Lipofilling of the upper eyelid to treat paralytic lagophthalmos.

Lagophthalmos is one of the most unpleasant and dangerous conditions that affect patients with facial palsy. The lack of ocular protection leads to corneal problems (such as conjunctival infections, acute and chronic keratitis, corneal ulcerations, and blindness). A dynamic reanimation of blinking eyelids is the therapeutic gold standard. However, success is not guaranteed with these dynamic techniques; even if results are good, blinking is usually restored within a year of the initial operation. Procedures that act more rapidly and have a higher success rate are needed. We proposed that lipofilling of the upper eyelid would improve eye closure, exploit the advantages of using autologous fat, and avoid the risks of exposure or migration associated with loading the lid with gold. Between 2012 and September 2018, we did upper eyelid lipofilling procedures for 75 patients with unilateral facial palsy. The main favourable result of lipofilling of the upper lid was the immediate improvement in corneal discomfort. Everybody described a partial to total increase in corneal comfort postoperatively. In the treatment of paralytic lagophthalmos, lipofilling of the upper eyelid produces favourable aesthetic and functional results, ocular health is restored, and the patients' quality of life is improved.

Lipofilling of the atrophied lip in facial palsy patients.

AIM: Patients affected by unilateral facial palsy often show partial or complete atrophy of the orbicularis oris. The lower hemilip on the affected side may have partial functional recover due to direct reinnervation stemming from the unaffected side. This explains why atrophy of the paralysed side is sometimes limited. Negative esthetic and functional findings include partial invisibility of the vermillion border due to lip inversion resulting from muscle flaccidity, asymmetry of the lower lip, oral incompetence, and speech and nutrition impairments of variable degree. In this study, we used Coleman lipofilling as a secondary and ancillary procedure to consolidate the results already obtained with dynamic reanimation, specifically aiming to reduce the volumetric loss due to atrophy of the orbicularis oris muscle. METHODS: Eight patients underwent lipofilling to restore volumetric loss due to muscular denervation atrophy. Six of our patients were affected by inveterate facial palsy and one by an acute form of facial palsy. The last patient presented with high-grade bilateral upper lip atrophy due to Moebius syndrome. Two patients underwent a second lipofilling intervention. RESULTS: The esthetic volume increase and the ameliorated lip competence were immediately noticeable after the first lipofilling, to great patient satisfaction. As a result of the variable rate of resorption over time of the grafted fat, it may be advisable to repeat the procedure in some patients to maximize results. CONCLUSION: Lipofilling represents a useful and safe ancillary technique for camouflage of lower lip atrophy in paralysed patients.

Technical refinements in mandibular reconstruction with free fibula flaps: outcome-oriented retrospective review of 99 cases.

Congenital disease, major trauma, tumour resection and biphosphonate-related osteonecrosis can lead to partial, subtotal, or total loss of the mandibular bone. Minor defects can be easily reconstructed using bone grafts, whereas microvascular free tissue transfer may be unavoidable in the case of major bone loss or poor quality of soft tissue. Simple bone or composite osteocutaneous fibula free flaps have proven invaluable and remain the workhorse for microvascular mandibular reconstruction in daily practice. Our experience with 99 consecutive fibular free flaps confirms the available data in terms of high success rate. In these cases, 90% had total success, while 7 had complete flap failures. Three of our patients showed skin paddle necrosis with bony conservation. This report focuses on the technical refinements used by the authors that can prove valuable in obtaining predictable and precise results: in particular, we discuss surgical techniques that avoid vascular pedicle ossification by removing the fibular periosteum from the vascular pedicle itself and reduce donor site morbidity and aid in management of the position in the new condylar fossa. Finally, new technologies such as intraoperative CT and custom premodelled fixation plates may also increase the predictability of morpho-functional results.

Extensive rhabdomyoma of the head and neck region: a case report and a literature review.

Rhabdomyomas are rare mesenchymal benign tumors of striated muscle origin that can be classified into cardiac and extracardiac types. Cardiac rhabdomyomas are considered as hamartomatous lesion because of their association with phacomatosis. Extracardiac type is further classified into adult, fetal and genital form, depending on the individual tumor's degree of differentiation. Adult head and neck rhabdomyomas are rare pathologies of adult patients, with a male predominance. The occurrence of multifocality is a rare manifestation of this uncommon lesion. Presenting symptoms are related to the location and dimension of the tumors and they include upper airway obstruction, Eustachian tube dysfunction, dysphagia and mucosal and neck mass. Because of their high rate of recurrence, radical resection is the treatment of choice of this kind of tumors. In this article is reported a rare and particularly large case of head and neck adult rhabdomyoma, presenting with an history of sleep apnea and night-time stridor.

Iliac crest fresh-frozen allografts and autografts in maxillary and mandibular reconstruction: a histologic and histomorphometric evaluation.

AIM: The aim of this paper was to compare histologically and histomorphometrically the osseointegration of iliac crest fresh-frozen allografts and autografts in human pre-prosthetic maxillary and mandibular onlay bone blocks reconstruction. METHODS: Twelve patients with edentulous atrophic ridges, scheduled for implant-supported prosthetic restorations, underwent reconstruction using iliac crest fresh-frozen allografts (group A, six patients) or autografts (group B, six patients). Four-to-nine months later implants were placed in the augmented areas and bone specimens were simultaneously obtained using trephine burs. The specimens were processed for ground sections and evaluated histologically and histomorphometrically. RESULTS: The postoperative course was uneventful in all patients in group B and in all except one in group A. Late complications occurred in 5 patients of group A. Dental implants could be inserted in all cases. Specimens from group A showed a vascularized bone with osteoprogenitor stem cells and medium-high grade of bone remodeling. Small areas of necrotic bone were observed sporadically. Sections obtained from group B revealed an advanced stage of bone remodeling. The histomorphometric analysis showed in group A a mean proportion of 24.7±14.7% for lamellar bone, 28.4±13.3% for newly formed bone and 46.9±16.9% for bone marrow; in group B the corresponding values were 25.3±15.3%, 22.9±11.0%, 51.7±15.7%. No statistically significant difference was found (Wilcoxon Test; P>0.05). CONCLUSION: There were no significant histological differences between group A and B. Larger studies with long term follow-up are needed to confirm that fresh-frozen allografts are a reliable alternative to autografts.

[Double innervation (facial/masseter) on the gracilis flap, in the middle face reanimation in the management of facial paralysis: a new concept]. / Double innervation (facial/masseter) sur le lambeau gracile dans les réanimations du tiers moyen de la face lors de la prise en charge des paralysies faciales : nouveau concept.

INTRODUCTION: The facial paralysis is a non-rare condition that has very disabling functional, morphological and psychological repercussions. The current gold standard in facial reanimation is revascularized re-innervated muscle transfers. MATERIALS AND METHODS: In this paper, we report the results of a new method using the gracilis flap with a double innervation on the masseter motor nerve and the controlateral facial nerve via a sural graft in a single stage intervention, on a series of six patients. RESULTS: No failure was observed. The average delay of a voluntary contraction was 3.8months, and 7.2months for a spontaneous one. Three of the six patients had "excellent" results according to the Terzis and Noah classification, two were classified as "good" and one "average". DISCUSSION: A choice is to be made between a method advocating a natural and spontaneous dynamicity (controlateral facial nerve stimulus) and a method focusing on the quality and quantity of contractions (ipsilateral trijeminal stimulus). In this new technique, we combine the two methods: a free gracilis transfer with a dual innervation on the healthy controlateral facial nerve via a sural graft, on one hand, and a second anastomosis on the ipsilateral masseter nerve, on the other hand. CONCLUSION: This new proposed method seems to be, according to our results, a reliable technique rallying voluntary contraction and emotional smile.

Surgical access to condylar fractures in panfacial traumas.

AIM: Surgical access to the condyle in panfacial fractures is a delicate and debated issue. The aim of the study was to propose a protocol which would apply in the treatment of panfacial fractures requiring access to the condyles. METHODS: A case series of 10 patients (8 males and 2 females) with panfacial fractures consisting of 16 extracapsular mandibular condylar fractures associated with 3 symphyseal, 7 parasymphyseal, 1 mandibular angle, 6 Le Fort II, 3 orbitomaxillomalar, 5 zygomatic arch fractures were included in this study. Reduction and fixation were achieved using the mini-retromandibular access in 6 patients with 10 extracapsular condylar fractures while in 4 patients with 6 extracapsular condylar fractures access to the condyles consisted in a face-lift-type preauricular access, as a caudal extension of a coronal or hemicoronal incision required for the reduction and fixation of other fractures of the upper and middle thirds. RESULTS: A good morphological and functional outcome was achieved in all patients. No surgical complication associated with access to the condyles or treatment of the condylar fractures was registered. CONCLUSION: The proposed protocol could be used as a guide in choosing access to the condyles in panfacial traumas.

Autonomized flaps in secondary head and neck reconstructions.

Free flaps, with their very high rates of success and low donor site morbidity, are considered the gold standard in head and neck reconstruction, allowing the transfer of ideal tissues for head and neck reconstruction. Nonetheless, under certain circumstances they may be contraindicated or cannot be utilized. We describe four subjects in which delayed locoregional flaps were used to reconstruct head and neck defects after a previous flap failure. Due to adverse anatomic and systemic conditions these patients were not suitable for a free flap, and thus one delayed prelaminated temporalis fasciocutaneous flap placement and three delayed supraclavicular flap (one of which was prelaminated) placements to reconstruct large defects of the cheek and commissural region needed to be performed. All flaps and grafts were viable. All patients in this case series had acceptable functional and aesthetic outcomes. Donor-site morbidity was negligible. Delayed locoregional flap placement required a total of three surgical sessions. Although limited, our experience suggests that in cases in which a free flap is contraindicated or not ideal, locoregional flaps may be a valid and safe alternative. Limitations of these procedures include increased duration of hospitalization and, foremost, the need for three-step surgery.

Lingual nerve lesion during ranula surgical treatment: case report.

Iatrogenic lingual nerve (LN) injuries are quite common in oral surgery both in maxillo-facial surgery and in oral surgery. LN runs superficially into the lateral mouth floor just beneath the mucous layer and this position enhances damage frequency. This article lists the different aetiologies of iatrogenic LN injuries and it almost focuses on lesions due to surgical treatment of ranulas. In the case report a LN lesion due to oral ranula excision is discussed; the patient experienced anaesthesia and hyperpatia in the corrisponded tongue side. It was treated with a microneurosugical anastomosis of LN, after amputation neuroma excision. The partial and definitive recovery of perception happened in six months and was deemed satisfying with 70% of functionality restored (results compared with the functionality of the contralateral side). An algorithm for diagnosis and therapy indication for iatrogenic injuries to nerves is also proposed. In case of surgical treatment, funcitonal recovery manifests after 4-6 month; a functional recovery of 70% of total nerve function is possible. The variable that most affects nerve functional recovery is surgical treatment timing; it must be performed as soon as possible.

Pericranium graft in reconstructive surgery of atrophied maxillary bones.

In preprosthetic surgery the autologous bone is universally considered the gold standard. Calvaria is, among many options, one of the preferred for its unique characteristics of hardness, easy of harvest and very low morbidity at donor site. Moreover, it gives the possibility of harvesting the pericranium. This technique, recently introduced in common practice in Milan, allows to harvest a large quantity of periosteum to cover bone grafts perioperativly. Periosteal tissue is used to cover bone grafts for two reasons. First, it would provide a layer of tissue that, thanks to its osteogenic potential, would prevent bone resorption. Second, this would interpose a layer of soft tissue to act as a cushion between the bone and mucosal flap to minimize the risk of wound dehiscence, that would bring to bone exposure and consequent failure of reconstruction. Five jaw reconstructions were performed with autologous bone and pericranium. In all cases the outcome was good, the grafts took with correct bone volume preservation. Implants were positioned according to prosthetic needs. In one case a vascular necrosis of a mucosal flap occurred. Bone exposure was prevented by the periosteum, which was revascularized after few days, allowing bone integration. Considering its potential protective capability towards bone grafts and the lack of donor site morbidity, this technique should be considered as a standard procedure in preprosthetic reconstructive surgery.

Transthoracic hernia after harvesting a costal and latissimus dorsi flap.

Ribs are one of the most widely used grafts in craniofacial surgery. Harvesting a costochondral graft is easy and safe. The main complications are related to pneumothorax and chest-wall deformity in children. A complication is described in a patient who underwent an orbito-zygomatic reconstruction with two contiguous ribs and a latissimus dorsi free flap, and who subsequently developed a transthoracic hernia that required reconstruction with polypropylene mesh.