Is Head and Neck Free Flap Reconstruction Feasible in Jehovah's Witness Patients?

BACKGROUND: Jehovah's Witnesses (JW) population are members of a religious group that refuses blood transfusion. This presents a dilemma for surgical teams when performing major surgical procedures on these patients. PURPOSE: This study aimed to assess the safety and feasibility of undergoing microvascular free flaps for maxillofacial reconstruction in JW patients and whether the type of underlying pathology impacts outcomes. STUDY DESIGN, SETTING, AND SAMPLE: This was a multi-institutional retrospective cohort study. The sample consisted of all JW patients who have undergone microvascular free tissue transfer for maxillofacial pathology between January 2016 and January 2021. PREDICTOR VARIABLE: The primary predictor variable was the underlying pathology for which patients underwent head and neck free flap reconstruction; this was benign versus malignant disease. MAIN OUTCOME VARIABLES: The primary outcome variables were safety, defined as discharge from the hospital with no mortality, and feasibility defined as successful free flap reconstruction. COVARIATES: Other variables included age, race, sex, length of surgery, length of hospital stay, and intraoperative use of vasopressors. ANALYSIS: Data analysis was performed utilizing t-tests for means and χ2 for proportions. Alpha was set at < 0.05. RESULTS: A total of 12 participants from 7 participating sites met the inclusion criteria. There were 9 males and 3 females with a mean age of 58.3 ± 8.3 years. There were no deaths in this cohort and all patients were discharged from the hospital. All 12 free flap reconstructions were successful with no incidents of free flap loss; none of the patients received any blood transfusions or any other blood products. Subgroup analysis showed that patients treated for malignant disease versus benign disease had longer operations (11.2 ± 2.9 vs 6.3 ± 0.2 hours, P < .01) and a longer hospital length of stay (11.8 ± 4.9 vs 5.3 ± 0.5 days, P = .04). CONCLUSION AND RELEVANCE: Our series supports the safety and feasibility of maxillofacial free flap reconstruction in this challenging subset of patients. Microvascular reconstructive surgeries for malignant diseases often result in longer operative times and hospital stays.

The Use of Urinary Bladder Matrix for Reconstructing Avulsed Traumatic Soft Tissue Injuries to the Maxillofacial Region.

INTRODUCTION: The purpose of the study was to provide an overview of our initial experience utilizing urinary bladder matrix (UBM) for reconstructing avulsed injuries resulting from trauma. MATERIALS AND METHODS: This retrospective case series evaluated patients presented with avulsed soft tissue injuries to the head and neck who underwent reconstruction with UBM. Patients were treated by Oral and Maxillofacial Surgery Service in Louisiana State University Health Sciences Center (Baton Rouge, LA). Descriptive variables were collected. Descriptive statistics were calculated. RESULTS: Eight patients (mean age 55.8 y) met our inclusion criteria. Wounds were located in the scalp (n=2, 25%), mandible (n=2, 25%), upper eyelid (n=1, 12.5%), cheek (n=1, 12.5%), nose (n=1, 12.5%), or neck (n=1, 12.5%). The depth of the wound extended from the skin to the subcutaneous tissue (n=1, 12.5%), muscle (n=2, 25%), bone (n=3, 37.5%), and/or cartilage (n=1, 12.5%). The mean wound diameter was 47.9 cm 2 (range 17-85 cm 2 ). Wounds were classified as acute (n=6, 75%) or chronic wounds (n=2, 25%). At 6 months, all patients had achieved complete healing with no need for additional surgical procedures (n=8, 100%) with a mean healing time of 36.5 days (range 14-90 d). CONCLUSION: Urinary bladder matrix minimize donor-side morbidity, eliminates contraction, and offers a wide range of product sizes to cover a wide range of maxillofacial soft tissue defects in a single-stage manner.

The Incidence of COVID-19 Patients in Oral and Maxillofacial Surgery.

PURPOSE: The SARS-CoV-2 global pandemic has resulted in widespread changes to healthcare practices across the United States. The purpose of this study is to examine the incidence of COVID-19 patients in the oral-maxillofacial surgery setting in order to help guide perioperative protocols during the pandemic. METHODS: In this retrospective cohort study, predictor variables (presence of preoperative symptoms on presentation, patient age, patient gender, patient race, hospital location, and presence of statewide stay-at-home orders) were examined with outcome variables (SARS-CoV-2 test results) over 10 months between March 2020 and December 2020 for patients undergoing surgical procedures in the operating room by the following Oral-Maxillofacial Surgery Departments: - Louisiana State University Health Sciences Center (Baton Rouge, LA) - University of Illinois at Chicago (Chicago, IL) - University of Texas Health Science Center at Houston (Houston, TX) Data analysis included Fisher exact tests to compare categorical variables across COVID test groups and Wilcoxon rank sum tests to compare continuous covariates. Two-sample tests of proportions were used to compare observed COVID-19 positivity rates to other study results. RESULTS: Out of 684 patients in 3 institutions, 17 patients (2.5%, 95% CI = 1.5 to 4.0%) tested positive for COVID-19 over a 10 month interval (March 1, 2020- December 31, 2020). The majority of patients that tested positive were asymptomatic in the preoperative setting (P-value = .09). They were significantly more likely to be African-American (P-value = .015) and less likely to have a stay-at-home order present at the time of surgery (P-value = .033). Age, gender, and hospital location did not play a statistically significant role. CONCLUSION: Our results demonstrate a 2.5% incidence of COVID-19 infection in the total population of patients undergoing scheduled oral-maxillofacial surgeries in 3 major healthcare systems across the United States. This data may help inform perioperative protocols and infection control measures during the COVID-19 pandemic.

Can Radiographic Tumor Volume of Oral Squamous Cell Carcinoma Help Predict Clinical and Pathological Tumor Features?

PURPOSE: Radiographic tumor volume (RTV) of oral squamous cell carcinoma (SCC) is seldom measured in practice. Aims of the study are to estimate RTV of SCC and to investigate its relationship with clinical and pathological stage, tumor margin status, recurrence, and need for chemo/radiation. METHODS: The design is a retrospective cohort study. The predictor variable is SCC RTV. The primary outcome variables are clinical and pathological tumor size. The secondary outcomes are margin status and postoperative chemo/radiation. Tumor dimensions were measured on preoperative maxillofacial or neck computer tomography images with contrast. Information on patient and tumor characteristics was obtained. Pearson correlation, t test, ANOVA and log rank test were used for statistical analysis. The significance level was set at .05. RESULTS: Thirty-six subjects aged 36 to 86 were included in the study. Positive association was found between clinical T stage and RTV (P = .0003) and between pathologic T stage and RTV (P = .002). Mean value of RTV was significantly higher in the group with positive margins (P = .0004). RTV was significantly higher in cancers requiring adjuvant chemo/radiation (P = .033). Mean RTV for patients with recurrence was 1.86 cm3 as compared to 1.29 cm3 for patients with no recurrence. Higher tumor volumes were more likely to be associated with recurrence. CONCLUSIONS: RTV is a variable that is readily available to head and neck surgeons. RTV is associated with clinical and pathological tumor sizes, margin status, need for adjuvant chemo/radiation and tumor recurrence.

The Early Effects of Coronavirus Disease-2019 on Head and Neck Oncology and Microvascular Reconstruction Practice: A National Survey of Oral and Maxillofacial Surgeons Enrolled in the Head and Neck Special Interest Group.

PURPOSE: The coronavirus disease-2019 (COVID-19) pandemic has affected healthcare systems across the nation. The purpose of this study is to gauge the early effects of the COVID-19 pandemic on head and neck oncology and reconstructive surgery (HNORS) practice and evaluate their practice patterns especially ones that might be impacted by COVID-19 and compare them to the current literature. METHODS: This study is a cross-sectional study that surveyed fellowship-trained oral and maxillofacial surgeons in HNORS. This cohort of surgeons was contacted via a generated email list of surgeons enrolled in the American Association of Oral and Maxillofacial Surgeons pathology special interest group. An electronic survey contained 16 questions to assess the COVID-19 effect on HNORS practice and capture their practice patterns from mid-March to mid-April 2020. Statistical analysis was performed to analyze counts, percentages, and response rates. RESULTS: We had a 60% response rate (39 of 64); 72% of our responders worked at academic institutions, 18% marked themselves as hybrid academic/private practice, and only 10% were considered hospital-based surgeons. Only 8% of the survey respondents were requested to pause head and neck cancer surgery, whereas 24% were requested to pause free flap surgery during the pandemic. Fifty-five percent agreed that the head and neck and reconstructive surgery should be conducted during a pandemic. Finally, 45% thought that two weeks was a reasonable delay for head and neck cancer cases, whereas 29% thought they should not be delayed for any amount of time. Regarding practice patterns, microvascular reconstruction was the favored method (100%). Respondents generally admitted patients to an intensive care unit postoperatively (92%) and were kept on a ventilator (53%). CONCLUSION: The COVID-19 pandemic had a small impact on the surgical treatment of patients with head and neck oncology. Most HNORS surgeons are practicing in accordance with recently published literature.

Use of Vascularized Myo-Osseous Fibula Free Flap to Reconstruct a Hemimandibular Defect With a Concomitant Skull Defect Arising From Stock Condylar Prosthesis Displacement Into the Middle Cranial Fossa.

Functional reconstruction of the temporomandibular joint (TMJ) is a controversial topic among oral and maxillofacial surgeons; this controversy becomes more complicated when one dives into the dilemma of the ideal reconstructive modality. TMJ defects might result from various etiologies, such as blunt or penetrating traumatic injuries, advanced degenerative joint disease, or various pathologic conditions, including benign and malignant conditions, that might arise from the TMJ or adjacent tissues. Reconstruction of the TMJ is vital because of its essential function in mastication, articulation, speech, and facial esthetics and symmetry. In the pediatric population, the TMJ acts as a growth center. TMJ reconstructive surgery might be influenced by various factors that can steer the surgeon toward adopting a specific reconstructive modality. These factors can be classified into preoperative factors that include the overall general health of the patient, expectations, and socioeconomic status that might be an obstacle in using custom-made solutions. The surgeon's experience, level of comfort, and training are crucial influencing factors. TMJ reconstructive options consist of autogenous grafts or alloplastic options. Autogenous grafts encompass 2 broad subcategories. The first is the vascularized option, and a good example is the vascularized fibula free flap. The second subcategory includes nonvascularized grafts, such as costochondral grafts and sternoclavicular grafts. Alloplastic grafts include various TMJ stock joints or custom-made patient-specific prostheses and stock condylar prostheses. The goals of TMJ reconstruction are to establish a pain-free normal range of mouth opening, stable occlusion, and absence of facial deformity. Complication rates in TMJ surgery are low and include surgical infection, nerve injury, failure or fracture of the prosthesis, or injury to adjacent structures. This report presents a case of a stock condylar prosthesis displaced into the middle cranial fossa, which was managed with a 2-stage approach of removing the displaced prosthesis and then reconstruction with a fibula vascularized free flap and a simultaneous contralateral sagittal split osteotomy.

The Use of Virtual Surgical-Guided Osteoplasty for Maxillofacial Brown Tumors.

A 28-year-old African American female with end-stage renal disease on dialysis secondary to preeclampsia presented to the office as a referral for large multifocal tumors of maxilla and mandible. Surgical pathology and laboratory findings were supportive of secondary hyperparathyroidism leading to multifocal brown tumors. She underwent osteoplasty after using virtual surgical planning to create stereolithic models to visualize the tumor and fabricate cutting guides to minimize the risk of injury to adjacent nerves and teeth. Brown tumors can be resistant to medical management with unreliable regression in size. With the advent of customized surgical guides, more precise and judicious surgery can be performed on these types of tumors safely.

Pedicle Orientation in Free-Flap Microvascular Maxillofacial Reconstruction.

Oncologic and traumatic defects of the maxilla can pose a challenge to patients, reconstructive surgeons, and maxillofacial prosthodontists in an attempt to provide satisfactory treatment. Oral-nasal and oral-antral fistulas are frequently treated with soft tissue flaps, osteocutaneous flaps, or a maxillofacial obturator. The free fibula microvascular osteocutaneous flap has proved the workhorse of these maxillary and mandibular reconstructions. The success of microvascular reconstruction often hinges on flap viability in the immediate postoperative period. With most flap failures attributed to vascular compromise resulting from clot formation and venous congestion, uncompressed, and nontortuous pedicle positioning demands surgical attention. Although the use of the free fibula flap in maxillary reconstruction is a well-described and predictable procedure, the specifics of the flap inset with respect to pedicle positioning and technique within the maxilla and neck have not been clearly detailed in the available studies. In the present technique note, we have provided our surgical description for pedicle positioning and anatomic alterations in an attempt to improve microvascular anastomosis flap success.

Use of Virtual Surgical Planning for Simultaneous Maxillofacial Osteotomies and Custom Polyetheretherketone Implant in Secondary Orbito-Frontal Reconstruction: Importance of Restoring Orbital Volume.

Correction of orbito-frontal defects involves a multitude of surgical challenges, and requires careful and detailed planning. In the trauma setting, one must be prepared to deal with injuries to adjacent structures and be able to incorporate their repair into the surgical plan to maximize the functional and esthetic reconstruction for the benefit of the patient. Victims who have sustained trauma of the cranial complex in combination with mid-facial trauma, particularly involving the orbit, present a difficult scenario, especially when future ocular prosthetic rehabilitation is a concern. The authors present a patient of virtual surgical planning-guided planning of mid-facial osteotomies and custom implant creation for the secondary reconstruction of a patient who sustained extensive orbito-frontal trauma, requiring not only cranial vault recontouring, but also reconstruction of the mid-facial and orbital complex to accommodate an ocular prosthesis that would demonstrate proper anatomical relationships to maximize esthetics and function.

Case Reports of Two Unusual Donor Site Complications of the Pectoralis Major Myocutaneous Flap and Literature Review.

The pectoralis major myocutaneous flap (PMMF), once considered a workhorse flap for head and neck reconstruction, is still used for a wide range of head and neck reconstruction in the era of microvascular free tissue transfer flap (MFTF) for many reasons including low donor site morbidity. Numerous studies have reported the flap-related complications of PMMF in depth but have seldom discussed the donor site complications in detail. This article reports 2 unusual donor site complications and reviews the published data on general donor site complications resulting from PMMF use.

Inaugural Survey on Practice Patterns of Orbital Floor Fractures for American Oral and Maxillofacial Surgeons.

PURPOSE: In recent years, several studies have reported on practitioners' preferences for the treatment of orbital floor fractures, showing widely varying practice patterns. The purpose of the present study was to identify the practice patterns among oral and maxillofacial surgeons involved in the management of orbital floor fractures in the United States and compare them with the available published data. MATERIALS AND METHODS: An anonymous survey was created and electronically mailed to surgeons. We also reviewed the published data on orbital floor fractures using a PubMed and MEDLINE search. The responses to the survey were analyzed using descriptive statistics. RESULTS: The factors that had the greatest influence on the surgeon's decision to operate were a defect size > 2 cm2, enophthalmos, entrapment, and persistent diplopia. The most common surgical approach reported was a preseptal transconjunctival approach (32.0%), followed by the subciliary (27.9%) and postseptal transconjunctival (26.2%) approaches. The most commonly reported implant for orbital reconstruction was titanium (65.4%), followed by Medpor (43.7%) and composite Medpor and titanium (26.4%). The review of the published data showed a consensus among many of the operative indications mentioned, including a large defect size, enophthalmos, clinical entrapment, and persistent diplopia. CONCLUSIONS: Oral and maxillofacial surgeons in the United States have a wide range of practice habits in the management of orbital floor fractures. Although the quality of the available evidence is poor, it supports a consistent approach to the management of orbital floor fractures in terms of the indications and surgical approach. The choice of reconstructive material and timing of repair remain more controversial. A clear need exists for improvement in the available data to help guide and set standards of care for the specialties managing orbital floor fractures.

A Detailed Analysis of Mandibular Angle Fractures: Epidemiology, Patterns, Treatments, and Outcomes.

PURPOSE: The purpose was to analyze mandibular angle fractures by examining epidemiologic trends and mechanisms of injury and to determine whether a statistically meaningful relation existed between certain treatment modalities and patient outcomes. MATERIALS AND METHODS: A retrospective chart analysis was performed, and data were limited to 1 operator. Treatment variables were methods of fixation, postoperative intermaxillary fixation (IMF), and retention versus extraction of teeth in the line of fracture. Outcomes were rates of postoperative infection, fracture healing, and overall patient comfort. Analysis was performed using the Fisher exact test, Wald test, and χ(2) test, with a P value less than .05 considered significant. RESULTS: One hundred three patients were included in this study. The mean age was 30.4 years, most patients were men, and most injuries occurred during physical altercations and on the left side of the face. The most common concomitant fracture was of the contralateral parasymphysis. A statistically meaningful relation was noted between methods of fixation and healing and overall patient comfort, with the Champy technique and reconstruction plate being associated with the highest rates of bony union and patient comfort. No statistically relevant correlation was found between methods of fixation and rates of infection. There was no statistically relevant link for extraction versus retention of healthy teeth in the line of fracture or use of IMF with patient comfort, postoperative infection, or fracture healing. CONCLUSION: Although the Champy technique and reconstruction plates were associated with better postoperative outcomes, such as patient comfort and fracture healing, these should not be used interchangeably. IMF and extraction versus retention of teeth in the line of fracture did not influence any of the outcomes.

Quality of life assessment in patients after mandibular resection and free fibula flap reconstruction.

PURPOSE: The aim of the present study was to assess patients' quality of life (QOL) after mandibular resection and reconstruction with the free fibula flap (FFF). MATERIALS AND METHODS: We performed a retrospective study of all patients who underwent segmental mandibular resection and FFF reconstruction at the Division of Oral and Maxillofacial Surgery, McGill University Health Center. The patients were contacted and asked to complete a QOL assessment at least 1 year after surgery. The patients' photographs were taken and evaluated for the esthetic outcomes after surgery by 2 dental health professionals using a visual analog scale and compared with the patients' self-evaluations. A descriptive analysis was used for data analysis. RESULTS: Seventeen patients underwent segmental mandibular resection and reconstruction with a FFF, and 11 completed the QOL questionnaire. Two patients were deceased at the start of the study, 1 refused to complete the QOL questionnaire, and 3 had developed disease recurrence and were not asked to complete the QOL questionnaire. Of the 11 patients who completed the QOL assessment, 8 rated their overall QOL as outstanding, very good, or good and 3 reported it to be fair. No significant correlation was found between the patients' self-reported esthetic evaluation and the third-party evaluations. CONCLUSIONS: Most patients who underwent mandibular resection and FFF reconstruction reported satisfaction with their overall QOL. We did not find a correlation between the patients' perceived esthetic outcome and the dental healthcare professionals' assessment.

Evolving trends in the management of orbital floor fractures.

BACKGROUND: The management of orbital floor fractures is diverse and continues to evolve. The purpose of the current study was to provide an updated summary of the literature, with a focus on interspecialty differences, and contrast that with current treatment strategies of actively practicing plastic surgeons. METHODS: A survey was conducted of surgeons who currently manage orbital floor fractures. The results are summarized and compared with a 10-year literature review (2002-2012) of surgical approaches, indications and timing of surgery, and implant selection in various surgical disciplines. Inclusion criteria included studies in English language with 10 or more patients. RESULTS: The survey response rate was 56%, of which 86 surgeons were identified to currently manage orbit fractures. A third of participants reported they are less likely to operate on these fractures relative to earlier in their career. Six factors were found to have the greatest influence on surgeon's operative decision: enophthalmos, hypophthalmos, positive forced duction, defect size, motility restriction, and persistent diplopia. The most common preferred approach to the orbit is midlid/infraorbital (45%) followed by transconjunctival (31%) and subciliary (24%). Medpor and titanium are the most preferred implants (83%) compared with autologous bone (5%). CONCLUSIONS: Significant interdisciplinary and intradisciplinary differences in the management of orbital fractures exist. The most significant trends are the growing popularity of alloplastic versus autogenous materials for orbital floor reconstruction and the fact that one-third of surgeons are more likely to opt for a nonoperative (conservative) approach compared with earlier in their careers.

Reticular Myxoid Odontogenic Neoplasm with Novel STRN::ALK Fusion: Report of 2 Cases in 3-Year-Old Males.

Odontogenic tumors represent a collection of entities ranging from hamartomas to destructive benign and malignant neoplasms. Occasionally, pathologists encounter gnathic lesions which clearly exhibit an odontogenic origin but do not fit within the confines of established diagnoses. Here, we describe two such odontogenic tumors, both affecting 3-year-old males. Each case presented as a destructive, radiolucent mandibular lesion composed of mesenchymal cells, some with unique multi-lobed nuclei, frequently arranged in a reticular pattern and supported by a myxoid stroma with focal laminations. Production of odontogenic hard tissues was also seen. Because of their unique microscopic features, both cases were investigated by next-generation sequencing and found to harbor the same STRN::ALK oncogene fusion. To our knowledge, these cases represent the first report of an odontogenic tumor with a STRN::ALK gene rearrangement. We propose the possibility that this neoplasm could be separate from other known odontogenic tumors. Both patients were treated with surgical resection and reconstruction. The prognosis of patients with this entity is currently uncertain but shall become more apparent over time as more cases are identified and followed.

Mouthwash as a non-invasive method of indocyanine green delivery for near-infrared fluorescence dental imaging.

SIGNIFICANCE: X-ray imaging serves as the mainstream imaging in dentistry, but it involves risk of ionizing radiation. AIM: This study presents the feasibility of indocyanine green-assisted near-infrared fluorescence (ICG-NIRF) dental imaging with 785-nm NIR laser in the first (ICG-NIRF-I: 700 to 1000 nm) and second (ICG-NIRF-II: 1000 to 1700 nm) NIR wavelengths. APPROACH: Sprague Dawley rats with different postnatal days were used as animal models. ICG, as a fluorescence agent, was delivered to dental structures by subcutaneous injection (SC) and oral administration (OA). RESULTS: For SC method, erupted and unerupted molars could be observed from ICG-NIRF images at a short imaging time (<1 min). ICG-NIRF-II could achieve a better image contrast in unerupted molars at 24 h after ICG injection. The OA could serve as a non-invasive method for ICG delivery; it could also cause the glow-in-dark effect in unerupted molars. For erupted molars, OA can be considered as mouthwash and exhibits outstanding performance for delivery of ICG dye; erupted molar structures could be observed at a short imaging time (<1 min) and low ICG dose (0.05 mg / kg). CONCLUSIONS: Overall, ICG-NIRF with mouthwash could perform in-vivo dental imaging in two NIR wavelengths at a short time and low ICG dose.

Detection and analysis of enamel cracks by ICG-NIR fluorescence dental imaging.

Cracked teeth are the third most common cause of tooth loss, but there is no reliable imaging tool for the diagnosis of cracks. Here, we demonstrate the feasibility of indocyanine green near-infrared fluorescence (ICG-NIRF) dental imaging for the detection of enamel cracks and enamel-dentin cracks in vitro in the first (ICG-NIRF-I, 700-950 nm) and second (ICG-NIRF-II, 950-1700 nm) imaging windows with transmission excitation light, and compared ICG-NIRF with conventional NIR illumination-II (NIRi-II) and X-ray imaging. Dentin cracks were detected by CT scan, while most enamel cracks, undetectable under X-ray imaging, were clearly visible in NIR images. We found that ICG-NIRF-II detected cracks more effectively than NIRi-II, and that light orientation is an important factor for crack detection: an angled exposure obtained better image contrast of cracks than parallel exposure, as it created a shadow under the crack. Crack depth could be evaluated from the crack shadow in ICG-NIRF and NIRi-II images; from this shadow we could determine crack depth and discriminate enamel-dentin cracks from craze lines. Cracks could be observed clearly from ICG-NIRF images with 1-min ICG tooth immersion, although longer ICG immersion produced images with greater contrast. Overall, our data show that ICG-NIRF dental imaging is a useful tool for diagnosing cracked teeth at an early stage.