Orthognathic surgery: a randomized study comparing Piezosurgery and Saw techniques.

INTRODUCTION: The purpose of this study was to evaluate specific parameters: intra-operative time, facial swelling, degree of pain (VAS scale), recovery time and neurosensory disturbance in patients who underwent orthognathic surgery either using piezo or saw devices. MATERIAL AND METHODS: We designed a retrospective study, which included 100 patients who underwent bilateral sagittal split osteotomy (BSSO) surgery combined with maxillary Le Fort I. They were separated into 2 groups of 50 patients each. The surgeries were performed between September 2015 and April 2017 by the same surgeon. RESULTS: Intra-op time is unchanged but patients operated with the Piezo devices requested fewer painkilling medication and were dismissed on the second day after the surgery. Neurosensory recovery was statistically significant in the Piezo group. CONCLUSION: Far less post-op swelling and the reduction in the use of painkillers lead to a speedier recovery in patients who underwent orthognathic surgery using Piezosurgery. These patients also recovered more sensitivity in the lower lip area. KEY WORDS: Orthognatic surgery, Piezosurgery, Saw.

Our Experience Managing Difficult Accidental Chainsaw Trauma.

BACKGROUND: Chainsaw and circular-saw injuries represent a rare condition within the maxillofacial region. The purpose of this clinical report is to describe the injuries and the clinical and surgical management of these rare traumas. METHODS: In this clinical report, 11 patients presenting themselves to the emergency room in the hospital "Policlinico Le Scotte," Siena, from March 2016 to September 2017 with severe chainsaw and circular-saw injuries, were included. All of the patients underwent general anesthesia and surgical treatment. This study describes 3 of the 11 patients with saw injuries. RESULTS: No complications occurred during surgeries and a good primary closure of the wound margins were achieved in all patients. However, after surgery, the authors experienced some complications in 2 patients: the 1st one displayed chewing problems due to extensive local edema; the 2nd one developed a total loss of vision in his left eye, even though there was no damage inflected to the eye ball during the trauma or surgery. CONCLUSION: All the patients were followed during the 1st year after surgery. The authors evaluated the patients at 3 months, 6 months, and after 1 year, and none of them developed complications or alterations related to the trauma. However, 1 patient is still experiencing loss of vision and he is under constant specialized follow-up.

Indocyanine Green Sentinel Node in Merkel Cell Carcinoma of the Cheek.

Merkel cell carcinoma (MCC) is a rare malignant tumor with a neuroendocrine phenotype. The authors report a case of MCC of the left cheek region in an 85-year-old Caucasian woman who also received sentinel node biopsy using both Technectium-99m-labeled (99mTc) lymphoscintigraphy and indocyanine green lymphography.

The Second Division of Trigeminal Nerve for Corneal Neurotization: A Novel One-Stage Technique in Combination With Facial Reanimation.

Corneal neurotization represents an effective surgical strategy to restore corneal sensibility in patients affected by neurotrophic keratopathy.Corneal sensibility is essential in preserving structure and function of the eye. Loss of corneal sensibility can lead to a degenerative condition of the cornea known as neurotrophic keratopathy.Moreover, patients suffering from facial palsy show failure of full eyelid closure resulting in chronic corneal exposure and subsequent progressive damage.Reports have shown that the use of the contralateral ophthalmic division of the trigeminal nerve can be effective in restoring corneal sensibility. In the present study the authors expose a new technique by means of which direct neurotization of the anesthetic cornea was achieved using the homolateral second division of the trigeminal nerve. Effectiveness of the technique was evaluated using in vivo confocal microscopy.To the best of authors' knowledge, this is the first report of this technique in literature.

Relationship Between the Quantity of Nerve Exposure During Bilateral Sagittal Split Osteotomy Surgery and Sensitive Recovery.

AIM AND OBJECTIVES: The purpose of this study was to evaluate how different exposures of the V3 nerves during orthognathic surgery impact neurosensory disturbances. METHODS: The study included 127 patients who underwent either bilateral sagittal split osteotomy (BSSO) or BSSO with maxillary le Fort 1. They were divided into 6 groups, identified by the quantity of V3 nerve exposure. All patients were examined in a pre-op period and again after 1, 3, 6 months post-op. The standardized tests used were to clarify the objective and subjective neurosensory status of the exposed nerve. Neurosensory evaluation included; a pin prick test, the 2 points discriminator, light touch, warm and cold tests, and blunt discrimination. They were all done bilaterally on the lower lip area. RESULTS: In only 2 patients the nerve was damaged during surgery and thus they were not included in this study. In 10.2% of patients there was no nerve exposure, 25.2% had longitudinal vestibular segment nerve exposed, 22.8% had the longitudinal upper-vestibular segment exposed, 20.5% had the longitudinal lower-vestibular segment exposed, 14.2% had the longitudinal upper-lower-vestibular segment exposed, and in 7.1% of patients the nerve was totally exposed. Given the estimated time of 1 month there was 100% recovery in patients whose nerve was unexposed. Considering the other patients, the authors had a variable number of patients who did not recover completely. CONCLUSION: The authors estimate a correlation between the recovery time and the quantity of the exposed nerve. There is a high incidence of neurosensory disturbance in the lower lip and chin after BSSO and intraoperative quantity of nerve exposure.

Giant palatal schwannoma.

Schwannoma is a benign tumor that arises from nerves that contain Schwann cells. We report a case of giant schwannoma of the hard palate, which originated from the greater palatine nerve and is interesting for its large dimensions.

LEOPARD syndrome: maxillofacial care.

This article reports a case of a boy with LEOPARD syndrome with unusual mandibular osteolytic osteoclastic-like lesions and eruption disorder. The patient was referred to our department for bilateral facial swelling: systemic examinations, diagnosis, and dental and maxillofacial care are reported.

"Naked microvascular bone flap" in oral reconstruction.

Since the 1980s, bone free flaps have been used to reconstruct the maxilla and the mandible. The vascular pedicle, through the supply of nutritional substances and drugs from the bloodstream, ensures the vitality of the flap, rapid bone integration, and reduced risk of infection.However, due to many surgeons' concerns about orocervical and orosinusal fistulas and infections, bone flaps are usually buried and protected by mucosal flaps or a second skin flap whenever it is not possible to harvest a skin paddle together with the bone flap.The authors, convinced that naked bone free flaps, if well vascularized, are capable of healing and repairing the osteomucosal deficit on their own, with no risk of infection or fistulas, began to harvest, for oral reconstructions, naked bone flaps, that is, bone flaps covered only by a muscle layer 5 to 20 mm thick.In this study, the authors present a review of their experience in oral cavity reconstructions by harvesting naked and covered bone free flaps, retrospectively evaluating the occurrence of major and minor, early and late complications, associated with the different reconstructive technique.

Calvarial onlay graft and submental incision in treatment of atrophic edentulous mandibles: an approach to reduce postoperative complications.

PURPOSE: The aim of this study was to test our approach based on the use of calvarial graft and extraoral approach, in treatment of severe mandibular atrophies with implant surgery and prosthetic rehabilitation. METHODS: We selected 6 patients, 4 females and 2 males, completely edentulous with a severe mandibular atrophy (class VI Cawood and Howell classification). Mean age of patients was 63 years, ranging from 60 to 67 years. Mandibles were reconstructed with a submental incision with calvarial bone graft harvested from parietal area. After a mean of 4.2 months, each patient received 4 implants, and after a mean of 4.67 months, implants were loaded. RESULTS: No complications occurred in donor site or on the mandible, and all patients recovered well. No extraoral scar occurred. A total of 25 implants were inserted, and, with exception of an early failure and successive replacement, all implants were osseointegrated at successive visits. After 1-year follow-up, our analysis showed 100% implants survival and correct fit and success of prosthetic rehabilitation. CONCLUSIONS: Results of this study showed an uneventful recovery for all patients with our approach and reduced healing time of bone graft. So extraoral approach with submental incision and calvarial graft is a reliable method in reconstruction of atrophic mandibles, and staged implant surgery is suggested.

Management of a bulky capillary hemangioma in the parapharyngeal space with minimally invasive surgery.

In this article, the authors report their management with minimally invasive surgery of a bulky capillary hemangioma in the parapharyngeal space. Parapharyngeal space capillary hemangioma is a rare tumor in adults. Because of its rarity and difficulty to treat, we suggest a multidisciplinary approach in choosing the best treatment, with an accurate follow-up.

Complications of orbital floor repair with silastic sheet: the skin fistula.

Treatment of orbital floor fracture is a subject of great interest in maxillofacial surgery. Many materials have been described for its reconstruction.In this article, the authors report a case of a patient who, 7 years from a previous orbital floor fracture and treatment with silastic sheet, presented herself to their clinic for the failure of the material used for its reconstruction and a skin fistula.Orbital floor repair with silastic sheet is an old method that no one uses anymore, but we still observe cases of late complications with this material. So a fine knowledge of silastic sheet complications is needed for young surgeons.The authors report the case and perform a literature review about the use of more modern biomaterials for orbital floor reconstruction.

Postsurgical predictive theoretical thickness (PTT) of frontal sinus anterior wall as key point in surgical management of frontal bossing: proposal of a new analytic method.

BACKGROUND: Frontal bossing is a malformation characterized by peculiar prominent forehead, and commonly it can be associated with cranial synostosis and endocrine disorder; however, nonsyndromic conditions are described as well.Literature controversies on proper frontal bossing surgical treatment showed evidence of 2 main surgical procedures: frontal bone reshaping and bone en bloc mobilization.A decision-making criterion between these 2 techniques has never been described in literature. METHODS: In this paper, the authors introduce their brand-new analytic method for decision-making between bur shaping and en bloc mobilization in frontal bossing treatment, and describe a successful case of a nonsyndromic frontal bossing patient, treated with their unconventional surgical technique. RESULTS: Our analytic method indicated that bur shaping was not indicated in this particular case: aggressive remodeling of excessive thin wall could lead to sinus perforation, which could turn into unsatisfied aesthetic and functional outcome.So we planned for a bilateral orbitofrontal en bloc reposition, followed by internal rigid fixation. No postoperative complications occurred. Postoperative CT scan revealed good bone repositioning and recovery. CONCLUSIONS: The authors explained their analytic method based on careful presurgical CT-scan measurements for decision-making between bur shaping and en bloc mobilization.

Single-step nasal reconstruction with osteocutaneous forearm flap after total rhinectomy.

PURPOSE: Nasal defects resulting from tumor excision can be classified according to tissues involved, such as skin, cartilage, and bone. Although in the case of "simple" defects, reconstruction with loco-regional flap eventually associated with cartilage grafts can lead to satisfactory results; in the case of total or partial rhinectomy, a minimum of 3 and a maximum of 7 operations have to be performed in the current series to achieve an acceptable end result. We present the case of a total rhinectomy reconstruction in a single-step procedure with an osteocutaneous forearm free flap (RFOFF). CLINICAL REPORT: A 50-year-old man underwent total rhinectomy to excise a pathologically proven T4aN0 moderately differentiated squamous cell carcinoma of the nose; contemporary single-step reconstruction with an RFOFF was performed. Adjuvant radiotherapy was performed. RESULT: At 18 months of follow-up, the patient is free of disease and no postirradiation flap damage has been experienced; the flap notably did not appear to be bulky. CONCLUSIONS: We believe that the RFOFF is morphologically and functionally better than other flaps owing to its capability to adapt to the new environments of the nasal cavity, and to avoid, when possible, a three-dimensional reconstruction of the same.

Role of a new orthognathic surgery in maxillomandibular reconstruction by free flaps.

PURPOSE: The objective of this study was to describe the orthognathic surgery techniques for the treatment of occlusal anomalies in those patients who underwent complex maxillomandibular reconstruction with bony free flap. MATERIALS AND METHODS: The authors describe their personal technique developed over years of experience with reconstruction of mandibular defects with bony free flaps. RESULTS: The outcomes in these patients who were treated according to our surgical planning were completely satisfying, with a 100% stability of the treated bones. CONCLUSIONS: Orthognathic procedure on bony free flaps for the reconstruction of mandibular defects is nowadays accepted. Patients who underwent major mandibular destruction due to oncologic disease or trauma outcomes can now benefit from this technique.

Iliac crest flap: donor site morbidity.

INTRODUCTION: Starting from the 1980s, with the advent of microsurgery, microvascular flaps are used for the reconstruction of wide and complex bone defects of the maxillomandibular district. Compared with conventional and implant-supported prostheses, the free flaps allow aesthetic-functional rehabilitations more adapt to answer to problems that these wide disablements involve. The anatomic characteristics of the crest flap make it one of the best available flap in the maxillomandibular bone reconstruction. METHODS: The authors introduce a retrospective analysis of their own experience in the reconstruction of wide and complex bone defects of the maxillomandibular district. Specifically, the attention is focused on the use of the iliac crest flap. The surgical technique of flap preparation is discussed. Moreover, a review of results from international studies about the morbidity of the donor site is presented and compared with own experience. RESULT: As reported in the literature, the iliac crest flap donor site may encounter several complications. Among these, chronic pain, loss of regional sensibility or paresthesias, hematoma, seroma, walking troubles, unaesthetic scars, abdominal hernia, and loss of the normal bone profile of the hip. DISCUSSION: At present, the use of the iliac crest free flap in the microvascular reconstruction of the complex deficits of the maxillomandibular district represents a well-established method in the experience of the maxillofacial surgeon. Several information about results obtained in the maxillomandibular rehabilitation are available from the literature; however, little attention has been addressed to complications and morbidity of the donor site. Such aspect will be discussed in this work.

Scapula free flap for complex maxillofacial reconstruction.

INTRODUCTION: Composite tissue defects of the mandible and maxilla, after resection of head and neck malignancies, osteoradionecrosis, malformations, or traumas, cause functional and aesthetic problems. Nowadays, microvascular free flaps represent the main choice for the reconstruction of these defects. Among the various flaps proposed, the scapula flap has favorable characteristics that make it suitable for bone, soft tissue, or combined defects. MATERIALS: We report 7 cases of reconstruction of complex maxillofacial defects with subscapular system flaps. The patients treated had Romberg syndrome (1 case), malignant tumors (5 cases), and result of previous trauma (1 case).Location of deficit was the maxilla (3 cases), the mandible (2 case), the ethmoidal-maxillary region (1 case) and the upper and middle thirds of the face in the last case. METHODS: In 2 cases, a parascapular system flap was used; in 5 cases, a composite flap with latissimus dorsi muscle and scapular bone. RESULTS: Neither failure of the harvested flaps nor complications in the donor site were evidenced. A good aesthetic and functional outcome was obtained in all cases. DISCUSSION: : Many free flaps have been proposed for the reconstruction of defects in the maxillofacial region such as fibula, deep circumflex iliac artery, scapula, among the bone flaps; and forearm, rectus abdominis, and anterolateral thigh, among the soft tissue flaps. The choice of the flap to use depends on the length of the bone defect and the amount of soft tissues required. The subscapular system has the advantage of providing different flaps based on the same pedicle. The osteofasciocutaneous scapular free flap, in particular, allows wide mobility of soft tissues (parascapular flap) with respect to its bone component (scapular bone), resulting suitable for defects of large size involving both the soft tissues and the bone. CONCLUSIONS: Although the fibula flap and the deep circumflex iliac artery flap remain the first choice for bone reconstructions of the mandible and maxilla, the scapula flap has some features that make its use extremely advantageous in some circumstances. In particular, we advocate the use of the osteomuscular latissimus dorsi-scapula flap for reconstruction of large-volume defects involving the bone and soft tissues, whereas fasciocutaneous parascapular flaps represent a valid alternative to forearm flap and anterolateral thigh flap in the reconstruction of soft tissue defects.

Intraosseous hemangiomas.

Intraosseous hemangiomas are classified as benign tumors of vascular nature. Some authors describe them as hamartomas. They originate and expand inside bone structures. They are usually congenital, rarely of posttraumatic origin. In the Maxillo-Facial Surgery departments of the Universities of Rome "La Sapienza" and "Tor Vergata," from 1990 to 2004, 11 cases of intraosseous hemangioma have been diagnosed. In 6 cases, the neoplasm localized in the zygomatic region; in 3 cases, at the mandible level; in 1 patient, in the maxillary site; and in 1 patient, in the frontal bone. Literature review and the case of a male patient affected by left orbitozygomatic hemangioma are described.