MRI and frozen section evaluation of mylohyoid muscle in determining surgical approach for T2-T3 floor of the mouth cancer.

PURPOSE: The choice of surgical approach for floor of the mouth (FOM) cancer, particularly for intermediate-stage tumors (cT2-cT3), remains controversial. This study aims to evaluate a method considering mylohyoid muscle (MM) invasion as a determinant for surgical approach selection, utilizing magnetic resonance imaging (MRI) preoperatively and frozen section (FS) analysis intraoperatively. METHODS: This observational retrospective cohort study analyzed patients undergoing surgical resection of cT2 and cT3 FOM squamous cell carcinoma (SCC) between January 2013 and June 2023. MM infiltration assessed by preoperative MRI determined the surgical approach: clear infiltration led to compartmental surgery (CS), while doubtful or absent infiltration led to transoral surgery (TOS). Conversion from TOS to CS occurred intraoperatively based on macroscopic evidence or positive FS. Data collected included demographic, clinical, surgical, and pathological variables. Survival analysis was conducted using Kaplan-Meier method. RESULTS: Among 44 patients included, majority had cT2 tumors (59.1%). MM resection was necessary in 22.7% of cases. Overall survival (OS) and progression-free survival (PFS) did not significantly differ between TOS and CS groups. Radiological depth of invasion (rDOI) < 10 mm is correlated with MM preservation in 89% of cases, while rDOI > 10 mm is correlated with MM resection only in 23.8% of cases. Pathological depth of invasion (pDOI) discrepancies were observed in the two groups: in CS group is shown a higher pDOI (> 10 mm) confirmation (90%). Surgical complications and functional outcomes differed between TOS and CS groups. CONCLUSION: Considering MM invasion for surgical approach selection in cT2-cT3 FOM tumors appears oncologically safe, with better functional outcomes in muscle preservation. Preoperative MRI for MM assessment combined with intraoperative FS analysis provides reliable guidance for surgical decision-making.

Dermoid Cysts on the Floor of the Mouth.

OBJECTIVE: The authors analyzed the clinical features and treatment results of surgical patients with a final diagnosis of dermoid cyst on the floor of the mouth over 14 years at our hospital. PATIENTS AND METHODS: A total of 5 patients with a final diagnosis of dermoid cyst of the floor of the mouth from January 2010 to December 2023 were enrolled. RESULTS: All patients complained of swelling in the submentum or floor of the mouth. The mean tumor size was 4.2±1.0 cm. All patients underwent complete surgical resection. A transcervical approach was performed in 3 patients, and an intraoral approach was implemented in 2 patients. There were no major complications after surgery with either method. The follow-up period was 71.4±75.7 months. There was no disease recurrence during follow-up. CONCLUSION: Dermoid cysts rarely occur on the floor of the mouth but should be considered in the differential diagnosis of other oral cavity tumors. Dermoid cysts on the floor of the mouth can be safely removed using the current transoral approach without scarring or recurrence.

[Removal of a dermoid cyst of the floor of the mouth in a patient with severe hemophilia A]. / Udalenie dermoidnoi kisty dna rta u bol'nogo tyazheloi formoi gemofilii A.

The article presents a case of a surgical treatment of removing a dermoid cyst of the floor of the oral cavity in a patient with severe hemophilia A. A detailed analysis was carried out of the surgical operation, postoperative management, coagulation factor replacement therapy and accompanying therapy, as well as the features of anesthesia, which allowed a surgical intervention without any hemorrhagic and infectious complications.

Vascular Anatomy for the Prevention of Sublingual Hematomas: Life-Threatening Complication of Genioplasty.

After genioplasty, the occurrence of bleeding is rare; however, rapid enlargement or displacement of the tongue secondary to lingual or sublingual hematoma can lead to life-threatening airway obstruction, necessitating prompt recognition, and immediate management. Therefore, the investigators aimed to evaluate the underlying etiologies of sublingual hematoma and relevant anatomy to facilitate early recognition of the initial presentation of these hematomas and appropriate management. The authors conducted a literature review on cases of delayed sublingual hematoma after genioplasty. The authors also report a case of delayed hematoma after performing genioplasty. The anatomical structures involved with the development of rare and serious hematomas therein are the sublingual and submental arteries, which are located in the sublingual area, rendering them susceptible to injury during genioplasty. The results of this study suggest that submental artery ligation should be performed for proper management of airway obstruction, if symptoms of sublingual bleeding are observed during the surgical procedure. If there is continuous bleeding despite the submental artery ligation, sublingual artery ligation should be performed.

The Relevance of Fluid and Blood Management Using Microcirculatory Parameters in Children Undergoing Craniofacial Surgery.

ABSTRACT: Perioperative management of bleeding in children can be challenging. Microvascular imaging techniques have allowed evaluating the effect of blood transfusion on the microcirculation, but little is known about these effects in children. We aimed to investigate the effects of blood management using macro- and micro-hemodynamic parameters measurement in children undergoing craniofacial surgery. This is a prospective observational repeated measurement study including fourteen children. The indications for blood transfusion were changes of hemoglobin/hematocrit (Hct) levels, the presence of signs of altered tissue perfusion and impaired microcirculation images. Total and perfused vessel densities, proportion of perfused vessels, microvascular flow index, and systemic parameters (hemoglobin, Hct, lactate, mixed venous oxygen saturation, K+, heart rate, mean arterial blood pressure) were evaluated baseline (T1), at the end of the surgical bleeding (T2) and end of the operation (T3). Four patients did not need a blood transfusion. In the other 10 patients who received a blood transfusion, capillary perfusion was higher at T3 (13[9-16]) when compared with the values of at T2 (11[8-12]) (P < 0.05) but only 6 patients reached their baseline values. Although blood transfusions increased Hct values (17 ±â€Š2.4 [T2]-19 ±â€Š2.8 [T3]) (P < 0.05), there was no correlation between microvascular changes and systemic hemodynamic parameters (P > 0.05). The sublingual microcirculation could change by blood transfusion but there was not any correlation between microcirculation changes, hemodynamic, and tissue perfusion parameters even with Hct values. The indication, guidance, and timing of fluid and blood therapy may be assessed by bedside microvascular analysis in combination with standard hemodynamic and biochemical monitoring for intraoperative bleeding in children.

Epidermoid Cyst of the Floor of the Mouth.

ABSTRACT: Epidermoid cysts are rare, slow-growing, benign, developmental cysts that are derived from abnormally situated ectodermal tissue. Epidermoid cysts may grow anywhere on the body and about 7% of them are located in the head and neck region. They are usually asymptomatic over years but can be symptomatic due to secondary changes or the growing size. Clinically, the lesion presents as a slow-growing asymptomatic mass, usually located in the midline, above or below the mylohyoid muscle. Surgical excision from the floor of the mouth is indicated to relieve symptoms and prevent possible infection. This swelling on the floor of the mouth can sometimes cause serious problems with difficulty for swallowing and speaking. The purpose of this report is to present a case of sublingual epidermoid cyst of the floor of the mouth.

Floor of mouth prosthesis with removable depressible tongue: A clinical report.

The rehabilitation of a patient with a total glossectomy with a prosthetic device is challenging and depends on the individual patient. Ablation of a tongue tumor leaves defects that can be either surgically reconstructed or replaced by a prosthesis to help recreate normalcy and balance in the oral cavity. This clinical report describes a prosthetic design to rehabilitate a patient after a total glossectomy. This approach successfully recreated the glossal surface with a soft, hollow, depressible structure that emulates the tongue during speech and a solid structure to facilitate swallowing. The components were joined by magnets.

Combined rehabilitation of a lower lip defect after resection of floor of mouth cancer: A clinical report.

This clinical report describes the successful prosthetic rehabilitation of a deficient lower lip in an edentulous patient who had undergone surgery for removal of a squamous cell carcinoma of the anterior floor of the mouth and vestibule. The rehabilitation used a combined approach of an extraoral lip prosthesis joined by 3 magnets to an intraoral implant-retained mandibular resection prosthesis. The outcome demonstrated rehabilitation of the lower third of the face by eliminating loss of fluids and by improving the facial profile, lip contour and competence, esthetics, the patient's eating ability, speech intelligibility, and reported quality of life.

Diagnosis and management of hypoglossal nerve-derived schwannoma in the floor of mouth: a case series.

BACKGROUND: Schwannomas or neurilemmomas are well-encapsulated, benign, solitary, and slow-growing tumors that originate from Schwann cells of the nerve sheath. Extracranial schwannoma is reported to have a relatively high incidence in the tongue while an extremely low incidence in the floor of mouth. In the current study, we presented the first case series of hypoglossal nerve-derived schwannoma in the floor of mouth in Asia. METHODS: A retrospective study of 9 surgical cases of hypoglossal nerve-derived schwannoma in the floor of mouth was performed. The patient and tumor characteristics were evaluated by physical, radiological and pathological examination. Details of operation and complications were also recorded. RESULTS: Hypoglossal nerve-derived schwannoma in the floor of mouth showed a well-defined boundary with a firm texture, smooth surface and good mobility on palpation. The median maximum diameter of the tumors was 4.3 cm (range 2.8-7.0 cm). The median operative time and bleeding volumes were 89.4 min (range 47-180 min) and 99.2 mL (range 15-200 mL), respectively. All cases received complete surgical excision. CONCLUSION: In this study, we presented the diagnosis and management of hypoglossal nerve-derived schwannoma in the floor of mouth for the first time in Asia. The study provided us with a recommendation for consideration of the diagnosis of hypoglossal schwannoma when a patient presents with a mass in the floor of mouth.

[Results of modified submandibular surgical approach usage for the mouth floor phlegmons treatment with respect to dynamic of local non-specific resistance]. / Rezul'taty primeneniya modifitsirovannogo podnizhnechelyustnogo operativnogo dostupa dlya lecheniya odontogennykh flegmon dna polosti rta s uchetom dinamiki lokal'noi nespetsificheskoi rezistentnosti.

THE AIM OF THE STUDY: Was increasing of treatment effectiveness of patients with mouth floor odontogenic phlegmon (MFOP) by modified of surgical approach usage. MATERIALS AND METHODS: The prospective controlled, randomized, simple blinded clinical trial, II b level of evidence, comprised 86 patients with MFOP which formed main and control groups. The main group consisted of 40 patients treated with designed «Method for surgical treatment of odontogenic oral phlegmon of mouth floor with partial dissection of sublingual-submandibular sac¼. The control group involved 46 patients treated with traditional surgical procedure. The differences significance between the values has been evaluated with nonparametric Fisher's exact P-test and parametric Student's t-test for independent samples. RESULTS: The modified surgical approach statistically significantly (p<0.05) decreased the number of inflammatory complications (from 26±7% to 9±4%), terms of secondary sutures application (from 7.9±1.4 to 5.7±1.6 days) and time of hospital stay (from 9.4±1.8 to 8.3±1.7 days). On the 5th day of treatment white blood cells count in the main group was significantly (p<0.05) lower (7.2±1.1·109/l) than in controls (9.4±1.3·109/l) showing improved intoxication syndrome resolution in the main group. Index of reaction of bacteria adsorption to the oral epithelium in the main group on the 5th day of treatment was significantly (p<0.05) higher (77.1±6.9%) than in controls (62.4±7.1%). More successful correction of local non-specific resistance was registered in the main group. CONCLUSION: The proposed modified submandibular surgical approach is more effective for the treatment of patients with MFOP.

Reconstruction of a Gunshot-Caused Mouth Floor Defect Using a Nasolabial Flap and a De-Epithelialized V-Y Advancement Flap.

ABSTRACT: We present reconstruction of a gunshot-caused mouth floor defect using a nasolabial flap and a de-epithelialized V-Y advancement flap.A 58-year-old man presented 14 days after bullet injury passed from anterior chin to the right postauricular area. Upon examination, the central incisors, alveolar bones, and soft tissues of the mouth floor were lost. Bone fragments and failed miniplates were exposed. Pus discharge filled the defect.On the 23rd post-trauma day, right unilateral nasolabial flap was used to cover the oral side of the mouth floor. This flap was centered on the nasolabial fold and its base was situated on the commissure of the lips. The flap was raised in the soft tissue, just superficial to the facial muscles, transferred into the oral cavity through an incision made in the cheek mucosa, and sutured to the margin of the defect. A de-epithelialized dermal and subcutaneous flap was used to reconstruct the deep portion of the mouth floor through the V-Y advancement method. At the lower border of the mandible, a 3-cm-wide V-Y advancement flap was designed. The de-epithelized portion was inserted into the mouth floor and sutured to the defect margin. On 30th post-trauma day, left commissure-based buccal mucosal flap was used for the gingivobuccal sulcus defect. The apex was near the retromolar trigone. The elevated flap was transferred to the lower gingivobuccal sulcus defect. On POD 28, the nasolabial flap and commissure-based buccal myomucosal flap was divided and inset respectively.These flaps can be used for moderate-sized mouth floor defects.

Reconstruction of Anterior Mandible and Mouth Floor Using the Myofascial Iliac Crest Free Flap After Tumor Resection.

The current study introduces a novel approach of anterior mandible and mouth floor reconstruction with the myofascial iliac crest free flap. A series of 4 patients who presented between May 2015 and July 2017 had benefited from this technique. The myofascial component of this flap was designed to be attached to the iliac crest, and the flap was obtained after identifying the neurovascular pedicle. We transferred the iliac crest, with an outward-oriented placement, to the mandibular defect as the base of the alveolar process. We found that the iliac crest can provide sufficient bone height and an aesthetic shape for the reconstruction of the anterior mandible. More important, we also observed that the myofascial component on the flap surface completely replaced the oral mucosa in as early as 1 month after the operation. Moreover, the proper soft tissue volume can be achieved using this approach for better functional reconstruction of the oral mucosa. No obvious scar contracture of the myofascial component was observed during the follow-up period. The myofascial iliac crest free flap could provide a suitable reconstruction method for combined oral mucosa-mandible defects.

Impact of advanced age on microvascular reconstruction of the lower facial third: An American College of Surgeons NSQIP study.

BACKGROUND: Microvascular reconstruction is the standard of care in head and neck reconstruction, though its perioperative safety in an older population has been controversial due to safety concerns, warranting further investigation. MATERIALS AND METHODS: An "older" (≥71 years) cohort undergoing reconstruction after mandibulectomy/glossectomy was compared to the remaining population in a National Surgical Quality Improvement Program (2008-2016) analysis. Cases required both a mandibulectomy/glossectomy and microvascular or local flap reconstruction (exclusion criteria: missing ages and simultaneous microvascular and local flap reconstruction). Demographics, comorbidities, and procedure types were analyzed on 985 patients (236 [24.4%] were ≥71). Outcomes were compared by reconstruction type. Regressions were performed calculating the impact of age on length of hospital stay (LOHS) and operative time. RESULTS: Ablative procedures were comparable, but older patients received local flaps at higher rates (22.5% vs. 9.6%; p < .001). The older population had more comorbidities (higher ASA class [p < .001], diabetes [p < .001], and hypertension [p < .001]). After Bonferroni correction, univariate subgroup analyses of soft tissue and bone/composite microvascular flaps revealed similar outcomes (except increased medical complications in the older cohort undergoing a bone free flap [p = .002]). Controlling for a variety of factors, older age resulted in longer LOHS (B: 1.4 days; 95% CI: 0.1-2.8 days; p = .035), but not operative time (B: -21.90 min; 95% CI: -52.76 to 8.96 min; p = .164). CONCLUSION: While increased age (≥70 years) was associated with a longer LOHS, complication rates were comparable. Although limited by the retrospective nature, evidence supports microvascular reconstruction in the elderly population with comparable outcomes.

The facial artery perforator flap for intraoral reconstruction of a mouth floor defect.

Facial artery perforator flaps have been recently reported by different authors for perioral, nasal alar and cheek defects, but not for intraoral reconstruction. We have extended the use of the facial artery perforator flap in a 56-year-old man with a squamous cell carcinoma of left mouth floor, who was submitted to tumor resection with marginal mandibulectomy and left supraomohyoid neck dissection. The flap was designed according to the size of the defect (5 × 3 cm), centered on the perforator to create a symmetric flap and was tunnelled intraorally by means of a 90° rotation. The postoperative period was uneventful, allowing timely initiation of adjuvant radiotherapy. After 8 months, there were no signs of local recurrence or wound dehiscence, and functional outcomes were satisfactory. The main advantages of this flap in this case were the reduction in morbidity at the donor site with preservation of nerves, muscles and facial artery, and it allowed greater freedom. To the best of the authors' knowledge, this technique has not been reported before. It may constitute an important reconstructive option when dealing with similar defects, if our results are confirmed in larger series.

The "Flap Suture Anchoring" Technique for Safe Oral Floor Reconstruction With Preservation of Alveolar Process.

Flaps-based microsurgery is routinely applied to reconstruct oral floor defects caused by oncologic resection. To prevent orocutaneous fistulae, flaps are frequently sutured with buccal vestibule mucosa after sacrificing the alveolar process. The patients suffered denture loss and irreversible structural damage. For reliable oral floor reconstruction with preservation of alveolar process, the authors introduced the flap "suture anchoring" technique. Oral floor, hemiglossal-oral floor, and tongue base-parapharyngeal wall-oral floor defects were included in this study. The flap anchoring technique involves structural oral floor reconstruction with a chimeric anterolateral thigh-free flap or radial forearm flap with adipofascial tissue extension. The dead space in oral floor is filled with vastus lateralis muscle or adipofascial tissue, then holes are drilled on the alveolar bone among tooth root, beneath the attached gingiva. Skin paddle is sutured with 4-0 sutures through the alveolar holes thus anchored to the mandible. By applying this technique, there was no wound infection or orocutaneous fistulae in all patients postoperatively, even experienced postoperative radiotherapy. In addition, a soft and natural jaw-tongue furrow could be formed to allow the free movement of tongue. Taken together, the flap anchoring technique offers a safe and reliable approach to recover oral function and preservation of occlusion.

The Retaining Ligament of the Anterior Digastric Muscle.

The anterior belly of the digastric muscle (ABDM) is important in numerous esthetic surgeries including rhytidectomy, alteration of the cervicomental angle via partial resection of the ABDM muscle belly, and suprahyoid muscular medialization and suspension. Recently, the connection between the ABDM and the mylohyoid muscle (MH) has been proposed as important for the mechanism of the digastric corset procedure. This report refers to the connection between the ABDM and the MH as a type of retaining ligament of the anterior digastric muscle (RLAD). This report is the first to directly demonstrate the existence of the RLAD, via photograph and video, and document variation in its attachment sites, its composition, and its behavior when traction forces are applied. In addition to the importance of the RLAD in plastic surgery, the RLAD may affect neurovascular structures between the ABDM and MH and serve as a physical barrier separating the submental fascial space from the submandibular fascial space and, therefore, influence the spread of infection.

Extraoral approach of the surgical treatment of sublingual epidermoid cyst: A case report.

Epidermoid and dermoid cysts account for <0.01% of all oral cavity lesions with dermoid cyst which is twice as common to epidermoid. Epidermoid cysts are benign lesions that occur rarely in children. They usually present early in life as an asymptomatic mass. The treatment option is surgical and intraoral or extraoral approaches can be performed according to the localization and size of the mass. This report presents an 11 year old child with a sublingual epidermoid cyst treated extraorally.

Submental Osteocutaneous Perforator Flap for Maxillary and Mandibular Reconstruction Following Tumor Resection.

Many different flaps have been used for reconstruction of the oral mucosa and the maxilla and mandible after tumor resection. These flaps might contain bone and might be free or locoregional. This study presents 2 cases of intraoral reconstruction using a submental osteocutaneous perforator flap to reconstruct the maxilla in one case and the mandible in the other. A reverse-flow flap was used for maxillary reconstruction In these cases, the functional, esthetic, and oncologic outcomes were favorable at 9 and 12 months of follow-up.

Unusual Anatomic Variations Associated With Bilateral Ulnar Artery Hypoplasia.

Variations and anomalies of upper extremities have been commonly reported in routine dissection, clinical practices, and cadaver studies. Despite ongoing research on arterial variations of upper extremities, the absence of bilateral ulnar artery is extremely rare with only 3 patients reported. As the authors are presenting a successfully treated patient, initially prepped for radial forearm osteocutaneous free flap for treatment on oromandibular defect after a wide resection of head and neck cancer lesion, being confirmed to have bilateral ulnar artery hypoplasia and due to this, the patient had to change her surgical plan to fibular osteocutaneous free flap.

Large plunging schwannoma of the floor of the mouth involving the mylohyoid nerve: a case report and review of the literature.

Extracranial schwannomas are rare in the oral cavity, accounting for only 1% of all tumors of this type. This article presents a case study of a schwannoma arising from the mylohyoid nerve that presented as a large nodular swelling in the floor of the mouth extending into the submandibular space.