[Treatment of cutaneous malignant melanoma in the head and neck region : An update]. / Therapie des kutanen malignen Melanoms im Kopf-Hals-Bereich : Ein Update.

Major progress has been made in the treatment of malignant melanoma during recent years. On the one hand, reliable evidence-based recommendations regarding surgical resection as well as lymph node management have been established on the basis of results from randomized multicenter studies. On the other hand, the advent of targeted therapies has led to spectacular improvements in the treatment of metastasized melanomas. Knowledge concerning treatment algorithms and updates thereof is also essential for maxillofacial surgeons. The German S3 guideline on diagnosis and treatment of melanoma was published in 2013 and revised in 2016 and 2018. This article informs readers about these developments and addresses the items relevant for treatment of head and neck melanomas in particular.

[Basal cell carcinoma of the face and scalp : An update on treatment options]. / Basalzellkarzinom der Gesichts- und Kopfhaut : Update der Therapieverfahren.

The treatment of malignant tumors of the facial skin is an important part of the specialty oral and maxillofacial surgery. In two successive CME articles, important aspects of frequent entities are dealt with for the facial area. The current article deals with basal cell carcinoma, the most common localization of which is by far the facial area. Surgical resection is the treatment modality of first choice. A risk-adapted approach involving complete histopathological margin assessment is recommended for basal cell carcinoma at risk for recurrence or aggressive spread in order to spare healthy skin and to control subclinical tumor growth. There are specific caveats for non-surgical treatment options, such as topical medication, destructive procedures, and radiotherapy. This article describes indications and treatment methods with a focus on surgical resection techniques.

Prospective clinical study comparing intraligamentary anesthesia and inferior alveolar nerve block for extraction of posterior mandibular teeth.

OBJECTIVES: The aim of the study was to compare the efficacy of intraligamentary anesthesia (ILA) with conventional inferior alveolar nerve block (IANB) for extraction of mandibular posterior teeth. MATERIALS AND METHODS: In a prospective clinical trial, a total of 301 mandibular posterior teeth were extracted in 266 patients. Randomization was conducted into those who received ILA (patients n = 98; teeth n = 105) and those who received IANB (patient n = 140; teeth n = 140). Twenty-eight patients were subjected to bilateral mandibular dental extractions and received both ILA und IANB (teeth n = 56 (ILA n = 28; IANB n = 28)). The primary objective was to evaluate the differences in pain during injection, in pain during tooth extraction (numeric rating scale (NRS)), and in anesthetic quality (complete/sufficient vs. insufficient/no effect). Differences in latency time, amount of anesthetic solution, need for second injection, and duration of local numbness as well as in the incidence of dry socket were assessed. RESULTS: ILA had significant lower pain of injection (p < 0.001), shorter latency time (p < 0.001), and shorter duration of local numbness (p < 0.001) and required lesser amount of local anesthetic solution (p < 0.001) together with a similar anesthetic quality (p = 0.082) compared to IANB. Concerning pain during extraction (p = 0.211), frequency of second injection (p = 0.197), and incidence of dry socket (p = 0.178), no significant differences were detected. CONCLUSION: ILA fulfills the requirements of a minimal invasive and patient-friendly local anesthetic technique. In accordance, it represents a safe and reliable alternative to IANB for extraction of mandibular posterior teeth. CLINICAL RELEVANCE: ILA can be recommended for routine dental extractions.

Influence of needle bevel design on injection pain and needle deformation in dental local infiltration anaesthesia - randomized clinical trial.

The aims of this in vivo study were to evaluate the impact of needle bevel design on patients' pain perception and the mechanical deformation of the needle tip after the injection. In a prospective single-blinded trial, 150 patients received conventional infiltration anaesthesia for dental treatment by one examiner. Patients were randomized for one out of three different needle bevel types (scalpel-designed bevel needle (SB), n=50; triple bevel needle (TB), n=50; regular bevel needle (RB), n=50). Subjects' self-reported injection pain perception was evaluated using a numeric rating scale (NRS). For each needle tip, deformations after single use were measured using SEM. A significant lower injection pain level was found in SB (mean 2.1±1.2) than in TB (mean 3.5±1.6;) and RB (mean 3.4±1.0; all P<0.001). A needle deformation was detected in about 97.3% of all needles (SB 50/50, TB 50/50, and RB: 46/50). A higher number of barbs were found in SB (29/50) versus TB (17/50) and RB (19/50). For dental local infiltration anaesthesia, injection needles with a scalpel-designed bevel demonstrated significantly less injection pain. Needle tip deflections after anaesthetic agent infiltration, especially barbed hooks on the non-cutting edge may result in greater soft tissue trauma.

Dental implants and immediate loading: multivariate analysis of success factors.

OBJECTIVES: The authors had for aim to examine factors potentially influencing the success of immediate implant placement and loading. MATERIALS AND METHODS: One hundred and ninety-five consecutive patients (16.5 to 80.4 years of age) were provided with 310 prostheses supported by 896 immediately loaded implants. The mean follow-up was 27.5 months. Univariate and multivariate Cox regression was performed to analyze potential modifiers of implant success. RESULTS: The overall implant success rate was 96.7%. The statistically significant modifiers of success on multivariate analysis (P<0.05) were duration of functional use (P<0.001), type of superstructure (P<0.001), implant-abutment connection (P<0.001), and maxilla versus mandible (P=0.026). None of the other investigated factors (age, gender, implant location/design/length) were statistically significant modifiers of success. DISCUSSION: Our study results demonstrate high success rates for immediately loaded implants whatever types and superstructure used. Prosthetic designs and their implementation have a significant effect on the success rate of implant-supported restoration, with adjusted hazard ratios of up to 51. Maxilla versus mandible was the only significant non-external modifier when using an adjusted hazard ratio of 2.75.

Meningiomas involving the sphenoid wing outcome after microsurgical treatment--a clinical review of 73 cases.

OBJECTIVE: Sphenoid wing meningiomas represent a difficult to access subtype of intracranial meningiomas involving important neurovascular structures such as the optic nerve, cavernous sinus or carotid artery. They cause neurological compromises by direct compression of adjacent cranial nerves. Insidious and aggressive dural, bony, and orbital involvement produces several difficulties for adequate resection leading to higher rates of recurrence. METHODS: This retrospective case analysis consists of 73 patients who were surgically treated for meningiomas involving the sphenoid wing, where a pterional approach was performed between April 2001 and February 2006. 51 women and 22 men with a mean age of 59.4 years were operated on. The follow-up period ranged from 3-75 months (mean 29.8 months). Patients were divided into the following groups based on the site of the tumor: group 1: outer part of the sphenoid ridge (lateral, n=16); group 2: middle part of the sphenoid ridge (intermediate, n=5); group 3: inner part of the sphenoid ridge (medial, n=22); and group 4: spheno-orbital meningioma (n=30). RESULTS: The majority of patients presented with visual impairment (55%), followed by generalized headaches (36%) and visual field defects (33%). Total microscopic tumor resection was achieved in 35 patients (47.9%). Visual acuity improved in 58% of the patients, with 23% returning to normal vision. Preexisting cranial nerve deficits remained unchanged in the majority of patients (79%) and improved in 18%. Temporary new cranial nerve deficits occurred in 6 cases, and 1 patient (1%) developed permanent third nerve palsy. The mortality rate was 3% (2 patients) and the rate of permanent nonvisual morbidity was 7% (5 patients). 12 patients (16%) received postoperative radiotherapy. In 6 of 7 patients who were observed for at least 1 year after radiotherapy, stable tumor volume was noted at the follow-up review (mean 30.2 months, range 16-50 months), which provides a tumor growth control rate of 86%. The overall recurrence rate was 15% (11 of 73 patients). CONCLUSION: The result of this study affirms the safety of microsurgical treatment strategies, so that sufficient tumor control can be achieved with minimal morbidity and satisfying functional results in most cases.

[Current opinion in treatment of soft tissue sarcoma]. / Aktuelle Therapie der Weichteilsarkome im Kopf-/Halsbereich.

The present work discusses soft tissue sarcoma in the head and neck area, due to the rare occurrence and the sparse data situation is still a large number of unexplained riddles. The head and neck surgeon plays the central role in the diagnosis and treatment of the vast majority of soft tissue sarcoma in the head and neck area. It is crucial that these tumors immediately should be send to specialized centers. An larger excisional biopsy should be avoided. When histology and tumor extension are secured an interdisciplinary treatment concept should be discussed, or the patient if possible will be introduced in ongoing clinical studies.

[Nasal dermoid sinus cyst: accidental coincidence or syndrome association?]. / Nasendermoide bei Peters-Plus-Syndrom: Zufall oder Syndromexpression?

BACKGROUND: Peters anomaly is a rare congenital glaucoma disease. The Peters' plus syndrome is characterized by distinct malformations. As some of the common craniofacial malformations like cleft lip and palate are frequent in Peters' plus syndrome, no nasal dermoid sinus cysts has been reported so far. Nasal dermoid sinus cysts usually present in isolation, although associations to other anomalies or syndromes are possible. The occurrence of such an anomaly may be either accidental, or present a syndrome association. PATIENTS AND METHOD: One patient with an unilateral cleft lip and Peters' plus syndrome had undergone removal of nasal dermoid sinus cyst previously and was referred for management of recurrent disease. Complete surgical removal and plastic reconstruction was performed. RESULTS: Concerning the common (lateral) cleft lip nasal deformity with no midline nasal masses, there are reasons for the assumption that a coincidence of both anomalies might be accidental. Especially in Peters' plus syndrome no occurrence of nasal dermoids has thus far been documented. However, the embryological pathway of the frontonasal region differs from lip and palate development in time and location: So unique formation of both lesions seems inconsistent. Complete surgical removal and plastic reconstruction simultaneously or in a second step are recommended. CONCLUSION: As two cases of arhinia and Peters anomaly have been described in 1978, midline nasal masses might be a possible appearance of Peters' plus syndrome.

Maturation of capillary-like structures in a tube-like construct in perfusion and rotation culture.

In an effort to engineer capillary-like networks in vitro, different cultivation methods were compared. Five small-diameter tube-like constructs ('vessel equivalents') were fabricated from porcine gelatin scaffolds and seeded with human adipose tissue stromal cells and umbilical vein endothelial cells. After initial growth, the vessel equivalents were divided. One segment was exposed to pulsatile perfusion and the other was kept in rotating culture. Specimens harvested at the start of the experiments and after 16 days of rotation or perfusion were compared histomorphometrically with respect to capillary-like network formation in the vessel wall. Most capillary-like structures were found in the luminal portion of perfused vessel equivalents. Maturation of these capillary-like structures ascertained by recruitment of alpha-actin-positive cells also reached the highest degree in the luminal portion of perfused specimens. Perfused specimens showed significantly less apoptosis. Pulsatile perfusion promotes the development and maturation of a capillary-like network in this in-vitro approach.

[Secondary reconstruction of the eye socket with a free radial forearm flap]. / Sekundäre Rekonstruktion der anophthalmischen Orbita mit einem Radialislappen.

We report on two patients (38 and 52 years old) suffering from severe post-enucleation socket syndrome (PESS) after enucleation of the bulbus with postoperative irradiation of the orbit due to malignant eye tumors. The secondary reconstruction of the contracted eye socket was performed by a free vascularized radial forearm flap to create a permanent eye socket with augmentation of the content of the orbital space. In the follow-up period of 12 months the patients were able to wear a cosmetically acceptable ocular prosthesis without notable secondary graft contracture. The free vascularized radial forearm flap is an alternative procedure to a dermis fat graft for the secondary reconstruction of the orbit in patients with a severe PESS.

[Granular cell tumor of the orbit]. / Granularzelltumor der Orbita.

Granular cell tumor (GCT, Abrikossoff tumor) is an extremely rare, benign tumor with a neurogenic origin occurring most commonly in the upper aerodigestive tract. GCT of the orbit is a rarity, representing a diagnostic and therapeutic challenge. We report on a 26 year old man suffering from unilateral ocular hypertension and retrobulbar pain. Exophthalmos and disturbance of motility were not noted by the patient. The surgical removal of the GCT, extending into the orbital apex, was performed by an interdisciplinary team using a combination of "midfacial degloving" and LeFort I-osteotomy.

[Nasal dermoid and sinus cysts in patients with cleft malformations]. / Nasenfisteln und -zysten bei Patienten mit Lippen-Kiefer-Gaumen-Spalten.

BACKGROUND: Nasal dermoid sinus cysts are uncommon congenital lesions. They are usually isolated occurrences and are not associated with syndromes or additional malformations. The coincidence of both, cleft malformations and nasal dermoid sinus cysts, has seldom been reported. CASE REPORTS: Within the last 2 years two patients with reconstructed cleft lip and palate and additional nasal dermoid sinus cysts underwent surgical removal. One patient with bilateral complete cleft lip exhibited a fistula from the medial third of the nasal dorsum up to the glabella. Another patient with unilateral cleft lip and Peters' plus syndrome had undergone removal of a nasal dermoid sinus cyst 12 years ago and was referred for management of recurrent disease. DISCUSSION: Concerning the common cleft-dependent nose malformations with no midline nasal masses, there are reasons for the assumption that a coincidence of both anomalies might be accidental. Especially in Peters' plus syndrome no frequent occurrence of nasal dermoids has thus far been documented. However, the proximity and temporal closeness of an embryological pathway of the frontonasal region and lip development could also argue for a unique formation of both lesions. Complete surgical removal and plastic reconstruction simultaneously or in a second step are recommended.

[Restoration of lid function in peripheral facial palsy by implanting gold weights]. / Rehabilitation der Lidfunktion bei peripherer Fazialisparese mit Goldgewichtimplantaten.

BACKGROUND: Lagophthalmos is a common functional and aesthetic problem in patients with facial palsy. The implantation of a rigid gold weight is one technique to improve eyelid closure. The effectiveness of lid loading was investigated, taking into consideration complications ascribed to rigid implants. PATIENTS AND METHODS: We present 11 patients with facial palsy treated with that technique between April 2001 and October 2005. Before and after operation ophthalmological investigations were performed. The patients were questioned about their subjective satisfaction, and the remaining eye lid gap in the closed state was assessed. RESULTS: A good up to perfect lid closure could be achieved. Of the 11 patients, 9 reported being very contented with the result. Except for one case of extrusion, disturbed healing processes did not occur. We did not observe any occurrence of astigmatism as a result of the rigid lid load. All patients reduced their use of eye ointment and eye covers. We observed a visible bulging of the implant contour in 4 of 11 patients. However, not one of them felt discontented. All patients stated that they would undergo the lid loading procedure again. CONCLUSIONS: The implantation of rigid gold weights for lid loading in patients suffering from lagophthalmos due to peripheral facial palsy is considered a simple and effective treatment for improving eyelid closure. Whether or not flexible implants will lead to better results needs to be further investigated.

[Orbital diseases in childhood]. / Orbitaerkrankungen im Kindesalter.

BACKGROUND: Orbital diseases in childhood are rare and differ from orbital lesions occurring in adults. Most paediatric orbital tumours are benign, but rapid tumour growth can nevertheless threaten vision or lives. PATIENTS: Retrospectively, we analyzed data of 41 consecutive patients with orbital disease, treated in our hospital between 2000 and 2004. The data was evaluated using descriptive statistics and case reports. RESULTS: All children (from neonatals up to 16 years of age) with orbital disease were included in the study. The most common benign disease of the entire collective was an epidermal cyst (n = 18), followed by orbital capillary haemangioma (n = 4) in children under 3 years, and preseptal cellulitis in children older than 3 years. 5 patients were treated for malignant tumours, of which one patient under 3 years had an orbital metastasis of an abdominal neuroblastoma. CONCLUSION: Awareness of orbital diseases in childhood, as a rare entity, is crucial for timely diagnosis and appropriate treatment, to save the vision and lives of affected children.

[Hemangiopericytoma (extrapleural solitary fibrous tumour). Exemplified and discussed on the basis of two cases]. / Hämangioperizytom (extrapleuraler solitärer fibröser Tumor). Dargestellt und diskutiert anhand zweier Patientenbeispiele.

BACKGROUND: Hemangiopericytoma was first mentioned in 1942. It is a very uncommon potentially malignant vascular tumour which can occur at every site of the body. According to the WHO, most of the tumours formerly diagnosed as hemangiopericytomas are considered to be extrapleural solitary fibrous tumours. The diagnosis of "hemangiopericytoma" is now only determined if a constant histological picture of hemangiopericytoma is present. The tumour can lead to lymphogenous or hematogenous metastasis. The major location of occurrence is the cutis and subcutis. It originates from the pericytes of the vascular wall. This is reflected in its vascular character and therefore the hemangiopericytoma might clinically be mistaken for a hemangioma. CASE REPORTS: Patient 1: 60 years, female; diagnosis: malignant suboccipital hemangiopericytoma; size: 4.9 x 4.5 x 4.2 cm; pT1bNXMX L0 V0 Pn0; stage IA; grading G1; R0.Patient 2: 38 years, male; diagnosis: benign hemangiopericytoma infraorbital left; size 1.5 x 1.5 x 1.5 cm. DISCUSSION: Most often the hemangiopericytoma becomes clinically conspicuous as a slowly growing, painless swelling. The consistency ranges from soft to dense, and the color is greyish-blue. The slow and painless growth carries the danger of a clinically wrong diagnosis and thus delayed therapy. The histological diagnosis of hemangiopericytoma is determined by biopsy. Besides histology, MRI and angiography are methods that can be employed to diagnose hemangiopericytoma. The therapy of choice is the complete tumour-resection with a safety margin of 1 cm. In the case of an aggressive growth pattern, adjuvant postoperative radiotherapy is recommended. Until now there has been no documented specific therapy concept for managing incomplete resection and the occurrence of metastasis. There are reports about chemo- and radiotherapy either on their own or combined which evidence differing degrees of success. Lifelong monitoring is necessary because recrudescences and metastases can occur even decades later.

[Intraoral application of vacuum-assisted closure in the treatment of an extended mandibular keratocyst]. / Intraorale Vakuumtherapie zur Behandlung einer ausgedehnten Zyste des Unterkieferknochens.

In extended cysts of the jaw bone particular demands are made in terms of wound closure, especially if an intraoral surgical approach is chosen. A tight closure is even more important if the bony defect has been filled with an alloplastic material or autologous cancellous bone. In our case a keratocyst of the left mandibular angle and ascending ramus was treated. After enucleation of the cyst and grafting with autologous cancellous bone the graft was lost following a wound breakdown. Subsequently a system was developed to apply intraoral V.A.C.-therapy. This led to a safe separation of the cystic defect and the oral cavity and a conditioning of the wound ground. A grafting with an alloplastic material was carried out successfully. With this method the length of treatment could be reduced by several months compared to a conventional therapy with an obturator.

In vitro model of a vascular stroma for the engineering of vascularized tissues.

A major problem for the in vitro engineering of larger tissue equivalents like those required in reconstructive surgery is the lack of solutions for sufficient nutrition and oxygenation. The starting point of our investigation was the question of whether the principles of in vitro angiogenesis can be applied and utilized for tissue engineering. A soft tissue model was developed, consisting of human adipose tissue stromal cells and umbilical vein endothelial cells in a fibrin-microcarrier scaffold. Capillary-like structures were visualized using UEA-I-lectin labelling and confocal laser scanning microscopy. Length of capillary-like structures was measured in an image analysis system. Under serum-free culture conditions, maintenance of capillary-like structures was significantly increased in comparison to serum-containing cultures. The application of vascular endothelial growth factor (VEGF) resulted in a high initial angiogenic response; long-term stabilization of capillary-like structures could not be achieved, however supplementation with IGF-1 resulted in the highest values and the slightest decrease in length of capillary-like structures, so that the results could be interpreted as an improved stabilization.

[Tissue engineering of vascularized bone and soft tissue transplants]. / Untersuchungen zum Tissue engineering vaskularisierter knöcherner und weichgewebiger Transplantate.

The utilization of in vitro angiogenesis in tissue engineering might be useful in order to establish an artificial vascular network. However, it remains unclear how far the in vitro preformation of vascular structures may contribute to the perfusion of larger artificial tissue aggregates regarding the improvement of oxygenation and nutrition. In an in vitro study, we developed a model of a vascularized tissue. Stromal cells of a target tissue, e.g., adipose tissue or bone tissue, were expanded in vitro and seeded onto microcarriers or microparticles. Densely covered microcarriers were brought into a fibrin matrix together with endothelial cells. In order to demonstrate the formation and stabilization of capillary-like structures, UEA-I labeled specimens were evaluated using laser scanning microscopy and digital image analysis. The stabilization of capillary-like structures was better with stromal cells from bone marrow than from adipose tissue. In one of the culture aggregates, the total length of capillary-like structures increased after 6 weeks of cultivation to up to 140 mm/mm3. Additional tests were performed utilizing hyperbaric oxygenation. In the oxygenation group, a significant increase in the length of capillary-like structures was found. The method implies the option of coculturing different tissue elements and of an in vitro preformation of vascularized tissues.

[Institutionalization of skull base surgery. Development, concept and initial experiences of the interdisciplinary center for skull base surgery of the Leipzig University]. / Institutionalisierung der Schädelbasischirurgie. Aufbau, Konzept und erste Erfahrungen des Interdiziplinären Zentrums für Schädelbasischirurgie der Universität Leipzig (IZSL).

The treatment of complex tumorous, inflammatory, traumatic, vascular processes, or developmental disorders of the skull base increasingly needs the interdisciplinary cooperation of specialties involved in diagnostics or treatment. Due to this inevitable cooperation of different hospital specialties, institutionalization of skull base surgery, organized as a center or working group, seems recommendable. Moreover, such a center may have additional effects on the external representation of skull base surgery, which is also important. On the initiative of 11 departments and institutes of the university hospital of Leipzing, the Interdisciplinary Center of Skull Base Surgery (IZSL) was founded in March 1997. The following aims were proclaimed: improvement of the interdisciplinary clinical treatment of patients with skull base diseases, evaluation of the patient's data, advancement of clinical and experimental research on the field of skull base surgery, as well as the organization of meetings for training and teaching and scientific meetings. Structure, concept, and first experiences of the interdisciplinary center of skull base surgery are discussed.