Long-term mandibular growth in patients with airway obstruction treated with mandibular distraction.

Congenital craniofacial malformations play an important role in upper airway obstruction. One of the main causes is mandibular hypoplasia which is present in the pierre robin sequence. Mandibular distraction osteogenesis (MDO) is one of the most commonly used treatments for the resolution of upper airway obstruction in patients that do not respond to a conservative treatment. We performed a long term follow up of syndromic and non-syndromic patients with pierre robin sequence where the lateral xrays were studied before surgery (T1), after MDO (T2) and long-term follow-up (T3, at least 5 years). Possible complications of the surgery were also studied through panoramic x-rays and clinical controls. The results evidenced an increase of mandibular length comparing T1-T2 and a good stability during the long-term follow-up. The Sd patients presented smaller mandible dimensions. We had not found any complications during the follow-up. The scars outcomes are modest, but none of the patients requested a surgical correction. Mandibular distraction osteogenesis is a treatment to be considered in patients with upper airway obstruction that do not respond to conservative treatments. The results of the surgery are stable and the complications in experienced hands are low.

Correlation between Malocclusion and Mandibular Fractures: An Experimental Study Comparing Dynamic Finite Element Models and Clinical Case Studies.

Mandibular fractures are very common in maxillofacial trauma surgery. While previous studies have focused on possible risk factors related to post-operative complications, none have tried to identify pre-existing conditions that may increase the risk of mandibular fractures. We hypothesized, through clinical observation, that anatomical conditions involving poor dental contacts, such as malocclusions, may increase the risk of mandibular fractures. This work was subdivided into two parts. In the first part, Digital Imaging and Communications in Medicine (DICOM) data of four healthy patients characterized by different dentoskeletal occlusions (class I, class II, class III, and anterior open bite) have been used to develop four finite element models (FEMs) that accurately reproduce human bone structure. A vertical and lateral impact have been simulated at increasing speed on each model, analyzing the force distribution within the mandibular bone. Both vertical and lateral impact showed higher level of stress at the impact point and in the condylar area in models characterized by malocclusion. Specifically, the class III and the open bite models, at the same speed of impact, had higher values for a longer period, reaching critical stress levels that are correlated with mandibular fracture, while normal occlusion seems to be a protective condition. In the second part of this study, the engineering results were validated through the comparison with a sample of patients previously treated for mandibular fracture. Data from 223 mandibular fractures, due to low-energy injuries, were retrospectively collected to evaluate a possible correlation between pre-existing malocclusion and fracture patterns, considering grade of displacement, numbers of foci, and associated CFI score. Patients were classified, according to their occlusion, into Class I, Class II, Class III, and anterior open bite or poor occlusal contact (POC). Class I patients showed lower frequencies of fracture than class II, III, and open bite or POC patients. Class I was associated with displaced fractures in 16.1% of cases, class II in 47.1%, class III in 48.8% and open bite/POC in 65.2% of cases (p-value < 0.0001). In class I patients we observed a single non-displaced fracture in 51.6% of cases, compared to 12.9% of Class II, 19.5% of Class III and 22.7% of the open bite/POC group. Our analysis shows that class I appears to better dissipate forces applied on the mandible in low-energy injuries. A higher number of dental contacts showed a lower rate of multifocal and displaced fractures, mitigating the effect of direct forces onto the bone. The correlation between clinical data and virtual simulation on FEM models seems to point out that virtual simulation successfully predicts fracture patterns and risk of association with different type of occlusion. Better knowledge of biomechanics and force dissipation on the human body may lead to the development of more effective safety devices, and help select patients to plan medical, orthodontic/dental, and/or surgical intervention to prevent injuries.

Current management and future challenges in salivary glands cancer.

Salivary gland cancers (SGCs) are rare, accounting for less than 5% of all malignancies of the head and neck region, and are morphologically heterogeneous. The diagnosis is mainly based on histology, with the complementary aid of molecular profiling, which is helpful in recognizing some poorly differentiated, borderline, or atypical lesions. Instrumental imaging defines the diagnosis, representing a remarkable tool in the treatment plan. Ultrasound and magnetic resonance are the most common procedures used to describe the primary tumour. The treatment of SGCs is multimodal and consists of surgery, radiotherapy, and systemic therapy; each treatment plan is, however, featured on the patient and disease's characteristics. On 24 June 2022, in the meeting "Current management and future challenges in salivary gland cancers" many experts in this field discussed the state of the art of SGCs research, the future challenges and developments. After the meeting, the same pool of experts maintained close contact to keep these data further updated in the conference proceedings presented here. This review collects the insights and suggestions that emerged from the discussion during and after the meeting per se.

Pressure Garment Therapy with Custom Facial Mask in Complex and Traumatic Facial Wounds: Case Series.

Pressure garment therapy is frequently used to prevent pathologic scarring, especially in burns. Less common is its use for the treatment of facial wounds. Pathologic scarring can create functional and aesthetic problems, which can have psychological implications. The aim of this study is to report our experience in the treatment of traumatic facial wounds using an elastic custom facial mask.

The Maxilla-Mandibular Discrepancies through Soft-Tissue References: Reliability and Validation of the Anteroposterior Measurement.

This research aimed to identify a new measurement to diagnose the sagittal maxillary and mandibular difference that considers the patient's profile (soft tissue Wits appraisal: obtained by projecting points A and B on the occlusal plane and subsequently measuring the linear distance between the two points). This new measurement was compared to the conventional Wits appraisal obtained to diagnose sagittal jaw discrepancy. In total, 300 subjects (162 males, 138 females) aged between 6 and 50 years requiring orthodontic treatment were analyzed. The cephalometric tracings on the pre-treatment lateral cephalometric radiographs were obtained and the two measurements taken were the Wits appraisal and a new measurement which were both calculated and compared. The analysis of the linear correlations between the conventional Wits value and the measurement obtained on the soft-tissue were undertaken. The relevance was established at 5% (p < 0.05). The mean values were also calculated within sex and age classes, and comparisons between sexes were obtained employing the t test Student's for independent samples. Subsequently, chi-square analysis was also utilized to verify the sex distributions in the age groups considered. The results obtained suggested that these two measurements were significantly correlated with each other, with no characteristic patterns of sex or age. These data allowed an estimation of the reference values of the new measurement (-1.9 mm and 5.4 mm for patients with Class I molar relationship) showing that the former was more variable than the latter. The new measurement could allow for an accurate evaluation of the jaws sagittal discrepancy from soft tissue analysis.

Effectiveness of Resective Surgery in Complex Ameloblastoma of the Jaws: A Retrospective Multicenter Observational Study.

Ameloblastoma is a rare, benign, odontogenic tumor of epithelial origin, characterized by locally aggressive, expansive growth. Treatment is controversial due to the risk of relapse. The aim of this multicenter retrospective study was to evaluate the effectiveness of complete resection in cases of complex ameloblastoma, which is considered at a higher risk of recurrence. Patients who met at least one of these criteria were included: recurrence, soft-tissue involvement, complete erosion of internal/external cortical walls with involvement of the inferior margin of the mandible, and invasion of the maxillary sinus or nasal cavity. Demographic data, tumor site, type of surgery, histological features, and follow-up information were collected for each patient. The cohort included 55 patients with a mean follow-up of 108 ± 66 months. A multivariate logistic model was used to evaluate variables independently associated with relapse. There were six soft-tissue or maxillary sinus relapses, with a recurrence rate of 10.9%. Most of them arose in patients previously treated. The statistical analysis identified the maxillary location as a fundamental relapse risk factor. En bloc resection with large surgical safety margins seemed to be effective in preventing the relapses. However, complete resection was less effective in preventing recurrences in the soft tissues or maxillary sinus.

The Comprehensive Facial Injury (CFI) Score Is an Early Predictor of the Management for Mild, Moderate and Severe Facial Trauma.

Identifying groups of patients with homogeneous characteristics and comparable outcomes improves clinical activity, patients' management, and scientific research. This study aims to define mild, moderate, and severe facial trauma by validating two cut-off values of the Comprehensive Facial Injury (CFI) score and describing their foreseeable clinical needs to create a useful guide in patient management, starting from the first evaluation. The individual CFI score, overall surgical time, and length of hospitalization are calculated for a sample of 1400 facial-injured patients. Receiver Operating Characteristic (ROC) analysis and the corresponding Area Under the Curve (AUC) is tested, and a CFI score ≥4 is selected to discriminate patients undergoing surgical management under general anesthesia (Positive Predictive Value, PPV of 91.4%), while a CFI score ≥10 is selected to identify patients undergoing major surgical procedures (Negative Predictive Value, NPV of 91.7%). These results are enhanced by the consensual trend of Length of Stay outcome. The use of the CFI score allows us to distinguish between the "Mild facial trauma" with a low risk of hospitalization for surgical treatment, the "Moderate facial trauma" with a high probability of surgical treatment, and the "Severe facial trauma" that requires long-lasting surgery and hospital stay, with an increased incidence of Intensive Care Unit admission.

Surgical Navigation in Mandibular Reconstruction: Accuracy Evaluation of an Innovative Protocol.

Aim: the purpose of this work is to present an innovative protocol for virtual planning and surgical navigation in post-oncological mandibular reconstruction through fibula free flap. In order to analyze its applicability, an evaluation of accuracy for the surgical protocol has been performed. Methods: 21 patients surgically treated for mandibular neoplasm have been included in the analysis. The Brainlab Vector Vision 3.0® software for surgical navigation has been used for preoperative surgical planning and intra-operative navigation. A post-operative accuracy evaluation has been performed matching the position of mandibular landmarks between pre-operative and post-operative CT scans. Results: the maximal discrepancy observed was included between -3.4 mm and +3.2 mm, assuming negative values for under correction and positive values for overcorrection. An average grade of accuracy included between 0.06 ± 0.58 mm and 0.43 ± 0.68 mm has been observed for every mandibular landmark examined, except for mandibular angles that showed a mean discrepancy value included between 1.36 ± 1.73 mm and 1.46 ± 1.02 mm when compared to preoperative measurements. Conclusion: a satisfying level of accuracy has been observed in the protocol presented, which appears to be more versatile if compared to closed custom-made systems. The technique described may represent a valid option for selected patients, but it cannot be considered for routine activity because of the complexity of the method, the mobility of the jaw, the necessity of surgical navigator and the long surgical learning curve that is required.

"6 Anatomical Landmarks" Technique for Satisfactory Free-Hand Orbital Reconstruction With Standard Preformed Titanium Mesh.

Study Design: Retrospective study. Objective: Resolution of clinical signs and symptoms following orbital fractures depends on the accurate restoration of the orbital volume. Computer-Assisted procedures and Patient Specific Implants represent modern solutions, but they require additional resources. A more reproducible option is the use of standard preformed titanium meshes, widely available and cheaper; with their use quality of results is proportional to the accuracy with which they are positioned. This work identifies 6 reproducible and constant anatomical landmarks, as an intraoperative guide for the precise positioning of titanium preformed meshes. Methods: 90 patients treated at the Maxillofacial Surgery Department, Niguarda Trauma Center, Milan, for unilateral orbital reconstruction (January 2012 to December 2018), were studied. In all cases reconstruction was performed respecting the 6 proposed anatomical landmarks. The outcomes analyzed are: post-operative CT adherence to the 6 anatomical markers and symmetry achieved respect to controlateral orbit; number/year of re-interventions and duration of surgery; resolution of clinical defects (at least 12-months follow-up); incidence of complications. Results: Satisfactory results were obtained in terms of restoration of orbital size, shape and volume. Clinical defects early recovered with a low incidence of complications and re-interventions. Operating times and radiological accuracy have shown a progressive improvement during years of application of this technique. Conclusions: The proposed "6 anatomical landmarks" is an easy free-hand technique that allows everyone to obtain high levels of reconstructive accuracy and it should be a skill of all surgeons who deal with orbital reconstruction in daily clinical activity.

Extra-oral approach to lower third molar: a rare surgical indication.

The avulsion of the impacted lower third molar is one of the most common procedures in oral surgery. Even though it is characterized by possible complications due to the lesion of lingual and inferior alveolar nerves, the intra-oral surgical approach represents the first-choice strategy when planning surgery. However, in case of ectopic tooth in the mandibular basal bone, it is appropriate to consider an extra-oral transcutaneous surgical approach. The ectopia of the inferior wisdom tooth represents a very rare clinical condition and sometimes it is even unknown by patients and dentists: further evidence of this fact is represented by the paucity of paper related to the topic that can be found in the international scientific literature. The experience of the Department of Maxillofacial Surgery of San Gerardo Hospital in Monza (Italy) in management and treatment of ectopic impacted lower third molar is exposed through the presentation of three cases of ectopic third molar. Two out of three patients, aware of the risks related to the surgical procedure, refused the treatment proposed. One patient underwent surgical avulsion of the wisdom tooth through extra-oral transcervical approach. No early or late complications have been observed. Extra-oral surgical approach for ectopic lower third molar should be considered for selected cases. Given the rarity of the clinical condition and the procedure-related risks, accurate preoperative information has to be provided to the patient by physician and the procedure should only be performed by expert and competent surgeons.

The burden of facial trauma on mortality in patients with multiple injuries: A single-center analysis of 1862 motorcycle accidents.

The study aims to assess the influence on mortality of motorcycle road accidents, caused by injuries to the head, chest, abdomen, face, skin, pelvis and extremities. Road motorcycle accidents consecutively admitted to Level I Trauma Center were retrospectively analyzed. Each body site involvement was classified through Abbreviated Injury Score (AIS-98), and Comprehensive Facial Injury (CFI) score; Injury Severity Score (ISS) was also calculated. The data collected were subjected to a descriptive analysis and inferential statistic, with uni- and multivariate analysis; mortality was the main outcome examined. 1862 patients were studied. Limbs (53.9%) and Head (53.8%) are the most involved body site, facial trauma regards 19.4% of the sample. Only 4.4% of Facial injuries occurred as isolated, 71.6% were associated to Head involvement. The overall mortality was 4.6% and 80.0% of dead patients were affected by Head injury. Multivariate analysis shows that head (OR=3.06, p <0.0001), thoracic (OR=1.82, p <0.0001) and abdominal trauma (OR=1.41, p =0.019) are predicting the risk of death. Facial trauma does not directly influence mortality and, however severe and distracting it may be, becomes secondary to the management of frequently associated brain injuries. Severity scores targeted to the risk of death, such as AIS and AIS-derived, are ineffective in describing the true characteristics of facial injuries. The CFI score has been shown to predict the weight of surgical treatment and the outcome of the hospital stay, therefore its use is recommended.

Epidemiology of Maxillo-Facial Trauma During COVID-19 Lockdown: Reports From the Hub Trauma Center in Milan.

STUDY DESIGN: Retrospective study. OBJECTIVE: Following SARS-CoV-2 pandemic break-out a lockdown period for the population and a reorganization of the Health System were needed. Hub-function Centers for time-dependent diseases were identified and Niguarda Hospital (Milan) was selected as main Regional Trauma Center. The purpose of our study is to report the experience of Niguarda Maxillofacial Trauma Team during this period, pointing out epidemiological changes in the presentation of trauma in comparison to the previous 3 years. METHODS: Two hundred and sixteen patients were admitted to the Emergency Department from 8th March 2020 to 8th May 2020. One hundred and eighty-one had a diagnosis of Major Trauma and 36 had also facial fractures; 35 patients had isolated facial fractures. Data were compared to the activity during the same period in 2017-2019 and statistical analysis was carried out concerning demographic and clinical characteristics, trauma dynamics and positivity to COVID-19. RESULTS: Cumulative curves of patients admitted because of Major Trauma describe a superimposable linear trend in years 2017-2019, while 2020 shows an increase from April 16th. Average age and number of more severe patients were higher than previous years. Epidemiological changes concerned road accidents, accidents involving pedestrians and cyclists, interpersonal violence, suicide attempts and domestic accidents. The incidence of facial fractures was confirmed through years and, according to its measured severity, 75% of patients required management. COVID-19 positivity without systemic symptoms didn't influence the type of treatment. CONCLUSION: The COVID-19 lockdown offers a unique opportunity to study the reversal epidemiological effects on trauma.

Analysis of Different Safety Devices in the Prevention of Motorcycle-Related Craniofacial Trauma - A Retrospective Study.

Introduction: Motorcycle accidents are one of the most frequent causes of trauma. Safety devices and helmets can influence the severity of injuries. Our retrospective study wants to evaluate the different effectiveness of Open-face and Full-face helmets in the prevention of craniofacial trauma. Materials and Methods: The sample consists of 440 patients admitted to two Level I Trauma Centres in Northern Italy, between January 2002 and February 2019, because of motorcycle-related craniofacial trauma. For each patient personal data were collected, as well as type and site of fractures, type of helmet, if worn, Comprehensive Facial Injury (CFI) score and Abbreviated Injury Score (AIS-Head) for head injuries. Inferential statistical analysis was then conducted. Results: Two hundred and eighty-eight patients wore Open-face helmets (69.7%) and 125 patients wore Full-face ones (30.3%). Mean CFI score (Standard deviation - SD) observed in patients with Open-face helmets was 7.0 (SD: 6.8) and surgery was required in 149 cases (51.7%); while it was 4.9 (SD: 6.0) in patients with Full-face helmets for whom surgery was required in 43 cases (34.4%) (P < 0.0001 and P = 0.002, respectively). Multivariate analysis shows that severity of facial trauma is a significant risk factor for head injury severity with OR 1.90 (95% confidence interval: 1.43 - 2.51) and P < 0.0001. Discussion: Full-face helmets are definitely considered to be more protective for facial trauma, which is also a significant risk factor for the severity of head injuries. The type of helmet chosen influences the need of surgical treatment in case of craniofacial trauma.

Understanding the relevance of comprehensive facial injury (CFI) score: Statistical analysis of overall surgical time and length of stay outcomes.

Comprehensive facial injury (CFI) score is a powerful and extremely simple scale used to grade the clinical severity of all facial injuries, and is expressed in terms of the overall surgical time needed for definitive treatment. Its statistical validation was previously reported in 2019. The aim of this study was to investigate further the link with duration of surgery, applying the score to a larger sample of patients, and to evaluate the relationship between CFI score and other extremely relevant dependent variables: length of stay (LOS) in high care units (HCU) and in intensive care units (ICU). 1406 patients with diagnosis of at least one facial bone fracture, and treated by the same team in two highly specialized trauma centers, were studied. For each patient a specific CFI score is assigned and overall surgical time, length of stay, and presence of associated injuries were recorded. Data were divided into six clusters according to CFI score: (1) 0-5, (2) 6-10, (3) 11-15, (4) 16-20, (5) 21-25, and (6) >25. Regressions between CFI clusters and duration of surgery (minutes), LOS in ICU (days), and in HCU (days) were established. In addition, the presence of associated head and/or somatovisceral injuries was analyzed and related to CFI score. Statistical analysis confirmed linear regression existing between each CFI cluster and overall surgical time (p < 0.00001), with improved significance of the results using median values of surgical duration for each cluster (p = 0.0001). It also demonstrated the existence of linear regression between all CFI clusters and LOS in HCU (p = 0.0001) and between CFI clusters 3-6 and median values of LOS in ICU (p = 0.0001). Finally, associated injuries were observed to be more frequent in high CFI score clusters, occurring in around 90% of patients with a CFI score >25 (p < 0.00001). Association of head and facial injuries play a major role in high LOS in ICU values, whereas coexistence of facial, head and somatovisceral involvement increases LOS in ICU to over twice that for single association. Surgical time and length of stay are outcomes traditionally used to assess the statistical significance of many new proposed trauma score. The strong correlation demonstrated between CFI score and each of these variables confirms its value and reliability. CFI score is proven to be an ideal, simple, informative, and reproducible tool for measuring severity of facial injuries and their clinical impact. It allows correlation with associated head and somatovisceral injuries, focusing attention on the interesting field of reciprocal influences in simultaneous, multidistrectual involvement. None of the previously proposed facial injury severity scales have offered such informative and statistically significant features.

The CFI score: Validation of a new comprehensive severity scoring system for facial injuries.

At the time of writing there is no measuring scale for the severity of facial trauma that can effectively summarize its clinical relevance, and can therefore be proposed as a definitive tool in trauma center decision making. This paper introduces a new, simple, comprehensive, and reproducible score for facial trauma, in which its severity is expressed in relation to the surgical duration necessary for definitive treatment. This parameter is identified as the most significant in expressing the commitment of care required. Statistical validation of this comprehensive facial injury (CFI) score involved a sample of 1050 patients, treated by the same team in two highly specialized trauma centers. It demonstrated a linear regression between CFI score and surgical duration, and a high degree of accuracy in forecasting overall surgical time for each type of facial injury. The descriptive capacity of CFI score, and its extremely simple use, make it a perfect tool for widespread application and for facilitating communication inside trauma centers. It also allows the classification of homogeneous groups of patients - a prerequisite for benchmarking and effective analysis of results. The CFI model is definitively proposed for the classification of facial injuries, and therefore for the integration of maxillofacial skills, within the trauma team.

Management of atrophic mandibular fractures: An Italian multicentric retrospective study.

PURPOSE: The aim of this multicentric study was to retrospectively evaluate the surgical outcome of atrophic mandible fractures treated with open reduction and rigid fixation (ORIF), using load-bearing plates. MATERIALS AND METHODS: 55 patients from three trauma centers were retrieved for the study. Inclusion criteria were: edentulous patients with mandibular body fractures; mandibular body thickness <20 mm. Collected data included: cause of fracture; degree of atrophy (according to Luhr's classification); characteristics of the fracture; adequacy of reduction; postoperative complications. All patients were treated with ORIF, using 2.0 mm, large-profile, locking bone plates and 2.4 mm locking bone plates. No bone graft was used in any case. RESULTS: 12 patients were classified as class I atrophy, 18 patients as class II, and 25 patients as class III. Mean mandibular height at the site of fracture was 12.8 mm (ranging from 5.4 mm to 20 mm). 22 were unilateral fractures and 23 were bilateral. Mild displacement was observed in 11 fractures, moderate in 34, severe in 16, and comminution was present in seven fractures. Adequacy of reduction was judged good in 62 fractures and poor in six fractures. Transient weakness of the marginal branch of the facial nerve was recorded in 11 patients and permanent weakness in two patients. All patients achieved a complete fracture healing. CONCLUSION: External open reduction and rigid fixation (ORIF) with locking, load-bearing plates is a reliable and predictable treatment for atrophic edentulous mandible fracture. Immediate bone grafting should not be considered mandatory unless there is consistent bone loss.

Assessing the precision of posttraumatic orbital reconstruction through "mirror" orbital superimposition: A novel approach for testing the anatomical accuracy.

Orbital reconstruction in cases of trauma is usually performed using the unaffected side orbital volume as a reference, but this measurement does not fully consider the anatomical characteristics of orbital surfaces. We propose a novel procedure based on the registration of 3D orbital segmented surfaces. Reconstructed orbits from 20 patients and healthy orbits from 13 control subjects were segmented from the post-operative CT-scans. The 3D orbital model from the unaffected orbit was "mirrored" according to the sagittal plane and superimposed onto the reconstructed one, with calculation of volumes, asymmetry index and point-to-point RMS (root mean square) distances. Inter- and intra-observer errors were tested through Bland-Altman plot. Differences in volume, asymmetry index and RMS value between the control group and the treated patients were assessed through two-way ANOVA and Student's t-test (p < 0.05). According to Bland-Altman test, intra- and inter-operator repeatability was respectively 87% and 89%. No significant differences in volume or asymmetry index between the control group and the treated patients were observed (p > 0.05), but the RMS value was significantly larger in the latter ones (on average, 0.90 ± 0.26 mm vs. 0.67 ± 0.17 mm, p < 0.05). Results show that the reconstructed orbits present a morphologically different surface from the unaffected ones.

Homologous Banked Bone Grafts for the Reconstruction of Large Cranial Defects in Pediatric Patients.

PURPOSE: Autogenous bone represents the best material in pediatric reconstructive cranioplasty because of its compatibility with growth; however, its availability is limited. Alternative use of alloplastic materials would have the advantage of unlimited amount, but shows an increased risk of complications and incompatibility with growth. Fresh frozen banked cadaveric bones could be ideal for the reconstruction of large cranial defects in growing patients, because it offers unlimited amount of structural grafts with biomechanics properties quite similar to the autologous bones. RESULTS: The authors report 2 cases of growing patients (13 months female and 9 years old male) undergoing the reconstruction of large (about 70 cm and 50 cm respectively) cranial vault defects, by using structural homologous banked bone grafts.Analytic main reconstruction materials risks/benefits evaluation, literature review of few previously reported pediatric cranioplasty with homologous bone, and both clinical cases satisfactory radiologic long-term results (beyond 4 years of F.U.) are reported. CONCLUSION: Structural homologous banked bone grafts appear as a valid solution for pediatric canioplasty reconstruction of wide defects, entailing the advantages of available without limitations and compatibility with future growth. The risk of transmissible infections seems minimal and is totally counterbalanced by the stability of long-term results.

Negative pressure wound therapy in complex cranio-maxillofacial and cervical wounds.

The care and the management of the healing of difficult wounds at the level of the skull-facial face many problems related to patient compliance and the need to perform multiple dressings, with long periods of healing and, occasionally, a very long hospitalisation period. The introduction and evolution of negative pressure wound therapy (NPWT) in the treatment of difficult wounds has resulted in better healing, with a drastic reduction in terms of time and biological costs to the patient and cost to the health care system. The main aim of this study is to describe and discuss, using out our experience, the usefulness of NPWT in the cranial-facial-cervical region. We studied 16 patients with complex wounds of the cranial-facial-cervical region treated with NPWT. We divided clinical cases in four groups: cervicofacial infectious disease, healing complications in oncological-reconstructive surgery, healing complications of injury with exposure of bone and/or internal fixations and healing complications in traumatic injury with loss of substance. We evaluated complete or incomplete wound healing; application time, related also to hospitalisation time; days of intensive care unit (ICU) stay; management of the upper airways; timing of medication renewal; and patient comfort and compliance (on a scale of 1-5). Depression values were always between -75 and -125 mmHg in a continuous aspiration pattern. For every patient, we used the ActiVAC Therapy Unit, derived from the vacuum-assisted closure system (Kinetic Concepts Inc., San Antonio, TX). Medication renewals were performed every 48-72 hours. The NPWT application time ranged from 4 to 22 days (mean of 11·57 day). Therapy was effective to gain a complete restitutio ad integrum in every patient included in the group of cervicofacial infectious disease. Therapy has, however, been well tolerated in our series; this is probably due to the decreased number of applications, the ease of use and the comfort of the system relative to traditional dressing. Results were satisfactory for most of cases treated; faster and more effective wound healing was achieved. The lower number of NPWT applications, relating to standard dressings, led to an increase in patient comfort and compliance and a decrease in the use of medical, and in some cases economic, resources according to international literature.