Assessing the Outcomes of Focused Heating of the Skin by a Long-Pulsed 1064 nm Laser with an Integrated Scanner, Infrared Thermal Guidance, and Optical Coherence Tomography.

BACKGROUND AND OBJECTIVE: Long-term benefits can be predicted by the incorporation of more intelligent systems in lasers and other devices. Such systems can produce more reliable zones of thermal injury when used in association with non-invasive monitoring and precise laser energy delivery. The more classical endpoint of tumor destruction with radiofrequency or long-pulsed (LP) 1064 nm laser is the non-specific appearance of tissue graying and tissue contraction. Herein we discuss combining non-invasive LP 1064 nm Nd:YAG treatment with the assistance of optical coherence tomography (OCT) and the forward-looking infrared (FLIR) thermal camera while testing literature-based formulae for thermal destruction. STUDY DESIGN/MATERIALS AND METHODS: The skin on the forearm and back of two consenting volunteers was marked and anesthetized with lidocaine with epinephrine. The parameters of a scanner-equipped LP 1064 nm Nd:YAG laser were adjusted to achieve an epidermal/superficial dermal heating of between 50°C and 60°C over a specified time course. Experimental single treatments examined various adjusted parameters including, fluence, pulse overlap, pulse duration, scan size, and pulse rate. A FLIR camera was used to record skin temperature. Outcome measures included skin temperature, post-treatment appearance, and OCT assessment of skin and vascular damage. The clinical response of each treatment was followed daily for 4 weeks. RESULTS: Optimal protocols initially raised the skin temperature to between 55°C and 60°C, which was carefully maintained using subsequent laser passes over a 60-second time course. Immediately post laser, clinical responses included erythema, edema, and blistering. Immediate OCT revealed increased vascularity with intact, dilated blood vessels. Prolonged exposure above 60°C resulted in sub-epidermal blistering and an absence of blood flow in the treatment area with prolonged healing. CONCLUSION: The LP 1064 nm laser can be used to achieve heat-related tissue injury, though the narrow parameters necessary for the desired endpoint require the assistance of IR thermal regulation to avoid unacceptable outcomes. The use of the laser scanner ensures precise energy delivery over a defined treatment area. Future studies might explore this as a selective hyperthermic method for the treatment of non-melanoma skin cancer. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

The Diagnostic Role of Optical Coherence Tomography (OCT) in Measuring the Depth of Burn and Traumatic Scars for More Accurate Laser Dosimetry: Pilot Study.

BACKGROUND: In recent decades, a number of optimal diagnostic technologies have emerged to assist in tissue visualization. Real-time monitoring of skin during laser therapies will help optimize laser parameters for more ef cient therapies. One of these technologies, optimal coherence tomography (OCT), may be used to help visualize burn and traumatic scars. When lasing severe scars, lasers have tunable pulse energies, which are made proportional to the scar thickness as estimated by palpation and the physician eye. This has historically been estimated by the clinician with no objective data. OCT is an emerging non-invasive imaging technique that provides a cross-sectional image of tissue micro-architecture from a depth of 0.7 - 1.5 mm. The signal intensity is related to the tissue optical scattering properties, which in turn is related to tissue constituents such as collagen density. Thus, OCT may provide an objective non-invasive measurement of scar depth. STUDY: Thirty burn and traumatic scars were imaged with quality, traceable, and veri able OCT data from burn and trauma patients both pre- and post- laser therapy. OCT was rapid and ef cient (approximately 2 minutes) to scan skin to visualize real-time scar tissue in different areas of heterogenous scars. The OCT image of the scar was compared to that of normal tissue in order to identify scar tissue and estimate its depth. Laser parameters were then dialed to treat full thickness of the scar. RESULTS: Clinical and OCT correlation between atrophic versus hypertrophic scars was found. However, in most cases the clinicians underestimated the depth of the scar in the dermis. CONCLUSION: The treatment of burn and traumatic scars for both civilian and wounded warriors can be challenging. As these scars are often very deep, OCT allows for non-invasive examination of the thickness of the scar allowing the physician better accuracy for laser settings in the treatment for the full thickness of the scar tissue. J Drugs Dermatol. 2016;15(11):1375-1380..

Full-thickness skin graft from the neck for coverage of the radial forearm free flap donor site.

PURPOSE: This study describes the use of a full-thickness skin graft (FTSG) from the neck to cover the radial forearm free flap (RFFF) donor site in patients undergoing neck dissection and microvascular reconstruction for ablative head and neck oncologic surgery. The authors propose that an FTSG from the neck provides sufficient tissue quantity and quality, fewer surgical sites, and decreased surgical time and cost compared with other FTSG harvest sites and split-thickness skin grafts (STSGs). MATERIALS AND METHODS: This was a retrospective study of 50 patients from 2007 to 2012 who underwent ablative surgery for oral and head and neck cancer with concomitant cervical lymphadenectomy and RFFF reconstruction with repair of the donor site using an FTSG harvested along the neck dissection incision. Patients who underwent donor site repair using other techniques, such as ulnar transposition flaps, were excluded. Medical records and perioperative photographs were reviewed. RESULTS: Primary closure of the neck without dehiscence was achieved in all cases. There were no recipient site infections. Minor skin graft loss occurred in a minority of patients and was managed with local wound care until healing by secondary intention. No patients required surgical revision of the forearm. CONCLUSIONS: An FTSG from the neck provides adequate coverage for most RFFF harvests and offers favorable functional and esthetic outcomes. The primary advantage is avoiding a third surgical site. Complications were comparable to those using FTSGs from other harvest sites. Importantly, cross-contamination from the head and neck with the forearm was shown not to be an issue.

Fixation of Le Fort I osteotomies with poly-DL-lactic acid mesh and ultrasonic welding--a new technique.

PURPOSE: This report describes a technique for use of resorbable mesh (Resorb-X) and an ultrasonic sonotrode unit (SonicWeld Rx) to bond a pin (SonicPin Rx) to the mesh and underlying bone for Le Fort I osteotomy fixation, precluding the need to tap, shortening the time needed for fixation, and eliminating many disadvantages of titanium. In total, 659 cases have been performed from October 2005 through December 2010. This study examined the first 103 consecutive Le Fort osteotomies performed with this resorbable system and thus those with the longest follow-up. MATERIALS AND METHODS: One hundred three consecutive patients who had completed growth and presurgical orthodontics were operated on using the Resorb-X plating system and SonicWeld Rx. Intraoperative adverse events were monitored and a minimum 12-month postoperative follow-up for complications was completed. RESULTS: One patient (0.9%) had maxillary mobility at initial postoperative evaluation that resolved without malocclusion. Two patients (1.9%) exhibited signs of residual soreness and swelling in the maxilla, attributed to sterile abscess formation. At last follow-up, all patients demonstrated a clinically stable maxilla with correction of their malocclusion. CONCLUSION: Use of ultrasonic-aided pins in fixation of resorbable mesh plates, in Le Fort I osteotomies, is a viable technique and superior resorbable plating system because it is easy to use, results in adequate fixation strength, and shortens time of application by eliminating the need for tapping. In addition, this resorbable system eliminates many disadvantages associated with using all-titanium fixation.

Dental implants after reconstruction with free tissue transfer.

The transfer of composite tissue flaps by microvascular techniques has become the standard for reconstructing complex defects of the oral and maxillofacial regions. Despite advances in these techniques, sites reconstructed by free tissue transfer (free flaps) are often compromised by scarring, bulky tissue, and altered architecture. Dental rehabilitation is often impossible without endosseous implants to aid in stabilization and retention of prostheses. The most commonly used free flaps, however, have significant shortcomings with regard to implant placement, prosthetics, and maintenance. This article describes some site development and prosthetic techniques that can be applied to improve outcomes when dental implants are used in conjunction with free flap reconstruction.

Characteristics of head and neck cancer patients referred to an oral and maxillofacial surgeon in the United States for management.

PURPOSE: The purpose of this study was to report the characteristics of patients with head and neck cancer, excluding cutaneous malignancies, referred to an oral and maxillofacial surgeon in the United States for management. MATERIALS AND METHODS: We performed a retrospective chart review of all head and neck cancer patients referred to the senior author's oral and maxillofacial surgery practice over 12 consecutive months. Data were extracted from the patients' comprehensive record and included demographics, social history, site, histologic diagnosis, staging, treatment, and referral patterns. RESULTS: A total of 90 patients, 51 men and 39 women (male-female ratio, 1.3:1), with a mean age of 64.4 years (range, 32-91 years) were referred with head and neck cancer, excluding skin cancer, over the 12-month period and were included in the study. Regarding ethnicity, 88.8% of the patients were white, 11.1% African American, and 1.1% Asian. Most of the patients, 84.4%, were referred from within the state, but only 21.1% of these resided within the metropolitan area of the senior author's practice. Of the patients in the study population, 95.5% had either private or state-provided/federally provided insurance. Social history showed that 59.9% of patients were current or past smokers, 31.1% were nonsmokers, and 8.8% were smokeless tobacco users, and only 18.8% admitted to alcohol use. Approximately 80% of patients were initially evaluated by a general dentist, oral and maxillofacial surgeon, or periodontist, and 93% of referrals were from other oral and maxillofacial surgeons. Over 90% of lesions were located in the oral cavity, and only 6.6% were oropharyngeal primary cancers. Squamous cell carcinoma made up 89% of the lesions, whereas minor salivary gland and metastatic carcinomas comprised the other 11%. At the time of diagnosis, 64.4% of the lesions were early stage (I/II) and 35.6% were late stage (III/IV). Analysis of treatment modalities showed that 87.8% underwent surgery, excluding biopsy, as part of their therapy. Of these, 83.5% were treated with surgery only, whereas the others received both surgery and some form of adjuvant therapy. Five patients were treated with concurrent chemoradiation therapy. CONCLUSION: Our results suggest that patients referred to an oral and maxillofacial surgery practice for management of head and neck cancer are different from those described in previous reports regarding demographics, social history, site, and stage of disease at diagnosis and treatment. This finding may be explained by the unique referral pattern for oral and maxillofacial surgeons treating head and neck cancer.

Neck dissection: nomenclature, classification, and technique.

Lymph node status is the single most important prognostic factor in head and neck cancer because lymph node involvement decreases overall survival by 50%. Appropriate management of the regional lymphatics, therefore, plays a central role in the treatment of the head and neck cancer patients. Performing an appropriate neck dissection results in minimal morbidity to the patient, provides invaluable data to accurately stage the patient, and guides the need for further therapy. The purposes of this article are to present the history and evolution of neck dissections, including an update on the current state of nomenclature and current neck dissection classification, describe the technique of the most common neck dissection applicable to oral cavity cancers, and discuss some of the complications associated with neck dissection. Finally, a brief review of sentinel lymph node biopsy will be presented.

Mini-implant temporary anchorage devices: orthodontic applications.

Skeletal anchorage, the concept of using the skeleton to control tooth movement, has been reported in the orthodontic literature since the early 1980s. Various forms of skeletal anchorage, including miniscrews, mini-plates, and intentionally ankylosed teeth have been reported in the literature. Recently, great emphasis has been placed on the miniscrew type of temporary anchorage device (TAD). These devices are small, are implanted with a relatively simple surgical procedure, and increase the potential for better orthodontic results. This article will present the indications of these devices along with clinical cases, discuss some of the common complications associated with these devices, and describe the placement and removal procedures for self-drilling TADs.

The necessity of routine clinic follow-up visits after third molar removal.

PURPOSE: This randomized clinical trial was conducted to evaluate the clinical necessity of routine follow-up visits after third molar removal under local anesthesia and intravenous sedation in patients aged 15 to 35 years. PATIENTS AND METHODS: Sixty consecutive cases that required surgical removal of impacted third molars in an outpatient basis were performed by board-certified oral and maxillofacial surgeons. Sixty patients were divided randomly into 2 groups: one group received a 2-week postoperative follow-up appointment and the other received no follow-up. All patients received postoperative instructions and were contacted by telephone on the day after surgery. At 2 weeks postoperatively, all patients either returned to the clinic or were interviewed by telephone. RESULTS: Forty-eight patients were included in this study. The mean age was 20.35 years (range, 15 to 33 years). There were no statistical differences in the number of patients and gender between groups of patients who received clinic or telephone follow-up (significance <.05). Seventy-three percent (35 of 48) of total patients preferred telephone follow-up, and 27% (13 of 48) of patients preferred clinic follow-up. Eighty-five percent (29 of 34) of patients who did not have any complaints on postoperative day 1 preferred telephone follow-up (significance <.01). CONCLUSIONS: A routine follow-up visit following third molar removal under intravenous sedation is not necessary in patients between 15 and 35 years of age. However, preoperative and postoperative instruction should be clearly specified. A selective review policy may be appropriate if a patient is mentally retarded, is taking psychoactive drugs, or has an intraoperative complications or a complaint registered via telephone call.

A simple and reliable landmark for identification of the supraorbital nerve in surgery of the forehead: an in vivo anatomical study.

PURPOSE: In this in vivo study, we set out to determine the reliability of the medial margin of the iris as a landmark for the course of the supraorbital neurovascular bundle at the supraorbital rim. PATIENTS AND METHODS: Seventy-five patients (73 women and 2 men) undergoing endoscopic brow lift procedures were enrolled, for a total of 150 sides. With the patient focused on a distant point, a line was constructed preoperatively along the mid-sagittal plane, tangential to the medial iris. After general anesthesia and initial dissection, a 27-gauge needle was placed (without the aid of the endoscope) through this line, parallel to the mid-sagittal plane at the orbital rim. Measurements were then taken following creation of the optical cavity. Measurements were taken from the course of the deep (lateral) branch of the supraorbital nerve to the needle. In addition, measurements were taken from the course of the supraorbital nerve to the course of the supratrochlear nerve. RESULTS: In 84 sides, the needle was at the nerve; in 48 sides, the needle was less than 1 mm to the nerve; and in 18 sides, the needle was 2 mm from the edge of the nerve. Overall, the nerve was an average of 0.56 +/- 0.7 mm from the needle, and in no case was the nerve course greater than 3 mm from the landmark. The supratrochlear nerve was located medial to the supraorbital nerve an average of 9.0 +/- 1.0 mm. CONCLUSIONS: Based on our findings, the medial iris, as opposed to the mid-pupil line, serves as a reliable topographical landmark for the course of the supraorbital nerve at the supraorbital rim.

Effect of restraint systems on maxillofacial injury in frontal motor vehicle collisions.

PURPOSE: Motor vehicle collisions (MVCs) are the leading cause of maxillofacial fractures. Additionally, maxillofacial injuries are the most common injury related to air bag deployment. We sought to characterize the occupant restraint system (seat belt and air bag) and collision characteristics associated with MVC-related maxillofacial injuries. MATERIALS AND METHODS: The 1991-2000 National (United States) Automotive Sampling System Crashworthiness Data System (CDS) data files were used. The CDS is a national probability sample of passenger vehicles involved in police-reported tow-away MVCs. Analysis was limited to front seat occupants involved in frontal collisions of delta-V (estimated change in velocity) of greater than 15 km/hr. The risk of facial injury was calculated according to occupants' restraint use (unrestrained, seat belt only, air bag only, and seat belt and air bag combined) and compared using risk ratios (RRs) and associated 95% confidence intervals (CIs). RESULTS: Occupants restrained with a seat belt only (RR, 0.48; 95% CI, 0.40 to 0.57) or a seat belt and an air bag (RR, 0.83; 95% CI, 0.73 to 0.94) had a significantly reduced risk of any facial injury compared with completely unrestrained occupants. There was no association for those restrained with an air bag only (RR, 1.19; 95% CI, 0.82 to 1.73). A similar pattern of results was observed for moderate to severe facial injuries and for facial fractures. CONCLUSION: Seat belt use significantly reduces the risk of facial injury in frontal MVCs. Air bag use was not associated with the risk of facial injury.

Referral patterns for the treatment of facial trauma in teaching hospitals in the United States.

PURPOSE: The management of facial trauma is considered an integral part of the training of several specialties, including general plastic surgery, otolaryngology, and oral and maxillofacial surgery. Referral patterns of patients who have sustained facial trauma to these various specialty services, however, vary at different institutions according to physician preferences and protocols. The purpose of this project was to examine the referral patterns of facial trauma in the United States at teaching hospitals. MATERIALS AND METHODS: A questionnaire survey of physician-chiefs of emergency or trauma services at teaching hospitals was carried out. Scenarios involving a variety of facial injury patterns were presented, and a hypothetical referral was requested. In addition, questions regarding preferences and opinions regarding the various services were included. RESULTS: Most teaching hospitals had a formal protocol for the referral of patients with facial injuries. With the exception of mandible fractures, referral patterns for patients with facial injuries were relatively even across the 3 specialties. Interestingly, only 56% of respondents would seek the same referral for themselves or relatives in the same way as they would refer a patient based on their in-house protocol. In regard to timeliness, efficiency, and perceived competency in the handling of facial trauma, oral and maxillofacial surgery had statistically significant higher scores than otolarygology and plastic surgery, which were not statistically distinguishable between each other. CONCLUSIONS: All 3 specialties appear to be involved in the management of facial trauma at teaching institutions in the United States; therefore, it seems unlikely that any one specialty will be singled out as the sole provider of these services at all institutions.

Is detection of oral and oropharyngeal squamous cancer by a dental health care provider associated with a lower stage at diagnosis?

PURPOSE: Stage at diagnosis is the most important prognostic indictor for oral and oropharyngeal squamous cell cancers (SCCs). Unfortunately, approximately 50% of these cancers are identified late (stage III or IV). We set out to examinationine the detection patterns of oral and oropharyngeal SCCs and to determine whether detection of these cancers by various health care providers was associated with a lower stage. PATIENTS AND METHODS: Data were gathered on 51 patients with newly diagnosed oral or oropharyngeal SCC through patient interview and chart audit. In addition to demographic data, specific inquiry was made regarding the circumstances surrounding the identification of the lesion. The main outcome measure was tumor stage grouping based on detection source. RESULTS: Health care providers detecting oral and oropharyngeal SCCs during non-symptom-driven (screening) examinations were dentists, hygienists, oral and maxillofacial surgeons, and, in 1 case, a denturist. All lesions detected by physicians occurred during a symptom-driven examination. Lesions detected during a non-symptom-driven examination were of a statistically significant lower average clinical and pathologic stage (1.7 and 1.6, respectively) than lesions detected during a symptom-directed examination (2.6 and 2.5, respectively). Additionally, a dental office is the most likely source of detection of a lesion during a screening examination (Fisher exact test, P =.0006). Overall, patients referred from a dental office were of significantly lower stage than those referred from a medical office. Finally, patients who initially saw a regional specialist (dentist, oral and maxillofacial surgeon, or otolaryngologist) with symptoms related to their lesion were more likely to have appropriate treatment initiated than those who initially sought care from their primary care provider. CONCLUSION: Overall, detection of oral and oropharyngeal SCCs during a non-symptom-driven examination is associated with a lower stage at diagnosis, and this is most likely to occur in a dental office. A regional specialist was more likely than a primary care provider to detect an oral or oropharyngeal SCC and initiate the appropriate treatment during the first visit for symptoms related to the lesion.