Smell and taste recovery in coronavirus disease 2019 patients: a 60-day objective and prospective study.

BACKGROUND: The long-term recovery rate of chemosensitive functions in coronavirus disease 2019 patients has not yet been determined. METHOD: A multicentre prospective study on 138 coronavirus disease 2019 patients was conducted. Olfactory and gustatory functions were prospectively evaluated for 60 days. RESULTS: Within the first 4 days of coronavirus disease 2019, 84.8 per cent of patients had chemosensitive dysfunction that gradually improved over the observation period. The most significant increase in chemosensitive scores occurred in the first 10 days for taste and between 10 and 20 days for smell. At the end of the observation period (60 days after symptom onset), 7.2 per cent of the patients still had severe dysfunctions. The risk of developing a long-lasting disorder becomes significant at 10 days for taste (odds ratio = 40.2, 95 per cent confidence interval = 2.204-733.2, p = 0.013) and 20 days for smell (odds ratio = 58.5, 95 per cent confidence interval = 3.278-1043.5, p = 0.005). CONCLUSION: Chemosensitive disturbances persisted in 7.2 per cent of patients 60 days after clinical onset. Specific therapies should be initiated in patients with severe olfactory and gustatory disturbances 20 days after disease onset.

Impact of COVID-19 epidemic on maxillofacial surgery in Italy.

Maxillofacial departments in 23 surgical units in Italy have been increasingly involved in facing the COVID-19 emergency. Elective surgeries have been progressively postponed to free up beds and offer human and material resources to those infected. We compiled an inventory of 32 questions to evaluate the impact of the SARS-COV2 epidemic on maxillofacial surgery in 23 selected Italian maxillofacial departments. The questionnaire focused on three different aspects: the variation of the workload, showing both a reduction of the number of team members (-16% among specialists, -11% among residents) due to reallocation or contamination and a consistent reduction of elective activities (the number of outpatient visits cancelled during the first month of the COVID-19 epidemic was about 10 000 all over Italy), while only tumour surgery and trauma surgery has been widely guaranteed; the screening procedures on patients and physicians (22% of maxillofacial units found infected surgeons, which is 4% of all maxillofacial surgeons); and the availability of Personal Protective Equipment, is only considered to be partial in 48% of Maxillofacial departments. This emergency has forced those of us in the Italian health system to change the way we work, but only time will prove if these changes have been effective.

Lipofilling of the upper eyelid to treat paralytic lagophthalmos.

Lagophthalmos is one of the most unpleasant and dangerous conditions that affect patients with facial palsy. The lack of ocular protection leads to corneal problems (such as conjunctival infections, acute and chronic keratitis, corneal ulcerations, and blindness). A dynamic reanimation of blinking eyelids is the therapeutic gold standard. However, success is not guaranteed with these dynamic techniques; even if results are good, blinking is usually restored within a year of the initial operation. Procedures that act more rapidly and have a higher success rate are needed. We proposed that lipofilling of the upper eyelid would improve eye closure, exploit the advantages of using autologous fat, and avoid the risks of exposure or migration associated with loading the lid with gold. Between 2012 and September 2018, we did upper eyelid lipofilling procedures for 75 patients with unilateral facial palsy. The main favourable result of lipofilling of the upper lid was the immediate improvement in corneal discomfort. Everybody described a partial to total increase in corneal comfort postoperatively. In the treatment of paralytic lagophthalmos, lipofilling of the upper eyelid produces favourable aesthetic and functional results, ocular health is restored, and the patients' quality of life is improved.

Three-dimensional assessment of restored smiling mobility after reanimation of unilateral facial palsy by triple innervation technique.

The aim of this study was to assess surgically restored facial mobility using an optical 3D instrument. Eleven patients (age range 42-76 years) with unilateral facial palsy, treated by triple innervation procedure (masseteric and partial hypoglossal reinnervation, plus double cross-face facial grafting), performed five facial animations: rest position, smiling by contracting the healthy side, clenching the teeth, and pushing the tongue against the lower incisors and Mona Lisa smiling. These were recorded by stereophotogrammetry. Sixty healthy subjects were also recorded. The 3D reconstruction of each facial expression was registered onto the rest position scan, and the root mean square (RMS) point-to-point distance between the two 3D surfaces was calculated automatically for the facial thirds. RMS values on the rehabilitated hemiface were 74.8% (upper third), 46.6% (middle third), and 54.1% (lower third) of those recorded in healthy subjects. RMS values were higher in the middle and lower thirds than in the upper third, and during smile provided by masseteric stimulus (P<0.05). The rehabilitated hemiface differed more from healthy subject values than the healthy hemiface did (P<0.05). On average, patients were more asymmetric than healthy subjects (P=0.004). The proposed method is non-invasive and non-contact, and it can quantify localized facial movements after surgical procedures.

Three-dimensional superimposition for patients with facial palsy: an innovative method for assessing the success of facial reanimation procedures.

Facial palsy is a severe condition that may be ameliorated by facial reanimation, but there is no consensus about how to judge its success. In this study we aimed to test a new method for assessing facial movements based on 3-dimensional analysis of the facial surfaces. Eleven patients aged between 42 and 77 years who had recently been affected by facial palsy (onset between 6 and 18 months) were treated by an operation based on triple innervation: the masseteric to temporofacial nerve branch, 30% of the hypoglossal fibres to the cervicofacial nerve branch, and the contralateral facial nerve through two cross-face sural nerve grafts. Each patient had five stereophotogrammetric scans: at rest, smiling on the healthy side (facial stimulus), biting (masseteric stimulus), moving the tongue (hypoglossal stimulus), and corner-of-the-mouth smile (Mona Lisa). Each scan was superimposed onto the facial model of the "rest" position, and the point-to-point root mean square (RMS) value was automatically calculated on both the paralysed and the healthy side, together with an index of asymmetry. One-way and two-way ANOVA tests, respectively, were applied to verify the significance of possible differences in the RMS and asymmetry index according to the type of stimulus (p=0.0329) and side (p<0.0001). RMS differed significantly according to side between the facial stimulus and the masseteric one on the paralysed side (p=0.0316). Facial stimulus evoked the most asymmetrical movement, whereas the masseteric produced the most symmetrical expression. The method can be used for assessing facial movements after facial reanimation.

Prevention of bisphosphonate-related mandibular fractures.

Mandibular fracture is usually the clinical end of bisphosphonate-related osteonecrosis of the jaw. This is a painful complication and patients cannot feed as usual, with a worsening of their quality of life. The goal of treatment in bisphosphonate related osteonecrosis of jaw (BRONJ) patients is to slow progression of bone necrosis. We present a novel technique for treatment of severe mandibular BRONJ in stage 3 patients that present with a high risk to develop fracture, since they have a residual unaffected mandibular bone height less than 6 mm. We treated 10 patients in this clinical situation with an extra-oral application of a reconstructive plate superficial to the platysma, to keep the plate separated from the infected site to avoid contamination and consequent need of removal, followed by an intraoral approach for active curettage of mandibular necrosis. The preservation of blood supply to the mandible and avoidance of direct contact of the infected site with the reconstructive plate are some advantages of this technique. This plate allows enhancement of mandibular strength, allowing proper treatment of the BRONJ site on the oral side without fear of causing a mandibular fracture when the residual mandible is thin. This technical solution guarantees these patients an extended disease-free period since it is effective in preventing mandibular fractures in patients with low mandibular residual height left after the BRONJ onset.

Facial reanimations: part I--recent paralyses.

Unilateral facial paralysis is a common condition: 1 in every 60 people will experience Bell's palsy during the course of their life, and the residual deficits are particularly problematic for those who do not spontaneously recover the function of the facial nerve. Functionally the most relevant defect is lack of corneal lubrication because of inability to close the eyelid or blink. Morphologically, this presents as obvious ptosis caused by absence of the muscle tone at rest. "Restitutio ad integrum" of a paralysed face by operation is currently impossible, but realistic targets are improvement of facial symmetry and partial recovery of closure of the eyelids and smiling. Movements of the forehead and lower lip tend to be neglected targets for intervention because they are of less functional importance. Recent paralyses are those in which the mimetic musculature may be reactivated by provision of neural input, and the time limit is generally 18-24 months. Electromyography helps to detect it by assessing the presence of muscular fibrillations. If those are not detectable paralyses are considered to be long-standing, and new musculature must be transferred into the face, generally by transplantation of a muscular free flap or of the temporalis muscle in several different ways. When the facial nerve has been severed by trauma or during operation, immediate reconstruction must be considered and the simplest and most efficient is direct neurorrhaphy. If an appreciable part of the nerve is missing and the proximal and distal nerve stumps do not meet, an interpositional nerve graft must be placed to guarantee neural continuity. When reconstruction of the total extracranial branch of the facial nerve is required, the thoracodorsal nerve has proved to be highly effective. In case immediate reconstruction cannot be accomplished and the trunk of the facial nerve is not available as a donor nerve, mimetic musculature may be reactivated by provision of new neural input. Strong inputs from the masseteric or hypoglossus nerves may be mixed with those that arise from branches of the contralateral facial nerve after 2 cross-face nerve grafts have been placed, and good functional recovery is generally obtained. Several ancillary procedures are required to improve the end results in most cases.

Lipofilling of the atrophied lip in facial palsy patients.

AIM: Patients affected by unilateral facial palsy often show partial or complete atrophy of the orbicularis oris. The lower hemilip on the affected side may have partial functional recover due to direct reinnervation stemming from the unaffected side. This explains why atrophy of the paralysed side is sometimes limited. Negative esthetic and functional findings include partial invisibility of the vermillion border due to lip inversion resulting from muscle flaccidity, asymmetry of the lower lip, oral incompetence, and speech and nutrition impairments of variable degree. In this study, we used Coleman lipofilling as a secondary and ancillary procedure to consolidate the results already obtained with dynamic reanimation, specifically aiming to reduce the volumetric loss due to atrophy of the orbicularis oris muscle. METHODS: Eight patients underwent lipofilling to restore volumetric loss due to muscular denervation atrophy. Six of our patients were affected by inveterate facial palsy and one by an acute form of facial palsy. The last patient presented with high-grade bilateral upper lip atrophy due to Moebius syndrome. Two patients underwent a second lipofilling intervention. RESULTS: The esthetic volume increase and the ameliorated lip competence were immediately noticeable after the first lipofilling, to great patient satisfaction. As a result of the variable rate of resorption over time of the grafted fat, it may be advisable to repeat the procedure in some patients to maximize results. CONCLUSION: Lipofilling represents a useful and safe ancillary technique for camouflage of lower lip atrophy in paralysed patients.

Technical refinements in mandibular reconstruction with free fibula flaps: outcome-oriented retrospective review of 99 cases.

Congenital disease, major trauma, tumour resection and biphosphonate-related osteonecrosis can lead to partial, subtotal, or total loss of the mandibular bone. Minor defects can be easily reconstructed using bone grafts, whereas microvascular free tissue transfer may be unavoidable in the case of major bone loss or poor quality of soft tissue. Simple bone or composite osteocutaneous fibula free flaps have proven invaluable and remain the workhorse for microvascular mandibular reconstruction in daily practice. Our experience with 99 consecutive fibular free flaps confirms the available data in terms of high success rate. In these cases, 90% had total success, while 7 had complete flap failures. Three of our patients showed skin paddle necrosis with bony conservation. This report focuses on the technical refinements used by the authors that can prove valuable in obtaining predictable and precise results: in particular, we discuss surgical techniques that avoid vascular pedicle ossification by removing the fibular periosteum from the vascular pedicle itself and reduce donor site morbidity and aid in management of the position in the new condylar fossa. Finally, new technologies such as intraoperative CT and custom premodelled fixation plates may also increase the predictability of morpho-functional results.

Extensive rhabdomyoma of the head and neck region: a case report and a literature review.

Rhabdomyomas are rare mesenchymal benign tumors of striated muscle origin that can be classified into cardiac and extracardiac types. Cardiac rhabdomyomas are considered as hamartomatous lesion because of their association with phacomatosis. Extracardiac type is further classified into adult, fetal and genital form, depending on the individual tumor's degree of differentiation. Adult head and neck rhabdomyomas are rare pathologies of adult patients, with a male predominance. The occurrence of multifocality is a rare manifestation of this uncommon lesion. Presenting symptoms are related to the location and dimension of the tumors and they include upper airway obstruction, Eustachian tube dysfunction, dysphagia and mucosal and neck mass. Because of their high rate of recurrence, radical resection is the treatment of choice of this kind of tumors. In this article is reported a rare and particularly large case of head and neck adult rhabdomyoma, presenting with an history of sleep apnea and night-time stridor.

Extra-platysma fixation of bisphosphonate-related mandibular fractures: a suggested technical solution.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is an evolving epidemic. Often the patients are in poor general condition and therefore the aim of surgical treatment is generally limited to pain control and restoration of feeding ability. We present a useful surgical technique for the stabilization of BRONJ-related mandibular fractures, including application of a reconstructive plate. With an extraoral approach, a 2.5-mm reconstructive locking plate is contoured and placed in the plane of dissection, superficial to the platysma. The fracture site is accessed through an intraoral approach, which limits surgery to curettage and rinsing of the surgical site. Since there is no removal of the periosteal support to the residual stumps, the blood supply to the affected mandible is maintained. Avoidance of direct contact of the infected fractured site with the reconstructive plate is another advantage of working in a surgical plane over the platysma muscle. Although fracture healing is not achieved, plate fixation with this technique is stable and painless and patients can easily eat; therefore, patients enjoy a great improvement in their quality of life. We consider this easy and effective procedure to be a reliable palliative solution in these patients.

[Double innervation (facial/masseter) on the gracilis flap, in the middle face reanimation in the management of facial paralysis: a new concept]. / Double innervation (facial/masseter) sur le lambeau gracile dans les réanimations du tiers moyen de la face lors de la prise en charge des paralysies faciales : nouveau concept.

INTRODUCTION: The facial paralysis is a non-rare condition that has very disabling functional, morphological and psychological repercussions. The current gold standard in facial reanimation is revascularized re-innervated muscle transfers. MATERIALS AND METHODS: In this paper, we report the results of a new method using the gracilis flap with a double innervation on the masseter motor nerve and the controlateral facial nerve via a sural graft in a single stage intervention, on a series of six patients. RESULTS: No failure was observed. The average delay of a voluntary contraction was 3.8months, and 7.2months for a spontaneous one. Three of the six patients had "excellent" results according to the Terzis and Noah classification, two were classified as "good" and one "average". DISCUSSION: A choice is to be made between a method advocating a natural and spontaneous dynamicity (controlateral facial nerve stimulus) and a method focusing on the quality and quantity of contractions (ipsilateral trijeminal stimulus). In this new technique, we combine the two methods: a free gracilis transfer with a dual innervation on the healthy controlateral facial nerve via a sural graft, on one hand, and a second anastomosis on the ipsilateral masseter nerve, on the other hand. CONCLUSION: This new proposed method seems to be, according to our results, a reliable technique rallying voluntary contraction and emotional smile.

Double innervation in free-flap surgery for long-standing facial paralysis.

OBJECTIVE: One-stage free-flap facial reanimation may be accomplished by using a gracilis transfer innervated by the masseteric nerve, but this technique does not restore the patient's ability to smile spontaneously. By contrast, the transfer of the latissimus dorsi innervated by the contralateral facial nerve provides the correct nerve stimulus but is limited by variation in the quantity of contraction. The authors propose a new one-stage facial reanimation technique using dual innervation; a gracilis muscle flap is innervated by the masseteric nerve, and supplementary nerve input is provided by a cross-face sural nerve graft anastomosed to the contralateral facial nerve branch. METHODS: Between October 2009 and March 2010, four patients affected by long-standing unilateral facial paralysis received gracilis muscle transfers innervated by both the masseteric nerve and the contralateral facial nerve. RESULTS: All patients recovered voluntary and spontaneous smiling abilities. The recovery time to voluntary flap contraction was 3.8 months, and spontaneous flap contraction was achieved within 7.2 months after surgery. According to Terzis and Noah's five-stage classification of reanimation outcomes, two patients had excellent outcomes and two had good outcomes. CONCLUSIONS: In this preliminary study, the devised double-innervation technique allows to achieve a good grade of flap contraction as well as emotional smiling ability. A wider number of operated patients are needed to confirm those initial findings.

Autonomized flaps in secondary head and neck reconstructions.

Free flaps, with their very high rates of success and low donor site morbidity, are considered the gold standard in head and neck reconstruction, allowing the transfer of ideal tissues for head and neck reconstruction. Nonetheless, under certain circumstances they may be contraindicated or cannot be utilized. We describe four subjects in which delayed locoregional flaps were used to reconstruct head and neck defects after a previous flap failure. Due to adverse anatomic and systemic conditions these patients were not suitable for a free flap, and thus one delayed prelaminated temporalis fasciocutaneous flap placement and three delayed supraclavicular flap (one of which was prelaminated) placements to reconstruct large defects of the cheek and commissural region needed to be performed. All flaps and grafts were viable. All patients in this case series had acceptable functional and aesthetic outcomes. Donor-site morbidity was negligible. Delayed locoregional flap placement required a total of three surgical sessions. Although limited, our experience suggests that in cases in which a free flap is contraindicated or not ideal, locoregional flaps may be a valid and safe alternative. Limitations of these procedures include increased duration of hospitalization and, foremost, the need for three-step surgery.

Lingual nerve lesion during ranula surgical treatment: case report.

Iatrogenic lingual nerve (LN) injuries are quite common in oral surgery both in maxillo-facial surgery and in oral surgery. LN runs superficially into the lateral mouth floor just beneath the mucous layer and this position enhances damage frequency. This article lists the different aetiologies of iatrogenic LN injuries and it almost focuses on lesions due to surgical treatment of ranulas. In the case report a LN lesion due to oral ranula excision is discussed; the patient experienced anaesthesia and hyperpatia in the corrisponded tongue side. It was treated with a microneurosugical anastomosis of LN, after amputation neuroma excision. The partial and definitive recovery of perception happened in six months and was deemed satisfying with 70% of functionality restored (results compared with the functionality of the contralateral side). An algorithm for diagnosis and therapy indication for iatrogenic injuries to nerves is also proposed. In case of surgical treatment, funcitonal recovery manifests after 4-6 month; a functional recovery of 70% of total nerve function is possible. The variable that most affects nerve functional recovery is surgical treatment timing; it must be performed as soon as possible.

The masticator space. Value of computed tomography and magnetic resonance imaging in localisation and characterisation of lesions.

Aim of the study was to assess the different roles of magnetic resonance imaging and computed tomography in the evaluation of anatomical origin and pathological nature of lesions involving the masticator space. Overall 41 cases (31 computed tomography and 14 magnetic resonance imaging) of lesions involving masticator space were retrospectively reviewed by two experienced radiologists in consensus. Reference standards were histopathological results and clinical-radiological follow-up after one year. Both computed tomography and magnetic resonance imaging were performed with and without intravenous injection of contrast. Computed tomography and magnetic resonance imaging were correct in identifying the space of origin of lesions respectively in 96% and 92% of cases. Computed tomography correctly diagnosed the nature of lesions in 81% of cases and magnetic resonance imaging in 93% of cases; computed tomography and magnetic resonance imaging correctly characterized, respectively, 88% and 100% of malignant lesions and, respectively, 73% and 83% of benign lesions. In conclusion both computed tomography and magnetic resonance imaging were effective in the identification of the origin of non-extensive lesions involving masticator space. Computed tomography was more precise in depicting lesions originating from masticator space, while magnetic resonance imaging was more correct in depicting lesions originating from contiguous spaces and involving secondarily the masticator space. Magnetic resonance imaging should always be preferred to characterise lesions, nevertheless computed tomography should be chosen in cases with suspected inflammatory involvement of mandible bone.

Repair of a perforated sinus membrane with a palatal fibromucosal graft: a case report.

The sinus lift procedure in association with dental implant placement and autologous bone grafting enables clinicians to achieve the prosthetic rehabilitation of the posterior edentulous maxilla, when the vertical height of the atrophic crest is reduced. The most commonly reported intraoperative complication of sinus augmentation is membrane perforation, which may lead to infection, with the risk of graft loss or resorption, and acute or chronic sinusitis. We present a technique for repairing a perforated Schnei-derian membrane with a de-epithelialized fibromucosal graft harvested from the palate of a 50-year-old man. In the postoperative period, no wound infections, sinusitis, or bleeding were observed. This technique allowed good prosthetic rehabilitation 3 months postoperatively. This technical procedure is a quick and easy way to treat this surgical complication, allowing repair of the Schneiderian membrane perforation with autologous tissue, without other surgical accesses or need to modify the existing surgical access. In addition, our procedure causes no patient discomfort or adds significant morbidity, with only a moderate increase in surgical time compared to the planned procedure.