Maxillomandibular Reconstruction Using Insourced Virtual Surgical Planning and Homemade CAD/CAM: A Single-Center Evolution in 75 Patients.

BACKGROUND: Virtual surgical planning (VSP) and computer-aided design and manufacturing (CAD/CAM) of surgical guides and jigs have dramatically changed the predictability of bony reconstruction of the jaw. VSP craftsmanship can lead to precision and enables the surgeon to complement the donor bone osteotomies with bony resection of the jaw. In recent years, immediate dental rehabilitation has become an integral part of VSP. However, outsourced CAD/CAM technology is expensive and may not be an option for many institutions worldwide. METHODS: The authors present here a consecutive series of 75 maxillofacial reconstructions from 2015 to 2020. We established an insourced "in-house" protocol for VSP and "home-made" CAD/CAM for the reconstruction of maxilla-mandibular defects with fibula, iliac crest, and scapular angle flaps. All patient files were analyzed retrospectively, and relevant parameters influencing the reconstructive outcome were determined. RESULTS: The authors went from a fibula-based protocol toward the selection of optimal vascularized bone for immediate placement of osteointegrated implants. Bone flap survival was 94.7% after 4 months. The 3-year patient survival is 77.6%. The authors show the multiple steps required for the routine use of in-house CAD/CAM and report the related financial balance. CONCLUSIONS: Insourced VSP and CAD/CAM has evolved into a valuable strategy in maxillomandibular reconstruction that promotes accuracy and precision and allows for occlusion-based planning with quality-of-life and aesthetic outcomes as essential parts of the reconstruction even in high-level oral cancers. Further reductions in the hardware and software acquisition costs may lead to widespread implementation of this innovative technology. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Long-term results of distal oblique bundle reinforcement for treatment of chronic bidirectional instability of the distal radioulnar joint.

Distal oblique bundle (DOB) reinforcement for treatment of post-traumatic bidirectional instability of the distal radioulnar joint (DRUJ) has previously been reported. The objective of the current study was to assess the incidence of symptomatic graft failure and the need for secondary wrist procedures at a longer follow-up in an updated patient cohort of 27 patients with 28 DOB reinforcement procedures. Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and patient-rated wrist/hand evaluation (PRWHE) outcome measures were also evaluated. At median 82 months follow-up, pre- to postoperative QuickDASH score improved from a mean of 62 (SD 14) to 31 (SD 22) (p < 0.01) and PRWHE score from a mean of 67 (SD 17) to 34 (SD 23) (p < 0.01). Symptomatic graft failure with resultant painful DRUJ instability occurred in four out of 28 procedures, which was better than the published results of alternative surgical options for DRUJ instability. DOB reinforcement presents a relatively safe, effective and durable method for treatment of post-traumatic DRUJ instability.Level of evidence: III.

The ECLiPSE Procedure as an Alternative to Mastopexy following Implant Removal.

With the rise in number of breast implant removals for a variety of indications, strategies to improve aesthetic outcomes, while minimizing scars and operating time, will prove to be of benefit. We present here a novel periareolar sickle skin excision as a good option for women with mild to moderate ptosis and central loss of breast volume following implant removal/capsulectomy. METHODS: The ECLiPSE (Explant, Capsulectomy, Lift using Periareolar Sickle skin Excision) was utilized in 53 patients with a median follow-up of 24 weeks. RESULTS: The majority of these patients had breast implants for cosmetic augmentation and the most common indication for implant removal was capsular contracture (n = 47, 88.7%). Forty-six patients (86.8%) scored a high or very high satisfaction with the outcome of the procedure. CONCLUSION: We believe that the ECLiPSE procedure is a useful option that can produce a reasonable aesthetic outcome following implant removal/capsulectomy while minimizing visible scarring.

An uncommon presentation of a cutaneous angiosarcoma.

Cutaneous angiosarcoma (cAS) is a rare and aggressive malignant vascular tumor, which mostly occurs in the head and neck region. The outcome of cAS is poor and timely diagnosis is paramount, but often delayed because of the slow onset and the variance in presentation. This paper reports on a case of an 88-year old woman who presented with a persisting "hematoma" in the left retro-auricular region. Although considered at initial differential diagnosis, no signs of malignancy were identified in histopathology and imaging in the diagnostic work-up. At first, short-term follow-up showed no progression of the lesion. But 3 months after the first presentation additional biopsies were taken, because of rapid expansion of the lesion. The initial histopathological findings were most consistent with a benign vascular lesion, with signs of hemorrhage and reactive inflammation. However, the additional immunohistochemical analysis showed the presence of MYC oncoprotein, which confirmed the clinical suspicion of angiosarcoma. Because size and location of the lesion rendered complete resection unattainable, radiotherapy was commenced, but no significant volume reduction could be achieved. Therefore, palliative irradiation was initiated. The patient passed away 1 month later. Clinical diagnosis is often difficult and little is known about imaging of cAS. Histology and immunohistochemistry can be misleading, as cAS are easily mistaken for other lesions. Most studies report that multimodality treatment with surgery and radiotherapy is preferable, but this can be challenging in the head & neck region.