Handgrip Strength Predicts Poorly the Surgical Outcome or Length of Hospitalization in Patients With Surgically Operated Oral Cancer.

BACKGROUND/AIM: Handgrip strength has been used to evaluate the potential of elderly patients to survive different medical conditions or procedures, or to predict the nutritional status and length of hospitalization. The aim of this study was to evaluate the use of handgrip strength as a predictor of the length of hospitalization and need for prolonged intensive care in patients with oral malignancies requiring surgical resection and simultaneous primary reconstruction with microvascular free flap. PATIENTS AND METHODS: This is a retrospective study of 37 head and neck carcinoma patients operated between 2012 and 2014 who had undergone a handgrip force test. The microvascular free flaps used were: radial forearm flap (n=23), anterolateral thigh flap (n=10), and iliac crest free flap (n=4). RESULTS: Average stay at the hospital was 13.3 days after the operation and there was a 2.9-days need for intensive care. Handgrip strength did not predict susceptibility to complications, duration of hospitalization, or 12-month survival in the study population. CONCLUSION: Other anamnestic and medical factors and not handgrip strength should be considered when evaluating operability of the patient or their individual risks for microvascular reconstruction.

Virtual 3D planning and prediction accuracy in two bimaxillary face transplantations in Helsinki.

BACKGROUND: The aim of this study was to describe the 3D planning process used in our two composite face transplantations and to analyze the accuracy of a virtual transplantation in predicting the end-result of face transplantation. METHODS: The study material consists of two bimaxillary composite face transplantations performed in the Helsinki University Hospital in 2016 and 2018. Computed tomography (CT) scans of the recipient and donor were used to define the osteotomy lines and perform the virtual face transplantation and to 3D print customized osteotomy guides for recipient and donor. Differences between cephalometric linear and angular measurements of the virtually simulated and the actual postoperative face transplantation were calculated. RESULTS: No changes to the planned osteotomy lines were needed during surgery. The differences in skeletal linear and angular measurements of the virtually simulated predictions and the actual postoperative face transplantations of the two patients varied between 0.1-5.6 mm and 0.7°-4°. The postoperative skeletal relationship between maxilla and mandible in both patients were almost identical in comparison to the predictions. CONCLUSIONS: 3D planning is feasible and provides close to accurate bone reconstruction in face transplantation. Preoperative virtual transplantation assists planning and improves the outcome in bimaxillary face transplantation.

Alloplastic Temporomandibular Joint Reconstruction in Congenital Craniofacial Deformities.

ABSTRACT: Temporomandibular joint (TMJ) reconstruction with alloplastic prosthesis is a commonly performed procedure, which can be used as a treatment for improving pathologic conditions affecting the TMJ. Depending of the severity of the condition, the patient's ability to eat can be impaired, which in turn can affect their quality of life. Several syndromes can affect the patient's facial features, and some of those also affect TMJ's. Use of alloplastic prosthesis in TMJ's affecting syndromes, by means of correcting TMJ conditions and mandibular deformities, is still rather uncommon. Purpose of our study is to review the use TMJ total prosthesis as a treatment modality for correcting TMJ conditions and the reconstruction of mandibular deformities in congenital syndromes affecting the facial features. This study consists of a retrospective cohort of patients treated with TMJ reconstruction with alloplastic prosthesis at the Helsinki University Hospital during the past decade. All subjects with congenital syndrome who underwent TMJ reconstruction were included the study. The cohort consisted of seven patients and ten joints treated. Temporomandibular joints affecting syndromes were Goldenhar syndrome, hemifacial macrosomia, Nager syndrome, and Treacher-Collins syndrome. The majority of the patients have had several previous operative treatments on the facial skeleton during their childhood, which in turn probably affected and compromised the TMJ surgery outcome. Mouth opening was sufficiently achieved as average maximal opening was 34 mm (range 24-42 mm) postoperatively. Temporomandibular joint reconstruction with alloplastic prosthesis can offer new tools and approaches for treatment of facial deformities in syndromes with craniofacial abnormalities. Impaired jaw functions and asymmetry can be addressed with the use of alloplastic prostheses, achieving sufficient mouth opening and restoring the symmetry of the lower facial skeleton.

Perioperative Dexamethasone Is Associated With Higher Short-Term Mortality in Reconstructive Head and Neck Cancer Surgery.

PURPOSE: Studies of the effects of perioperative dexamethasone (DEX) during oncologic surgery are scarce. The first aim of the present study was to clarify whether perioperative DEX affects the short-term mortality in patients with head and neck cancer (HNC). The second aim was to analyze the causes of death and predictors affecting long-term mortality. PATIENTS AND METHODS: The present prospective, double-blind randomized, controlled study included patients with HNC who had undergone microvascular reconstruction from 2008 through 2013. The patients were randomized into 2 groups: the receipt of perioperative DEX for 3 days (study group) or no DEX (control group). The patients' data and cause of death were registered until the end of 2017. The primary cause of death was used in the analyses. RESULTS: A total of 93 patients were included in the present study: 51 in the DEX group (study group) and 42 in the NON-DEX group (control group). Altogether 38 patients died during a median follow-up period of 5.3 years. During the first year, more deaths had occurred in the DEX group than in the NON-DEX group: at 1 month, 4% versus 0%; at 6 months, 14% versus 0%; and at 12 months, 22% versus 5% (P = .043). The overall survival rate for all patients was 59%. HNC was the primary cause of death for most of the patients who died. On univariate analysis, the deceased patients had more advanced disease (higher T classification, P = .002; higher stage, P = .008), a greater need for a gastrostoma (P = .002), more often received postoperative chemotherapy (P = .005), and more often had locoregional (P = .025) or distal (P < .001) metastases. In the multivariate Cox model, the most important long-term predictors of death were the presence of distant metastases (P < .001), a Charlson comorbidity index (CCI) of 5 to 9 (P < .001), and the use of perioperative DEX (P = .004). CONCLUSIONS: The use of perioperative DEX was associated with higher short-term mortality after reconstructive HNC surgery. The most important long-term predictors of death were the receipt of DEX, the presence of distant metastases, and a CCI of 5 to 9. These findings do not encourage the routine use of perioperative DEX for these patients.

The Effect of Dexamethasone on Pain Severity After Zygomatic Complex Fractures.

The authors sought to assess the effect of systemic perioperative dexamethasone (DXM) on pain severity after zygomatic complex (ZC) fracture surgery. To achieve this, the authors conducted a prospective randomized observer-blinded trial on 63 patients with isolated ZC fracture requiring surgical intervention. Patients randomly received either perioperative systemic DXM (10 or 30 mg), or served as controls receiving no DXM, and postoperative pain severity was assessed. Pain was measured with a 10 cm visual analogue scale (VAS) each time that analgesics (1 g paracetamol 4 times daily or oxycodone upon request) were administered, and analyzed as the area under the VAS curve for the immediate postoperative 24 hours. This further divided experienced pain into 2 categories (mild, or moderate to severe) using VAS = 4 as the cutoff. For statistics the authors used χ test, Mann-Whitney U test, and logistic regression analysis, setting significance at P < 0.05. Zygomatic complex fracture patients receiving perioperative systemic DXM experienced milder pain compared with controls (P = 0.04). Subgroups receiving DXM (10 or 30 mg) reported no statistical difference regarding pain (P = 0.43). Overall, patients receiving DXM experienced less pain, thus DXM may be recommended as pre-emptive analgesic. Nonetheless, considering the possible adverse effects, a 10 mg single dose may be sufficient.

More Harm Than Benefit of Perioperative Dexamethasone on Recovery Following Reconstructive Head and Neck Cancer Surgery: A Prospective Double-Blind Randomized Trial.

PURPOSE: Prospective studies on the effect of dexamethasone after microvascular reconstructive head and neck surgery are sparse despite the widespread use of dexamethasone in this setting. The aim of this study was to clarify whether perioperative use of dexamethasone would improve the quality and speed of recovery. The authors hypothesized that dexamethasone would enhance recovery and diminish pain and nausea. MATERIALS AND METHODS: Ninety-three patients with oropharyngeal cancer and microvascular reconstruction were included in this prospective double-blinded randomized controlled trial. Patients in the study group (n = 51) received dexamethasone 60 mg over 3 perioperative days; 42 patients did not receive dexamethasone and served as controls. Patient rehabilitation, postoperative opioid and insulin consumption, postoperative nausea and vomiting (PONV), and C-reactive protein (CRP), leukocyte, and lactate levels were recorded. RESULTS: There was significantly less pain in the study group (P = .030) and the total oxycodone dose for 5 days postoperatively was lower (P = .040). Dexamethasone did not significantly lessen PONV for 5 days postoperatively (P > .05). There were no differences between groups in intensive care unit or hospital stay or in other clinical measures of recovery. Patients receiving dexamethasone required significantly more insulin compared with patients in the control group (P < .001). Lactate and leukocyte levels were significantly higher (P < .001) and CRP levels were significantly lower in the study group. CONCLUSION: The only benefit of perioperative dexamethasone use was lower total oxycodone dose; however, the disadvantages were greater. Because dexamethasone can have adverse effects on the postoperative course, routine use of dexamethasone as a pain or nausea medication during reconstructive head and neck cancer surgery is not recommended.

Behavior of C-reactive protein in association with surgery of facial fracture and the influence of dexamethasone.

PURPOSE: To clarify pre- and postoperative C-reactive protein (CRP) levels in patients with facial fractures and to investigate the influence of perioperatively administered dexamethasone on postoperative CRP levels. PATIENTS AND METHODS: Facial fracture patients were randomized to receive perioperatively a total dose of 30 mg of dexamethasone (Oradexon®), whereas patients in the control group received no glucocorticoid. The analysis included patients who had CRP measured pre- and postoperatively. RESULTS: A total of 73 adult patients with facial fractures were included in the final analysis. Mean CRP level was elevated preoperatively and the level increased further after surgery. However, postoperative CRP rise was significantly impeded by dexamethasone (p < 0.001), regardless of gender, age, treatment delay, site of fracture, surgical approach, and duration of surgery. CRP rise halved on the 1st postoperative day when dexamethasone was used. In addition, dexamethasone resulted in a CRP decrease on the 2nd postoperative day, whereas the CRP rise continued in the control group. CONCLUSIONS: CRP rise is a normal body response after facial fracture and surgery that can be markedly reduced with dexamethasone. CRP changes should be considered with caution if perioperative dexamethasone is used.

The Helsinki Face Transplantation: Surgical aspects and 1-year outcome.

BACKGROUND: Since 2005, at least 38 facial transplantations have been performed worldwide. We herein describe the surgical technique and 1-year clinical outcome in Finland's first face transplant case. METHODS: A 34-year-old male who had a severe facial deformity following ballistic trauma in 1999 underwent facial transplantation at the Helsinki University Hospital on 8th February 2016. Three-dimensional (3D) technology was used to manufacture donor and recipient patient-specific osteotomy guides and a donor face mask. The facial transplant consisted of a Le Fort II maxilla, central mandible, lower ⅔ of the midface muscles, facial and neck skin, oral mucosa, anterior tongue and floor of mouth muscles, facial nerve (three bilateral branches), and bilateral hypoglossal and buccal nerves. RESULTS: At 1-year follow-up, there have thus far been no clinical or histological signs of rejection. The patient has a good aesthetic outcome with symmetrical restoration of the mobile central part of the face, with recovery of pain and light touch sensation to almost the entire facial skin and intraoral mucosa. Electromyography at 1 year has confirmed symmetrical muscle activity in the floor of the mouth and facial musculature, and the patient is able to produce spontaneous smile. Successful social and psychological outcome has also been observed. Postoperative complications requiring intervention included early (nasopalatinal fistula, submandibular sialocele, temporomandibular joint pain and transient type 2 diabetes) and late (intraoral wound and fungal infection, renal impairment and hypertension) complications. CONCLUSION: At 1 year, we report an overall good functional outcome in Finland's first face transplant.

Postoperative leukocyte changes in facial fracture patients: a randomized prospective study with short-term dexamethasone.

PURPOSE: We investigated leukocyte changes in facial fracture patients undergoing surgery. Of specific interest was the effect of perioperative dexamethasone on leukocyte changes. METHODS: Facial fracture patients were randomized to receive perioperatively a total dose of 30 mg of dexamethasone, whereas patients in the control group received no glucocorticoid. All patients received antibiotics until postoperative days 7-10. Leukocyte count was measured on postoperative days 1 and 2. Clinical infections were observed during the follow-up. RESULTS: A total of 110 adult patients were included in the study. Postoperative leukocytosis was found in 91.2% of patients receiving dexamethasone and in 67.9% of controls. Dexamethasone was associated strongly with leukocyte rise (p < 0.001) on both postoperative days. Transoral surgery and younger age (≤40 years) showed significant associations with leukocytosis on the first postoperative day (p = 0.002). In regression analyses, dexamethasone associated with leukocytosis most significantly (p < 0.001). No association was found with infections. CONCLUSIONS: Dexamethasone use was the most significant predictor of leukocyte rise. As a drug response, perioperative dexamethasone caused sixfold postoperative leukocytosis. High-dose dexamethasone-induced leukocytosis may confuse the clinical decision-making especially in assessment of early infections.

A Comparison of Bone Resorption Over Time: An Analysis of the Free Scapular, Iliac Crest, and Fibular Microvascular Flaps in Mandibular Reconstruction.

PURPOSE: The aim of the present study was to compare the resorption of the bone in the free scapular, free iliac crest, and free fibular microvascular flaps in mandibular reconstruction over time. PATIENTS AND METHODS: In the present retrospective study, we analyzed 186 consecutive patients with scapular, fibular, or deep circumflex iliac artery (DCIA) osseous free microvascular flaps in mandibular reconstruction. We followed up the patients clinically and using multislice computed tomography (MSCT) with volume analyses of the bone. The volume of the bone was analyzed against time. RESULTS: A total of 38 patients fulfilled the study criteria. Resorption of the osseous flaps was found to continue for several years. At 2 years, the volume loss was 14% for the scapula, 3% for the DCIA, and 1% for the fibula. Three-dimensional (3D) volume analysis of the MSCT scans showed more resorption than 2-dimensional analyses of the radiographs. Postoperative radiation therapy, patient age, and patient gender did not correlate with bone resorption. CONCLUSIONS: After microvascular mandibular reconstruction, the volume reduction over time is the least in the fibula and the greatest in scapula, with that of the DCIA in between. The volume reduction continues for several years in all of these. For assessment of the volume reduction of osseal reconstruction, a 3D volume analysis is more reliable than height by width measurements.

Analgesic Effect of Perioperative Systemic Dexamethasone on Blowout Fracture Surgery.

PURPOSE: To clarify the effect of systemic dexamethasone (DXM) on pain and postoperative opioid (oxycodone) consumption after blowout fracture surgery. MATERIALS AND METHODS: A prospective randomized observer-blinded trial of 20 patients who had a blowout fracture requiring surgical intervention was conducted. Patients were randomly assigned to receive a total dose of intravenous DXM 30 mg perioperatively or no DXM (controls). Pain was assessed postoperatively using a 10-cm visual analog scale (VAS) each time analgesics (acetaminophen every 6 hours or oxycodone upon request) were administered. The VAS area under the curve (VAS AUC) for 24 hours postoperatively represented the outcome. Data were analyzed using χ2 test, Student t test, 2-tailed Mann-Whitney U test, and linear regression, with a P value less than .05 indicating significance. RESULTS: Patients with blowout fracture receiving perioperative systemic DXM exhibited a significantly lower average VAS AUC (P = .04). After controlling for other confounding variables, this result remained significant (P = .03). CONCLUSIONS: DXM appears to decrease postoperative pain and thus is recommended as a pre-emptive analgesic in blowout fracture surgery.

The free scapular flap with latissimus muscle reduces fistulas in mandibular reconstruction.

INTRODUCTION: The free scapular chimeric flap is a less common choice for facial reconstruction. This study aimed to evaluate the versatility and safety of the flap, the procedure for a two-team approach, the safety of the osteotomies, the possibility of dental implants and donor-site sequelae and complications. PATIENT AND METHODS: We analysed 34 consecutive patients with oral cancer undergoing large resections in the maxillofacial region as well as scapular chimeric free flap reconstruction. We performed 26 mandibular, six maxillary and two orbital reconstructions using a two-team approach, mainly without repositioning the patient. RESULTS: No flaps were lost. Three patients with a scapular bone and fasciocutaneous flap developed a post-operative fistula, whereas no fistulas developed when the flaps included a muscular component. All osteotomies showed confirmed osseal consolidation. Seven patients received a total of 23 dental implants for oral rehabilitation; no implants were lost. CONCLUSIONS: The scapular flap is reliable and contains sufficient bone to tolerate both multiple osteotomies and osseointegrated dental implants. The flap can be harvested in a slightly tilted decubital position, thus shortening the theatre time. The use of a separate muscle around the scapular bone in mandibular reconstruction is associated with a lower risk of oral fistulas.

A Survey of the Use of Perioperative Glucocorticoids in Oral and Maxillofacial Surgery.

PURPOSE: The aim of the study was to clarify the use of perioperative glucocorticoids (GCs) in association with oral and maxillofacial surgical procedures. MATERIALS AND METHODS: We conducted a survey of consultant oral and maxillofacial surgeons (OMSs) working in tertiary and secondary referral hospitals in Finland. RESULTS: The administration of GCs is common among OMSs (85.2% of respondents), especially in association with orthognathic surgery (100% of respondents) and facial fractures (43.5%). All OMSs who administered GCs reported that they reduce swelling. The next most common reasons for administering GCs were established practice (43.5%) and pain reduction (39.1%). The regimens differed widely from a 5-mg single dose to a 116-mg total dose of dexamethasone equivalent. CONCLUSIONS: GCs are widely administered by OMSs, especially in major surgery. The literature shows some benefits of their use in dental and orthognathic operations, and their use seems rather safe. Proof of efficacy remains to be determined for other major maxillofacial surgical procedures; thus further studies are needed.

Influence of perioperative dexamethasone on delayed union in mandibular fractures: A clinical and radiological study.

BACKGROUND: The aim was to clarify the occurrence of delayed union after surgical treatment of mandibular fracture and investigate whether an association exists between perioperative use of dexamethasone and delayed union. MATERIAL AND METHODS: Thirty-seven patients were included in a prospective randomized study. Of these patients, 19 (51.4%) were randomized to receive a total dose of 30 mg of dexamethasone and 18 (48.6%) served as controls. Patients underwent clinical and radiological investigation immediately, one month, three months and six months postoperatively. Radiographs were evaluated by an experienced, blinded senior oral radiologist. RESULTS: Delayed fracture union was found in 9 patients (24.3%). It was associated significantly with angle fractures (p=0.012). Delayed union occurred more frequently in patients who received dexamethasone (36.8%) than in those who did not (11.1%) (p=0.068). The association of infection with delayed union was significant (p=0.027). Moreover, dexamethasone was significantly (p=0.019) associated with delayed fracture union with concomitant infection. Gender, age group, smoking habit, treatment delay and duration of surgery were not associated with delayed union. CONCLUSIONS: Infection was associated with delayed union. Short-term high-dose dexamethasone predisposed to complicated fracture union, especially in patients with angle fractures. The relationship between dexamethasone and delayed bone healing without infection remains unresolved.

Health-related quality of life after surgical treatment of mandibular fracture.

OBJECTIVES: We evaluated health-related quality of life (HRQoL) before and after surgical treatment of mandibular fracture and assessed patients' perceptions of the esthetic and functional outcomes of surgery. STUDY DESIGN: We established a prospective study of adult patients who were to undergo open reduction and rigid fixation of mandibular fracture. Of the patients, 49 met the inclusion criteria, and of these, 45 agreed to participate. HRQoL was measured with the generic 15-dimensional (15-D) instrument, and patients' satisfaction was assessed with an additional questionnaire. RESULTS: The average preoperative 15-D score among patients (0.891) was significantly lower than that in the general population (0.964) (P < .01). Patients were worse off on 9 of the 15 dimensions of HRQoL; however, at 3 months following surgery, all dimensions had improved to the level observed in the general population. CONCLUSIONS: HRQoL is significantly reduced after mandibular trauma but improves in a few months after surgery. Sensory disturbance is the most significant disadvantage of the surgery.

Pulp necrosis of teeth retained at the mandibular fracture site and the effect of dexamethasone on its occurrence.

OBJECTIVES: The main purpose was to determine the occurrence of pulp necrosis (PN) of teeth retained at the mandibular fracture site. An additional purpose was to investigate whether perioperative use of dexamethasone increases the risk of PN. PATIENTS AND METHODS: A follow-up study on 24 adult dentate patients with mandibular body, symphysis or parasymphysis fracture. These patients had been selected from a larger cohort who had participated in a randomized study of maxillofacial fractures and dexamethasone. All patients who were suspected of having a need for endodontic treatment were evaluated by an endodontist. RESULTS: PN was diagnosed in six patients (25.0%) in one or two teeth. Of a total of 33 teeth situated in the fracture line, six (18.2%) were diagnosed as having PN. PN was more common in teeth in which the fracture line ran through the apex (21.7%) than in those in which the fracture line was in contact with the tooth cranially to the apex (10.0%). The association between PN and dexamethasone was not significant. CONCLUSION: PN is common after mandibular fractures, particularly when the fracture line runs through the apex of the tooth. Use of short-term, high-dose dexamethasone perioperatively did not significantly increase the risk for PN.

Rapidly growing and ulcerating metastatic renal cell carcinoma of the lower lip: A case report and review of the literature.

Renal cell carcinomas (RCCs) have a tendency to metastasize at an early stage, therefore, the patients frequently exhibit metastatic disease at the time of diagnosis. Common locations for the metastases are adjacent organs and abdominal lymph nodes; however, occasionally metastasis to the peripheral organs may be the initial clinical symptom. The 71-year-old male patient in the current case suffered from radioresistant and aggressively behaving RCC metastasis in the mandible and lower lip, which was successfully managed by surgical resection. RCC metastasis to the facial area is considered to be uncommon based on a review of the existing literature. RCC are somewhat radioresistant and therefore, palliative surgery must be considered when treating patients with this metastatic disease.

Effects of perioperatively administered dexamethasone on surgical wound healing in patients undergoing surgery for zygomatic fracture: a prospective study.

OBJECTIVE: The aims of the study were to clarify the occurrence of disturbance in surgical wound healing (DSWH) after surgery of zygomatic complex (ZC) fractures and to determine whether perioperatively applied dexamethasone increases the risk for DSWH. STUDY DESIGN: Of 64 patients who were included in a single-blind prospective trial, 33 perioperatively received a total dose of 10 mg or 30 mg of dexamethasone. The remaining 31 patients served as controls. RESULTS: DSWH occurred in 9 patients (14.1%). Occurrence of DSWH was 24.4% in patients who received dexamethasone and 3.2% in controls. The association between DSWH and dexamethasone was significant (P = .016). Intraoral approach also was associated with DSWH significantly (P = .042). No association emerged between DSWH and age, gender, time span from accident to surgery, or duration of surgery. CONCLUSIONS: DSWH occurred significantly more frequently in patients who received perioperative dexamethasone. Because of increased risk of DSWH, perioperative dexamethasone cannot be recommended in open reduction and fixation of ZC fractures.

Impairment of wound healing after operative treatment of mandibular fractures, and the influence of dexamethasone.

Our aim was to clarify the incidence of impaired wound healing after open reduction and ostheosynthesis of mandibular fractures, and to find out whether the use of dexamethasone during the operation increased the risk. Patients were drawn from a larger group of healthy adult dentate patients who had participated in a single-blind, randomised study, the aim of which was to clarify the benefits of operative dexamethasone after treatment of facial fractures. The present analysis comprised 41 patients who had had open reduction and fixation of mandibular fractures with titanium miniplates and monocortical screws through one or 2 intraoral approaches. The outcome variable was impaired healing of the wound. The primary predictive variable was the perioperative use of dexamethasone; other potential predictive variables were age, sex, smoking habit, type of fracture, delay in treatment, and duration of operation. Wound healing was impaired in 13/41 patients (32%) (13/53 of all fractures). The incidence among patients who were given dexamethasone and those who were not did not differ significantly. Only age over 25 was significantly associated with delayed healing (p=0.02). The use of dexamethasone 30 mg perioperatively did not significantly increase the risk of impaired wound healing in healthy patients with clinically uninfected mandibular fractures fixed with titanium miniplates through an intraoral approach. Older age is a significant predictor of impaired healing, which emphasises the importance of thorough anti-infective care in these patients during and after the operation.