Optical Coherence Tomography Findings Following Orbital Fractures.

INTRODUCTION: A closed globe trauma is often associated with orbital wall fractures. In addition to diplopia, further eye disturbances can be observed. The aim of this preliminary prospective study was to investigate the optical coherence tomography (OCT) findings in patients that presented with orbital fractures in association with diplopia but without decreased visual acuity or further ocular symptoms. METHODS: Only patients who were admitted and surgically treated for orbital wall fractures and that presented diplopia were included in this study. Patients with post traumatic ocular symptoms were excluded. All the patients that were diagnosed with an orbital fracture underwent an ophthalmological assessment, including best-corrected visual acuity (BCVA), examination of fundus oculi, Hess Scheme, OCT, and OCT angiography. RESULTS: Five patients met the inclusion criteria and were enrolled. Hess Scheme examinations confirmed the presence of diplopia in all the included patients. The examination of fundus oculi did not reveal any pathology in 4 patients, whereas in a patient a commotio retinae (Berlin's Edema) was diagnosed in the infero-papillary field. Following OCT assessment, a pachycoroid was observed in 4 patients. CONCLUSIONS: A thorough ophthalmological assessment in patients that have suffered from orbital fractures is fundamental. In particular, OCT examinations seem to provide more insight into the detection and monitoring of choroidal changes after ocular trauma without visible macular changes.

Management of maxillofacial trauma in the elderly: A European multicenter study.

BACKGROUND/AIMS: Management of maxillofacial trauma in the geriatric population poses a great challenge due to anatomical variations and medical comorbidities. The aim of this study was to analyze the management variables, timing, and outcomes of facial fractures in elderly patients (aged 70 years or more) at several European departments of oral and maxillofacial surgery. MATERIALS AND METHODS: This study was based on a systematic computer-assisted database that allowed the recording of data from all geriatric patients with facial fractures from the involved maxillofacial surgical units across Europe between 2013 and 2017. RESULTS: A total of 1334 patients were included in the study: 665 patients underwent closed or open surgical treatment. A significant association (P < .005) was found between the presence of concomitant injuries and a prolonged time between hospital admission and treatment. The absence of indications to treatment was associated with comorbidities and an older age (P < .000005). CONCLUSIONS: Elderly patients require specific attention and multidisciplinary collaboration in the diagnosis and sequencing of trauma treatment. A prudent attitude may be kept in selected cases, especially when severe comorbidities are associated and function is not impaired.

Psychodynamic Features Associated With Orthognathic Surgery: A Comparison Between Conventional Orthognathic Treatment and "Surgery-First" Approach.

PURPOSE: The aims of this study were to assess the personality traits of orthognathic patients and to investigate and compare the changes related to psychosocial well-being, self-esteem, anxiety, and quality of life between presurgical and postsurgical phases in patients undergoing traditional and surgery-first orthognathic treatments. PATIENTS AND METHODS: This prospective study recruited patients referred for traditional 3-stage orthognathic treatment and surgery-first orthognathic treatment. Patients were administered psychological and quality-of-life tests 3 times: during the last visit before surgery, about 4 weeks after surgery, and 6 months after surgery. RESULTS: Of the 33 patients included, 14 presented parameters that were suggestive of personality (borderline, compulsive, antisocial, passive-aggressive) disorders. The results of the 36-item Short Form Health Survey showed significant differences with better scores for the "surgery-first" group for bodily pain, vitality, social functioning, and mental health (P < .05). As for the Beck Depression Inventory second edition results, at final check, surgery-first patients reported fewer depressive symptoms too. CONCLUSIONS: A surgery-first orthognathic approach allows a precocious re-establishment of harmonic esthetics of the face, thus positively influencing the compliance and psychological status of the patients.

The "European Mandibular Angle" Research Project: The Epidemiologic Results From a Multicenter European Collaboration.

PURPOSE: The aim of this study was to analyze the demographic variables and causes and characteristics of mandibular angle fractures managed at several European departments of maxillofacial surgery. MATERIALS AND METHODS: This study was based on a multicenter systematic database that allowed the recording of data from all patients with mandibular angle fractures between January 1, 2013, and December 31, 2017. The following data were recorded: gender, age, etiology, side of angle fracture, associated mandibular fractures, presence of third molar, intermaxillary fixation, and osteosynthesis. RESULTS: The study included 1,162 patients (1,045 male and 117 female patients). A significant association was found between the presence of a third molar and the diagnosis of an isolated angle fracture (P < .0000005). Furthermore, assaults were associated with the presence of voluptuary habits (P < .00005), a younger mean age (P < .00000005), male gender (P < .00000005), and left-sided angle fractures (P < .00000005). CONCLUSIONS: Assaults and falls actually represent the most frequent causes of angle fractures. The presence of a third molar may let the force completely disperse during the determination of the angle fracture, finding a point of weakness.

Surgical approach to oral lichen planus by submucosal autologous fat grafting.

Oral lichen planus is a chronic autoinflammatory mucositis. Oral lesions are predominantly white; they tend to be bilateral while involving the buccal mucosa especially cheek, tongue, gums, lips, and palate. Many topical and systemic agents are currently used with unpredictable results. Fat grafting is characterized by the placement of multiple parcels of purified fat with blunt cannulas; at the beginning, it was introduced to improve facial aesthetics. Recently, it has been translated to other surgical cases such as posttraumatic deformities and craniofacial anomalies and as ancillary reconstructive procedure after tumor resections. The successful results of this procedure encouraged us to use this approach to a clinical case of oral lichen planus refractory to conventional therapy.

Persisting subcutaneous emphysema of eyelids mimicking orbital tumor.

Eyelids emphysema is a rare condition due to air trapping in subcutaneous tissue of the orbit. It has been clinically and radiologically documented, but histologic evaluation has not been noted. We report a case of a middle-aged woman with periorbital swelling due to self-induced Valsalva maneuver, persisting after decompressive therapy. A fine-needle biopsy was performed and showed a mixed population of osteoclastic-like giant cells and mononuclear epithelioid cells, which were suspected of pathological proliferative disease. Specimens from blepharoplasty indicated pseudocystic empty spaces surrounded by epithelioid cells and giant cell granulomas. Immunohistochemical stains favored diagnosis of benign granulomatous disease, such as subcutis cystic pneumatosis. Histologic examination represented an important tool for differential diagnosis with soft tissue neoplasms of the orbit in subcutis emphysema with unusual clinical presentation and abnormal course.

Proposal of a presurgical algorithm for patients affected by obstructive sleep apnea syndrome.

PURPOSE: To propose an algorithm for the preoperative management of patients with obstructive sleep apnea syndrome (OSAS) and review the surgical outcomes in such patients. MATERIALS AND METHODS: This prospective cohort study involved 71 patients with OSAS who underwent presurgical upper airway endoscopy and cephalometry before being assigned to treatment categories based on the site(s) of obstruction, the pattern of collapse, the characteristics of the soft tissue, the air space between the base of the tongue and the posterior wall of the pharynx, and the severity of OSAS. Six months after surgery, they were followed up using polysomnography and the Epworth Sleepiness Scale. The pre- and postsurgical data were compared using a paired Student t test. RESULTS: The mean preoperative apnea/hypopnea index of the 71 patients (61 male and 10 female) was 40.98 events/hour (range, 14.7 to 87.6 events/hr), and the mean postoperative apnea/hypopnea index was 13.96 events/hour (range, 0 to 20 events/hr). The difference was statistically significant (P < .001). CONCLUSIONS: This algorithm was developed on the principle that every patient with OSAS should be considered individually. In the authors' opinion, taking into account the number, site(s), pattern, and degree of the collapse/obstruction is a reasonable means of ensuring the correct diagnosis and treatment.

Mandibular symphyseal fracture simulated by a foreign body in the chin.

INTRODUCTION: Penetrating foreign bodies occurring after maxillofacial injuries are a diagnostic challenge for the trauma surgeon. Different materials and various sites of penetration in the maxillofacial region are described in the literature. We present the peculiar course of a patient with an endoral retained foreign body after a penetrating facial injury. The diagnostic pitfall in this type of trauma is highlighted owing to the hyperdensity of the foreign body that, at the computed tomographic (CT) axial scan, simulated a vestibular cortical fracture of the mandibular body and deceived both the radiologist and the surgeon. CLINICAL REPORT: We introduce the case of a boy who fell from his bicycle. Computed tomography was performed to detect any bone injuries. The radiologic report stated that a left condylar fracture was presented, associated to a vestibular cortical fracture of the mandibular body. Anamnestic questions revealed that the boy fell from his bicycle in a dug-up street. Clinical examination revealed 2 extraoral open wounds in the subnasal and periorbital areas and an endoral linear wound in the inferior fornix at the mandibular symphyseal region. Consequently, the left condylar fracture was surgically treated, and the mandibular body was explored by the endoral wound revealing an intact cortex: the road metal was removed from the soft tissue of the chin. The initial diagnostic pitfall was clarified: the radiodense foreign bodies penetrated the endoral wound in the soft tissue of the chin during the fall. They simulated a vestibular cortical fracture of the mandibular body at the CT scan deceiving both the radiologist and the surgeon. DISCUSSION: According to the literature, soft tissue foreign bodies can be detected by ultrasonography, plain radiography, CT, and magnetic resonance imaging. Superficially retained foreign bodies are easily detected with ultrasonography if they are not covered by overlying bone or gas. If this easily available technique had been applied initially in this case, the correct diagnosis might have been established at the initial admittance. Deeply located foreign bodies are best visualized by CT. The foreign body in the case introduced was made by radiopaque substance it presented the same radiodensity as the bone.

Direct access to a frontal sinus osteoma and reconstruction of the orbital roof displaced by the lesion by titanium mesh.

Osteomas are the most common benign tumors of the paranasal sinuses. They are usually localized in the frontal sinus and less often in the other paranasal sinuses. In this article, we report the surgical treatment of an unknown frontal sinus osteoma discovered after an acute exophthalmos. We have chosen an external approach to obtain a radical excision of the tumor, but we prefer a direct frontal incision following a horizontal wrinkle to the classic bicoronal flap to avoid an unsightly scar because of patient's hair loss. We discuss the surgical approach, the reconstruction of the roof of the orbit involved, and patient's satisfaction.

Total nasal prosthesis after resection of a recurrence of skin carcinoma on a forehead flap in a post-rhinectomy site.

The nose is the most common site for facial skin cancer; nonmelanoma skin cancers are the most common tumors of this region. Median and paramedian forehead flaps have been proposed for nasal defects greater than 2.5-3 cm in diameter. The aim of this study was to describe a peculiar case of a recurrence of a squamous cell carcinoma in a forehead flap of a post-rhinectomy site managed by a fabrication of a total nasal prosthesis as salvage procedure. To the best of our knowledge, this is the first reported case in the scientific literature of a recurrence of a squamous cell carcinoma in a forehead flap of a post-rhinectomy site; this peculiar clinical report adds knowledge in the complex field of nasal reconstruction.

Surgical management of posttraumatic intraorbital hematoma.

Retrobulbar hematoma is a rare condition but represents a diagnostic and therapeutic emergency. It occurs in between 0.3% and 3.5% of facial traumas and can be caused by direct or indirect injury of the orbit; they can be classified into intraorbital and subperiosteal hematoma. We describe 4 different cases of posttraumatic retrobulbar hematoma treated at the Unit of Maxillofacial Surgery of the Novara Major Hospital between January 2005 and December 2009, each different from the others for morphologic aspects, and we discuss its diagnosis and management. Surgery decompression of the orbit is recommended when visual deficit arises and when there is no response to pharmacologic therapy. Several techniques for orbital decompression have been proposed. The lateral canthotomy and/or the inferior cantholysis are the 2 techniques most practiced. Anterior-chamber paracentesis is effective, but it is rarely indicated for frequent complications such as cataract formation, herniation of the iris, infection, and trauma to the canal of Schlemm. Other procedures including transantral ethmoidectomy, transantral sphenoidectomy, and transfrontal craniotomy are described.

Analysis of complications following endoscopically assisted treatment of mandibular condylar fractures.

BACKGROUND: Within the field of facial reconstructive surgery, minimally invasive procedures are used for the treatment of temporomandibular joint disorders, traumas, and salivary glands and base of skull tumors. The recent report of endoscopic approach for treating subcondylar fractures of the mandible is designed to provide a new method for the treatment of subcondylar fractures using an endoscope through a limited transoral incision. To the best of our knowledge, the advantages and the disadvantages of an endoscopically assisted approach to mandibular condylar fracture have not been verified in studies with a high level of evidence. The objective of this article was to present our experience regarding the endoscopically assisted reduction of subcondylar mandibular fractures with a special focus on complications. METHODS: The records of 14 patients who underwent surgical repair of subcondylar fractures by transoral endoscopic-assisted technique from January 2005 to December 2008 at the Maxillofacial Surgery Unit of Novara Major Hospital were reviewed retrospectively. The measures for the surgical objectives included the following outcome variables: (1) operation time, (2) cosmetic outcome, (3) salivary fistulas, (4) infection, (5) delayed wound healing, (6) facial nerve damage, (7) hemorrhage, (8) repeat interventions, (9) bone consolidation, (10) occlusion changes, and (11) temporomandibular joint dysfunction. RESULTS: Our data show that we have had 4 complications (28%) experienced by 4 different patients: (1) arterial hemorrhage, (2) facial nerve injury, (3) nonunion, and (4) partial condylar reabsorption. CONCLUSIONS: Although we cannot draw statistically significant conclusions, we think that further randomized clinical trials should be necessary to analyze this method; we believe that there is not an ideal approach for a fracture, but each patient needs to be fully evaluated carefully preoperatively, and the more convenient approach needs to be selected for each case.

Intraoral transposition of pedicled temporalis muscle flap followed by zygomatic implant placement.

Despite the recent advances of sophisticated reconstructive surgical techniques, management of maxillectomy defects continues to be challenging. For a selected group of patients, who cannot sustain a sophisticated microsurgical reconstructive procedure, a prosthetic obturator is indicated to separate the oral cavity from the sinonasal cavities. After the development of the osseointegration concept, dental implants have proven to be indicated for the rehabilitation of patients who underwent maxillectomy. Recently, surgeons can use a computer-assisted software package, which enables them to insert implants after a detailed analysis of the residual bone. For some patients with limited amount of residual maxillary bone, unusual surgical sites such as the zygomatic complex have been tested. We introduce a successful 2-step surgical procedure using a pedicled temporalis muscle flap and zygomatic implant placement to reconstruct a maxillary defect after oncological resection.

Analysis of complications after surgical repair of orbital fractures.

BACKGROUND: The term "orbital blow-out fracture" is referred to as the mechanism by which an impact to the eyeball is transposed as a mechanical energy to the orbital walls, causing them to fracture. Despite a proper surgical technique, a successful anatomic reconstruction of the orbit, and an accurate follow-up, 3 complications are still frequently observed at long-term follow-up: diplopia, enophthalmos, and hypesthesia of the infraorbital nerve territory. In this retrospective study, we analyze the incidence, the specific characterization, and the potential risk factors of these 3 complications. METHODS: The records of 75 patients who underwent surgical repair of isolated orbital blow-out fracture from January 2001 to December 2007 at the Maxillofacial Surgery Unit of the Novara Major Hospital were reviewed retrospectively. Patients who had other coexisting facial fractures or orbital rim involvement were excluded from this study. The mean follow-up reached 39 months (range, 6-81 months). Enophthalmos was measured by a Hertel exophthalmometer; diplopia was evaluated by an optometrist with cover test, red glass test, and Hess-Lancaster test; and hypesthesia of the infraorbital nerve territory was checked by clinical examination. The studied parameters included patient's age and sex, time interval between trauma and surgery, location of the fracture, and implant material. The χ test for nonparametric data was used, and a P value of less than 0.05 was considered statistically significant. RESULTS: Sex, location of the fracture, and implant material were not considered statistically significant (P > 0.05). The unique variable that influenced our data was the time interval between trauma and surgery (P > 0.05). DISCUSSION: Although the surgical technique was executed properly and the immediate postoperative recovery was uneventful, diplopia, enophthalmos, and infraorbital nerve dysfunction were the frequent complications. We stress the fact that orbital blow-out fracture is generally not considered a technically demanding procedure, but the outcome can be very disappointing; the surgical procedure must be managed very carefully by experienced surgeons to lower the high rates of these 3 common complications. However, we can report that the incidence of diplopia, enophthalmos, and infraorbital nerve dysfunction are decreased by an immediate intervention and an early surgical repair of the orbital blow-out fracture. Patients who had surgery within 2 weeks of trauma have a lower risk to develop postoperative complications; this study supports an early surgical treatment of orbital blow-out fractures, when it is indicated.

A peculiar orbital roof blow-in fracture.

An orbital blow-in fracture is defined as a displaced fracture of the orbital rim or wall when the fractured bone fragment is pulled into the orbit, resulting in a decreased orbital volume. Orbital blow-in fractures is generally localized at the orbital roof. Surgical treatment is required and should be early to avoid any damage to the visual. We report a peculiar case of indirect blow-in orbital roof fracture associated with fracture of the parietal bone.

Transient cardiac failure due to Takotsubo cardiomyopathy after surgical reduction of nasal fracture.

INTRODUCTION: Takotsubo syndrome, also known as ampulla cardiomyopathy, broken heart syndrome, idiopathic apical ballooning syndrome, and stress-induced myocardial stunning, has been first described by Japanese authors in 1996 and subsequently specified in 2001; it derives from the resemblance between the ancient round-bottomed, narrow-necked Japanese fishing pots used to trap octopus in Asia and the end-systolic appearance of the left ventricle on ventriculography. CLINICAL REPORT: We introduce the case of a woman who was involved in a traffic car crash and, subsequently, was admitted to the Maxillo-Facial Unit of the Novara Major Hospital with a diagnosis of nasal fracture. She underwent general anesthesia for the reduction of the fracture; after surgery, she developed acute chest pain, elevated cardiac biomarkers, ischemic electrocardiogram changes, and transient akinesis of the left ventricle without significant epicardial coronary artery disease. A diagnosis of takotsubo syndrome was made. CONCLUSIONS: This syndrome, which presents the same clinical features of a ventricular failure, is probably underdiagnosed, but after the introduction of sophisticated cardiac imaging and coronary intervention, more cases are identified and an unnecessary thrombolytic therapy can be spared. This reversible condition, which is, to our knowledge, never mentioned after a craniomaxillofacial surgical procedure, should be considered in the diagnostic algorithm for all patients presenting with acute onset of chest pain, elevated cardiac biomarkers, and ischemic changes on the electrocardiogram after a general anesthesia.

Ameloblastic carcinoma: rare localization of a rare neoplasm.

Ameloblastic carcinoma (AC) is a rare neoplasm of the maxillofacial district. It usually occurs in the posterior region of the jaw. In one third of cases, it occurs in the maxilla, usually in the posterior portion. From a review of international literature, we found 60 cases described. A 77-year-old patient presented to our division of maxillofacial surgery after the onset of a vegetans lesion of the maxilla. He had already been subjected to a first histologic examination that detected an AC. Surgery consisted of removal of a trapezoidal flap of the maxillary bone containing the mass. Histologic examination confirmed preoperative biopsy findings. Because of the low compliance, we did not plan for surgical reconstruction.Surgical resection is the treatment of choice for this kind of lesion, leaving at least a 2-cm free margin. Neoadjuvant radiotherapy may be useful for tumor debulking.

A benign isolated schwannoma of the orbit.

Schwannomas are benign encapsulated tumors, originating from Schwann cells of the peripheral nerves. Schwannomas accounts for approximately 1% of all orbital tumors. Most schwannomas originate from branches of the oculomotor, trochlear, trigeminal, and abducens nerves and from sympathetic and parasympathetic fibers. The progressive growth may cause compression of the optic nerve with papilledema or optic atrophy. Prompt diagnosis and early treatment are necessary to avoid important ocular consequences. We report a successful surgical treatment of orbital schwannoma in a 75-year-old woman.

Surgical technique of the transoral approach to remove a lipoma of the buccal fat pad.

BACKGROUND: In 1727, Heister (Compendium anatomicum. Altdorf, Guill, Koleshii: editio tertia 1727: 134, table VIII and figs. 36-37) described the buccal fat pad (BFP) as an independent anatomic structure of the face; in 1801, Bichat (Anatomie generale appliquee a la physiologie et a la medecine. Paris, France: Brosson, Gabon et Cie Libraires, 1801:60) reported his fatty histologic finding. According to the literature, several pathologic tumorous conditions can arise from BFP, such as lipoma, lipoblastomatosis, liposarcoma, hemangioma, arteriovenous malformation, and nodular fasciitis; all of which are rare. After a revision of the English literature performed through PubMed between 1948 and 2008, we found 10 cases of lipomas arising from the BFP (7 cases are simple subtype, 2 are spindle cell lipoma, and 1 is fibrolipoma). The aims of this study were to introduce our clinical report of this rare pathologic entity, describe the surgical technique of the transoral approach, and discuss the potential pitfalls regarding the preoperative diagnosis and the close interrelation among the BFP, the facial buccal branches (FBBs), and the parotid duct (PD). CLINICAL REPORT: A 43-year-old man was referred to the Maxillofacial Unit of the Novara Major Hospital with a 6-month history of a painless swelling in the right cheek. Clinical examination revealed a clearly visible, tender, slightly fluctuant mass, situated anterior to the masseter muscle and extended to the submandibular region. The patient underwent an ultrasound, a computed tomography, and a magnetic resonance imaging. Under general anesthesia with nasotracheal intubation, the patient underwent intraoral resection of BFP lipoma. DISCUSSION: The 2 major areas of discussion are the potential pitfall regarding the preoperative diagnosis and the close anatomic interrelation among the BFP, the FBB, and the PD. First, the spindle cell lipoma, one of the most common BFP lipoma variant, can be histologically and clinically similar to a well-differentiated liposarcoma, which can be recurrent and metastatic. This issue warrants that a careful workup of the tumorous mass of the buccal space and a BFP origin must be considered in every situation. Finally, according to the recent literature, the anatomic variations of the interrelation between the FBB and the BFP are classified into 2 groups: (1) FBB passing lateral to the BFP and (2) branches crossing inside the BFP. The anatomic variations of the interrelation between the PD and the BFP are classified into 3 groups: (1) PD passing lateral to the BFP, (2) PD crossing deep to the BFP, and (3) PD running along the superior border of the BFP.