International consensus recommendations on face transplantation: A 2-step Delphi study.

Face transplantation is a viable reconstructive approach for severe craniofacial defects. Despite the evolution witnessed in the field, ethical aspects, clinical and psychosocial implications, public perception, and economic sustainability remain the subject of debate and unanswered questions. Furthermore, poor data reporting and sharing, the absence of standardized metrics for outcome evaluation, and the lack of consensus definitions of success and failure have hampered the development of a "transplantation culture" on a global scale. We completed a 2-round online modified Delphi process with 35 international face transplant stakeholders, including surgeons, clinicians, psychologists, psychiatrists, ethicists, policymakers, and researchers, with a representation of 10 of the 19 face transplant teams that had already performed the procedure and 73% of face transplants. Themes addressed included patient assessment and selection, indications, social support networks, clinical framework, surgical considerations, data on patient progress and outcomes, definitions of success and failure, public image and perception, and financial sustainability. The presented recommendations are the product of a shared commitment of face transplant teams to foster the development of face transplantation and are aimed at providing a gold standard of practice and policy.

Application of Facial Artery Perforator Flap in Nasal and Perinasal Reconstruction.

This paper reports the results of an observational study in 23 patients to evaluate the application of the facial artery perforator flap in nasal and perinasal reconstruction after skin cancer surgery. In the long term, all flaps survived, and the patients achieved satisfactory esthetic reconstruction without functional alterations or major complications. Immediately postoperatively, 2 flaps presented early venous congestion, and 1 had minor superficial skin necrosis that healed without additional intervention. In 3 cases, it was combined with a second simultaneous local flap for synchronous or extensive skin tumors. The facial artery perforator flap is a reliable and versatile option that can be considered the preferred alternative for single-stage restorations of complex small to medium-sized nasal and perinasal defects that allow reconstruction of both external and internal nasal structures.

Trends in mortality rates for oral and oropharyngeal cancer in Spain, 1979-2018.

OBJECTIVE: To analyse mortality rate trends in Spain for oral cavity and oropharyngeal cancer (OCOPC) from 1979 to 2018, evaluating differences between oral cavity cancer (OCC) and oropharyngeal cancer (OPC). MATERIALS AND METHODS: Death certificates and mid-year population data were collected from the Spanish National Statistics Institute. Age-standardized mortality rates were calculated using the direct method. Joinpoint regressions were used to identify significant changes in mortality trends. Independent effects of age, period and cohort (APC) were estimated. RESULTS: A total of 52,057 deaths were registered from OCOPC, 38,988 from OCC and 13,069 from OPC between 1979 and 2018. While OCC mortality rates declined, OCOPC rates increased slightly and OPC significantly. OCC and OPC mortality reached their highest values between 1979 and 1992, when OCC rates began to decrease in males and OPC levelled off until 2018. Lip cancer suffered the highest drop. APC models showed a mortality increase in males and females from 40 to 45 and 50 to 55 years of age, respectively. CONCLUSIONS: Favourable OCC mortality trends was plausibly influenced by decreased tobacco/alcohol consumption, while OPC rise was probably associated with increased human papillomavirus infection. The importance of closely monitoring these cancers by age group, sex and location, and continuing with preventive measures against known risk factors, is highlighted.

Neurotrophic Keratitis in a Pediatric Patient With Goldenhar Syndrome and Trigeminal Aplasia Successfully Treated by Corneal Neurotization.

Herein, the authors report an unusual case of a 6-year-old boy with right-sided Goldenhar syndrome and trigeminal nerve aplasia who developed neurotrophic keratopathy (NK). Despite the use of therapeutic contact lenses and multiple temporary tarsorrhaphy, NK worsened showing a central corneal scar, neovascularization, and significant stromal thinning, with risk of corneal perforation. Cochet-Bonnet esthesiometry revealed complete corneal anesthesia. To minimize additional corneal complications, the patient underwent indirect corneal neurotization by a sural nerve autograft anastomosed to the contralateral supratrochlear nerve. At 24-month follow up, no epithelial defects, complications, or recurrence were observed. Significant improvements in corneal sensitivity with esthesiometry score of 20 mm and reflex blinking were achieved. This case highlights corneal anesthesia should be suspected among Goldenhar syndrome ophthalmologic abnormalities and monitored before corneal changes become irreversible. Since corneal neurotization can successfully improve corneal sensation, it could be considered as an early therapeutic option to avoid refractory NK.

Estimated projection of oral cavity and oropharyngeal cancer deaths in Spain to 2044.

BACKGROUND: Oral cavity cancer (OCC) and oropharyngeal cancer (OPC) are two common malignancies whose mortality is worryingly increasing worldwide. However, few studies have estimated the mortality trends for these cancers in the coming years. This study analysed the mortality rates for OCC and OPC observed between 1980 and 2019 to generate a predictive model for the next 25 years in Spain. METHODS: Mid-year population data and death certificates for the period 1980-2019 were obtained from the Spanish National Institute of Statistics. The Nordpred program (Norwegian Cancer Registry, Oslo, Norway) was used to calculate adjusted mortality rates as well as estimated mortality projections with an age-period-cohort model for the period 2020-2044. RESULTS: The specific mortality rate per 100,000 inhabitants for OCC decreased from 2.36 (1980-1984) to 2.17 (2015-2019) and is expected to decline to 1.68 (2040-2044), particularly in males. For OPC, mortality rates rose from 0.67 (1980-1984) to 1.23 (2015-2019) and are projected to drop to 0.71 (2040-2044). In the group of females > 65 years predictions showed rising mortality rates for both OCC and OPC. The predictive model projects more deaths in females than in males for OCC in the period 2040-2044, while deaths for OPC will decrease in males and gradually increase in females. CONCLUSIONS: Although OCC mortality rates have been found to decrease in males in the last observed decades, there is still room to improve them in females > 65 years in the future by promoting campaigns against smoking and alcohol consumption. OPC mortality will become a growing health problem. Vaccination campaigns for the prevention of human papillomavirus-associated cancers may have a long-term impact on the mortality of these cancers, which should be evaluated in upcoming studies. CLINICAL RELEVANCE: Our findings highlighted the importance of closely monitoring OCC and OPC mortality rates in the coming years by age group and sex, and the need to continue preventive measures against the main known risk factors, such as tobacco, alcohol, and human papillomavirus infection.

Quality of life in early age Spanish children treated for cleft lip and/or palate: a case-control study approach.

OBJECTIVE: The objectives of this study were to evaluate health-related quality of life (HRQoL) in 4-7-year-old children treated for cleft lip and/or palate (CL/P) compared to healthy controls and to estimate a possible association with cleft type, gender, age, and surgical re-interventions. MATERIALS AND METHODS: A total of 171 children with CL/P (mean age 5.7 years) and 186 healthy controls (mean age 5.5 years) were included in the study. Sixty-four (37.4%) children experienced both cleft lip and palate, 56 (32.8%) cleft lip only, and 51 (29.8%) cleft palate only. HRQoL in children was assessed by Kiddy-KINDL and COHIP-14 questionnaires and in parents by KINDL-p. Total score and dimensions of each questionnaire were compared between cleft children, their parents, and controls. RESULTS: The total scores and dimension scores of Kiddy-KINDL showed similar values between CL/P and control groups, except for "self-esteem" dimension (p = 0.036). The comparison of Kiddy-KINDL and KINDL-p showed a statistically significant total score (82.11 vs. 80.44, p = 0.047). The CL/P group presented significantly worse values with respect to controls in total score of COHIP-14 (10.53 vs 5.01, p < 0.001) and in all its dimensions. CONCLUSIONS: Children treated for CL/P had a negative impact on HRQoL at early age compared to controls. Significant differences were found in the psychological and functional dimensions related to lip and palatal affectation, respectively. Parents reported significantly worse scores than their children. HRQoL measurement provided valuable complementary information to better inform to parents and make clinical decisions in children with CL/P at early age. CLINICAL RELEVANCE: Our findings suggested that Spanish children between 4 and 7 years of age with a history of surgically treated CL/P experienced a poorer HRQoL when compared with their non-cleft peers.

Application of Human Amniotic Membrane in Temporomandibular Joint Osteoarthritis.

Human amniotic membrane (HAM) has recently been used as an interpositional material to prevent ankylosis or primary re-ankylosis after temporomandibular joint (TMJ) arthroplasty. Here, the authors describe an unusual case of a 32-year-old woman who presented with a noninflammatory degenerative osteoarthritis of the TMJ in which a HAM was placed following a high condylar arthroplasty and discectomy and show the clinicoradiological results. The procedure resulted in total pain relief and significant improvement in jaw movements. On the long-term follow-up computed tomography, complete remodeling of the glenoid fossa with formation of new ectopic bone was observed. While the application of a HAM can be an alternative procedure to prevent ankylosis when performing a discectomy and arthroplasty, this clinical report highlights the possibility that it can induce ectopic bone formation at this location.

Facial Donor Restoration: One-Step Technique.

PURPOSE: Successful management of facial allotransplantation requires planning and overcoming a long list of obstacles, not least, the restoration of the donor cadaver (DC). MATERIALS AND METHODS: We have presented an innovative single-step facial reconstruction technique for the DC using light-curing material to simplify the infrastructure needs and optimize the time and costs associated with traditional facial restoration techniques reported to date. We also developed a study based on the creation of 7 facial masks over a white male formaldehyde-preserved cadaver head to evaluate the production time of the mask, likeness to the original face, temperature, and adaptation of the mask to the defect. RESULTS: The average time for the adjustment of the light-curing resin sheets over the DC, photopolymerization, and cosmetic adjustment and application over the facial defect was 5, 4, and 16.4 minutes, respectively, for a global average time of 25.4 minutes. In all cases, the likeness to the original was good, and the average temperature over the donor area was 19.8°C. The adaptation of the mask to the facial defect was accurate in all cases. CONCLUSIONS: The presented one-step technique proposed for facial restoration of the DC had a short learning curve, low costs, and accurate and predictable results.

Mandibular Fracture as First Sign of an Occult Intraosseous Hemangioma.

Intraosseous hemangioma (IH) in the maxillofacial area is a very uncommon neoplasm. Here, the authors show an exceptional case not previously reported in the literature of a 65-year-old man who presented with a pathological mandibular fracture following a facial trauma that was the first sign of an occult cavernous IH. Complete excision of the tumor in the mandibular ramus reduced the risk of severe bleeding and prevented long-term recurrence, whereas immobilization of the fracture obtained an excellent functional result. This clinical report highlights the possibility that a previously unknown primary IH may debut as a pathological fracture and the importance of differential diagnosis in this location.

Extragingival Pregnancy Pyogenic Granuloma on the Lip.

Pregnancy pyogenic granuloma is considered a benign common growth that usually develops on the gingiva in the second and third trimester of gestation, in response to local irritation, trauma or hormonal factors. Here, the authors report a case of a primigravida who presented an extragingival pyogenic granuloma with a rapid progression in the post-partum. The occurrence on the lower lip in the first few days after delivery was a relatively rarity in the present case which provoked a meaningful state of anxiety and cancerophobia to the female. Complete excision was curative and brought immediate relief of pain and discomfort. This clinical report highlights the possibility of pyogenic granuloma presenting like a rapid-growing mass on the lip and the importance of clinical differential diagnosis of such presentation in this atypical location.

Effectiveness of facial exercise therapy for facial nerve dysfunction after superficial parotidectomy: a randomized controlled trial.

OBJECTIVES: To compare the effectiveness of a daily home-based facial exercise therapy with a supervised rehabilitation technique for the treatment of postoperative facial dysfunction in patients undergoing conventional superficial parotidectomy. DESIGN: Prospective, randomized trial, controlled. SETTING: Surgery and Rehabilitation Units, university hospital. SUBJECTS: Consecutive patients ( n=79, mean age 48 years) who underwent superficial parotidectomy with facial nerve dissection were randomly divided into two groups. INTERVENTION: Control group (CG) were given a daily homework manual to perform ordinary postoperative facial mimic exercises autonomously in front of the mirror at home. Experimental group (EG) patients with moderate-severe paresis received supervised rehabilitation therapy that consisted in weekly sessions with facial exercises and massages and performed daily facial exercises at home. EG patients with slight paresis were instructed to undertake self-massage and mirror exercises. MAIN OUTCOME MEASURES: Postoperative dysfunction of facial nerve and branches was quantified measuring the prevalence, magnitude and duration of paresis by the House-Brackmann Facial Nerve Grading System up to 12th months. RESULTS: Facial paresis incidence at 1st week was 77.2%, being the marginal-mandibular nerve the most affected (64.5%). No statistically significant differences were found at any time of the study when comparing the frequency, magnitude and duration of paresis between EG and CG and among patients who had presented moderate-severe paresis. In the absence of intraoperative nerve injury, complete recovery of facial mobility was observed within 12 months, regardless of treatment group. CONCLUSION: Rehabilitation therapy and mirror facial exercises performed autonomously at home were equally effective for postoperative functional recovery.

Sentinel Lymph Node Biopsy in Oral and Oropharyngeal Squamous Cell Carcinoma: Statistical Validation and Impact of Micrometastasis Involvement on the Neck Dissection Decision.

PURPOSE: To evaluate the effectiveness of sentinel lymph node biopsy (SLNB) as an optimal staging method in oral and oropharyngeal squamous cell carcinoma (OOSCC) and the impact of the extent of SLN involvement on the decision for neck dissection (ND). MATERIALS AND METHODS: A prospective cohort study was performed in 96 consecutive patients with stage T1 to T4N0M0 OOSCC (mean follow-up, 62.9 months). SLN localization was determined using cervical lymphoscintigraphy and single-photon emission computed tomography. Patients underwent SLNB examination and ND. The ND specimen was investigated by hematoxylin and eosin (H&E) staining and the SLNs were investigated using H&E staining and step-serial sectioning and cytokeratin antibodies AE1 and AE3. The statistical study calculated the sensitivity and negative predictive value (NPV). The sample size of 96 patients was calculated for a 95% confidence interval with an accuracy of ±2% and an estimated a priori sensitivity of 99% compared with the benchmark. The impact of extent of SLN involvement on the decision for ND was analyzed by χ(2) test. A logistic regression model was used to assess the association of predictor variables with SLN involvement and neck disease. RESULTS: The diagnostic accuracy, sensitivity, NPV, and negative likelihood ratio were 95%, 88%, 94%, and 0.06. The statistical comparison between the extent of metastatic involvement of the SLN and neck disease was important for SLN macrometastasis (odds ratio = 11.9), but not for SLN micrometastasis (odds ratio = 0.93). CONCLUSIONS: SLNB examination is an excellent staging method in OOSCC. The present data indicate a very small risk of additional lymph node metastasis with SLN micrometastasis.

Deep dry needling of trigger points located in the lateral pterygoid muscle: Efficacy and safety of treatment for management of myofascial pain and temporomandibular dysfunction.

BACKGROUND: To determine whether deep dry needling (DDN) of trigger points (TPs) in the lateral pterygoid muscle (LPM) would significantly reduce pain and improve function, compared with methocarbamol/paracetamol medication. MATERIAL AND METHODS: Forty-eight patients with chronic myofascial pain located in the LPM were selected and randomly assigned to one of two groups (DDN test group, n=24; drug-treated control group, n=24). The test group received three applications of needling of the LPM once per week for three weeks, while control group patients were given two tablets of a methocarbamol/paracetamol combination every six hours for three weeks. Assessments were carried out pre-treatment, 2 and 8 weeks after finishing the treatment. RESULTS: A statistically significant difference (p<0.05) was detected for both groups with respect to pain reduction at rest and with mastication, but the DDN test group had significantly better levels of pain reduction. Moreover, statistically significant differences (p<0.05) up to day 70 in the test group were seen with respect to maximum mouth opening, laterality and protrusion movements compared with pre-treatment values. Pain reduction in the test group was greater as a function of pain intensity at baseline. The evaluation of efficacy as assessed both by patients/investigators was better for the test group. 41% of the patients receiving the combination drug treatment described unpleasant side effects (mostly drowsiness). CONCLUSIONS: DDN of TPs in the LPM showed better efficacy in reducing pain and improving maximum mouth opening, laterality, and protrusion movements compared with methocarbamol/paracetamol treatment. No adverse events were observed with respect to DDN.

Virtual reality AYRA software for preoperative planning in facial allotransplantation.

PURPOSE: The purpose of this study was to validate a virtual reality software for the recording of anthropometric measurements as a first step towards matching donors with recipients in the preoperative planning process which precedes the harvest of a facial allograft. METHODS: Anthropometric measurements of both soft and bone tissue were recorded in 5 cryopreserved human heads to compare conventional analogue measurements with digital measurements obtained from 3-dimensional (3D) reconstructions produced using AYRA software. To test the degree of correlation between both measuring methods, intraclass correlation coefficient (ICC) was applied to each pair of measurements. RESULTS: ICCs calculated were greater than 0.6 (substantial or almost perfect correlation) for all of the pairs of variables, with the exception of 2 of the measurements studied in bone tissue. CONCLUSIONS: In facial transplantation, preoperative planning is crucial to select an allograft whose anatomical compatibility with the recipient defect is as close as possible. The dimensions of the potential face donor must be congruent to ensure the procedure's feasibility and the adequate insertion of the allograft into the defect. The recording of anthropometric measurements with the virtual reality software displayed an equivalent correlation to those produced using a conventional analogue method. The 3D reconstructions obtained by using a virtual reality software can play a useful role to facilitate the characterization of the donor face.

Maxillomandibular osteomyelitis associated with osteopetrosis.

Osteopetrosis is a heterogeneous disorder characterized by abnormal bone remodeling and increased bone density primarily due to defective osteoclast resorption. The diagnosis is based on a history of numerous fractures and radiological findings indicative of osteosclerosis, usually sufficient for a definitive diagnosis. We present a quite rare case of osteopetrosis complicated by recurrent episodes of maxillomandibular osteomyelitis associated with cutaneous fistulization and purulent nasal discharge. We used intravenous antibiotic therapy and necrotic bone debridement that prevented the appearance of acute infections over a 3-year follow-up, but the complete healing of the case was not achieved.

Long-Term Clinical Outcomes in Patients with Chronic Rhinosinusitis with Nasal Polyps Associated with Expanded Types of Endoscopic Sinus Surgery.

(1) Background: Surgical criteria for chronic rhinosinusitis with nasal polyps (CRSwNP) remain unresolved. This study addresses these discrepancies by comparing the clinical outcomes of expanded-functional endoscopic sinus surgeries (E-FESS) with more-limited FESS (L-FESS). (2) Methods: A database was analyzed retrospectively to compare surgical outcomes in CRSwNP patients who underwent E-FESS versus those subjected to L-FESS. Quality of life, endoscopic and radiological outcomes were compared at the baseline and two years after surgery. The clinical status of the responder was defined when a minimal clinically important difference of 12 points in SNOT-22 change was achieved. (3) Results: A total of 274 patients met the inclusion criteria and were analyzed; 111 underwent E-FESS and 163 were subjected to L-FESS. Both groups exhibited significant clinical improvements, although a greater magnitude of change in SNOT-22 (14.8 ± 4.8, p = 0.002) was shown after E-FESS. Higher significant improvements for endoscopic and radiological scores and lower surgical revision rates were also noted in the E-FESS group. (4) Conclusions: E-FESS provides better clinical outcomes and reduced revision surgery rates when compared to L-FESS in CRSwNP patients two years after surgery, irrespective of any comorbidity. Further randomized prospective studies are needed to comprehensively contrast these results.

Facial transplantation: a concise update.

OBJECTIVES: Update on clinical results obtained by the first worldwide facial transplantation teams as well as review of the literature concerning the main surgical, immunological, ethical, and follow-up aspects described on facial transplanted patients. STUDY DESIGN: MEDLINE search of articles published on "face transplantation" until March 2012. RESULTS: Eighteen clinical cases were studied. The mean patient age was 37.5 years, with a higher prevalence of men. Main surgical indication was gunshot injuries (6 patients). All patients had previously undergone multiple conventional surgical reconstructive procedures which had failed. Altogether 9 transplant teams belonging to 4 countries participated. Thirteen partial face transplantations and 5 full face transplantations have been performed. Allografts are varied according to face anatomical components and the amount of skin, muscle, bone, and other tissues included, though all were grafted successfully and remained viable without significant postoperative surgical complications. The patient with the longest follow-up was 5 years. Two patients died 2 and 27 months after transplantation. CONCLUSIONS: Clinical experience has demonstrated the feasibility of facial transplantation as a valuable reconstructive option, but it still remains considered as an experimental procedure with unresolved issues to settle down. Results show that from a clinical, technical, and immunological standpoint, facial transplantation has achieved functional, aesthetic, and social rehabilitation in severely facial disfigured patients.