Transoral versus transfacial surgical approach to maxillary tumors: evaluation of outcomes and perspectives.

Neoplasms of the maxilla have multiple different origins and histology, and often extend towards the infratemporal fossa, orbit, or skull base. Extensive resection may be required, often leading to poor esthetic and functional results. Usually, these lesions are removed via a transfacial approach. The aim of this study was to compare the outcomes of the transoral versus transfacial approach for maxillary tumors. A single-institution retrospective study was conducted on patients with maxillary-midface tumors, treated between January 2009 and December 2019. The patients were divided into two groups according to the surgical approach, transfacial or transoral, and the following outcomes were assessed: extent of the resection based on Brown's classification; postoperative pathology margin assessment; reconstruction technique; esthetic/functional results. A total of 178 patients were included. A satisfactory resection was obtained in both groups, with the transoral cohort achieving a higher rate of clear oncological margins (positive margins: transoral group 3.7% versus transfacial group 6.8%, P = 0.389) and a significantly higher University of Washington Quality of Life score (mean 72.2 versus 67.8, P < 0.001). Even large and invasive tumors can be treated successfully with the transoral approach, avoiding unesthetic facial scars while still providing complete resection of the tumor.

Self-inflicted craniomaxillofacial gunshot wounds: management, reconstruction, and outcomes.

Suicide by firearm remains one of the leading causes of violence-related injury death in the United States each year. The mortality rate from these injuries is high, resulting in a paucity of outcome data in the literature regarding injuries to the maxillofacial region. This has largely been attributed to a lack of funding for research in this area compared to other leading causes of mortality in the United States. The aim of this study was to detail the authors' experience and approach to complex maxillofacial reconstruction using both local reconstructive methods and microvascular free tissue transfer. A retrospective cohort study was designed, including patients who sustained self-inflicted gunshot wounds to the maxillofacial region between January 1, 2012 and May 1, 2020. Forty-one patients met the inclusion criteria. The majority of the patients were male (87.8%). Mean patient age was 44.2 ± 16.6 years. Alcohol or drugs, and a psychiatric history were present in a majority of the cases. The most involved anatomical region was the midface (75.6% of cases). Seven patients required free tissue transfer for reconstruction, with many needing multiple flaps. Self-inflicted gunshot wounds represent challenging reconstruction scenarios, often in the setting of severe psychological trauma, and require a multidisciplinary team to ensure the optimal outcome.

Contrasting opioid use for pain management in microvascular head and neck reconstruction: an international study.

Opioids are often the mainstay of postoperative pain management, despite strong evidence of their ill effects and potential for long-term addiction. The goal of this study was to quantify opioid use and contrast pain management strategies of multiple international institutions performing fibula free flap reconstruction. A retrospective multicenter cohort study was designed, including five international centers. For inclusion, the patients had to have undergone a primary fibula free flap reconstruction of the mandible. A total of 185 patients were included. The median opioid use across all centers at 72 hours was 133 oral morphine equivalents. The highest utilization was in the USA (P < 0.001), which was approximately six times that of Italy, four times that of Argentina, and twice that of India, despite all centers performing a similar procedure. Based on this study there are clear differences in prescribing practices and ideologies among surgeons from different countries.

Validated image ordering guidelines for odontogenic infections.

Overuse of computed tomography (CT) is a prevalent problem across multiple disciplines in healthcare and is common in the workup of odontogenic infections. To address this problem, an imaging pathway was created through collaboration of the oral maxillofacial surgery and emergency medicine departments to reduce unnecessary CT orders. A prospective study was implemented to assess the success of the imaging pathway to guide in the selection of the most appropriate radiological imaging modality when managing an odontogenic infection. Subjects included were adults, presenting through the emergency department for confirmed odontogenic infection. The primary outcome was the rate of unnecessary CT scans performed after the introduction of the pathway. Statistics were performed via the t-test, χ2 test, and multiple regression analysis; P < 0.05 was considered significant. Between February 1 and December 15, 2019, 100 patients met the inclusion criteria and were enrolled. The rate of unnecessary CT scans was 25.6%, compared to 56.6% prior to the introduction of the imaging pathway. The pathway did not misclassify any patient to not receive a CT when it was medically necessary. Use of the imaging pathway has the potential to reduce unnecessary CT imaging for odontogenic infections, without negatively affecting patient outcomes.

An analysis of unplanned readmissions after head and neck microvascular reconstructive surgery.

The 30-day readmission rate is a highly scrutinized metric of quality surgical care, because readmission is costly and perceived to be avoidable with planning and patient education. Head and neck surgery patients generally have multiple risk factors for readmission, as readmitted patients are generally older, with more co-morbidities, lower socio-economic status, and a history of multiple emergency department visits and readmissions. A retrospective cohort study was implemented to determine the incidence and etiology of 30-day readmission after microvascular head and neck reconstructive surgery, focusing on social risk factors. Data were analyzed by χ2 test, analysis of variance, t-test, and logistic regression, with statistical significance set at P<0.05. Of 209 patients included in this study, 35 (16.7%) had a 30-day readmission. Increased needs at discharge were associated with increased readmission, while other social risk factors were less significant for a readmission in this study.

Head and neck surgery is a risk factor for atrial fibrillation: incidence and outcomes.

Atrial fibrillation (AF) is the most common postoperative arrhythmia and can cause increased length of stay, costs, morbidity, and mortality. Little information exists about postoperative AF after major head and neck surgery, but it is thought to occur more frequently than after surgery at other extra-thoracic sites. A retrospective cohort study was implemented, including patients who had undergone major head and neck surgery and who had follow-up records covering a minimum of 60 days postoperative. The main outcome was the incidence of new onset postoperative AF after major head and neck surgery; secondary outcomes were the incidence of any AF, the role of cardiology, predictors of AF postoperatively, and clinical outcomes. A total 337 patients were included. Twenty-four patients experienced AF postoperatively (7.1%), of whom 12 (3.6%) had new onset AF. New onset AF was associated with advanced age of ≥65 years (odds ratio 11.6, P=0.027) and having a laryngectomy (odds ratio 9.9, P=0.003). Postoperative AF following major head and neck surgery is not a rare phenomenon and can be associated with considerable morbidity and costs due to the need for intensive care, specialty consultations, additional testing and laboratory studies, and cardiology follow-up.

Accuracy of virtual planned surgery versus conventional free-hand surgery for reconstruction of the mandible with osteocutaneous free flaps.

Virtual surgical planning (VSP) promises higher accuracy, efficiency, and superior patient outcomes, helping normalize outcomes from surgeons of different experience levels. A systematic review was conducted in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The objective was to evaluate the accuracy and secondarily efficiency of VSP compared with free-hand surgery, for mandibular reconstruction with free flaps. Six studies met inclusion criteria and had quantitative data suitable for meta-analysis. Intercondylar distance and gonion angle were used to assess accuracy, evaluated by mean change from preoperative VSP and postoperative imaging. The mean weighted difference in VSP intercondylar distance was 2.0 mm, compared with 3.9 mm for free hand (P=0.101) and mean change in gonion angle for VSP was 3.6°, compared with 7.7° for free hand (P<0.05). Efficiency assessed by mean ischemia time, was 73.8min and 109.9min, for VSP and free hand, respectively (P=0.203), and by total operative time, which was 391.8 min and 457.6 min in the VSP and free hand, respectively (P=0.340). VSP is consistently proven to be more accurate and efficient than traditional free-hand surgery; however, a standardized method for accuracy and efficiency measurements is still missing, causing heterogeneity among the scientific reports.

[Impact of demographic change on the employment for carers in central Germany. An analysis of Saxony, Saxony-Anhalt, and Thuringia]. / Auswirkungen des demografischen Wandels auf die Fachkräftesituation im Pflegebereich in Mitteldeutschland. Eine Analyse für Sachsen, Sachsen-Anhalt und Thüringen.

This article provides a detailed analysis of the current state of the labor market for long-term carers in the Federal States of Saxony, Saxony-Anhalt, and Thuringia and uses model calculations to derive trends until the year 2025. Examining the current situation, we look at the ratio of unemployed persons to registered job vacancies, the duration of the vacancy, the short-term and long-term employment trend, the replacement demand, and the job-specific unemployment rates. In addition, wages are discussed as the central clearing mechanism between labor demand and labor supply. Employment bottlenecks are evident for nurses and social workers, which will be exacerbated in the future owing to a strong demographic change. On the one hand, demand for long-term care will grow along with the increase of elderly people. On the other hand, the labor force potential and hence the supply of long-term carers will decrease. Model calculations show that in these three Federal States, between 18,100 and 31,700 long-term carers (in full-time employment) will additionally be needed for the elderly. Employers in this field will face grave challenges in meeting these needs.