British Journal of Oral and Maxillofacial Surgery 44 (2006) 531533

Use of PalacosR-40 with gentamicin to reconstruct temporal defects after maxillofacial reconstructions with temporalis aps
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 ap is a useful ap 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 (19942005). 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 t and ll 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 ap; Acrylic implant; Head and neck oncology; Reconstruction

Introduction The temporalis, one of the muscles of mastication, arises from the temporal fossa over the area between the inferior temporal 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 suitable as a surgical ap. Lentz rst 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 delineated the blood supply and described the use of the temporalis ap in 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

obvious at the anterior edge which lies behind the orbital rim above the zygomatic arch. Koranda et al.5 dismissed this complication and Huttenbrink6 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 ll the defect at the donor site. We studied 24 men and 17 women of whom 14 had reconstructions of the retromolar, tonsillar or oor 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 ll the defect, including bone, fat, and acrylic and hydroxyapatite bone cement. Harvesting of bone produces considerable morbidity at the donor

Corresponding author. Tel.: +44 7739880826. E-mail address: addenbrookes@hotmail.com (S. Wright).

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

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S. Wright et al. / British Journal of Oral and Maxillofacial Surgery 44 (2006) 531533 Table 1 Composition of monomer and polymer Gentamicin Methyl methacrylate (coloured with chlorophyll) Benzoyl peroxide Zirconium dioxide Methyl methacrylate N,N-Dimethyl-p-toluidine Chlorophyllcopper complex

Power sachet (polymer) 40.8g Liquid (monomer) 18.8g

Technique The temporalis ap 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 vacuum 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 dead space with a tonsillar swab during the initial setting period (Fig. 4). Any gross excess is trimmed off by hand or surgical

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 and is biocompatible. Falconer and Phillips used a custom-made heat-cured acrylic plate with cement to ll the dead space.8 This required a wax impression to be taken during the operation, and laboratory processing added time to the operation. We have used a cold-cured acrylic material with an incorporated antibiotic that can be moulded and adjusted to t the defect.

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

Material The cold-cured acrylic that we used was Palacos R-40 with gentamicin (Heraeus Kulzer GmbH). This material is radioopaque and sets rapidly. It is formed by mixing two separate 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 56 min into a mechanically uniform solid. Polymerisation is an exothermic reaction with temperatures rising to as high as 80 C. Although the spontaneous generation of heat accelerates the reaction, the polymerisation of this self-curing resin occurs even if the temperature is reduced by irrigation with cold saline.

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

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

not the rst 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 pressure in the pulmonary artery, increased pulmonary vascular resistance, arterial hypotension and hypoxaemia, circulatory shock 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 the other patients no problems were identied and cosmesis was good. Palacos R-40 with gentamicin is easy to use, and it can be custom-moulded to t and ll 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. The blood supply of the human temporalis muscle: a vascular corrosion cast study. J Anat 1996;189:4318. 2. Lentz JG. Resection du col condyle avec interposition dun lambeau temporal entre les surfaces de resection. Assoc Franc de Chirurg (Paris) 1895;9:1137. 3. Bradley P, Brockbank JJ. The temporalis muscle ap in oral reconstruction. Oral Maxillofac Surg 1981;9:13945. 4. Cordeiro PG, Wolfe SA. The temporalis muscle ap revisited on its centennial: advantages and disadvantages, newer uses, and disadvantages. Plast Reconstr Surg 1996;98:9807. 5. Koranda FC, McMohan MF, Jernstrom VR. The temporalis muscle ap for intraoral reconstruction. Arch Otolaryngol Head Neck Surg 1987;113:7403. 6. Huttenbrink KB. Temporalis muscle ap: an alternative in oropharyngeal reconstruction. Laryngoscope 1986;96:10348. 7. Habel G, Hensher R. The versatility of the temporalis muscle ap in reconstructive surgery. Br J Oral Maxfac Surg 1986;24:96101. 8. Falconer DT, Phillips JG. Reconstruction of the defect at the donor site of the temporalis muscle ap. Br J Oral Maxfac Surg 1991;29:168. 9. Persing JA, Cronin AJ, Delashaw JB, Edgerton MT, Henson SL, Jane JA. Late surgical treatment of unilateral coronal synostosis using methyl methacrylate. J Neurosurg 1987;66:7939.

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

instrument (Fig. 5). Copious cold saline irrigation is used during polymerisation. Once the initial set has been achieved, the resin can be cooled further in a bowl of cold water until the nal set. The resin can then be replaced in the defect and ne 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 ap is no longer popular and