Management of Zygomaticomaxillary Complex Fractures Utilizing Intraoperative 3-Dimensional Imaging: The ZYGOMAS Protocol.

PURPOSE: Utilization of technology to aid in the assessment, planning, and management of complex craniomaxillofacial injuries is increasingly common. Limited data exist regarding the implication of intraoperative CT/3-Dimensional imaging on decision making in the management of zygomaticomaxillary complex (ZMC) fractures. This study characterizes the utilization of the intraoperative CT scanner for ZMC fracture surgery and analyzes the impact of the intraoperative CT scanner on fracture management. Using these findings, we sought to propose an algorithm to guide the appropriate utilization of intraoperative 3-Dimensional imaging in ZMC fracture surgery. METHODS: This retrospective case series evaluates the use of the intraoperative CT scanner for orbitozygomatic trauma surgery at a level 1 trauma center from February 2011 to September 2016. We evaluated the preoperative CT images assessing for the number of displaced sutures, the presence of adjacent fractures requiring fixation, the presence of comminution of the zygomaticomaxillary buttress or body of the zygoma, as well as the number of axes displaced ≥ 5 mm. This information was evaluated to provide guidance on the appropriate utilization of the intraoperative scanner in ZMC fracture management. RESULTS: A total of 71 patients were identified to have intraoperative facial CT scans and surgery for ZMC fractures over the study time period. There was a 23.9% (17/71) CT directed revision rate. There was a significantly increased likelihood of CT directed revision for fractures with adjacent fractures requiring fixation, and those with ≥ 2 axes displaced ≥ 5 mm. Using these findings, we proposed the ZYGOMAS algorithm outlining the indications for use of intraoperative CT in management of ZMC fractures. CONCLUSIONS: If available, intraoperative CT/3-Dimensional imaging should be utilized in the management of ZMC fractures with the requirement for orbital floor reconstruction, where adjacent fractures require fixation and/or when ≥ 2 axes are displaced ≥ 5 mm.

The Radial Forearm Flap: A Technique Modification for Oral Cavity Composite Defects Involving a Marginal Mandibulectomy.

The radial forearm flap is a versatile reconstructive option for oral cavity defects with highly reliable success rates. We encountered more than one flap compromise when we used a radial forearm flap to reconstruct the soft tissue and provide coverage over the mandible, after a marginal mandibulectomy. From this observation, we modified our technique for radial forearm harvest and inset to avoid placing the pedicle in compression against the mandible. The purpose of this article is to present the cases that led to this observation, and present the technique modification in design and execution that we have used.

The Biaxial Double-Barrel Fibula Flap-A Simplified Technique for Fibula Maxillary Reconstruction.

PURPOSE: Previously described techniques for microvascular fibula reconstruction of Brown Class II to IV maxillectomy defects are complex, require multiple osteotomies, result in a short pedicle, and inadequately reconstruct the dental alveolus in preparation for endosseous implants. This report describes a simplified technique for Brown Class II to IV defects that re-creates facial support, allows for dental reconstruction with appropriately positioned implants, and maintains adequate pedicle length. MATERIALS AND METHODS: A retrospective chart review was performed of all patients with Brown Class II to IV maxillectomy defects immediately reconstructed with a biaxial double-barrel fibula flap technique. The reconstructive surgeon evaluated each patient at least 1 month after reconstruction for enophthalmos, facial symmetry, nasal patency, satisfactory jaw position, deglutition, intelligible speech, and intraoperative need for vein grafting. RESULTS: The sample was composed of 6 patients (mean age, 54 yr; range, 33 to 78 yr; 67% women) who underwent reconstruction with the biaxial double-barrel fibula flap technique for Brown Class II to IV defects. None of these patients required vein grafting. None of these patients had flap failure. Diagnoses for these patients were a hybrid odontogenic tumor (n = 1), squamous cell carcinoma (n = 3), adenoid cystic carcinoma (n = 1), and sinonasal melanoma (n = 1). All 6 patients had excellent facial contour and malar projection, regular oral intake, 100% intelligible speech, and a new maxillary skeletal Class I relation without need for intraoperative vein grafting. One patient developed enophthalmos related to inferior rectus sacrifice and removal of orbital fat. Complications included development of nasal synechia and occlusion of the maxillary sinus ostium (n = 1). CONCLUSIONS: The biaxial double-barrel fibula flap technique achieves the goals of providing adequate facial support and an alveolar segment amenable to implant dentistry. It allows for intelligible speech, deglutition, orbital support, and separation of the oronasal, orbital, and sinus cavities. In addition, it minimizes the need for vein grafting.

What Is the Role of Elective Neck Dissection in the Management of Patients With Buccal Squamous Cell Carcinoma and Clinically Negative Neck?

PURPOSE: Buccal squamous cell carcinoma (BSCC) is rare in the United States. Given its location, few anatomic barriers to spread exist and it has been found to have a high locoregional recurrence rate. The role of elective neck dissection (END) in patients with clinically negative neck (N0) is not clear. This study aims to answer the following research question: Among patients with N0 BSCC, does END improve locoregional control rates, distant metastasis rates, and 2- and 5-year survival rates? MATERIALS AND METHODS: A retrospective cohort study was conducted. The sample included patients who received a diagnosis of BSCC. The primary predictor variable was END status (yes or no). Five institutions participated between June 2001 and June 2011: University of Washington, University of Michigan, University of Tennessee, North Memorial Oral and Maxillofacial Surgery in Minnesota, and Head and Neck Surgical Associates (Portland, OR). The primary outcome variable was locoregional recurrence. Secondary outcome variables were distant metastasis and 2- and 5-year survival rates. Other variables collected were demographic characteristics, initial operation, adjuvant therapy, clinical and pathologic data, and staging. Kaplan-Meier and Cox proportional hazards statistics were computed. RESULTS: The sample was composed of 98 patients with clinical N0 BSCC. The mean age was 66 years (range, 30-88 years), and 54% were men. Of the patients, 74 (76%) underwent END. The locoregional recurrence-free rate was 61% for END versus 38% for no END (P = .042). The distant metastasis rate was 4% for END versus 9% for no END. The 2- and 5-year disease-free survival rates were 91% and 75% (P = .042), respectively, for END and 85% and 63% (P = .019), respectively, for no END. CONCLUSIONS: END had a therapeutic effect, as evidenced by a lower locoregional recurrence rate, lower distant metastasis rate, and improved 2- and 5-year survival rates.

Use of Intraoperative Computed Tomography in Craniomaxillofacial Trauma Surgery.

PURPOSE: The use of technology to aid in assessment, planning, and management of complex craniomaxillofacial injuries is increasingly common. Preoperative computed tomography (CT) evaluation is considered the standard of care, and intraoperative imaging is becoming increasingly accessible. Limited data exist regarding the implication of intraoperative CT on decision making in the management of all sites of facial fractures. The purposes of this study were to characterize the use of an intraoperative CT scanner for craniomaxillofacial surgery within our institution, to quantify the effect of intraoperative CT on surgical decision making, and to attempt to provide guidance on when to use this technology. PATIENTS AND METHODS: This retrospective case series characterizes the use of an intraoperative CT scanner for craniomaxillofacial trauma surgery at a level 1 trauma center in Portland, Oregon, from February 2011 to September 2016. We evaluated the following variables: the number of intraoperative CT scans performed for craniomaxillofacial surgery including the number of scans for each patient, the number of scans for each operative visit, the CT-directed revision rate (overall and for specific preoperative diagnoses), and the indication for imaging. This information was evaluated to provide guidance on appropriate use of an intraoperative scanner. RESULTS: A total of 161 patients were identified to have intraoperative facial CT scans from February 2011 to September 20, 2016, at Legacy Emanuel Medical Center. A total of 212 intraoperative facial CT scans were performed across 168 separate operations. The overall CT-directed revision rate was 28%. CT-directed revision rates for fracture subsites are as follows: orbital, 31%; zygomaticomaxillary complex, 24%; Le Fort I, 8%; Le Fort II and III, 23%; naso-orbital-ethmoidal, 23%; mandible, 13%; and frontal sinus, 0%. No CT-directed revisions were performed during removal of hardware, during placement of craniofacial implants, or in temporomandibular joint replacement surgery. CONCLUSIONS: If available, intraoperative CT should be routinely considered in the operative management of orbital fractures and pan-facial fractures, as well as complex zygomaticomaxillary complex, Le Fort II and III, and naso-orbital-ethmoidal fractures. Consideration also should be given to the use of intraoperative CT in cases of complex mandible fractures involving severe comminution or the condylar region. Intraoperative CT should not be routinely used for the management of Le Fort I fractures or frontal sinus fractures.

Functional Anatomic Computer Engineered Surgery Protocol for the Management of Self-Inflicted Gunshot Wounds to the Maxillofacial Skeleton.

PURPOSE: Virtual surgical planning (VSP) is an indispensable aid in craniomaxillofacial reconstruction, yet no protocol is established in facial gunshot wounds. We review our experience with computer-aided reconstruction of self-inflicted facial gunshot wounds (SIGSW'S) and propose a protocol for the staged repair. METHODS: A retrospective case series enrolling patients with SIGSW's managed with the Functional Anatomic Computer Engineered Surgical protocol (FACES) was implemented. Subjects were evaluated at least one month postoperatively. Outcome variables were jaw position, facial projection, oro-nasal communication, lip competence, feeding tube and tracheostomy dependence, descriptive statistics were computed. The FACES protocol implemented during the initial hospitalization is as follows 1) damage control; 2) selective debridement; 3) VSP reconstruction back converted into navigation software 4) navigation assisted midfacial skeletal reconstruction; 5) computer aided oro-mandibular reconstruction with or without microvascular free flaps using custom cutting guides/hardware; 6) navigation assisted, computer aided palatomaxillary reconstruction with or without microvascular free flaps using cutting guides/hardware; 7) navigation assisted reconstruction of the internal orbit; 8) and confirmation of accurate reconstruction using intraoperative CT. RESULTS: The sample was composed of 10 patients, mean age of 43 years (range, 28 - 62 years, 70% M), 100% with SIGSW's to the submental/submandibular region. All had satisfactory facial projection (n=10), nine had satisfactory jaw position, were decannulated by one month's follow up and were feeding tube independent (90%). All traumatic oro-antral communications were closed (n=8, 7 surgical, 1 obturator), seven had adequate lip competence (70%). Complications included fibula malunion (n=1), plate exposure (n=2) infection (n=2), intracranial abscess (n=1) and microstomia (n=2). CONCLUSION: Computer-aided surgery is an indispensable tool in the reconstruction of SIGSW's. Successfully implemented, it proved to be a useful adjunct for: the restoration of orbital volume, facial projection and symmetry; the inset of composite tissue, and the facilitation of dental implant supported prosthetic rehabilitation.

Microvascular Free Tissue Transfer for Head and Neck Reconstruction in Children: Part I.

BACKGROUND: Limited outcome data exist regarding the survival of microvascular free flaps for head and neck reconstruction in children. The objectives of this study were to perform a systematic review of the literature and meta-analysis comparing the survival of the most commonly used free flaps used for head and neck reconstruction in children. METHODS: A systematic search of PubMed, Embase, and Scopus was conducted using various keywords up to January 1, 2015. Meta-analysis was used to compare the survival of the most commonly used free flaps. The primary predictor variable was free flap type. The primary outcome variable was flap failure. The pooled relative risk (RR) with 95% confidence intervals (CIs) was estimated using a Mantel-Haenszel, fixed-effects model. RESULTS: The authors reviewed 25,303 abstracts. Five studies met inclusion criteria. A total of 646 children received a total of 694 free flaps. The pooled survival rate among all free flaps was 96.4%. The fibula free flap (fibula) and subscapular system free flaps (scapula) were the most commonly used flaps. There was no difference in survival when comparing the scapula (RR = 0.59, 95% CI: 0.26, 1.56, P = 0.29), or fibula (RR = 1.91, 95% CI: 0.55, 6.65, P = 0.31) to other free flaps, or when comparing the scapula to the fibula (RR = 2.29; 95% CI: 0.40, 13.08, P = 0.35). CONCLUSIONS: Free tissue transfer is highly successful in children. Although data are limited, there appears to be no difference in survival among various free flaps used for head and neck reconstruction in children.

Survival of microvascular free flaps in mandibular reconstruction: A systematic review and meta-analysis.

BACKGROUND: Free tissue transfer is commonly used in the reconstruction of post-ablative defects of the mandible. Due to lack of statistical power, comparing the survival of various free flaps, even in large studies, is challenging. The purpose of this study was to perform a meta-analysis comparing the survival of the most commonly used free flaps for mandibular reconstruction. METHODS: We searched PubMed, EMBASE, and SCOPUS for relevant studies. A meta-analysis using the Peto one-step odds ratio (OR) with 95% confidence intervals (CI) was used to compare the pooled survival of the most commonly used free flaps for mandibular reconstruction. RESULTS: Of the 25,303 studies reviewed, 17 were selected for data extraction. A total of 1,221 subjects received 1,262 free flaps. Sixty-five free flaps failed. The pooled survival of all free flaps used for mandibular reconstruction was 94.8%. The deep circumflex iliac artery (DCIA) flap was associated with a seven-fold increase in failure when compared to the radial forearm free flap (Peto OR 7.40; 95% CI 1.38, 39.75, P = 0.02). There was no difference in survival when comparing other commonly used free flaps. CONCLUSIONS: The results of this study suggest that free flap reconstruction of the mandible is highly successful. With the exception of the increased survival of the radial forearm when compared to the DCIA, there is no difference in recipient site survival when comparing various free flaps for mandibular reconstruction.

Low prealbumin level is a risk factor for microvascular free flap failure.

PURPOSE: The purposes of this study were 1) to estimate and compare the 1-month survival rates of patients with acute malnutrition (low prealbumin level) and patients who are not malnourished (normal prealbumin level) and 2) to identify risk factors associated with microvascular free flap failure. MATERIALS AND METHODS: To address the research purposes, we designed a retrospective cohort study and enrolled a sample composed of patients who underwent head and neck microvascular reconstruction and had prealbumin levels measured in the perioperative period. The primary predictor variable was nutritional status (low vs normal prealbumin level). The primary outcome variable was flap survival. One-month survival rates were estimated by use of Kaplan-Meier survival analyses. Risk factors for free flap failure were identified by use of multivariate marginal Cox proportional hazards modeling. RESULTS: The sample was composed of 162 patients who underwent microvascular free tissue transfer during the study enrollment period. The 1-month survival estimates for patients who were and were not malnourished were 76.5% (95% confidence interval [CI], 48.8% to 90.5%) and 95.2% (95% CI, 90.1% to 97.7%), respectively (P = .002). In the adjusted Cox hazards proportions model, acute malnutrition was associated with a 4-fold increased risk of failure (P = .04) in comparison with those patients with a normal nutritional status. CONCLUSIONS: Acute malnutrition in patients undergoing microvascular free flap reconstruction in the head and neck region was associated with an increased risk for free flap failure.

Thin serial step sectioning of sentinel lymph node biopsy specimen may not be necessary to accurately stage the neck in oral squamous cell carcinoma.

PURPOSE: The purpose of this study was to assess the predictability of sentinel lymph node biopsy (SNB) for oral squamous cell carcinoma (OSCC) when pathologic processing is performed without serial step sectioning. MATERIALS AND METHODS: We prospectively enrolled 36 patients with T1 or T2 cN0 OSCC into this institutional review board-approved prospective cohort study, and they underwent gamma probe-guided SNB in addition to selective neck dissection. The rate of patients with negative SNB results whose neck dissection was also negative for metastasis (negative predictive value) was the primary endpoint. RESULTS: Of the 28 patients whose sentinel lymph nodes were found to be pathologically and clinically node negative by routine hematoxylin-eosin stain and immunohistochemistry, 27 were found to have no other pathologically positive nodes, corresponding to a negative predictive value of 96%. CONCLUSION: The results of this study suggest that SNB performed without the use of thin serial step sectioning may accurately predict neck stage in OSCC.

Trends and attitudes regarding head and neck oncologic surgery: a survey of United States oral and maxillofacial surgery programs.

PURPOSE: The purposes of this study were to: 1) estimate the prevalence and trends of American oral and maxillofacial surgery (OMS) programs in recruiting head and neck oncologic surgery (HNOS) -trained faculty, performing HNOS oncologic procedures and microvascular reconstruction, and presenting HNOS research at academic meetings; 2) estimate whether HNOS and microvascular reconstruction involvement varies among programs with or without a program director or chair trained in HNOS; 3) estimate whether HNOS involvement varies among those OMS programs that regularly attend and do not attend tumor board; 4) estimate whether HNOS involvement varies among those programs that have and have not presented HNOS research at an academic meeting; 5) estimate whether HNOS involvement varies among doctor of medicine-integrated and 4-year OMS programs. MATERIALS AND METHODS: Investigators developed and distributed a survey to all US OMS program directors and/or chair composed of questions regarding faculty prevalence and recruitment, frequency and trends in cases, and the priority of applicants for residency with regard to HNOS. There were 18 close-ended questions, and one open-ended question. Responses were recorded in categorical, Likert, ordinal, and numerical format. Bivariate associations were calculated using Fisher exact test and logistic regression. RESULTS: Sixty-three of 101 surveys were returned (62.3%). Ten program directors or chair completed a fellowship in HNOS (15.9%). Programs with an HNOS-trained program director or chair were more likely to have another HNOS-trained faculty member (P = .01), performed more malignant tumor resections (P < .001), neck dissections (P < .001), and microvascular free-flap reconstructions (P = .02) than programs without program directors or chair trained in HNOS. Programs that regularly attended tumor board performed an increasing number of malignant tumor resections (P = .008); and neck dissections (P = .003) than programs that did not regularly attend their institution's tumor board. Presentations of HNOS-related research at national meetings did not differ between doctor of medicine-integrated and 4-year OMS programs (P = .7). There was no difference in the prevalence of HNOS-trained program directors and chair between doctor of medicine-integrated and 4-year programs (P = .7). CONCLUSIONS: This study's data and comments suggest that programs involved in HNOS have a strong involvement in expanded scope OMS and related academic activities.

Fellowship Training in Oral and Maxillofacial Surgery: Opportunities and Outcomes.

The pursuit of fellowship training stems from one's desire to master a focused area of surgery. Successful applicants tend to have published articles and participated in other scholarly activities. They commonly have a mentor within the subspecialty of their interest. Selection of the program is generally based on the breadth of experience available followed by faculty reputation and location. Advantages to the successful fellowship graduate include the experience and confidence to provide specialized and efficient care to patients. Enhancements to an academic department with a fellowship program include mentorship for residents and guidance toward fellowship, as well as an increased level of scholarly activity.

Reliability of intraoperative navigation in restoring normal orbital dimensions.

PURPOSE: To assess the reliability and effectiveness of intraoperative navigation in restoring normal orbital and globe dimensions in traumatic and postablative orbital defects. MATERIALS AND METHODS: To address the research purpose, the investigators initiated a retrospective cohort study and enrolled a sample of subjects that underwent primary or secondary reconstruction for unilateral orbital deformities secondary to traumatic injury or tumor surgery during the study enrollment period. Using computed tomographic datasets, pre- and postoperative orbital volume and globe projection were measured using Analyze software (Mayo Clinic Biomedical Imaging Resource, Rochester, MN). Intraclass correlation coefficient (ICC) was used to evaluate the reliability between preoperative unaffected orbit and the postoperative affected orbital and globe dimensions. A matched pairs t test was used to assess the difference in pre- and postoperative orbital volume and globe projection. RESULTS: The sample was composed of 23 subjects that underwent orbital reconstruction secondary to traumatic of postablative defects. There was a linear and reliable relationship between preoperative unaffected and postoperative affected orbital volumes (ICC, 0.67; 95% CI, 0.37 to 0.86), and preoperative unaffected and postoperative affected globe projections was high (ICC, 0.87; 95% CI, 0.69 to 0.94). There was a significant difference in pre- and postoperative mean orbital volume (30.6 vs 25.5 cm(3), P ≤ 0.001), and pre- and postoperative globe projection (51.2 vs 53.6 mm, P ≤ 0.001). CONCLUSIONS: The results of this study suggest that intraoperative navigation-assisted orbital reconstruction is reliable in restoring orbital volume and globe projection to pretraumatic and preablative conditions.

The Buccal Fat Pad Flap.

This article presents an overview of the history of the buccal fat pad flap, its relevant anatomy, and its indications and contraindications. The surgical technique for its harvest is described, as are the postoperative care and possible complications.

Updates in Management of Craniomaxillofacial Gunshot Wounds and Reconstruction of the Mandible.

This article includes updates in the management of mandibular trauma and reconstruction as they relate to maxillomandibular fixation screws, custom hardware, virtual surgical planning, and protocols for use of computer-aided surgery and navigation when managing composite defects from gunshot injuries to the face.

Survival analysis and risk factors for recurrence in oral squamous cell carcinoma: does surgical salvage affect outcome?

PURPOSE: The purpose of this retrospective study was to review the outcomes and recurrence rates of subjects with oral cavity squamous cell carcinoma treated at a single institution by primary surgical resection, with or without adjuvant radiation or chemotherapy, to identify factors that affect locoregional control and determine whether surgical salvage affects survival. MATERIALS AND METHODS: The records of 157 subjects diagnosed with oral cavity squamous cell carcinoma treated at a single institution from 1997 to 2007 were identified. Data on demographics, site, clinical stage, pathologic stage, treatment, recurrence, and survival were collected. Defined outcome measures were overall survival, disease-free survival, and length of survival after recurrence. Analysis of the data was performed by use of the Cox proportional hazards model. Kaplan-Meier survival curves were created for disease-free survival, as well as survival by histologic grade, nodal status, recurrence, and tumor stage. RESULTS: We identified 157 subjects, with 155 meeting the inclusion criteria. The overall 5-year survival rate was 48%, with a disease-free survival rate of 42% (95% confidence interval, 36%-53%). Survival was found to be influenced by stage (P = .0001), nodal status (P = .0025), and histologic grade (P = .04). There were 24 subjects with recurrence (15%). Of these, 11 had local recurrence (46%), 9 had regional recurrence (37%), 2 had distant recurrence (8%), 1 had both local and regional recurrence (4%), and 1 had both local and distant metastasis (4%). Recurrence was not found to be significantly affected by pathologic stage (P = .71), clinical stage (P = .6), histologic grade (P = .178), postoperative radiation therapy (P = .54), postoperative chemotherapy (P = .66), N-positive status (P = .71), or whether the subject underwent a neck dissection (P = .984). Surgery significantly increased both overall survival time (P = .009) and survival time after recurrence (P = .006). Radiation therapy (P = .4) and chemotherapy (P = .82) did not have a survival benefit as therapy for recurrence. CONCLUSIONS: Survival is influenced by stage at presentation, nodal status, and histologic grade. No variables were found to influence recurrence rates. Surgery significantly increased overall survival time, and salvage surgery increased survival after recurrence.

Transoral robotic surgery and neck dissection for HPV-positive oropharyngeal carcinoma: Importance of nodal count in survival.

BACKGROUND: In this study we determine the survival in patients with HPV-positive oropharyngeal carcinoma treated with transoral robotic surgery (TORS), neck dissection and risk-adapted adjuvant therapy. METHODS: We retrospectively identified 122 patients with HPV-positive oropharyngeal carcinoma treated with TORS and neck dissection between 2011 and 2018. Survival probability was calculated. We determined the effect of the type of neck dissection performed (modified radical neck dissection-MRND vs. selective neck dissection - SND), extranodal extension (ENE), margin status, and presence of ≥ 5 metastatic nodes on survival. RESULTS: Our patient population had a five-year overall survival of 91.0% (95% C.I. 85-97%). The five-year probability of recurrence or cancer-associated death was 0.0977 (95% C.I. 0.0927-0.1027). The five-year probability of cancer-associated death was 0.0528 (95% C.I. 0.048-0.0570). All patients who died of their disease had distant metastasis. Our PEG dependence rate was 0%. Patients with ENE and positive margins who underwent adjuvant chemoradiation did not have worse survival. Presence of ≥ 5 metastatic nodes portended worse survival after controlling for age, positive ENE and margins. Low yield (<18 nodes) on neck dissection worsened DFS on multivariable analysis. Furthermore, patients who underwent SND did not have worse OS than those who underwent MRND. CONCLUSION: Our study demonstrates that surgery could be simplified by performing TORS with SND rather than MRND. The one true poor prognostic factor in HPV-positive oropharyngeal carcinoma patients who undergo surgery is high nodal burden. Patients with high nodal burden are much more likely to die from their disease.

Infection prevalence and patterns in self-inflicted gunshot wounds to the face.

OBJECTIVE: Self-inflicted gunshot wounds (SIGSWs) to the craniomaxillofacial region are uncommon injuries but are associated with a high mortality rate. Therefore, treating these patients is a rare occurrence even in the largest trauma centers. As with many rare conditions, data specifically addressing this injury pattern are scarce. Because of the proximity of the blast, even low-velocity injuries can be associated with significant avulsion of tissue, comminution of structures, and tissue die back. Previous case reports have recommended the use of prophylactic antibiotics, but no study has specifically investigated the postinjury infection rate or microbial patterns in this patient population. The purpose of this study was to answer the following clinical question: "Among patients with SIGW to the maxillofacial region, what is the prevalence of postinjury infection, and are there any microbial patterns that can guide empiric antibiotic selection?" STUDY DESIGN: We designed retrospective cohort study at a level I trauma center in Portland, Oregon. Data on 17 patients who had sustained a SIGSW involving the maxilla or the mandible and survived their initial injury were collected from 2010 to 2017. RESULTS: Patients who had a culture-positive infection within 30 days of their injury were defined to have a postinjury infection. Six of the 17 patients (35%) developed a postinjury infection, with an average time to infection of 11 days from initial injury (range 3-19 days). Of the 17 subjects, 15 (88%) received a course of prophylactic antibiotics, on average, for 14 days (range 3-24 days). Of the 6 cases of postinjury infection, culture grew gram-negative bacteria in 4 cases-anaerobic bacteria in 2 and polymicrobial organisms in 2. There was no clear pattern or prevalence of any specific bacterium, but cultures notably included Staphylococcus aureus, Enterobacter species, Bacteroides species, and Escherichia coli. CONCLUSIONS: SIGSWs are associated with a high rate of postinjury infection (35%) despite prophylactic antibiotic usage in 88% of these cases. Given the antimicrobial patterns observed in this study, prophylactic antibiotics in this patient population should include empiric coverage for gram-negative and anaerobic bacteria.

Analysis of microvascular free flaps for reconstruction of advanced mandibular osteoradionecrosis: a retrospective cohort study.

PURPOSE: Previous studies have suggested that radiation therapy does not impact local complication rates after microvascular free flap (MVFF) reconstruction for head and neck cancer. There is little data, however, indicating whether or not the presence of osteoradionecrosis (ORN) affects treatment outcome. The purpose of this retrospective cohort study is to review the outcome of patients undergoing MVFF reconstruction for ORN and to determine if there is a difference in outcome and/or complications when compared to similarly reconstructed patients who received radiation therapy but did not develop ORN, as well as un-radiated controls. PATIENTS AND METHODS: The records of 305 consecutive patients who underwent MVFF reconstruction for a variety of cancer-related therapies or post-traumatic craniofacial defects from 1994 to 2004 were reviewed. Of these, all patients who underwent surgery for Marx stage III ORN involving the mandible were identified (n = 21). For purposes of comparison, patients who received preoperative radiation therapy (XRT) and underwent similar reconstruction but did not have ORN were identified and included in the study group. Similarly matched patients who never received XRT served as controls. Patients were reconstructed with a variety of MVFFs harvested from the fibula (n = 48), radial forearm (n = 11), rectus abdominus (n = 3), latissimus dorsi (n = 3), serratus anterior (n = 1) and iliac crest (n = 1). The study cohort was divided according to XRT status: group 1 (ORN), patients that received XRT and developed ORN (n = 21); group 2 (no ORN), patients that received XRT but did not develop ORN (n = 21); and group 3 (control), patients that never received XRT (n = 25). The following data were collected: age, gender, diagnosis, recipient site, donor site, hyperbaric oxygen therapy (HBO), flap complications, flap survival, patient survival. Outcome measures were defined as flap survival, complications and resolution of ORN. Descriptive statistics were recorded and an analysis of variance was calculated to evaluate differences between the 3 groups. The Fisher's exact test was used to evaluate whether a complication occurred more frequently in any one particular group. RESULTS: The mean age of the 67 patients included in the study was 57 years (SD = 15.4) years (M = 32, F = 35) and there were no significant demographic differences between the 3 groups (P = .8528). All patients were successfully reconstructed although 21% required reoperation for various reasons. Overall flap survival was 88% (ORN = 86%, no ORN = 87%, control = 90%) and there was no difference between the 3 groups studied (P = 1.0). Complications were evenly distributed among the 3 groups (50% overall) and included skin necrosis (P = .824), wound infection (P = .6374), salivary fistula (P = .1178), and partial flap loss (P = 1.0). Carotid blowout occurred in 2 patients in the ORN group, however, this was not statistically significant (P = .1844). Fourteen of the 21 patients in the ORN group had received preoperative HBO. CONCLUSION: Overall MVFF survival and complication rates among patients with ORN versus control groups are the same in this study cohort. Free tissue transfer is a viable option for advanced mandibular ORN.

Updates in Management of Craniomaxillofacial Gunshot Wounds and Reconstruction of the Mandible.

This article includes updates in the management of mandibular trauma and reconstruction as they relate to maxillomandibular fixation screws, custom hardware, virtual surgical planning, and protocols for use of computer-aided surgery and navigation when managing composite defects from gunshot injuries to the face.