Perioperative anticoagulation in head and neck free flap reconstructions: Experience of an anticoagulative scheme and its modification.

OBJECTIVES: Microvascular anastomoses in microvascular reconstructions induce rheological changes in the anastomosed vessels and are usually counteracted by anticoagulative medication. There is no regimen commonly agreed on. This study provides an easy to use anticoagulative regimen. PATIENTS AND METHODS: Consecutive cases of either anticoagulative regimen between 2013 and 2018 that underwent microvascular reconstruction in the head and neck area were included in this retrospective study, resulting in 400 cases in total. Two different anticoagulative regimens were applied to 200 patients in each group: (a) intraoperatively administered unfractionated 5000 I.U. high molecular weight heparin (HMWH) and postoperatively low molecular weight heparin (LMWH, Enoxaparin) 1 mg/kg/body weight postoperatively and (b) intraoperatively LMWH 0.5 mg/kg/body weight as well as 12 h later and 1 mg/kg/body weight postoperatively. RESULTS: The LMWH cohort showed fewer overall thromboembolic (8.5% vs. 11%; p = .40) and peripheral thrombotic events (1% vs. 3.5%; p = .18) and lung embolisms (3% vs. 4%; p = .59). The number of thromboses at the site of the anastomosis was equally distributed. In regard to flap-specific complications, LMWH was associated with a positive effect, in particular with respect to total flap losses (5% vs. 7%; p = .40) and wound-healing disorders (14.5% vs. 20%; p = .145). CONCLUSION: Findings indicate that intra- and postoperatively administered LMWH as the only anticoagulative medication seems reliable in our clinical routine of head and neck free flap reconstructions.

NAM-help or burden? Intercultural evaluation of parental stress caused by nasoalveolar molding: a retrospective multi-center study.

OBJECTIVES: Nasoalveolar molding (NAM) was developed to facilitate easier treatment and better outcomes for cleft lip and palate (CLP) patients. The aim of this study was to investigate the parental burden and possible intercultural differences of this treatment modality, which is often argued to burden parents to an extraordinary amount. MATERIALS AND METHODS: Standardized questionnaires (available in English, Mandarin, and German) with 15 non-specific and 14 NAM-specific items to be retrospectively answered by Likert scales by parents of unilateral CLP patients with completed NAM treatment. RESULTS: The parents of 117 patients from two treatment centers in Taiwan and Germany were included. A very high level of overall satisfaction was found in both countries with significant intercultural differences in prenatal parent information, feeding problems, dealing with 3rd party's perception, and experienced personal effort. CONCLUSION: NAM is an effective treatment tool for children's CLP deformities and their caregivers in overcoming the feeling of helplessness. Intercultural differences may be due to infrastructural reasons, cultural attitudes and habits, or different public medical education. CLINICAL RELEVANCE: In addition to facilitating easier surgical treatment, NAM can be seen as a powerful coping strategy for parents dealing with a CLP deformity of their child and does not seem to burden them extraordinarily.

A prospective longitudinal study of postnatal dentoalveolar and palatal growth: The anatomical basis for CAD/CAM-assisted production of cleft-lip-palate feeding plates.

This study describes the dentoalveolar and palatal growth during the first months of life. Knowledge concerning this development is essential to avoid unwanted events such as mucosal ulcerations or restriction of growth when cleft-lip and palate (CLP) patients are treated. The results involve the generation of CAD/CAM CLP-feeding plates. Intraoral impressions from 32 healthy newborns were taken monthly for 5 months, supplemented by measurements of body weight, length, and occipital-frontal head circumference. The casts were digitalized, and two observers manually selected defined anatomical landmarks on virtual 3-D models. The distances between these landmarks were evaluted. Statistical analysis included an inter-rater agreement analysis and the determination of growth. In total, 213 casts were analyzed, with 65 models excluded because of inaccuracies in impression-taking or cast production. Overall longitudinal growth was 20.3%, whereas transversal growth reached a maximum of 21.1%. Vertical growth was 32.4% at the tuberal level. On the basis of these results, a semiautomated series of feeding plates allowing for monthly expansion could be generated. The acquired data serve as a useful reference for other pediatric and orthofacial investigations and treatments. One such application is the automated, fully virtual manufacture of CLP-feeding plates based on only one impression-taking. Our data reveal when caution is needed to prevent ulceration. The series of plates generated can minimize the time-consuming impression-taking and the production of further plaster models. The method of measurement is suitable for documentary purposes. Clin. Anat. 30:846-854, 2017. © 2017 Wiley Periodicals, Inc.

Functional Outcome of CAD/CAM-Assisted versus Conventional Microvascular, Fibular Free Flap Reconstruction of the Mandible: A Retrospective Study of 30 Cases.

Background Different advantages of virtually planned and guided mandibular reconstructions have been described. Functional analyses and comparisons with conventionally reconstructed patients. Methods We retrospectively analyzed 30 cases of mandibular reconstructions that involved virtually planned or conventional microvascular, fibular free flaps that occurred between April 2011 and December 2014 at a single center. The results were also compared with a healthy cohort of 30 participants. Axiographic measurements were performed postoperatively, and uni- and multivariate regressions analyses were performed to determine the association between possible predictor variables on functional outcome. Results Operation time, hospital stay, number of osteotomies, incidence of postoperative temporomandibular joint pain, noise, and tension did not differ significantly between the conventional and computer-aided design/computer-aided manufacturing (CAD/CAM) groups (each p > 0.05). Mouth opening and protrusion and laterotrusion also did not differ significantly (each p > 0.05) but were significantly reduced compared with the healthy group. Univariate analysis showed a significant influence of postoperative irradiation on mouth opening and laterotrusion in the conventional group (p = 0.047 and p = 0.028). In addition, multivariate analysis showed a significant influence of indication and number of osteotomies on laterotrusion (p = 0.005 and p = 0.043). Uni and multivariate analyses revealed a significant influence of indication, preoperative irradiation, and number of osteotomies on protrusion and mouth opening in the CAD/CAM group (p = 0.016, p = 0.044, and p = 0.028). Conclusion CAD/CAM-assisted reconstructions of the mandible give comparable functional results with those of the conventional technique, but no functional superiority has been established. Nevertheless, the integration of virtual planning and guided surgery is definitely of significant value but should be indicated individually case by case.

The value of perioperative antibiotics on the success of oral free flap reconstructions.

The subject of the presented study was to monitor and compare problems and outcomes of reconstructive surgery with microvascular free flaps in the head and neck region between groups of patients treated with perioperative antibiotics and a group of patients without antibiotics. Patients requiring oral reconstructive surgery following cancer resections with microvascular free flaps were prospectively evaluated (2007-2012). Antibiotic therapy was started 30 min before the operation and administered for 10 days. Three hundred and fifty patients were included (208 male, 59.4%; 142 female, 40.6%; mean age 59.8 ± 13.2 years). 330 patients received perioperative antibiotics. Twenty patients (5.7%) who received no antibiotics for specific reasons served as the control group. Wound infections developed in 33 of 122 patients (27%) who received benzylpenicillin, 17 of 88 patients (19.3%) who received amoxicillin combined with sulbactam and 25 of 120 patients (20.8%) who received cefuroxime. Ten patients (50%) who did not receive antibiotics developed wound infections. Receiving no antibiotics or penicillin showed no benefit (P = 0.11). Those receiving cefuroxime showed significantly lower incidence of wound infections (P = 0.034; risk decreased by the factor 2.88). The use of amoxicillin combined with sulbactam showed the lowest rate of wound infections (P = 0.018; risk decreased by the factor 3.46). The use of amoxicillin combined with sulbactam appears to be the most appropriate prophylactic antibiotic followed by cefuroxime in oral microsurgical free flap reconstructions. These data may serve as a guide until a controlled multicenter prospective trial is performed comparing newer antibiotics against current standards.

Diagnostic value of retrospective PET-MRI fusion in head-and-neck cancer.

BACKGROUND: To assess the diagnostic value of retrospective PET-MRI fusion and to compare the results with side-by-side analysis and single modality use of PET and of MRI alone for locoregional tumour and nodal staging of head-and-neck cancer. METHODS: Thirty-three patients with head-and-neck cancer underwent preoperative contrast-enhanced MRI and PET/CT for staging. The diagnostic data of MRI, PET, side-by-side analysis of MRI and PET images and retrospective PET-MRI fusion were systematically analysed for tumour and lymph node staging using receiver operating characteristic (ROC) analysis. The results were correlated to the histopathological evaluation. RESULTS: The overall sensitivity/specificity for tumour staging for MRI, PET, side-by-side analysis and retrospective PET-MRI fusion was 79%/66%, 82%/100%, 86%/100% and 89%/100%, respectively. The overall sensitivity/specificity for nodal staging on a patient basis for MRI, PET, side-by-side analysis and PET-MRI fusion was 94%/64%, 94%/91%, 94%/82% and 94%/82%, respectively. MRI, PET, side-by-side analysis and retrospective image fusion were associated with correct diagnosis/over-staging/under-staging of N-staging in 70.4%/18.5%/11.1%, 81.5%/7.4%/11.1%, 81.5%/11.1%/7.4% and 81.5%/11.1%/7.4%, respectively.ROC analysis showed no significant differences in tumor detection between the investigated methods. The Area Under the Curve (AUC) for MRI, PET, side-by-side analysis and retrospective PET-MRI fusion were 0.667/0.667/0.702/0.708 (p > 0.05). The most reliable technique in detection of cervical lymph node metastases was PET imaging (AUC: 0.95), followed by side-by-side analysis and retrospective image fusion technique (AUC: 0.941), which however, was not significantly better then the MRI (AUC 0.935; p > 0.05). CONCLUSIONS: We found a beneficial use of multimodal imaging, compared with MRI or PET imaging alone, particular in individual cases of recurrent tumour disease. Side-by-side analysis and retrospective image fusion analysis did not perform significantly differently.

Identification of perioperative risk factor by laser-doppler spectroscopy after free flap perfusion in the head and neck: a prospective clinical study.

The aim of this study was to evaluate perioperative flap perfusion using noninvasive monitoring with a laser-Doppler flowmetry and spectrophotometry unit (O2C) and identify whether perioperative blood flow, velocity, hemoglobin level (Hb), and oxygen saturation (SO2 ) measured could be used as indicators of free flap success. Measurements of blood flow, velocity, Hb, and SO2 were performed in 196 microvascular flaps, which had been transferred into the oral cavity to reconstruct ablative defects after surgery for oral cancer. The values were calculated superficially on the skin surface and at a depth of 8 mm. The results showed that perioperative absolute values measured were not associated with an increased rate of microvascular revisions or free flap failure. Independent predictors of microvascular revisions at the first postoperative day were the development of a falling trend in superficial and deep blood flow, and velocity in comparison with baseline values of variables measured. On day 2, all superficial and deep values of Hb, flow, and velocity were independent prognostic factors (P < 0.01), demonstrated as a downward trend were associated with a need for revision. The superficial and deep values of SO2 (P = 0.59 and 0.43, respectively) were not associated with ultimate free flap failure. This is the first clinical study to demonstrate that during early free flap integration to the recipient site different parameters of perfusion and oxygenation play an important role at different points of time. Within the first two postoperative days, changes in these parameters can help influence the decision to revise microvascular anastomoses.

Three-Dimensional Analyses of Postoperative Effects of Surgically Assisted Rapid Palatal Expansion (SARPE) on the Soft Tissue of the Midface Region and the Upper Airway Space Using Stereophotogrammetry and Cone Beam Computed Tomography (CBCT).

BACKGROUND: Surgically assisted rapid palatal expansion (SARPE) is an established method to treat transverse maxillary hypoplasia in skeletally mature adult patients. SARPE affects the surrounding soft tissue. In addition, effects on the airway and breathing have been described. Aim of this study was to assess the effects of SARPE on the nasal soft tissue and the upper airway by means of three-dimensional stereophotogrammetry and cone beam computed tomography (CBCT). METHODS: This retrospective study used preoperative and postoperative cone beam computed tomography (CBCT) scans and three-dimensional stereophotogrammetry. Ten skeletally adult patients (4 male, 6 female; mean age 27.68 years) with transverse maxillary hypoplasia were included. Patients had undergone SARPE procedure, performed by the same surgical team using the same technique. Nasal soft tissue changes were analyzed, using three-dimensional stereophotogrammetry records taken preoperatively (t0) and at the postoperative checkup appointment (t1). The upper airway was assessed using CBCT scans for surgical planning (t0) and the first scan taken after SARPE (t1). RESULTS: In stereophotogrammetry, it was shown that only a few soft tissue nasal parameters increased significantly and SARPE leads to mainly clinically irrelevant changes in nasal soft tissue. In CBCT, only a significant increase in nasopharyngeal airway volume was found. DISCUSSION: Results were in alignment with literature. The effects of SARPE on the nasal soft tissue are mostly statistically insignificant and clinically irrelevant. Airway volume significantly increased in the nasopharyngeal area. Further research on SARPE effects should be conducted to reinforce SARPE as a treatment option for sleep apnea patients.

Infantile human labial glands: Distribution of aquaporins and claudins in the context of paracellular and transcellular pathways.

Human labial glands consist of saliva-secreting cells which are formed by serous and predominantly mucous glandular cells. The following excretory duct system converts the isotonic saliva into a hypotonic fluid. Liquids are transported across the membrane of epithelial cells by paracellular or transcellular mode of action. We studied aquaporins (AQP) and tight junction proteins in the endpieces and duct system of human labial glands of 3-5-month-old infants for the first time. AQP1, AQP3, and AQP5 represent the transcellular transport; tight junction proteins like claudin-1, - 3, - 4, and - 7 regulate the permeability of the paracellular pathway. Specimens of 28 infants were included in this study and analyzed histologically. AQP1 was present in myoepithelial cells and in endothelial cells of small blood vessels. AQP3 showed basolateral plasmamembrane localization in glandular endpieces. AQP5 was localized at the apical cytomembrane in serous and mucous glandular cells and at the lateral membrane in serous cells. Ducts remained unstained with the antibody to AQP1, AQP3, and AQP5. Claudin-1, - 3, - 4, and - 7 were expressed mainly in the lateral plasmamembrane of serous glandular cells. In the ducts, claudin-1, - 4, and - 7 were detected at the basal cell layer, claudin-7 also at the lateral cytomembrane. Our findings provide new insights into the localization of epithelial barrier components necessary for regulating saliva-modification in infantile labial glands.

PET-MRI fusion in head-and-neck oncology: current status and implications for hybrid PET/MRI.

PURPOSE: To review the current status and clinical effect of PET-MRI image fusion in the staging of head-and-neck cancer and to show its implications for imaging with future hybrid PET/MRI scanners. MATERIALS AND METHODS: We reviewed the current literature in order to provide an overview of the potential of the combination of the anatomic and functional imaging capabilities of magnetic resonance imaging (MRI) and of the potential for molecular and metabolic imaging with Positron emission tomography (PET). The research question was whether these image devices might be of synergistic value. RESULTS: PET with [18F]-fluorodeoxyglucose has shown promising results for the assessment of lymph node involvement in cancer, the identification of distant metastasis and synchronous and metachronous tumors, and the evaluation of tumor recurrence or carcinoma of an unknown primary. For morphologic imaging, MRI has several advantages compared with computed tomography in the head-and-neck area. This is mainly because of the superior soft tissue contrast and fewer artifacts from dental implants. Moreover, MRI allows functional imaging, such as the assessment of perfusion with dynamic contrast-enhanced MRI. The published data indicate that image fusion should be beneficial in the case of the recurrence of oromaxillofacial cancer and in the evaluation of potential metastatic lymph nodes. However, retrospective image fusion is technically demanding in the head-and-neck area, mainly because of the varied patient positions used for the various scanners and the anatomic complexity of this region. CONCLUSIONS: Combined PET/MRI scanners might overcome the above-named problems. Both sequential and fully integrated PET/MRI scanners are now available in selected departments, and future studies will show whether hybrid PET/MRI is of greater clinical value than PET/CT and retrospective image fusion techniques.

Expression of host defence peptides in the lip vermilion mucosa during early infancy.

Emerging resistance to antibiotics has become a major problem. Host defence peptides (HDPs), which are effector molecules of the innate immune system, show broad antimicrobial activity. Synthetic derivates are currently being investigated as new anti-infectious agents. In infants, the use of conventional antibiotics is limited to a few substances because of adverse reactions. The new HDP substances might become alternatives to conventional antibiotics, but knowledge of the physiological quantities of the HDPs in infants is essential because of a narrow therapeutic index of currently available derivates. This study compares the mRNA levels of five major HDPs between infants and adults to test the hypothesis that HDP gene expression differs between these groups. Expression profiles of human beta-defensin (hBD)-1, hBD-2 and hBD-3, psoriasin and RNase 7 were assessed in the lip vermilion mucosa of infants (n = 15) and adult controls (n = 15) using real-time polymerase chain reaction. A significantly lower expression of hBD-2 (P = 0.043), hBD-3 (P = 0.014) and psoriasin (P = 0.018) was found in infants. No difference between the groups was noted with respect to transcript levels of hBD-1 and RNase 7. In conclusion, several HDPs are expressed at lower levels in infants, but not all. The results emphasize the need to adjust the dose of agents based on the specific HDP level for the treatment of infantile infections.

RapidNAM: Algorithm for the Semi-Automated Generation of Nasoalveolar Molding Device Designs for the Presurgical Treatment of Bilateral Cleft Lip and Palate.

OBJECTIVE: Nasoalveolar molding (NAM) is an accepted presurgical treatment modality for newborns with cleft lip and palate (CLP). However, the therapy is time-consuming and requires high expertise. To facilitate the treatment, we reveal an algorithm for the automated generation of patient individual NAM devices for neonates with bilateral cleft lip and palate (BCLP) and present results of software validation. METHODS: The algorithm was implemented utilizing Python 2.7 and Blender 2.78a based on 17 digitized (3D-scanning) impressions of maxillae with BCLP. The algorithm segments alveolar structures, bridges clefts, and generates a series of NAM device designs, destined for 3D-printing for subsequent treatment. The datasets were used for first software tests. For validation, a follow-up study was carried out using six new, independent maxilla models. The generated NAM plate designs were examined regarding their potential clinical usability. Furthermore, a deviation analysis was carried out, which measured the plate models' and upper jaw models' surface deviations. RESULTS: Series of NAM devices were generated automatically in 21 out of 23 cases. We calculated an average surface deviation of 0.140 mm (SD: 0.016 mm). Four out of six plate series (follow-up trials) were assessed as probably usable with minor adjustments. CONCLUSION: The algorithm generates 3D-printable series of NAM device designs reliably. We expect most of the series to be clinically usable and that the first plates of each series will fit the patients' maxillae. SIGNIFICANCE: The proposed algorithm has the potential to reduce the therapist's manual work and therefore time effort/costs related to NAM.

Diversity of mucins in labial glands of infants.

Mucins as highly glycosylated proteins comprise multiple functions like protection, homeostasis, immune defense, cell signaling. Various epithelial tissues including glandular structures express different specific mucin types. We investigated labial salivary glands in infants for the occurrence of MUC1, MUC2, MUC3, MUC4, MUC5AC, MUC5B, and MUC7 by immunohistochemistry. MUC1 and MUC4 were detected in serous and ductal glandular cells, partially intensified at the apical plasma membrane. MUC3 was found in ductal glandular cells and in myoepithelial cells. MUC5B exhibited a mosaic expression pattern in mucous glandular endpieces. MUC2 and MUC7 were abundant in serous acini. Glandular structures were negative for MUC5AC. A comprehensive study of specific mucins in labial salivary glands of infants was presented for the first time. As a representative of the minor salivary glands, labial glands are, due to their localization, directly exposed to environmental influences. The distribution of a broad spectrum of mucins in infantile labial glands indicates their importance early in human development to sustain oral health.

Identifying perioperative volume-related risk factors in head and neck surgeries with free flap reconstructions - An investigation with focus on the influence of red blood cell concentrates and noradrenaline use.

INTRODUCTION: The amount of fluids administered intraoperatively seems to influence the postoperative outcome, and especially the transfusion of red blood cell concentrates (RBC) are known to have an increased risk of postoperative complications. This prospective study focuses on patients planned with microvascular free flap reconstruction and investigates the effect of various types and amounts of volumes given intraoperatively and on the intensive care unit with regard to overall postoperative complications. MATERIAL AND METHODS: In this prospective study, 52 consecutive patients planned for reconstruction with microvascular free flaps were included. Intraoperatively administered volumes including blood products were documented by the anesthesiologists as well as volumes given during the intensive care unit stay. Postoperative complications were registered for the entire hospital stay. Statistical analysis was carried out correlating the amount and type of volumes with the incidence of postoperative complications. RESULTS: The intraoperative use of RBC showed a close to statistically significant increased risk of postoperative complications (mean/SD concentrates: 0.5/1.1 [no complications] vs. 1.0/1.4 [complications], p = 0.058). In a multivariate analysis with stepwise selection the use of human albumin, gelatin, or Ringer's acetate showed no correlation with complications. The overall blood loss, however, had no significant influence on the incidence of complications (mean/SD ml: 1187/761 [no complications] vs. 1004/600 [complications], p = 0.37). The use of noradrenalin during reconstructive surgeries with microvascular flaps bears statistically no increased risk of failure (mean/SD µg/kg/min: 36/23 [no flap loss] vs. 22/15 [flap loss], p = 0.289) or complications (mean/SD µg/kg/min: 34/22 [no complications] vs. 35/23 [complications], p = 0.807). CONCLUSION: In our investigation, the use of crystalloids and colloids seems to have no influence on the postoperative outcome, but the use of RBC may have an increased overall incidence of postoperative complications. A careful hemostasis to limit the use of RBC remains essential despite available options of substitutions. The use of infusion-pump-administered noradrenaline seems valuable to sustain a stable circulation during surgeries with microvascular free flaps and may have no negative impact on postoperative complications.

Author Correction: A semi-automated virtual workflow solution for the design and production of intraoral molding plates using additive manufacturing: the first clinical results of a pilot-study.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Rapid autonomisation of a combined fibular- and anterolateral thigh flap transferred by a wrist carrier to an irradiated and vessel depleted neck.

In an irradiated and vessel depleted neck, we used the wrist carrier technique to provide flap perfusion until autonomisation took place. A combined anterolateral thigh- and osteocutaneous fibular flap was anastomosed to the radial vessels of an irradiated patient with a vessel depleted neck for reconstruction of the lower face. Periodical pedicle occlusion started immediately after surgery. On day 16, cutaneous blood flow and oxygenation were still reduced, but wound healing was uneventful.

Tumor size and depth in primary malignant melanoma in the oral cavity influences survival.

PURPOSE: Primary oral malignant melanoma (OMM) is rare, and there are few studies examining the impact of this disease. This study aims to assess the outcome of surgically treated patients with OMM treated at a single institution. PATIENTS AND METHODS: Ten patients with OMM treated at the Department of Oral and Maxillofacial Surgery, Ruhr-University Bochum, Bochum, Germany, between 1992 and 2002 were analyzed retrospectively. Treatment included wide local excision with or without modified neck dissection, supplemented by radiotherapy and chemotherapy. Clinical and histologic data were analyzed by univariate analysis. RESULTS: Five patients were diagnosed with stage I disease, 4 with stage II disease, and 1 with stage III disease at presentation. The alveolar arch (40%) and palate (30%) were the most frequently affected sites. The adjusted hazard ratio was 4.513 (95% confidence interval, 1.47-13.89) for size and 1.919 (95% confidence interval, 1.03-3.59) for depth, yielding a poor prognosis (P = .009 and P = .048, respectively). The mean survival rate of the patients succumbing to disease was 19 +/- 17 months. CONCLUSIONS: Primary OMM carries a poor prognosis. Early identification of OMM and its treatment by radical surgery comprise the single most important treatment strategy. Any pigmented lesion in the oral cavity not clearly clinically amenable to diagnosis should be excised for histologic confirmation. Analysis of the lymph node status, supplemented by sonography or other imaging, and postoperative histologic evaluation of the size and depth should be performed routinely. In cases in which the mucosal melanoma may not be the primary site, all potential primary sites should be examined.

Reverse flow facial artery as recipient vessel for perforator flaps.

In perforator flaps, anastomosis between flap and recipient vessels in the neck area is often difficult due to small vessel diameter and short pedicle. The aim of this study was to investigate whether the retrograde flow of the distal, paramandibular part of the facial artery would provide sufficient pressure and size to perfuse perforator flaps. Before and after occlusion of the contralateral facial artery, retrograde and anterograde arterial pressure was measured on both sides of the facial artery in 50 patients. The values were compared with the mean systemic arterial pressure. Diameters of facial arteries in the paramandibular region and perforator flap vessels were evaluated by morphometry. Arterial pressure in the distal facial artery with retrograde flow was 76% of the systemic arterial pressure. The latter equaled approximately the anterograde arterial pressure in the proximal end of the facial artery. Mean arterial pressure of the facial arteries decreased after proximal occlusion of the contralateral facial artery, which was not significant (P = 0.09). Mean diameter of the distal facial arteries in the mandibular region was 1.6 mm (range 1.3-2.2 mm; standard deviation 0.3 mm; n = 50), that of the perforator flap arteries 1.3 mm (0.9-2.6 mm; 0.4 mm; n = 20). Facial arteries, based on reverse flow, successfully supported all 20 perforator flaps. Retrograde pulsatile flow in the distal facial artery sustains perforator flaps even if the contralateral facial artery is occluded. Proximity of the distal facial arteries to the defect compensates for short pedicles. Matching diameters of the arteries are ideal for end-to-end anastomosis.

The absolute and relative effects of presurgical nasoalveolar moulding in bilateral cleft lip and palate patients compared with nasal growth in healthy newborns.

BACKGROUND: This study investigated the efficiency of nasoalveolar moulding (NAM) in patients presenting with bilateral cleft lip and palate (BCLP). It focused explicitly on nasal outcome and therefore made comparisons with healthy age-matched infants with normal nasal development. METHODS: Nasal impressions from 19 BCLP patients were analysed at the beginning and at the end of NAM treatment. In addition, nasal impressions from 32 healthy newborns were taken monthly for 4 months. The casts were digitalized and analysed, using defined anatomic landmarks, by two independent observers. Initial values were compared with outcome parameters at the end of NAM therapy and with the healthy cohort. RESULTS: NAM significantly elongated the columella in BCLP patients, with an increase of 106.5% versus 14.5% in healthy newborns. Nostril height showed significant expansion from 4.2 mm to 5.6 mm on the right side, and from 4.3 mm to 6.2 mm on the left side. CONCLUSION: NAM significantly elongated columella length and increased nostril height. The comparison with healthy newborns showed the effectiveness of early cartilage moulding. Detailed knowledge about absolute and relative early nasal growth was gained. However, despite highly effective NAM treatment in BCLP, nasal dimensions will not reach healthy proportions.

Prenatal intrauterine maxillary development - An evaluation with three-dimensional ultrasound.

OBJECTIVES: The aim of this prospective study was to investigate normal fetal maxillary development with volume ultrasound during the prenatal phase, for a better estimation of maxillary growth processes. METHODS: Some 210 3D volumes were obtained in two measurement series from 38 healthy women (gestational age: 19+2 to 31+4 weeks) using a GE Voluson™ E10 ultrasound system. Maxillary length and width were determined in the axial and sagittal planes. Clearly defined, reproducible landmarks were used for measurements. The results were correlated with gestational age and compared with previously reported studies. RESULTS: Total maxillary length ranged from 10.30 to 24.75 mm, total maxillary width from 13.65 to 37.30 mm in an observation period during the second trimester, with high reproducibility for all landmarks. All evaluation results showed steep growth with exponential character. Length growth was determined to be more dominant than width growth. Intra-rater correlation was evaluated to be almost perfect (ICC (3) > 0.8). CONCLUSION: This study presents measurements of physiological fetal maxillary development. The defined landmarks proved to be representative for further investigations. This study serves as a baseline for a better understanding of fetal maxillary growth processes, and may be useful for standardising detection of malformations or intrauterine growth restrictions.