Current status of surgery first approach (part II): precautions and complications / 대한악안면성형재건외과학회지

The choice of surgical technique in orthognathic surgery is based primarily on the surgical treatment objectives (STO), which is a fundamental component of the orthognathic treatment process. In the conventional orthodontics-first approach, presurgical planning can be performed twice, during the preorthodontic (initial STO) and presurgical phases (final STO). Recently, a surgery-first orthognathic approach (SFA) without presurgical orthodontic treatment has been introduced and combined initial and final STO at the same time. In contrast to the conventional surgical-orthodontic treatment protocol that includes preoperative orthodontics for dental decompensations to maximize stable postoperative occlusion, the SFA potentially shortens the treatment period and minimizes esthetic concerns during the decompensation period because skeletal problems are corrected from the beginning. The indications for the SFA have been proposed in the literature, but no consensus exists. Moreover, because dental occlusion of the pre-orthodontic arches cannot be used as a guide for establishing the surgical treatment plan, there are fundamental limitations in accurate prediction of postsurgical results in the SFA. Recently, the concepts of postsurgical orthodontic treatment are continuously changing and evolving to overcome this inherent limitation of the SFA. The elimination of presurgical orthodontics can change the paradigm of orthognathic surgery but still requires cautious case selection and thorough discussion and collaboration between orthodontists and surgeons regarding the goals and postoperative management of the orthognathic procedure.

Clinical Factors Associated with the Non-Operative Airway Management of Patients with Robin Sequence

BACKGROUND: The indications for surgical airway management in patients with Robin sequence (RS) and severe airway obstruction have not been well defined. While certain patients with RS clearly require surgical airway intervention and other patients just as clearly can be managed with conservative measures alone, a significant proportion of patients with RS present with a more confusing and ambiguous clinical course. The purpose of this study was to describe the clinical features and objective findings of patients with RS whose airways were successfully managed without surgical intervention. METHODS: The authors retrospectively reviewed the medical charts of infants with RS evaluated for potential surgical airway management between 1994 and 2014. Patients who were successfully managed without surgical intervention were included. Patient demographics, nutritional and respiratory status, laboratory values, and polysomnography (PSG) findings were recorded. RESULTS: Thirty-two infants met the inclusion criteria. The average hospital stay was 16.8 days (range, 5–70 days). Oxygen desaturation (<70% by pulse oximetry) occurred in the majority of patients and was managed with temporary oxygen supplementation by nasal cannula (59%) or endotracheal intubation (31%). Seventy-five percent of patients required a temporary nasogastric tube for nutritional support, and a gastrostomy tube placed was placed in 9%. All patients continued to gain weight following the implementation of these conservative measures. PSG data (n=26) demonstrated mild to moderate obstruction, a mean apneahypopnea index (AHI) of 19.2±5.3 events/hour, and an oxygen saturation level <90% during only 4% of the total sleep time. CONCLUSIONS: Nonsurgical airway management was successful in patients who demonstrated consistent weight gain and mild to moderate obstruction on PSG, with a mean AHI of <20 events/hour.

Clinical applications of virtual, non-contrast head images derived from dual-source, dual-energy cerebrovascular computed tomography angiography

Background: This study set out to evaluate the utility of cerebrovascular virtual non-contrast [VNC] scans. Materials and Methods: Conventional non-contrast [CNC] and dual-energy computed tomography angiography [DE-CTA] head scans were conducted on 100 subjects, of which 46 were normal, 15 had parenchymal hematomas of the brain, 13 had ischemic infarction, 22 had tumors, and 4 had calcified lesions. VNC images were extracted from the DE-CTA head scans by post-processing. The true [or conventional] and VNC images were compared in terms of the mean CT attenuation value and signal-to-noise ratio [SNR] of the cerebral parenchyma, the image quality, the lesion detection sensitivity, and the radiation exposure level. Results: The image qualities of the CNC and VNC scans were [4.95 +/- 0.22] points and [3.94 +/- 0.24] points [t = 31.18, P < 0.05], the mean CT values for the CNC and VNC images were [34.6 +/- 2.44] and [28.6 +/- 5.40] HU [t = 10.126, P < 0.05], the SNRs were [9.45 +/- 1.26] and [6.87 +/- 1.77], and the HU for white matter was [t = 11.859, P<0.05], respectively. The effective radiation doses from the DE-CTA head scans and the conventional non-contrast scans were [8.55 +/- 0.57] mSv and [9.41 +/- 1.00] mSv, respectively. No significant difference in the lesion detection sensitivities was observed between the CNC and VNC scans, except for tiny calcified lesions, which could not be identified by a VNC scan. Conclusion: VNC and contrast-enhanced images could be obtained from DE-CTA head scans and could aid in the diagnosis of cerebral lesions. The radiation dose from the VNC scan was less than that from the CNC scan