The patient is examined within 24 hours. Expediency in treatment of large hematomas is essential to avoid compromise of flap vascularity and skin slough. Typically, within the first 48 hours after surgery, hematomas consist of a fresh clot of gel or liquid consistency. As the clot matures during the next several days, it becomes firmer and adherent to the underlying wound bed and cannot be easily aspirated. After approximately 2 weeks, fibrinolysis begins, and the hematoma liquefies Fig. At this point, repeated aspiration or drainage may be necessary to facilitate adherence of the flap to the wound bed Fig.
Partial primary wound closure was also planned at superior aspect of defect. Repair of smaller skin defect occurring in area of anticipated standing cutaneous deformity of rotation flap is noted. B, Wound repaired. C, Postoperative result at 2 weeks. Flap necrosis at peripheral border may have been related to development of hematoma at the base of flap.
Courtesy of Shan R. Baker, MD. B, Hematoma developed 1 week postoperatively, after restarting of anticoagulant medication warfarin. C, One month after evacuation of hematoma. Lower eyelid retraction noted. Massage of lower eyelid initiated. D, Postoperative result at 6 months. A thorough understanding and appreciation of facial anatomy is a crucial prerequisite for performing facial reconstructive procedures. Perhaps one of the most devastating complications associated with facial surgery is injury to the facial nerve or one of its branches.
Although it is rare, extensive dissection in the preauricular area could lead to injury to the main branch of the facial nerve. More commonly, the marginal mandibular or temporal branches of the facial nerve are injured. Familiarity with cross-sectional anatomy of the temple and mandibular regions is essential before surgical dissection in these areas.
Unfortunately, if more proximal branches of the facial nerve are cut, it leads to permanent impairment of facial movement because effective treatment is lacking. Sensory nerves are also susceptible to injury during facial reconstructive procedures. Extensive undermining along the superior bony orbital rim may injure the supraorbital and supratrochlear nerves, leading to dysesthesias in their sensory distributions.
The infraorbital and mental nerves are less susceptible to injury but may be compromised during dissection in their respective areas. The great auricular nerve may be injured during subcutaneous dissection in the periauricular area. This nerve is identified and preserved when skin is dissected away from its attachment to the superior aspect of the sternocleidomastoid muscle.
Local Flaps for Facial Reconstruction
Avoidance of injury to the nasal cartilaginous framework is important for nasal symmetry and function to be maintained. Inadvertent injury to these structures may lead to obvious nasal deformities, including alar retraction, nasal valve collapse, saddle nose deformity, and tip asymmetries. On occasion, preexisting structural abnormalities of the nose are corrected during reconstructive surgery of the nose, when the exposure of the nasal framework is sufficient to allow alterations that could provide potential improvement in aesthetic and functional outcomes.
Injury to eyelid structures may lead to devastating consequences, including lagophthalmos, lacrimal duct obstruction, visual field obstruction, and vision loss. Facial surgeons should be familiar with the cross-sectional anatomy of the upper and lower eyelids, especially the connective tissue support apparatus and the position and location of the levator muscle. Injury to these structures is best avoided because treatment is extremely difficult if scarring has occurred. Fortunately, infection during facial surgery is reported to be as low at 2. Higher infection rates are associated with wounds that are repaired in a delayed fashion, as is often the case with facial flaps used to repair wounds created by micrographic surgery.
Wound infection is associated with poor outcomes. Infection of a cutaneous flap is usually associated with distortion from inflammatory edema. Release of toxic substances and free radicals from inflammatory mediators leads to decreased collagen production and early degradation of suture materials with potential wound dehiscence. Necrosis of all or part of the flap may develop, with the final scar being widened or thickened.
Systemic dissemination of bacteria may occur if wound infections are not treated promptly. Although perioperative antibiotic prophylaxis is controversial in clean wounds, it has been shown to be effective in decreasing wound infection rates when it is used for clean-contaminated wounds. It is also important to avoid crushed, charred, or excessively thinned tissue. Staphylococcus aureus is the most common single pathogen causing wound infections, but streptococci, gram-negative bacteria, and oral anaerobes may also be isolated from infected wounds.
They are also employed in patients with underlying medical conditions that may predispose to infection, such as diabetes and immunosuppression. In these cases, a preoperative dose of intravenous cephalosporin is administered, followed by 5 days of an oral cephalosporin. In penicillin-allergic patients, clindamycin is used. In patients with open wounds older than 3 days, a 5-day course of oral cephalosporin is recommended before the surgical repair. This will decrease the bacterial colonization of the granulation tissue that has developed in the depths of the wound. Excessive pain or erythema at the wound site may herald an infection Fig.
These clinical signs usually appear between the fourth and eighth days after wound closure. Make area accessible to the instruments. Lengthen clinical crown.
Reconstruction of facial defects with local flaps – a training model for medical students?
Create easily clearable gingival — alveolar form. A, Removal of a pocket distal to the maxillary second molar may be difficult if there is minimal attached gingiva. If the bone ascends acutely apically, the removal of this bone may make the procedure easier. B, Long distal tuberosity with abundant attached gingiva is an ideal anatomic situation for distal pocket eradication.
The shorter this area, the more difficult it is to treat any deep distal lesion around the terminal molar. A, Pocket eradication distal to a mandibular second molar with minimal attached gingiva and a close ascending ramus is anatomically difficult. B, For surgical procedures distal to a mandibular second molar, abundant attached gingiva and distal space are ideal. Modified distal wedge procedure Buccal and palatal flaps are elevated a and the rectangular wedge is released from the tooth and underlying bone by sharp dissection and removed b.
Modified distal wedge procedure. Following bone recontouring and root debridement, the flaps are trimmed and shortened to avoid overlapping wound margins and sutured a. A close soft tissue adaptation should be accomplished to the distal surface of the molar. The remaining fibrous tissue pad distal to the buccolingual incision line is "leveled" by the use of a gingivectomy incision. Depending on the shape of the point; The following qualities of the ideal suture material are compiled from Postlethwait ,Varma and colleagues , and Ethicon : 1.
Pliability, for ease of handling 2. Knot security 3. Sterilizability 4. Appropriate elasticity 5. Nonreactivity 6. Adequate tensile strength for wound healing 7. Chemical biodegradability as opposed to foreign body breakdown The closeness of sutures depend upon the underlying tension across the suture line. Closer spaced sutures are indicated in areas of underlying muscular activity such as tongue or in other areas of increased tension.
It is a papillary preservation technique. The suturing permits coronal positioning, flap stabilization, and primary interproximal closure. This technique is recommended for use only with modified Widman flaps and regeneration procedures in which there is adequate thickness of the papillary tissue. The technique involves use of one of the interrupted sutures, which is either anchored about the adjacent or slung around the tooth to hold both papillae. When multiple teeth are involved, this is preferred.
The main disadvantage of continuous sutures is that if the suture breaks, the flap may become loose or the suture may come untied from multiple teeth. This suture is often used for the interproximal areas of diastema 2. This is most often the case on the palate, where additional tension is often required, or when the papillary tissue is thin and friable. Continuous locking suture used primarily for edentulous areas. The needle is placed at the line angle area of the facial or lingual flap adjacent to the tooth, anchored around the tooth, passed beneath the opposite flap, and tied.
A to D, Distal wedge suture. This suture is also used to close flaps that are mesial or distal to a lone-standing tooth. The closed anchor suture, another technique to suture distal wedges. Penetration : the needle point is positioned perpendicular to the tissue surface and underlying bone. It is the inserted completely through the tissue until bone is engaged.
Rotation : the body is now rotated about the needle point in the direction opposite to that in which the needle is intended to travel. The needle point is held lightly against the bone so as not to damage or dull the needle point. Care must be taken not to lift or damage the periosteum. In this way, the needle will not be pushed through the tissue.
Exit : the final stage of gliding and rotation is needle exit. Periosteal sutures for an apically displaced flap.
Holding sutures, shown at the bottom, are done first, followed by the closing sutures, shown at the coronal edge of the flap. Knot must be firm …. Knot should not be placed on incision lines.. Avoid excessive tension….. An added throw does not increase the strength of the knot. Final tension or final throw should be as nearly horizontal as possible.
The area should be swabbed with hydrogen peroxide for removal of encrusted necrotic debris, blood, and serum from about the sutures. A sharp suture scissors should be used to cut the loops of individual or continuous sutures about the teeth. The location of the knots should be noted so that they can be removed first. This will prevent unnecessary entrapment under the flap. Cohen Once it is tightened to the desired extent, it can be locked into place by another over hand knot, made in opposite direction of first two. This ability to be tightened makes the slip knot extremely useful in many surgical situations example it can be used to stretch flaps to achieve primary healing over a surgical site.
Introduced in by Dr. Peripac — this is a pre mixed dressing. Methacrylic gels exhibit clase adaptation, constant flow for 3 days and excellent compatibilty with wound site. Collagen dressing: it is a collagen sponge.
Eg: Collacote —type I collagen derived from bovine Achilles tendon. Cyanoacrylates: with the spray, an application of cyanoacrylate can be completed in 0. Limitations: Not the choice of dressing to be used in situations where the flap has to be apically retained ,due to its soft state before curing.
Contain polymerisable monomers which may cause skin sensitization. In favour ward in advocated the use of wonder pack to avoid pain, infection, root sensitivity. Linghorne in , studied different periodontal dressings to determine their bacteriostatic properties and found it to be an effective bacteriostatic agent. Loe and Slilness , reported that dressing provided more favorable environment for healing. Blanquie stated that porpose of dressing is to control post operative discomfort, act as a splint for losse teeth, allow tissue healing under aseptic conditions,prevent re establishment of periodontal pocket and desenitize denuded cementum.
Jones and Cassingham in their study concluded that dressings caused more pain and discomfort to the patients without serving any useful purpose in flap surgery. It refreshes the mouth and decrease plaque formation in the oral cavity which is usually increased postoperatively because of the compromised toothbrushing of the patient. DAY 1 Analgesics,cold packs, avoidance of wound disturbance After day 1 Pain , swelling, bleeding should diminish or disappear. Chemical plaque control recommended. After 5 — 10 days: Remove dressing and sutures, Professionally de — plaque supragingivally.
The dento gingival junction should not be probed or instrumented for 6 to 8 weeks following surgery. There are also bacteria and an exudates or transudate as a result of tissue injury. The blood clot is replaced by granulation tissue derived from the gingival connective tissue, the bone marrow and periodontal ligament. Union of the flap to the tooth is still weak, owing to the presence of immature collagen fibers, although the clinical aspect may be almost normal.
There is a beginning of functional arrangement of the supra crestal fibers. This results in a bone loss of about 1 mm; the bone loss is greater if the bone is thin. However, in interdental areas, which have cancellous bone, the subsequent repair results in total restitution without any loss of bone, bone repair results in loss of marginal bone. No regeneration at the edges of the wound. Corners of the wound show revascularization.
Flap Definition, History, and Classification
Rete pegs flat. Collagen metabolism You just clipped your first slide! Clipping is a handy way to collect important slides you want to go back to later. Now customize the name of a clipboard to store your clips. Visibility Others can see my Clipboard. Cancel Save. J Infect Chemother. Risk factors for wound infection after surgery in primary oral cavity cancer patients. Multivariate analysis of risk factors for wound infection in head and neck squamous cell carcinoma surgery with opening of mucosa. Study of surgical procedures. Oral Oncol.
JAMA Surg. Risk factors for postoperative complications in oral cancer and their prognostic implications. Arch Otolaryngol Head Neck Surg. Risk factors of postoperative infection in head and neck surgery. Auris Nasus Larynx. Risk factors of surgical site infection in patients undergoing major oncological surgery for head and neck cancer. Risk factors for surgical site infection in cervico-facial oncological surgery.
Local Flaps for Facial Reconstruction | Pocket Dentistry
J Craniomaxillofac Surg. Methods to reduce postoperative surgical site infections after head and neck oncology surgery. Lancet Oncol. Surgical errors and risks - the head and neck cancer patient. Ota Y. Research on actual condition of intraoral complications by cancer treatment and establishment of its prevention method.
A clinical study of postoperative infection in oral and maxillofacial surgery. J Jpn Stomatol Soc. Oral health care reduces the risk of postoperative surgical site infection in inpatients with oral squamous cell carcinoma. Support Care Cancer. Accessed April; Influence of toothbrushing, eating and smoking on Dentocult SM Strip mutans test scores. Oral Microbiol Immunol. Marsh PD. Dental plaque: biological significance of a biofilm and community life-style. J Clin Periodontol. Collins LM, Dawes C. The surface area of the adult human mouth and thickness of the salivary film covering the teeth and oral mucosa.
J Dent Res. Ecological approaches to oral biofilms: control without killing. Caries Res. Periodontal microbial ecology. Periodontol The time course and microbiology of surgical site infections after head and neck free flap surgery. The oral microbiome-an update for oral healthcare professionals. Br Dent J. Ritz HL.
Microbial population shifts in developing human dental plaque.
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Arch Oral Biol. Scannapieco FA. Role of oral bacteria in respiratory infection. J Periodontol. In vitro release of elastase from human blood and gingival crevicular neutrophils. Microbial biofilms. Ann Rev Microbiol. Arweiler NB, Netuschil L. The Oral Microbiota. Adv Exp Med Biol. Microbiological and clinical effects of a single course of periodontal scaling and root planing, and of adjunctive tetracycline therapy. Radiotherapy and wound healing. Int Wound J. Risk factors for wound infection in head and neck cancer surgery: a prospective study.
Head Neck. Development, testing, and application of the oral assessment guide. Oncol Nurs Forum. The oral health assessment tool-validity and reliability. Aust Dent J.