Bilateral sagittal split osteotomy-parameters and correlations of postoperative pain management.

OBJECTIVES: Postoperative pain management is of utmost interest for patients undergoing orthognathic surgery. Currently, there is a lack of information regarding process and outcome parameters of postoperative pain management after bilateral sagittal split osteotomy. MATERIALS AND METHODS: In a prospective clinical study, 31 adults were evaluated on the first postoperative day following bilateral sagittal split osteotomy using the standardized questionnaire of the Germany-wide project Quality Improvement in Postoperative Pain Management (QUIPS). It allows a standardized assessment of patients' characteristics, pain parameters, outcome, and pain therapy process parameters. RESULTS: Pain management consisted mainly of premedication with midazolam, sufentanil, and metamizol intraoperatively; piritramide in the recovery room; and metamizol and tramadol on ward. Twenty patients (64.5%) showed inadequate pain management with pain levels ≥4. Patients receiving tramadol as opioid on ward presented significantly higher maximum pain levels (p = .037). Significantly lower satisfaction with postoperative pain intensity (p > .001) and significantly higher desire for additional pain medication (p = .023) were detected, when duration of surgery was above the median of 107.5 min. CONCLUSIONS: Inadequate pain management on the first postoperative day following bilateral sagittal split osteotomy was widespread on our ward. QUIPS helped us to identify it and thereby gave us the possibility to improve the situation. Prolonged duration of surgery seems to be a predictor of an elevated postoperative pain medication demand. CLINICAL RELEVANCE: Only the establishment of an ongoing monitoring of postoperative pain management can help to reduce or even avoid inadequate postoperative pain management. In accordance to the existing literature, we found inadequate postoperative pain management more widespread than thought.

A small 'lick' will sink a great ship: fulminant septicaemia after dog saliva wound treatment in an asplenic patient.

Capnocytophaga canimorsus is a bacterium transmitted through the saliva of dogs. An infection can cause severe sepsis with acral necrosis and is potentially fatal. Here, we report the case of a 41-year-old man who was infected through a wound that was licked by his dog. He went into septic shock with disseminated intravascular coagulation and subsequently lost both lower legs, his nose and all the fingers on both hands.

Poly Implant Prothèse and Rofil Substandard Breast Implant Explantations from a Large German Single Centre from 2011 to 2014: A Comparative Study.

BACKGROUND: Following a Europe-wide scandal, substandard breast implants containing silicone for industry purposes produced by Poly Implant Prothèse (PIP&Rofil) were explanted due to its potential health risks. OBJECTIVE: We investigated whether these implants actually imposed a threat to patients' health. METHODS: In this retrospective single-centre case-control study, we compared patients with breast augmentation receiving implant explantation (01/2011-01/2015). Data were collected retrospectively from the patients' records. Patients were split into two groups: PIP&Rofil and implants of other manufacturers. RESULTS: A total of 307 patients with 495 breast implants met the inclusion criteria, 64 patients with 115 PIP&Rofil implants and 243 patients with 380 implants of other manufacturers. Comparison of descriptive statistics between the two groups revealed that for a variety of indicators (e.g. patient age, breast cancer, aesthetic vs. reconstructive indication, implant volume, submuscular vs. subglandular implant position) PIP implants differ from non-PIP implant patients. Raw mean comparison showed higher rupture rates for non-PIP implants, 28.42 % (PIP 23.48 %). However, when controlling for implant indwelling time, PIP implants had shown higher rupture rates. Both groups had similar rates of capsular contracture (PIP: 71.30 %, Others: 72.63 %) with different distribution of Baker Scores (Baker 2/3/4: PIP 5/8/13 and non-PIP 3/24/135). CONCLUSION: Concerning patient symptoms, we did not find any objective reason to justify implant explantation of PIP&Rofil implants as a solely precautionary measure. As PIP&Rofil implants showed shorter retention periods until rupture and ruptured implants can cause symptoms or health problems, PIP&Rofil implants should be regularly monitored and explanted if there is evidence of rupture. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Morphologic outcome of bimaxillary surgery--an anthropometric appraisal.

OBJECTIVES: To adequately perform orthognathic surgery procedures, it is from basic interest to understand the morphologic changes caused by orthognathic surgery. Anthropometric analyses of standardized frontal view and profile photographs could help to investigate and understand such changes. STUDY DESIGN: We present a pre- to postoperative evaluation of orthognathic surgery results based on anthropometric indices described by Farkas and cephalometric measurements. 30 Class III patients undergoing maxillary advancement by Le Fort I Osteotomy and mandibular setback by bilateral sagittal split osteotomy were evaluated. Preoperative as well as three and nine months postoperative lateral cephalograms as well as standardized frontal view and profile photographs were taken. On the photographs 21 anthropometric indices given by Farkas were evaluated. In cephalograms SNA and SNB angle as well as Wits appraisal were investigated. RESULTS: The investigated anthropometric indices showed a significant increase of the vertical height of the upper lip without changing the relation of the upper vermilion to the cutaneous upper lip. The lower vermilion height increased relatively to the cutaneous lower lip without vertical changes in the lower lip. Due to maxillary advancement the upper face height increased meanwhile the lower face height decreased due to mandibular setback. SNA and SNB angle and Wits appraisal showed typical changes related to surgery. CONCLUSIONS: The investigated photo-assisted anthropometric measurements presented reproducible results related to bimaxillary surgery.

Soft tissue outcome after mandibular advancement--an anthropometric evaluation of 171 consecutive patients.

OBJECTIVES: There is an ongoing discussion in the literature about preoperative planning and postoperative evaluation of orthognathic surgery and its impact on facial appearance and aesthetics. MATERIALS AND METHODS: We present an anthropometric and cephalometric evaluation of orthognathic surgery results based on reference anthropometric data. In 171 Class II patients, mandibular advancement by bilateral sagittal split osteotomy was performed. Preoperative as well as 3 and 9 months postoperative standardized frontal view and profile photographs and lateral cephalograms were evaluated in a standardized manner by use of 21 anthropometric indices. In cephalograms, SNA and SNB angle as well as Wits appraisal were investigated. Results of anthropometric and cephalometric measurements were correlated. RESULTS: Lower vermilion contour, vermilion and cutaneous total lower lip height, nose-lower face height, nose-face height, upper face-face height, upper lip- and chin-mandible height index showed significant pre- to postoperative changes as well as SNB angle and Wits appraisal. Furthermore, medial-lateral cutaneous upper lip height, vermilion and cutaneous total lower lip height and philtrum-mouth width index presented significant correlations to cephalometric measurements. CONCLUSIONS: The investigated anthropometric indices and cephalometric measurements presented reproducible results related to surgery. The correlation of cephalometric to anthropometric measurements has been proven useful for preoperative planning and postoperative evaluation of orthognathic surgery patients. CLINICAL RELEVANCE: The presented anthropometric measurements and their observed correlation to cephalometric measurements could lead to a better prediction and optimized planning of the soft tissue result in orthognathic surgery patients and thereby improve the aesthetic outcome.

Long-term outcomes of Gillies and McLaughlin's dynamic muscle support in irreversible facial paralysis: A retrospective single-centre study with 25-year follow-up.

The aim of this study was to evaluate the long-term outcomes of Gillies and McLaughlin's dynamic muscle support with regard to functional outcomes and assess possible effects of comorbidities on both functional outcomes and reoperation and complication rates. A retrospective single-centre study was conducted in all patients (n = 154) who underwent surgical correction of irreversible facial paralysis from 1994 to 2018. Patients with either Gillies procedure or McLaughlin's dynamic muscle support or a combination of these techniques were included in the analysis. Data on reoperations, comorbidities, complications, functional outcomes and patient satisfaction were analysed. Sixty-nine patients had Gillies and McLaughlin combination, 12 patients had Gillies and 33 patients had McLaughlin procedure alone. Patient satisfaction was generally high (>80%) and highest when McLaughlin procedure alone was performed and in patients without comorbidities. Reoperations were performed in 80 patients (70%; mean 2.2 ±â€¯1.7) and complications affected 16 patients (14%). Smile ability and movement control of the corner of the mouth were achieved in >85% of patients operated, whereas complete eyelid closure and facial symmetry at rest were attained in only 46%‒68% of patients. Patients with no underlying medical conditions were able to smile more often, had motor control of the corner of the mouth, better facial symmetry at rest and fewer complications. Although newer surgical techniques are offered in many centres, this study shows that conventional facial reanimation of irreversible facial paralysis with Gillies or McLaughlin's dynamic muscle support or a combination of both produces yield good results and, therefore, continues to be a viable treatment option for many patients.

Presence of Biofilms on Polyurethane-Coated Breast Implants: Preliminary Results.

Polyurethane-coated breast implants seem to be associated with lower medium- and long-term capsular contracture rates in comparison to textured or smooth implant surfaces. Although the etiology of capsular contracture is uncertain, bacterial biofilms have been suggested to trigger chronic peri-implant inflammation, eventually leading to capsular contracture. It is unknown whether polyurethane-coated implants are less prone to biofilm colonization than other implant surfaces. We extracted data from patient records included in a prospective cohort between 2008 and 2011. All patients who underwent removal of polyurethane-coated implants were included in this current study and screened for presence of biofilms by sonication. In addition, implant- and patient-related data were analyzed. Of the ten included polyurethane-coated breast implants, six had been inserted for reconstructive purposes and four for aesthetic reasons. The median implant indwelling time was 28.3 mo. Overall, sonication cultures were positive in 50% of implants. Propionibacterium acnes and coagulase-negative staphylococci were the predominant pathogens isolated from biofilm cultures. Like other implant surfaces, polyurethane-coated implants are prone to biofilm colonization. Further investigations are needed to determine why capsular contracture rates seem to be lower in polyurethane implants than in other implant surfaces. Notably, in this study, 40% of the implants were explanted from breasts with severe capsular contracture.

Perioral aging--an anthropometric appraisal.

To adequately perform perioral rejuvenation procedures, it is necessary to understand the morphologic changes caused by facial aging. Anthropometric analyses of standardized frontal view and profile photographs could help to investigate such changes. Photographs of 346 male individuals were evaluated using 12 anthropometric indices. Data from two groups of health subjects, the first exhibiting a mean age of nearly 20 and the second of nearly 60 years, were compared. To evaluate the influence of combined nicotine and alcohol abuse, the data of the second group were compared to a third group exhibiting a similar mean age who were known alcohol and nicotine abusers. Comparison of the first to the second group showed significant decrease of the vertical height of upper and lower vermilion and relative enlargement of the cutaneous part of upper and lower lips. This effect was stronger in the upper vermilion and medial upper lips. The sagging of the upper lips led to the appearance of an increased mouth width. In the third group the effect of sagging of the upper lips, and especially its medial portion was significantly higher compared to the second group. The photo-assisted anthropometric measurements investigated gave reproducible results related to perioral aging.

Evaluation of nasal reconstruction procedures results.

Before undergoing a reconstructive procedures of the nose most patients ask how they will look postoperatively. Anthropometric measurements of the nose described by Farkas represent standard values. A comparison of pre- and postoperative anthropometric measurements may help to double-check the correctness of intraoperative "eye-balling" measurements with regards to postoperative appearance. Sixty-three patients underwent reconstruction of nasal ala, tip or dorsum. An analysis of standardized pre- and postoperative photographs included measurements of nose width, nose height, nasal tip protrusion, columella width, ala length, intercanthal width, mouth width, philtrum width, upper lip height, lateral upper lip height, cutaneous upper lip height and upper face height. Preoperative measurements were compared to data given by Farkas in young adults. Postoperative changes were evaluated clearly distinguishing between reconstruction of nasal ala, tip and dorsum. All anthropometric indices showed significant differences compared to the Farkas population. There was no significant pre- to postoperative change in any reconstructed region observed, indicating adequate intraoperative measurements. The application of Farkas' anthropometric measurements described in this study showed reliable and objective results and can help to double-check the previous intraoperative measurements. The correct application of these surgical techniques leads to a satisfying and near to normal postoperative look of the patient.