Главная страница arrow Библиотека arrow Публикации англоязычные arrow Use of porous polyethylene for correcting defects





Забыли пароль?
Ещё не зарегистрированы? Регистрация
Use of porous polyethylene for correcting defects
Автор A. Baj, S. Spotti, S. Marelli, G.A. Beltramini, A.B. Giannм   

Transposition of the temporalis myofascial flap results in permanent aesthetic stigma in the donor site. Reconstruction of this deformity is

desirable. The Authors present personal experience in the use of a porous polyethylene prosthesis to camouflage the temporal defects following

transposition of the temporalis myofascial flap. From 2002 to 2005, 12 patients (5 male, 7 female, age range 36–84 years, mean 60),

following the transposition of the temporalis myofascial flap, underwent reconstruction of the temporal region defect using porous highdensity

polyethylene temporal implants. The majority of the neoplasms removed proved to be squamous cell carcinomas of the alveolar

crest or of the sinusal antrum. The standard surgical technique was used, namely, hemicoronal access and placement of 12 porous highdensity

polyethylene prostheses (5 left, 7 right). The size of the implants to be used (small, medium, large) was decided during the surgical

operation. Of the 12 patients, 2 underwent post-operative radiotherapy, 6 weeks after the implantation of the prosthesis, without adopting

any particular precautions to protect the area directly involved in the prosthesis implant. All patients are alive and free from disease, and

implant placement appears to be free from post-operative complications. During the period of radiotherapy no complications. directly or

indirectly related to the prosthetic implant, arose. Placement of the high-density polyethylene prosthesis fulfilled its filling effect on the

deficit with a cosmetic success rate of 90%, as it was well integrated with no evident discontinuity between the edges of the prosthesis and

the surrounding tissue or any alteration in the physiological convexity of the treated region. There were no incidents of pain or dysaesthesia

of the skin covering the prosthesis. In conclusion, reconstruction of the temporal defect after temporalis myofascial flap transposition with

the use of high-density polyethylene implants is an easy and safe method, with excellent functional and aesthetic results.

Introduction

Reconstruction of maxillary defects following removal of

malignant tumours from the upper maxilla has evolved

significantly over the last 15 years and the techniques

most commonly applied today are based on the use of

microvascular flaps
1; however, if it is not possible to prepare

a microvascular flap, one of the most frequently used

reconstructive options is the transposition of the temporalis

myofascial flap (TMF)
2. The TMF, quick and easy

to prepare, has been used for over a century for covering

medium-large congenital, traumatic and oncological

defects and its use has been widely documented in the

international literature
3-6.

One of the main drawbacks of the transposition of this

flap is the permanent residual aesthetic stigma in the temporal

region. From the very first applications of the TMF,

attempts to achieve craniomaxillofacial reconstruction,

such as splitting the temporalis, have been applied aimed

at minimizing the negative aesthetic aspects incurred.

The Authors present their experience in using a porous

polyethylene prosthesis to camouflage the temporal defects

following the transposition of the temporalis muscle.

Materials and methods

Between January 2002 and January 2005, 12 patients (5

male, 7 female, aged between 36–84 years: mean 60), following

the transposition of the TMF, underwent reconstruction

of the temporal region defect using prefabricated

sterile porous high-density polyethylene (HDPE) temporal

implants.

The majority of the neoplasms removed proved to be squamous

cell carcinomas of the alveolar crest or of the sinusal

antrum and the remaining deficits, resulting from

maxillectomy, were classified according to the 1997 Spiro

index
7.

Reconstruction surgery was carried out at the same time

as maxillectomy in all 12 cases.

The standard surgical technique applied was hemicoronal

access and placement of the HDPE prostheses (5 left,

7 right) (Figs. 1-2). The size of the implants to be used

(small, medium, large) was decided during the surgical

operation.

The largest prosthesis was not used in any of the 12 patients

as its excessive dimensions made it impossible to

disguise its outline and, therefore, it offered poor localregional

cosmetic results.

In our experience, the small size proved suitable for female

patients whilst the medium size was more than sufficient

for defects in male patients.

Results

The follow-up period for this type of patient varies between

a minimum of one to a maximum of three years. To

date, all the patients are alive and free from disease, and

implant placement appears to be free from post-operative

complications, both immediate and later with a 100% success

rate.

In all cases, the prosthesis had to be remodelled in order

to adapt it to the infra-temporal region, with the most frequent

modifications being reduction and shortening of the

implant.

All implants were soaked in an antibiotic solution before

placement and, once positioned, were sprayed with the

same solution before being stabilized and covered by the

tailored flap.

Of the 12 patients, 2 underwent post-operative radiotherapy

(RT), 6 weeks after implantation of the prosthesis,

without adopting any particular precautions to protect the

area directly affected by the prosthesis implant. During

the period of RT, no complications, directly or indirectly,

related to implant of the prosthesis occurred.

The radiological findings of the prosthesis proved to be

identical to those of the contralateral temporal musculature.

Placement of the HDPE prosthesis has displayed its

filling effect on the deficit, with a good cosmetic result, in

all our patients, as it was well integrated with no evident

Fig. 1. Intra-operative view: temporalis myofascial flap. discontinuity between the edges of the prosthesis and the

surrounding tissue or any alteration in the physiological

convexity of the region treated (Figs. 3A-3B).

There were no cases of pain or dysesthesia of the skin

covering the prosthesis; great care and attention were focused

on the hemicoronal suture, in order to prevent margin

inversion, as well as on post-operative management

of the wound.

Discussion

The surgical treatment of tumours located in the middle

third of the face presents a reconstruction challenge to the

cervicofacial surgeon, in terms of oncological resection

and reconstruction of the residual deficit
1 8.

Bone-containing free flaps provide the best solution for

maxillary reconstruction needs. Transposition of the temporalis

muscle is the method of choice for reconstruction

in most cases when preparation of a microsurgical

flap is not an option. Unfortunately, however, the loss

of volume, in the temporal region, results in profile deformity

in this area, characterized by a depression and

consequently over-projection of the zygomatic arch and

cheek bone which, from an aesthetic point of view, is less

than desirable (Fig. 4). The aesthetic deficit, in the temporal

region, thus objectively represents a post-operative

complication common to every operation of this type.

Reconstruction to repair the profile deformity after the

preparation of a TMF, should be aimed at overcoming the

residual subcutaneous histic deficit by placing an implant

to reduce the volume of the defect caused by the transposition

of the
temporalis, thus restoring facial symmetry 9.

The ideal filling material for this type of defect needs to

have specific structural characteristics which favour tissue

growth and endoprosthetic vascularization, providing

greater adaptability and integration with the skeletal

structure with which it comes into contact, and ensuring

it maintains its position and three-dimensional compensation

effect over time
10.

Over the last 15 years, numerous alloplastic materials

have been used to reconstruct the donor site after TMF

transposition, amongst which, the most frequently employed

has been acrylic bone cement.

Over the last few years, research and industry, in this

sector, have made various bio-compatible allogenic implants

available, based on different molecular and structural

compounds, each of which with its own advantages

and disadvantages
11. Bio-materials, on account of their

chemo-physical characteristics, have intrinsic properties

which are fundamental to the application for which they

are used: bio-compatibility with the implant site to reduce

the risk of immunologic reaction and rejection, morphologic

and volumetric stability of the prosthesis over time,

rapid endo-prosthetic vascularization to reduce the risk

of infection and, last but not least, easy application and

malleability of the material to reduce the risk of it being

visible.

With the parallel development of means of osteosynthesis,

over the last decade, and titanium stabilizers, possibilities

for three-dimensional reconstruction have increased enormously

Polyethylene has been used since 1947 as a synthetic

replacement for deformed or hypoplastic osteocartilaginous

parts and the studies of Rubin and Yaremchuk 12

have demonstrated that this material has the ideal characteristics

for use in reconstructive surgery for the aesthetic-

functional restoration of facial flap donor sites.

Our experience, at present, is limited to a group of 12

patients, in whom we achieved a rapid and satisfactory

camouflaging of the
temporalis myofascial flap donor site

with the use of HDPE prostheses.

The results, at 3-year follow-up, remain stable and symmetry

of the temporal region shows no sign of integument

depletion or surfacing of the prosthetic material (Figs.

3A-3B).

In fact, the use of the prosthesis, purely as a filling and camouflaging

element and not as a support for soft tissues, minimizes

the natural decubitus tendency of the bio-materials.

In conclusion, in our experience, HDPE has proved,

thanks to its bio-compatibility, morphologic and volumetric

stability over time, rapid vascularization and easy

application, to be the most suitable material for the reconstruction

and enhancement of bone contours in craniofacial

profile correction in patients who have undergone

TMF transposition.

The use of HDPE prostheses in the reconstruction of defects

in the temporal region following transposition of a

TMF would appear to be a safe and efficacious method,

without serious immediate and long-term post-operative

complications
13‑15; in patients undergoing RT, the medium/

short-term results would appear to be the same as

those in patients who did not receive this type of treatment,

thus confirming the wide range of application for

the HDPE prosthesis.

References

1 Rogers SN, Lowe D, McNally D. Health-related quality

of life after maxillectomy: a comparison between

prosthetic obturation and free flap
. J Oral Maxillofac Surg

2003;61:174–81.

2 Bradley P, Brockbank J. The temporalis muscle flap in oral

reconstruction. J Maxillofac Surg 1981;9:139–45.

3 Shagets FW, Panje WR, Shore JW. Use of temporalis muscle flaps in complicated defects of the head and face. Arch

Otolaryngol Head Neck Surg 1986;112:60–5.

4 Koranda FC, McMahon MF, Jernstrom VR. The temporalis muscle flap for intraoral reconstruction. Arch Otolaryngol

Head Neck Surg 1987;113:740–3.

5 Habel G, Hensher R. The versatility of temporalis muscle flap in reconstructive surgery. Br J Oral Maxillofac Surg

1986;24:96–101.

6 Colmenero C, Martorell V, Colmenero B. Temporalis myofascialflap for maxillofacial reconstruction. J Oral Maxillofac

Surg 1991;49:1067–73.

7 Spiro RH, Strong EW, Shah JP. Maxillectomy and its classification.

Head Neck 1997;19:309–14.

8 Brown JS, Rogers SN, McNally DN. A modified
classification for the maxillectomy defect. Head Neck

2000;22:17–26.

9 Lacey M, Antonyshyn O. Use of porous high-density polyethylene implants in temporal contour reconstruction. J

Craniofac Surg 1993;4:74–8.

10 Costantino PD, Friedman CD, Lane A. Synthetic biomaterials in facial plastic and reconstructive surgery. Fac Plast

Surg 1993;9:1–15.

11 Smith JE, Ducic Y, Adelson R. The utility of the temporalis

muscle flap for oropharyngeal, base of the tongue and nasopharyngeal

reconstruction.
Otolaryngol Head Neck Surg

2005;132:373–80.

12 Rubin PJ, Yaremchuk MJ. Complications and toxicities of

implantable biomaterials used in facial reconstructive and

aesthetic surgery: A comprehensive review of the literature
.

Plast Reconstr Surg 1997;100:1336–53.

13 Sauer BW. Implants. Technical aspects of porex surgical

polyethylene implants. In: Janecka IP, TiedemannK, editors.

Skull base surgery: anatomy, biology and technology. Philadelphia, PA: Lippincott-Raven; 1997.

p. 353–67.

14 Menderes A, Baytekin C, Topcu A. Craniofacial reconstructionwith high-density porous polyethylene implants. J

Craniofac Surg 2004;15:719–24.

15 Rapidis AD, Day TA. The use of temporal polyethylene implant

after temporalis myofascial flap transposition: clinical

and radiographic results from its use in 21 patients.
J Oral

Maxillofac Surg 2006;64:12–22.

источник

A. Baj, S. Spotti, S. Marelli, G. A. Beltramini, A. B. Giannì

Department of Maxillo-Facial Surgery, Istituto Ortopedico Galeazzi, University of Milan, Milan, Italy

 
« Пред.   След. »