Predictors of Intraoperative Difficulty and Postoperative Examination Abnormalities in 164 Orbital Operations.

BACKGROUND: Although orbital fractures are common, prediction of outcomes in orbital surgery can be quite challenging. PURPOSE: We aim to identify predictors of intraoperative difficulty, operating time, and postoperative examination abnormalities in subjects undergoing post-traumatic orbital reconstructions. STUDY DESIGN, SETTING, AND SAMPLE: This is a retrospective cohort study of all consecutive orbital operations performed at a private, Level 1 trauma center in Portland, Oregon, USA over an 82-month period. All subjects that underwent exploration of the internal orbit for traumatic indications during the study period were included in the cohort. PREDICTOR VARIABLES: Four plating styles, surgical approach (transorbital vs transantral), days from injury to first surgery, fracture size (approximated as a rectangle using linear measurements from computed tomography scans), anteroposterior fracture position, and medial wall involvement were examined. OUTCOME VARIABLES: The primary outcome variable was intraoperative difficulty (defined as requiring revision after intraoperative imaging or return to the operating room). Secondary outcome variables included operating time and postoperative examination abnormalities. COVARIATES: Age and sex were included. ANALYSES: χ2 and Regression analyses were performed using a significance level of P < .05. RESULTS: One hundred and sixty four orbital operations were performed (90 isolated injuries and 74 combined orbital/midface injuries) on 155 subjects (73% male, mean age 39.8 years, standard deviation 16.7). In subjects with isolated orbital fractures, medial wall involvement was associated with intraoperative difficulty (P = .01). When using a transantral approach, intraoperative difficulty was more likely in more anterior fractures (P = .02). Plating style was associated with operating time (P = .03), with median times from 81 to 105 minutes (range 21 to 248 minutes). Postoperative examination abnormalities were more likely in the transorbital approach group (P = .01). Neither days to first surgery nor intraoperative difficulty were associated with postoperative examination abnormalities. Postoperative eyelid changes were seen in 13.6% of transorbital approaches and 0% of transantral approaches. Correction of gaze restriction and enophthalmos were more likely than correction of diplopia (P < .01). CONCLUSIONS AND RELEVANCE: Medial wall involvement is associated with intraoperative difficulty in orbital surgery. Anteriorly positioned fractures are better treated transorbitally, while posterior fractures may be amenable to transantral repair, thus avoiding risk of lower eyelid changes.

Fellowship Training in Oral and Maxillofacial Surgery: Opportunities and Outcomes.

The pursuit of fellowship training stems from one's desire to master a focused area of surgery. Successful applicants tend to have published articles and participated in other scholarly activities. They commonly have a mentor within the subspecialty of their interest. Selection of the program is generally based on the breadth of experience available followed by faculty reputation and location. Advantages to the successful fellowship graduate include the experience and confidence to provide specialized and efficient care to patients. Enhancements to an academic department with a fellowship program include mentorship for residents and guidance toward fellowship, as well as an increased level of scholarly activity.

Interdisciplinary prosthetic rehabilitation following bilateral maxillectomy with total upper lip and unilateral zygoma resection: A clinical report.

This clinical report describes the design and fabrication of an implant-retained and soft-tissue-supported obturator prosthesis and a magnetic retained midfacial prosthesis for a patient with a midfacial defect following bilateral total maxillectomy, removal of the left zygoma, and excision of the entire upper lip. The patient underwent multiple head and neck surgeries for 4 separate primary oral cancers, 1 recurrence, and 1 pulmonary metastasis. The definitive obturator prosthesis was retained by 1 zygomatic implant with soft-tissue support and retention. The midfacial prosthesis was attached to the obturator prosthesis with magnets, improving appearance and the recovery of significant aspects of the patient's speech and swallowing. Some improvement in mastication was observed.

Updates in Management of Craniomaxillofacial Gunshot Wounds and Reconstruction of the Mandible.

This article includes updates in the management of mandibular trauma and reconstruction as they relate to maxillomandibular fixation screws, custom hardware, virtual surgical planning, and protocols for use of computer-aided surgery and navigation when managing composite defects from gunshot injuries to the face.

The Buccal Fat Pad Flap.

This article presents an overview of the history of the buccal fat pad flap, its relevant anatomy, and its indications and contraindications. The surgical technique for its harvest is described, as are the postoperative care and possible complications.

Management of Zygomaticomaxillary Complex Fractures Utilizing Intraoperative 3-Dimensional Imaging: The ZYGOMAS Protocol.

PURPOSE: Utilization of technology to aid in the assessment, planning, and management of complex craniomaxillofacial injuries is increasingly common. Limited data exist regarding the implication of intraoperative CT/3-Dimensional imaging on decision making in the management of zygomaticomaxillary complex (ZMC) fractures. This study characterizes the utilization of the intraoperative CT scanner for ZMC fracture surgery and analyzes the impact of the intraoperative CT scanner on fracture management. Using these findings, we sought to propose an algorithm to guide the appropriate utilization of intraoperative 3-Dimensional imaging in ZMC fracture surgery. METHODS: This retrospective case series evaluates the use of the intraoperative CT scanner for orbitozygomatic trauma surgery at a level 1 trauma center from February 2011 to September 2016. We evaluated the preoperative CT images assessing for the number of displaced sutures, the presence of adjacent fractures requiring fixation, the presence of comminution of the zygomaticomaxillary buttress or body of the zygoma, as well as the number of axes displaced ≥ 5 mm. This information was evaluated to provide guidance on the appropriate utilization of the intraoperative scanner in ZMC fracture management. RESULTS: A total of 71 patients were identified to have intraoperative facial CT scans and surgery for ZMC fractures over the study time period. There was a 23.9% (17/71) CT directed revision rate. There was a significantly increased likelihood of CT directed revision for fractures with adjacent fractures requiring fixation, and those with ≥ 2 axes displaced ≥ 5 mm. Using these findings, we proposed the ZYGOMAS algorithm outlining the indications for use of intraoperative CT in management of ZMC fractures. CONCLUSIONS: If available, intraoperative CT/3-Dimensional imaging should be utilized in the management of ZMC fractures with the requirement for orbital floor reconstruction, where adjacent fractures require fixation and/or when ≥ 2 axes are displaced ≥ 5 mm.

Does the Lack of Gender-Specific Apnea-Hypopnea Index Cutoff for Obstructive Sleep Apnea Impact Surgical Selection?

PURPOSE: The apnea-hypopnea index (AHI) is the parameter on which the severity of obstructive sleep apnea (OSA) is based and is also the determinant for both clinicians and third-party payers for surgical procedures. The purpose of this retrospective cross-sectional chart review is to examine differences in symptoms and AHI between men and women with OSA and whether this may impact timing and selection of surgical care. METHODS: Retrospective cross-sectional study of patients aged 18 years and older who presented at a single center for surgical evaluation of OSA from January 2017 to 2020. AHI, oxygen desaturation index, respiratory disturbance index, and lowest oxygen saturation were obtained from polysomnography. The predictor variable was gender, and the outcome variable was AHI. Unadjusted and multivariate adjusted linear regression models were used to compare differences in AHI between gender, controlling for age, body mass index (BMI), Epworth sleepiness scale, and fatigue severity scale. Poisson regression analysis with robust error was used to assess the relative risks of antidepressant and anxiolytic medication use between genders. RESULTS: A total of 408 consecutive new patients seen for surgical evaluation to treat OSA (248 men and 160 women) were included. Median patient age was 40 years for men and 41 years for women. Median AHI for men was 22.1 events per hour and 13.7 for women (P < .001). When adjusted for age and BMI, men have 33.2% higher AHI than women, with age contributing to 2% and BMI contributing to 6% of the difference. When controlling for age, BMI, Epworth sleepiness scale, and fatigue severity scale, women have a 2.2 increased relative risk of taking anxiolytic or antidepressant medications. CONCLUSIONS: Women with OSA seeking surgery in a dedicated sleep practice have 33% lower AHI than men when controlling for age, BMI, and symptoms. Based on our findings, non-gender-specific AHI may handicap the surgeon from offering the full range of available procedures to women with OSA.

Transoral robotic surgery and neck dissection for HPV-positive oropharyngeal carcinoma: Importance of nodal count in survival.

BACKGROUND: In this study we determine the survival in patients with HPV-positive oropharyngeal carcinoma treated with transoral robotic surgery (TORS), neck dissection and risk-adapted adjuvant therapy. METHODS: We retrospectively identified 122 patients with HPV-positive oropharyngeal carcinoma treated with TORS and neck dissection between 2011 and 2018. Survival probability was calculated. We determined the effect of the type of neck dissection performed (modified radical neck dissection-MRND vs. selective neck dissection - SND), extranodal extension (ENE), margin status, and presence of ≥ 5 metastatic nodes on survival. RESULTS: Our patient population had a five-year overall survival of 91.0% (95% C.I. 85-97%). The five-year probability of recurrence or cancer-associated death was 0.0977 (95% C.I. 0.0927-0.1027). The five-year probability of cancer-associated death was 0.0528 (95% C.I. 0.048-0.0570). All patients who died of their disease had distant metastasis. Our PEG dependence rate was 0%. Patients with ENE and positive margins who underwent adjuvant chemoradiation did not have worse survival. Presence of ≥ 5 metastatic nodes portended worse survival after controlling for age, positive ENE and margins. Low yield (<18 nodes) on neck dissection worsened DFS on multivariable analysis. Furthermore, patients who underwent SND did not have worse OS than those who underwent MRND. CONCLUSION: Our study demonstrates that surgery could be simplified by performing TORS with SND rather than MRND. The one true poor prognostic factor in HPV-positive oropharyngeal carcinoma patients who undergo surgery is high nodal burden. Patients with high nodal burden are much more likely to die from their disease.

Four Practical Reconstructive Techniques Using the Transantral Approach to the Orbital Floor Without the Need for an Endoscope.

Fractures of the orbital floor have traditionally been treated through transorbital approaches. Transconjunctival approaches risk entropion, whereas transcutaneous approaches risk ectropion or hypertrophic scarring. The intraoral transantral approach to the orbital floor has the advantage of minimizing the risk of any eyelid changes while providing appropriate access to reduce the herniated orbital contents and restore orbital volume. This article describes 4 plating methods for reconstructing a fractured orbital floor using a transantral approach. Many prior descriptions of transantral treatment of the orbital floor have relied heavily on the use of an endoscope. This article describes an osteotomy technique that does not require an endoscope but requires only a high-quality headlight for visualization.

Infection prevalence and patterns in self-inflicted gunshot wounds to the face.

OBJECTIVE: Self-inflicted gunshot wounds (SIGSWs) to the craniomaxillofacial region are uncommon injuries but are associated with a high mortality rate. Therefore, treating these patients is a rare occurrence even in the largest trauma centers. As with many rare conditions, data specifically addressing this injury pattern are scarce. Because of the proximity of the blast, even low-velocity injuries can be associated with significant avulsion of tissue, comminution of structures, and tissue die back. Previous case reports have recommended the use of prophylactic antibiotics, but no study has specifically investigated the postinjury infection rate or microbial patterns in this patient population. The purpose of this study was to answer the following clinical question: "Among patients with SIGW to the maxillofacial region, what is the prevalence of postinjury infection, and are there any microbial patterns that can guide empiric antibiotic selection?" STUDY DESIGN: We designed retrospective cohort study at a level I trauma center in Portland, Oregon. Data on 17 patients who had sustained a SIGSW involving the maxilla or the mandible and survived their initial injury were collected from 2010 to 2017. RESULTS: Patients who had a culture-positive infection within 30 days of their injury were defined to have a postinjury infection. Six of the 17 patients (35%) developed a postinjury infection, with an average time to infection of 11 days from initial injury (range 3-19 days). Of the 17 subjects, 15 (88%) received a course of prophylactic antibiotics, on average, for 14 days (range 3-24 days). Of the 6 cases of postinjury infection, culture grew gram-negative bacteria in 4 cases-anaerobic bacteria in 2 and polymicrobial organisms in 2. There was no clear pattern or prevalence of any specific bacterium, but cultures notably included Staphylococcus aureus, Enterobacter species, Bacteroides species, and Escherichia coli. CONCLUSIONS: SIGSWs are associated with a high rate of postinjury infection (35%) despite prophylactic antibiotic usage in 88% of these cases. Given the antimicrobial patterns observed in this study, prophylactic antibiotics in this patient population should include empiric coverage for gram-negative and anaerobic bacteria.

The Radial Forearm Flap: A Technique Modification for Oral Cavity Composite Defects Involving a Marginal Mandibulectomy.

The radial forearm flap is a versatile reconstructive option for oral cavity defects with highly reliable success rates. We encountered more than one flap compromise when we used a radial forearm flap to reconstruct the soft tissue and provide coverage over the mandible, after a marginal mandibulectomy. From this observation, we modified our technique for radial forearm harvest and inset to avoid placing the pedicle in compression against the mandible. The purpose of this article is to present the cases that led to this observation, and present the technique modification in design and execution that we have used.

The Biaxial Double-Barrel Fibula Flap-A Simplified Technique for Fibula Maxillary Reconstruction.

PURPOSE: Previously described techniques for microvascular fibula reconstruction of Brown Class II to IV maxillectomy defects are complex, require multiple osteotomies, result in a short pedicle, and inadequately reconstruct the dental alveolus in preparation for endosseous implants. This report describes a simplified technique for Brown Class II to IV defects that re-creates facial support, allows for dental reconstruction with appropriately positioned implants, and maintains adequate pedicle length. MATERIALS AND METHODS: A retrospective chart review was performed of all patients with Brown Class II to IV maxillectomy defects immediately reconstructed with a biaxial double-barrel fibula flap technique. The reconstructive surgeon evaluated each patient at least 1 month after reconstruction for enophthalmos, facial symmetry, nasal patency, satisfactory jaw position, deglutition, intelligible speech, and intraoperative need for vein grafting. RESULTS: The sample was composed of 6 patients (mean age, 54 yr; range, 33 to 78 yr; 67% women) who underwent reconstruction with the biaxial double-barrel fibula flap technique for Brown Class II to IV defects. None of these patients required vein grafting. None of these patients had flap failure. Diagnoses for these patients were a hybrid odontogenic tumor (n = 1), squamous cell carcinoma (n = 3), adenoid cystic carcinoma (n = 1), and sinonasal melanoma (n = 1). All 6 patients had excellent facial contour and malar projection, regular oral intake, 100% intelligible speech, and a new maxillary skeletal Class I relation without need for intraoperative vein grafting. One patient developed enophthalmos related to inferior rectus sacrifice and removal of orbital fat. Complications included development of nasal synechia and occlusion of the maxillary sinus ostium (n = 1). CONCLUSIONS: The biaxial double-barrel fibula flap technique achieves the goals of providing adequate facial support and an alveolar segment amenable to implant dentistry. It allows for intelligible speech, deglutition, orbital support, and separation of the oronasal, orbital, and sinus cavities. In addition, it minimizes the need for vein grafting.

What Is the Role of Elective Neck Dissection in the Management of Patients With Buccal Squamous Cell Carcinoma and Clinically Negative Neck?

PURPOSE: Buccal squamous cell carcinoma (BSCC) is rare in the United States. Given its location, few anatomic barriers to spread exist and it has been found to have a high locoregional recurrence rate. The role of elective neck dissection (END) in patients with clinically negative neck (N0) is not clear. This study aims to answer the following research question: Among patients with N0 BSCC, does END improve locoregional control rates, distant metastasis rates, and 2- and 5-year survival rates? MATERIALS AND METHODS: A retrospective cohort study was conducted. The sample included patients who received a diagnosis of BSCC. The primary predictor variable was END status (yes or no). Five institutions participated between June 2001 and June 2011: University of Washington, University of Michigan, University of Tennessee, North Memorial Oral and Maxillofacial Surgery in Minnesota, and Head and Neck Surgical Associates (Portland, OR). The primary outcome variable was locoregional recurrence. Secondary outcome variables were distant metastasis and 2- and 5-year survival rates. Other variables collected were demographic characteristics, initial operation, adjuvant therapy, clinical and pathologic data, and staging. Kaplan-Meier and Cox proportional hazards statistics were computed. RESULTS: The sample was composed of 98 patients with clinical N0 BSCC. The mean age was 66 years (range, 30-88 years), and 54% were men. Of the patients, 74 (76%) underwent END. The locoregional recurrence-free rate was 61% for END versus 38% for no END (P = .042). The distant metastasis rate was 4% for END versus 9% for no END. The 2- and 5-year disease-free survival rates were 91% and 75% (P = .042), respectively, for END and 85% and 63% (P = .019), respectively, for no END. CONCLUSIONS: END had a therapeutic effect, as evidenced by a lower locoregional recurrence rate, lower distant metastasis rate, and improved 2- and 5-year survival rates.

Use of Intraoperative Computed Tomography in Craniomaxillofacial Trauma Surgery.

PURPOSE: The use of technology to aid in assessment, planning, and management of complex craniomaxillofacial injuries is increasingly common. Preoperative computed tomography (CT) evaluation is considered the standard of care, and intraoperative imaging is becoming increasingly accessible. Limited data exist regarding the implication of intraoperative CT on decision making in the management of all sites of facial fractures. The purposes of this study were to characterize the use of an intraoperative CT scanner for craniomaxillofacial surgery within our institution, to quantify the effect of intraoperative CT on surgical decision making, and to attempt to provide guidance on when to use this technology. PATIENTS AND METHODS: This retrospective case series characterizes the use of an intraoperative CT scanner for craniomaxillofacial trauma surgery at a level 1 trauma center in Portland, Oregon, from February 2011 to September 2016. We evaluated the following variables: the number of intraoperative CT scans performed for craniomaxillofacial surgery including the number of scans for each patient, the number of scans for each operative visit, the CT-directed revision rate (overall and for specific preoperative diagnoses), and the indication for imaging. This information was evaluated to provide guidance on appropriate use of an intraoperative scanner. RESULTS: A total of 161 patients were identified to have intraoperative facial CT scans from February 2011 to September 20, 2016, at Legacy Emanuel Medical Center. A total of 212 intraoperative facial CT scans were performed across 168 separate operations. The overall CT-directed revision rate was 28%. CT-directed revision rates for fracture subsites are as follows: orbital, 31%; zygomaticomaxillary complex, 24%; Le Fort I, 8%; Le Fort II and III, 23%; naso-orbital-ethmoidal, 23%; mandible, 13%; and frontal sinus, 0%. No CT-directed revisions were performed during removal of hardware, during placement of craniofacial implants, or in temporomandibular joint replacement surgery. CONCLUSIONS: If available, intraoperative CT should be routinely considered in the operative management of orbital fractures and pan-facial fractures, as well as complex zygomaticomaxillary complex, Le Fort II and III, and naso-orbital-ethmoidal fractures. Consideration also should be given to the use of intraoperative CT in cases of complex mandible fractures involving severe comminution or the condylar region. Intraoperative CT should not be routinely used for the management of Le Fort I fractures or frontal sinus fractures.

Functional Anatomic Computer Engineered Surgery Protocol for the Management of Self-Inflicted Gunshot Wounds to the Maxillofacial Skeleton.

PURPOSE: Virtual surgical planning (VSP) is an indispensable aid in craniomaxillofacial reconstruction, yet no protocol is established in facial gunshot wounds. We review our experience with computer-aided reconstruction of self-inflicted facial gunshot wounds (SIGSW'S) and propose a protocol for the staged repair. METHODS: A retrospective case series enrolling patients with SIGSW's managed with the Functional Anatomic Computer Engineered Surgical protocol (FACES) was implemented. Subjects were evaluated at least one month postoperatively. Outcome variables were jaw position, facial projection, oro-nasal communication, lip competence, feeding tube and tracheostomy dependence, descriptive statistics were computed. The FACES protocol implemented during the initial hospitalization is as follows 1) damage control; 2) selective debridement; 3) VSP reconstruction back converted into navigation software 4) navigation assisted midfacial skeletal reconstruction; 5) computer aided oro-mandibular reconstruction with or without microvascular free flaps using custom cutting guides/hardware; 6) navigation assisted, computer aided palatomaxillary reconstruction with or without microvascular free flaps using cutting guides/hardware; 7) navigation assisted reconstruction of the internal orbit; 8) and confirmation of accurate reconstruction using intraoperative CT. RESULTS: The sample was composed of 10 patients, mean age of 43 years (range, 28 - 62 years, 70% M), 100% with SIGSW's to the submental/submandibular region. All had satisfactory facial projection (n=10), nine had satisfactory jaw position, were decannulated by one month's follow up and were feeding tube independent (90%). All traumatic oro-antral communications were closed (n=8, 7 surgical, 1 obturator), seven had adequate lip competence (70%). Complications included fibula malunion (n=1), plate exposure (n=2) infection (n=2), intracranial abscess (n=1) and microstomia (n=2). CONCLUSION: Computer-aided surgery is an indispensable tool in the reconstruction of SIGSW's. Successfully implemented, it proved to be a useful adjunct for: the restoration of orbital volume, facial projection and symmetry; the inset of composite tissue, and the facilitation of dental implant supported prosthetic rehabilitation.

Recommendations for Care of Geriatric Maxillofacial Trauma Patients Following a Retrospective 10-Year Multicenter Review.

PURPOSE: The purpose of this study was to analyze maxillofacial trauma sustained by patients at least 75 years old. With the injury patterns identified, treatment recommendations for the contemporary oral and maxillofacial surgeon are made. PATIENTS AND METHODS: This study was a retrospective case series using data from 2 level 1 trauma centers. The variables of interest included age at traumatic event, gender, mechanism of trauma, concomitant injuries, radiographic studies performed, management of maxillofacial injuries, and disposition. Numerical analysis was completed with statistical software. RESULTS: One hundred seventy-six patients at least 75 years old who sustained facial trauma were identified. Ground-level falls caused most cases of maxillofacial trauma in the geriatric population. The median age at the time of trauma was 83 and 85 years for men and women, respectively. The most common injuries were midface fractures. Intracranial hemorrhage was the most common concomitant injury, and all but 1 patient underwent computed tomography of at least the head after their traumatic event. Most maxillofacial injuries were treated without operative repair. CONCLUSIONS: The information gained from this study suggests that oral and maxillofacial surgeons should counsel geriatric patients on the risk of falls and encourage the prevention of potential hazards for falls in their homes.

Updates in Management of Craniomaxillofacial Gunshot Wounds and Reconstruction of the Mandible.

This article includes updates in the management of mandibular trauma and reconstruction as they relate to maxillomandibular fixation screws, custom hardware, virtual surgical planning, and protocols for use of computer-aided surgery and navigation when managing composite defects from gunshot injuries to the face.

Resorbable Suture as Wound Drain.

The placement of a resorbable suture on one edge of a wound can effectively retard the mucosal closure of the defect and thereby duplicate the function of a passive surgical drain. The placement of a double or triple loop of a resorbable suture such as chromic gut on one side of the wound edge can provide an inexpensive and self-eliminating wound drain.

Microvascular Free Tissue Transfer for Head and Neck Reconstruction in Children: Part I.

BACKGROUND: Limited outcome data exist regarding the survival of microvascular free flaps for head and neck reconstruction in children. The objectives of this study were to perform a systematic review of the literature and meta-analysis comparing the survival of the most commonly used free flaps used for head and neck reconstruction in children. METHODS: A systematic search of PubMed, Embase, and Scopus was conducted using various keywords up to January 1, 2015. Meta-analysis was used to compare the survival of the most commonly used free flaps. The primary predictor variable was free flap type. The primary outcome variable was flap failure. The pooled relative risk (RR) with 95% confidence intervals (CIs) was estimated using a Mantel-Haenszel, fixed-effects model. RESULTS: The authors reviewed 25,303 abstracts. Five studies met inclusion criteria. A total of 646 children received a total of 694 free flaps. The pooled survival rate among all free flaps was 96.4%. The fibula free flap (fibula) and subscapular system free flaps (scapula) were the most commonly used flaps. There was no difference in survival when comparing the scapula (RR = 0.59, 95% CI: 0.26, 1.56, P = 0.29), or fibula (RR = 1.91, 95% CI: 0.55, 6.65, P = 0.31) to other free flaps, or when comparing the scapula to the fibula (RR = 2.29; 95% CI: 0.40, 13.08, P = 0.35). CONCLUSIONS: Free tissue transfer is highly successful in children. Although data are limited, there appears to be no difference in survival among various free flaps used for head and neck reconstruction in children.