R-40 for Reconstruction

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British Journal of Oral and Maxillofacial Surgery 44 (2006) 531–533

Use of Palacos®R-40 with gentamicin to reconstructtemporal defects after maxillofacial reconstructions

with temporalis flaps

S. Wright ∗, F. Bekiroglu, N.M. Whear, N.R. Grew

Department of Oral & Maxillofacial Surgery, New Cross Hospital, Wolverhampton WV10 0QP, United Kingdom

Accepted 15 November 2005

Available online 18 January 2006

Abstract

The temporalis muscle flap is a useful flap for the reconstruction of oral ablative defects. A complication of its use that was overlooked was the

crater-like defect created when the muscle is stripped from its attachment on the temporal fossa. The cold-cure acrylic we use is Palacos®R-40

with Gentamicin (Heraeus Kulzer GmbH). This material is radio-opaque, rapidly setting and contains gentamicin. We present a total of 41

cases over an 11-year period (1994–2005). We have a 97.6% (n = 40) success rate. Infection developed in only one case, which leads to the

removal of the acrylic implant. The use of Palacos®R-40 with Gentamicin is easy to use, it can be custom-moulded to fit and fill the defect

any of shape and size. It has minimal complications and high success rate with acceptable results to the patients.

© 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Temporalis flap; Acrylic implant; Head and neck oncology; Reconstruction

Introduction

Thetemporalis, oneof themuscles of mastication,arises from

the temporal fossa over the area between the inferior tempo-

ral line and the infratemporal crest and from the deep surface

of the temporalis fascia. The fan-shaped muscle converges

towards the coronoid process of the mandible and is supplied

by three arteries: the anterior and posterior deep temporal

arteries, and the middle temporal artery.1 This makes it suit-

able as a surgical flap.

Lentz first described its use in 1895 after resection of the

condylar neck for ankylosis of the temporomandibular joint.2

Bradley and Brockbank reported animal studies that delin-

eated the blood supplyand describedthe useof thetemporalis

flapin the reconstruction of oral defects.3 Cordeiro and Wolfe

reviewed its use in 1996.4

When the muscle is stripped from its attachment on the

temporal fossa it leaves a crater-like defect. This is most

∗ Corresponding author. Tel.: +44 7739880826.

E-mail address: [email protected] (S. Wright).

obvious at the anterior edge which lies behind the orbital

rim above the zygomatic arch. Koranda et al.5 dismissed this

complication and Huttenbrink 6 wrote that the area would be

smoothed out by scarring after a few months. Habel and

Hensher7 recognised the problem and suggested that only

the posterior part of the muscle should be used. The defect,

however, is substantial and does not smooth out with time

(Fig. 1).

We describe 41 consecutive operations in which cold cure

acrylic was used to fill the defect at the donor site. We studied

24 men and 17 women of whom 14 had reconstructions of the

retromolar, tonsillar or floor of mouth and 27 of the maxilla.

The technique is simple, gives a good cosmetic result, and is

free of complications in our experience.

Method

Many materials have been used to fill the defect, including

bone, fat, and acrylic and hydroxyapatite bone cement. Har-

vesting of bone produces considerable morbidity at the donor

0266-4356/$ – see front matter © 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjoms.2005.11.014



532 S. Wright et al. / British Journal of Oral and Maxillofacial Surgery 44 (2006) 531–533

Fig. 1. Showing donor site defect without reconstruction.

site because of the quantity required. The disadvantages of

fat include donor site morbidity, cyst formation, and atrophy,

which may necessitate secondary grafting. Hydroxyapatite

bone cement is suitable but is costly. Acrylic is cheaper andis biocompatible. Falconer and Phillips used a custom-made

heat-cured acrylic plate with cement to fill the dead space.8

This required a wax impression to be taken during the oper-

ation, and laboratory processing added time to the operation.

We have used a cold-cured acrylic material with an incorpo-

rated antibiotic that can be moulded and adjusted to fit the

defect.

Material

The cold-cured acrylic that we used was Palacos®R-40 with

gentamicin (Heraeus Kulzer GmbH). This material is radio-

opaque and sets rapidly. It is formed by mixing two sep-

arate pre-measured sterile components: powder (polymer)

and liquid (monomer) (Table 1). When the polymer and the

monomer are mixed, the liquid activates the catalyst in the

powder. As polymerisation proceeds, the dough-like mass

hardens within 5–6 min into a mechanically uniform solid.

Polymerisation is an exothermic reaction with temperatures

rising to as high as 80 ◦C. Although the spontaneous gener-

ation of heat accelerates the reaction, the polymerisation of

this self-curing resin occurseven if thetemperatureis reduced

by irrigation with cold saline.

Table 1

Composition of monomer and polymer

Gentamicin

Power sachet

(polymer) 40.8g

Methyl methacrylate (coloured with chlorophyll)

Benzoyl peroxide

Zirconium dioxide

Liquid (monomer)18.8g

Methyl methacrylate

N , N -Dimethyl- p-toluidineChlorophyll–copper complex

Technique

The temporalis flap is raised in the usual way, rotated to

reconstruct the surgical defect, and the underlying bone is

dried (Fig. 2). The powder and liquid are combined in a vac-

uum mixer (Fig. 3) and when a dough-like stage is achieved,

the material is moulded into the defect. It is important to

avoid trapping the material under the zygomatic arch. If this

occurs, it will require either osteotomy of the zygomatic arch

or sectioning of the acrylic. Our practice is to pack the deadspace with a tonsillar swab during the initial setting period

(Fig. 4). Any gross excess is trimmed off by hand or surgical

Fig. 2. Temporalis muscle is rotated to reconstruct the surgical defect.

Fig. 3. Palacos®R-40 with Gentamicin (powder and liquid) and vacuum

mixer.



S. Wright et al. / British Journal of Oral and Maxillofacial Surgery 44 (2006) 531–533 533

Fig. 4. Insertion of tonsillar swab to avoid undercut.

Fig. 5. Acrylic implant moulded, trimmed and placed in situ.

instrument(Fig.5). Copious cold salineirrigation is used dur-

ing polymerisation. Once the initial set hasbeen achieved, the

resin can be cooled further in a bowl of cold water until the

final set. The resin can then be replaced in the defect and fine

adjustments made with an acrylic bur.

A drain is inserted into the dead space during closure to

avoid infection or the development of a haematoma.

Discussion

With advances in reconstructive techniques in the head and

neck, the temporalis muscle flap is no longer popular and

not the first choice, but it retains its place as a salvage

procedure.

Absorption of the monomer and its toxicity have been

reported in orthopaedic journals but not in craniofacial

and maxillofacial journals.9 These include increased pres-

sure in the pulmonary artery, increased pulmonary vascular

resistance, arterial hypotension and hypoxaemia, circulatoryshock and cardiac arrest.

Infection developed in only one of the 41 patients and the

acrylic implant had to be removed. This occurred within 2

weeks of insertion of the implant. At subsequent follow-up

of theotherpatientsno problems were identifiedand cosmesis

was good.

Palacos®R-40 with gentamicin is easy to use, and it can be

custom-moulded to fit and fill any shape and size of defect. It

has minimal complications and high success rate. It is readily

available and cheap compared with other materials available

on the market.

Acknowledgement

We thank Mr. B.G. Millar for allowing us to use his cases as

part of our data.

References

1. Cheung LK. Theblood supplyof the human temporalis muscle:a vascular

corrosion cast study. J Anat 1996;189:431–8.

2. Lentz JG.Resection du colcondyleavecinterpositiond’unlambeau tem-

poral entre les surfaces de resection. Assoc Franc de Chirurg (Paris)

1895;9:113–7.3. Bradley P, Brockbank JJ. The temporalis muscle flap in oral reconstruc-

tion. Oral Maxillofac Surg 1981;9:139–45.

4. Cordeiro PG, Wolfe SA. The temporalis muscle flap revisited on its cen-

tennial: advantages and disadvantages, newer uses, and disadvantages.

Plast Reconstr Surg 1996;98:980–7.

5. Koranda FC, McMohan MF, Jernstrom VR. The temporalis muscle

flap for intraoral reconstruction. Arch Otolaryngol Head Neck Surg

1987;113:740–3.

6. Huttenbrink KB. Temporalis muscle flap: an alternative in oropharyngeal

reconstruction. Laryngoscope 1986;96:1034–8.

7. Habel G, Hensher R. The versatility of the temporalis muscle flap in

reconstructive surgery. Br J Oral Maxfac Surg 1986;24:96–101.

8. Falconer DT, Phillips JG. Reconstruction of the defect at the donor site

of the temporalis muscle flap. Br J Oral Maxfac Surg 1991;29:16–8.

9. Persing JA, Cronin AJ, Delashaw JB, Edgerton MT, Henson SL, JaneJA. Late surgical treatment of unilateral coronal synostosis using methyl

methacrylate. J Neurosurg 1987;66:793–9.

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