Osteocutaneous-flap-related osteomyelitis following mandibular reconstruction: a cohort study of an emerging and complex bone infection.

Osteocutaneous flap (OCF) mandible reconstruction is at high risk for surgical site infection. This study aimed to describe diagnosis, management, and outcome of OCF-related osteomyelitis. All patients managed at our institution for an OCF-related osteomyelitis following mandible reconstruction were included in a retrospective cohort study (2012-2019). Microbiology was described according to gold-standard surgical samples, considering all virulent pathogens, and potential contaminants if present on at least two samples. Determinants of treatment failure were assessed by logistic regression and Kaplan-Meier curve analysis. The 48 included patients (median age 60.5 (IQR, 52.4-66.6) years) benefited from OCF mandible reconstruction mostly for carcinoma ( n = 27 / 48 ; 56.3 %) or osteoradionecrosis ( n = 12 / 48 ; 25.0 %). OCF-related osteomyelitis was mostly early ( ≤ 3 months post-surgery; n = 43 / 48 ; 89.6 %), presenting with local inflammation ( n = 28 / 47 ; 59.6 %), nonunion (wound dehiscence) or sinus tract ( n = 28 / 47 ; 59.6 %), and/or bone or device exposure ( n = 21 / 47 ; 44.7 %). Main implicated pathogens were Enterobacteriaceae ( n = 25 / 41 ; 61.0 %), streptococci ( n = 22 / 41 ; 53.7 %), Staphylococcus aureus ( n = 10 / 41 ; 24.4 %), enterococci ( n = 9 / 41 ; 22.0 %), non-fermenting Gram-negative bacilli ( n = 8 / 41 ; 19.5 %), and anaerobes ( n = 8 / 41 ; 19.5 %). Thirty-nine patients (81.3 %) benefited from surgery, consisting of debridement with implant retention (DAIR) in 25 / 39 (64.1 %) cases, associated with 93 (IQR, 64-128) days of antimicrobial therapy. After a follow-up of 18 (IQR, 11-31) months, 24 / 48 (50.0 %) treatment failures were observed. Determinants of treatment outcomes were DAIR (OR, 3.333; 95 % CI, 1.020-10.898) and an early infectious disease specialist referral (OR, 0.236 if ≤ 2  weeks; 95 % CI, 0.062-0.933). OCF-related osteomyelitis following mandibular reconstruction represents difficult-to-treat infections. Our results advocate for a multidisciplinary management, including an early infectious-disease-specialist referral to manage the antimicrobial therapy driven by complex microbiological documentation.

Trans-oral versus cervico-facial lift approach for mandibular angle resection in facial feminization: A retrospective study.

INTRODUCTION: Mandibular angle resection is an important procedure in facial feminization surgery. Two different approaches are described: trans-oral and cervico-facial lift (CFL) approaches. The aim of the study was to compare surgical outcomes and patient's satisfaction between the two approaches. MATERIAL AND METHODS: We retrospectively analyzed medical charts of patients who underwent mandibular angle resection in the same center by the same surgeon between 2017 and 2019. Aesthetic and functional results were objectively assessed using serial photographs and subjectively with patient self-assessments. All patients benefited from a medical consultation at least 6 months after the surgery. RESULTS: Seven patients benefited from trans-oral approach and 14 from CFL approach. The mean age was 42. No major complications occurred. No long-term nerve damage was found. Aesthetic evaluation showed mostly an improved result. All patients answered positively to the quality of life survey. DISCUSSION: These preliminary results of the study suggest that mandibular angle resection is a much-needed and safe surgical procedure regardless of the surgical approach. Patients who underwent facial feminization surgery frequently present a mixed indication of CFL and mandibular angle resection. The study is limited by the low number of patients included. Moreover, interpretation of results is biased because the patients benefited from other minor facial cosmetic procedures in the same surgery. We reported the first analysis of transgender patient's satisfaction concerning mandibular angle resection. This procedure improves quality of life as well as facial aesthetics for transgender patients.

Efficacy of Surgical Excision and Brachytherapy in the Treatment of Keloids: A Retrospective Cohort Study.

OBJECTIVE: To demonstrate the efficacy of a protocol combining surgical excision and high-dose-rate brachytherapy for treatment of keloids. METHODS: The authors performed a unicentric retrospective cohort study between 2013 and 2018. The minimum follow-up was 12 months. All patients treated for keloids at the authors' institution were included. Extralesional excision was performed with placement of a brachytherapy sheath under the skin. The total dose of irradiation was 18 Gy. The postoperative results were evaluated for aesthetic and functional outcomes with a validated scale, as well as the presence or absence of recurrence. RESULTS: Fifteen patients were lost to follow-up. Thirty-eight patients with 67 keloids were included. The control rate was 94%. The aesthetic and functional outcomes were considered good in 62% of cases. The main limitation of the study was the small patient population. CONCLUSIONS: Extralesional excision combined with postoperative high-dose-rate brachytherapy seems to be one of the most effective invasive protocols to treat and prevent keloids.

Bilateral radical neck dissection with immediate reconstruction of the internal jugular vein.

Head and neck surgery for advanced neck disease may require ablation of critical structures, including the internal jugular vein (IJV). Although unilateral ligation of the IJV is not commonly associated with a significant increase in morbidity, bilateral sacrifice of the internal venous system may cause severe complications. We present the case of a 60-year-old man with a T4N2cM0 tumour of the left and right hypopharynx. The evolution of the disease required a bilateral modified radical neck dissection and sacrifice of both IJVs. We describe a vein grafting technique for the IJV using the external jugular vein as a donor vessel. Postoperative computed tomography imaging confirmed adequate blood perfusion. This report describes two new and accessible surgical options for immediate IJV grafting. Although this modification slightly increases the surgery time and technical difficulty, it allows immediate restoration of venous perfusion, which may improve the prognosis and patient outcomes.