Postoperative infections associated with microvascular free flaps in head and neck reconstruction: Analysis of risk factors and results with a standardized prophylaxis protocol.

Currently, large defects of the head and neck regions are mainly reconstructed using microvascular free flap. Postoperative infections, including surgical site infections (SSIs) and medical postoperative infections (MPI), are important causes of morbidity and worsening of surgical outcomes. The authors aimed to analyze the results obtained using a standardized prophylaxis protocol in a series of 100 consecutive patients who underwent microvascular reconstruction surgery between 2016 and 2021 at a single institution, to identify the risk factors, which could be overcome, to minimize the incidence of infectious complications. In this study, 24 patients developed infectious complications. Higher American Society of Anesthesiologists (ASA) score was statistically associated with higher risk of infectious complications (p = 0.01), need for postoperative transfusions (p = 0.01), and higher T and N stage (p = 0.03 and p = 0.02, respectively) in patients with cancer. We also found a correlation between the increase in surgery duration, hospitalization, and intensive care unit (ICU) stay with higher risk of infection (p = 0.03, p = 0.01, and p = 0.001, respectively). Nine patients reported partial or total flap necrosis and in this group of patients, a higher incidence of infectious complication was recorded (p = 0.001). Our experience shows that SSIs and MPIs affect the global and surgical outcomes of patients and both their incidences can be reduced by correcting potential risk factors preoperatively (e.g., anemia), intraoperatively (amount of blood loss and duration of surgery), and postoperatively (duration of hospitalization and ICU stay and early elimination of potential sources of infection).

Oral bisphosphonate-induced osteonecrosis complications in patients undergoing tooth extraction: a systematic review and literature updates.

OBJECTIVE: Bisphosphonates, the most common anti-resorptive medications, are internalized by osteoclasts, where they inhibit the macrophage colony-stimulating factor (M-CSF) pathway, preventing their differentiation, inhibiting anchorage to the cell membrane, and inducing apoptosis. In patients undergoing oral bisphosphonate therapy, oral surgery involves a high risk of developing drug-related osteonecrosis of the jaws (BRONJ/MRONJ), among the possible complications. MATERIALS AND METHODS: A systematic search was carried out on the PubMed, Scopus and Cochrane Library search engines, using the keywords "oral bisphosphonates AND tooth extraction", "third molar extraction AND oral bisphosphonates". In addition, we manually evaluated the articles included in references from other sources and an analysis of the Gray Literature was performed. A secondary outcome was to evaluate the assessment of pharmacological (antibiotics) use in the BRONJ/MRONJ management. The revision protocol followed the indications of the Cochrane Handbook, and was registered in the INPLASY database, while the drafting of the manuscript was based on PRISMA. RESULTS: The results of the systematic review, after the study identification and selection process, included a total of 7 studies: 4 retrospective studies, 2 prospective studies and 1 case report. The main complication was represented by osteonecrosis of the jaws, which appears to be related to the duration of treatment with bisphosphonates; in addition, data regarding the anatomical location of post-extraction sites, the sex and age of patients, comorbidities and various systemic risk factors were extrapolated. The most frequent post-extraction complication in patients treated with oral bisphosphonates is osteonecrosis of the jaws, with a significant prevalence in the posterior region of the mandible. In some cases, delayed healing of the surgical wound was also found; moreover, the duration of exposure to oral bisphosphonates influences the onset of complications. CONCLUSIONS: Ongoing studies continue to unravel the role of the oral environment response in alveolar bone homeostasis and how it might contribute to the induction of BRONJ/MRONJ. Approaching the problem from this perspective could provide new directions for the prevention of BRONJ/MRONJ and expand our understanding of the unique oral microenvironment.

Osmo Pocket© vs VITOM®: comparison of surgical educational video recording means in head and neck reconstructive surgery.

PURPOSE: To highlight the needs for better intraoperative educational video recording in head and neck reconstructive surgery and to provide some information to standardize camera positioning in operative room. METHODS: The Authors compared the Osmo Pocket© and the VITOM® 0° Telescope, evaluating the faculty and trainees point of view through specific questionnaires. The study was performed during two Masterclasses on Head and Neck Reconstructive Surgery that took place in the Hospital Casa Sollievo della Sofferenza in 2018 e 2019. Camera positioning in the Operative Room was also assessed. RESULTS: In the faculty group, Osmo Pocket© was reported as frequently interfering with surgical intervention; the need for repositioning was reported more frequently in recording with VITOM®, that was evaluated as better in keeping a good "recording flow". In trainees' group, the perceived image quality with VITOM® was more appreciated, while Osmo Pocket© was considered superior in surgical field vision. Regarding the systems' positioning in the OR, in all the surgical procedures it was observed the need for the first operator and the trainees to have the HD monitor placed in front of them. Only during forearm flap harvesting the HD monitor was placed laterally to the first operator and the trainees. CONCLUSIONS: The Osmo Pocket© is a cheap solution and allows a stable and continuous vision of the operative field, without the needing for stop and repositioning. The Vitom®, despite its major costs and the needing for periodic repositioning, allows a better view of anatomical details with less discomfort for the surgeon. Moreover it's important a standardization of the video means positioning in the operative room to reduce the pre-operative times and to aid in the choice of the most useful method for educational video recording.

Functional outcomes in tongue reconstruction with myomucosal buccinator flaps.

OBJECTIVE: Buccal myomucosal local flaps in oral cavity reconstruction are a valid option for small-to-moderate defects. Nevertheless, few articles report about functional recovery. The purpose of the present analysis is to evaluate the impact of these flaps on function and quality of life. STUDY DESIGN: The study, retrospectively conducted on 36 patients who were surgically treated for tongue cancer between 2012 and 2018 at the Unit of Maxillo-Facial Surgery, Foundation IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo (Italy), evaluates functional outcomes using the following 4 questionnaires: Performance Status Scale for Head and Neck Cancer Patients, M.D. Anderson Dysphagia Inventory, Speech Handicap Index, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module. RESULTS: All patients are able to eat soft or more solid foods, and most of them eat quietly in public. Although 50% of cases reported a certain degree of dysphagia, it does not impact self-esteem and social relationships. Only 20% of patients have severe problems with speech. However, more than half of the cases (65%) report oral problems. CONCLUSIONS: The collected data confirm the suitability of the myomucosal cheek flaps for tongue reconstruction. Most patients report a good functional recovery and satisfactory quality of life even if none of them has a recovery comparable to the presurgical state.

Recurrent squamous cell carcinoma of the lower lip: salvage surgery outcome.

Squamous cell carcinoma (SCC) of the lip is one of the most commonly occurring oral cancers, mainly involving the lower lip. Despite a good prognosis in cases of early detection, survival rates drop dramatically in the presence of recurrence. While there are many studies in the literature regarding the management of primary tumours, the rate of recurrence in lower lip SCC is low and therefore there are few data and articles about them. We retrospectively reviewed patients affected by recurrent SCC of the lower lip treated surgically from 2011 to 2019 in a single centre. Data and results were compared with those in the literature. A total of 16 patients (mean [range] age: 78.1 [62-93] years) were eligible for inclusion. The disease-free survival rate at 2 and 5 years was 29.6% and the overall survival rate at 2 and 5 years was 14.4%. A significantly higher rate of failure and a worse prognosis was observed in patients with neck involvement. The prognosis of recurrent lower lip SCC is unfavourable with extremely low survival rates. This issue is probably linked to the oncological pathology but also to the advanced age of most patients, the presence of several comorbidities and, consequently, the high risk of perioperative mortality. For this reason, the analysis of data sets reported in the literature may help the surgeon in the management of recurrences and selection of patients.

Inferior alveolar nerve reconstruction in extensive mandibular resection: Technical notes.

The inferior alveolar nerve (IAN) is a sensitive branch of the mandibular nerve innervating the lower lip, the chin, the buccal mucosa and the teeths. Lesions of the IAN are reported to occur in the 64,4% of maxillo-facial procedures, leading to anesthesia, hypoestesia and/or neurogenic discomfort. An extensive segment of the nerve can be moreover removed during mandibular resection for benign or malignant pathologies. Nervous grafts can be used in these cases to restore the nerve continuity. In order to optimize the procedure and to allow a concomitant mandibular osseous reconstruction, the Authors identified several standardized steps. The technique described allows to perform confortable and safe nervous anastomoses and to reduce the risk of damage and tension during the flap insetting phases.

Impact of COVID-19 epidemic on maxillofacial surgery in Italy.

Maxillofacial departments in 23 surgical units in Italy have been increasingly involved in facing the COVID-19 emergency. Elective surgeries have been progressively postponed to free up beds and offer human and material resources to those infected. We compiled an inventory of 32 questions to evaluate the impact of the SARS-COV2 epidemic on maxillofacial surgery in 23 selected Italian maxillofacial departments. The questionnaire focused on three different aspects: the variation of the workload, showing both a reduction of the number of team members (-16% among specialists, -11% among residents) due to reallocation or contamination and a consistent reduction of elective activities (the number of outpatient visits cancelled during the first month of the COVID-19 epidemic was about 10 000 all over Italy), while only tumour surgery and trauma surgery has been widely guaranteed; the screening procedures on patients and physicians (22% of maxillofacial units found infected surgeons, which is 4% of all maxillofacial surgeons); and the availability of Personal Protective Equipment, is only considered to be partial in 48% of Maxillofacial departments. This emergency has forced those of us in the Italian health system to change the way we work, but only time will prove if these changes have been effective.

Management of free flap failure in head and neck surgery.

Free flap surgery is overall considered the gold standard in head and neck reconstruction, with a success rate of 95%. The management of a total flap necrosis and which solution, between a pedicled or a second free flap, is safer for a salvage procedure is still controversial. Object of this study is to describe the authors' management of total free flap loss in head and neck reconstruction and compare the choices and results to those reported in the literature. From January 2012 to January 2016, 149 consecutive free flaps were performed at the Maxillo- Facial Operative Unit of the Hospital Casa Sollievo della Sofferenza in San Giovanni Rotondo (Italy) for reconstruction of head and neck defects. Of these, 6 flaps were lost due to a total necrosis. In 5 cases it was decided to harvest a second free flap, and in the remaining patient a temporalis muscle flap was used. All the free salvage flaps were successful, without complications and with a good aesthetic and functional recovery. Analysing the data obtained, and comparing them with those reported in the literature, it can be concluded that a second subsequent free flap can be considered an ideal and safe procedure in salvage surgery.

Intraoperative navigation in complex head and neck resections: indications and limits.

PURPOSE: The surgical removal of head and neck tumors often represents a highly complex surgery. The three-dimensionality and the anatomy of the head and neck area make sometimes difficult a correct intraoperative orientation and the obtaining of an adequate oncological safety. In the present pilot study, the authors propose a protocol of application of intraoperative navigation in the resection of head and neck tumors. The purpose is to develop a methodology that can be helpful to ensure oncologic free margins of resection and to facilitate the orientation of the specimen by pathologists. MATERIALS AND METHODS: A sample of 16 patients with head and neck tumors was selected, and they were differentiated into two groups: a "study group" treated with CT computer-assisted surgery and a "control group" surgically treated without the use of technology. The following data were analyzed: operative and pre-surgical planning times, issues related to the use of the technologies, respect of the planned landmarks, description and orientation of the surgical specimen and distance of the tumor from the margins of resection. RESULTS: In the "study group" were noticed a reduced rate of errors in the specimen orientation and an increased distance of the tumor from the margins of resection. Similar operative times were observed in both groups. CONCLUSIONS: Intraoperative navigation resulted to be a reliable method to improve oncological safety in a selected group of patients.

Endoscopic transnasal approach and intraoperative navigation for the treatment of isolated blowout fractures of the medial orbital wall.

The aim of this study is to describe the reduction of medial orbital wall fractures using a combination of two different techniques: the endoscopic reduction and the navigation aided reconstruction. The endoscopic approach avoids an external incision and allows the observation of the fracture site clearly. Navigation-aided reconstruction is essential to achieve precise and predictable results in orbital reconstruction. It consists in an ideal virtual reconstruction of the target area created using a mirroring tool, and superimposing and comparing the unaffected and the affected sides. This technique opens a broad spectrum of possible surgical approaches, especially in situations in which anatomical landmarks for precise positioning of bone fragments, or bone grafts, are missing. This study is the first to combine these two techniques. The study was carried out in seven patients who underwent endoscopic reduction of isolated blowout fractures of the medial orbital wall and navigation-aided reconstruction at the authors' institution. This pilot study clearly shows that a combination of the endoscopic reduction and the navigation-aided reconstruction provides functional results and great advantages in terms of anatomical preservation and postoperative morbidity.

The submental island flap: pedicle elongation and indications in head and neck reconstruction.

BACKGROUND: The submental island flap is an axial pattern skin flap first described by Martin et al. in 1993. When used to reconstruct skin defects it matches the recipient site in terms of colour, texture and thickness. One of the main limitations to its application is the arc of the pedicle allowing coverage of only the lower two thirds of the face. METHODS: A retrospective review was performed of all patients who had had a submental island flap reconstruction at the Operative Unit of Maxillo-Facial Surgery of the University Hospital of Parma, Italy, between 2001 and 2011. The Authors focused on the surgical technique adopted, the clinical indications and the results obtained. They analysed the different ways to elongate the pedicle and discuss their thoughts on the choice of reconstruction. A flowchart was created to help in the decisional process. RESULTS: Between 2001 and 2011 the submental island flap was used to reconstruct head and neck defects in 22 patients. Thirteen patients had defects of the oral cavity; the remaining 9 patients had skin defects involving the pre-auricular region, the temporal area and the peri-nasal cheek skin. No major complications occurred and in one case a partial necrosis of the distal portion of the flap was observed. Five patients underwent surgical revision involving intraoral flap debulking 6-10 months after the primary procedure. DISCUSSION AND CONCLUSIONS: The techniques to elongate the pedicle used and described were: additional dissection of the pedicle, Y-V procedure, reverse flow flap, section of facial vein and microvascular anastomosis. Their choice is mainly conditioned by the site of the defect.

The masseteric nerve: a versatile power source in facial animation techniques.

The masseteric nerve has many advantages including low morbidity, its proximity to the facial nerve, the strong motor impulse, its reliability, and the fast reinnervation that is achievable in most patients. Reinnervation of a neuromuscular transplant is the main indication for its use, but it has been used for the treatment of recent facial palsies with satisfactory results. We have retrospectively evaluated 60 patients who had facial animation procedures using the masseteric nerve during the last 10 years. The patients included those with recent, and established or congenital, unilateral and bilateral palsies. The masseteric nerve was used for coaptation of the facial nerve either alone or in association with crossfacial nerve grafting, or for the reinnervation of gracilis neuromuscular transplants. Reinnervation was successful in all cases, the mean (range) time being 4 (2-5) months for facial nerve coaptation and 4 (3-7) months for neuromuscular transplants. Cosmesis was evaluated (moderate, n=10, good, n=30, and excellent, n=20) as was functional outcome (no case of impairment of masticatory function, all patients able to smile, and achievement of a smile independent from biting). The masseteric nerve has many uses, including in both recent, and established or congenital, cases. In some conditions it is the first line of treatment. The combination of combined techniques gives excellent results in unilateral palsies and should therefore be considered a valid option.

Selective deep lobe parotidectomy for pleomorphic adenomas.

The authors' experience of the selective deep lobe parotidectomy for the treatment of pleomorphic adenomas of the deep parotid lobe is presented. A retrospective analysis of 11 patients treated between 1997 and 2010 was performed; seven were males and four were females, ranging in age from 35 to 51 years. Parameters evaluated included facial nerve weakness, the occurrence of Frey's syndrome, cosmetic outcome, and recurrence. Follow-up ranged from 18 months to 11 years. No major complications, permanent facial nerve weakness, or Frey's syndrome occurred. Four patients developed temporary facial nerve impairments that lasted between 2 and 6 weeks, and two developed a sialocele that healed in 9 days in one case and 12 days in the other. The overall cosmetic assessment was excellent in eight patients, good in two, and satisfactory in the remaining one. No recurrences occurred. The selective deep lobe parotidectomy can be considered an effective technique for the management of deep parotid lobe pleomorphic adenomas. The major advantages of this procedure include a reduction in complications such as facial nerve impairments and Frey's syndrome, and an improved cosmetic outcome.

Rehabilitation with endosseous implants in fibula free-flap mandibular reconstruction: a case series of up to 10 years.

PURPOSE: To evaluate the clinical outcome and the aesthetic and functional results of implant rehabilitation of fibula free-flap reconstructed mandibles. MATERIALS AND METHODS: The charts of patients who underwent mandibular reconstruction with fibula free flap and implant prosthodontic rehabilitation between 1998 and 2008 at the Operative Unit of Maxillofacial Surgery of Parma, Italy, were reviewed. In the study the estimated survival rates of implants placed in reconstructed mandibles we identified the prognostic factors and evaluated the functional outcomes. RESULTS: Fourteen patients with a mean age of 50 years (range 15-63 years), were included in the study. A total of 62 implants were positioned. Complications occurred in 7 cases, an improvement in function and aesthetics was reported by the majority of patients. CONCLUSIONS: A high survival rate for implants placed in fibula free-flap reconstructed mandibles was observed. Although different factors were believed to be associated with a poorer prognosis (radiotherapy, composite defects, etc.) no statistically significance was found, showing no absolute contraindications to implant placement.

Orthognathic surgery for the complete rehabilitation of Moebius patients: principles, timing and our experience.

Moebius syndrome is a rare disorder found in approximately 1/100,000 neonates and the treatment of facial palsy is now well established worldwide and consists of free-muscle transplants reinnervated with motor nerves. Dentofacial deformities are often detected in Moebius patients, and different degrees of micrognathia are often present, particularly in patients with complete expressions of Moebius syndrome. However only two published reports have described the surgical treatment of such anomalies in these patients; in both cases, the suggested approach consisted of orthognathic surgery followed by soft-tissue management. In this paper we discuss the indications and correct timing of orthognathic surgery and suggest to perform facial animation at an early age and then to wait for the completion of maxillofacial skeletal growth before performing orthognathic surgery. Finally, facial animation should precede orthognathic surgery in adult patients to prevent lower lip deformities and to ensure more predictable and satisfactory results.

Free flaps in elderly patients: outcomes and complications in head and neck reconstruction after oncological resection.

INTRODUCTION: Free flaps represent the first reconstructive option for many head and neck defects. The increasing life expectancy of the population results in increasing numbers of ageing patients facing complex reconstructive surgery. In this study we evaluated our experience with free-flap transfers in older patients, analysing the post-operative reconstructive and systemic complications. MATERIALS AND METHODS: Between 2000 and 2009, 360 patients underwent free flap reconstruction of defects resulting from the treatment of head and neck tumours at the Operative Unit of Maxillofacial Surgery, University - Hospital of Parma, Italy. Fifty-five patients (15.3%) were more than 75 years old at the time of treatment. RESULTS: At the end of the follow-up successful free-flap transfer was achieved in 360 of the 373 flaps harvested (96.5%). The overall reconstructive complication rate was 31.4%, (31.8% in the younger group and 29.1% in the remaining patients). Medical complications were observed in 29.2% of cases (less than 75 years: 28.8%; more than 75 years: 30.9%). The ASA status was associated with a statistically significantly higher incidence of complications within patients less than 75 years old (p < 0.0001). DISCUSSION AND CONCLUSIONS: The results of this study, in agreement with previous studies, provide evidence that free-tissue transfer may be performed in ageing patients with a high degree of technical success. The chronologic age cannot be considered an appropriate criterion in the reconstructive decision. On the contrary, a careful selection of the patients based on comorbidities and general conditions (ASA status) is of primary importance in reducing post-operative complications and to improving the results of surgery.

The Bozola flap in oral cavity reconstruction.

The buccinator musculomucosal flaps are actually considered the main reconstructive option for small-moderate defects of the oral mucosa. In this paper we present our experience with the posteriorly based buccinator musculomucosal flap. A retrospective review was performed of all patients who had had a Bozola flap reconstruction at the Operative Unit of Maxillo-Facial Surgery of Parma, Italy, between 2003 and 2010. The Bozola flap was used in 19 patients. In most cases they had defects of the palate (n=12). All flaps were harvested successfully and no major complications occurred. Minor complications were observed in two cases. At the end of the follow up all patients returned to a normal diet without alterations of speech and swallowing. We consider the Bozola flap the first choice for the reconstruction of defects involving the palate, the cheek and the postero-lateral tongue and floor of the mouth.

Successful salvage surgery after treatment failures with cross graft and free muscle transplant in facial reanimation.

BACKGROUND: The microneurovascular transfer of a free-muscle transplant is the procedure of choice for facial animation, It is characterized by low morbidity in both adult and paediatric patients. In spite of the improvements in microsurgical techniques, failures due to absent revascularization or reinnervation of the transplanted muscle or infections causing flap necrosis are observed. We propose a second surgical procedure based on the gracilis muscle transplant reinnervated by the masseteric nerve as a solution for these cases. METHODS: We analyzed and report on two patients treated in our department after the failure of a previous cross-facial nerve graft and free muscle transplant. They were treated with a new facial reanimation using the contralateral gracilis muscle and the masseteric nerve as the donor nerve. RESULTS AND DISCUSSION: We did not observe any postoperative complications, and all of the flaps survived. Reinnervation and contraction of the muscle appeared 3-4 months postoperatively, with good functional and aesthetic results. CONCLUSIONS: This technique is a one-step procedure characterized by reliable flap harvesting, low donor site morbidity and good activity of the masseteric nerve. We consider it as a good option for treatment of facial animation failures.

Facial animation in patients with Moebius and Moebius-like syndromes.

Moebius syndrome, a rare congenital disorder of varying severity, involves multiple cranial nerves and is characterised predominantly by bilateral or unilateral paralysis of the facial and abducens nerves. Facial paralysis causes inability to smile and bilabial incompetence with speech difficulties, oral incompetence, problems with eating and drinking, including pocketing of food in the cheek and dribbling, as well as severe drooling. Other relevant clinical findings are incomplete eye closure and convergent strabismus. The authors report on 48 patients with Moebius and Moebius-like syndromes seen from 2003 to September 2007 (23 males and 25 females, mean age 13.9 years). In 20 cases a reinnervated gracilis transplant was performed to re-animate the impaired sides of the face. In this series, all free-muscle transplantations survived the transfer, and no flap was lost. In 19 patients complete reinnervation of the muscle was observed with an excellent or good facial symmetry at rest in all patients and whilst smiling in 87% of cases. In conclusion, according to the literature, the gracilis muscle free transfer can be considered a safe and reliable technique for facial reanimation with good aesthetic and functional results.