Prophylaxis of microvascular thrombosis using direct oral anticoagulants (DOAC) in microvascular free tissue transplantation - a pilot study.

INTRODUCTION: We conducted this pilot study to assess direct oral anticoagulants (DOACs) in the prevention of microvascular thrombosis. MATERIALS AND METHODS: Five patients undergoing microvascular free tissue transplantation received rivaroxaban or apixaban (depending on their home medication). We compared this group to 19 patients who received enoxaparin subcutaneously. We evaluated the rate of graft loss due to microvascular thrombosis and the number of transfusions administered intra- and postoperatively. RESULTS: There was no graft loss due to microvascular thrombosis in either of the groups. There was no significant difference in the number of intraoperative (study group mean 1.00 (SE 0.32) vs. control group mean 1.11 (SE 0.59); p = 0.876) and postoperative (study group mean 1.2 (SE 0.37) vs. control group mean 1.74 (SE 0.34); p = 0.310) red blood cell transfusions. CONCLUSION: Based on our results in this pilot study, DOACs can be used with microvascular flaps. Further studies with larger sample sizes should be performed to find an optimal medication regimen both for patients already taking DOACs and perhaps even for those not taking DOACs.

Speech assessment following microsurgical soft palate repair.

The aim of this study was to analyze speech intelligibility of children, who had undergone microsurgical soft palate repair according to Sommerlad. Cleft palate patients were treated by closure of the soft palate according to Sommerlad at about 6 months of age. At the age of 11, their speech was evaluated through automatic speech recognition. Word recognition rate (WR) was used as the outcome parameter of automatic speech recognition. To validate automatic speech results, an institute for speech therapy evaluated the speech samples for perceptual intelligibility. The results of this study group were compared to an age-matched control group. A total of 61 children were evaluated in this study, 29 in the study group and 32 in the control group. Study group patients had a lower word recognition rate (mean 43.03, SD 12.31) compared to the control group (mean 49.98, SD 12.54, p = 0.033). The magnitude of the difference was considered small (95% CI of the difference 0.6-13.3). The study group patients received significantly lower scores in the perceptual evaluation (mean 1.82, SD 0.58) compared to the control group mean (mean 1.51, SD 0.48, p = 0.028). Again, the magnitude of the difference was small (95% CI of the difference 0.03-0.57). Within the limitations of the study it seems that microsurgical soft palate repair according to Sommerlad at the age of 6 months might be a relevant alternative to other well established surgical techniques.

Pseudogout growing from the temporomandibular joint into the middle cranial fossa.

Calcium pyrophosphate dihydrate deposition disease (CPDD or pseudogout) is a degenerative joint disease. It is defined by the presence of calcium pyrophosphate dihydrate crystals. It usually manifests in the knee and wrist. Manifestation in the temporomandibular joint (TMJ) is only reported in case reports. We present a patient with CPDD mimicking a malignant tumor of the TMJ. A 53-year-old woman presented with progressive pain and a slow-growing swelling of the left TMJ. Imaging showed an extensive mass in the infratemporal fossa extending into the middle cranial fossa and compressing the temporal lobe. Assuming a potential malignancy, we excised the growth, which extended into the dura. We covered the resulting tissue defect within the primary surgery using a microsurgically anastomosed scapular flap and performed further reconstructive surgeries. Calcium pyrophosphate dihydrate crystals were found in the histopathologic examination of the excised tissue, resulting in the diagnosis of CPDD. That is a benign diagnosis, but we treated it like a malignancy. This leads us to the question, was there overtreatment? Tumoral CPDD in the TMJ can be a difficult diagnosis to obtain. The treatment remains controversial, but complete excision of the mass was performed in most reported cases.

Quality of life and survival rate after primary surgical treatment of oral squamous cell carcinoma: A retrospective study with 18 years of follow-up.

The aim of this study is to evaluate the long-term survival rates and assess the long-term quality of life (QoL) of patients treated for oral squamous cell carcinoma (OSCC). Patients, who underwent primary surgical tumor resection for OSCC at a single hospital center in Germany between 1998 and 2016, were eligible for inclusion in this analysis of survival rates and QoL parameters. The University of Washington-QoL version 4 (UW-QoL v4) questionnaire was administered to the patients in the years 2015 and 2016. The cases of 145 patients with the histological diagnosis of OSCC were included in this study. Despite a common distribution of tumor stage, the 1-year survival rate was 88.0% and the 5-year survival rate was 70.0%. The QoL questionnaire item, 'pain' (84) was selected most frequently. Chewing (50) and swallowing (58) yielded the lowest score. Chewing and swallowing impairment correlated significantly with an increase in tumor size, higher tumor stages, and the use of radio (chemo-)therapy (p < 0.001). In this retrospective study, patients reported significant long-term dysphagia and difficulty chewing. These parameters should be investigated in prospective studies to evaluate methods that could reduce the risk of suffering from these impairments.

Training strategies for a sustainable medical care: a survey among assistant and chief physicians in a tertiary care hospital in Germany.

PURPOSE: As an essential part of the health care system, the requirements for specialist training are subject to a continuous process of change. The aim of the present study was to evaluate the current specialist training situation of all departments in a tertiary care hospital in Germany. Differences between assistant and chief physicians should be pointed out. MATERIALS AND METHODS: The analysis of the current training situation was carried out on the basis of an individually created questionnaire. The questionnaire content included career goal and specialism. The characteristic values initial training (IT), training structure (TS) and training content were measured on a numeric scale from 1 to 5. In addition, an overall assessment of the trainers' competences was performed. The questionnaire was sent to 208 assistant physicians (AP) and 34 chief physicians (CP). RESULTS: Totally 92 APs (44.2%) and 22 CPs (64.7%) participated. Senior physician was the most common career goal (34.1%), followed by the branch (28.6%). The importance of the topics initial training (IT) and training structure (TS) were evaluated as mean value: ITCP=1.5, ITAP=1.6; p=0.701 and TSCP=1.4, TSAP=1.5; p=0.669. The results concerning the implementation of the topics IT and TS in the daily routine show significant differences between APs and CPs (ITCP=2.0, ITAP=3.2; p=0.002; TSCP=1.9, TSAP=3.0; p<0.001). Skills lab training was acknowledged as the most important training format (CP=1.3, AP=1.5; p=0.401). The practical medical skills of the professional trainers were evaluated as high: AP: 94.6% (CP: 100.0%), as well as the training in interprofessional collaboration: AP: 79.4% (CP: 100.0%). CONCLUSION: Our data underline the importance of specialist training subjects. These are partly perceived very differently by APs and CPs. Innovative concepts for the induction phase, well-structured training curricula, providing management skills, the overall use of skills labs and digital documentation might support the satisfaction and the outcome of specialist training. This could also improve quality in patient care.

Customized virtual surgical planning in bimaxillary orthognathic surgery: a prospective randomized trial.

OBJECTIVES: The aim of the present study was to compare conventional (CSP) versus customized virtual surgical planning (VSP) in bimaxillary orthognathic surgery. The primary goal was to compare the accuracy of defined angles. The secondary purpose was to analyze the accuracy of the splints, the time required for surgery, and the costs of both methods. MATERIALS AND METHODS: A total of 21 patients (nCSP = 12; nVSP = 9) treated by two-jaw orthognathic surgery were analyzed prospectively between the years 2014 and 2016. Customized VSP consisted of virtual planning as well as CAD/CAM printing of splints and pre-bent osteosynthesis plates. The evaluated parameters were the difference between planned and postoperative situation (SNA/SNB/ANB), accuracy of splints, time required for surgery (min), and total costs of planning (€). RESULTS: When compared to CSP, VSP appears to be a more accurate method for orthognathic treatment planning with significant differences in the angle outcome (SNA p < 0.001; SNB p = 0.002; ANB p < 0.001). There were significant differences in splint accuracy in favor of CAD/CAM splints (p = 0.007). VSP significantly reduced the duration of operation (p = 0.041). Nevertheless, VSP increased the total costs (481.80 € vs. 884.00 €). CONCLUSIONS: When using virtual 3D technology in combination with printed acrylic splints, 3D models of the jaws and pre-bent osteosynthesis, there is a noticeable reduction in the duration of the operation in conjunction with an improvement in accuracy. CLINICAL RELEVANCE: Virtual model surgery and the prefabrication of splints and plates may replace traditional orthognathic surgery as it becomes cost-effective.

Early intensive rehabilitation after oral cancer treatment.

PURPOSE: The treatment of oral cancer requires an effective rehabilitation strategy such as an early intensive rehabilitation (EIR) program. MATERIALS AND METHODS: The medical records and data of 41 patients who participated in an EIR program and 20 control group patients were analyzed. These patients all underwent surgical resection of the primary tumor followed by microsurgical reconstruction using free flaps. The length of stay (LOS) at the acute care hospital was compared between the two groups. Four indexes were used to evaluate the effectiveness of the EIR program. RESULTS: EIR patients stayed an average of 11.6 fewer days at the acute care hospital. All indexes showed significant improvements (p < 0.001). The Barthel Index (BI) and the Early Intensive Rehabilitation Barthel Index (EIR-BI) improved by 36.0 and 103.6 points, respectively. At discharge, the Bogenhausener Dysphagia Score (BODS) had improved to a score of 11.0 compared to the 13.9 at admission. EIR patients had a Work Ability Index (WAI) score of 25.7. CONCLUSION: Length of stay at the acute care hospital can be reduced using early intensive rehabilitation if patients are transferred to an intensive rehabilitation clinic early.

The Microsurgical Approach in Primary Cleft Rhinoplasty-An Anthropometric Analysis.

PURPOSE: Oral and maxillofacial surgeons use different approaches to repair the nasal deformity of patients with a cleft lip deformity, differing in technique and timing. The aim of this longitudinal study was to analyze a new surgical technique to treat the cleft nasal deformity at 4 to 6 weeks of life using a microscope. MATERIALS AND METHODS: Twenty-seven newborn patients with a cleft lip deformity were treated by primary repair of the nasal deformity using a microscope at 4 to 6 weeks of life. The procedure includes a columellar incision, alar cartilage plication sutures according to Daniel (Plast Reconstr Surg 103:1491, 1999), and trans-columellar sutures. All patients were photographed at specific time points up to 1 year after surgery. Established angles and distances were analyzed and compared with normal values of age-matched children by Farkas (Anthropometry of the Head and Face [ed 2]. New York: Lippincott Williams and Wilkins, 1994). RESULTS: All parameters improved through surgery and showed stable values at follow-up assessments. Almost ideal values concerning symmetry, as indicated by columellar deviation and nostril comparison, were obtained. Measurements of nasal morphology were similar to established norm values. CONCLUSION: The authors recommend the early treatment of cleft nasal deformity using microscopic surgery because it shows stable and symmetrical results at least up to 1 year after surgery. Clinical observations up to adolescence suggest no growth disturbance or deterioration of nasal shape.

Use of ultrasonic scalpel and monopolar electrocautery for skin incisions in neck dissection: a prospective randomized trial.

PURPOSE: Ultrasonic scalpel (UC) and monopolar electrocautery (ME) are standard equipment for soft tissue surgery. The aim of the present study was to compare intraoperative and postoperative patterns of patients using either UC or ME for skin incisions in neck dissection. MATERIAL AND METHODS: In a prospective randomized study of 30 patients, the thermal effects of UC (n = 15) and ME (n = 15) were examined using real-time infrared thermographic imaging. Additionally, tissue damage was evaluated histopathologically. The other measured variables were operation and bleeding time, postoperative pain score (only neck incision area), in-patient time, and complications. RESULTS: UC significantly reduces the thermal effects, compared to ME (p < 0.001). The mean depth of tissue damage (i.e., necrosis) was 272.7 µm for UC and 284.7 µm for ME with no significant difference (p = 0.285). From the third postoperative day, patients treated using UC had noticeably less pain in the neck incision area (t3 p = 0.010; t4 p < 0.001; t5 p < 0.005). Cutting time was reduced for ME by 36.1 s (p < 0.001) and the bleeding time was decreased by 40.9 s for UC (p < 0.001). The total preparation time was the same (p = 0.402). When comparing in-patient time (p = 0.723), as well as complications, no significant differences were seen. CONCLUSION: UC results in less postoperative pain and less bleeding in the neck incision area. Accordingly, UC is superior to ME for skin incisions in neck dissection.

Etiology and injury patterns of maxillofacial fractures from the years 2010 to 2013 in Mecklenburg-Western Pomerania, Germany: A retrospective study of 409 patients.

OBJECTIVE: The aim of the present study was to illustrate the injury patterns and the etiology of accident victims with maxillofacial fractures in the state of Mecklenburg-Western Pomerania (M-P), Germany. MATERIAL AND METHODS: Between 2010 and 2013, patients with maxillofacial fractures from the Department of Oral and Maxillofacial Surgery at the Helios Kliniken Schwerin, were evaluated with a specially constructed data set in a retrospective analysis. After review of the patient records, a case-related data collection was performed with the pre-set characteristics: age, gender, age group, maxillofacial fracture, and cause of injury. RESULTS: Of 409 patients, 79% (n = 323) were male and 21% (n = 86) were female. A fracture of the zygomaticomaxillary complex was most frequently observed (31%; n = 240). Midface fractures with orbital floor involvement were the most common fracture types (48.4%; n = 137). A significant percentage of the fractures (45.2%; n = 185) were caused by interpersonal violence; 70.8% (n = 131), and thus the majority of the patients who were treated due to a brutal offense, had consumed alcohol. Within this group, men in the age group of 20-29 years were most prevalent (38.7%; n = 125). Etiologically, 25.2% (n = 103) of fractures were caused by a fall. CONCLUSION: The regionalization of data on the distribution, emergence, and localization of maxillofacial fractures in M-P allows not only a national comparison but also an international comparison with areas that are in a similar strong socio-demographic change, as it applies to the East German population. This provides the opportunity to develop the global preventive measures and to apply suitable quality management.

A three-dimensional comparison of the pharyngeal airway after mandibular distraction osteogenesis and bilateral sagittal split osteotomy.

PURPOSE: The goal of this retrospective study was to examine the radiological changes in the pharyngeal airway following mandibular distraction osteogenesis (DO) and bilateral sagittal split osteotomy (BSSO). MATERIAL AND METHODS: Between 2005 and 2009, a total of 41 nonsyndromic patients underwent a mandibular osteotomy (nDO = 23; nBSSO = 18). Digital volume tomography images were created for preoperative and postoperative evaluations of both groups. The Dolphin 3D program was used for comparative analysis of the pharyngeal airways. RESULTS: After DO, the airway volumes (VOL) improved by 6.8 mL. In comparison, an improvement of 5.9 mL was observed as result of BSSO. The minimum axial areas (AREA) of the enlargements increased by 109.1 mm(2) with DO and 103.1 mm(2) with BSSO. The airway areas (SA) increased by 193.8 mm(2) with DO and 185.2 mm(2) with BSSO. There were no significant differences between two surgical procedures in terms of the parameters describe above (pVOL = 0.358; pAREA = 0.752; pSA = 0.777). However, the initial preoperative values (pVOL = 0.020; pAREA = 0.005) and the patients' ages (pAREA = 0.042; pSA = 0.007) did have significant effects on the postoperative values. CONCLUSION: Both DO and BSSO expanded the pharyngeal airways of all nonsyndromic patients.

Pathophysiology of the Eustachian tube--relevant new aspects for the head and neck surgeon.

OBJECTIVES: The impact of cranio-maxillofacial procedures upon Eustachian tube function is still largely unknown. The aim of this presentation is to depict new aspects of Eustachian tube function and to demonstrate its importance to cranio-maxillofacial surgery. METHODS: Two different groups of patients were examined both clinically and by MRI of the Eustachian tube region. One of these groups comprised 15 adult patients with a history of cleft palate; another consisted of 32 patients with a history of a so-called patulous Eustachian tube. RESULTS: Clinical and MRI-findings revealed that the problem of persistent chronic middle ear disease with cleft palate patients depends crucially on the integrity of the pterygoid hamulus and of the tensor veli palatini muscle after cleft palate repair. The masticatory muscles on the other hand also play an important role in Eustachian tube function in non-cleft patients. CONCLUSION: The maxillofacial surgeon should be aware that he holds a key position for preventing as well as treating Eustachian tube pathophysiology.