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

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

Midline mandibular osteotomy in an asymmetric patient.

This case report shows the possibility of the application of a mandibular osteotomy to resolve mandibular asymmetry with independent and discordant movements of both bony segments. The authors report the case of a 25-year-old woman referred for mandibular asymmetry, with a transverse excess of the right hemi mandible and vertical defect of the left one. The patient underwent a bilateral sagittal split osteotomy, midline osteotomy, and genioplasty, which corrected the mandibular asymmetry with contraction of the entire right hemi mandible. A slight left vertical increase was also obtained through the surgically created lateral open bite. In the follow-up assessment, the patient's face appeared symmetrical with normalization of the bizygomatic-bigonial relationships, and the facial shape corresponded to ideal anthropometric features. This technique resulted in resolution of mandibular asymmetry. In addition, mandibular osteotomy permits the esthetic management of the shape of the entire mandibular body in relation to the other third of the face.

Malignant tumors of intraoral minor salivary glands.

Between 1995 and 2004, 43 patients with intraoral minor salivary gland carcinomas were diagnosed and treated at the Department of Maxillofacial Surgery, University of Parma, Italy. The palate was the most common site of involvement and comprised 53.5% of the cases. Adenoid cystic carcinoma was the most common histological type (60.6%), followed by mucoepidermoid carcinoma (27.9%). All patients were treated with surgery as the primary modality. Neck dissection was performed in 20.9% of patients, and more than half (72.1%) were treated with adjuvant radiation therapy. The range of the follow-up was 24-132 months (mean: 66 months). Of the 43 patients examined in this study, 12 died due to the tumor. Treatment failure was documented in 18 of the 43 patients (41.9%). Disease-free intervals ranged from 1 month to 9 years and 13.9% of the patients had local failure, whereas 25,6% had distant metastases. The survival rates at 2, 5, and 10 years were 90.7%, 71.8%, and 68%, respectively. The local control rates were 93.1% at 2 years and 83.1% at 5 and 10 years. The 2-, 5-, and 10-year rates for freedom from distant relapse were 95.2%, 83.4%, and 57.5%, respectively. The T stage, cervical lymph node metastasis, surgical margin status and perineural invasion were statistically significant to the outcome.

Free and locoregional flap associations in the reconstruction of extensive head and neck defects.

Head and neck surgical defects after oncological resection of advanced carcinoma involving the oral cavity are often composite and involve bone, mucosa, soft tissues and skin. For the most extensive defects, the simultaneous association of two free flaps is the best choice to improve the function of the preserved structures. This procedure is difficult and involves prolonged surgery, therefore it is only possible in selected patients. In some composite head and neck defects the association of free and locoregional flaps seems to be indicated. This study, discusses the use of free and locoregional flap association, focusing on its aesthetic advantages and functional results. From January 1995 to December 2006, 30 patients received simultaneous locoregional and free flap transfer for closure of post-ablative oral cavity defects. Microvascular tissue transfer included the radial forearm, anterolateral thigh, rectus abdominis, and fibula and iliac crest free flaps. Locoregional flaps included the cervicofacial, cervicopectoral, deltopectoral, pectoralis major, latissimus dorsi and posterior scalp flaps. Based on the good functional and aesthetic outcome and low rate of complications, the association of free and locoregional flaps represents a good reconstructive option for patients with extensive post-oncological composite head and neck defects.

The submental island flap in head and neck reconstruction.

The authors describe their experience with the submental island flap for the primary correction of head and neck deformities following oncologic surgery, over the past 5 years. The use of this flap is reported in 12 patients, with a mean age of 67 years, requiring facial or intraoral reconstruction. A brief review of the key points and some refinements in the operative technique are discussed. The reconstruction of defects with a submental island flap was successful in every patient. Complications encountered were one case of temporary palsy of the marginal mandibular branch of the facial nerve and one case of orocutaneous fistula. All the donor site defects were closed primarily. The submental island flap is an excellent choice for the reconstruction of head and neck defects because of its reliability, versatility, colour and texture match, and relative ease of application.

Masseteric nerve for gracilis muscle re-innervation in unilateral facial palsy: Impact on quality of life.

BACKGROUND: Unilateral established or congenital facial palsies are usually treated with neuromuscular transplantation to reanimate the impaired side of the face. One of the most debated points is the motor nerve to choose for the reinnervation of the transplant. Contra-lateral healthy facial nerve is usually preferred, but in selected cases motor nerve to masseter is considered a valuable option. However only a few clinical studies focused on quality of life in this subset of patients are available in literature. METHODS: Twenty patients treated for established or congenital unilateral facial palsy reanimated with gracilis muscle transplant reinnervated with masseteric nerve were retrospectively analyzed. The FDI questionnaire on quality of life was administered before and after surgery and statistical analysis of results was conducted to score changes. RESULTS: Overall results of the questionnaire resulted in a statistically significant improvement after surgery, with a p value of 0.05. CONCLUSION: Facial animation with gracilis muscle transplant re-innervated with masseteric nerve is a safe and reliable procedure in selected unilateral facial palsy patients. Results reported here confirm that surgery mainly improves the functional aspects of a patient's daily life quality, while the impact on social interactions and self-perception is less significant. The comparison of these results with those obtained in patients treated with gracilis muscle transplant re-innervated via contralateral facial nerve suggests that spontaneity is probably highly relevant to improve social aspects of QOL in this subset of patients.

Which cephalometric analysis for maxillo-mandibular surgery in patients with obstructive sleep apnoea syndrome?

Maxillo-mandibular advancement MMA is considered an efficacious treatment for patients affected by severe obstructive sleep apnoea syndrome (OSAS). Even though OSAS improvement is the main goal of MMA, excessive maxillo-mandibular protrusion should be avoided to guarantee pleasant postoperative facial aesthetics. In order to attain such a result, the amount of MMA should be planned preoperatively by both aesthetic and cephalometric analyses. Steiner and Delaire cephalometric analyses are commonly used in the preoperative planning of orthognatic surgery for dentofacial deformities, however controversies still exist about the basis and postoperative aesthetic results of such cephalometric analyses in OSAS patients candidate for MMA. Forty-eight patients affected by severe OSAS were submitted to MMA. Pre- and post-operative Steiner and Delaire cephalometric tracings were assessed in each subject. For Steiner analysis, the variation in the SNA and SNB angles was measured, while for Delaire tracings the variation in the C3/FM-CPA and C3/FM-Me angles was assessed. Mean MMA was 6.9 + 3.8 mm for the maxilla and 13.6 + 5 mm for the mandible. After surgery, an improvement of the apnoea-hypopnoea index was recorded (40.47 + 7.64 preoperative vs. 12.56 + 5.78 postoperative). In all patients, both cephalometric analyses showed presurgical bimaxillary retrusion. After surgery, the mean value of Steiner's SNA angle increased from 78.18° to 85.58° (p < 0.001), while mean Delaire's C3/FM-CPA angle increased from 81.19° to 89.71° (p < 0.001). The mean value of Steiner's SNB angle increased from 74.33° to 80.73° (p < 0.001), while Delaire's C3/FM-Me angle increased from 80.10° to 87.29° (p < 0.001). Postoperatively, both the maxilla and mandible were in a more protrusive position (p < 0.001) according to Steiner analysis compared with Delaire tracing. Basing MMA on Delaire cephalometric analysis leads to an increased advancement of the maxillo-mandibular complex than Steiner tracing. The consequences of this aspect on facial aesthetics should be considered during surgical planning and preoperative informed consent in OSAS patients candidate for MMA.

On the feasibility of intraoral maxillo-malar osteotomy.

The maxillo-malar osteotomy is one of the osteotomies developed over the years to correct the deformities of the midface without modifying the nasal projection. After having for many years approached the osteotomy through the classic double access, intraoral and subciliary, we verified the feasibility of this osteotomy via an intraoral route only. For this purpose we modified slightly the classic osteotomy lines, however still including in the mobilized fragment the most prominent and therefore the most aesthetically important portion of the zygoma. At the lower orbital rim the medial osteotomy cut is performed with a fissure bur, the lateral one with an oscillating saw. Both the osteotomies are extended posteriorly in the orbital floor with a fine osteotome. Then, after having performed all other osteotomy cuts, the maxillo-malar complex is down-fractured. The residual thin bone structures which connect the maxillo-malar complex to the cranio-facial skeleton are broken during a careful downfracture, avoiding fracture between the maxilla and zygoma. The complex is advanced and stabilized with intermaxillary fixation, osteosynthesis and bone grafts. A bone graft to the orbital floor is unnecessary.

The temporalis muscle flap in temporo-mandibular joint surgery.

In the treatment of the severely damaged TMJ structural components (ankylosis, arthrosis, tumour, perforation or degeneration of the disc), it is advisable to insert a biological interposition between bony articular surfaces. The temporal muscle, due to its anatomical, topographical, and functional properties, can be successfully employed for this purpose. Based on the experience of Tessier, Delaire and Rowe, a temporalis muscle flap, inferiorly based, is rotated downwards and medially to the zygomatic arch, interposed and then fixed to condyle and capsule. Using this surgical technique, 12 patients and 13 temporo-mandibular joints were treated with good functional results and without any complication.

Orbital marginotomies for treatment of orbital and periorbital lesions.

Access osteotomies allowing temporary displacement of various segments of the orbital rim provide direct visualization of deep orbital and paraorbital regions. These marginotomies are classified, according to the orbital region involved, as lateral, medial, superior, or inferior, and they provide adequate exposure of the corresponding orbital wall and its surrounding structures. Since these procedures are without complications and cause no unpleasant cosmetic effects, they are highly recommended for the treatment of various lesions in this area as well as for correction of malformations.

Mandibular leiomyoma in an infant. Report of a case.

A case of mandibular leiomyoma in a 8-month-old baby is reported. This is the 5th case of intrabony leiomyoma of the jaws reported so far. The tumor presented as a symptomless swelling of the mandibular ramus and required a limited resection. The pertinent literature is reviewed and the histological features discussed.

A comparison of open and closed treatment of condylar fractures: a change in philosophy.

A comparison between two samples of patients with condylar fractures is reported: the first treated non-surgically and the second with open reduction and rigid internal fixation. The functional results for both groups were similar. However, open reduction gave better occlusal results, anatomic restoration and faster recovery rates than non-surgical techniques.

Role of surgical reduction of condylar fractures in the management of panfacial fractures.

We present nine panfacial fractures that were treated during a two-year period in which the first step in treatment was reduction of condylar fractures. There was no evidence of dental or skeletal alterations and measurement of the mandibular ramus and radiographic examination show that posterior facial height as well as projection and width of the inferior lower third of the face, was restored. The correct timing of surgical intervention and the use of rigid fixation allows the restoration of the morphological and functional nature of the face after panfacial fractures.

[Retropharyngeal lymphadenopathy in patients with advanced stage squamous cell carcinoma of the oropharynx: report of 2 cases and review of the literature]. / Linfoadenopatia retrofaringea nei pazienti affetti da carcinoma squamocellulare dell'orofaringe in stadio avanzato: presentazione di due casi clinici e analisi della letteratura.

Drawing from two cases which came under observation, the authors consider the high incidence of retropharyngeal metastases in oropharyngeal carcinoma. The diagnosis is made on the basis of radiographic examinations such as CAT and NMR which reveal the increase in size, the presence of central necrosis of the lateral retropharyngeal lymph nodes and the asymmetry of the long neck muscle. In the presence of advanced oropharyngeal carcinoma, the treatment calls for dissection of this space, even when radiology does not show any evident involvement. Lymph node positivity worsens the prognosis. Because of the marked significance of this involvement, some authors have proposed further N staging. Adjuvant RT completes the therapeutic protocol for such patients.

[Lymphatic metastases in the parotid region from malignant skin neoplasm of the head: considerations for surgical treatment based on personal clinical experience]. / Metastasi linfatiche della loggia parotidea da neoplasie maligne della testa: considerazioni sul trattamento chirurgico in base all'esperienza clinica personale.

The present paper considers some of the problems linked to the surgical treatment of parotid metastases. The authors base these considerations on their limited personal cases and on the most accredited literature. In the presence of cutaneous malignancies of the upper portion of the face, accurate clinical-radiological evaluation must be made of the parotid and neck region. Elective parotidectomy is performed when the cutaneous carcinoma is quite extensive or located in proximity of the gland or when the case involves a melanoma. Depending on the oncological margins, a sub-total parotidectomy may be enough; however, the facial nerve must be sacrificed if there is a clinical deficit or if it is directly affected by the tumor. As the dimensions of the neoplasm increase, the feasibility of saving the nerve decreases. Prophylactic treatment of the neck is advisable in parotid metastases from cutaneous malignancies, particularly melanoma. Nevertheless, it is possible to perform a selective dissection, avoiding the V level of the neck as the incidence of its involvement is quite low. Prognosis for these tumors is extremely poor. Of the eleven patients surgically treated, only 4 (36%) survived: 2 passed away from other causes not involved in the base pathology; 2 for distant metastases but with no signs of local recurrence and 1 other for recurrence of the primary pathology in the maxillary sinus mucosa. There is no difference in the survival of the two main histological groups: 2 out of 3 of the patients with melanoma (67%) died as did 3 out of 5 (60%) of those with epidermal carcinoma. This does not, obviously, include the two patients who died from other causes.

[Neoplastic seeding of squamous carcinoma of the tongue onto the tracheotomy site: a case report]. / Insemenzamento neoplastico di carcinoma squamoso della lingua in sede di tracheotomia.

Neoplastic spreading by seeding occurs through mechanical transfer of some cells from a tumor mass onto healthy tissue of an implantation site. There is significant experimental proof of neoplastic cells seeding in surgical wounds although this seldom occurs in cases of surgery for head and neck tumors. We consider the description of a squamous cell carcinoma of the tongue which spread to the tracheotomy site, most probably through a iatrogenic seeding and conclude that use of a few simple precautions could minimize the frequency of such unfortunate complications.

[Primary reconstruction of lateral oro-mandibular defects using titanium plates (Thorp) and revascularized non-osseous flaps: a personal experience]. / Ricostruzione primaria di difetti oro-mandibolari laterali con placche in titanio (thorp) e lembi rivascolarizzati non-ossei: nostra esperienza.

Reconstruction of a particular defect is an highly complex problem, that is reflected in the number and variety of techniques proposed. This is particularly true for reconstruction of mandibular segment defects usually together with the need to repair oro-pharnygeal soft tissues defects of various size. The high rate of successes that can be obtained today using microvascular reconstruction techniques explains the reason why bone free flaps have progressively become the "gold standard" used as benchmark for all other forms of primary mandibular reconstruction. However, for selected patients (elderly patients or individuals in poor general health; the presence of lateral oro-mandibular defects or soft tissue defects significantly exceeding the bone defect) the association of non-osseous microvascular free flaps (such as forearm skin flaps or miocutaneous free flaps of the abdominal rectus muscle) with a titanium mandibular reconstruction plate (THORP) can prove a valid alternative. Indeed, in these cases reconstruction of choice would be the association of two free flaps, one osseous and the other non osseous. The use of THORP-type mandibular reconstruction plates in repairing lateral defects increases the overall risk of complications related to the reconstruction technique which is already hindered by the risks associated with the use of microvascular free flaps. The present work starts with a retrospective evaluation of 5 years series of primary mandibular reconstruction for lateral oro-mandibular defects following oncological surgery. The role of THORP-type titanium mandibular plates, used in combination with non-osseous free flaps in the treatment of selected patients, is then described and discussed.

[Personal experience in mandibular reconstruction with free flaps revascularized with "double barrel" fibula]. / La ricostruzione mandibolare con lembo rivascolarizzato di fibula "double barrel": nostra esperienza.

The introduction of microvascular surgical techniques with bone flaps has made it possible to restore first form and then function in patients undergoing post-oncological oromandibular resection. Revascularized bone differs from avascular grafts in that the residual mandibular stumps heal much more quickly, even in areas where trophism is poor due to prior surgery and/or radiation therapy. The fibula flap is easy to withdraw and permits two teams to work simultaneously. The bone tissue can be grafted well, is easy to shape and osteotomizes with acceptable donor site morbidity. Using the double barrel technique introduced by Bahr in 1994 the neo-mandibular reconstruction can be made to the ideal height, enabling graft-prosthetic rehabilitation and providing the ideal skeletal support for the soft tissues in the lower third of the face. The present case study reports on 7 patients who underwent mandibular reconstruction with fibula flaps using the double barrel technique at the Department of Maxillo-Facial Surgery in Parma, Italy between June 1995 and December 1999. All flaps were successfully transplanted and none of the cases showed partial necrosis of either the bone or skin flaps.