Immediate Inferior Alveolar Nerve Reconstruction With Ablative Mandibular Resection Results in Functional Sensory Recovery.

BACKGROUND: Ablative mandibular resection with sacrifice of the inferior alveolar nerve (IAN) results in loss of sensation and decreased quality of life. PURPOSE: The purpose of this study is to evaluate functional sensory recovery (FSR) of immediate IAN allograft reconstruction performed during ablative mandibular resection at 1 year following surgery. STUDY DESIGN, SETTING, SAMPLE: This is a single-center retrospective cohort study that included consecutive subjects who underwent mandibular resection with IAN discontinuity and used a nerve allograft of ≥40 mm. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: The primary predictor variable is the use of an immediate nerve allograft in mandibular reconstruction. MAIN OUTCOME VARIABLE(S): The main outcome variable is FSR at 1 year using the Medical Research Council Scale. COVARIATES: Covariates include subject age, sex, specific pathology, nerve gap length, and development of neuropathic pain. ANALYSES: Statistical analysis of comparison of neurosensory outcomes was measured by bivariate statistics, weighted values, repeated measures, analysis of variance, and McNemar test. RESULTS: The study sample was composed of 164 subjects, of whom 55 (33.5%) underwent nerve allograft reconstruction and 30 (18.3%) did not have nerve reconstruction. Seventy-nine subjects (48.2%) did not meet the inclusion criteria. In the entire nerve allograft group of 55 subjects, FSR was achieved in 80% at 1 year; however, in benign disease alone, 31 of 33 (94%) achieved FSR at 1 year. In the nonallograft group (all benign disease), only 2 of 30 (7%) achieved FSR at 1 year. The significant covariates were age and pathology. Benign pathologic resections were 5.2 times more likely to achieve FSR than malignancies, and all subjects ≤ 18 years of age achieved FSR. After adjusting for age, sex, pathology, nerve gap length, nerve allograft was significantly associated with achieving FSR at 1 year (adjusted odds ratio = 5.52, 95% confidence interval = (1.03, 29.51), P value = .045 < .05). CONCLUSION AND RELEVANCE: Immediate long-span IAN allograft reconstruction is effective in restoration of sensation with an overall 80% of subjects achieving FSR at 1 year, while benign disease resulted in 94% FSR at 1 year. Immediate IAN reconstruction should be considered with mandibular resection involving the IAN, especially for children and benign disease.

Bimaxillary Immediate Prosthetic Rehabilitation Using a Custom Maxillary Subperiosteal Implant and Fibula-Free Flap Mandibular Reconstruction After Tumor Ablation.

Subperiosteal implants (SPIs) using rigid fixation have recently emerged as an acceptable alternative to conventional endosteal implants when there is limited or absent alveolar bone. Modern advances in digital technology and manufacturing have improved the usability and stability of this latest generation of SPIs. Herein, we present the first reported case of a modern patient-specific SPI placed in the United States and, to the authors' knowledge, the first reported case performed in conjunction with a simultaneous free flap reconstruction of the opposing arch, and immediate dental rehabilitation of both arches in the world.

Contemporary Surgical Management of Craniofacial Fibrous Dysplasia Using Computer-Assisted Surgery and Intraoperative Navigation.

Craniofacial fibrous dysplasia (CFD) is a rare developmental disease of bone, which typically presents as a painless, expansile mass causing deformity of the craniofacial skeleton. In rare circumstances, compression of neurovascular structures may arise, causing symptoms such as pain, visual impairment, and hearing loss. Traditionally, CFD debulking has been performed with "freehand" techniques using preoperative imaging and anthropometric norms to determine the ideal amount of tissue removal. The advent of computer-assisted surgery, computer-aided design, and computer-aided manufacturing (CAD/CAM) has revolutionized the management of CFD. Surgeons can now fabricate patient-specific osteotomy/ostectomy guides, allowing for increased accuracy in bone removal and improved cosmetic outcomes. This series of 3 cases describe our institution's technique using patient-specific ostectomy "depth guides", which allow for maximum removal of fibro-osseous tissue while sparing deep and adjacent critical structures. These techniques can be widely applied to the craniofacial skeleton to assist in the surgical management of CFD.

Association of pre-treatment lymphocyte-monocyte ratio with survival outcome in patients with head and neck cancer treated with chemoradiation.

BACKGROUND: Given the role of systematic inflammation in cancer progression, lymphocyte-monocyte ratio (LMR) from peripheral blood has been suggested as a biomarker to assess the extent of inflammation in several solid malignancies. However, the role of LMR as a prognostic factor in head and neck cancer was unclear in several meta-analyses, and there is a paucity of literature including patients in North America. We performed an observational cohort study to evaluate the association of LMR with survival outcomes in North American patients with head and neck cancer. METHODS: A single-institution, retrospective database was queried for patients with non-metastatic head and neck cancer who underwent definitive chemoradiation from June 2007 to April 2021 at the Roswell Park Comprehensive Cancer Center. Primary endpoints were overall survival (OS) and cancer-specific survival (CSS). The association of LMR with OS and CSS was examined using nonlinear Cox proportional hazard model using restricted cubic splines (RCS). Cox multivariable analysis (MVA) and Kaplan-Meier method were used to analyze OS and CSS. Pre-radiation LMR was then stratified into high and low based on its median value. Propensity scored matching was used to reduce the selection bias. RESULTS: A total of 476 patients met our criteria. Median follow up was 45.3 months (interquartile range 22.8-74.0). The nonlinear Cox regression model showed that low LMR was associated with worse OS and CSS in a continuous fashion without plateau for both OS and CSS. On Cox MVA, higher LMR as a continuous variable was associated with improved OS (adjusted hazard ratio [aHR] 0,90, 95% confidence interval [CI] 0.82-0.99, p = 0.03) and CSS (aHR 0.83, 95% CI 0.72-0.95, p = 0.009). The median value of LMR was 3.8. After propensity score matching, a total of 186 pairs were matched. Lower LMR than 3.8 remained to be associated with worse OS (HR 1.59, 95% CI 1.12-2.26, p = 0.009) and CSS (HR 1.68, 95% CI 1.08-2.63, p = 0.02). CONCLUSION: Low LMR, both as a continuous variable and dichotomized variable, was associated with worse OS and CSS. Further studies would be warranted to evaluate the role of such prognostic marker to tailor interventions.

Is Head and Neck Free Flap Reconstruction Feasible in Jehovah's Witness Patients?

BACKGROUND: Jehovah's Witnesses (JW) population are members of a religious group that refuses blood transfusion. This presents a dilemma for surgical teams when performing major surgical procedures on these patients. PURPOSE: This study aimed to assess the safety and feasibility of undergoing microvascular free flaps for maxillofacial reconstruction in JW patients and whether the type of underlying pathology impacts outcomes. STUDY DESIGN, SETTING, AND SAMPLE: This was a multi-institutional retrospective cohort study. The sample consisted of all JW patients who have undergone microvascular free tissue transfer for maxillofacial pathology between January 2016 and January 2021. PREDICTOR VARIABLE: The primary predictor variable was the underlying pathology for which patients underwent head and neck free flap reconstruction; this was benign versus malignant disease. MAIN OUTCOME VARIABLES: The primary outcome variables were safety, defined as discharge from the hospital with no mortality, and feasibility defined as successful free flap reconstruction. COVARIATES: Other variables included age, race, sex, length of surgery, length of hospital stay, and intraoperative use of vasopressors. ANALYSIS: Data analysis was performed utilizing t-tests for means and χ2 for proportions. Alpha was set at < 0.05. RESULTS: A total of 12 participants from 7 participating sites met the inclusion criteria. There were 9 males and 3 females with a mean age of 58.3 ± 8.3 years. There were no deaths in this cohort and all patients were discharged from the hospital. All 12 free flap reconstructions were successful with no incidents of free flap loss; none of the patients received any blood transfusions or any other blood products. Subgroup analysis showed that patients treated for malignant disease versus benign disease had longer operations (11.2 ± 2.9 vs 6.3 ± 0.2 hours, P < .01) and a longer hospital length of stay (11.8 ± 4.9 vs 5.3 ± 0.5 days, P = .04). CONCLUSION AND RELEVANCE: Our series supports the safety and feasibility of maxillofacial free flap reconstruction in this challenging subset of patients. Microvascular reconstructive surgeries for malignant diseases often result in longer operative times and hospital stays.

Immediate Free Fibula Flap After Maxillectomy With Simultaneous Full-arch Dental Implant-Supported Prosthetic Rehabilitation of the Midface and Mandible: The "Super Reconstruction Concept".

Immediate reconstruction and dental rehabilitation for ablative defects of the head and neck in one surgery is now a commonly used technique among reconstructive surgeons. Often patients are edentulous or partially edentulous in the jaw opposing that with pathology. In this case, only rehabilitating the dental arch affected by pathology would not render the patient with a functional occlusion. We introduce the "super reconstruction" concept which includes not only rehabilitating the dental arch affected by pathology but also the opposing arch, giving the patient a fully functional occlusion at the time of ablative surgery. This concept is described through a case of a patient with a T4aN0M0 squamous cell carcinoma of the maxilla who underwent total maxillectomy, immediate fibula flap reconstruction of the maxilla with, and full arch dental implant placement into the maxilla and opposing mandible with prosthetic rehabilitation.

Morbidity Associated With Anterior Versus Posterior Cranial Vault Expansion for Early Treatment of Syndromic Craniosynostosis: A Systematic Review and Meta-Analysis.

PURPOSE: The purpose of this systematic review and meta-analysis was to estimate and compare rates of unplanned reoperation and complications after undergoing either fronto-orbital advancement (anterior cranial vault expansion) or posterior cranial vault expansion as an early surgery in the management of syndromic craniosynostosis. MATERIALS AND METHODS: A literature search was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant articles were identified in 2 electronic databases (PubMed and EMBASE) from the time of electronic publication to November 2020. Quality assessment and risk of bias were appraised using the Grading of Recommendations Assessment, Development and Evaluation system. A meta-analysis was performed comparing rates of reoperation and complications between participants who underwent anterior or posterior cranial vault expansion as an early surgery. RESULTS: Of 1,373 screened records, 7 met inclusion criteria. Six were included in the meta-analysis. The studies that met inclusion criteria reported on 103 patients treated with anterior techniques and 72 patients treated with a posterior approach. Anterior cranial vault expansion was associated with significantly higher rates of reoperation (Peto odds ratio = 2.83; 95% confidence interval = 1.19, 6.74, P = .02) and complications (Peto odds ratio = 2.61; 95% confidence interval = 1.12, 6.12, P = .03) than posterior cranial vault expansion. CONCLUSIONS: Both anterior and posterior approaches are suitable options in the treatment of syndromic craniosynostosis depending on patient-specific factors. Anterior cranial vault expansion was associated with higher rates of unplanned reoperation and complications than posterior techniques in this analysis. Because of the paucity of literature which met inclusion criteria, this study was not able to assess critical outcome variables such as distance distracted/volumetric expansion, estimated blood loss, and cost. Larger studies evaluating both techniques under multiple institutions with long-term follow-up are indicated.

Immediate Reconstruction of the Infraorbital Nerve After Maxillectomy: Is it Feasible?

PURPOSE: Ablative procedures of the midface may require sacrifice of the infraorbital nerve (ION) resulting in permanent paresthesia of its dermatome. Because the ION is not commonly reconstructed, the goal of this study was to determine the feasibility of nerve allograft reconstruction. PATIENTS AND METHODS: A retrospective cohort of patients underwent immediate ION allograft reconstruction, during August 2018 to August 2019 at a single academic medical center by a single surgeon (M.M.). Demographic and clinical variables were collected. The outcome of interest was clinical neurosensory testing using the Medical Research Council Scale and subjective recovery, which was recorded using a visual analog scale at 3, 6, and 12 months after surgery. RESULTS: This cohort series consisted of 3 consecutive patients who underwent immediate ION allograft reconstruction. At 6 months, all patients achieved functional sensory recovery (S3, S3+, and S4) and acceptable subjective improvement. CONCLUSIONS: Immediate nerve allograft reconstruction of the ION is a viable option to achieve functional sensory recovery.

Is There a Correlation Between Comprehensive Basic Science Examination and United States Medical Licensure Examination Step 1 Performance Among Oral and Maxillofacial Surgery Residents?

PURPOSE: Oral and maxillofacial surgery (OMS) applicant Comprehensive Basic Science Examination (CBSE) scores are scrutinized by residency programs and medical schools because of their perceived predictive value for United States Medical Licensure Examination (USMLE) Step 1 performance. The purpose of this study was to answer the following question: Is there a correlation between the OMS applicant's CBSE score and his or her later USMLE Step 1 score? MATERIALS AND METHODS: We e-mailed all current 45 dual-degree OMS residency programs to request participation in the study. Participating programs submitted residents' CBSE scores and USMLE Step 1 scores. RESULTS: Of 45 United States-based, dual-degree OMS residency programs, 23 (51%) enrolled in the study, including data for 152 residents from 2012 to 2018. The mean CBSE score was 71 (range, 47 to 99). The mean USMLE Step 1 score was 220 (range, 177 to 266). The Pearson correlation coefficient for the relationship between the CBSE and USMLE Step 1 scores was 0.36. The overall USMLE pass rate was 97%. On the USMLE Step 1, OMS residents outperformed their translated CBSE score by an average of 15 points. Of the 50 residents (33%) with a translated CBSE score below the passing level, 94% passed the USMLE Step 1. Residents who had a translated passing CBSE score outscored residents with a translated failing score by 14 points when taking the USMLE Step 1 (225 vs 211). CONCLUSIONS: Although no statistically significant difference in the USMLE Step 1 pass rates was found between OMS residents with a translated passing CBSE score and those with a translated failing CBSE score, a weak positive correlation was noted between CBSE and USMLE Step 1 scores. These data do not support the use of a certain cutoff CBSE score for OMS applications by OMS program directors, especially as it pertains to interview offers.

Patient Characteristics and Causes of Facial Fractures in the State of California.

PURPOSE: Each year, more than 400,000 emergency department (ED) visits in the United States are due to facial fractures. To inform targeted interventions to prevent facial fractures, the purpose of this study was to identify patient characteristics associated with causes of facial fractures in California. MATERIALS AND METHODS: The 2005 to 2011 California State Emergency Department Database was used for this cross-sectional study. The study population was composed of all ED visits for facial fractures. The primary outcome was cause of injury: fall, firearm injury, motor vehicle traffic accident, pedal cycle accident, pedestrian accident, transport accident, and assault. Predictor variables included patient characteristics, such as age, gender, insurance type, and race and ethnicity. Multivariable logistic regression models were used. RESULTS: There were 198,870 ED visits for facial fractures from 2005 to 2011. The patients' average age was 35.7 years. Most ED visits were by male patients (71%), privately insured patients (35%), and white patients (52%). Approximately 65% of visits were on weekdays and 93% were routinely discharged. Closed fractures of nasal bones, other facial bones, orbital floor, malar and maxillary bones, and mandible were the most prevalent (91%) facial fractures. Assaults (44%), falls (24%), and motor vehicle traffic crashes (6%) were the top 3 causes of facial fractures. Elderly patients (odds ratio [OR] = 6.17), female patients (OR = 2.25), and Medicare enrollees (OR = 1.51) were statistically more likely to have fall-related fractures than patients 45 to 64 years old, male patients, and privately insured patients. Blacks (OR = 0.46) and micropolitan residents (OR = 0.76) were statistically less likely to have fall-related fractures than whites and metropolitan residents. CONCLUSIONS: Violence among youth and falls among the elderly are predominant causes of facial fractures. The uninsured contribute to more than one fourth of ED visits for facial fractures. Interventions targeted at these population groups can curb the prevalence of these fractures.

Is Augmentation Required to Correct Malar Deficiency With Maxillary Advancement?

PURPOSE: Patients with maxillary hypoplasia also have malar deficiency; therefore, planning can include consideration for simultaneous malar augmentation. The purpose of this study was to compare pre- and postoperative profiles of patients who underwent Le Fort I advancement, with and without malar augmentation, to assess the subjective perception of changes in malar eminence projection. MATERIALS AND METHODS: Patients who had maxillary advancement and mandibular setback with and without malar augmentation were evaluated through a survey consisting of pre- and postoperative photographs that were assessed by professionals and laypersons, and a visual analog scale was used to assess the malar region. Next, pre- and postoperative images were shown side by side and participants were asked to indicate which patients had undergone malar augmentation. Statistical analysis used Wilcoxon signed rank test, independent-samples t test, Spearman rank order correlation, and Mann-Whitney U tests. RESULTS: Of 43 patients, 23 met the inclusion criteria and only 7 of the 23 patients received simultaneous malarplasty. Patients in the 2 groups were perceived as having an increase in malar eminence projection postoperatively. In the malarplasty and non-malar cohorts, laypersons and professionals noted an increase in projection (P < .05). Laypersons tended to overestimate the number of malar procedures performed (sensitivity, 59.5%; specificity, 56.8%), whereas professionals were better able to accurately exclude malar augmentation (sensitivity, 44.2%; specificity, 69.9%). CONCLUSIONS: Most patients with maxillary hypoplasia undergoing Le Fort I advancement can expect a subjective improvement in malar projection. The decision for malar augmentation at the time of maxillary advancement should be considered based on patient desires, but, in general, maxillary advancement alone might be sufficient for an optimal malar esthetic outcome.

Laser-Assisted Indocyanine Green Imaging for Assessment of Perioperative Maxillary Perfusion During Le Fort I Osteotomy: A Pilot Study.

PURPOSE: To determine the changes in maxillary perfusion during different stages of Le Fort I osteotomies as measured by laser-assisted indocyanine green imaging (LAICGI) and to determine whether various clinical factors affect maxillary vascular perfusion. MATERIALS AND METHODS: The medical records of those who had undergone Le Fort I osteotomy with LAICGI at the University of Illinois from 2016 to 2017 were reviewed retrospectively. The maxillary perfusion levels using LAICGI were measured before induction, after induction, after down fracture, after segmentalization (for segmental osteotomies), and after wound closure. The effects of clinical variables, including gender, race, American Society of Anesthesiologists physical status, type of Le Fort I osteotomy, intraoperative status of the descending palatine vessels, maxillary movements (anteroposterior, vertical, transverse), and hemodynamic data (mean arterial blood pressure, heart rate), were analyzed. RESULTS: Compared with the preoperative baseline values, the indocyanine green (ICG) levels decreased after down fracture and mobilization, segmentalization, and wound closure; no statistically significant differences were found among these 3 points. Segmentalization did not affect the ICG levels compared with the nonsegmentalized cases. Male gender and the amount of maxillary impaction were significantly associated statistically with decreased ICG levels, although the difference was not clinically significant. CONCLUSIONS: Compared with the baseline levels, maxillary perfusion, as measured by LAICGI, decreased from down fracture to wound closure. Segmentalization did not appear to influence maxillary perfusion, although male gender and impaction were associated with decreased perfusion. Because of its safety and convenience, LAICGI shows promise as a method of assessing maxillary perfusion in future largescale prospective studies linking perioperative perfusion to the occurrence of aseptic necrosis.

Virtual Surgical Planning for Inferior Alveolar Nerve Reconstruction.

PURPOSE: The purpose of this study was to assess the outcomes after preoperative virtual surgical planning (VSP) for inferior alveolar nerve (IAN) reconstruction in ablative mandibular surgery. MATERIALS AND METHODS: We performed a retrospective evaluation of consecutive surgical cases using standard VSP for hard tissue resection and reconstructive surgery in addition to IAN VSP performed simultaneously during surgery. Cases were assessed regarding the planning time, additional costs involved, surgeon's subjective impression of the process, accuracy of the prediction during surgery, and operative time during surgery compared with cases performed without VSP. RESULTS: The study sample was composed of 5 cases of mandibular resection for benign disease, with bony, soft tissue, and neural reconstruction with the use of VSP. The addition of IAN reconstruction to the VSP session added no additional expense to the planning session but resulted in an additional 22.5 minutes (±7.5 minutes) for the webinar session. From a subjective standpoint, IAN VSP provided the surgeon with a discreet plan for surgery. From an objective standpoint, IAN VSP provided the exact length and diameter of nerve graft required for surgery, facilitated the surgeon's ability to visualize the actual nerve graft procedure, and limited the additional time required for simultaneous nerve reconstruction. CONCLUSIONS: Despite perceived prejudice against simultaneous IAN reconstruction with complex mandibular resection and reconstruction, the use of IAN VSP may facilitate the actual surgical procedure and result in considerably improved patient outcomes without considerable additional time or cost associated with this protocol.

Senior Oral and Maxillofacial Surgery Resident Confidence in Performing Invasive Temporomandibular Joint Procedures.

PURPOSE: The purpose of this study was to evaluate the level of confidence that senior-level oral and maxillofacial surgery (OMS) residents have in the management of temporomandibular joint (TMJ) disorders, determine their exposure to various invasive TMJ procedures during training, and assess their confidence in performing those procedures on completion of residency. MATERIALS AND METHODS: A questionnaire was designed, and a link to a University of Illinois at Chicago Qualtrics Survey platform (Qualtrics, Provo, UT) was e-mailed to all program directors at Commission on Dental Accreditation-accredited OMS training programs in the United States. The program directors were asked to forward the 20-multiple-choice question anonymous survey to their senior-level residents for completion. The survey included the program's demographic characteristics, resident's confidence in assessing and managing patients with temporomandibular disorders (TMDs), resident's experience performing various invasive TMJ procedures, and whether the resident believed he or she had received sufficient education and clinical experience in the management of TMJ disorders. The data were collected and summarized by use of a standard spreadsheet analysis, as well as appropriate descriptive and analytical statistical tests. RESULTS: The response rate was 28.0%. Of the 56 respondents, 52 (92.9%) reported having received instruction in nonsurgical management of TMDs. All respondents confirmed that invasive TMJ procedures were performed in their program. The most commonly performed procedure was TMJ arthrocentesis (mean rating, 3.11), followed by open TMJ surgery (mean rating, 2.82). The least-performed invasive surgical procedure was autogenous total TMJ replacement surgery (mean rating, 1.39). Eighty percent of residents reported being comfortable managing the TMD patient. The only procedure with which the respondents were highly confident was TMJ arthrocentesis (mean rating, 3.89). CONCLUSIONS: This study suggests that confidence levels in the management of the TMD patient are related directly to the invasive TMJ procedure experience obtained during residency. This finding may have implications on the practice patterns of OMS surgeons as it relates to access to care for the TMD patient.

Does Receiving a Blood Transfusion Predict for Length of Stay in Children Undergoing Cranial Vault Remodeling for Craniosynostosis? Outcomes Using the Pediatric National Surgical Quality Improvement Program Dataset.

PURPOSE: Recent interventions have aimed at reducing the need for blood transfusions in the perioperative period in patients with craniosynostosis undergoing cranial vault remodeling. However, little is known regarding whether the receipt of a blood transfusion influences the length of hospital stay. The purpose of this study was to assess whether the receipt of a blood transfusion in patients undergoing cranial vault remodeling is associated with an increased length of stay. MATERIALS AND METHODS: To address the research purposes, we designed a retrospective cohort study using the 2014 Pediatric National Surgical Quality Improvement Program (NSQIP Peds) dataset. The primary predictor variable was whether patients received a blood transfusion during cranial vault remodeling. The primary outcome variable was length of hospital stay after the operation. The association between the receipt of blood transfusions and length of stay was assessed using the Student t test. The association between other covariates and the outcome variable was assessed using linear regression, analysis of variance, and the Tukey test for post hoc pair-wise comparisons. RESULTS: The sample was composed of 756 patients who underwent cranial vault remodeling: 503 who received blood transfusions and 253 who did not. The primary predictor variable of blood transfusion was associated with an increased length of stay (4.1 days vs 3.0 days, P = .03). Other covariates associated with an increased length of stay included race, American Society of Anesthesiologists status, premature birth, presence of a congenital malformation, and number of sutures involved in craniosynostosis. CONCLUSIONS: The receipt of a blood transfusion in the perioperative period in patients with craniosynostosis undergoing cranial vault remodeling was associated with an increased length of stay.

Microvascular Free Tissue Transfer for Head and Neck Reconstruction in Children: Part I.

BACKGROUND: Limited outcome data exist regarding the survival of microvascular free flaps for head and neck reconstruction in children. The objectives of this study were to perform a systematic review of the literature and meta-analysis comparing the survival of the most commonly used free flaps used for head and neck reconstruction in children. METHODS: A systematic search of PubMed, Embase, and Scopus was conducted using various keywords up to January 1, 2015. Meta-analysis was used to compare the survival of the most commonly used free flaps. The primary predictor variable was free flap type. The primary outcome variable was flap failure. The pooled relative risk (RR) with 95% confidence intervals (CIs) was estimated using a Mantel-Haenszel, fixed-effects model. RESULTS: The authors reviewed 25,303 abstracts. Five studies met inclusion criteria. A total of 646 children received a total of 694 free flaps. The pooled survival rate among all free flaps was 96.4%. The fibula free flap (fibula) and subscapular system free flaps (scapula) were the most commonly used flaps. There was no difference in survival when comparing the scapula (RR = 0.59, 95% CI: 0.26, 1.56, P = 0.29), or fibula (RR = 1.91, 95% CI: 0.55, 6.65, P = 0.31) to other free flaps, or when comparing the scapula to the fibula (RR = 2.29; 95% CI: 0.40, 13.08, P = 0.35). CONCLUSIONS: Free tissue transfer is highly successful in children. Although data are limited, there appears to be no difference in survival among various free flaps used for head and neck reconstruction in children.

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.