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.

Proximal peroneal perforator in dual-skin paddle configuration of fibula free flap for composite oral reconstruction.

BACKGROUND: Composite defects of the oral cavity are often the result of trauma or advanced-stage tumor extirpation. The resultant deformity frequently requires a three-dimensional reconstruction of bone and soft-tissue. The fibula free flap is the preferred method of reconstruction, with various modifications focused on providing supplemental soft-tissue coverage. The objective of this study was to ascertain both anatomic and clinical data regarding the proximal peroneal perforator and its contribution to the evolution of the fibula free flap. METHODS: Ten cadaver lower extremities were dissected to isolate the most proximal perforator supplying skin over the proximal lateral lower leg. Data were recorded regarding perforator presence, location, and course. Furthermore, review of clinical cases in which the proximal perforator was used in fibula free flap design was performed for operative data collection. RESULTS: Cadaveric dissections revealed the proximal perforator to be present in 90 percent of specimens. Most commonly, the perforator, originating from the peroneal artery, traveled a short intramuscular course through the soleus muscle prior to supplying the overlying skin. In all clinical cases, the perforator was easily located with Doppler prior to incision, and there were no cases of flap failure or skin paddle loss. Flap inset was found to be optimal in all cases, with no tethering or undue tension. CONCLUSIONS: The proximal peroneal perforator was found to be anatomically reliable and clinically useful in composite oral cavity reconstruction following tumor removal. The gained separation between skin paddles allows for greater versatility in flap design and inset. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Correction of the crooked nose.

Correction of the deviated nose is one of the most difficult tasks in rhinoplasty surgery and should be approached in a systematic manner to ensure a satisfied patient and surgeon. Correction of the deviated nose is unique in that the patient's complaints frequently include aesthetic and functional characteristics. Equal importance should be given to the preoperative, intraoperative, and postoperative aspects of the patient's treatment to ensure a favorable outcome.

Biomaterials for reconstruction of the internal orbit.

Orbital floor injuries, alone or combination with other facial fractures, are one of the most commonly encountered midface fractures. Techniques for orbital reconstruction have migrated away from autogenous bone grafts to well-tolerated alloplasts, such as titanium and Medpor. Material for reconstructing the orbit can then be selected based on requirements of the defect matched to the mechanical properties of the material. Material selection is largely and ultimately dependent upon surgeon preference.

Preparation of the neck for microvascular reconstruction of the head and neck.

Reconstruction of congenital, developmental, or acquired head and neck defects remains a significant challenge for the oral and maxillofacial surgeon. Microvascular free tissue transfer has several advantages over nonvascularized bone grafts and pedicled soft tissue flaps that currently make it the modality of choice for the reconstruction of extirpative defects of the head and neck. Preoperative planning must include detailed attention to the technical aspects of the microvascular procedure. This includes a thorough understanding of the vascular anatomy of the patient's neck; vascular anatomy of the various flaps including pedicle lengths; and a knowledge of how to facilitate microvascular surgery in the neck and to manage complicating factors in the difficult neck.

Vascularized options for reconstruction of the mandibular condyle.

The temporomandibular joint is elegant in its design, which may make it difficult if not impossible to comprehensively reconstruct. Although a broad range of nonvascularized options exists for reconstruction of degenerative conditions of the temporomandibular joint, vascularized reconstructions such as the fibula or the second metatarsal phalangeal joint are more appropriate for defects resulting from oncologic resection or in patients with compromised soft tissue. An anatomically based classification system for these defects is presented.

A review of psychological outcomes and suicide in aesthetic breast augmentation.

Aesthetic surgery is an essential component of plastic surgery and has become increasingly popular in American society. In 2002, 1.8 million surgical cosmetic procedures were performed in the United States, representing a 294 percent increase from 1992. The 1992 U.S. Food and Drug Administration moratorium on silicone breast implants arose in response to numerous reports of connective tissue disease associated with silicone gel breast augmentation and has led to a decade-long battle over the safety of silicone breast implants that continues today. Numerous scientific and epidemiologic studies of the past decade have established that there is no association between silicone breast prostheses and systemic disease. Recently, a new front has opened in the conflict regarding the safety of breast augmentation: the psychological impact of breast augmentation. Quality studies assessing the psychological characteristics of breast augmentation patients and the psychological impact of breast augmentation surgery are few and most studies are flawed in their methods. Recent reports have provided corroborating evidence to support the psychological benefits of cosmetic surgery and breast augmentation. New reports citing an increased risk for suicide among women with breast implants have brought renewed concerns but are unable to demonstrate a cause-and-effect relationship between breast implants and suicide. The present challenge is to determine whether the increased risk reported in epidemiologic studies is falsely associated with breast implants or whether it represents underlying risk factors or psychopathology in women undergoing breast augmentation that puts them at increased risk for suicide. The purpose of this article is to review the literature regarding the psychological impact of breast augmentation and assesses current scientific findings, with emphasis on the validity of suicide risk in breast augmentation patients.

A protocol for the management of frontal sinus fractures emphasizing sinus preservation.

PURPOSE: The purpose of this retrospective study is to review the incidence and etiology of frontal sinus fractures at an urban trauma center and validate a treatment protocol by assessing the outcome of a consecutive series of patients treated over a 10-year period. PATIENTS AND METHODS: All patients with frontal sinus fractures admitted to our trauma service from 1995 to 2005 were managed by the same surgeons using similar treatment philosophies based on the amount of displacement or comminution of the anterior and/or posterior table, the integrity of the nasofrontal duct, and the neurologic status of the patient as determined by clinical and radiographic examination. Using information obtained from the Trauma Registry and from individual physician chart notes, a database was created for the purpose of assessing outcome, defined as complications, length of hospital stay, and death. Demographics, injury severity score, fracture pattern, mechanism of injury, length of hospital stay, the number of operations, concomitant maxillofacial injuries, treatment, follow-up, and complications were statistically described. Outcome measures were evaluated by Student's t test using continuous variables. RESULTS: One thousand two hundred seventy-five patients with facial fractures were identified during the study period, of which 144 patients (11.3%) carried the diagnosis of frontal sinus fracture; 28 patients had inadequate records, leaving a study group of 116 patients. The majority of patients were male, had a mean age of 33.7 years, and presented with significant injuries demonstrated by a mean injury severity score of 23.7 and mean length of hospital stay of 8.9 days. The most common mechanisms of injury were blunt trauma resulting from a motor vehicle collision, fall, assault, or other accidents. Sixty-six patients presented with nondisplaced frontal sinus fractures that were managed nonoperatively; 50 patients had frontal sinus injuries that required surgical repair consisting of: 1) open reduction and internal fixation of the anterior table alone, with preservation of the sinus membrane (n = 29); 2) removal of all sinus mucosa, obliteration of the frontal sinus with autogenous abdominal fat, and reconstruction of the anterior table (n = 5); and 3) removal of all sinus mucosa, cranialization of the frontal sinus, and lining of the nasofrontal recess with a pericranial flap (n = 16). Six patients died of concomitant injuries. With follow-up ranging between 0 and 90 weeks, there were no known complications in the patients treated nonoperatively; 82% of the patients maintained normal sinus function and anatomy and the overall complication rate was 6.9%. Complications occurred in 16% of those patients treated surgically: including brain abscess, contour deformity, osteomyelitis, hematoma, meningitis, and mucocele. There was no statistically significant association between complications and other patient variables (P > .05), other than the test for injury severity score, which was different between survivors and nonsurvivors (P < .01). CONCLUSION: Application of the management protocol described in this report results in functional sinus preservation for the majority of patients, with relatively few significant perioperative complications.

The efficacy of postoperative antibiotic regimens in the open treatment of mandibular fractures: a prospective randomized trial.

PURPOSE: The purpose of this study was to determine the necessity and/or effectiveness of postoperative antibiotics in the treatment of mandible fractures. MATERIALS AND METHODS: This study is a prospective, randomized trial composed of patients who presented for operative treatment of open mandibular fractures and subsequently underwent open reduction and internal fixation at 1 institution. Mandibular fractures treated by an intraoral and/or extraoral open reduction with internal fixation were included in this study. The patients were randomly divided into 2 groups based on whether or not they received postoperative antibiotics. Both groups received preoperative antibiotics of various regimens as well as intraoperative antibiotics on the day of surgery. Group Ab patients received 2.4 mIU of intramuscular penicillin G benzathine, or if allergic, a 5- to 7-day regimen of oral clindamycin. Group non-Ab patients received no antibiotics postoperatively. Patients followed between 5 and 8 weeks were included in the data set. RESULTS: A total of 291 patients were enrolled in the study, of which 181 patients met the inclusion criteria. Group Ab included 81 and group non-Ab 100 patients. Twenty-two patients had evidence of infection noted within the 8-week follow-up period. There were 8 infections in group Ab and 14 infections in group non-Ab. Statistical analysis with the Pearson Chi-square and Student's t test showed no statistically significant difference (P = .399) between groups Ab and non-Ab. CONCLUSION: This study could not prove any statistically significant benefit to the administration of postoperative antibiotics in patients undergoing open reduction and internal fixation of mandibular fractures.

Aesthetic management of the nasal component of naso-orbital ethmoid fractures.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Discuss the critical anatomic structures of the nose that are affected in naso-orbital ethmoid fractures. 2. Discuss the advantages of early, complete nasal reconstruction of these fractures. 3. Apply a clinical algorithm to such nasal reconstruction. 4. List the techniques used in aesthetic reconstruction of the nose in naso-orbital ethmoid fractures. BACKGROUND: Fractures of the naso-orbital ethmoid complex pose challenging management issues. Although basic treatment principles have been well described, the aesthetic management of the nasal component has not been adequately addressed in the literature. METHODS: When secondary nasal deformities occur, they are difficult to correct. Optimal primary correction of the nasal deformity is accomplished using the following four principles: (1) rigid fixation of the nasal pyramid and restoration of nasal height and length; (2) restoration of tip projection; (3) septal reduction/reconstruction; and (4) lateral nasal wall augmentation. RESULTS: Successful management of naso-orbital ethmoid fractures is a complex and challenging task. Both the bony and soft-tissue components must be addressed and the extent of the injury must be adequately diagnosed to avoid omission of critical steps in the reconstruction. Inadequate treatment of naso-orbital ethmoid fractures can produce a severe cosmetic deformity that is very difficult to correct secondarily. CONCLUSION: The authors discuss the nasal component of naso-orbital ethmoid complex injuries and detail the key principles in their algorithm for aesthetic nasal reconstruction.

Tracheotomy versus endotracheal intubation for airway management in deep neck space infections.

PURPOSE: The aim of the present study was to compare costs and outcomes for patients with deep neck infections who were treated with either tracheotomy or endotracheal intubation. MATERIALS AND METHODS: The charts of 85 patients with deep neck space infections were retrospectively studied. Requirements for inclusion in the study were incision and drainage in the operating room, involvement of more than 1 deep anatomic space, impending airway compromise, and maintenance of a postoperative artificial airway. The 85 patients were divided into 2 groups based on the type of airway used for treatment. Group 1 (n = 34) included patients who received a tracheotomy, and group 2 (n = 51) included patients whose airways were maintained with endotracheal intubation until the swelling had resolved sufficiently for extubation. RESULTS: Patients in group 1 had a shorter overall hospital stay (4.8 vs 5.9 days, NS) and spent less time in the intensive care unit (1.1 vs 3.1 days, P <.05). The overall incidence of complications was 6% for group 1 and 10% for group 2. The rate of complications secondary to loss of airway was 3% for group 1 and 6% for group 2. Average costs associated with intensive care resources were 5 times greater and overall hospital stay costs were 60% greater for group 2. CONCLUSIONS: Although both methods of airway control are useful and have a unique set of complications, the use of tracheotomy allowed earlier movement to a noncritical care unit and was associated with fewer intensive care costs and less overall cost of hospitalization. Tracheotomy may therefore provide better utilization of critical care resources in this group of patients.

Modified tumescent technique for outpatient facial laser resurfacing.

PURPOSE: The study goal was to retrospectively review the effectiveness of a modified tumescent technique to provide anesthesia for facial laser resurfacing in an office-based setting. PATIENTS AND METHODS: The charts of 54 consecutive patients treated with facial laser resurfacing at a large outpatient clinic were retrospectively reviewed for type of intravenous sedation/analgesia, adequacy of anesthesia, complications, and discharge criteria. All patients were treated with a modified tumescent technique with or without intravenous sedation. RESULTS: All patients tolerated the procedure extremely well. There were no anesthesia-related complications regarding loss of airway/airway obstruction, desaturation, or prolonged recovery periods. Several patients tolerated the procedure comfortably without intravenous sedation/analgesia. CONCLUSIONS: The modified tumescent technique is a valuable method to provide patient comfort during facial laser resurfacing while reducing the risk for anesthesia-related complications.

Nasal reconstruction--beyond aesthetic subunits: a 15-year review of 1334 cases.

A retrospective analysis was performed on 1334 patients who underwent nasal reconstruction between 1986 and 2001. The senior author performed all reconstructions in this series after Mohs' histographic excisions. Only secondary reconstructions were performed without a preceding Mohs' excision. Methods of reconstruction, number of operations per patient, locations of defects, and complications were recorded. Using preoperative and postoperative photographs, aesthetic results were reviewed. Basal cell carcinoma was the most common lesion, followed by squamous cancer and melanoma. The average age of the patients was 51 years. Cancers most commonly arose on the dorsum, ala, and tip. Of 1334 cases, a 1.9 percent recurrence rate was documented. The average time between surgery and clinical recognition of recurrence was 39 months. All recurrent lesions were reexcised by the Mohs' technique. Eighty-one percent of reconstructions were completed in three or fewer stages. Seventy-five percent of reconstructions were completed in two stages. Primary dermabrasion or primary laserbrasion using carbon dioxide or erbium lasers was used in nearly every case. Early secondary dermabrasion or laserbrasion was used in a few cases where indicated. A 1.2 percent revision rate was noted (16 patients). Thirteen partial flap necroses required revision. Three patients experienced dehiscence at the donor site of paramedian forehead flaps. A preferred philosophy toward nasal reconstruction is described. The goal is to achieve optimal cosmetic and functional results while minimizing stages and resection of healthy tissue. Six core principles are advocated that guide efficient and successful nasal reconstruction: (1) maximal conservation of native tissue is advised; (2) reconstruction of the defect, not the subunit, is advised; (3) complementary ablative procedures, such as primary dermabrasion, enhance the final result and decrease the number of revisionary procedures; (4) primary defatting also decreases the number of revisionary procedures; (5) when possible, the use of axial pattern flaps is preferred; and (6) good contour is the aesthetic endpoint.