Transoral Robotic Thyroidectomy for Papillary Thyroid Carcinoma: Perioperative Outcomes of 100 Consecutive Patients.

BACKGROUND: Endoscopic transoral thyroidectomy is a recently introduced technique of remote access thyroidectomy. We previously reported the feasibility of the robotic approach (TORT). Nevertheless, experience to date is limited, with scant data on outcomes in patients with papillary thyroid carcinoma (PTC). METHODS: This was a retrospective analysis of prospectively collected data. Patients with PTC, who underwent TORT at a single center between March 2016 and February 2017, were analyzed. RESULTS: There were a total of 100 patients (85 women, 15 men) with a mean age of 40.7 ± 9.8 years, and a mean tumor size of 0.8 ± 0.5 cm. Nine patients underwent a total thyroidectomy, and 91 underwent a lobectomy. The operative time for a total thyroidectomy and lobectomy was 270.0 ± 9.3 and 210.8 ± 32.9 min, respectively. Ipsilateral prophylactic central neck compartment dissection was performed routinely with retrieval of 5.0 ± 3.6 lymph nodes. Perioperative morbidity was present in nine patients including transient recurrent laryngeal nerve palsy (n = 1), postoperative bleeding requiring surgical intervention (n = 1), zygomatic bruising (n = 2), chin flap perforation (n = 1), oral commissure tearing (n = 2), and chin dimpling (n = 2). There was no conversion to endoscopic or conventional open thyroid surgery. CONCLUSION: In this study, TORT could be safely performed in a large series of patients with PTC without serious complications. In selected patients, TORT by experienced surgeons could be considered an alternative approach for remote access thyroidectomy.

Reconstruction of the lower vermilion with a musculomucosal flap from the upper lip in the repair of extensive lower lip and chin defects.

In the repair of extensive lower lip and chin defects, the reconstruction of vermilion at the same time is a great challenge to plastic surgeons. We describe a novel method for the reconstruction of lower vermilion with musculomucosal flap from the upper lip in the repair of extensive lower lip and chin defects. Two patients underwent extensive lower lip and chin reconstruction together with vermilion reconstruction. This technique used 3 basic components: musculomucosal flap from the upper lip, buccal mucosal advancement flap, and cutaneous rotational flap from the neck. All the flaps survived without significant complications. Labial function in the motions of expression and speaking was maintained. The patients could basically close their mouths completely, and there were no drooping or small-mouth deformities postoperatively. Functional and cosmetically acceptable lower-lip and chin reconstructions in both patients were achieved.

Unusual sequela from a pencil stab wound reveals a retained graphite foreign body.

Penetrating pencil-tip injuries are common among children and usually resolve without long-term sequelae. However, failure to detect and remove embedded pencil fragments can result in increased morbidity or misdiagnoses of other, more serious, conditions. We report on the case of a 10-year-old boy stabbed with a pencil on his right chin. Initial treatment in the emergency department included irrigation and closure of the laceration. Following suture removal, the patient returned to the emergency department (with bright-purple drainage from the wound site). Radiographic evaluation led to the discovery of an embedded foreign body requiring surgical removal.

Sporotrichosis on the face of a 7-year-old boy following a bicycle accident.

A 7-year-old boy presented with an annular verrucous plaque on the chin of 5 weeks duration. The lesion occurred after a bicycle accident and was unresponsive to antibiotics. Fungal culture grew Sporothrix schenckii. Sporotrichosis should be considered and fungal culture obtained whenever a nodule or plaque fails to respond to initial treatment.

Solitary giant neurofibroma of the mental nerve: a trauma-related lesion?

Neurofibroma is a benign neoplasm derived from peripheral nerves whose etiology is still unclear. It may present as a solitary lesion or be associated with other diseases such as neurofibromatosis type I and II syndrome. This paper aims to report an extremely rare case of a solitary giant neurofibroma of the mental nerve whose etiology was related to a local trauma. A 14-year-old female patient presented an extensive left facial mass with a size of 7 × 5 × 4 cm, located between the teeth 33 and 37 in the mandible region. It has begun to grow 3 months after a local trauma. Imaging studies were suggestive of a soft-tissue lesion, with minimal bone changes and maintaining the integrity of the mandibular canal and mental foramen. Histopathological tests showed spindle cells with undulated and hyperchromatic nuclei, and sparse cytoplasm in a stroma composed of dense fibrous connective tissue. Immunohistochemistry revealed positive expression for the proteins S-100 and vimentin, confirming the diagnosis of neurofibroma. The patient underwent surgical removal of the lesion by intraoral approach and evolved with an excellent cosmetic result and no signs of recurrence after 2 years of follow up. We report a rare case of solitary giant neurofibroma whose etiology was related to a local trauma. To our knowledge, this is the first report of a mental nerve neurofibroma. Although the etiology remains unclear, we suggest the investigation of local trauma as a possible etiologic factor for solitary neurofibromas of the jaw.

Bilateral complicated crown fractures secondary to chin injury: a case report.

Traumatic injuries to the chin are not uncommon in children. Nevertheless, crown fractures, which are common sequelae to this type of injury, might be overlooked, especially if dental care is not sought immediately after a visit to a non-dental facility. The present case report reviews the delayed diagnosis and treatment outcome of a bilateral posterior complicated crown fracture affecting mandibular second primary molars in a young child. Pharmacologic and orthodontic considerations are also discussed in the paper.

Reconstruction of lower face defect or deformity with submental artery perforator flaps.

BACKGROUND: Reconstruction of lower face defects or deformity often presents as a challenge for plastic surgeons. Many methods, including skin graft, tissue expander, or free flap are introduced. Submental artery perforator flaps have been used in the reconstruction of defects or deformities of the lower face. METHODS: Between August 2006 and December 2008, 22 patients with lower face defects or deformity underwent reconstruction with pedicled submental artery perforator flaps. Their age ranged between 14 and 36 years. The perforator arteries were detected and labeled with a hand-held Doppler flowmeter. The size of flaps ranged from 4 × 6 to 6 × 7 cm, and the designed flaps included the perforator artery. RESULTS: All the flaps survived well, except 1 flap which resulted in partial necrosis in distal region and healed after conservative therapy. No other complication occurred with satisfactory aesthetic appearance of the donor site. CONCLUSIONS: The submental artery perforator flap is a thin and reliable flap with robust blood supply. This flap can reduce donor-site morbidity significantly and is a good choice for reconstructive surgery of lower face.

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

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

Heterotrophic ossification on a skin graft in a postburn scar of the chin.

Some patients who have heterotrophic ossification (HO) in a postburn scar are occasionally seen in the clinic. The occurrence of HO following hip and abdominal surgery is common in males, whereas females are frequently affected following burns. The HO of skin grafts in burn scars of the superior body parts is uncommon, especially on the face. We report a recent case of a male patient in whom HO arose on skin grafts on his chin. The patient presented with a history of a painless chin mass for 48 years. Computed tomography scan suggested that the mass was located within subcutaneous tissue away from the lower jaw. The density of the mass was almost the same as the cortical bone of the lower jaw. The mass was completely resected under general anesthesia. It was a rectangular mass of 3× 0.5× 0.3 cm. Histological examination gave the diagnosis of HO, which was also confirmed by immunohistochemical stainings for vimentin. Recurrence was not found in this case by clinical and radiologic follow-up at 1 year after surgery.

Post-traumatic bifid condyle: the pathogenesis analysis.

This study investigated the characteristic of bifid condyle secondary to temporomandibular joint (TMJ) trauma, aiming to analyse the pathogenesis of post-traumatic bifid condyle. Four cases identified as having bifid condyle secondary to TMJ trauma were involved in this study. The relative information extracted from the case records included patients' complaint, history of injury and radiographic appearance, which were used to analyse the characteristic and pathogenesis of post-traumatic bifid condyle. The results indicated that there was a correlation between condylar trauma degree and bifid condylar head appearance after trauma. For severe condylar fracture, it might result in Y-shaped condyle associated with TMJ ankylosis; and condylar groove could be associated with the slight trauma in condyle articulating surface. In conclusion, as a specific entity, post-traumatic bifid condyle may develop in cases with insufficient remodelling capacity after condyle trauma, and it seems that the severity degree of trauma, the site of trauma and its relation to the insertion of the lateral pterygoid muscles are factors associated with the appearance and orientation of bifid condyle.

An unusual pattern of self-inflicted injury after dental local anesthesia: a report of 2 cases.

The local anesthetics used in dentistry are considered very safe and have a low incidence of adverse reactions associated with their administration. A frequent finding by clinicians engaged in treatment of children is, following a dental appointment requiring local anesthesia to treat dental disease, a child may bite his or her lip out of curiosity associated with the unfamiliar sensation of being numb or inadvertently because no pain is felt. We describe two unusual case reports of postanesthetic self-inflicted injuries in this article. The first being the ulceration due to lip biting and the scratch injury on the chin after inferior alveolar nerve block. The second report presents an unusual scratch injury on the ala of nose following maxillary infiltration anesthesia. The common treatment modalities and the possible methods of prevention are discussed.

[Surgical strategy for neck burns and their sequelae]. / Stratégie chirurgicale des brûlures du cou et de leurs séquelles.

Burns of the neck are common and expose them to functional and aesthetic complications which are sometimes very serious. Care in the acute stage and treatment of sequelae contribute to a common goal of restoration: Maintain or recreate a chin-neck angle and get a quality skin as close as possible to the original skin, in terms of flexibility, texture, thickness and color. The wide variety of cases encountered requires knowing the armamentarium available to us today, and the anatomical basis and clinical underlying indications.

Biomechanical optimization of bone plates used in rigid fixation of mandibular symphysis fractures.

PURPOSE: To design and optimize a bone plate for fractures of the mandibular symphysis that will provide maximum fracture stability with minimal implanted volume and patient intrusion. The design will be driven by the unique biomechanics specific to this fracture location. MATERIALS AND METHODS: A finite element model of a fractured human mandible was created using computed tomography scans. The boundary conditions included simulating molar, canine, and incisal loading. The bone plate design process included a shape optimization routine and design parameter analysis using the model. The optimized bone plate design was finally compared with standard bone plate configurations according to stress and strain measures. RESULTS: Compared with the miniplate combination, the InterFlex III plate, with the same thickness and just 14% more implanted volume, had only 55% of the plate stress and 25% less fracture strain under the strongest loads considered by the model. Compared with the band/fracture plate combination, the InterFlex plate had 88% of the fracture strain and 74% of the plate stress, despite having only 60% of the plate volume. CONCLUSIONS: The results have demonstrated that the new optimized plate is a hybrid of fixation hardware with the small profile of the smallest miniplate configuration and the superior fixation strength and safety that exceeds that of the larger fracture plate configuration.

Massive subcutaneous emphysema developing before surgery for mandibular fracture: a case report.

Preoperative massive subcutaneous emphysema before intubation is extremely rare. However, this complication may be potentially lethal, depend on the condition of air spreading. Subcutaneous emphysema which occurs intra- or postoperative period is sometimes iatrogenic because the air is introduced into the tissue space through the hole injured by the operation. But the emphysema in this case occurred preoperatively by the pressure of the bag valve mask, because the patient had an intra-oral wound, which reaches the submental space. In this report, we describe an extremely rare case of preoperative massive emphysema of the patient with the mandibular fracture.

[Repair of nose, lips and chin mutilations. The customary repairs versus allografts]. / Réparation des mutilations du triangle nasolabio-mentonnier. Plasties conventionnelles versus allogreffes.

Central-facial mutilations, located within the nose lips and chin triangle, require great quality repairs regarding morphology and function. Plastic surgery history affords the ideas evolution in this field crossing over nose and lips reconstructions, which were the subject of successive reports within our society, in 1994 (nose reconstruction) and 2002 (lips reconstruction). Now a day, following this progress, the plastic surgeon has a large choice of reliable techniques. His choice is dictated by a precise evaluation of the limits of the substance loss to repair, according to a (mapping) classification of the nose-lip and chin triangle. This classification defines three units (nose-labial, bilabial and chin-labial) as reflexion bases to the therapeutic indications. This anatomical and surgical approach was built starting from a retrospective study of 195 central-facial mutilations caused by ballistic damage and dog bites. The results evaluation makes possible to carry out a reflexion on the potential indications regarding allograft as a therapeutic alternative to the traditional reconstructions of this territory.

Parasymphyseal fracture associated with fracture of a maxillary primary molar in a child: case report.

Bone and posterior tooth fractures can be serious injuries that are difficult to diagnose, particularly in emergencies. The aim of this study was to report a case of a parasymphyseal fracture associated with the fracture of a maxillary primary molar in a child.

What would you do?

A review of the consequences and treatment of traumatic injury to the chin of a 5-year-old child resulting in a complete fracture and dislocation of the mandibular left condyle. The success of elastic therapy is demonstrated.

Complications following chin laceration reparation using tissue adhesive compared to suture in children.

BACKGROUND: Tissue adhesive is widely used in the emergency department to repair minor lacerations but there exists a debate as to whether it should be used for chin lacerations. The main objective of this study was to evaluate the rate of wound dehiscence of chin lacerations repaired with tissue adhesive in comparison to sutures. METHODS: This was a retrospective chart review including all children requiring a facial laceration reparation in a single tertiary care paediatric hospital. The primary outcome was wound dehiscence in the 30 days following reparation, comparing the use of tissue adhesive and sutures. The independent variable of interest was the use of tissue adhesive vs suture. A random sample of charts was reviewed in duplicate to insure reliability of the chart review. RESULTS: Among the 2044 children presenting with a facial laceration requiring an intervention, 1804 (88%) were repaired using tissue adhesive. The laceration was located on the chin in 360 (18%) of patients. The use of tissue adhesive was not statistically associated with a higher risk of dehiscence for all facial lacerations (difference: 0.2; 95%CI: -1.9 to 0.8%), nor for chin lacerations (difference 2.2%; 95%CI: -7.5 to 4.4%). However, the probability of dehiscence was higher for chin laceration in comparison to other localizations (difference of 1.6%; 95%CI: 0.5-3.6%). CONCLUSION: While the rate of dehiscence was higher for chin lacerations compared to other facial localizations, the risk of dehiscence was not statistically different for chin laceration repaired with tissue adhesive or sutures.

Abordagem cirúrgica em fratura de sínfise e côndilo mandibular bilateral em paciente pediátrico: um relato de caso / Surgical approach for syphysis and bilateral mandibular condyle fracture in a pediatric patient: a case report

As indicações de tratamento das fraturas mandibulares em paciente pediátrico variam em conservador, fixação não rígida e interna rígida. Alterações no crescimento ósseo, disfunções na articulação temporomandibular e assimetrias faciais podem ser decorrentes ao insucesso do tratamento. O objetivo deste trabalho consiste em relatar abordagem cirúrgica em fratura de sínfise e côndilo mandibular bilateral em paciente pediátrico. Paciente gênero feminino, 09 anos de idade, foi encaminhada ao Hospital Geral do Estado - Bahia vítima de queda de nível, cursando com trauma em face. Apresentou queixa principal, referida pela progenitora, de dificuldades em fechar a boca. Ao exame físico, a paciente apresentou mobilidade atípica à manipulação da mandíbula, mordida aberta anterior, equimose sublingual, ausência das unidades dentárias 74 e 75, com abertura bucal regular e suturas em posição em região de mento. Ao exame de imagem de tomografia computadorizada da face, pôde-se notar sinais sugestivos de fratura em região de sínfise e côndilos mandibulares bilateral. Após diagnóstico das fraturas, a paciente foi submetida à cirurgia sob anestesia geral para redução e fixação das mesmas. Realizou-se acessos em ferimento na região mentual e retromandibular bilateral com posterior síntese das fraturas utilizando fixação interna rígida com placas do sistema 2.0mm, associada a odontossíntese na fratura de sínfise. Ao acompanhamento periódico, a eleição do tratamento cirúrgico para fraturas mandibulares em pacientes pediátricos, pode permitir segurança no crescimento ósseo mandibular e facial(AU)

The indications for treatment of mandibular fractures in pediatric patients vary from conservative, non-rigid fixation and rigid internal fixation. Changes in bone growth, temporomandibular joint disorders and facial asymmetries may be due to treatment failure. The objective of this work is to report a surgical approach to bilateral symphysis and mandibular condyle fractures in a pediatric patient. Female patient, 9 years old, was sent to the State General Hospital - Bahia, victim of a fall in level, suffering from trauma to the face. She presented a main complaint, mentioned by her mother, of difficulties in closing her mouth. On physical examination, the patient presented atypical mobility when manipulating the jaw, anterior open bite, sublingual ecchymosis, absence of dental units 74 and 75, with regular mouth opening and sutures in position in the chin region. When examining the computed tomography image of the face, signs suggestive of fracture in the region of the symphysis and bilateral mandibular condyles were noted. After diagnosis of the fractures, the patient underwent surgery under general anesthesia to reduce and fix them. Access was performed on a wound in the mental and bilateral retromandibular region with subsequent synthesis of the fractures using rigid internal fixation with 2.0mm system plates, associated with odontosynthesis in the symphysis fracture. With periodic monitoring, the choice of surgical treatment for mandibular fractures in pediatric patients can allow for safe mandibular and facial bone growth(AU)