an option. They may also be beneficial for patients who wish to avoid or who are not good candidates for more complex reconstruction. Full-thickness skin grafts often have a better color and texture match to adjacent skin when compared to split-thickness grafts; however, split-thickness grafts have lower metabolic demand and increased survival rate. Composite grafts may be very useful in the repair of defects with unique contour and support requirements, such as the nasal ala and eyelid. With all grafts, thoughtful planning and sound surgical technique are critical in achieving the best possible functional and aesthetic result.

Propeller Flap: Surgical Option after Resection of Lower Limb Melanoma

Objective: To describe a series of cases of lower limb reconstruction using an axial reverse flow flap (propeller flap) after melanoma excision. Patients and methods: From August 2014 to December 2016, at the Plastic Surgery Service at UNIFESP, five patients with defects in the lower limbs after melanoma resection were reconstructed using propeller flap. In all cases, the perforating vessels were previously mapped using Doppler ultrasound. Results: The size of the defect ranged from 4 cm × 3 cm to 8 cm × 4.5 cm. One case had a 180º rotation. In all the others, a 90° rotation was sufficient. All patients had good aesthetic results. Conclusion: The propeller flap is a simple and low cost technique. It is indicated for reconstruction of the distal third of small and/or medium-sized lower limb. The aesthetic result is satisfactory with the thickness and color of the flap very similar to the excised area.

EXPERIENCE OF USING ENAMEL MATRIX PROTEIN IN COMBINATION WITH A CORONARY ADVANCED FLAP AND A CONNECTIVE TISSUE GRAFT TO ELIMINATE GUM RECESSION

The article presents the experience of complex managing a patient with gum recession in the area of the maxillary premolars. Periodontal treatment of gum recession consisted of initial therapy, including supra- and subgingival scaling, root planing, pharmacotherapeutic support (broad-spectrum antiseptics, drugs that stimulate regeneration), surgical combined method based on the use of enamel matrix protein to stimulate regenerative processes. The clinical material Emdogaine is a combination of an enamel matrix derivative and propylene glycol alginate, which performs the function of a carrier. Biora company has been producing it for more than 20 years (Emdogain, BIORA): now the rights to this material belong to Straumann). This preparation was developed to stimulate regeneration of periodontal tissues. Amelogenin is a specific enamel protein capable of stimulating regeneration of lost periodontal tissues by influencing cell differentiation. Dental cement is an osteoid connective tissue that covers the roots of teeth and serves to attach periodontal fibers. Application of an enamel matrix derivative to the sanitized root surface leads to regeneration of non-cellular cement and to the formation of periodontal tissues, which was observed in our study. Transplantation of free connective tissue grafts to eliminate gum recessions makes it possible to effectively eliminate gum recession in most clinical cases (complete root coverage, an increase in the level of clinical attachment from the keratinized attached gum area). In our clinical case, free grafts were obtained in the donor area of the maxillary tuberosity. Transplantation of free connective tissue grafts provides an aesthetic result and is currently considered a standard technique for eliminating gum recession. According to the clinical study, a combined use of connective tissue grafts and the enamel matrix derivative, an additional use of enamel matrix derivative enabled to obtain a satisfactory result and to improve the appearance of the dentition. Such combined surgeries are indicated in an aesthetically significant area. The described materials, methods and stages of patient's follow up can serve as the basis for the protocol of managing patients with gum recession.

Is the Treatment of the Tear Trough Deformity with Hyaluronic Acid Injections a Safe Procedure? A Systematic Review

Among the various therapeutic options for the treatment of tear trough deformities, the use of hyaluronic acid-based fillers has constantly been increasing. The aim of this research is to conduct a systematic review of the published literature related to the use of hyaluronic acid-based dermal fillers for the treatment of tear trough deformities and possible related complications. A search of the published literature was conducted following the PRISMA guidelines, including PubMed, Cochrane Library, and Ovid databases. Text words and Medical Search Headings (MeSH terms) were used to identify nine articles included in our analysis. The most used filler was Restylane (Galderma). The injection technique was performed through the use of a cannula or, more frequently, with a needle, through the execution of boluses or retrograde release. The injection plane was predominantly the supra-periosteal layer. The most observed side effects were mild and included redness, edema, contour irregularities, bruising, and blue-gray dyschromia. The degree of patient satisfaction was high, with an optimal aesthetic result that was maintained for 6 to 12 months. Although the duration of treatment of tear trough deformities with HA fillers is not comparable to surgical treatment, this is a minimally invasive, safe procedure, quick to perform, and with a high degree of patient satisfaction.

V-shaped radial forearm free flap is a new way to reduce the morbidity of the donor area

Background. Radial forearm free flap is one of the most frequently used in the head and neck reconstruction. A significant disadvantage is the appearance of the donor site. We have developed and introduced into clinical practice a V-shaped fabrication skin of the flap, which allows direct closure of the donor site and reduces morbidity. Aim. To assess the possibility of direct closure of the donor site and to reduce the morbidity of the donor site when performing the V-shaped fabrication of the skin area of the flap. Materials and methods. During the period from 2014 to 2020, the radial free flap was used in 43 cases. In 15 (35%) cases, a V-shaped fabrication of the skin area was used during flap harvest, which made it possible to carry out a direct closure of the donor site. The length of the skin area stretched from the top of the wrist, not reaching 34 cm to the elbow bend and varied from 715 cm, on average 12 cm. The width of the flap was determined by the elasticity of the forearm skin, was maximum in the middle third and varied from 2 up to 4 cm, averaging 3.3 cm. If necessary, the upper and lower edges of the skin area can be sutured together, as well as the entire medial edge of the flap. This technique increases the flap width by almost 2 times. This arrangement was applied in 8 cases. Results. When comparing the results of using the two techniques, the following data were obtained: "V-shaped" fabrication of the skin was used mainly in women (11/15 73%) for reconstruction limited defects in the retromolar region (5/15), soft (4/15) or hard palate (6/15). Most of the patients had localized T1-T2 (10/15) stage. None of the patients had any problems with the healing of the donor area. An excellent aesthetic result was obtained in all patients. In the group of standard harvest, the predominance of males was noted (17/28). Defects had a varied localization, most patients was with relapses after chemo-radiation treatment (10/28) or primary locally advanced T3-T4 stage process (6/28) 16, with a localized T1-T2 stage (11/28) 11, in one case, delayed reconstruction was performed. In all cases, the plastic of the donor site was performed with a split skin autograft. Partial necrosis of the donor site flap was observed in 9 patients (32%), in 4 cases with exposure of the flexor muscle tendon. Conclusion. As a result of the comparative analysis of the two methods, we concluded that the use of V-shaped fabrication of the skin area of the radial forearm flap allows to obtain better aesthetic results of the donor site, however, the use of this technique leads to a significant reduction in the length of the vascular pedicle and a decrease in the width of the flap.

Hard and Soft Tissue Augmentation with Single-Implant Restoration in the Esthetic Zone

The removal of the central incisor of the upper jaw is a challenging process, since the restoration of a single implant in the esthetic zone is of great responsibility. When tooth extraction with immediate implant placement is not possible, modern protocols imply the use of the socket preservation technique. This method of preserving socket properties significantly reduces changes that occur during the healing process of the postextracted area and along with soft tissue augmentation allows to achieve a satisfying aesthetic result. The aim of present case report is to assess capabilities of socket preservation concept and application of soft tissue augmentation in the anterior maxillary region. The treatment steps of a 35-year-old woman who needed to remove tooth 11 with further dental implant placement are described. The clinical case is of interest because after socket preservation and soft tissue augmentation, an acceptable aesthetic result was not reached. However, additional soft tissue augmentation made it possible to achieve the desired result, which was stable for 7 years.

Short-Facelift Approach in Temporal Artery Biopsy: Is It Safe?

Giant cell arteritis (GCA) is a quite common panarteritis of the elderly that affects medium- and large-size arteries. Despite the increasing role of imaging with advancing technology, the gold standard for the diagnosis of GCA is still the temporal artery biopsy. A described complication of superficial temporal artery biopsy (STAB), for which incidence is not clear, is the accidental damage of the frontal branch of the facial nerve. In this paper, we described the short-scar facelift surgical approach for STAB on 23 consecutive patients who underwent unilateral superficial temporal artery biopsy for GCA suspicion. We collected data in terms of postoperative complications, biopsy specimen length, biopsy result and cosmetic appearance of the scar. In our experience, this surgical approach combines the advantage of avoiding incisions within the dangerous anatomical area, minimizing the risk of facial nerve damage, with an acceptable complication rate and a good final aesthetic result which avoids visible scarring.

THE EFFECTIVESS OF EVALUATION OF OSTEOPATHIC SUPPORT OF PATIENTS SUFFERING FROM THE DISTURBED OCCLUSION AT THE DENTAL ALVEOLAR LEVEL

The eff ectiveness of simultaneous use of braces and methods of osteopathic correction was evaluated while treating 48 patients suff ering from occlusion disorders at the dental alveolar level. The indicators of osteopathic status, situational anxiety, and satisfaction with the aesthetic result of treatment were studied. It was found that the most typical somatic dysfunctions were the dysfunctions of the bones of the skull base, facial skull, cervical spine, chest, and of internal organs of the chest and neck. The inclusion of methods of osteopathic correction in the comprehensive treatment resulted in the better mobility of the structures of the skull, cervical spine, and chest, a decreased anxiety level and, consequently, an increased satisfaction with the aesthetic result of treatment.