Complex Craniofacial Cases through Augmented Reality Guidance in Surgical Oncology: A Technical Report.

Augmented reality (AR) is a promising technology to enhance image guided surgery and represents the perfect bridge to combine precise virtual planning with computer-aided execution of surgical maneuvers in the operating room. In craniofacial surgical oncology, AR brings to the surgeon's sight a digital, three-dimensional representation of the anatomy and helps to identify tumor boundaries and optimal surgical paths. Intraoperatively, real-time AR guidance provides surgeons with accurate spatial information, ensuring accurate tumor resection and preservation of critical structures. In this paper, the authors review current evidence of AR applications in craniofacial surgery, focusing on real surgical applications, and compare existing literature with their experience during an AR and navigation guided craniofacial resection, to subsequently analyze which technological trajectories will represent the future of AR and define new perspectives of application for this revolutionizing technology.

Pulsed electromagnetic fields (PEMF) as a valid tool in orthognathic surgery to reduce post-operative pain and swelling: a prospective study.

PURPOSE: PEMF (pulsed electromagnetic fields) founds application in several medical fields to accelerate bone wounds healing and to reduce inflammation. The aim of our study was to evaluate the effectiveness of PEMF in reducing postoperative swelling and pain in patients undergoing orthognathic surgery. METHODS: A prospective observational monocentric study was conducted on a sample of 30 patients undergone to orthognathic surgery in Maxillofacial Surgery Unit of University of Naples Federico II. The patients who followed these inclusion criteria were enrolled in the study: age ≥ 18 years, Class III malocclusion, Surgical procedure of Le Fort I osteotomy + Bilateral Sagittal Split Osteotomy (BSSO), Written informed consent. Patients were divided into two groups: Group SD) postoperative standard treatment with medical therapy and cryotherapy, Group SD + PEMF) postoperative standard therapy + PEMF. Each patient underwent a 3D facial scan, at one (1d) and four (4d) days after surgery to compare the swelling reduction. The pain score was assessed through VAS score and analgesics administration amount. RESULTS: In SD + PEMF group, the facial volume reduction between 1d and 4d scan was on average 56.2 ml (6.23%), while in SD group, it was 23.6 ml (2.63%). The difference between the two groups was 3.6% (p = 0.0168). VAS pain values were significantly higher in SD group compared to SD + PEMF group in the second day after surgery (P = 0.021) and in the total 4 days (P = 0.008). CONCLUSIONS: Our data suggest that PEMF is valid tool to promote faster postoperative swelling and pain reduction in patients undergoing orthognathic surgery.

Surgical management of Warthin tumor: long-term follow-up of 224 patients from 2002 to 2018.

PURPOSE: Warthin tumors (WT) are the second most common benign parotid gland neoplasms. They can occur as synchronous or metachronous lesions in 6-10% of cases. This study aims to compare the complication rate in 224 patients who underwent extracapsular dissection (ECD) or superficial parotidectomy (SP) for the treatment of a WT. METHODS: This retrospective study was conducted at the Department of Maxillo-Facial Surgery at the University of Naples "Federico II" from February 2002 to December 2018 on a group of patients who underwent surgical treatment for WT. The type of surgical technique was chosen based on Quer's classification. The complications evaluated were facial nerve palsy, hematoma, Frey's syndrome, and bleeding. RESULTS: A total of 224 patients treated from 2002 to 2018 for Warthin tumor were included in the study. Two hundred elven had solitary tumors (94.1%) and 13 had multicentric lesions (5.8%), of which 9 cases presented synchronous lesions and 4 cases presented metachronous lesions. Extracapsular dissection (ECD) was performed in 130 patients (58.3% of cases) and superficial parotidectomy (SP) in the other 94 (41.7% of cases). CONCLUSIONS: We consider both surgical techniques as valid. In our opinion, it is essential to study each case based on Quer's Classification to obtain the best surgical outcome. Based on a lower observed rate of complications such as facial nerve palsy, Frey's syndrome, and bleeding, ECD seems to be the best option for the surgical treatment of Quer Class I lesions.

Impact of Sarcopenia on Survival of Patients With Malignant Salivary Glands Tumors.

OBJECTIVE: Malignant salivary glands tumors (MSGTs) are a quite rare and heterogeneous group of tumors. Management of these lesions remains controversial and challenging. Thus, finding new prognostic factors that can help to guide the decision-making process, appears to be paramount. The aim of this study was to evaluate the prognostic performance of preoperative sarcopenia to stratify MSGTs patients at high risk of disease progression. STUDY DESIGN: Retrospective study. SETTING: A single-institution analysis (Maxillo-facial Surgery Unit, University of Naples Federico II). METHODS: The study consists of a retrospective analysis of 74 patients surgically treated for MSGTs. For all patients, the skeletal muscle index (SMI) was calculated and sarcopenia was defined as SMI < 41 in females and <43 in males. The correlation between sarcopenia and tumor variables was analyzed. The prognostic performance of sarcopenia was evaluated through survival Kaplan-Meier curves. RESULTS: Sarcopenia resulted statistically related to age (P < .001), tumor size (P < .001), lymph node metastases (P < .001), and American Joint Committee on Cancer tumor, node, metastasis stage (P < .001). Kaplan-Meier survival curves show that 47.3% of sarcopenic patients died before their final follow-up. CONCLUSION: Data obtained from our study seem to confirm the correlation between sarcopenia and other high-risk features. The early detection of sarcopenia in patients with negative prognostic factors could be used to implement the support therapeutic strategies aimed at restore the clinical conditions of the patients. Sarcopenia may be routinely investigated before surgery to suggest the implementation of precautionary therapeutic strategies to improve the standard treatment response, reducing possible complications.

Piezoelectric Condylectomy Through Transoral Endoscopic Approach: A Cadaveric Study.

Surgical approaches in the treatment of TMJ pathologies are a much-debated topic in literature. We propose a new surgical approach performed by intraoral access and completed by endoscopic magnification and long-tip piezosurgery assistance. A piezosurgery (Piezosurgery Plus, Mectron s.p.a. 2014) with a long angled tip (MT5-10 L) was used to perform an endoscopically assisted condylectomy. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03168-0.

Surgical management and side effects of parotid gland surgery for benign lesions: a retrospective analysis of our experience from 2012 to 2021.

Surgery is the treatment of choice for tumours in the parotid gland. We evaluated complications following parotid surgery. We conducted a retrospective study on 554 patients undergoing parotid surgery for benign parotid tumours from 2012 to 2021. We analysed complication rates between extracapsular dissection (ECD) and superficial parotidectomy (SP). We found 19 capsular ruptures in patients undergoing ECD (5.34%) and five among those undergoing SP (2.52%) [p < 0,05]; 16 cases of temporary facial paralysis among those undergoing ECD (4.49%) and 35 in patients undergoing SP (17.67%) [p < 0,05]; and eight instances of permanent facial nerve paralysis in patients undergoing ECD (2.25%) [p > 0,05] and 13 in patients undergoing SP (6.56%). Among the mid-term complications described were: 22 salivary fistulas among patients operated with ECD (6.18%) [p > 0,05] and 17 in patients with SP (8.58%) 17 sialoceles in those who underwent ECD (4.77%) and seven with SP (3.53%) [p > 0,05]. Regarding late complications, we found: surgical wound dehiscence, pathological scarring (keloid), Frey's syndrome, and recurrence, which affected 45 patients with ECD (12.64%) and 21 with SP for dehiscence (10.6%) [p < 0,05]; 28 keloids in patients with ECD (7.86%) and 15 in patients with SP (7.57%) [p > 0,05]; 12 cases of Frey's syndrome in patients with ECD (3.37%) and 36 with SP (18.18%) [p < 0,05]; and finally 22 recurrences in patients who underwent ECD (6.18%) and 13 in patients who underwent SP (6.56%) [p > 0,05], including 30 in the 273 patients with pleomorphic adenoma and five in the 214 patients with Warthin's tumour. We can conclude that the onset of the different complications after parotid gland surgery are related to the surgery performed. Our data confirm that there is a tight relationship between type of surgery performed and type of complication.

Support Tools in the Differential Diagnosis of Salivary Gland Tumors through Inflammatory Biomarkers and Radiomics Metrics: A Preliminary Study.

BACKGROUND: The purpose of this study was to investigate how the systemic inflammation response index (SIRI), systemic immune-inflammation index (SII), neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR), and radiomic metrics (quantitative descriptors of image content) extracted from MRI sequences by machine learning increase the efficacy of proper presurgical differentiation between benign and malignant salivary gland tumors. METHODS: A retrospective study of 117 patients with salivary gland tumors was conducted between January 2015 and November 2022. Univariate analyses with nonparametric tests and multivariate analyses with machine learning approaches were used. RESULTS: Inflammatory biomarkers showed statistically significant differences (p < 0.05) in the Kruskal-Wallis test based on median values in discriminating Warthin tumors from pleomorphic adenoma and malignancies. The accuracy of NLR, PLR, SII, and SIRI was 0.88, 0.74, 0.76, and 0.83, respectively. Analysis of radiomic metrics to discriminate Warthin tumors from pleomorphic adenoma and malignancies showed statistically significant differences (p < 0.05) in nine radiomic features. The best multivariate analysis result was obtained from an SVM model with 86% accuracy, 68% sensitivity, and 91% specificity for six features. CONCLUSIONS: Inflammatory biomarkers and radiomic features can comparably support a pre-surgical differential diagnosis.

Minimally Invasive "Trocar-Free" Approach for Rear Mandibular Fractures Management.

ABSTRACT: The request of minimally invasive surgery is progressively expanding the indications of endoscopically assisted intraoral access for mandibular traumas. The aim of our study is to assess how much the use of the angled drill may affect the outcome of patients treated for rear mandibular fracture. In our retrospective case-control trial we enrolled 36 patients with mandibular rear fractures treated through endoscopically assisted intraoral access. Eighteen patients were treated by using an angled drill ''trocar free,'' and 18 treated by linear drills placed through trocars. Surgical times, hospitalization times (HT), and major complications rate were compared between the 2 groups. Group 1 showed a significant reduction in HT (1.72 versus 2.22 days, P = 0.024) and an increase in the surgical times (3.0 versus 2.53 hours, P = 0.019). Significant reduction of total amount of complication was seen in group 1 versus group 2 ( P = 0.007). The ''trocar free'' approach allowed by angled drills, in our hands, greatly reduces the invasiveness of the surgery resulting in a significant reduction in HT and smaller share of vascular-nervous sequelae. Our results suggest the ''trocar free'' approach as a valuable choice when indicated for the treatment of rear mandibular fractures.

Efficacy of Hilotherapy face mask in improving the trend of edema after orthognathic surgery: a 3D analysis of the face using a facial scan app for iPhone.

PURPOSE: Cryotherapy after orthognathic surgery is essential for the control of facial edema. The aim of our study is to evaluate the efficacy of Hilotherapy face mask in reducing facial edema after orthognathic surgery, studying facial surfaces with an innovative, fast, economical 3D facial scan system based on an iPhone app. METHODS: Eighty-four patients with Class III were included: 35 patients treated with Hilotherm after orthognathic surgery (Group 1), 32 patients with ice packs (Group 2), 7 patients who refused cryotherapy (not 1 - not Group 2). Their facial scans performed immediately after surgery (T0), at 24 (T1), 48 (T2) and 72 h (T3) after surgery, were acquired in specific software, and the discrepancies between them were studied in an accurate 3D volumetric method. RESULTS: We measured a significantly better edema trend in Group 1 in the tragus-nasal wing line and in the tragus-labial commissure line at T1, and also in the tragus-menton line at T2 and T3. CONCLUSIONS: In conclusion, Hilotherapy represents a more comfortable and more effective cryotherapy system in controlling the trend of facial edema after orthognathic surgery. The method we used for the facial scans is accurate, cheap, smart, and fast. As demonstrated by the 3D volumetric study of the face, the regions of the middle third of the face are those in which the difference is most noticeable.

A Health Technology Assessment in Maxillofacial Cancer Surgery by Using the Six Sigma Methodology.

Squamous cell carcinoma represents the most common cancer affecting the oral cavity. At the University of Naples "Federico II", two different antibiotic protocols were used in patients undergoing oral mucosa cancer surgery from 2006 to 2018. From 2011, there was a shift; the combination of Cefazolin plus Clindamycin as a postoperative prophylactic protocol was chosen. In this paper, a health technology assessment (HTA) is performed by using the Six Sigma and DMAIC (Define, Measure, Analyse, Improve, Control) cycle in order to compare the performance of the antibiotic protocols according to the length of hospital stay (LOS). The data (13 variables) of two groups were collected and analysed; overall, 136 patients were involved. The American Society of Anaesthesiologist score, use of lymphadenectomy or tracheotomy and the presence of infections influenced LOS significantly (p-value < 0.05) in both groups. Then, the groups were compared: the overall difference between LOS of the groups was not statistically significant, but some insights were provided by comparing the LOS of the groups according to each variable. In conclusion, in light of the insights provided by this study regarding the comparison of two antibiotic protocols, the utilization of DMAIC cycle and Six Sigma tools to perform HTA studies could be considered in future research.

A Six Sigma DMAIC methodology as a support tool for Health Technology Assessment of two antibiotics.

Health Technology Assessment (HTA) and Six Sigma (SS) have largely proved their reliability in the healthcare context. The former focuses on the assessment of health technologies to be introduced in a healthcare system. The latter deals with the improvement of the quality of services, reducing errors and variability in the healthcare processes. Both the approaches demand a detailed analysis, evidence-based decisions, and efficient control plans. In this paper, the SS is applied as a support tool for HTA of two antibiotics with the final aim of assessing their clinical and organizational impact in terms of postoperative Length Of Stay (LOS) for patients undergoing tongue cancer surgery. More specifically, the SS has been implemented through its main tool, namely the DMAIC (Define, Measure, Analyse, Improve, Control) cycle. Moreover, within the DMAIC cycle, a modelling approach based on a multiple linear regression analysis technique is introduced, in the Control phase, to add complementary information and confirm the results obtained by the statistical analysis performed within the other phases of the SS DMAIC. The obtained results show that the proposed methodology is effective to determine the clinical and organizational impact of each of the examined antibiotics, when LOS is taken as a measure of performance, and guide the decision-making process. Furthermore, our study provides a systematic procedure which, properly combining different and well-assessed tools available in the literature, demonstrated to be a useful guidance for choosing the right treatment based on the available data in the specific circumstance.

The Role of a Deep Neuromuscular Block in the Treatment of Mandibular Subcondylar Fractures.

ABSTRACT: Mandibular fractures are the third most frequents maxillo-facial fractures. Most frequent site is the subcondylar region. Different approaches to reach subcondylar region, have been described. In the study was evaluated the advantages of neuromuscular block during endoscopic surgery for subcondylar fractures. Twenty-five patients affected by subcondylar fractures were enrolled in this study and divided in 2 groups; group A: patients who received an intraoperative booster of curare during surgical procedure and group B patients who underwent surgery treated without the intraoperative booster of curare. All patients were treated successfully by endoscope-assisted transoral approach. The analysis of time required for surgery showed a reduction in group A comparing to group B. The mean time for surgery for the patients in group B with displacement between 0° and 45° was 170 minutes, and for 45° to 90° was 230 minutes. In group A, the mean time was 117.5 minutes for patients with condylar displacement between 0° and 45°, and 147.5 minutes for the other group. In conclusion, deep neuromuscular block seems to improve the surgical conditions in patients undergoing subcondylar endoscopic assisted surgery, further study needs to assess this surgical technique in order to better define this surgical protocol.

Guidelines and Recommendations for Patient Management, Surgical Activities, and Safety in the Maxillofacial Unit and Head and Neck Department During COVID-19 Pandemic.

The recent pandemic has led to an unprecedented overload of sanitary systems around the world. Despite that a maxillofacial department is not a frontline specialty in the treatment of coronavirus disease 2019 infections, our department has found itself faced with numerous problems in keeping the care system active and efficient while ensuring safety for patients and healthcare professionals. Massive redistribution of health personnel was needed to improve prevention and personal safety measures. The education and training system has been kept active, giving residents a decisive role in managing the state of emergency response. This article outlines new guidelines for infection prevention: from clinical control, treatment processes, clinical management, protection, and disinfection of healthcare professionals.

Postoperative Management of Zygomatic Arch Fractures: In-House Rapid Prototyping System for the Manufacture of Protective Facial Shields.

Zygomatic fractures account for 10% to 15% of all facial fractures. The surgical management of isolated zygomatic arch fractures usually requires open reduction treatment without fixation through an intraoral access. Therefore, the main problem in the non-fixed treatment of zygomatic arch fractures is related to the difficulty in obtaining a stable reduction for a period long enough to guarantee the physiological bone healing process. We propose an innovative "in-house" rapid prototyping (RP) protocol for the 3D-zygoma mask manufacture of a patient-specific protective device to apply after zygomatic arch fracture reduction. Our study includes 16 consecutive patients who underwent surgical open reduction for an isolated zygoma fracture without fixation between January 2017 and February 2018. The patients received regular postoperative checks at weeks 1 and 2. Before the device was removed, a multiple choice questionnaire was administered to measure the degree of wearability of the mask. The estimated cost of the production is around &OV0556;5 per case and the construction time is around 90 minutes. Based on the encouraging results, obtained in our experience, we hope that other studies can be conducted to confirm our procedure and improve its functionality in the field of facial trauma.

Do combined otoplasty techniques really improve the surgical outcomes for prominent ear correction in adult patients?

OBJECTIVE: Prominent Ear is a genetic malformation of the human ear. It occurs due to malformation of cartilage during primitive ear development in intrauterine life. Multiple surgical techniques for the correction of protruding ears have been described which include: incisions, sutures, and cartilage scoring, isolated or in combination. To date, no ideal method that fulfills the aim of a complete surgical resolution has been described in adult patients. The aim of our study is to discuss the main surgical technique' described in order to identify technical association to obtain optimal surgical outcome with minimal surgical morbidity. MATERIALS AND METHODS: We've carried out a retrospective chart review of 74 patients suffering from protruding ears. Our cohort was divided in two groups based on the otoplasty technique performed, Mustarde (Group A) versus Chongchet + Furnas (Group B). RESULTS: With the exception of wound infections and hematomas, which have a similar incidence, the morbidity rate was higher in Group A patients. CONCLUSIONS: Both surgical approaches are effective for prominent ear correction but our combined technical procedure has advantages over patient satisfaction and recurrence rates. KEY WORDS: Combined technique, Otoplasty technique, Otoplasty in adult, Prominent ear deformity.

Infective complications after free flaps reconstruction in patients affected by head and neck cancer Our experience on 77 cases.

AIM: The success rates of free flaps in patients undergoing head and neck cancer (HNC) surgery are very high (95%- 97%) but the development of a surgical site infection (SSI) can put flap viability at risk. The aim of our study is to identify the risk factors for SSI in patients undergo free flaps reconstruction after head and neck cancer removal. MATERIAL OF STUDY: Seventyseven patients (44 male and 33 female) from April 2006 to April 2015 admitted at the Department of Maxillofacial Surgery of the University of Naples "Federico II" were included in this study. All the patients underwent free flap reconstruction for HNC. RESULTS: A microbiological analysis in 32 patients with signs of SSIs was performed, and 27 (35%) patients showed positive cul ture results, 5 patients were false positives. DISCUSSION: SSIs are one of the most common nosocomial infec tions that increase medical costs. HNC surgery frequently requires opening of the mouth floor, oropharynx, nasopharynx, or proximal esophagus, and these areas are likely to be contaminat ed by local microbiotics. Positive significant correlation between long operation timing and SSIs. CONCLUSION: Was observed the factors contributing to postoperative infections for patients affected by head and neck tumor. 35% of our study population devel oped an SSI (27/77). The most commonly discovered pathogen was MRSA (Methicillin-resistant Staphylococcus aureus). Were examinated sex, cardiovascular disease, blood loss more than 560 mL, and a long operation time ≥ 6 hours were significant risk factors for SSI. KEY WORDS: Free flaps, Head and neck cancer, Infective complications.

Searching for New Targets and Treatments in the Battle Against Squamous Cell Carcinoma of the Head and Neck, with Specific Focus on Tumours of the Tongue.

Squamous cell carcinoma of the head and neck, SCCHN, is a heterogeneous group of tumours not only concerning the site of origin but also regarding aetiology. The 5-year survival for the whole group of SCCHN tumours has not significantly improved over the last 20-25 years. Apart from tumour spread to lymph nodes, N status, gains and losses of specific chromosomes are the only factors shown to be independent prognostic markers for these tumours. Worldwide, an increasing number of people ≤ 40 years are seen being affected by tongue SCC, the most common tumour within the SCCHN group. Even without any clinical signs of metastasis, up to 30% of all tongue SCC have histologically detectable spread to lymph nodes. In this mini review, field cancerization, tumour microenvironment, the so called EMT (epithelial mesenchymal transition) process and the role of viruses in development of SCCHN are discussed as well as potential new therapeutic targets. For the group of tongue SCC, with the increasing incidence seen in young patients and particularly women, new data with impact on prognosis and treatment are urgently needed. But as long as data from the analyses of several sub sites are presented as valid for the whole group of tumours, this vital point is missed.

Incidental finding of upper lip Warthin tumor.

AIM: This report shows an incidental finding of Warthin tumor in upper lip mucosa during hospitalization for a biting lesion of cheek mucosa MATERIALS AND METHODS: A 32-year-old male affected by a biting lesion of cheek mucosa was presented at Maxillo- Facial Unit of Federico II University. Clinical examination showed as an incidental finding a solid mass in the superficial layer of upper lip mucosa. We performed mini-invasive surgical treatment to obtain a radical excision of the cheek lesion at the same time as excision of Warthin tumor. RESULTS: a follow up of 12 months was performed. The complete healing of the two wounds was achieved, with no recurrence of any of the pathologies. DISCUSSION: The location of this Warthin tumor of minor salivary glands is very unusual. The role of imaging in diagnosis of Warthin tumor of minor salivary glands is to define localization, shape and dimension, contour, malignant features, nodal involvement. The role of fine needle aspiration cytology (FNAC) is critical in the diagnosis and therapy of minor salivary gland tumors. The surgical treatment in patients affected by Warthin tumour of minor salivary glands is local excision with a wide tumor free margin to prevent potential recurrence. CONCLUSIONS: Warthin tumor of minor salivary glands is a rare disease. We report a singular case of Warthin tumor localized in the upper lip mucosa, found as an incidental finding during a recovery for a biting lesion of cheek mucosa. KEY WORDS: Incidental finding, Minor salivary glands, Warthin tumor.