Dermatologic surgery
Titanium mesh in the reconstruction of a malar defect: a case report Ant onio Fernandes Massa1,2, MD, Mercedes Otero-Rivas2, MD, and Manuel Angel 2 Rodrıguez-Prieto , MD
1 Department of Dermatology, Centro Hospitalar de Vila Nova de Gaia/Espinho (Vila Nova de Gaia and Espinho Hospital Center), Vila Nova de Gaia, Portugal, and 2 Department of Dermatology, Complejo n (Care Asistencial Universitario de Leo n), Leo n, Complex of the University of Leo Spain
Correspondence nio F. Massa, MD Anto Servicßo de Dermatologia Centro Hospitalar V. N. Gaia/Espinho, EPE ~o Fernandes Rua Conceicßa 4430 Vila Nova de Gaia, Portugal Tel: + 351 22 786 5100 E-mail: [email protected]
Abstract Background Increasing rates of non-melanoma skin cancer support the use of prosthetic materials for the closure of post-surgical defects with cartilage or bone involvement. The use of allografts, especially titanium, is well established in maxillofacial procedures but is uncommon in dermatologic surgery. Methods A 92-year-old man presented with a basal cell carcinoma measuring 293 cm on the right cheek. Computed tomography showed infiltration of the anterior maxillary sinus wall. The tumor was excised under general anesthesia. The final defect comprised skin, muscle, the central portion of the maxillary bone and part of the maxillary sinus mucous. The defect was closed with titanium mesh and covered with a rotation flap from the right cheek. The secondary defect created by the preauricular rotation was closed with a free skin graft from the supraclavicular area. Results The use of titanium mesh enabled satisfactory esthetic and functional results to be achieved safely and quickly. Conclusions Titanium mesh facilitates the repair of large defects and avoids the second
Conflicts of interest: None.
intervention and increased risk for infection associated with bone grafting. Reconstruction with titanium mesh is considered a valuable technique in post-trauma fractures and postoncologic defects but remains underused in dermatologic surgery. The present experience supports its use as a reliable option in bone replacement.
1278
Introduction
Materials and methods
The increasing incidence of non-melanoma skin cancer and rising demand for easier and safer surgical solutions support the use of prosthetic materials for the closure of large post-surgical defects with cartilage or bone involvement. The use of allografts, especially titanium, is well established in the repair of defects in the nasal,1 frontozygomatico-orbital,2,3 maxillary,4 and temporal5 areas. Although it is frequently used in maxillofacial procedures, this technique is uncommon in dermatologic surgery. Because titanium mesh has been used successfully in nasal reconstruction in our center,1 we employed this technique in a mid-face reconstruction. The advantages of titanium over other materials refer to its biocompatibility, versatility, and stability. It is malleable but firm, and its use is not limited by the size of the defect. Titanium mesh does not migrate because connective tissue grows through and around its lattice structure,2 and it has proven to be a safe and reliable material that carries little risk for infection and achieves good functional results.1,2,5
We present a 92-year-old man with a basal cell carcinoma
International Journal of Dermatology 2014, 53, 1278–1280
measuring 293 cm on the right cheek (Fig. 1a). The patient had demonstrated this lesion for seven years and had refused surgery six years previously. The lesion was ulcerated at its center and infiltrative under palpation. No regional lymph node involvement was detected. Computed tomography showed, as expected, infiltration of the anterior maxillary sinus wall. The tumor was excised under general anesthesia, and three stages of Mohs micrographic surgery were performed to result in the final defect (Fig. 1b). It comprised skin, muscle, the central portion of the maxillary bone, and part of the maxillary sinus mucous. To close this defect, we used a titanium mesh sheet (Synthes-Stratec Medical SA, Madrid, Spain) (Fig. 2), conveniently modeled and fixed to the periosteum with 4/0 absorbable polyglycolic acid sutures. To achieve cutaneous coverage, we performed a rotation flap on the right cheek. We then employed a free skin graft from the supraclavicular area to repair the secondary defect created by the preauricular rotation. ª 2014 The International Society of Dermatology
Massa et al.
Figure 1 (a) Basal cell carcinoma measuring 293 cm on the right cheek accompanied by ectropion in a 92year-old man at presentation and (b) the final defect after surgery
Titanium mesh in the reconstruction of a malar defect
(a)
Dermatologic surgery
(b)
Figure 2 Titanium mesh was inserted and modeled to repair the bone defect
Results The procedure achieved good functional and cosmetic results (Fig. 3). The ectropion of the right lower eyelid was present prior to surgery and was not corrected because the patient and his family refused a canthopexy. Discussion We have found titanium mesh to be a valuable tool in the repair of large bone defects. It provides a safe and quick approach that is effective in achieving the esthetic and functional goals of reconstruction, without ª 2014 The International Society of Dermatology
Figure 3 The patient demonstrates good cosmetic results at 8 weeks after surgery
the inconvenience of bone grafting, which requires a second intervention and carries a correspondingly increased risk for infection and necrosis. Among the complications recognized as associated with the use of allogenic materials are infection and extrusion, but long-term follow-up studies of titanium mesh in orbital reconstruction3 have established the safety and efficacy of this technique. Based on published studies and our International Journal of Dermatology 2014, 53, 1278–1280
1279
1280
Dermatologic surgery
Titanium mesh in the reconstruction of a malar defect
personal experience with this material, we do not believe that immunosuppressive therapy should be regarded as a contraindication. There also exists a risk for interference (but not impedance) with dosimetry and for radionecrosis.6
2
Conclusions
3
Reconstruction with titanium mesh is already considered a valuable technique in the correction of post-trauma fractures and post-oncologic defects in most surgical specialties. It remains underused in dermatologic surgery; however, our limited but reassuring experience leads us to believe it should be regarded as a reliable option in bone replacement.
4
5
6
References 1 Rodrˇguez-Prieto MA, Perez-Bustillo A, Alonso-Alonso T, et al. Partial nasal reconstruction with titanium
International Journal of Dermatology 2014, 53, 1278–1280
Massa et al.
mesh: report of five cases. Br J Dermatol 2009; 161: 683–687. Lazaridis N, Makos C, Iordanidis S, et al. The use of titanium mesh sheet in the fronto-zygomatico-orbital region. Case reports. Aust Dent J 1998; 43: 223–228. Gear AJ, Lokeh A, Aldridge JH, et al. Safety of titanium mesh for orbital reconstruction. Ann Plast Surg 2002; 48: 1–7. Dediol E, Uglesic V, Zubcic V, et al. Brown class III maxillectomy defects reconstruction with prefabricated titanium mesh and soft tissue free flap. Ann Plast Surg 2013; 71: 63–67. Guo J, Tian W, Long J, et al. A retrospective study of traumatic temporal hollowing and treatment with titanium mesh. Ann Plast Surg 2012; 68: 279–285. Allal AS, Richter M, Russo M, et al. Dose variation at bone/titanium interfaces using titanium hollow screw osseointegrating reconstruction plates. Int J Radiat Oncol Biol Phys 1998; 40: 215–219.
ª 2014 The International Society of Dermatology
Titanium mesh in the reconstruction of a malar defect: a case report Ant onio Fernandes Massa1,2, MD, Mercedes Otero-Rivas2, MD, and Manuel Angel 2 Rodrıguez-Prieto , MD
1 Department of Dermatology, Centro Hospitalar de Vila Nova de Gaia/Espinho (Vila Nova de Gaia and Espinho Hospital Center), Vila Nova de Gaia, Portugal, and 2 Department of Dermatology, Complejo n (Care Asistencial Universitario de Leo n), Leo n, Complex of the University of Leo Spain
Correspondence nio F. Massa, MD Anto Servicßo de Dermatologia Centro Hospitalar V. N. Gaia/Espinho, EPE ~o Fernandes Rua Conceicßa 4430 Vila Nova de Gaia, Portugal Tel: + 351 22 786 5100 E-mail: [email protected]
Abstract Background Increasing rates of non-melanoma skin cancer support the use of prosthetic materials for the closure of post-surgical defects with cartilage or bone involvement. The use of allografts, especially titanium, is well established in maxillofacial procedures but is uncommon in dermatologic surgery. Methods A 92-year-old man presented with a basal cell carcinoma measuring 293 cm on the right cheek. Computed tomography showed infiltration of the anterior maxillary sinus wall. The tumor was excised under general anesthesia. The final defect comprised skin, muscle, the central portion of the maxillary bone and part of the maxillary sinus mucous. The defect was closed with titanium mesh and covered with a rotation flap from the right cheek. The secondary defect created by the preauricular rotation was closed with a free skin graft from the supraclavicular area. Results The use of titanium mesh enabled satisfactory esthetic and functional results to be achieved safely and quickly. Conclusions Titanium mesh facilitates the repair of large defects and avoids the second
Conflicts of interest: None.
intervention and increased risk for infection associated with bone grafting. Reconstruction with titanium mesh is considered a valuable technique in post-trauma fractures and postoncologic defects but remains underused in dermatologic surgery. The present experience supports its use as a reliable option in bone replacement.
1278
Introduction
Materials and methods
The increasing incidence of non-melanoma skin cancer and rising demand for easier and safer surgical solutions support the use of prosthetic materials for the closure of large post-surgical defects with cartilage or bone involvement. The use of allografts, especially titanium, is well established in the repair of defects in the nasal,1 frontozygomatico-orbital,2,3 maxillary,4 and temporal5 areas. Although it is frequently used in maxillofacial procedures, this technique is uncommon in dermatologic surgery. Because titanium mesh has been used successfully in nasal reconstruction in our center,1 we employed this technique in a mid-face reconstruction. The advantages of titanium over other materials refer to its biocompatibility, versatility, and stability. It is malleable but firm, and its use is not limited by the size of the defect. Titanium mesh does not migrate because connective tissue grows through and around its lattice structure,2 and it has proven to be a safe and reliable material that carries little risk for infection and achieves good functional results.1,2,5
We present a 92-year-old man with a basal cell carcinoma
International Journal of Dermatology 2014, 53, 1278–1280
measuring 293 cm on the right cheek (Fig. 1a). The patient had demonstrated this lesion for seven years and had refused surgery six years previously. The lesion was ulcerated at its center and infiltrative under palpation. No regional lymph node involvement was detected. Computed tomography showed, as expected, infiltration of the anterior maxillary sinus wall. The tumor was excised under general anesthesia, and three stages of Mohs micrographic surgery were performed to result in the final defect (Fig. 1b). It comprised skin, muscle, the central portion of the maxillary bone, and part of the maxillary sinus mucous. To close this defect, we used a titanium mesh sheet (Synthes-Stratec Medical SA, Madrid, Spain) (Fig. 2), conveniently modeled and fixed to the periosteum with 4/0 absorbable polyglycolic acid sutures. To achieve cutaneous coverage, we performed a rotation flap on the right cheek. We then employed a free skin graft from the supraclavicular area to repair the secondary defect created by the preauricular rotation. ª 2014 The International Society of Dermatology
Massa et al.
Figure 1 (a) Basal cell carcinoma measuring 293 cm on the right cheek accompanied by ectropion in a 92year-old man at presentation and (b) the final defect after surgery
Titanium mesh in the reconstruction of a malar defect
(a)
Dermatologic surgery
(b)
Figure 2 Titanium mesh was inserted and modeled to repair the bone defect
Results The procedure achieved good functional and cosmetic results (Fig. 3). The ectropion of the right lower eyelid was present prior to surgery and was not corrected because the patient and his family refused a canthopexy. Discussion We have found titanium mesh to be a valuable tool in the repair of large bone defects. It provides a safe and quick approach that is effective in achieving the esthetic and functional goals of reconstruction, without ª 2014 The International Society of Dermatology
Figure 3 The patient demonstrates good cosmetic results at 8 weeks after surgery
the inconvenience of bone grafting, which requires a second intervention and carries a correspondingly increased risk for infection and necrosis. Among the complications recognized as associated with the use of allogenic materials are infection and extrusion, but long-term follow-up studies of titanium mesh in orbital reconstruction3 have established the safety and efficacy of this technique. Based on published studies and our International Journal of Dermatology 2014, 53, 1278–1280
1279
1280
Dermatologic surgery
Titanium mesh in the reconstruction of a malar defect
personal experience with this material, we do not believe that immunosuppressive therapy should be regarded as a contraindication. There also exists a risk for interference (but not impedance) with dosimetry and for radionecrosis.6
2
Conclusions
3
Reconstruction with titanium mesh is already considered a valuable technique in the correction of post-trauma fractures and post-oncologic defects in most surgical specialties. It remains underused in dermatologic surgery; however, our limited but reassuring experience leads us to believe it should be regarded as a reliable option in bone replacement.
4
5
6
References 1 Rodrˇguez-Prieto MA, Perez-Bustillo A, Alonso-Alonso T, et al. Partial nasal reconstruction with titanium
International Journal of Dermatology 2014, 53, 1278–1280
Massa et al.
mesh: report of five cases. Br J Dermatol 2009; 161: 683–687. Lazaridis N, Makos C, Iordanidis S, et al. The use of titanium mesh sheet in the fronto-zygomatico-orbital region. Case reports. Aust Dent J 1998; 43: 223–228. Gear AJ, Lokeh A, Aldridge JH, et al. Safety of titanium mesh for orbital reconstruction. Ann Plast Surg 2002; 48: 1–7. Dediol E, Uglesic V, Zubcic V, et al. Brown class III maxillectomy defects reconstruction with prefabricated titanium mesh and soft tissue free flap. Ann Plast Surg 2013; 71: 63–67. Guo J, Tian W, Long J, et al. A retrospective study of traumatic temporal hollowing and treatment with titanium mesh. Ann Plast Surg 2012; 68: 279–285. Allal AS, Richter M, Russo M, et al. Dose variation at bone/titanium interfaces using titanium hollow screw osseointegrating reconstruction plates. Int J Radiat Oncol Biol Phys 1998; 40: 215–219.
ª 2014 The International Society of Dermatology
