Titanium Internal Fixator Removal in Maxillofacial Surgery: Is It Necessary? A Systematic Review and Meta-Analysis.

Titanium plates and screws are essential devices in maxillofacial surgery since late 1980s, but despite their wide use there is no consensus in titanium internal fixators removal after bone healing. A systematic literature review and meta-analysis were conducted on seventeen retrospective studies. Effect size and 95% confidence intervals were calculated for plate removal (per plate and per patient) and for removal causes (infection, pain, screws complications, exposition, palpability). Odds ratio, 95% confidence intervals, and χ 2 test were measured for sex, smoking, and implant site. Heterogeneity was evaluated with Cochran and Inconstancy test. Obtained data were used to design Forest and Funnel plots. The aim of the study is to identify and clarify reasons and risk factors for plates and screws removal. Infection is the most frequent reason; the habit of tobacco usage and implant site (mandibula) are the main risk factors. The administration of antibiotic prophylaxis is essential, and patients must quit smoking before and after surgery. In conclusion there is no scientific evidence supporting the removal of internal devices as mandatory step of the postoperative procedure.

Minimally Invasive "Trocar-Free" Approach for Rear Mandibular Fractures Management.

ABSTRACT: The request of minimally invasive surgery is progressively expanding the indications of endoscopically assisted intraoral access for mandibular traumas. The aim of our study is to assess how much the use of the angled drill may affect the outcome of patients treated for rear mandibular fracture. In our retrospective case-control trial we enrolled 36 patients with mandibular rear fractures treated through endoscopically assisted intraoral access. Eighteen patients were treated by using an angled drill ''trocar free,'' and 18 treated by linear drills placed through trocars. Surgical times, hospitalization times (HT), and major complications rate were compared between the 2 groups. Group 1 showed a significant reduction in HT (1.72 versus 2.22 days, P = 0.024) and an increase in the surgical times (3.0 versus 2.53 hours, P = 0.019). Significant reduction of total amount of complication was seen in group 1 versus group 2 ( P = 0.007). The ''trocar free'' approach allowed by angled drills, in our hands, greatly reduces the invasiveness of the surgery resulting in a significant reduction in HT and smaller share of vascular-nervous sequelae. Our results suggest the ''trocar free'' approach as a valuable choice when indicated for the treatment of rear mandibular fractures.

Trans-Oral Robotic Surgery: 14 Cases of Pleomorphic Adenoma of the Parapharyngeal Space.

PURPOSE: The aim of this study has been to describe our experience with pleomorphic adenomas of the parapharyngeal space (PPS) treated with trans-oral robotic surgery (TORS). Tumors arising from the PPS comprise less than 0.5% of all head and neck tumors. Salivary gland tumors account for 40% to 50% of PPS lesions with pleomorphic adenomas representing the most common salivary tumors (80%-90%). Parapharyngeal space tumors cause nonspecific symptoms and may be difficult to diagnose. METHODS: In our study a preoperative diagnosis was conducted by fine needle aspiration biopsy and magnetic resonance imaging and the results were used to plan the correct surgical approach. RESULTS: In all cases we were able to employ TORS, a minimally invasive procedure that allows us to operate in narrow and anatomically complex spaces that we can only reach thanks to the use of well-articulated hand pieces. CONCLUSIONS: This report indicates that TORS is a safe surgical procedure for the excision of benign tumors of the PPS in selected cases.

Anterior Cartilage Rasping During Otoplasty Performed With an Adson Brown Cartilage Forceps.

ABSTRACT: Protruding ears are a common occurrence and can affect the aesthetics and psychosocial aspects of patients. Hundreds of procedures have been described over the years to correct the 2 main deformities related to protruding ears: conchal hypertrophy and anti-helical fold absence.For the rasping technique, the rasp is inserted posteriorly, from the side where the skin is excised;The ending part of the forceps looks like a small rasp, it worked very well and the surgery was completed without problemsThe authors think this tip could be a useful "tool" for all the surgeons used to perform cartilage rasping "in case of necessity" when rasp is not available.

Conjunctival Carcinomas Arising in the Anophthalmic Socket.

PURPOSE: The aim of this study was to report management and outcomes of patients in which conjunctival carcinomas arose in the anophthalmic socket. METHODS: The authors retrospectively analyzed the data of patients which presented the anophthalmic socket after surgery. The clinical records of 4 patients with histological diagnosis of conjunctival carcinoma in the anophthalmic socket, referred to our Department, between January 2014 and December 2019 was collected. RESULTS: The study included 4 men (median age 58 years). A previous enucleation surgery had been performed in all patients due to previous ocular trauma for three patients (Case 1, 3, and 4) and due to a retinoblastoma for 1 patient (Case 2). All patients underwent surgical excision of the lesion and only 1 patient (case 3) underwent orbital exenteration due to the high-grade of the cancer. The most common tumor was the squamous cell carcinoma (2 cases) followed by 1 case of high-grade mucoepidermoid carcinoma and 1 case of carcinoma in situ. Systemic work-up was performed for all the patients. Conjunctival TNM, according to the American Joint Committee on Cancer TNM staging system was used to stage the lesions. The median follow-up time was 15 months. CONCLUSION: Considering the severity and rarity of these tumors, a careful ophthalmological examination of the cavity and a correct revision of the prosthesis should be mandatory in order to ensure the elimination of any macro and microscopic irregularities that can then in the long-term cause chronic inflammation of the tissues and consequently promote the growth of carcinomas.

The Use of Dermal Substitutes for Donor Site Closure After Radial Forearm Free Flap Harvesting.

OBJECTIVE: The aim of our study was to analyze the aesthetic and functional outcome in the radial forearm free flap donor site using a simple split thickness skin grafting (STSG) closure compared with the use of dermal scaffold supporting the STSG closure. METHODS: The study analyzed 18 patients, divided in 2 groups based on the donor site closure modality. In STSG group, a simple STSG was used to cover the defect. In the DS + STSG group, the defect was covered by the use of dermal substitute (MatriDerm) supporting the STSG. Groups were compared on the following outcome variable: scar status; hand function; circumferences at most proximal and most distal point of the graft. All patients were followed up 1, 6, and 12 months post-operative. RESULTS: Nine patients from STSG group showed a difference in circumference between the operated and contralateral limbs respectively of 2.9 mm proximal and 1.2 mm distal; in the 9 patients of DS + STGS group the difference was respectively of 1.2 mm proximal and 1.3 mm distal. Welch unequal variances t-test demonstrated statistical significance of the values with P < 0.004 (P < 0.5). The average VSS was 1.82 ±â€Š0.2 for STSG group and 1.75 ±â€Š0.2 for DS + STGS group. The DASH score was 21.8% in STSG group and 19.4% in DS + STGS group. CONCLUSION: Our study shows that patients treated with Matriderm + STSG obtained a better result both in esthetic and functional outcomes.

The Role of a Deep Neuromuscular Block in the Treatment of Mandibular Subcondylar Fractures.

ABSTRACT: Mandibular fractures are the third most frequents maxillo-facial fractures. Most frequent site is the subcondylar region. Different approaches to reach subcondylar region, have been described. In the study was evaluated the advantages of neuromuscular block during endoscopic surgery for subcondylar fractures. Twenty-five patients affected by subcondylar fractures were enrolled in this study and divided in 2 groups; group A: patients who received an intraoperative booster of curare during surgical procedure and group B patients who underwent surgery treated without the intraoperative booster of curare. All patients were treated successfully by endoscope-assisted transoral approach. The analysis of time required for surgery showed a reduction in group A comparing to group B. The mean time for surgery for the patients in group B with displacement between 0° and 45° was 170 minutes, and for 45° to 90° was 230 minutes. In group A, the mean time was 117.5 minutes for patients with condylar displacement between 0° and 45°, and 147.5 minutes for the other group. In conclusion, deep neuromuscular block seems to improve the surgical conditions in patients undergoing subcondylar endoscopic assisted surgery, further study needs to assess this surgical technique in order to better define this surgical protocol.

Have There Been any Changes in the Epidemiology and Etiology of Maxillofacial Trauma During the COVID-19 Pandemic? An Italian Multicenter Study.

ABSTRACT: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had a significant impact on people's behavior. The aim of this study has been to evaluate how the SARS-CoV-2 pandemic has impacted the incidence and the features of maxillofacial fractures presented at 6 Italian tertiary centers. Clinical records of all the patients diagnosed for facial fractures between February 23 and May 23, 2019 and 2020 were retrospectively reviewed. Any differences in patient number and characteristics and fracture etiology and site between the 2 groups were then statistically analyzed.There has been a 69.1% decrease in the number of incoming patients during the pandemic. The number of foreign patients has decreased significantly (23.3% versus 9.6%, P = 0.011) while the average age has increased (38.6 versus 45.6 years old, P = 0.01). Specific statistical significant differences for accidental falls (31.8% versus 50.1%, P = 0.005) and sports injuries (16.9% versus 1.4%, P < 0.001) were found. Concerning fracture sites, significant differences have been found in relation to nasal (22.5% versus 11.4%, P = 0.009) and frontal sinus (0.9% versus 4.4%, P = 0.037) fractures. In conclusion, SARS-CoV-2 pandemic has significantly changed the epidemiology and the etiology of facial traumas.

Percutaneous Reduction of Isolated Zygomatic Arch Fractures: A 5-Year Experience.

PURPOSE: We evaluated the outcomes and differences in surgical time and hospitalization length for patients with an isolated zygomatic arch (ZA) fracture treated by percutaneous wire reduction with external fixation. PATIENTS AND METHODS: We designed and developed a retrospective study of patients with isolated ZA fractures treated from 2014 to 2019. The predictor variable was the operative treatment, represented by percutaneous reduction with external fixation. The primary outcome variables were the surgical time and hospitalization length. Other variables, including functional and esthetic results (evaluated by clinical and radiologic assessments) and the rate of immediate and delayed complications during a 6-month minimum follow-up period, were considered. Descriptive statistics were computed and compared with the international reported data. RESULTS: A total of 15 patients met specific inclusion and exclusion criteria. The 15 fractures were grouped using the classification reported by Kim et al as type 1A (n = 9) and type 1B (n = 6). No significant differences were found between the 2 groups, except for the fracture type. The operative treatment was performed with the patient under general anesthesia (n = 12) or local anesthesia with sedation (n = 3). Only 1 patient developed a complication (early hematoma). No other cases of early or delayed complications were reported. Two patients required a traditional surgical operation with the Gilles approach. The average hospitalization length and surgical time were 0.8 night and 18.4 minutes for the type 1A group and 0.7 night and 19.0 minutes for the type 1B group, respectively. Optimal esthetic and functional outcomes were obtained for all 15 patients. CONCLUSIONS: The results of the present study suggest that optimal esthetic and functional results can be obtained, minimizing the effect on soft tissues and patient discomfort, with a short surgical time and low rate of complications.

Pott's Puffy Tumor and Intranasal Cocaine Abuse.

Pott's puffy tumor (PPT) is a rare subperiosteal abscess of the frontal bone with osteomyelitis, which most commonly affects adolescents as a complication of frontal sinusitis or head trauma. The Authors describe a case of development of a PPT in a woman who abused of cocaine for at least five years and presented with a gradually enlarging mass of the forehead. The patient was treated surgically through combined endoscopic and open approach and medically with antibiotic therapy. The PPT, as rare complication of intranasal cocaine abuse, was described until now in four patients. Even rare it can be a fearsome complication, making of fundamental importance an early diagnosis and a correct management.

Anthropometric Parameters for Nose Evaluation and Nasal Surgery Planning.

BACKGROUND: The esthetic characteristics of face and nose are commonly evaluated before rhinoplasty using a completely subjective method, due to the lack of validated and reliable methods for quantifying facial esthetics and for accurate nose treatment planning. The aim of the study was to review the literature to determine and evaluate the points, distances, and angles commonly used in the treatment planning for rhinoplasty. METHODS: Research based on anthropometric studies of the face and nose, published from 1987 to 2018 was included. Finally, 138 papers were selected after a statistical analysis through a simple random and non-random sample selection, and all papers were evaluated in their entirety. RESULTS: According to the frequency of citation, 198 points, 336 distances, and 199 angles were listed. The first quartile of each distribution was eliminated, and frequency of more than 25% was selected. A group of 49 points, 77 distances, and 11 angles, were classified according to their anatomical region, that is, bone and soft tissues, was obtained. CONCLUSIONS: An enormous inhomogeneity and lack of standardized anthropometric measurement system, specifically of the nose, was evident, as the studies were conducted by authors of different origins. According to universally accepted parameters, the importance of a reliable method for nose surgery planning is highlighted.

Dentoalveolar Fractures: New Orthodontic Protocol Proposal and Pilot Study.

The goal of fracture treatment that includes the dentoalveolar process is to obtain the anatomic bone healing and the pre-injury occlusion restoration with functional and aesthetic recovery, avoiding dental or periodontal lesions. Fractures activates, in the damaged tissue, the Regional Acceleratory Phenomenon, a physiological healing process that can also be activated during orthodontic overloads. Orthodontic treatment in the traumatized area could exploit this phenomenon in order to sustain the cellular activity.The aim of this study is to propose a treatment protocol for dentoalveolar fractures based on the use of orthodontics in order to sustain the physiological healing process known as Regional Acceleratory Phenomenon.The authors present 2 cases of an 18 year old woman and 23 year old man affected by dentoalveolar fracture. The operative protocol the authors applied foresaw three steps of treatment: orthodontic brackets application, surgery, orthodontic treatment.The patients showed complete healing at the 3 months follow-up and were treated up to 18 months for further orthodontic treatment.The operative protocol proposed by the Authors appears to be a rational choice since it allows a single orthodontic device to be an "active splinting system", with fast application time, good acceptance by the patient, low complications rate; moreover, it produces any planned dental movements for further orthodontic treatments.

Guidelines and Recommendations for Patient Management, Surgical Activities, and Safety in the Maxillofacial Unit and Head and Neck Department During COVID-19 Pandemic.

The recent pandemic has led to an unprecedented overload of sanitary systems around the world. Despite that a maxillofacial department is not a frontline specialty in the treatment of coronavirus disease 2019 infections, our department has found itself faced with numerous problems in keeping the care system active and efficient while ensuring safety for patients and healthcare professionals. Massive redistribution of health personnel was needed to improve prevention and personal safety measures. The education and training system has been kept active, giving residents a decisive role in managing the state of emergency response. This article outlines new guidelines for infection prevention: from clinical control, treatment processes, clinical management, protection, and disinfection of healthcare professionals.

Surgical Management of Large Odontogenic Cysts of the Mandible.

INTRODUCTION: Odontogenic cysts are defined as those cysts that arise from odontogenic epithelium and occur in the tooth-bearing regions of the jaws. Cystectomy, marsupialization, or decompression of odontogenic cyst are the most common treatments proposed for this pathology. The aim of this study is to retrospectively evaluate the result of decompression based on the volumetric reduction of the cystic cavity and new bone formation by cone beam computerized tomography (CBCT). METHODS: The 16 patients affected by a large odontogenic mandibular cyst were enrolled in the study. All the patients underwent a surgical decompression of the cyst followed by the enucleation after a follow-up ranging from 6 to 9 months according to the volume's reduction and new bone formation. All the patients were evaluated with a CBCT before and after the surgical decompression to measure and analyze the percentage of reduction of the cystic volume before proceeding with the enucleation. RESULTS: The decompression of the cyst showed a reduction of the cystic volume ranging from 38.2% to 54.4% proportionally to the treatment duration. The highest percentage of volume reduction observed was 54.4% in 1 patient followed-up for 9 months, before the surgical enucleation. CONCLUSION: In our experience, the decompression seems to be the most suitable technique for the primary treatment of large odontogenic cyst of the jaws followed by the enucleation after 6 to 9 months. The CBCT is an objective method to evaluate the cystic volume reduction after the decompression and helps the surgeon with the surgical planning.

Postoperative Management of Zygomatic Arch Fractures: In-House Rapid Prototyping System for the Manufacture of Protective Facial Shields.

Zygomatic fractures account for 10% to 15% of all facial fractures. The surgical management of isolated zygomatic arch fractures usually requires open reduction treatment without fixation through an intraoral access. Therefore, the main problem in the non-fixed treatment of zygomatic arch fractures is related to the difficulty in obtaining a stable reduction for a period long enough to guarantee the physiological bone healing process. We propose an innovative "in-house" rapid prototyping (RP) protocol for the 3D-zygoma mask manufacture of a patient-specific protective device to apply after zygomatic arch fracture reduction. Our study includes 16 consecutive patients who underwent surgical open reduction for an isolated zygoma fracture without fixation between January 2017 and February 2018. The patients received regular postoperative checks at weeks 1 and 2. Before the device was removed, a multiple choice questionnaire was administered to measure the degree of wearability of the mask. The estimated cost of the production is around &OV0556;5 per case and the construction time is around 90 minutes. Based on the encouraging results, obtained in our experience, we hope that other studies can be conducted to confirm our procedure and improve its functionality in the field of facial trauma.

Self-Made Rapid Prototyping Technique for Orbital Floor Reconstruction: Showcases for Technical Description.

BACKGROUND: Restoring the orbital cavity integrity in orbital floor defects is a challenging issue due to the anatomical complexity of the floor's surface. This is a showcase for technical description of a novel "in house" rapid prototyping protocol aimed to customize implant for orbital floor reconstruction. METHODS: The authors present 4 cases to show our Computer-aided-design and Computer-aided-manufacturing digital workflow. The system was based on a 3D-printed press that; through a virtually designed mold, was used to conform a patient specific titanium mesh for orbital floor reconstruction. RESULTS: The merging procedure analysis by iPlan Cranial 3.0 (Brainlab, Munich, Germany) highlighted a 0.71 ±â€Š0.23 mm (P <0.05) discrepancy in a point-to-point superimposition between the digital planned reconstruction and the real in vivo result. CONCLUSIONS: The authors expect that this technique will reduce operative time and cost however further study and larger series may better define the applicability in everyday surgical practice.

Surgical Lip Remodeling After Injection of Permanent Filler.

BACKGROUND: A major concern regarding permanent lip fillers is difficulty with revision should this be required. Currently, the only way to treat lip sequelae is by surgical remodeling. OBJECTIVES: Based on the senior author's 6-year experience, the authors collectively suggest a surgical method to correct lip deformity in such situations. METHODS: The records of 38 patients with lip deformity who underwent surgery between 2011 and 2017 after receiving permanent filler injections were analyzed retrospectively. A total of 38 consecutive patients (69 lips) with an average age of 38.8 years (range, 28-52 years) were treated surgically. RESULTS: All patients experienced postoperative swelling (average duration, 15 days), and no infections were recorded. In 3 cases, a 1-cm dehiscence was documented, which healed by secondary intention. In 1 case, a hematoma noted several days after surgery resolved spontaneously within 3 weeks. In 2 upper lips, a minor touchup procedure (with the patient under local anesthesia) was performed 9 months after the initial surgery. Overall, patients noted that it took at least 6 to 9 months to achieve natural lip movement. The average time until softening of the lip tissue was 4 months. CONCLUSIONS: This study emphasizes the importance of informing patients that complete removal of permanent filler is not always possible. However, most of the authors' patients were pleased with the results. This study also highlights the importance of paying strict attention when approaching the area adjacent to the oral commissures in order to avoid potential reductions in mouth opening that can occur from postoperative scarring.

A Minimally Invasive Endoscopic Approach to Midcheek Mass: Showcase for Technical Description.

BACKGROUND: Surgical approaches to the midcheek area are challenging. This area is included between the lower eyelid above, and the upper lip below. The peculiar anatomical location makes it really important for attractiveness, thus the need to obtain a correct balance between the operation's safety and minimally invasive aspect. To the authors' knowledge, this is the first showcase and technical description of a novel minimally invasive endoscopic approach for midcheek mass removal. METHODS: Making 3 incisions in concealed area an endoscopically aided facial dissection was performed to remove a solitary venus malformation of the left midcheek region. RESULTS: After the surgical procedure was performed, no hematoma, no edema, or facial nerve paralysis were observed. To date, during the follow-up period, no recurrence of the lesion has been observed, and the quality of life of the patient was good with a minimally scar outcome. Magnetic resonance imaging, performed 2 weeks postoperatively, demonstrated a complete removal of the mass CONCLUSION:: The authors' finding experience suggests that the minimally invasive approach provides an excellent surgical window that achieves greater exposure for the dissection of the midcheek area. Further clinical applications are required to assess advantages and/or limitations of this procedure.

Maxillo-Mandibular Reconstruction in Pediatric Patients: How To Do It?

Maxillo-mandibular reconstruction in pediatric patients involves particular functional and cosmetic implications. Attention is required for the craniofacial growth over time, involvement of the permanent dentition, facial symmetry, and donor site morbidity. Our aim is to identify the best reconstructive options for maxilla-mandibular defects in children (<18 years) based on our experience with 25 pediatric patients. We believe that reconstruction has to be performed at the same time as resection in pediatric patients. Local flaps should be reserved for cases of maxillary defects because of malignant neoplasms, which ultimately have poor prognosis. In cases of large mandibular defects, radiotherapy is eventually required. When the condition of the soft tissues is poor (because of previous surgery, etc), free flaps potentially represent the best options. Nevertheless, in patients younger than 5 years old (with no damaged tissues), reconstruction with rib grafts should be performed, and the use of titanium plates should be reserved for very select cases (such as temporary reconstruction in toddlers).