Implications of the composite free flap harvest site on quality of life after head and neck surgery: a prospective series.

Quality of life (QOL) has become a primary determinant of the treatment outcome. There is a poor evidence base regarding the QOL implications of free flap harvest from the various different osseous composite donor sites. This prospective study assessed the impact of free flap harvest on QOL and compared QOL morbidity between fibula, scapula, and iliac crest (deep circumflex iliac artery; DCIA) donor sites in head and neck reconstructive surgery. This was a single-site prospective cohort clinical research study. Fifty-nine patients were recruited between 2017 and 2021; 30 underwent fibula flap reconstructive surgery, 17 scapula flap, and 12 DCIA flap. The patients were assessed using the University of Washington Quality of Life Questionnaire version 4 (UW-QOL v4) preoperatively and again at >12 months postoperatively. The results showed no significant change in the mean global QOL score postoperatively when compared to the preoperative baseline in any of the donor site groups. However, the mean postoperative scores for the appearance domain were significantly lower than the preoperative scores in all of the donor site groups. In addition, fibula flap patients had significantly reduced physical activity and recreation QOL domain scores postoperatively when compared to the preoperative scores.

Prospective study examining the use of thrombin-gelatin matrix (Floseal) to prevent post dental extraction haemorrhage in patients with inherited bleeding disorders.

The bleeding risk in individuals with inherited bleeding disorders (IBDs) during exodontia is traditionally managed with perioperative coagulation factors and/or desmopressin, in conjunction with systemic and topical perioperative tranexamic acid and meticulous primary closure. Factor replacement is costly, requires specialist input, and carries a risk of developing factor VIII (FVIII) inhibitors. This prospective study was performed to determine whether the use of a standardized Floseal and anti-fibrinolytic protocol could reduce postoperative bleeding in patients with IBDs undergoing dental extraction, as compared to factor replacement. All patients >18 years old attending Queensland Haemophilia Centre between November 2014 and July 2019 who required dental extractions were referred to the Oral and Maxillofacial Unit. Patients were consented for intraoperative Floseal administration instead of factor replacement. All other operative measures remained the same. The bleed rate was assessed against a historical control cohort. There were 34 extraction events in 32 patients. Four of the patients reported postoperative bleeding requiring factor supplementation or desmopressin; the bleeding rate was 11.8%. While not statistically significant, this was a reduction in the bleed rate compared to the traditional protocol (P = 0.35). Third molar extractions were 10.33 times more likely to cause postoperative bleeding (P = 0.018). The Floseal protocol was equipotent to the traditional perioperative factor replacement protocol. Floseal use is more economical, eliminates the risk of peri-procedural FVIII inhibitor development, and provides a haemostatic option for patients with very rare factor deficiencies, pre-existing clotting factor inhibitors, and those with anaphylaxis to clotting concentrates.

Outcomes of osseointegrated implants in patients with benign and malignant pathologies of the head and neck: a 10-year single-centre study.

The surgical management of head and neck pathologies involving the maxilla and mandible results in significant functional and aesthetic deficits, and ultimately reduced quality of life. Composite free flaps used for reconstruction address many of these deficits and create a foundation for the use of osseointegrated implants to support prosthetic replacement of the dentition. There are few comparative studies examining outcomes of implants in native and reconstructed bone in head and neck cancer patients. The aim of this retrospective cohort study was to compare survival rates and the effects of risk factors between implants placed in native and reconstructed bone. The Kaplan-Meier method estimated cumulative 1- and 5-year implant survival rates of 99.5% and 95% for native bone and 96% and 88% for reconstructed bone. Multivariate Cox regression found an increased risk of implant failure in reconstructed bone (hazard ratio (HR) 9.9, 95% confidence interval (CI) 3.4-29.7, P<0.001). Subgroup analysis of the cohorts found an increased risk of failure in the reconstructed group associated with radiotherapy (HR 6.4, 95% CI 1.8-22.3, P=0.004), current smoking (HR 23.2, 95% CI 2.7-198.6, P=0.004), and previous smoking (HR 9.0, 95% CI 1.1-71.9, P=0.038). There was no effect in the native bone group. Implants placed into reconstructed bone had higher rates of failure, and smoking status and radiotherapy increased the risk of implant failure.

Donor site morbidity of composite free flaps in head and neck surgery: a systematic review of the prospective literature.

Composite free flaps represent the cornerstone for the repair of osseous defects in the head and neck. For many patients, there are often multiple defect-suitable donor sites that may be utilised as part of the reconstructive process. Therefore, to optimise patient outcomes, an evidence-based approach to donor site selection is required to maximise quality of life and long-term functionality. A systematic review of the literature was conducted in accordance with PRISMA guidelines to evaluate the evidence for donor site selection based on minimising the associated donor site morbidity and optimising patient functionality postoperative. The fibula is associated with the greatest potential risk for wound healing complications. Fibula and scapula harvest has the potential to have a significant impact on physical performance. The iliac crest is most favourable in terms of aesthetic scar healing outcomes. Overall, however, the quality and quantity of evidence for all donor sites is limited. Each site is associated with specific complications and morbidity, of which the surgeon and patient must both be aware. Whilst a cross-sectional informed opinion of the likely advantages/disadvantages of one donor site over another can thus be made, there are few head-to-head studies available that directly compare donor sites.

A pilot study for presence of circulating tumour cells in adenoid cystic carcinoma.

Adenoid cystic carcinoma (ACC) is a rare salivary gland neoplasm with a poor long-term prognosis due to multiple recurrences and distant metastatic spread. Circulating tumour cells (CTCs) are tumour cells shed from a primary, recurrent, or metastatic cancer that are detectable in the blood or lymphatics. There is no literature to date confirming the presence of CTCs in ACC. The aim of this study was to determine whether CTCs are detectable in ACC. Blood samples were collected from eight patients with histologically confirmed ACC. The TNM stage of the tumour was recorded, as well as any prior treatment. CTCs were isolated by spiral microfluidics and detected by immunofluorescence staining. Three of the eight patients recruited (32.5%) had staining consistent with the presence of CTCs. Of these three patients with detectable CTCs, one had confirmed pulmonary metastasis, one had suspected pulmonary metastasis and was awaiting confirmation, and one had local recurrence confirmed on re-resection. One patient with known isolated pulmonary metastasis had previously undergone a lung metastasectomy and did not have CTCs detected. CTCs are detectable in ACC. In this small patient sample, CTCs were found to be present in those patients with recurrent local disease and known distant metastatic disease. CTCs in ACC should be investigated further for their potential use as an adjunct in staging, prognosis, and the detection of recurrence.

The utility of postoperative radiotherapy in intermediate-risk oral squamous cell carcinoma.

The effectiveness of postoperative radiotherapy (PORT) in improving outcomes remains debatable for oral squamous cell carcinoma (OSCC) patients with pathological intermediate-risk factors (IRFs) after surgery. A retrospective analysis was conducted on 432 intermediate-risk OSCC patients defined by histological reporting of close margin (<5mm), early nodal disease (pN1), depth of invasion/tumour thickness ≥5mm, perineural invasion, and/or lymphovascular invasion. Outcomes measured were disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). PORT was associated with an improvement in 5-year DFS on univariable analysis (80% vs 71%; P=0.044), but this did not remain significant on multivariable analysis. PORT was not associated with differences in DSS or OS. The surgical salvage rate was similar in the PORT and surgery-only groups (41% vs 47%; P=0.972). Perineural invasion was found to be an independent predictor of inferior DSS (hazard ratio (HR) 2.19), DFS (HR 1.89), and OS (HR 1.97). Significantly worse outcomes were observed for patients with ≥4 concurrent IRFs. The application of PORT was associated with lower rates of recurrence, but the benefit was less apparent on mortality. Patients with perineural invasion and multiple concurrent IRFs were found to be at greatest risk, representing a subset of intermediate-risk OSCC patients who may benefit from PORT.

Increasing frequency and severity of odontogenic infection requiring hospital admission and surgical management.

Odontogenic infections can become life-threatening if not managed in a timely manner, and they increase the physical cost of treatment to the patient and the financial cost to the public health system. We investigated the number of admissions to a Queensland tertiary hospital within a decade, and differences in the patients' characteristics, severity at presentation, and clinical outcomes. We compared patients with odontogenic infections who were taken to theatre at the Royal Brisbane & Women's Hospital (RBWH) between January 2003 and December 2004 with those treated between January 2013 and December 2014, a total of 292. Data on demographics, presentation, previous history, antimicrobial treatment, and admissions, were collated and analysed. There were no significant differences in demographics. In the 2013/2014 group there was a two-fold increase in infections related to lower third molars (p=0.001), a 50% increase in trismus (p=0.001), and a 20% increase in submandibular swelling (p=0.010). The percentage of patients admitted to the intensive care unit (ICU) was three and a half times higher in the 2013/2014 group (p=0.001). The presentation of odontogenic infections has increased in the decade from 2003/2004 to 2013/2014. Measures of the severity of disease have increased, while the basic characteristics of the patients have remained constant. Improved primary preventative measures and early interventions are therefore needed to alleviate the burden that these infections place on the public health system.

Pregnancy and childbirth after an iliac crest free flap.

We report two successful pregnancies and vaginal deliveries by patients who had previously had deep circumflex iliac artery free flaps that had been harvested for reconstruction in the head and neck.

Does intensity-modulated radiation therapy lower the risk of osteoradionecrosis of the jaw? A long-term comparative analysis.

The aim of this study was to analyze the impact of different radiation techniques on the long-term incidence of osteoradionecrosis in head and neck cancer. Risk factors and the occurrence of osteoradionecrosis were analyzed in a retrospective, comparative, observational study. Medical files and radiological images of 109 patients treated with primary intensity-modulated radiation therapy (IMRT) and 129 patients treated with primary three-dimensional conformal radiotherapy (3D-CRT) were evaluated. Proportional hazards models were used to analyse the effects of the radiation modality and patient characteristics on the necrosis risk. Twenty-two patients developed osteoradionecrosis (9.2%) during a mean follow-up of 4.3 years. A numerical difference was observed, with more osteoradionecrosis after 3D-CRT (n=18) than after IMRT (n=4). After correction for group differences and confounders, no statistical difference in risk was observed between the two treatment groups (P=0.37). Multivariate analysis showed evidence of a higher osteoradionecrosis risk for patients with a tumour of the oropharynx and for patients with tooth extraction after radiation therapy. Although the incidence of osteoradionecrosis tended to be lower after IMRT, due to the multifactorial aetiology it remains a severe problem and cannot be prevented by new radiotherapy techniques. Continuous efforts are necessary to control additional risk factors and avoid osteoradionecrosis.

Patient compliance and mandible fractures: a prospective study.

Fractures of the facial skeleton place a burden on healthcare systems at the individual and population level. It is suggested that a high proportion of such patients are non-compliant with various aspects of their care. It stands to reason that non-compliance would contribute to adverse outcomes and increased costs in general. The intent of this study was two-fold: to determine factors associated with poor compliance in the studied population of 215 patients with 359 mandible fractures, and to determine whether poor compliance is associated with an increased incidence of treatment complications. Being male, an illicit drug user, non-employed, and living furthest from care were the factors associated with non-compliance in the studied population. Compliance with soft diet, mouthwash, oral antibiotics, cigarette cessation, and review appointment attendance was 74%, 96%, 96%, 16%, and 58%, respectively. Global compliance scores of low, medium, and high were assigned to 27%, 59%, and 14% of participants, respectively. None of the individual postoperative compliance variables was found to be significantly associated with outcomes of treatment at the 5% level. Borderline associations were found. Globally non-compliant patients were significantly more likely to experience wound dehiscence. The utility of the current postoperative regimen should be further elicited.

A prospective study examining the effects of treatment timing in the management of mandible fractures.

The ideal timing for treatment of mandible fractures has not been well established. The objective of this study was to analyse the effects of treatment timing in the surgical management of mandible fractures. A prospective evaluation of 215 continuous patients with a total of 359 mandible fractures was undertaken. Nine outcome variables were analysed in relation to treatment delay by logistic regression modelling: wound dehiscence, hardware exposure, local postoperative infection, malocclusion, trismus, nerve damage, fracture non-union, return to theatre, and radiographic outcome. Nineteen additional variables were included in the analysis to adjust for potential confounding. Delay was measured in days and ranged from 0 to 41days, with a mean delay of 4.6days. The incidence of wound dehiscence, hardware exposure, local postoperative infection, trismus, nerve damage, fracture non-union and return to theatre was 6%, 4%, 11%, 8.5%, 47%, 2% and 8%, respectively. Objective malocclusion and poor radiographic outcomes were evident in 13% and 4.5% of cases, respectively. No statistically significant association was found between treatment delay and treatment outcomes. The findings of this study suggest it may be safe to delay the definitive treatment of mandible fractures. Treatment delay may allow for improved resource distribution and prioritization of more time-dependent interventions.

Reconstruction of major defects of the jaws.

Prosthetic replacements in the 19th and early 20th century were superseded by pedicled flaps and obturators. These have subsequently been superseded by free tissue transfer which currently is the mainstay of reconstructive jaw surgery. Although malignant and benign processes of the jaws are the predominant cause of segmental defects, a significant proportion still occurs due to trauma, or even iatrogenic causes such as radiotherapy. The varied aetiologies demand a nuanced approach to reconstruction and although the techniques remain similar the timing can be quite different. The maxilla and the mandible are both amenable to composite reconstruction with bone. The fibula, iliac crest, scapula, distal radius and medial femoral condyle are the most commonly utilised donor sites for vascularised reconstruction. Each has strengths and weaknesses and the requirements of the defect, and patient preference should outweigh surgeon preference. Osseointegrated implants allow reliable rehabilitation of the dentition by anchoring facial prostheses. Their integration into composite flaps is highly reliable although soft tissue management can be challenging. Virtual surgical planning and 3D printing have already impacted on the surgical workflow and improved the reliability and accuracy of results. If this technology can be applied to tissue typing and human tissue (instead of just plastic and metal) a fully prefabricated and vascularised jaw without donor site morbidity would be the ultimate aim.

Ten-year study of postoperative complications following dental extractions in patients with inherited bleeding disorders.

Dental extractions challenge the body's haemostatic mechanism. Postoperative bleeding from dental extraction can be prolonged, or even life threatening in patients with inherited bleeding disorders. Pre- and postoperative clotting factor replacements or systemic desmopressin (ddAVP) have been advocated at our institution to prevent bleeding complications in these patients. This study aimed to assess the postoperative bleeding rate in patients with inherited bleeding disorders that underwent dental extractions at our institution between 2003 and 2012. Patients with inherited bleeding disorders such as haemophilia A, haemophilia B, and von Willebrand's disease were included. Retrospective chart review was conducted. The result showed 53 extraction events occurred in 45 patients over the 10-year period. Ten out of 53 extraction events (18.9%) had postoperative bleeding requiring further factor replacement or ddAVP. Postoperative bleeding in one patient with mild haemophilia A was complicated by the development of inhibitors. Type and severity of bleeding disorder, bone removal, and use of a local haemostatic agent did not have any significant effect on postoperative bleeding. Despite the use of perioperative factors and desmopressin, the postoperative bleeding rates remain high for patients with inherited bleeding disorders. More studies are required to assess the safety and effectiveness of using local haemostatic control to achieve haemostasis following extractions.

Total temporomandibular joint replacement prostheses: a systematic review and bias-adjusted meta-analysis.

The aim of the present study was to determine which prosthesis has resulted in the best outcomes after total temporomandibular joint replacement (TMJR). A comprehensive electronic search was undertaken in September 2015. Inclusion criteria encompassed studies that described one of the three current TMJR systems and that had pre- and postoperative data on at least two of the following TMJR indications: pain, diet, function, and maximum inter-incisal opening (MIO). Sixteen papers were included in the systematic review, reporting 10 retrospective studies and six prospective studies (no randomized controlled or case-controlled trials). A total 312 patients with 505 TMJ Concepts prostheses, 728 patients with 1048 Biomet prostheses, and 125 patients with 196 Nexus prostheses were included in the analysis. There was no real difference between the various TMJR systems in terms of pain or diet scores. Function scores improved with the TMJ Concepts, but this was the only prosthesis for which data were available. Biomet prostheses appeared to have a greater increase in MIO mean gain compared to TMJ Concepts and Nexus prostheses; however this was heavily biased by one study. Without this study, there was no real difference in MIO. It is concluded that the prostheses are similar, but most data are available for the TMJ Concepts prosthesis, with results being favourable.

Removal versus retention of asymptomatic third molars in mandibular angle fractures: a randomized controlled trial.

The treatment dilemma provided by asymptomatic third molars in mandibular angle fractures remains controversial. This prospective randomized controlled trial was undertaken to determine whether there is an advantage to extraction or retention of the third molar whilst repairing a mandibular angle fracture. Sixty-four patients were allocated randomly to the two treatment groups. All underwent open reduction and internal fixation (ORIF) with standard postoperative care. The primary outcome measure was uncomplicated fracture healing. Secondary measures were surgical duration, malocclusion, wound healing, nerve injury, and return to theatre. All patients had uncomplicated fracture healing. The incidence of nerve injury was 16% for the retention group compared with 39% for the removal group (P=0.038). The average operating time for ORIF and third molar retention cases was 58.5min and for ORIF and third molar removal cases was 66.3min (P=0.26). There was no statistically significant difference between groups for wound healing, occlusion outcomes, or return to theatre. Given the additional risk of nerve injury and the additional operating time required for removal of a third molar, in the absence of an absolute indicator for removal of the third molar, it appears justifiable to advise retaining the tooth in the line of a mandibular angle fracture.

A multi-outcome analysis of the effects of treatment timing in the management of zygomatic fractures.

The aim of this study was to analyze the effects of surgical treatment delay in the management of zygomatic fractures. A retrospective case series of 99 patients was undertaken. Four outcome measures were analyzed in relation to delay: facial symmetry, facial scarring, trismus, and radiographic outcome. Five additional variables were subsequently analyzed: operation, diagnosis, primary operator, regular alcohol use, and regular cigarette use. Statistically significant associations were found between delay and facial scarring, and delay and radiographic outcome. For each additional delay of a day, the odds of facial scarring being present, compared to absent, decreased by 13% (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.76-0.98). For regular cigarette users, for each additional day of delay there was a 306-fold increased risk of having a radiographic outcome of major deviation from premorbid compared to equivalent to premorbid (OR 306.38, 95% CI 2.08-45,161.49). For non-regular cigarette users/non-users, for each additional day of delay there was a 1.5-fold increased risk of having a radiographic outcome of major deviation from premorbid compared to equivalent to premorbid (OR 1.50, 95% CI 1.08-2.09). These findings correlate with commonly held beliefs and anecdotal evidence. Despite the limitations, this study allows for an evidence-based approach to the timing of treatment of zygomatic fractures.

The relative survival of composite free flaps in head and neck reconstruction.

Various composite free flaps are available for reconstruction of bony head and neck defects. The aim of this study was to compare the relative success of four different bony free flaps. One hundred and seventy-three microvascular composite free flap reconstructions for bony defects of the head and neck region, performed over the period April 2008 to April 2015, were reviewed retrospectively. The type of free flap, indication for free flap reconstruction, age at harvesting of the free flap, use of pre- or postoperative radiotherapy, and free flap failure were examined. For the 173 reconstructions performed, 84 fibula free flaps, 43 iliac crest free flaps, 32 scapula free flaps, and 14 osteocutaneous radial forearm free flaps were harvested. The mean age at time of harvesting was 40.7 years for the iliac crest, 57.3 years for the fibula, 64.3 years for the scapula, and 73.9 years for the osteocutaneous radial forearm free flap. No complete free flap failure was documented, nor was there any failure of bony segments. Three fibula flap skin paddles did not survive. No returns to theatre for salvage were required. This study showed no difference in the survival rates of these four types of composite free flap.