What are the limitations of the non-patient-specific implant in titanium reconstruction of the orbit?

There is ongoing discussion about patient-specific implants (PSI) to reconstruct orbital defects. Although PSI offer excellent clinical outcome, they are expensive. Subsequently, their routine application is not indicated. The purpose of this study was to estimate the frequency of implant malposition and revision procedures after primary orbital repair with preformed plates and to identify cases where primary use of PSI would help to prevent revision surgery. All patients included in the study were operated on for orbital fractures at the Royal London Hospital between August 2017 and July 2018. Selection criteria included adult patients treated for orbital fractures with a titanium plate. Revision was planned in symptomatic patients presenting with clear implant malposition. Seventy-nine patients with 81 implants were included, 33 of whom had multiple orbital wall fractures (medial wall and floor or all four walls) and were summarised as group 2. Group 1 consisted of single orbital floor/medial wall fractures. The five patients for whom revision surgery was planned or undertaken because of radiological poorly positioned implants and substantial clinical symptoms all had multiple wall fractures. This finding was significant (p=0.006). The major reason for revision was a defect that was too large for the prescribed plate. Patients with large orbital defects needing surgical treatment are at risk of implant malposition. The orbital reconstruction with preformed plate evidences good outcome in single wall fractures. However, the risk of malposition increases massively with fracture size. We therefore postulate that in large, two-wall fractures, primary treatment with a PSI has to be considered.

Primary tuberculosis of the TMJ: presentation of a case and literature review.

Tuberculosis (TB) is a frequent health problem. The prevalence of extrapulmonary TB has increased in the last couple of years. Head and neck tuberculosis forms nearly 10% of all extrapulmonary manifestations of the disease. TB of the temporomandibular joint (TMJ) is rare; only a few cases have been reported. The clinical appearance of TB infection of the TMJ has been described as unspecific, resembling arthritis, osteomyelitis, cancer or any kind of chronic joint diseases. This article describes a 22-year-old woman with pain and left preauricular swelling. Magnetic resonance imaging and computed tomography showed an expansive process with destruction of the left condyle and condylar fossa. A fine needle aspiration examination of the swelling showed non-specific granulomatous inflammation. In the following days, a preauricular fistula developed, of which a swab and biopsy specimens were taken. Histological and microbiological examinations revealed an infection with Mycobacterium tuberculosis. The initial antituberculosis treatment consisted of a combination of four antibiotics and could be reduced to two antibiotics in the course of treatment. The treatment was completed successfully after 9 months.

Predictors of swallowing outcome in patients treated with surgery and radiotherapy for advanced oral and oropharyngeal cancer.

Retaining effective swallowing is a key element when optimising outcomes in the management of head and neck cancer. We report the functional swallowing outcomes for a cohort of 31 individuals with advanced oral and oropharyngeal cancer who underwent free or pedicled flap reconstruction of surgical defects. Swallowing was assessed pre and immediately post surgery and at four months post treatment. Swallowing assessments were related to site, size and volume of defect and composition of flap reconstruction. The effect of radiotherapy on swallowing was assessed among 17 of the 31 individuals who were submitted to radiotherapy after surgery. The proportion of patients on a total oral diet four months post treatment varied significantly by site of defect (Fishers exact test p=0.006), from 100% (7/7) of patients with a lateral defect to only 22% (2/9) of patients with a central defect. The proportion of patients on a total oral diet at the final assessment did not vary by flap reconstruction or radiotherapy.

[Lower eyelid reconstruction of traumatically caused cicatricial entropion with amniotic membrane or mucosal membrane grafts]. / Unterlidsrekonstruktion von traumatisch bedingten Narbenentropien mittels Amnionmembran- oder Mundschleimhauttransplantation.

BACKGROUND: A retrospective evaluation was undertaken of eyelid reconstruction with amniotic membrane or oral mucosal membrane transplantation in patients with lower lid cicatricial entropion after orbital surgery. PATIENTS AND METHODS: Seven patients (four women) were treated with a scar tissue dissection and an amniotic membrane or mucosal membrane transplantation between 2003 and 2006 (Five amniotic membrane grafts and two oral mucosal membrane grafts). In selected cases additional procedures like a lateral tarsal strip operation, a tarsal fracture, or the reinsertion of the lower lid retractors were performed. RESULTS: All patients showed a favourable postoperative result with a good anatomic correction of the entropion and a regression of the preoperative disturbances. All the grafts took well. Two patients had to be reoperated twice and one patient three times as a result of a relapse of the cicatricial entropion. However, as well in these patients the anatomical and functional result was favourable at the end. CONCLUSIONS: The difficult scar dissection with the subsequent amniotic membrane or oral mucosal membrane transplantation seems to be an appropriate procedure to reconstruct complicated cicatricial entropion after orbital surgery.

Comparative objective and subjective analysis of temporalis tendon and microneurovascular transfer for facial reanimation.

The aim of this study was to compare objectively and subjectively the results after temporalis tendon and microneurovascular transfer for reanimation of the paralysed face. For the objective analysis, measurements of the distances between static and dynamic points in three-dimensional space were performed at rest and during smiling. The patients were assessed subjectively by non-professionals scoring videotapes. The range of motion of the oral commissure on smiling was 1.7 mm (0.8, mean and SE) after tendon and 5.5 mm (1.6) after microneurovascular transfer (P < 0.05) without showing teeth, and 0.6 mm (1.3) vs 3.6 mm (2.4, ns) with showing teeth. Compared with the healthy side, the excursions reached 6% (16) after tendon and 71% (26, P < 0.05) after microneurovascular transfer for smiling without, and -4% (14) vs 19% (14, ns) for smiling with showing teeth, respectively. Virtually no difference was found in the measurements at rest as well as in the subjective evaluation. Swelling of the cheek (28%) and tethering of the skin (24%) were shown to be the most disturbing symptoms after microneurovascular transfer. Better excursion and symmetry of the oral commissure were achieved by microneurovascular reconstruction for voluntary smile. However, the aesthetic outcome after microneurovascular transfer is markedly impaired by chronic complications including swelling of the cheek and tethering of the skin, which were not detected by the three-dimensional measurement technique used. We conclude that the aesthetic appearance should be considered equally important as the range of motion in the reanimated face.