Modafinil

Helge Eilers MD

• Professor of Anesthesia and Perioperative Care
• University of California, San Francisco

https://anesthesia.ucsf.edu/people/helge-eilers

Use of Convalescent Whole Blood or Plasma Collected from Patients Recovered from Ebola Virus Disease for Transfusion insomnia lexapro cheap 100 mg modafinil with amex, as an Empirical Treatment during Outbreaks insomnia in early pregnancy purchase modafinil 100 mg visa. Experimental therapies: Growing interest in the use of whole blood and plasma from recovered Ebola patients (convalescent therapies) sleep aid walmart purchase modafinil mastercard. Safety and pharmacokinetic profiles of phosphorodiamidate morpholino oligomers with activity against ebola virus and marburg virus: results of two singleascending-dose studies sleep aid unisom purchase modafinil 200 mg with visa. A Change in vaccine efficacy and duration of protection explains recent rises in pertussis incidence in the United States sleep aid for 8 year old purchase modafinil 100 mg with mastercard. Long-term measles-induced immunomodulation increases overall childhood infectious disease mortality. Asthma and allergy in children with and without prior measles, mumps, and rubella vaccination. Orally available small-molecule polymerase inhibitor cures a lethal morbillivirus infection. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Ribavirin and interferon therapy in patients infected with the Middle East respiratory syndrome coronavirus: An observational study. Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do. Bordetella pertussis strains with increased toxin production associated with pertussis resurgence. Pertactin-negative Bordetella pertussis strains: Evidence for a possible selective advantage. Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, 2013. Notes from the Field: Outbreak of Pertussis in a School and Religious Community Averse to Health Care and Vaccinations-Columbia County, Florida, 2013. Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases. A change in vaccine efficacy and duration of protection explains recent rises in pertussis incidence in the United States. Department of Health and Human Services, Centers for Disease Control, Public Health Service [press release]. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Tdap) in Pregnant Women­Advisory Committee on Immunization Practices. Centers for disease Control and Prevention, National Center for Immunizations and Respiratory Diseases. Notes from the Field: Fatal Fungal Soft-Tissue Infections After a Tornado-Joplin, Missouri, 2011. Heart sounds and heart murmurs are important in identifying heart valve abnormalities and other structural cardiac defects. Electrocardiography is useful for determining rhythm disturbances (tachy- or bradyarrhythmias). Echocardiography is used to assess valve structure and function as well as ventricular wall motion; transesophageal echocardiography is more sensitive than transthoracic echocardiography for detecting thrombus and vegetations. Radionuclides, such as technetium-99m and thallium-201, are used to assess myocardial ischemia and myocardial viability in patients with suspected coronary artery disease. When patients cannot exercise, pharmacologic stress testing is used to assess the likelihood of coronary artery disease. Cardiac catheterization and angiography are used to assess coronary anatomy and ventricular performance. The chief complaint is a brief statement describing the reason the patient is seeking medical attention. The patient is asked to describe his or her current symptoms, including their duration, quality, frequency, severity, progression, precipitating and relieving factors, associated symptoms, and impact on daily activities. The patient should be asked about social habits that affect the cardiovascular system, including diet, amount of regular physical activity, tobacco use, alcohol intake, and illicit drug use. The quality of chest pain, its location and duration, and the factors that provoke or relieve it are important in ascertaining its etiology. Typically, patients with angina describe a sensation of heaviness or pressure in the retrosternal area that may radiate to the jaw, left shoulder, back, or left arm. It is precipitated by exertion, emotional stress, eating, smoking a cigarette, or exposure to cold, and it is usually relieved within minutes with rest or a sublingual nitroglycerin, although the latter also is effective in relieving chest pain due to esophageal spasm. Angina that is increasing in severity, longer in duration, or occurring at rest is called unstable angina; it should prompt the patient to seek medical attention expeditiously. With the patient lying supine at 30 degrees and his/her head rotated slightly to the left, the height of the fluid wave in the right internal jugular vein is determined relative to the sternal angle. The extent of elevation can be used to assess the severity of peripheral venous congestion, and its diminution can be used to assess the response to therapy. Arterial Pulses the carotid arterial pulse is examined for its intensity and, concurrently with the apical impulse, for concordance within the cardiac cycle. Diminished carotid arterial pulsations may be the result of a reduced stroke volume, atherosclerotic narrowing of the carotid artery, or obstruction to left ventricular outflow due to aortic valve stenosis or hypertrophic obstructive cardiomyopathy. Conversely, very forceful, hyperdynamic, "bounding" carotid arterial pulsations may be palpated in the patient with an increased stroke volume and suggests the presence of chronic aortic valve regurgitation or a high cardiac output due, for example, to hyperthyroidism, an arteriovenous shunt, or marked anemia. Normally, the systolic arterial pressure in the feet should be similar or even slightly higher than the pressure in the arms. The anterior chest wall is palpated to assess for the presence of tenderness in the sternal area, which may indicate that the patient has costochondritis. Percussion of the posterior chest is done to determine if a pleural effusion is present. Auscultation of the anterior and posterior lung fields is performed to assess for the presence of findings suggestive of pneumonia, airway obstruction, pneumothorax, pleural effusion, or pulmonary edema. Heart Sounds the typical "lub-dub" sound of the normal heart consists of the first heart sound (S 1), which precedes ventricular contraction and is due to closure of the mitral and tricuspid valves, and the second heart sound (S2), which follows ventricular contraction and is due to closure of the aortic and pulmonic valves. Normal heart sounds are S 1 (mitral and tricuspid valve closure) and S2 (aortic and pulmonic valve closure). The S3 occurs in early diastole as blood rapidly rushes into a volume-loaded ventricle (eg, with decompensated congestive heart failure). The S4 occurs in late diastole and is caused by atrial contraction into a stiff, noncompliant ventricle (eg, hypertrophy due to hypertension). The S3, a so-called ventricular gallop, is a low-pitched sound usually heard at the cardiac apex in early diastole (ie, immediately after S 2). It is caused by the vibrations that occur when blood rapidly rushes from the atrium into a volume-loaded ventricle. A so-called "physiologic" S3 is heard commonly in healthy children (who often have an increased cardiac output) and may persist into young adulthood. The S4 is a dull, low-pitched sound that is caused by the vibrations that occur when atrial contraction forces blood into a stiff, noncompliant ventricle. It is audible at the cardiac apex just before ventricular contraction (ie, just before S 1); it is not present in the subject with a normal heart. An S4 may be present in the patient with aortic stenosis, systemic arterial hypertension, hypertrophic cardiomyopathy, or coronary artery disease. Murmurs are auditory vibrations resulting from turbulent blood flow within the heart chambers or across the valves. Some murmurs are said to be "innocent" or "physiologic" and result from rapid, turbulent blood flow in the absence of cardiac disease. Fever, anxiety, anemia, hyperthyroidism, and pregnancy increase the intensity of a physiologic murmur. Auscultatory areas do not correspond to anatomic locations of the valves but to the sites at which particular valvular sounds are heard best. They begin with or after S 1 and end at or before S2, depending on the origin of the murmur. They are classified based on time of onset and termination within systole: midsystolic or holosystolic (pansystolic). Examples of midsystolic murmurs include pulmonic stenosis, aortic stenosis, and hypertrophic obstructive cardiomyopathy. Holosystolic murmurs occur when blood flows from a chamber of higher pressure to one of lower pressure throughout systole, such as occurs with mitral or tricuspid valve regurgitation or a ventricular septal defect. Aortic or pulmonic valve regurgitation causes a high-pitched diastolic murmur that begins with S2, whereas stenosis of the mitral or tricuspid valves causes a low-pitched, "rumbling" diastolic murmur. Continuous murmurs begin in systole and continue without interruption into all or part of diastole. Such murmurs are mainly a result of aortopulmonary connections (eg, patent ductus arteriosus) or arteriovenous connections (eg, arteriovenous fistula, coronary artery fistula, or arteriovenous malformation). Class I indications have unequivocal evidence or agreement that the specific procedure is useful and effective. For a specific clinical scenario, the guidelines also indicate the level of evidence for the recommendation. Level A evidence is said to be present if the recommendation is based on the results of multiple, randomized clinical trials. Level B evidence is said to exist if only a single randomized trial or multiple, nonrandomized trials exist. Level C evidence is said to be present if the recommendation is made solely on expert opinion. Markers of Myonecrosis When myocardial infarction (myonecrosis) occurs, proteins from the recently necrotic myocytes are released into the peripheral blood, where they can be detected using specific biochemical assays. These biomarkers of myonecrosis (a) aid in the diagnosis (or exclusion) of myocardial infarction as the cause of chest pain; (b) facilitate triage and risk stratification of patients with chest discomfort; and (c) identify patients who are appropriate candidates for specific therapeutic strategies or interventions. Cardiac troponin (cTn) is the preferred biomarker for the diagnosis of myonecrosis. The use of high-sensitive cTn assays improves the early diagnosis of patients with suspected myocardial infarction, particularly the early exclusion of it. Acute coronary syndrome patients with an elevated serum cTn concentration have a roughly fourfold higher risk of death and recurrent myocardial infarction in the coming months when compared to those with normal cTn concentrations. They benefit (ie, have a reduced incidence of death, recurrent myocardial infarction, and recurrent ischemia) from more intensive antiplatelet and antithrombotic therapy as well as prompt coronary angiography and revascularization, whereas those with a normal serum cTn obtain no benefit from such intensive therapy. The serum myoglobin concentration is elevated in the patient with myonecrosis, but it has a low specificity for myocardial infarction because of its high concentration in skeletal muscle. Because of its small molecular size and consequent rapid release (within 1 hour) following the onset of myonecrosis, it is utilized as a very early marker of myocardial infarction. Markers of Inflammation Inflammatory processes participate in the development of atherosclerosis and contribute to the destabilization of atherosclerotic plaques, which may ultimately lead to an acute coronary syndrome. Several mediators of the inflammatory response, including acute phase proteins, cytokines, and cellular adhesion molecules, have been evaluated as potential indicators of underlying atherosclerosis and as predictors of acute cardiovascular events. Measurements should not be taken when subjects are acutely ill (eg, with any acute febrile illness) or have a known autoimmune or rheumatologic disorder. They may also be elevated in patients with an acute coronary syndrome as a result of left ventricular systolic dysfunction, impairment of ventricular relaxation, and myocardial stunning. In addition, when considering the normal range for an individual, one must be aware that considerable variation in serum concentrations exists according to age, gender, weight, and renal function. Women and older patients have a higher normal range, whereas obese patients have lower values than the nonobese. They may be elevated in certain noncardiac conditions, including pulmonary embolism, chronic obstructive pulmonary disease, hypoxemia, sepsis, cirrhosis, and renal failure. Chest Radiography the chest X-ray provides supplemental information to the physical examination. Although it does not provide detailed information about internal cardiac structures, it can provide information about the position and size of the heart and its chambers as well as adjacent structures. The standard chest X-rays for evaluation of the lungs and heart are standing posteroanterior and lateral views taken with maximal inspiration; portable chest X-rays usually are less helpful. The posteroanterior chest X-ray outlines the superior vena cava, right atrium, aortic knob, main pulmonary artery, left atrial appendage (especially if enlarged), and left ventricle. The lateral chest X-ray allows one to assess the right ventricle, inferior vena cava, and left ventricle. These structures are visualized as shadows of differing density rather than as discrete entities. Left atrial enlargement is suspected if the left bronchus is elevated or the atrial appendage is enlarged. Left ventricular enlargement is the most common feature identified on chest X-ray and is seen as a lateral and downward displacement of the cardiac apex. Right ventricular enlargement is best seen on the lateral film, on which the heart appears to occupy the retrosternal space. A large pericardial effusion may appear as a large heart on a chest X-ray, but, in contrast to heart failure, pulmonary vascular congestion is not present (see below). With diminished pulmonary blood flow, as would be present in the patient with tetralogy of Fallot or pulmonic valvular stenosis, the peripheral pulmonary vessels are small in caliber and underfilled. Increased pulmonary blood flow, as occurs with a high cardiac output or left-to-right intracardiac shunting, may lead to enlargement and tortuosity of the central and peripheral pulmonary vessels. Pulmonary arterial hypertension (increased pulmonary resistance) is identified by enlargement of the central pulmonary arteries and diminished peripheral perfusion. Elevated pulmonary venous pressure-usually the result of an elevated left atrial pressure-is characterized by dilation of vessels in the upper lung zones (eg, cephalization of flow), owing to recruitment of upper lung vessels when blood is diverted from the constricted vessels in the lower lung zones. As pulmonary venous pressure increases, alveolar edema becomes evident, and pleural effusions may appear as blunting of the costophrenic angles. Leads V 1 and V2 are called right-sided precordial leads; leads V3 and V4, midprecordial leads; and leads V5 and V6, left-sided precordial leads. The depolarization wave is transmitted through the atria, which initiates atrial contraction. The depolarization wavefront then spreads through the ventricular muscle, from endocardium to epicardium, triggering ventricular contraction. Initially, a negative deflection (the Q wave) appears, followed by a positive deflection, the R wave, and finally a negative deflection, the S wave.

These vessels may provide collateral flow when they develop in the border between ischemic and nonischemic regions of the myocardium insomnia pms order modafinil once a day. Investigation into pharmacologic mechanisms to improve collateral vessel development has been largely disappointing insomnia houston purchase modafinil online. While chronic nitrates may assist in development of collateral vessels sleep aid over the counter modafinil 100 mg buy line, the use of growth factors and vasodilators have not produced the expected results sleep aid linked to alzheimers buy modafinil 100 mg with amex. Due to the variability in collateral vessel development across different species sleep aid med discount 100 mg modafinil mastercard, the use of animal models for study has significant limitations. These additional mechanisms include endothelial dysfunction, microvascular dysfunction, vasospasm, platelet activation and coagulation, as well as inflammation. Reduced vasodilator response may lead to the development of ischemia at lower levels of exertion. There can also be impairment in how the microvascular response to endogenous vasodilators and vasoconstrictors, with reduced and exaggerated responses, respectively. Patients without epicardial stenosis, but presenting with demand driven ischemia, are classified as having cardiac syndrome X. Instead, the process is arrested with an approximate 70% to 80% stenosis and reendothealialization. In this setting, macrophages and T lymphocytes produce and secrete cytokines, chemokines, and growth factors that activate endothelial cells, increase vasoreactivity, and proliferation of vascular smooth muscle cells. Since the size of the obstructive lesion does not change acutely, the amount of exertion needed to induce ischemia and angina is fairly predictable for an individual patient. For example, the patient knows when they work in the garden for 20 minutes or walk 5 blocks at a certain pace, before developing chest pain. Patients with this pattern of chest pain development are described as having a fixed angina threshold. In these patients the amount of exertion leading to chest pain may differ from day to day. An example would be the patient who could walk six blocks before experiencing angina yesterday, but today can only walk three blocks before becoming symptomatic. These patients also have an obstructing atherosclerotic plaque leading to a fixed decrease in supply, but they also have a reduction in myocardial oxygen supply due to transient vasospasm superimposed at the site of the obstructing plaque. While the fixed obstruction is usually sufficient to produce symptoms with exertion, episodes of transient vasospasm superimposed on the obstruction significantly reduce myocardial blood flow leading to ischemia. The changing pattern of ischemia in these patients reflects a variable amount of vasospasm under certain conditions. Angina episodes are typically more common in the morning hours due to the circadian release of vasoconstrictors. Exposure to cold temperature, emotion, and mental stress has also been reported to lower the angina threshold in patients with variable threshold angina. Patients with variant angina usually do not have a coronary flow-obstructing atherosclerotic plaque, but instead have a significant reduction in myocardial oxygen supply due to substantial vasospasm in epicardial vessels. Since the differential diagnosis of "chest" pain is fairly broad (Table 16-1), it is important to determine if symptoms are due to a cardiac or noncardiac pathology. The quality of cardiac chest pain is often described as squeezing, crushing, a heaviness, or tightness in the chest. Chest pain that is described as sharp in origin, pain that increases with inspiration or expiration, or a reproducible pain with palpation is usually not cardiac pain. The region of the pain is substernal and may radiate to the right or left shoulder, right or left arm (left more commonly than right), neck, back, or abdomen. The severity of cardiac chest pain can be difficult to quantify since pain is a subjective measure, but the pain is usually considered severe and ranked a five or higher on a ten-point scale. Other symptoms that may also be present during times of ischemia include diaphoresis, nausea, vomiting, and dyspnea. Esophageal pain is also relieved by food, antacids, milk, and occasionally warm liquids, while ischemic chest pain is not. Angina I occurs with strenuous, rapid, or prolonged exertion at work or recreation Slight limitation or ordinary activity. Angina occurs on walking or climbing stairs rapidly, on walking uphill, on walking or stair climbing after meals, in cold, in wind, under emotional Class stress, or only during the few hours after wakening. Patients with "atypical" angina meet two of the three criteria for typical angina. Patients meeting one or none of the typical angina characteristics are described as having noncardiac chest pain. Patient groups more likely to present with atypical angina include women and the elderly. To demonstrate the frequency of some of these symptoms, one study suggests that 65% of women with ischemia present with atypical symptoms. In addition to considering traditional risk factors, markers of inflammation, such as high sensitive C-reactive protein, have been investigated as risk factors for atherosclerosis. The value of C-reactive protein for primary prevention is growing, while the value for secondary prevention is less certain. It is likely that patients having atherosclerosis in cerebral or peripheral arteries also have atherosclerosis in their coronary arteries even if it has not yet led to episodes of angina. At the time of an ischemic episode, patients may present with tachycardia, diaphoresis, shortness of breath, and nausea. Other positive findings may include pulmonary rales, displaced point of maximal impulse, or a third heart sound in patients with heart failure. Since about 40% of patients who need a stress test cannot physically endure the test, the myocardium can also be stressed pharmacologically with adenosine, dipyridamole, or dobutamine. Stress testing can provide important diagnostic and prognostic information, especially when conducted with a nuclear imaging study to evaluate myocardial perfusion. The mechanism of the increase in troponin is not completely understood, but may be due to increased cardiac cell membrane permeability with repeated ischemia. Therapy in this approach generally is targeted at risk factor modification and other vasculoprotective therapies. Therapies used in this approach rarely have demonstrated an improvement in improving the quantity of life, but do improve the quality of life through a reduction in symptoms. Data derived from multiple randomized clinical trials with large numbers of patients B. Data derived from a limited number of randomized trials with small numbers of patients, careful analyses of nonrandomized studies, or observational registries C. Dietary therapy for all patients should include reduced intake of saturated fats (to <7% of total calories), trans fatty acids (to <1% of total calories), and cholesterol (to <200 mg/day). In addition to therapeutic lifestyle changes, a moderate or high dose of a statin therapy should be prescribed, in the absence of contraindications or documented adverse effects. All patients should be counseled about the need for lifestyle modification: weight control; increased physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products. For selected individual patients, such as those with a short duration of diabetes mellitus and a long life expectancy, a goal HbA1c of 7% or less is reasonable. A goal HbA1c between 7% and 9% is reasonable for certain patients according to age, history of hypoglycemia, presence of microvascular or macrovascular complications, or presence of coexisting medical conditions. Initiation of pharmacotherapy interventions to achieve target HgA1c might be reasonable. For all patients, the clinician should encourage 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, at least 5 days and preferably 7 days per week, supplemented by an increase in daily lifestyle activities (eg, walking breaks at work, gardening, and household work) to improve cardiorespiratory fitness and move patients out of the least-fit, least-active, high-risk cohort (bottom 20%). For all patients, risk assessment with a physical activity history and/or an exercise test is recommended to guide prognosis and prescription. Medically supervised programs (cardiac rehabilitation) and physician-directed, home-based programs are recommended for at risk patients at first diagnosis. It is reasonable for the clinician to recommend complementary resistance training at least 2 days per week. The initial goal of weight loss therapy should be to reduce body weight by approximately 5% to 10% from baseline. Follow-up, referral to special programs, and pharmacotherapy are recommended, as is a stepwise strategy for smoking cessation (Ask, Advise, Assess, Assist, Arrange, Avoid). Treatment of depression has not been shown to improve cardiovascular disease outcomes but might be reasonable for its other clinical benefits. The reduction in thromboxane A2 leads to reduced platelet activation and aggregation for the life of the platelet. Therefore, further increases in aspirin doses above 75 to 100 mg would be expected to provide little additional antiplatelet potency of aspirin. Compared to higher doses of aspirin (325 mg daily), low-dose aspirin has demonstrated a lack of significant impairment of endothelial secretion of prostacyclin, which is a natural vasodilator. Even though there may be some inhibition of prostacyclin with the use of aspirin, the effects on the endothelium are reversible, compared to the effect on platelets. Aspirin may also attenuate the synthesis of cytokines such as interleukin-2, interleukin-6, and interferon in leukocytes. A recent meta-analysis reported the average rate of aspirin nonresponsiveness to be 24%, but the range of reported nonresponsiveness is wide (0%-57%). The effect of aspirin on platelet aggregation is impaired when ibuprofen is given 2 hours before aspirin, but when aspirin is given first there is no effect on the ability of aspirin to inhibit platelet aggregation. A number of clinical trials have found a relationship between aspirin nonresponsiveness and increased risk of ischemic events. Even though patients with aspirin nonresponsiveness have demonstrated a higher rate of ischemic events, there are no recommendations for screening. Also, since increasing the dose of aspirin is unlikely to impact the incidence of nonresponsiveness or clinical outcomes, the only management strategy would be to change or add additional antiplatelet therapy. A number of trials have demonstrated that there is extensive variability in patient response to clopidogrel, but for the most part, the antiplatelet activity follows a bell-shaped curve. There is currently significant confusion about what to do if a patient is found to have a lack of appropriate response to clopidogrel therapy. If patients are even partially noncompliant with their clopidogrel therapy, the tests to evaluate clopidogrel therapy will demonstrate a lack of response. At this time genetic testing is not the answer to explaining poor antiplatelet response to clopidogrel therapy. They may also possess some antithrombotic properties through inhibition of platelet aggregation and augmentation of the endogenous fibrinolytic system. Benefits were consistent across all groups of patients enrolled, regardless of the location of atherosclerotic disease. The positive benefits demonstrated in most actively controlled trials support the use of a high dose or higher-intensity statin regimen. High-intensity statin options include atorvastatin 40 or 80 mg daily or rosuvastatin 20 or 40 mg daily. It should be noted that atorvastatin 80 mg is considered the preferred dose, and that the 40 mg dose was only used in one trial in patients who could not tolerate the 80 mg dose. Moderate-intensity statin regimens include once daily atorvastatin 10 to 20 mg, rosuvastatin 5 to 10 mg, simvastatin 20 to 40 mg, pravastatin 40 mg, lovastatin 40 mg, pitavastatin 2 to 4 mg, and twice daily fluvastatin 40 mg. The most probable reason for the difference in the results is based on the size of the trials. This includes a diet rich in fruits, vegetables, and low-fat dairy products, regular physical exercise, a reduction in dietary sodium, and limited alcohol consumption. One of the most important impacts of getting a patient to quit smoking is advice from their clinician recommending and discussing the importance of smoking cessation. Nonpharmacologic methods for smoking cessation are just as important as pharmacotherapy. Self-help programs, telephone counseling, behavioral therapy, and even exercise have had a beneficial effect at getting patients to quit smoking. Nicotine replacement therapy had demonstrated a nearly doubling of the rate of smoking cessation success. Sustained-release bupropion has also demonstrated a 2-fold increase in smoking cessation rates. Empagliflozin inhibits the sodium-glucose cotransporter 2, consequently inhibiting renal glucose resorption and thereby lowering plasma glucose levels. There was a significant 35% relative reduction in hospitalizations for heart failure with the use of empagliflozin. It is unlikely the mechanism of the benefit of empagliflozin is due the magnitude of glucose lowering since there was only an approximate 0. Empagliflozin was more likely to cause genital infections compared to placebo, but otherwise adverse effects were similar between the groups. While sulfonylurea agents provide a similar reduction in HbA1c, their potentials to induce hypoglycemia and weight gain make metformin a more attractive option. The predominant adrenergic receptor type in the heart is the 1-receptor, and competitive blockade minimizes the influence of endogenous catecholamines on the chronotropic and inotropic state of the myocardium. It should be noted that even 1-selective agents lose their selectivity and provide additional 2-blockage at higher doses. Most side effects experienced with the use of -blockers are typically an extension of their pharmacologic activity. Patients receiving -blockers may experience bradycardia, hypotension, heart block, impaired glucose metabolism, and altered serum lipids. Central nervous system adverse effects, such as fatigue, depression, insomnia, and overall malaise, are somewhat less severe, but account for a significant number of -blocker discontinuations. Impotence has been reported in approximately 1% of patients receiving -blockers and inability to maintain an adequate erection has been reported in up to 25% of patients in some series. Patients without these preexisting disease states usually do not suffer from these adverse effects and it is important to note that even patients at risk for adverse effects receive significant benefit from the use of -blockers. If -blocker therapy needs to be discontinued, doses need to be tapered over 2 to 3 weeks to prevent abrupt withdrawal. During -blocker therapy, there is a known up regulation of -receptors on the myocardium.

Successful outcomes in midfacial reconstruction involve a mastery of a broad range of soft tissue and bony flaps and craniofacial plating techniques sleep aid 25mg review discount 100 mg modafinil, as well as an understanding of the requirements for prosthetic rehabilitation insomnia problems 100 mg modafinil buy with visa, which is used in place of reconstruction in some cases sleep aid 25mg 200 mg modafinil otc, often in concert with local and distant tissue-transfer procedures sleep aid hormone order modafinil with american express. This chapter discusses reconstruction of both orbital and palatomaxillary defects insomnia download buy modafinil toronto, because the two frequently occur in concert. The maxillae contribute to forming the boundaries for three cavities: the roof of the mouth, the floor and lateral wall of the nasal cavity, and the floor and medial walls of the orbit. The maxillae attach laterally to the zyomatic bones, which comprise part of the orbital floor and the lateral orbital wall, as well as provide shape to the cheek. In addition to the zygomatic bones, the maxillae also articulate with the frontal and ethmoid bones of the cranium, and the nasal, lacrimal, inferior nasal conchal, palatine, and vomer bones of the face. The superior margin of the orbit is the frontal bone, the inferior margin is the maxilla, palatine, and zygomatic bones, the medial margin is the frontal, lacrimal, and ethmoid bones, and the lateral margin is the zygomatic and sphenoid bones. The orbit lies below the anterior cranial fossa, above the maxillary sinus, lateral to the nasal cavity, and anterior to the middle cranial fossa (medially) and the temporal fossa (laterally). From the orbital rim, the orbit tapers posteriorly to an apex, the entrance of the optic canal. Two large discontinuities, the superior and inferior orbital fissures, converge upon one another in the back of the orbit just lateral to the apex. There is no consensus in the literature on the nomenclature of types of maxillectomy. In many publications, the terms partial and subtotal have been used interchangeably. Spiro et al6 divided maxillectomies into limited, subtotal, and total, depending on whether the resection involved predominantly one wall, at least two walls including the palate, or the entire maxilla. Others subclassify partial maxillectomy into infrastructure (where only the upper alveolus and hard palate below the level of the nasal floor are removed), medial (where the medial wall of the maxilla, often along with the medial third of the inferior orbital wall and the medial orbital wall, is removed), suprastructure (where all the walls of the maxilla, except the hard palate and upper alveolus, are removed), and subtotal (where all the walls of the maxilla, except the orbital floor and the zygomatic buttress, are removed). Orbital exenteration involves removal of all the orbital contents, in contrast to enucleation, which involves removal of only the globe. In standard orbital exenteration, both eyelids and at least the anterior part of the orbit are removed. This technique is used for many adnexal cancers involving the eyelid with orbital extension. When the eyelid skin and orbicularis muscles are not involved in the cancerous process, such as in some palpebral conjunctival and orbital cancers, the anterior lamella of the eyelid (skin or musculocutaneous layer) can be spared and used for coverage of the exenterated orbital defect. As a matter of aesthetic preference, the eyelids may still be removed by some surgeons and replaced by skin from the reconstructive flap. In extended orbital exenteration, cancers of the paranasal sinuses, nasal cavity, and periorbital and facial soft tissues extending to the orbit require more radical surgical ablation, in which one or more orbital bony walls and neighboring structures, such as the sinuses and facial skin, may be resected. Both total maxillectomy and suprastructure maxillectomy may be combined with orbital exenteration, technically making each procedure an extended orbital exenteration but more often referred to as an orbitomaxillectomy by most surgeons. This surgery is usually indicated for benign or lowgrade tumors arising from the lateral nasal wall. Formerly performed through a lateral rhinotomy incision, it is now frequently performed endoscopically. For the remainder of maxillary and orbital resections, reconstruction or rehabilitation must be addressed with flaps, grafts, and/or prosthetics. The amount of hard and soft palate resected, as well as the location of the resection and the plans for dental restoration, will dictate whether a prosthetic obturator is indicated or a bony or soft tissue flap should be performed. Accurate reconstruction here, with grafts, implants, or bony flaps, is mandatory for useful eye function. If an extended orbital exenteration or orbitomaxillectomy is performed, a pedicled or free flap may be indicated to separate the orbit from the nasal cavity and sinuses, or occasionally the intracranial cavity. A pedicled or free flap may also be needed to serve as the lining of the remaining orbit for an orbital prosthetic if one is desired by the patient. A final consideration is whether facial skin and soft tissues, such as the lips, eyelids, or nose, will be included in the resection. Maxillectomy types include: (a) superstructure maxillectomy, (b) posterior palatomaxillectomy, (c) hemipalatomaxillectomy, (d) premaxillary resection, and (e) bilateral palatomaxillectomy. Suprastructure Maxillectomy Suprastructure maxillectomies result in defects that do not involve the palate. Suprastructure defects that do not violate the bony orbit usually do not need reconstruction. Exceptions include when facial soft tissues are included in the resection and soft tissue cheek reconstruction is needed. Another exception may be when intracranial contents at the skull base have been exposed. In the latter case, a bulky soft tissue free flap that obliterates the maxillary sinus is recommended to isolate the intracranial cavity from the nasal cavity by creating a watertight seal against the dura or brain, thereby preventing cerebrospinal fluid leaks and meningitis, although small defects are often sealed with local or pedicled flaps, such as the temporoparietal fascial flap. In this case, a hemipalatomaxillectomy is performed with resection of the orbital floor, which is termed a total maxillectomy by some, although others use this term to include defects in which the orbital floor is spared. To avoid confusion, the status of the orbital floor should be mentioned separately. In this case, orbital exenteration is combined with a superstructure maxillectomy, which is termed an orbitomaxillectomy by some authors. Unilateral Posterior Palatomaxillectomy While any number of palatoalveolar defects are possible, Okay et al2 have recommended distinguishing defects based on whether function can be satisfac- 7 Midfacial Reconstruction torily restored with an obturator or if a free flap is required. Palatoalveolar defects that spare both canine teeth can often be successfully treated with an obturator. In these cases, cantilever forces resulting in unstable prosthetic retention are minimized because of the favorable root morphology of the canine adjacent to the obturator and the generous arch length provided by the remaining alveolus. Thus, defects including unilateral posterior palatomaxillectomy defects or anterior defects limited to the premaxilla, which bears the four incisor teeth, can be obturated and should be considered separately from those that cannot, including those that involve half the palate and those that involve the entire anterior arch or whole palate. Based on this information, unilateral palatomaxillectomy defects posterior to the canine tooth can usually be treated with an obturator. However, due to inadequate stability of the obturator in some patients, especially edentulous ones, and longterm costs associated with periodic adjustment and replacement of the prosthesis, autologous tissue may still be preferred in some patients. Additionally, exposure of the intracranial contents, loss of the orbital floor or orbital contents, and resection of the facial soft tissues are indications for free flap reconstruction. We reconstruct posterior palatomaxillary defects with soft tissue rather than bony free flaps. The aesthetic challenge is usually to provide adequate volume to the cheek to support the facial soft tissues and to avoid a hollow appearance. An analogous situation is present in the mandible, where posterior mandibular reconstruction with soft tissue flaps can often achieve good results with regard to both function and appearance, provided the flap has adequate bulk. As with the mandible, restoration of posterior maxillary dentition, which is not easily visible even when smiling, is not a priority to many patients. Both flaps can be dissected in a way that minimizes their muscular components, and the flaps can be safely defatted in patients who have more subcutaneous adipose tissue than desired. By utilizing distal perforators, pedicle length is usually satisfactory in both flaps to reach the neck blood vessels without need for interposition vein grafting. The radial forearm fasciocutaneous free flap can be used on more obese individuals or for small defects in which bulk is not needed to provide cheek projection. Suturing to the palatal mucosa should ideally take place over the bony palatal remnant to avoid an oronasal fistula, or drill holes can be made in the bony palate and a deep layer of sutures placed through them for an extra degree of wound closure stability. For all free flap reconstructions in the midface, the facial artery and vein or the superficial temporal artery and vein are the preferred recipient vessels when available. When the facial artery and vein are used as recipient blood vessels, a subcutaneous tunnel is created within the cheek to the neck, which should prevent injury to the distal branches of the facial nerve. Unilateral Hemipalatomaxillectomy Unlike unilateral posterior palatomaxillectomy defects, defects where the resection of the palate and alveolus extends anterior to the canine tooth are difficult to obturate because of the greater cantilever forces acting on the prosthesis, which must rely on less dentition for retention. This is consistent with our experience, in which many patients who desire dental restoration are unable to accommodate a conventionally retained prosthesis, in contrast to patients who undergo a posterior palatomaxillectomy. However, they do not provide a rigid skeletal framework, which can result in a loss of anterior maxillary projection on the side of the defect, and they cannot accept osseointegrated implants for dental restoration. To accommodate a conventional dental prosthesis, the soft tissue flap must not protrude excessively into the oral cavity. However, achieving a concave palatal reconstruction with soft tissue flaps can be technically challenging, especially if the lateral portion of the defect includes some or all of the buccal mucosa. In such cases, options include initial placement of an obturator, if possible, followed by delayed osteocutaneous free flap reconstruction after the conclusion of radiation, or proceeding with immediate bony reconstruction and simultaneous osseointegrated implant placement. Some centers do perform delayed osseointegrated implant placement even into irradiated bony free flaps after treatment with hyperbaric oxygen therapy, although the efficacy of this strategy still needs to be established. In terms of bony free flap selection, many donor sites have been suggested, including the fibula,10 scapula,11 radius,12 rib, and iliac crest. Regardless of which flap is used, we recommend making osteotomies to simulate the complex shape of the native maxilla as closely as possible. While it is tempting to simply place vascularized bone in a nonanatomic position and shape, our experience is that the soft tissues of the cheek will eventually contract and reveal the shape of the underlying bone, especially when postoperative radiation is administered. Anterior Palatomaxillectomy (Premaxillary Resection) Premaxillary defects usually arise from resection of lip or nasal pathologies. Most such defects are amenable to obturation alone or a soft tissue free flap combined with a dental prosthesis that clasps to the remaining teeth to maintain midfacial projection and to support the lip and nose. Osteocutaneous free flaps, such as the fibular osteocutaneous free flap or the radial forearm osteocutaneous free flap, may also be used to reconstruct the defect. The advantage of an osteocutaneous flap in this area is maintenance of upper lip and nose support without an obturator as well as the possibility of osseointegrated implant dental restoration. They also require bony reconstruction for dental restoration with osseointegrated implants, which are usually necessary to retain a prosthesis. In addition, for sizable defects involving both maxillary bones, the fibula offers the longest length of bone of the various flap options. In our experience, 14 to 16 cm of bone length is typically needed to reconstruct a bilateral maxillectomy defect. The lateral surface of the fibula is used to restore the vertical maxillary height, measured from the orbital rim to the occlusal plane of the hard palate, by orienting it such that it faces anteriorly on the face. The peroneal vessels, therefore, assume a posterior position facing the maxillary sinus. Some flexor hallucis longus muscle is usually included with the flap to obliterate the maxil- lary sinus cavity and to provide adequate soft tissue around the vascular pedicle to prevent its desiccation. The orientation of the skin paddle depends on the location of its perforator blood supply, and it may be longitudinally or transversely oriented in relation to the long axis of the fibula. When the bony defect extends more laterally or posteriorly on one side than another, that side is usually preferred for the microvascular anastomosis due to closer proximity to the recipient blood vessels. Alternatively, the side with better recipient blood vessels, if any, is selected for the microvascular anastomosis. The leg that is ipsilateral to the side of the planned microvascular anastomosis is selected for fibular osteocutaneous free flap harvest so that the skin paddle can be used to restore the palate. Vein grafts are used when pedicle length is inadequate to reach the recipient vessels. We prefer to use the facial blood vessels as recipients when available, due to their proximity to the defect and their good caliber match to the peroneal blood vessels. The configuration of the reconstruction plate is such that it simulates the width and projection of the native maxilla. The fibula is osteotomized to resemble the Greek letter omega in the horizontal plane. Separate plates may be used to fix the fibular construct to the remaining facial skeleton, thereby facilitating anterior plate removal at a later date, if needed to allow room for osseointegrated implant placement. Closing wedge osteotomies are performed on the fibula with a reciprocating saw, taking care not to injure the vascular pedicle. When reconstructing bilateral maxillectomy defects, the lateral portions of the omega recreate the malar regions. For unilateral (see the section on hemipalatomaxillectomy, above) or less than complete bilateral defects, a shorter segment of bone is used and one or more osteotomies can be omitted. The portion of the fibular free flap that replaces the anterior maxillae is inset at the vertical level of the resected alveolus, rather than at the level of the dentition, to provide room for an implant-retained dental prosthesis. A slight downward angulation of the portion of the fibula used to recreate the anterior maxillae is usually desirable to fully restore vertical facial height. Dental restoration with osseointegrated implants is performed 3 to 6 months after fibular free flap reconstruction. In patients with significant subcutaneous adipose tissue in their fibular free flap skin paddle, thinning of the fat is usually performed simultaneously with placement of the implants. Partial or total hardware removal is sometimes necessary to place the osseointegrated dental implants. Many surgeons, however, feel that bone grafts are relatively more resistant to radiation-associated complications than alloplasts are. Obviously, alloplastic materials have the advantages of being available in virtually unlimited quantities and of incurring no donor-site morbidity. When using the fibular osteocutaneous free flap for reconstructing hemipalatomaxillectomy and bilateral palatomaxillectomy defects that include resection of the orbital floor, we include some soleus or flexor hallucis longus muscle with the fibular osteocutaneous free flap to support a bone graft or alloplastic orbital floor reconstruction. A double-barreled design to reconstruct both the floor and the hard palate is possible19 but challenging because of the limited space in the midface. Orbital Exenteration Defects the primary goal of reconstruction of orbital exenteration defects is to line the orbital cavity with durable tissue and to exclude the nasal or sinus cavities when the medial or inferior orbital wall has been removed, as well as to protect the brain when the orbital roof has been removed. A deep orbital cavity facilitates prosthetic fit, while a shallow orbital cavity, or an orbital reconstruction that sits flush with the face or is convex, may not securely hold a prosthesis without osseointegrated implants or may cause the prosthesis to protrude unnaturally. Healing by secondary intention and granulation may be the simplest treatment after tumor resection. When completely healed by secondary intention, the orbital cavity is only slightly shallowed by granulation tissue, rendering inspection of local tumor recurrence relatively easy. It is our preference to accelerate wound closure using a meshed or unmeshed split-thickness skin graft, which can be utilized to line the orbital cavity.

This is usually done with loupe magnification sleep aid 100 mg 100 mg modafinil free shipping, as the lingual nerve is inaccessible to the operating microscope insomnia 2 hours a night 200 mg modafinil mastercard. Sensory recovery of the flap with this technique has been well documented and insomnia 57 buy modafinil with mastercard, therefore sleep aid jittery buy generic modafinil 200 mg on line, sensory reinnervation is strongly recommended insomnia 2 hours a night modafinil 200 mg low cost. After the vascular and neural anastomoses are completed, the extra adipofascial tissue or muscle from the flap is carefully positioned to fill the submandibular space while avoiding pedicle compression. The neck wound is then irrigated with an ample amount of warm normal saline (2 or 3 L), taking care not to squirt the saline directly on the vascular pedicle to avoid vessel spasm. All areas should be carefully examined, even if they have already been examined by the ablative surgeons. A 15 Fr Blake drain is placed on each side of the neck, lateral to the internal jugular vein. At this point, the neck is slightly flexed (take out the shoulder roll and flex the neck to a neutral position), and the vascular pedicle is examined again. Because the neck is usually hyperextended during surgery, flexing the neck to a normal position can significantly change the position of the vascular pedicle, causing kinking or compression. Finally, the reinforced endotracheal tube is replaced with a #6 Shiley tracheostomy tube, if this has not been done by the ablative surgeons. Unlike with hemiglossectomy, once most or all of the tongue is removed, mobility of the remaining tongue is no longer a concern. Tissue bulk is important for reconstructing large defects of the tongue for two reasons. First, it is needed to help the neotongue touch the palate to produce better speech and push food toward the hypopharyx. Second, the tissue bulk diverts saliva and food to the lateral pharyngeal gutters during swallowing to minimize aspiration. It also has the advantages of providing sensory and motor reinnervation and minimal donorsite morbidity. Using muscle alone with skin grafting is not recommended because significant atrophy can occur quickly, especially after radiotherapy, resulting in a funnel shape that allows food to pour into the hypopharynx and larynx, causing aspiration. Reconstruction of Total or Subtotal Glossectomy Defects Goals of Reconstruction Although functional outcomes after reconstruction for partial glossectomy defects are generally good, speech and swallowing functions after reconstruction for total and subtotal glossectomy defects remain disappointing. The extent of surgical resection may be the most important factor affecting function. The gracilis myocutaneous flap and the latissimus dorsi myocutaneous flap also have been used, with motor reinnervation. The pedicled pectoralis flap, however, may be used in high-risk patients who are poor candidates for free flap reconstruction or in patients in whom a free flap has failed. The posterior incision can then be redesigned according to the exact locations of the perforators if necessary. An additional 5 cm of nerve length can be obtained by subcutaneously dissecting the nerve in the upper thigh. Flap Insetting As in hemiglossectomy reconstruction, flap insetting begins at the base of the tongue or lateral pharynx. The tip and edges of the flap are sutured to the mandibular gingiva or around the teeth, since it is not possible to recreate the ventral sulcus. Patients undergoing reconstruction for total or subtotal glossectomy defects often have a more advanced stage of cancer that requires bilateral neck dissection, which results in a skeletonized neck. Such reconstruction may reduce the risk of orocutaneous fistula and wound infection. Laryngeal Suspension Because the suprahyoid musculature is removed during total and subtotal glossectomy, the hyoid bone needs to be resuspended to the mandible to minimize the risk of aspiration. Laryngeal suspension from the mandible is performed with circumhyoid sutures (0-Prolene) placed through drill holes on both sides of the mentum. Care should be taken to avoid compression of the vascular pedicle by the suspension sutures. The muscle included in the flap provides excellent protection of the vascular pedicle. However, its use in tongue reconstruction has been infrequent and produces uncertain results. It is technically impossible to recreate the complex movements of the tongue and restore all of its functions. The goals of reconstruction, therefore, are to improve airway protection and speech and swallowing functions. Aspiration can be partially overcome by static, anterior suspension of the larynx from the anterior mandible with transhyoid sutures, as described above. The mobility of the larynx after surgery and radiotherapy is severely limited; therefore, attempting to orient the muscle flap vertically from the hyoid bone to the mandible to elevate the larynx may not be fruitful. Since a mobile tongue cannot be recreated, speech will need to rely on the bulk of the reconstructed tongue touching the palate. Thus, the main goal of functional muscle transfer for total tongue reconstruction should be to improve swallowing function. It has been proposed that orienting the muscle horizontally as a sling with the ends anchored to the pharyngeal constrictors and the medial pterygoids may help to elevate the neotongue. However, the sling effect is minimal, since the placement of the muscle is quite flat, and not as dramatic as has been described. Both sides of the neck are usually exposed during surgery and are easily accessible. However, many patients who have undergone previous surgery and/or radiation therapy may have a frozen neck due to significant scarring. The transverse cervical vessels, which are available in 92% of patients,9 can be a good choice. In addition, using the transverse cervical vessels keeps the vascular pedicle straight. The neurovascular pedicle travels within the muscle and separates the superficial and deep layers of the muscle. The motor nerve to the muscle, a branch of the femoral nerve, is dissected out and is separated from the main motor nerve proximally. First, the blood supply to the horizontally oriented proximal skin paddle is more reliable, since the cutaneous perforators are proximally located and horizontally oriented. Partial necrosis of the skin paddle is very rare, unlike the distal third of a traditional longitudinally oriented skin paddle. Second, the cross orientation between the muscle and skin is ideal for flap insetting, in which the muscle is oriented horizontally and the skin is oriented vertically. The skin paddle extends from the femoral vessels anteriorly to the posterior midline of the thigh. Flap dissection begins at the anterior edge of the skin paddle, proceeding in the subcutaneous plane medially until the gracilis muscle is seen. The vascular and neural pedicles are then dissected out as in the conventional gracilis flap. The skin paddle is oriented vertically and sutured to the pharyngeal, buccal, and gingival mucosa as described above. Thus, it is likely that muscle fibrosis may precede reinnervation after radiotherapy, making motor reinnervation less effective. In selected patients with a good prognosis and no need for postoperative radiotherapy, motor nerve reinnervation may achieve some degree of muscle movement and prevent muscle flap atrophy. At the very least, it serves as a noninnervated flap, providing coverage and bulk without adding much operating time. Functional muscle transfer is not indicated in partial glossectomy reconstruction because the function of the remaining tongue is far superior to that of the reinnervated muscle. Many patients then develop fluid overload and subsequent cardiopulmonary complications. Delirium tremens prophylaxis should be given to patients who are known to be heavy drinkers, which is common among patients with head and neck cancer. In patients with a history of alcohol abuse and narcotic dependence, postoperative confusion and agitation are common and may cause hypertension, hematoma, anastomotic breakdowns, and avulsion of the vascular pedicle. Therefore, prompt management of these issues with neuropsychiatric staff is important. Broad-spectrum antibiotics, such as ampicillinsulbactam, are usually continued for 3 days or longer, as indicated. This can be reduced to every 2 hours for 2 days thereafter and then every 4 hours until discharge. Patients should rinse their mouths frequently with saline or chlorhexidine mouthwash for several weeks. Surgical Outcomes and Complications Functional Outcomes Following hemiglossectomy reconstruction with the techniques described above, more than 90% of patients are able to resume an oral diet without the need for tube feeding, and most patients can tolerate a regular or soft diet, depending on their dental status. Tumor recurrence, a bulky flap, and aspiration can prevent resumption of an oral diet. Aspiration frequently occurs in patients when the surgical resection extends to the epiglottis. With proper training by speech pathologists, most motivated patients can relearn how to swallow. All patients who have undergone a hemiglossectomy and reconstruction should be able to have their feeding tubes removed and to speak intelligibly. This approach has significantly expedited recovery and shortened the length of hospital stay. It is not uncommon for these 34 I Topics in Head and Neck Reconstruction total or subtotal glossectomy reconstruction remain disappointing. Overall, approximately half of the patients require partial or complete tube feeding. Sensory Recovery After Reinnervation Spontaneous sensory recovery can occur without sensory nerve reinnervation, as has been shown in several studies. Boyd et al14 observed nearnormal sensory recovery in eight patients with partial glossectomy defects with the use of the radial forearm free flap transferred intraorally and reinnervated by coapting the lateral antebrachial cutaneous nerve to the lingual nerve. They also demonstrated that flap sensation was superior to that in the native forearm skin. Similar findings were reported in another study,15 which also demonstrated that only the lingual and alveolar nerves, and not the posterior auricular nerve or the cervical plexus, provided adequate sensory recovery. Sensory reinnervation for total or subtotal glossectomy reconstruction is infrequently performed. Postreconstruction radiotherapy resulted in delayed sensory recovery, but the end results were no different after 12 months. Swallowing function was also found to be better in patients with innervated flaps than in those without. All patients expressed pleasure at the return of sensation after a long period of having a "woody flap. Neck wound infection is the result of prolonged wound exposure and oral contamination during surgery. Copious irrigation and obliteration of submandibular dead spaces are important for preventing postoperative wound infection, which often occurs 5 to 7 days after surgery. Once infection occurs, early drainage and thorough débridement and irrigation may enable primary wound closure over a drain. If adequate vascularized tissue remains in the upper neck after débridement, no additional intervention is needed. The pectoralis major muscle flap is commonly used for this purpose and to protect the carotid artery, which is particularly important in patients who have had prior chemoradiation therapy. Early recognition of wound infection and intervention are crucial to avoiding delays in adjuvant therapy, as postoperative radiotherapy usually starts 4 to 6 weeks after surgery. Intraoral leaks, dehiscence, or fistula can result from: (1) improper suturing technique; (2) compromised tissue quality, such as in the previously irradiated neck/oral cavity; and (3) wound infection. The gingival mucosa is thin and can be easily torn; therefore, meticulous tissue-handling techniques are essential. Too many small stitches and tight knots may cause skin or mucosa edge ischemia, leading to dehiscence and leakage. The area behind the mandible is often difficult to sew and may require particular attention. As long as the submandibular/upper neck dead space is filled with well-vascularized tissue, leaks usually heal within 2 weeks with proper care. A dead space can lead to an orocutaneous fistula, in which case a pectoralis major muscle flap may be needed. A skin paddle is usually not necessary, as the exposed muscle will mucosalize within several days. Summary Reconstruction of oral cavity defects should focus on function as well as reliable coverage. Consideration should also be given to minimizing donorsite morbidity and to maximizing aesthetic results. The anterolateral thigh and vertical rectus abdominis myocutaneous flaps are our first choices if the body habitus is appropriate. Careful planning and attention to detail during surgery may prevent many postoperative complications. Early recognition and intervention for complications may prevent delay in adjuvant therapy and disastrous consequences. Expert Commentary by Ming-Huei Cheng this chapter provides very practical information for surgeons to follow and to apply to their own clinical cases. It comprehensively covers the assessment of oral defects, surgical planning, selection of the appropriate flap for different defects, surgical technique, functional outcome evaluation, and management of possible complications. The figures provide excellent illustrations of outcomes of oral cavity reconstruction.

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