The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Brief Clinical Studies
procedure in similar studies, but our results showed clearly that NLA increased in skeletonization, whereas NTP did not have a meaningful change in this step. In cephalic resection, NLA decreased about 2 degrees, and NTP was reduced about 0.5 mm. Although Guyuron4 and Ingels and Orhan11 reported that cephalic resection will increase NLA, both these studies did not analyze the effects of cephalic resection on NTP. We believe that even in conservative cephalic resection one of the main tip support mechanisms is weakened, so it is not surprising that it causes both NLA and NTP to reduce. However, it should be noted that results might change because of scar formation in the medium term after a couple of months. In next stage, 18- to 22-mm columellar struts were placed in all cases and resulted in about a 4-degree increase in NLA and 0.3-mm increase in the NTP. Nearly the same findings were reported by Guyuron.1–3 In Bafaqeeh’s16 study, columellar struts were placed in nearly half of their 61 patients. Strut was not effective in 12 patients, and it increased projection in 20 patients. In another study by Ingels and Orhan11 with nearly the same number of patients (n = 62), a cartilaginous strut was used in 36 patients, whereas 26 patients did not receive a strut. Results showed increased NTP and rotation and also an increased NLA for the strut group. Tip sutures are usually performed for different purposes. They may be used to rotate the tip, to narrow a wide tip, to equalize asymmetric domes, to increase and strengthen the support of tip, and to control the convexity of lateral crura. We used tip spanning sutures as the preferred method of the surgeon to refine the tip. It was performed in 18 of 50 patients. It caused about a 1-mm increase in NTP, and it did not affect the NLA. Guyuron and Behmand17 reported that interdomal suture, which is another technique of tip suture, will result in maximum 1- to 2-mm increase in NTP. As we see our knowledge of nasal dynamics increases, we will be able to obtain more predictable results and use these maneuvers more discriminately. As the authors of the current study aim to, further studies should investigate the long-term effects with inclusion of possible scar formation as well as other postoperative patientrelated and nonrelated factors, so that the knowledge in that field can further increase. In conclusion, different steps of rhinoplasty showed various impacts on the NLA and NTP. Whereas strut insertion caused the highest mean increase in NLA, tip spanning was the most effective regarding the change in NTP. Expectably, cephalic resection was associated with decrease in NLA and NTP.
REFERENCES 1. Guyuron B. Dynamics of rhinoplasty. Plast Reconstr Surg 1991; 88:970–978 2. Guyuron B. Dynamic interplays during rhinoplasty. Clin Plast Surg 1996;23:223–231 3. Guyuron B. Dynamics in rhinoplasty. Plast Reconstr Surg 2000;105:2257–2259 4. Guyuron B. Dynamics of rhinoplasty. Aesthetic Plast Surg 2002;26:S10 5. Fuleihan NS. The transvestibular approach: a new horizon in rhinoplasty. Arch Facial Plast Surg 2006;8:273–282 6. Zoumalan RA, Morris LG, Zeitler DM, et al. Effects of various submucous resection techniques of septal cartilage on nasal tip projection. Int Forum Allergy Rhinol 2001;1:78–82 7. Coskun BU, Sozen E, Seneldir S, et al. Does the open rhinoplasty incision decrease nasal projection? Eur Arch Otorhinolaryngol 2012;269:867–870 8. Chauhan N, Sardesai MG, Burchard AE, et al. Nasal tip refinement: analysis of surgical technique, efficacy, and secondary effect of skin thickness. Aesthet Surg J 2010;30;39–43 9. Corrado A, Bloom JD, Becker DG. Domal stabilization suture in tip rhinoplasty. Arch Facial Plast Surg 2009;11:194–197
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10. van Heerbeek N, Ingels KJ, van Loon B, et al. Three dimensional measurement of rhinoplasty results. Rhinology 2009;47:121–125 11. Ingels K, Orhan KS. Measurement of preoperative and postoperative nasal tip projection and rotation. Arch Facial Plast Surg 2006; 8:411–415 12. Ingels K, Orhan KS. Measuring nasal tip and double width; effect of transdomal and lateral crura suturing. Rhinology 2007;45:79–82 13. Yu MS, Jang YJ. Modified vertical dome division technique for rhinoplasty in Asian patients. Laryngoscope 2010;120:668–672 14. Sadeghi M, Saedi B, Arvin Sazegar A, et al. The role of columellar struts to gain and maintain tip projection and rotation: a randomized blinded trial. Am J Rhinol Allergy 2009;23:47–50 15. Spörri S, Simmen D, Briner HR, et al. Objective assessment of tip projection and the nasolabial angle in rhinoplasty. Arch Facial Plast Surg 2004;6:295–298 16. Bafaqeeh SA. Open rhinoplasty: effectiveness of different tip plasty techniques to increase nasal tip projection. Am J Otolaryngol 2000;21:231–237 17. Guyuron B, Behmand RA. Nasal tip sutures. Part II: the interplays. Plast Reconstr Surg 2003;112:1130–1145
Bipedicled Scalp Flaps for Reconstruction of High-Tension Electric Burns of Calvarium Chandan N. Jadhav, MBBS, MS, Ramesh Kumar Sharma, MBBS, MS Abstract: High-tension electrical calvarial burns are extremely rare and difficult to reconstruct. Invariably, these are third- or fourthdegree–deep burns involving the bone and underlying brain. Historically, these wounds have been treated conservatively, adding to morbidity and prolonged treatment. Two patients with high-tension electrical calvarial burns presented to us 2 weeks after the injury, one fourth–degree deep with infected necrotic calvarium and scalp, resulting in a full-thickness frontoparietal defect with herniation of the brain. The other patient had third-degree burns over the occiput with surrounding seconddegree–deep burns extending onto the nape of the neck with patches of second-degree deep burns over the vertex. Both patients had the risk for being subjected to prolonged anesthesia. The defects were covered with bipedicled scalp flap. In the face of sepsis and other comorbidities where more complicated flaps are risky, this flap provides a simple and reliable method of reconstruction. Key Words: Calvarial electrical burns, bipedicled scalp flap
From the Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Received September 23, 2013. Accepted for publication February 9, 2014. Address correspondence and reprint requests to Chandan N. Jadhav, MBBS, MS, MCh, No. 140/2-1, 3 Block, 4 Main, Thyagarajanagar, Bangalore 560028, India; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000886
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Brief Clinical Studies
H
igh-tension calvarial burns with involvement of the dura mater and brain, secondary to electrical injury, are rare. The resultant defect of the skull is a challenge to the reconstructive surgeon. Several methods of reconstruction have been described. Spontaneous separation of necrotic calvarium with skin grafting over the granulation tissue is no longer being followed because of delayed would healing.1,2 Doing burr holes in the outer table of the skull to promote granulation tissue, followed by coverage with skin grafts, is also a described method.1,2 Another alternative was to debride the necrotic scalp tissue, leaving behind the dead bone, to be covered by vascularized tissue. The dead bone acts as a scaffold for some amount of creeping substitution to occur from the surrounding calvarium.3 The use of local flaps, as well as free tissue transfers, had also been described.4–8 When the high-tension electrical injury extends to the brain, it can result in life-threatening neurologic sequelae. Debridement of significant brain matter can also result in various neurologic deficits. Immediate coverage of the exposed dura and brain is crucial to prevent cerebrospinal fluid (CSF) leak and decrease the risk for infection. Few cases have been reported, with high-tension electrical injury involving the dura mater and brain. We present 2 instances of high-tension electrical calvarial burns successfully covered with bipedicled scalp flaps.
CLINICAL REPORT Patient 1 A 28-year-old man was referred to us 2 weeks after a high-tension electrical injury, which he sustained accidentally on his right frontoparietal region of the calvarium. He also had a history of fall from height with contusion of the parietal cortex. He presented to us with infected wound over the partially debrided scalp and calvarium. Neurosurgery consultation was sought, and all the necrotic scalp, dead bone, dura, and necrotic brain were further debrided, resulting in a right frontotemporoparietal skull defect of 12 10 cm with herniating brain matter (Fig. 1). Postoperatively, the patient was on ventilator for approximately a week and had a motor response of withdrawal to painful stimulus. The patient was under high risk to be subjected to prolonged anesthesia. A reconstructive plan was made using the remaining part of the tongue lie scalp tissue, basing it anteriorly as a transposition flap to cover the temporal defect. The residual D-shaped defect was covered with bipedicled scalp flap running across the vertex, with one end based anteriorly on the left side and the other end posteriorly over the right side. This resulted in a robust flap receiving its blood supply from the left supratrochlear and supraorbital vessels and the right occipital vessel. Single-layer closure was done without repairing the dura. Donor defect was covered with intermediate-thickness split skin graft (SSG). Initially, prophylactic lumbar drain was used to prevent CSF leak. Two weeks after the operation, it was noted that both the flaps were well settled and that the suture line healed without any
FIGURE 1. Top right, Right frontotemporoparietal calvarial defect with herniated brain. Top left, Local anterior–based transposition flap from the tongue-shaped scalp tissue. Bottom right, Bipedicled scalp flap from the adjoining scalp, oblique orientation. Bottom left, Three weeks after the operation.
FIGURE 2. Top right, Exposed occiput and the surrounding granulation tissue over the nape of the neck. Top left, Bipedicled scalp flap based on the posterior auricular vessels. Bottom right, Surrounding raw area and donor defect skin grafted. Bottom left, Two months after the operation.
complications. The patient’s general condition improved, with spontaneous breathing effort and motor response of spontaneous movements. This patient did not have any significant neurologic deficit and was discharged 3 weeks postoperatively.
Patient 2 A 45-year-old man sustained a high-tension electrical injury to the occipital region accidentally at his workplace. He was referred to us 2 weeks after the injury with exposed occiput of 8 5 cm and dirty granulation tissue over the adjoining scalp and nape of the neck. He also had sustained patchy second-degree superficial burns over the vertex. He had associated cardiac and renal comorbidities, giving him an American Society of Anesthesiologists score of IV. In view of the high risk associated with prolonged anesthesia, a reconstructive plan of bipedicled scalp was made. This flap was based on the bilateral posterior auricular vessels. Intermediate-thickness SSG was used to cover the surrounding raw area and the donor area of the scalp (Fig. 2). The patient was followed up 2 months postoperatively, wherein he had well-settled hair-bearing bipedicled scalp flap and SSG over the nape of the neck and donor site of scalp. He was on postoperative scar management protocol to prevent contracture, hypertrophy, and restriction of neck movements.
DISCUSSION We have presented 2 successful cases using a bipedicled scalp flap for coverage of large calvarial defects, one with involvement of the dura and brain. The traditional surgical management of deep electrical burn injuries to the scalp and calvarium was to wait for spontaneous separation of necrotic bone. Recently, the management of these patients has involved staged excision of necrotic soft tissue, making drill holes of the outer table and waiting for granulation tissue to sprout, over which SSG is being done. However, this resulted in prolonged wound healing, painful dressing changes, and entrapment of sequestra.1–3,6 Bizhko and Slesarenko3 described a series of 22 patients with electrical injuries of the calvarium, who were managed with vascularized local flaps over exposed, devitalized bone. Immediate coverage of full-thickness calvarial defects is advised not only to prevent intracranial infection but also to decrease the morbidity with prolonged open wounds and prevent CSF leak.7,9 The 2 patients who presented to us had a patient’s general condition and other comorbidities not favoring prolonged anesthesia for microsurgical reconstruction. Hence, bipedicled scalp flaps formed a simple and reliable alternative as a local flap to cover these large defects. The bipedicled scalp flap is also very robust because it preserves bidirectional flow through choke anastomosis as described by Marty et al,10 allowing large flaps to survive. Dural reconstruction was not attempted in the first case because of significant cerebral edema, herniation of the brain through the calvarial defect, and the possibility of sequestration of infection.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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CONCLUSIONS Bipedicled scalp flaps are simple, useful, and reliable reconstructive option for large calvarial defects, especially in individuals not fit for prolonged microsurgery. It also has the advantage of replacing “like with like” tissue. Vascularized cover of these calvarial wounds is essential to prevent life-threatening infections and promote early recovery.
REFERENCES 1. Sheridan RL, Choucair RJ, Donelan MB. Management of massive calvarial exposure in young children. J Burn Care Rehabil 1998;19:29–32 2. Groenevelt F, van Trier AJ, Khouw YL. The use of allografts in the management of exposed calvarial electrical wounds of the skull. Ann N Y Acad Sci 1999;888:109–112 3. Bizhko IP, Slesarenko SV. Operative treatment of deep burns of the scalp and skull. Burns 1992;18:220–223 4. Benito-Ruiz J, Baena-Montilla P, Navarro-Monzonis A, et al. Severe electric injury of the skull. Burns 1994;20:553–556 5. Shen Z. Reconstruction of refractory defect of scalp and skull using microsurgical free flap transfer. Microsurgery 1994;15:633–638 6. Worthen EF. Surgical treatment of electrical burns of the scalp and skull: past and present. Clin Plast Surg 1982;9:161–165 7. Ioannides C, Fossion E, McGrouther AD. Reconstruction for large defects of the scalp and cranium. J Craniomaxillofac Surg 1999;27:153–159 8. Sun YH, Wang SH, Cao DX, et al. Early treatment of burned scalp and skull. Chin Med J (Engl) 1984;97:755–757 9. Barret JP, Dziewulski P, McCauley RL, et al. Dural reconstruction of a class IV calvarial burn with decellularized human dermis. Burns 1999;25:459–462 10. Marty F, Montandon D, Gumner R, et al. Subcutaneous tissue in the scalp: anatomical, physiological and clinical study. Ann Plast Surg 1986;16:368
Influence Analysis of Cleft Type and Supernumerary Teeth Eruption in the Prognosis of Bone Graft in Patients With Cleft Palate Cristiano Gaujac, DDS, MSc,* Eduardo Francisco de Souza Faco, DDS, MSc,* Elio Hitoshi Shinohara, DDS, PhD,† Renato Andre de Souza Faco, DDS, MSc,‡ Flávia Priscila Pereira, DDS, PhD,* Wirley Gonçalves Assunção, DDS, MSc§ From the *Field of Oral Implants; †Department of Surgery and Integrated Clinic, Universidade Estadual Paulista, Dental School of Araçatuba; Araçatuba Universidade Estadual Paulista (UNESP); ‡Hospital de Reabilitação de Anomalias Craniofaciais USP, Bauru, São Paulo; and §Department of Prosthesis, Dental School of Araçatuba, Araçatuba, São Paulo, Brazil. Received June 19, 2013. Accepted for publication February 10, 2014. Address correspondence and reprint requests to Cristiano Gaujac, DDS, MSc, Postgraduate Program in Dentistry, Field of Oral Implants, Campus Araçatuba, Dental School of Araçatuba, UNESP, Rua José Bonifácio, 1193, 16015-050 Araçatuba-São Paulo/Brazil. E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000903
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Objective: The aim of this study was to investigate the influence of cleft type and supernumerary tooth eruption on the treatment of palatal clefts with alveolar bone grafts. Materials and Methods: In this article, medical records of 40 patients with palatal clefts and associated supernumerary teeth who were treated with alveolar bone grafting in the Hospital for Craniofacial Anomalies Rehabilitation were assessed. The patients were studied to assess the influence of supernumerary teeth and the cleft severity on the prognosis of the alveolar bone graft. Results: Forty medical records were included in the assessment. When the teeth in the cleft had an anatomic shape close to canine, we called them precanine. When they were very small or malformed, we called them anomalous lateral incisors. The teeth studied showed good prognoses and were more expressive in the preforaminal clefts (87.5%) than in the transforaminal ones (62.5%). Moreover, the transforaminal clefts presented a higher percentage in satisfactory and poor prognoses (37.5%). The authors found that supernumerary teeth influenced the maintenance of alveolar bone graft height and that transforaminal clefts presented a worse prognosis than preforaminal clefts. Key Words: Cleft palate, bone graft, supernumerary teeth, treatment
S
ome dental malformations affecting patients with cleft lip and palate are related to the number, shape, size, time of formation, calcification, and eruption. In addition, both dentitions can be affected by these malformations.1 Dental abnormalities in number are 7 times more prevalent in patients with cleft lip and palate in comparison with the population in general.2 There is also a high incidence of this anomaly in the lateral incisors.3 Surgical treatments that reach only the soft tissue present a poor prognosis with limited orthodontic treatment. In addition, they also present instability of the maxillary segments, mainly in the premaxilla, in cases of bilateral clefts and nasal asymmetry by lack of alar base support (unilateral cases). Young patients need to use prosthesis in those cases.4 Similar to the canines that erupt through the bone graft, the lateral incisors or supernumerary teeth can erupt in the cleft area.5–7 The ideal period to perform a bone graft to the eruption of these teeth would be between 5 and 7 years, when teeth present one third or half of the root formation.8 The purpose of this study was to investigate (1) the influence of cleft type in the eruption of supernumerary teeth in the treatment of cleft palate with bone graft and (2) the durability of these teeth.
MATERIALS AND METHODS Medical records of patients treated in the Hospital for Craniofacial Anomalies Rehabilitation were assessed. The inclusion criteria were as follows: (1) patients with complete image documentation (occlusal and periapical radiographs of 40 days and 2 years) (Fig. 1); (2) patients undergoing alveolar bone graft placement; and (3) patients with malformed or supernumerary teeth in the cleft area and who do not present permanent teeth successors. The palatal clefts were classified according to the relationship with the incisive foramen as reference9 and were divided into 4 groups: unilateral preforaminal (UPF), unilateral transforaminal (UTF), bilateral preforaminal (BPF), and bilateral transforaminal (BTF). The scale of Bergland et al4 was used to determine the height of bone septum (Fig. 1A). This scale measures the amount of bone between the cervical area of the permanent canine and the © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
procedure in similar studies, but our results showed clearly that NLA increased in skeletonization, whereas NTP did not have a meaningful change in this step. In cephalic resection, NLA decreased about 2 degrees, and NTP was reduced about 0.5 mm. Although Guyuron4 and Ingels and Orhan11 reported that cephalic resection will increase NLA, both these studies did not analyze the effects of cephalic resection on NTP. We believe that even in conservative cephalic resection one of the main tip support mechanisms is weakened, so it is not surprising that it causes both NLA and NTP to reduce. However, it should be noted that results might change because of scar formation in the medium term after a couple of months. In next stage, 18- to 22-mm columellar struts were placed in all cases and resulted in about a 4-degree increase in NLA and 0.3-mm increase in the NTP. Nearly the same findings were reported by Guyuron.1–3 In Bafaqeeh’s16 study, columellar struts were placed in nearly half of their 61 patients. Strut was not effective in 12 patients, and it increased projection in 20 patients. In another study by Ingels and Orhan11 with nearly the same number of patients (n = 62), a cartilaginous strut was used in 36 patients, whereas 26 patients did not receive a strut. Results showed increased NTP and rotation and also an increased NLA for the strut group. Tip sutures are usually performed for different purposes. They may be used to rotate the tip, to narrow a wide tip, to equalize asymmetric domes, to increase and strengthen the support of tip, and to control the convexity of lateral crura. We used tip spanning sutures as the preferred method of the surgeon to refine the tip. It was performed in 18 of 50 patients. It caused about a 1-mm increase in NTP, and it did not affect the NLA. Guyuron and Behmand17 reported that interdomal suture, which is another technique of tip suture, will result in maximum 1- to 2-mm increase in NTP. As we see our knowledge of nasal dynamics increases, we will be able to obtain more predictable results and use these maneuvers more discriminately. As the authors of the current study aim to, further studies should investigate the long-term effects with inclusion of possible scar formation as well as other postoperative patientrelated and nonrelated factors, so that the knowledge in that field can further increase. In conclusion, different steps of rhinoplasty showed various impacts on the NLA and NTP. Whereas strut insertion caused the highest mean increase in NLA, tip spanning was the most effective regarding the change in NTP. Expectably, cephalic resection was associated with decrease in NLA and NTP.
REFERENCES 1. Guyuron B. Dynamics of rhinoplasty. Plast Reconstr Surg 1991; 88:970–978 2. Guyuron B. Dynamic interplays during rhinoplasty. Clin Plast Surg 1996;23:223–231 3. Guyuron B. Dynamics in rhinoplasty. Plast Reconstr Surg 2000;105:2257–2259 4. Guyuron B. Dynamics of rhinoplasty. Aesthetic Plast Surg 2002;26:S10 5. Fuleihan NS. The transvestibular approach: a new horizon in rhinoplasty. Arch Facial Plast Surg 2006;8:273–282 6. Zoumalan RA, Morris LG, Zeitler DM, et al. Effects of various submucous resection techniques of septal cartilage on nasal tip projection. Int Forum Allergy Rhinol 2001;1:78–82 7. Coskun BU, Sozen E, Seneldir S, et al. Does the open rhinoplasty incision decrease nasal projection? Eur Arch Otorhinolaryngol 2012;269:867–870 8. Chauhan N, Sardesai MG, Burchard AE, et al. Nasal tip refinement: analysis of surgical technique, efficacy, and secondary effect of skin thickness. Aesthet Surg J 2010;30;39–43 9. Corrado A, Bloom JD, Becker DG. Domal stabilization suture in tip rhinoplasty. Arch Facial Plast Surg 2009;11:194–197
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10. van Heerbeek N, Ingels KJ, van Loon B, et al. Three dimensional measurement of rhinoplasty results. Rhinology 2009;47:121–125 11. Ingels K, Orhan KS. Measurement of preoperative and postoperative nasal tip projection and rotation. Arch Facial Plast Surg 2006; 8:411–415 12. Ingels K, Orhan KS. Measuring nasal tip and double width; effect of transdomal and lateral crura suturing. Rhinology 2007;45:79–82 13. Yu MS, Jang YJ. Modified vertical dome division technique for rhinoplasty in Asian patients. Laryngoscope 2010;120:668–672 14. Sadeghi M, Saedi B, Arvin Sazegar A, et al. The role of columellar struts to gain and maintain tip projection and rotation: a randomized blinded trial. Am J Rhinol Allergy 2009;23:47–50 15. Spörri S, Simmen D, Briner HR, et al. Objective assessment of tip projection and the nasolabial angle in rhinoplasty. Arch Facial Plast Surg 2004;6:295–298 16. Bafaqeeh SA. Open rhinoplasty: effectiveness of different tip plasty techniques to increase nasal tip projection. Am J Otolaryngol 2000;21:231–237 17. Guyuron B, Behmand RA. Nasal tip sutures. Part II: the interplays. Plast Reconstr Surg 2003;112:1130–1145
Bipedicled Scalp Flaps for Reconstruction of High-Tension Electric Burns of Calvarium Chandan N. Jadhav, MBBS, MS, Ramesh Kumar Sharma, MBBS, MS Abstract: High-tension electrical calvarial burns are extremely rare and difficult to reconstruct. Invariably, these are third- or fourthdegree–deep burns involving the bone and underlying brain. Historically, these wounds have been treated conservatively, adding to morbidity and prolonged treatment. Two patients with high-tension electrical calvarial burns presented to us 2 weeks after the injury, one fourth–degree deep with infected necrotic calvarium and scalp, resulting in a full-thickness frontoparietal defect with herniation of the brain. The other patient had third-degree burns over the occiput with surrounding seconddegree–deep burns extending onto the nape of the neck with patches of second-degree deep burns over the vertex. Both patients had the risk for being subjected to prolonged anesthesia. The defects were covered with bipedicled scalp flap. In the face of sepsis and other comorbidities where more complicated flaps are risky, this flap provides a simple and reliable method of reconstruction. Key Words: Calvarial electrical burns, bipedicled scalp flap
From the Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Received September 23, 2013. Accepted for publication February 9, 2014. Address correspondence and reprint requests to Chandan N. Jadhav, MBBS, MS, MCh, No. 140/2-1, 3 Block, 4 Main, Thyagarajanagar, Bangalore 560028, India; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000886
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Brief Clinical Studies
H
igh-tension calvarial burns with involvement of the dura mater and brain, secondary to electrical injury, are rare. The resultant defect of the skull is a challenge to the reconstructive surgeon. Several methods of reconstruction have been described. Spontaneous separation of necrotic calvarium with skin grafting over the granulation tissue is no longer being followed because of delayed would healing.1,2 Doing burr holes in the outer table of the skull to promote granulation tissue, followed by coverage with skin grafts, is also a described method.1,2 Another alternative was to debride the necrotic scalp tissue, leaving behind the dead bone, to be covered by vascularized tissue. The dead bone acts as a scaffold for some amount of creeping substitution to occur from the surrounding calvarium.3 The use of local flaps, as well as free tissue transfers, had also been described.4–8 When the high-tension electrical injury extends to the brain, it can result in life-threatening neurologic sequelae. Debridement of significant brain matter can also result in various neurologic deficits. Immediate coverage of the exposed dura and brain is crucial to prevent cerebrospinal fluid (CSF) leak and decrease the risk for infection. Few cases have been reported, with high-tension electrical injury involving the dura mater and brain. We present 2 instances of high-tension electrical calvarial burns successfully covered with bipedicled scalp flaps.
CLINICAL REPORT Patient 1 A 28-year-old man was referred to us 2 weeks after a high-tension electrical injury, which he sustained accidentally on his right frontoparietal region of the calvarium. He also had a history of fall from height with contusion of the parietal cortex. He presented to us with infected wound over the partially debrided scalp and calvarium. Neurosurgery consultation was sought, and all the necrotic scalp, dead bone, dura, and necrotic brain were further debrided, resulting in a right frontotemporoparietal skull defect of 12 10 cm with herniating brain matter (Fig. 1). Postoperatively, the patient was on ventilator for approximately a week and had a motor response of withdrawal to painful stimulus. The patient was under high risk to be subjected to prolonged anesthesia. A reconstructive plan was made using the remaining part of the tongue lie scalp tissue, basing it anteriorly as a transposition flap to cover the temporal defect. The residual D-shaped defect was covered with bipedicled scalp flap running across the vertex, with one end based anteriorly on the left side and the other end posteriorly over the right side. This resulted in a robust flap receiving its blood supply from the left supratrochlear and supraorbital vessels and the right occipital vessel. Single-layer closure was done without repairing the dura. Donor defect was covered with intermediate-thickness split skin graft (SSG). Initially, prophylactic lumbar drain was used to prevent CSF leak. Two weeks after the operation, it was noted that both the flaps were well settled and that the suture line healed without any
FIGURE 1. Top right, Right frontotemporoparietal calvarial defect with herniated brain. Top left, Local anterior–based transposition flap from the tongue-shaped scalp tissue. Bottom right, Bipedicled scalp flap from the adjoining scalp, oblique orientation. Bottom left, Three weeks after the operation.
FIGURE 2. Top right, Exposed occiput and the surrounding granulation tissue over the nape of the neck. Top left, Bipedicled scalp flap based on the posterior auricular vessels. Bottom right, Surrounding raw area and donor defect skin grafted. Bottom left, Two months after the operation.
complications. The patient’s general condition improved, with spontaneous breathing effort and motor response of spontaneous movements. This patient did not have any significant neurologic deficit and was discharged 3 weeks postoperatively.
Patient 2 A 45-year-old man sustained a high-tension electrical injury to the occipital region accidentally at his workplace. He was referred to us 2 weeks after the injury with exposed occiput of 8 5 cm and dirty granulation tissue over the adjoining scalp and nape of the neck. He also had sustained patchy second-degree superficial burns over the vertex. He had associated cardiac and renal comorbidities, giving him an American Society of Anesthesiologists score of IV. In view of the high risk associated with prolonged anesthesia, a reconstructive plan of bipedicled scalp was made. This flap was based on the bilateral posterior auricular vessels. Intermediate-thickness SSG was used to cover the surrounding raw area and the donor area of the scalp (Fig. 2). The patient was followed up 2 months postoperatively, wherein he had well-settled hair-bearing bipedicled scalp flap and SSG over the nape of the neck and donor site of scalp. He was on postoperative scar management protocol to prevent contracture, hypertrophy, and restriction of neck movements.
DISCUSSION We have presented 2 successful cases using a bipedicled scalp flap for coverage of large calvarial defects, one with involvement of the dura and brain. The traditional surgical management of deep electrical burn injuries to the scalp and calvarium was to wait for spontaneous separation of necrotic bone. Recently, the management of these patients has involved staged excision of necrotic soft tissue, making drill holes of the outer table and waiting for granulation tissue to sprout, over which SSG is being done. However, this resulted in prolonged wound healing, painful dressing changes, and entrapment of sequestra.1–3,6 Bizhko and Slesarenko3 described a series of 22 patients with electrical injuries of the calvarium, who were managed with vascularized local flaps over exposed, devitalized bone. Immediate coverage of full-thickness calvarial defects is advised not only to prevent intracranial infection but also to decrease the morbidity with prolonged open wounds and prevent CSF leak.7,9 The 2 patients who presented to us had a patient’s general condition and other comorbidities not favoring prolonged anesthesia for microsurgical reconstruction. Hence, bipedicled scalp flaps formed a simple and reliable alternative as a local flap to cover these large defects. The bipedicled scalp flap is also very robust because it preserves bidirectional flow through choke anastomosis as described by Marty et al,10 allowing large flaps to survive. Dural reconstruction was not attempted in the first case because of significant cerebral edema, herniation of the brain through the calvarial defect, and the possibility of sequestration of infection.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e407
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Brief Clinical Studies
CONCLUSIONS Bipedicled scalp flaps are simple, useful, and reliable reconstructive option for large calvarial defects, especially in individuals not fit for prolonged microsurgery. It also has the advantage of replacing “like with like” tissue. Vascularized cover of these calvarial wounds is essential to prevent life-threatening infections and promote early recovery.
REFERENCES 1. Sheridan RL, Choucair RJ, Donelan MB. Management of massive calvarial exposure in young children. J Burn Care Rehabil 1998;19:29–32 2. Groenevelt F, van Trier AJ, Khouw YL. The use of allografts in the management of exposed calvarial electrical wounds of the skull. Ann N Y Acad Sci 1999;888:109–112 3. Bizhko IP, Slesarenko SV. Operative treatment of deep burns of the scalp and skull. Burns 1992;18:220–223 4. Benito-Ruiz J, Baena-Montilla P, Navarro-Monzonis A, et al. Severe electric injury of the skull. Burns 1994;20:553–556 5. Shen Z. Reconstruction of refractory defect of scalp and skull using microsurgical free flap transfer. Microsurgery 1994;15:633–638 6. Worthen EF. Surgical treatment of electrical burns of the scalp and skull: past and present. Clin Plast Surg 1982;9:161–165 7. Ioannides C, Fossion E, McGrouther AD. Reconstruction for large defects of the scalp and cranium. J Craniomaxillofac Surg 1999;27:153–159 8. Sun YH, Wang SH, Cao DX, et al. Early treatment of burned scalp and skull. Chin Med J (Engl) 1984;97:755–757 9. Barret JP, Dziewulski P, McCauley RL, et al. Dural reconstruction of a class IV calvarial burn with decellularized human dermis. Burns 1999;25:459–462 10. Marty F, Montandon D, Gumner R, et al. Subcutaneous tissue in the scalp: anatomical, physiological and clinical study. Ann Plast Surg 1986;16:368
Influence Analysis of Cleft Type and Supernumerary Teeth Eruption in the Prognosis of Bone Graft in Patients With Cleft Palate Cristiano Gaujac, DDS, MSc,* Eduardo Francisco de Souza Faco, DDS, MSc,* Elio Hitoshi Shinohara, DDS, PhD,† Renato Andre de Souza Faco, DDS, MSc,‡ Flávia Priscila Pereira, DDS, PhD,* Wirley Gonçalves Assunção, DDS, MSc§ From the *Field of Oral Implants; †Department of Surgery and Integrated Clinic, Universidade Estadual Paulista, Dental School of Araçatuba; Araçatuba Universidade Estadual Paulista (UNESP); ‡Hospital de Reabilitação de Anomalias Craniofaciais USP, Bauru, São Paulo; and §Department of Prosthesis, Dental School of Araçatuba, Araçatuba, São Paulo, Brazil. Received June 19, 2013. Accepted for publication February 10, 2014. Address correspondence and reprint requests to Cristiano Gaujac, DDS, MSc, Postgraduate Program in Dentistry, Field of Oral Implants, Campus Araçatuba, Dental School of Araçatuba, UNESP, Rua José Bonifácio, 1193, 16015-050 Araçatuba-São Paulo/Brazil. E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000903
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Objective: The aim of this study was to investigate the influence of cleft type and supernumerary tooth eruption on the treatment of palatal clefts with alveolar bone grafts. Materials and Methods: In this article, medical records of 40 patients with palatal clefts and associated supernumerary teeth who were treated with alveolar bone grafting in the Hospital for Craniofacial Anomalies Rehabilitation were assessed. The patients were studied to assess the influence of supernumerary teeth and the cleft severity on the prognosis of the alveolar bone graft. Results: Forty medical records were included in the assessment. When the teeth in the cleft had an anatomic shape close to canine, we called them precanine. When they were very small or malformed, we called them anomalous lateral incisors. The teeth studied showed good prognoses and were more expressive in the preforaminal clefts (87.5%) than in the transforaminal ones (62.5%). Moreover, the transforaminal clefts presented a higher percentage in satisfactory and poor prognoses (37.5%). The authors found that supernumerary teeth influenced the maintenance of alveolar bone graft height and that transforaminal clefts presented a worse prognosis than preforaminal clefts. Key Words: Cleft palate, bone graft, supernumerary teeth, treatment
S
ome dental malformations affecting patients with cleft lip and palate are related to the number, shape, size, time of formation, calcification, and eruption. In addition, both dentitions can be affected by these malformations.1 Dental abnormalities in number are 7 times more prevalent in patients with cleft lip and palate in comparison with the population in general.2 There is also a high incidence of this anomaly in the lateral incisors.3 Surgical treatments that reach only the soft tissue present a poor prognosis with limited orthodontic treatment. In addition, they also present instability of the maxillary segments, mainly in the premaxilla, in cases of bilateral clefts and nasal asymmetry by lack of alar base support (unilateral cases). Young patients need to use prosthesis in those cases.4 Similar to the canines that erupt through the bone graft, the lateral incisors or supernumerary teeth can erupt in the cleft area.5–7 The ideal period to perform a bone graft to the eruption of these teeth would be between 5 and 7 years, when teeth present one third or half of the root formation.8 The purpose of this study was to investigate (1) the influence of cleft type in the eruption of supernumerary teeth in the treatment of cleft palate with bone graft and (2) the durability of these teeth.
MATERIALS AND METHODS Medical records of patients treated in the Hospital for Craniofacial Anomalies Rehabilitation were assessed. The inclusion criteria were as follows: (1) patients with complete image documentation (occlusal and periapical radiographs of 40 days and 2 years) (Fig. 1); (2) patients undergoing alveolar bone graft placement; and (3) patients with malformed or supernumerary teeth in the cleft area and who do not present permanent teeth successors. The palatal clefts were classified according to the relationship with the incisive foramen as reference9 and were divided into 4 groups: unilateral preforaminal (UPF), unilateral transforaminal (UTF), bilateral preforaminal (BPF), and bilateral transforaminal (BTF). The scale of Bergland et al4 was used to determine the height of bone septum (Fig. 1A). This scale measures the amount of bone between the cervical area of the permanent canine and the © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
