Sublingual Gland and Mylohyoid Muscle Advancement: A Novel Combined Local Soft Tissue Reconstruction.

ABSTRACT: Here the authors present the surgical management of a 78-year-old female with a superficial squamous cell carcinoma of the mucosa overlying her edentulous mandibular alveolus with no evidence of bony invasion.Combining the superficial nature of the lesion, patient age and substantial medical comorbidities, a limited intra-oral resection was planned, to avoid the need for free flap reconstruction. The operation required a wide local excision with clear clinical margins and a mandibular rim resection.All of the currently available reconstructions would result in prolonged surgical time, donor site morbidity, and possible secondary procedures. To overcome these pitfalls, a sublingual gland and mylohyoid muscle advancement flap was designed and executed. By combining the mylohyoid muscle and sublingual gland tissue as an advancement flap in a tension-free manner, secured to the remaining circumferential mucosa, a watertight closure was achieved.After an uneventful recovery without complication the patient was discharged the following day. Complete epithelialization was observed on day 25. Adjuvant radiotherapy was offered to reduce the risk of recurrence and progression. To date, no bony exposure and no pathological fractures have occurred.In conclusion, the entire procedure is simple and innovative. There is minimal donor site morbidity, with an immediate return to oral diet and tolerable surgical risks. It requires a small amount of surgical time compared to other reconstructive options and an overall reduced inpatient stay.

Extensive Post-Traumatic Surgical Emphysema Exacerbated by Cocaine Insufflation.

Surgical emphysema (SE) is characterized by air in the soft tissues causing a crackling sensation on palpation. In oral and maxillofacial surgery, it might occur using conventional air-driven dental hand pieces, as a complication of trauma and with cocaine insufflation.The subcutaneous air may travel through tissue planes causing cervicofacial emphysema, pneumothorax, and pneumomediastinum. It may carry bacteria and potentially lead to cellulitis or necrotizing fasciitis.The SE is usually a self-limiting entity requiring analgesia, close observation of the airway, occasionally prophylactic antibiotics, and rarely steroids. Although, the consensus on antibiotic and corticosteroid therapy is unclear.Here presented an unusual and extensive presentation of surgical emphysema. A 29 years old male presented with emphysema following a left orbital-zygomatic complex fracture and following intranasal cocaine insufflation. It extended from the temple to the parotid region, down into the neck and into the mediastinum. No surgical intervention was required. The patient was discharged after 24 hours of observation with a week-long course of co-amoxiclav antibiotics and no corticosteroids administration.Typical instructions following facial bone fractures are to avoid nose blowing because of the risk of SE, however, avoidance of drug habits is rarely considered. This case report highlights the importance of tailored advice to this particular patient cohort.

Custom-Made Three-Dimensional Models for Craniosynostosis.

The use of computer-aided design and computer-aided manufacturing in oral and maxillofacial surgery is an ever-growing field.The availability of 3D models, cutting guides, and customised surgical instruments gives surgeons the opportunity to modify and improve their surgical procedures.Here, we discuss the use of computer-aided design-computer-aided manufacturing to improve the management of a case of nonsyndromic metopic synostosis through the construction of: A cutting guide for the cranium, custom-made orbital protectors, a 3D model of the predicted postoperative meninges to allow off the table bone recontouring, and a template frontal bar to allow more specific recontouring of the frontal bar.

Psychodynamic Features Associated With Orthognathic Surgery: A Comparison Between Conventional Orthognathic Treatment and "Surgery-First" Approach.

PURPOSE: The aims of this study were to assess the personality traits of orthognathic patients and to investigate and compare the changes related to psychosocial well-being, self-esteem, anxiety, and quality of life between presurgical and postsurgical phases in patients undergoing traditional and surgery-first orthognathic treatments. PATIENTS AND METHODS: This prospective study recruited patients referred for traditional 3-stage orthognathic treatment and surgery-first orthognathic treatment. Patients were administered psychological and quality-of-life tests 3 times: during the last visit before surgery, about 4 weeks after surgery, and 6 months after surgery. RESULTS: Of the 33 patients included, 14 presented parameters that were suggestive of personality (borderline, compulsive, antisocial, passive-aggressive) disorders. The results of the 36-item Short Form Health Survey showed significant differences with better scores for the "surgery-first" group for bodily pain, vitality, social functioning, and mental health (P < .05). As for the Beck Depression Inventory second edition results, at final check, surgery-first patients reported fewer depressive symptoms too. CONCLUSIONS: A surgery-first orthognathic approach allows a precocious re-establishment of harmonic esthetics of the face, thus positively influencing the compliance and psychological status of the patients.

Orbital trapdoor fracture: can it occur also in adults?

We describe here a peculiar case of a 30-year-old woman presenting with an orbital trapdoor fracture. Preoperative and postoperative magnetic resonance images are provided to explain the mechanism of the injury.

Primary bone xanthoma of the inferior orbital rim.

Primary bone xanthoma is an extremely rare benign bone tumor histologically characterized by mononuclear macrophage-like cells, abundant foam cells, and multinucleated giant cells. Xanthomas of the bone usually appear as a benign secondary manifestation of some diseases. Therefore, they are denominated primary xanthomas when the other diseases are discarded.We report a peculiar case of primary bone xanthoma of the inferior orbital rim in the absence of hyperlipidemic conditions. Surgical intervention was performed under local anesthesia via a subtarsal 1-cm incision. Histopathological examination confirmed the diagnosis of bone xanthoma. Primary bone xanthomas are extremely rare. Diagnosis of such lesions is challenging and requires both radiographic and histopathological features assessment. A careful work-up and a full lipid profile should be performed to rule out underlying diseases.

Surgical management of posttraumatic intraorbital hematoma.

Retrobulbar hematoma is a rare condition but represents a diagnostic and therapeutic emergency. It occurs in between 0.3% and 3.5% of facial traumas and can be caused by direct or indirect injury of the orbit; they can be classified into intraorbital and subperiosteal hematoma. We describe 4 different cases of posttraumatic retrobulbar hematoma treated at the Unit of Maxillofacial Surgery of the Novara Major Hospital between January 2005 and December 2009, each different from the others for morphologic aspects, and we discuss its diagnosis and management. Surgery decompression of the orbit is recommended when visual deficit arises and when there is no response to pharmacologic therapy. Several techniques for orbital decompression have been proposed. The lateral canthotomy and/or the inferior cantholysis are the 2 techniques most practiced. Anterior-chamber paracentesis is effective, but it is rarely indicated for frequent complications such as cataract formation, herniation of the iris, infection, and trauma to the canal of Schlemm. Other procedures including transantral ethmoidectomy, transantral sphenoidectomy, and transfrontal craniotomy are described.

Analysis of complications following endoscopically assisted treatment of mandibular condylar fractures.

BACKGROUND: Within the field of facial reconstructive surgery, minimally invasive procedures are used for the treatment of temporomandibular joint disorders, traumas, and salivary glands and base of skull tumors. The recent report of endoscopic approach for treating subcondylar fractures of the mandible is designed to provide a new method for the treatment of subcondylar fractures using an endoscope through a limited transoral incision. To the best of our knowledge, the advantages and the disadvantages of an endoscopically assisted approach to mandibular condylar fracture have not been verified in studies with a high level of evidence. The objective of this article was to present our experience regarding the endoscopically assisted reduction of subcondylar mandibular fractures with a special focus on complications. METHODS: The records of 14 patients who underwent surgical repair of subcondylar fractures by transoral endoscopic-assisted technique from January 2005 to December 2008 at the Maxillofacial Surgery Unit of Novara Major Hospital were reviewed retrospectively. The measures for the surgical objectives included the following outcome variables: (1) operation time, (2) cosmetic outcome, (3) salivary fistulas, (4) infection, (5) delayed wound healing, (6) facial nerve damage, (7) hemorrhage, (8) repeat interventions, (9) bone consolidation, (10) occlusion changes, and (11) temporomandibular joint dysfunction. RESULTS: Our data show that we have had 4 complications (28%) experienced by 4 different patients: (1) arterial hemorrhage, (2) facial nerve injury, (3) nonunion, and (4) partial condylar reabsorption. CONCLUSIONS: Although we cannot draw statistically significant conclusions, we think that further randomized clinical trials should be necessary to analyze this method; we believe that there is not an ideal approach for a fracture, but each patient needs to be fully evaluated carefully preoperatively, and the more convenient approach needs to be selected for each case.

Maxillomandibular advancement in obstructive sleep apnea syndrome: a surgical model to investigate reverse face lift.

BACKGROUND: The aging process is characterized by multiple signs affecting the upper, the middle, and the lower third of the face; coventionally, face-lift procedures and structural fat grafting are performed to create a younger face. During the life, craniofacial skeleton atrophies, leading to a reduction of the facial height and depth, while increasing the facial width. Maxillomandibular advancement (MMA) by orthognathic surgery restores the lost space dimension, projecting the cheeks, the mouth, and the nose. The aim of this study was to analyze the morphologic change of the face after MMA in patients with obstructive sleep apnea syndrome, focusing on the previously mentioned stigmata of the middle and the lower third of the aging face. METHODS: The records of 16 patients who underwent MMA for obstructive sleep apnea syndrome between January 2005 and December 2008 in the Unit of Maxillofacial Surgery at the Novara Major Hospital were included in this study. We explained to the patients the stigmata of a standard aging face, and we asked them to evaluate each sign affecting the middle and the lower third of their preoperative condition. One positive point was given for the presence of each sign reported by the patients. At 2 years after surgery, we asked the patients to evaluate the previously mentioned aging signs of their postoperative face. Again, 1 positive point was given for the presence of each sign reported by the patients. RESULTS: Although we did not perform statistical evaluation, 13 patients showed a degree of rejuvenation after MMA (the score of the postoperative face is less than the score of the preoperative face). Three patients reported no postoperative change; none reported a more aging face, with a successful "reverse face-lift" occurred in 81% of our cases. CONCLUSIONS: Simultaneous maxillary and mandibular advancements change the skeletal framework of the face, improving soft-tissue support and resulting in rejuvenation of the middle and the lower third of the face. This condition is demonstrated by the results of our study in that all patients appeared postoperatively more youthful from a self-evaluation.

Linfedema escrotal gigante / Giant scrotal lymphedema

RESUMEN La elefantiasis escrotal es una condición que ha sido históricamente descripta en áreas endémicas de filariasis, pero es menos frecuente su presentación idiopática o asociada a otras entidades. Presentamos un caso de elefantiasis escrotal gigante de causa adquirida idiopática, al que se le practicó la exéresis de la estructura linfedematosa y la reconstrucción del defecto con colgajos locales y autoinjerto cutáneo. El motivo de su divulgación radica en que se trata de un caso muy poco frecuente, ya sea por la baja incidencia y etiología, así como por la importante magnitud del problema para el individuo. El objetivo principal en el tratamiento del linfedema, en el caso presentado, fue devolverle al paciente funciones primarias y elementales de vida, además de disminuir la morbilidad y otorgarle una mejor calidad de vida.

ABSTRACT Scrotal elephantiasis is a condition that has been historically described in areas where filariasis is endemic, but idiopathic cases or those associated with other entities are rare. We report a case of a patient with idiopathic acquired giant scrotal elephantiasis who underwent excision of the lymphedematous structure and reconstruction of the defect with local flaps and skin autograft. The reason for this presentation is the uncommon nature of the case due to its low incidence, rare etiology and the magnitude of the problem experienced by the patient. The main goal in the treatment of lymphedema in this case was to restore primary and elementary functions of life to the patient, reduce morbidity and provide him with a better quality of life.

Superior Orbital Fissure Syndrome in Lateral Orbital Wall Fracture: Management and Classification Update.

The superior orbital fissure syndrome (SOFS) is an uncommon complication rarely occurring in association with craniofacial trauma. Work-up of a patient injured by a traumatic right orbitozygomatic complex fracture and SOFS is presented. Accurate computed tomography scan and three-dimensional reconstruction showed a medial displacement of the lateral orbital wall, compressing the right superior orbital fissure (SOF), without intraorbital bone fragment displacement or hemorrhage. Imaging also revealed a frontosphenotemporal fracture, according to Pellerin et al, that is, frequently associated with visual impairment. Our primary choice of therapy was a corticosteroid treatment in association with an early surgical approach. It consisted in en bloc reduction and osteosynthesis of the fracture through a bicoronal approach, recovering SOF size. A prompt and almost complete recovery of the abducens movement, without diplopia, was achieved in 1 week. The authors discuss indications and management of SOFS. The presence of fractures should urgently lead to surgery. We deny waiting for a medical treatment result, while preferring the prompt reduction of the fractures and extrication of the soft tissues. The main focus of this study is on patient's anatomical feature and fracture patterns.

One-year follow-up of transcoronary sinus administration of autologous bone marrow in patients with chronic refractory angina.

PURPOSE: Based on our preclinic studies with autologous unfractionated bone marrow (AUBM) via coronary sinus with transitory occlusion, a clinic study in patients with chronic refractory angina was designed. The objectives were to evaluate tolerance of the procedure, safety, and feasibility with 1 year follow-up. METHODS AND MATERIALS: Clinical study with inclusion and exclusion criteria defined by an Independent Clinical Committee was carried out. Fifteen patients underwent transcoronary sinus administration with a 15-min occlusion of freshly aspirated and filtered AUBM (60-120 ml). Feasibility was evaluated with Seattle Angina Questionnaire (SAQ), Canadian Cardiovascular Society (CCS) angina classification, perfusion dipyridamole, and coronary angiography. RESULTS: There were no changes in the tolerance parameters. There were no deaths or myocardial infarction during the follow-up. Three patients were readmitted into the hospital. During the follow-up, one patient was diagnosed with cancer of the lung. Improvement of 30% in the quality of life was evaluated by SAQ. The CCS angina classification showed that the mean angina class was 3.0+/-0.53 at baseline, which improved to 1.6+/-0.63 at 1 year (P<.001). Perfusion imaging (core lab) showed improvement in 12 of 15 patients, with a mean improvement of 40.9% at rest (22 vs. 13) (P<.01) and 45.3% at stress (26.5 vs. 14.5) (P<.05). Coronary angiography showed more collateral vessels in 10 of 15 patients. CONCLUSIONS: We can conclude that AUBM via coronary sinus is feasible in patients with chronic refractory angina after 1 year follow-up, and it appears to be safe.

Current opinions on surgical treatment of fractures of the condylar head.

Treatment of mandibular condyle fractures is still controversial, with surgical treatment slowly becoming the preferred option. However, fractures of the condylar head (diacapitular fractures) are still treated conservatively at many institutions. Recently, more and more surgeons have begun to perform open treatment for diacapitular fractures because it allows to restore the anatomical position of the fragments and disc, it allows an immediate functional movement of the jaw, and avoid the ankylosis of the temporomandibular joint induced by the trauma. Several techniques have been proposed to reduce and fix fractures of the condylar head, such as standard bone screws, resorbable screws, resorbable pins, and cannulated lag screws. Therefore, the aim of this article is to review the literature about the surgical treatment of fractures of the condylar head to resume the current knowledge about open treatment of such fractures.

Orbital lymphomas: clinical and radiological features.

The purpose of this prospective study was to evaluate the clinical and radiological features of a consecutive series of orbital lymphomas in two Institutions in the North West of Italy. A prospective study was performed of all cases of diagnosed orbital lymphomas. Data on patient demographics, symptoms and clinical findings, histological type of lymphoma, site of lesion, imaging, and systemic involvement were recorded in each case. The mean age of the enrolled 20 patients was 63.65 years. Most orbital lymphomas were located in the superior-lateral quadrant. Superior rectus muscle was the most frequently involved orbital structure. Most patients were affected by extranodal marginal-zone lymphomas. The diagnosis of orbital lymphomas may be challenging, because these neoplasms present few specific features. Although not typically performed by the maxillofacial surgeon, an understanding of the staging process is crucial for multidisciplinary management of orbital lymphomas.