Cancer case trends following the onset of the COVID-19 pandemic: A community-based observational study with extended follow-up.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impacted health care delivery worldwide. Cancer is a leading cause of death, and the impact of the pandemic on cancer diagnoses is an important public health concern. METHODS: This cross-sectional study retrospectively analyzed the electronic medical records of 80,138 cancer patients diagnosed between January 1, 2019, and May 31, 2021. Outcome measures included weekly number of new cancer cases and trends in weekly cancer cases, before and after the pandemic; patient demographics; and positive COVID-19 test rates. RESULTS: Beginning March 4, 2020, defined as the onset of the pandemic, weekly cancer cases declined precipitously (-110.0 cases per week [95% confidence interval, -190.2 to -29.8]) for 4 weeks, followed by a moderate recovery (+23.7 cases per week [9.1 to 38.4]) of 10 weeks duration. Thereafter, weekly cancer cases trended slowly back toward pre-COVID-19 baseline levels. Following the pandemic onset, there was a cumulative year-over-year decline in cancer cases overall of 7.3%, including a 20.2%, 14.3%, and 12.8% decline in nonmelanoma skin cancer, breast cancer, and prostate cancer, respectively. Changes in case volumes were accompanied by variations in patient characteristics, including region, age, gender, race, insurance coverage, and COVID-19 positive test rates (P < .01 for all). Among patients tested for COVID-19, 5.3% had a positive result. CONCLUSIONS: The data in this study demonstrate a substantial reduction in cancer diagnoses following the onset of COVID-19, which appear to reach expected pre-COVID norms 12 months later. The largest reduction was noted among cancers that are typically screen-detected or identified as part of a routine wellness examination.

"Custom" Plate in a Day-Accurate Predictive Hole Fabrication Using Point-of-Care 3-Dimensional Printing.

PURPOSE: In computer surgical planned (CSP) fibular reconstructions of the mandible, custom plates facilitate accurate and efficient transfer of the digital plan intraoperatively by a way of predrilled fixation holes. Stock plates are more easily accessible and are more economical but typically preclude the utilization of these predictive holes. The purpose of this article is to describe an accurate and economical alternative to custom plates, while still having the ability to create predictive holes for plate alignment and execution of a digital surgical plan. METHODS: An in vitro accuracy study was performed on a point-of-care resin-printed predictive hole guide termed "prebent plate analog" (PPA). Twenty stock 2.0 reconstruction plates prebent against a 3-dimensional printed mandibular model reconstructed with a 2-piece fibula were used to fabricate 20 PPAs. The proximal and distal 4 holes of each prebent plate and corresponding PPA were assessed using a heat map overlay, measuring difference in millimeters between matching points of the predictive hole segments. The median distance from the points of reference in the PPA versus the prebent plate was calculated for each predictive hole position in addition to the average error of the PPA to the stock plate. RESULTS: Eighteen PPAs were used for statistical analysis; 2 were damaged in transport. The mean error between the body (-0.265) and condylar segments (-0.116 mm) and mean difference in error between the proximal predictive holes (-0.124 mm) and distal predictive holes (-0.215 mm) on the PPA were not statistically different (P = .061, P = .314 general estimating equation regression, respectively). The mean error across the PPA predictive holes and corresponding holes of the prebent plates was -0.194 mm (P < .001, general estimating equation regression). CONCLUSIONS: The PPA is a precise and accurate analog that faithfully replicates the position of proximal and distal components of a prebent stock plate, thereby allowing for predictive hole placement in lieu of a custom plate in fibula mandibular reconstruction cases.

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.

Contemporary Techniques in Orbital Reconstruction: A Review of the Literature and Report of a Case Combining Surgical Navigation, Computer-Aided Surgical Simulation, and a Patient-Specific Implant.

PURPOSE: Complex orbital fractures can be surgically challenging because the orbital cavity contains several vital anatomic structures and visibility is limited. We present a case in which computer-aided surgical simulation (CASS), surgical navigation (SN), and a patient-specific implant (PSI) were used. Furthermore, the reported data regarding this topic were systematically searched and investigated. PATIENTS AND METHODS: A patient with a complex, failed orbital reconstruction was referred to our department. Despite the use of advanced tools, including a preformed PSI using a 1:1 mirrored, individual 3-dimensional model, several challenges remained. A systematic search of the relevant databases, scientific journals, and bibliographies of the included reports was conducted. Clinical studies involving CASS and SN in the treatment of at least 5 patients reported between 2016 and 2018 were included. RESULTS: The final reconstruction was planned virtually, and a milled PSI was produced and implanted under guidance of SN. The clinical outcome was acceptable to the patient. The literature search showed that superior results can be obtained when CASS and SN are involved in the treatment regimen. The average technical accuracy for SN has been reported to be less than 1 mm, and volume restoration has been reported to be significantly superior to that achieved with traditional methods. CONCLUSIONS: New technological advancements such as CASS involving SN seem to improve the outcomes of orbital reconstruction, especially in complex cases. Furthermore, planning, execution, and evaluation will be facilitated. Real-time guidance can also be used as a training tool for novice surgeons; however, factors such as financial investments, challenges in implementation, and a steep learning curve must be considered.

Four Practical Reconstructive Techniques Using the Transantral Approach to the Orbital Floor Without the Need for an Endoscope.

Fractures of the orbital floor have traditionally been treated through transorbital approaches. Transconjunctival approaches risk entropion, whereas transcutaneous approaches risk ectropion or hypertrophic scarring. The intraoral transantral approach to the orbital floor has the advantage of minimizing the risk of any eyelid changes while providing appropriate access to reduce the herniated orbital contents and restore orbital volume. This article describes 4 plating methods for reconstructing a fractured orbital floor using a transantral approach. Many prior descriptions of transantral treatment of the orbital floor have relied heavily on the use of an endoscope. This article describes an osteotomy technique that does not require an endoscope but requires only a high-quality headlight for visualization.

Does Mandible-First Sequencing Increase Maxillary Surgical Accuracy in Bimaxillary Procedures?

PURPOSE: In bimaxillary procedures, it is important to know how the chosen sequence affects the surgical outcome. The purpose of this study was to explore whether the theoretical advantages of using the mandible-first procedure were supported by clinical data. MATERIALS AND METHODS: The authors performed a retrospective investigation on a cohort compiled from 3 published retrospective studies. The sample was composed of patients treated at the Radboud University Nijmegen Medical Centre (Nijmegen, the Netherlands) from 2010 to 2014 and the Odense University Hospital (Odense, Denmark) from 2011 to 2015. The inclusion criterion was bimaxillary surgery without maxillary segmentation. The exclusion criterion was lack of a virtual surgical plan. The primary outcome variable was surgical accuracy, defined as the mean difference between the obtained outcome and the virtual surgical plan. The primary predictor variable was the comparison between mandible-first and maxilla-first sequencing. Secondary predictors were inferior maxillary repositioning and counterclockwise (CCW) rotation. The confounding variable was the virtually planned reposition. Results were analyzed by mixed-model regression encompassing all variables, followed by a detailed analysis of positive results using 2-sample t tests. RESULTS: Overall, 145 patients were included for analysis (98 women; mean age, 28 years). Operating on the mandible first notably influenced maxillary positioning and placed the maxilla 1.5 mm posterior and with 1.4° of CCW rotation compared with virtual surgical planning. The interaction of surgical sequence with maxillary rotation showed similar surgical accuracy between maxilla-first surgery with clockwise rotation and mandible-first surgery with CCW rotation. Inferior maxillary repositioning resulted in the maxilla being placed 1.7 mm (maxilla-first sequence) and 2.0 mm (mandible-first sequence) posterior to the planned position. CONCLUSION: Surgical accuracy was considerably influenced by sequencing in bimaxillary procedures. It remains important to know how the chosen sequence affects the surgical outcome so that the virtual surgical plan can be adjusted accordingly.

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.

A History of Orthognathic Surgery in North America.

This review highlights the contributions of American oral and maxillofacial surgeons to the field of orthognathic surgery. The present state of the art and science of orthognathic surgery is the harvest of yesterday's innovation and research. An improved understanding of the biological and surgical principles and the routine involvement of orthodontics have fueled widespread adoption of a coordinated approach to the treatment of dentofacial problems. Technologic advances in rigid internal fixation, virtual surgical planning with computer-aided manufacturing of occlusal splints and cutting guides, custom implants, and worldwide interest in the correction of dentofacial and craniofacial deformities have resulted in highly predictable, efficient, and safe treatment, which scarcely resembles the situation 70 years ago.

Patient-Specific Printed Plates Improve Surgical Accuracy In Vitro.

PURPOSE: It remains unclear to what extent patient-specific printed plates can improve surgical outcomes in orthognathic procedures. This study aimed to quantify the surgical accuracy of patient-specific printed plates in vitro and to compare the results with patients' actual surgical outcomes. PATIENTS AND METHODS: This in vitro study enrolled 20 postoperative orthognathic surgical patients, all treated with inferior maxillary repositioning. The preoperative midfaces were re-created in a 3-dimensionally printed model. The osteotomy and screw holes were placed at prespecified positions using a 3-dimensional guide. The dental segment was repositioned by means of the patient-specific plates. The primary outcome was the mean reposition at 3 dental reference points. The primary predictor variable was the obtained surgical reposition in vitro compared with the virtual surgical plan. Confounding variables were gender, age, occlusion, and bimaxillary surgery. The secondary outcome was surgical accuracy, and the secondary predictor was the in vitro outcomes versus the patients' surgical outcomes. Surgical accuracy was defined as the difference between the obtained reposition and the virtual surgical plan on a continuous scale. The differences were recorded in 3 dimensions according to the positive value of the 3 axes: right, anterior, and posterior. The results were analyzed using mixed-model regression and 1-sample t tests. RESULTS: In the 20 patients (age, 18 to 64 years; 40% of patients were women), the mean planned reposition was 2.9 mm anterior and 1.8 mm inferior. In all models, the osteotomy edge was rounded off to position the plate in the predetermined position. Overall, the maxilla was positioned 0.5 mm anterior and 0.3 mm inferior to the planned position using patient-specific plates. CONCLUSIONS: The patient-specific plates positioned the maxilla in close approximation to the planned position without surgically relevant differences. The osteotomy edge must be carefully inspected for interference with the patient-specific plates to avoid displacement of the planned maxillary repositioning.

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.

Surgical Navigation: A Systematic Review of Indications, Treatments, and Outcomes in Oral and Maxillofacial Surgery.

PURPOSE: This systematic review investigates the most common indications, treatments, and outcomes of surgical navigation (SN) published from 2010 to 2015. The evolution of SN and its application in oral and maxillofacial surgery have rapidly developed over recent years, and therapeutic indications are discussed. MATERIALS AND METHODS: A systematic search in relevant electronic databases, journals, and bibliographies of the included articles was carried out. Clinical studies with 5 or more patients published between 2010 and 2015 were included. Traumatology, orthognathic surgery, cancer and reconstruction surgery, skull-base surgery, and foreign body removal were the areas of interests. RESULTS: The search generated 13 articles dealing with traumatology; 5, 6, 2, and 0 studies were found that dealt with the topics of orthognathic surgery, cancer and reconstruction surgery, skull-base surgery, and foreign body removal, respectively. The average technical system accuracy and intraoperative precision reported were less than 1 mm and 1 to 2 mm, respectively. In general, SN is reported to be a useful tool for surgical planning, execution, evaluation, and research. The largest numbers of studies and patients were identified in the field of traumatology. Treatment of complex orbital fractures was considerably improved by the use of SN compared with traditionally treated control groups. CONCLUSIONS: SN seems to be a very promising addition to the surgical toolkit. Planning details of the surgical procedure in a 3-dimensional virtual environment and execution with real-time guidance can significantly improve precision. Among factors to be considered are the financial investments necessary and the learning curve.

African Americans in Oral and Maxillofacial Surgery: Factors Affecting Career Choice, Satisfaction, and Practice Patterns.

PURPOSE: There are few data available on the experience of minority surgeons in the field of oral and maxillofacial surgery (OMS). Therefore, the purpose of this study was to 1) explore factors that contribute to African Americans choosing OMS as a career, 2) examine satisfaction among minority oral and maxillofacial surgeons with the residency application and training process, 3) report on practice patterns among minority oral and maxillofacial surgeons, and 4) identify perceived bias for or against minority oral and maxillofacial surgeons in an attempt to aid the efforts of OMS residency organizations to foster diversity. MATERIALS AND METHODS: A 19-item survey was sent to 80 OMS practitioners by use of information from the mailing list of the National Society of Oral and Maxillofacial Surgeons, an American Association of Oral and Maxillofacial Surgeons-affiliated organization. All surveys were sent by mail and were followed by a reminder mailing after 8 weeks. Responses returned within 16 weeks were accepted for analysis. RESULTS: Of the 80 mailed surveys, 41 were returned within the 16-week parameter, representing a return rate of 51%. Most of the minority surgeon respondents were married men with a mean age of 60 years who worked as private practitioners. Most respondents practiced on the eastern and western coasts of the United States. Exposure in dental school was the most important factor in selecting OMS as a specialty. Location and prestige were the most important factors in selecting a residency program. Most respondents reported that race did not affect the success of their application to a residency program and did not currently affect the success of their practice. However, 25 to 46% of participants experienced race-related harassment, and 48 to 55% of participants believed there was a bias against African Americans in OMS. CONCLUSIONS: Our data suggest that a substantial number of minority oral and maxillofacial surgeons subjectively perceive race-based bias in their career, although it does not appear to affect professional success.

Surgical Splint Design Influences Transverse Expansion in Segmental Maxillary Osteotomies.

PURPOSE: In segmental maxillary procedures, it is imperative to obtain as much of the planned expansion as possible. Lack of obtained expansion, in addition to late relapse after splint removal, can result in relapse of the posterior crossbite. This study investigated the influence of 2 surgical splint designs on achieving the planned transverse expansion in bimaxillary surgery with segmental maxillary procedures. MATERIALS AND METHODS: Forty-two participants were included in a retrospective observational study. All participants had completed virtually planned bimaxillary surgery with 3-piece maxillary segmentation. The primary outcome variable was the transverse expansion obtained, measured as the expansion between the maxillary first molars on preoperative and postoperative cone-beam computed tomograms. The postoperative scan was performed 1 week after surgery with the splint still in place. To test measurement reliability, all measurements were performed twice by the same observer. The primary predictor variable was the planned expansion according to the virtual surgical plan. The primary covariate with influence on the obtained expansion was the surgical splint design. Other covariates of interest included patient age, patient gender, and surgeon. Descriptive and bivariate statistics were performed using Student t tests and linear regression analysis. RESULTS: Measurements showed high reliability, with an intraclass correlation coefficient of 0.99 and Bland-Altman plots without systematic errors. The obtained expansion was statistically different from the planned expansion (mean, -0.77 mm; standard deviation, 0.83). Surgical splint design meaningfully influenced transverse expansion: 77% of the planned expansion was obtained with high palatal coverage, whereas 50% was obtained with low palatal coverage. No other covariates influenced the expansion obtained. CONCLUSION: Not all the planned expansion is obtained during segmental bimaxillary surgery. Use of rigid surgical splints with high palatal coverage considerably improves the amount of expansion obtained and is recommended for segmental maxillary procedures.

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.

Accuracy of a computer-aided surgical simulation protocol for orthognathic surgery: a prospective multicenter study.

PURPOSE: The purpose of this prospective multicenter study was to assess the accuracy of a computer-aided surgical simulation (CASS) protocol for orthognathic surgery. MATERIALS AND METHODS: The accuracy of the CASS protocol was assessed by comparing planned outcomes with postoperative outcomes of 65 consecutive patients enrolled from 3 centers. Computer-generated surgical splints were used for all patients. For the genioplasty, 1 center used computer-generated chin templates to reposition the chin segment only for patients with asymmetry. Standard intraoperative measurements were used without the chin templates for the remaining patients. The primary outcome measurements were the linear and angular differences for the maxilla, mandible, and chin when the planned and postoperative models were registered at the cranium. The secondary outcome measurements were the maxillary dental midline difference between the planned and postoperative positions and the linear and angular differences of the chin segment between the groups with and without the use of the template. The latter were measured when the planned and postoperative models were registered at the mandibular body. Statistical analyses were performed, and the accuracy was reported using root mean square deviation (RMSD) and the Bland-Altman method for assessing measurement agreement. RESULTS: In the primary outcome measurements, there was no statistically significant difference among the 3 centers for the maxilla and mandible. The largest RMSDs were 1.0 mm and 1.5° for the maxilla and 1.1 mm and 1.8° for the mandible. For the chin, there was a statistically significant difference between the groups with and without the use of the chin template. The chin template group showed excellent accuracy, with the largest positional RMSD of 1.0 mm and the largest orientation RMSD of 2.2°. However, larger variances were observed in the group not using the chin template. This was significant in the anteroposterior and superoinferior directions and the in pitch and yaw orientations. In the secondary outcome measurements, the RMSD of the maxillary dental midline positions was 0.9 mm. When registered at the body of the mandible, the linear and angular differences of the chin segment between the groups with and without the use of the chin template were consistent with the results found in the primary outcome measurements. CONCLUSIONS: Using this computer-aided surgical simulation protocol, the computerized plan can be transferred accurately and consistently to the patient to position the maxilla and mandible at the time of surgery. The computer-generated chin template provides greater accuracy in repositioning the chin segment than the intraoperative measurements.

FcyRIIB is a novel immune checkpoint in the tumor microenvironment limiting activity of Treg-targeting antibodies.

Despite pre-clinical murine data supporting T regulatory (Treg) cell depletion as a major mechanism by which anti-CTLA-4 antibodies function in vivo, the two main antibodies tested in patients (ipilimumab and tremelimumab) have failed to demonstrate similar effects. We report analogous findings in an immunocompetent murine model humanized for CTLA-4 and Fcy receptors (hCTLA-4/hFcyR mice), where both ipilimumab and tremelimumab fail to show appreciable Treg depletion. Immune profiling of the tumor microenvironment (TME) in both mice and human samples revealed upregulation of the inhibitory Fcy receptor, FcyRIIB, which limits the ability of the antibody Fc fragment of human anti-CTLA-4 antibodies to induce effective antibody dependent cellular cytotoxicty/phagocytosis (ADCC/ADCP). Blocking FcyRIIB in humanized mice rescues Treg depleting capacity and anti-tumor activity of ipilimumab. For another target, CC motif chemokine receptor 8 (CCR8), which is selectively expressed on tumor infiltrating Tregs, we show that Fc engineering to enhance binding to activating Fc receptors, while limiting binding to the inhibitory Fc receptor, leads to consistent Treg depletion and single-agent activity across multiple tumor models, including B16, MC38 and MB49. These data reveal the importance of reducing engagement to the inhibitory Fc receptor to optimize Treg depletion by TME targeting antibodies. Our results define the inhibitory FcyRIIB receptor as a novel immune checkpoint limiting antibody-mediated Treg depletion in tumors, and demonstrate Fc variant engineering as a means to overcome this limitation and augment efficacy for a repertoire of antibodies currently in use or under clinical evaluation in oncology.

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.