Motor vehicle accidents-related maxillofacial injuries: a multicentre and prospective study.

OBJECTIVES: The purpose of this European multicenter prospective study was to obtain more precise information about the demographic characteristics and etiologic/epidemiologic patterns of motor vehicle accidents (MVA)-related maxillofacial fractures. STUDY DESIGN: Of the 3260 patients with maxillofacial fractures admitted within the study period, 326 traumas were caused by MVAs with a male/female ratio of 2.2:1. RESULTS: The maximum incidence was found in Zagreb (Croatia) (18%) and the minimum in Bergen (Norway) (0%). The most frequent mechanisms were car accidents, with 177 cases, followed by motorcycle accidents. The most frequently observed fracture involved the mandible, with 199 fractures, followed by maxillo-zygomatic-orbital (MZO) fractures. CONCLUSIONS: In all the 3 groups (car, motorcycle, and pedestrian), mandibular and MZO fractures were the 2 most frequently observed fractures, with some variations. The importance of analyzing MVA-related facial injuries and their features and characteristics should be stressed.

Combined Karapandzic-Abbé/Estlander/Stein flap for subtotal and total lower lip reconstruction.

BACKGROUND: Lower lip reconstruction remains a challenging task due to multi-functional and high aesthetic requirements that have to be achieved for successful outcome. This is particularly true to near-total lower lip defects, encompassing over 70% of lower lip loss due to cancer, trauma or burns. Despite the fact that numerous flaps and their modifications have been described over the past century, only a few valuable techniques and concepts withstood the test of time for sub-total lower lip defects, each having their own drawbacks. We describe a new approach to these defects combining bilateral Karapandzic and Abbe/Estlander/Stein flaps, not reported so far, and present our long term outcomes. METHODS: From 2012 to 2016, five patients with T4 lower lip squamous cell carcinoma (SCC) underwent near-total and total lower lip resection and reconstruction with a combination of bilateral Karapandzic flap and double Abbé/Estlander/Stein flaps from the upper lip. RESULTS: Our patients were between 44 and 88 years old (mean 66.6). All flaps healed uneventfully in all patients. Patients were followed up between 18 and 60 months (mean follow up 33.6 months). There were no local tumor recurrencies. All patients were able to eat perorally whilst reconstructed lips were fully functional. No drooling was observed and aesthetic outcomes were excellent. CONCLUSIONS: Combined bilateral Karapandzic and Abbe/Estlander/Stein flaps can produce excellent functional and aesthetic outcomes in near total and total lower lip reconstructions and should be considered a reliable reconstructive option in patients with more then 70% of lower lip loss.

Extended Karapandzic Flap Technique for Reconstruction of Lower Lip and Chin Defect.

PURPOSE: Near total defect of the lower lip adjacent to the chin remains a reconstructive challenge for surgeons in function and esthetics. The objective of this study was to present a modified extended Karapandzic technique for reconstruction of near total defects of the lower lip adjacent with the chin. MATERIALS AND METHODS: From 2000 to 2013, patients with lip cancer or oral cavity cancer who required subtotal lower lip and chin resection and subsequently underwent reconstruction with an extended Karapandzic flap were included in this retrospective study. Patient demographics, histopathology, tumor stage, localization, tumor extension, method of reconstruction, and postoperative complications were extracted from patients' documentation. RESULTS: Reconstruction of the lower lip and chin was performed in 21 patients using a combination of double local extended Karapandzic flaps with microvascular free flaps for intraoral and mandibular reconstruction. There was no flap necrosis; the main complications were fistula and exposure of the osteosynthesis plate. All lips were functional and the esthetic result was pleasing. All patients returned to a peroral diet, although a variable degree of microstomia was present. CONCLUSION: The extended Karapandzic flap technique provides superior results for esthetic and functional lip reconstruction and chin reconstruction compared with any other regional or free flap. Free flaps should be reserved for oral cavity and mandibular reconstruction, if needed.

Assault-related maxillofacial injuries: the results from the European Maxillofacial Trauma (EURMAT) multicenter and prospective collaboration.

OBJECTIVE: The aim of this study is to present and discuss the demographic characteristics and patterns of assault-related maxillofacial fractures as reported by a European multicenter prospective study. STUDY DESIGN: Demographic and injury data were recorded for each patient who was a victim of an assault. RESULTS: Assaults represented the most frequent etiology of maxillofacial trauma with an overall rate of 39% and the values ranging between 60.8% (Kiev, Ukraine) and 15.4% (Bergen, Norway). The most frequent mechanisms of assault-related maxillofacial fractures were fists in 730 cases, followed by kicks and fists. The most frequently observed fracture involved the mandible (814 fractures), followed by orbito-zygomatic-maxillary complex fractures and orbital fractures. CONCLUSIONS: Our data confirmed the strong possibility that patients with maxillofacial fractures may be victims of physical aggression. The crucial role of alcohol in assault-related fractures was also confirmed by our study.

European Maxillofacial Trauma (EURMAT) in children: a multicenter and prospective study.

OBJECTIVE: The aim of this study is to present and discuss the results of a European multicentre prospective study about pediatric maxillofacial trauma epidemiology during a year. STUDY DESIGN: The following data were recorded: gender, age, etiology, site of fracture, date of injury. Of the 3396 patients with maxillofacial fractures admitted within the study period, 114 (3.3%) were children aged 15 years and younger, with a male/female ratio of 2.6:1. Mean age was 10.9 years. Most patients (63%) were aged 11-15 years. RESULTS: The most frequent cause of injury was fall (36 patients). Sport injuries and assaults were almost limited to the oldest group, whereas falls were more uniformly distributed in the 3 groups. The most frequently observed fracture involved the mandible with 47 fractures. In particular, 18 condylar fractures were recorded, followed by 12 body fractures. CONCLUSIONS: Falls can be acknowledged as the most important cause of facial trauma during the first years of life. The high incidence of sport accidents after 10 years may be a reason to increase the use of mouthguards and other protective equipment. Finally, the mandible (and in particular the condyle) was confirmed as the most frequent fracture site.

European Maxillofacial Trauma (EURMAT) project: a multicentre and prospective study.

The purpose of this study was to analyse the demographics, causes and characteristics of maxillofacial fractures managed at several European departments of oral and maxillofacial surgery over one year. The following data were recorded: gender, age, aetiology, site of facial fractures, facial injury severity score, timing of intervention, length of hospital stay. Data for a total of 3396 patients (2655 males and 741 females) with 4155 fractures were recorded. The mean age differed from country to country, ranging between 29.9 and 43.9 years. Overall, the most frequent cause of injury was assault, which accounted for the injuries of 1309 patients; assaults and falls alternated as the most important aetiological factor in the various centres. The most frequently observed fracture involved the mandible with 1743 fractures, followed by orbital-zygomatic-maxillary (OZM) fractures. Condylar fractures were the most commonly observed mandibular fracture. The results of the EURMAT collaboration confirm the changing trend in maxillofacial trauma epidemiology in Europe, with trauma cases caused by assaults and falls now outnumbering those due to road traffic accidents. The progressive ageing of the European population, in addition to strict road and work legislation may have been responsible for this change. Men are still the most frequent victims of maxillofacial injuries.

A Diagnostic Conundrum: Ectopic Nasal Ossification, Submucosal Alveolar Cleft, Absent Posterior Atlantal Arch, and Corpus Callosum Lipoma.

A 19-year-old woman was referred for nasal breathing and aesthetic concerns regarding her nose. A computed tomography scan revealed a massive osseous shield anterior to the piriform aperture. Furthermore, there was a submucosal median alveolar cleft, and the posterior arch of C1 was missing. The magnetic resonance imaging brain scan revealed a curvilinear lipoma of corpus callosum. The ectopic nasal bone was removed by open rhinoplast,y and nasal function and aesthetics were restored. The described features defy conventional clinical diagnosis and severity classifications and present a diagnostic conundrum somewhere between a mild form of frontonasal dysplasia, oculoauriculofrontonasal syndrome, and Pai syndrome.

Soft tissue changes after mandibular setback and bimaxillary surgery in Class III patients.

OBJECTIVE: To evaluate the relationship between soft tissue and bone structure for Class III patients before and after bilateral sagittal split osteotomy (BSSO) and bimaxillary orthognathic surgery; to determine the impact of other factors on soft tissue change; and to evaluate correlations between thickness of tissue before surgery, SNA, SNB, and ANB angles, and soft tissue changes. MATERIALS AND METHODS: The study included 78 Class III patients treated only with BSSO or with BSSO and Le Fort I osteotomy. Lateral cephalograms were taken before and 3 months to 1 year after surgery. After all points of the Zagreb82 and Legan and Burstone profile analysis were traced, the ratio of five soft tissue points before and after surgery was evaluated. RESULTS: Soft tissue between points Sn and A and upper lip showed statistically significant changes for patients treated with bimaxillary surgery and BSSO. Only gender had an influence on soft tissue change. The correlation between soft tissue thickness and changes after surgery was significant. A change in SNB angle correlated with upper lip thickness for patients treated with BSSO but not for patients treated with BSSO and Le Fort I. SNA angle changes correlated with soft tissue changes between points Sn and A. CONCLUSION: Results of this study show soft tissue changes after BSSO and BSSO and Le Fort I and eliminate the deficiencies that were indicated in the meta-analysis of soft tissue changes from a previous study.

Advanced atherosclerosis of the vascular pedicle of radial forearm free flap in head and neck diabetic patient.

This study reports a case of severe atherosclerosis of the radial artery encountered during raising of a radial forearm free flap in a 56-year-old head and neck diabetic patient which precluded the use of the flap. This is a condition which most reconstructive surgeons are not aware of.

Brown class III maxillectomy defects reconstruction with prefabricated titanium mesh and soft tissue free flap.

BACKGROUND: Midface reconstruction is one of the most challenging tasks for the reconstructive surgeon. We present a technique for the reconstruction of the midface after total maxillectomy with preservation of orbital contents. METHODS: Skeletal reconstruction is achieved with a preoperatively bent titanium sheet mesh on a universal skeletal model. The alveolar ridge, the anterior wall of the maxillary sinus, the zygomatic prominence, the lower orbital rim, and the orbital floor are reconstructed with a titanium mesh. A soft tissue free flap, preferably anterolateral thigh free flap, is harvested as well. A part of the flap is deepithelized and put in front of the mesh to prevent exposure, and the other part is used for palatal reconstruction. RESULTS: Four male and 1 female patients were reconstructed with titanium mesh. Four free flaps were raised: 3 anterolateral thigh and 1 latissimus dorsi. All free flaps survived. All patients received postoperative irradiation with 64 Gy. Median follow-up was 12 months; no major complications occurred. Mesh was exposed in only 1 case, which was managed successfully with resuspension of the heavy latissimus dorsi myocutaneous flap. Midface projection and height, globe position, ocular movements, and vision where satisfactory in all cases. CONCLUSIONS: Midface reconstruction with titanium mesh and soft tissue free flap is a reliable and safe method for functional and aesthetic reconstruction after maxillectomy.

Modified Millard's technique in operations for unilateral cleft lip.

Many approaches have been described, but the rotation-advancement technique described by Millard remains one of the most popular repair techniques for correction of cleft lip. The technique described here is a modified method that can be used in primary cleft surgery but also for secondary correction, using the same incision with a small modification in design. Thirty-two patients were followed up for two years, all of whom had good postoperative results without secondary correction. The modification provides rotation and elongation of the lip where it is needed. This technique can be useful for all aspects of secondary cleft lip correction, but is also useful in primary surgery when the cleft side is too short.

Altered light-touch sensation after bilateral sagittal-split osteotomy: a prospective study of 50 patients.

OBJECTIVE: To prospectively evaluate the incidence of change in light-touch sensation in the innervated area of the lower alveolar nerve after bilateral sagittal-split osteotomy (BSSO) with attention on the time it takes to rebuild the function of the inferior alveolar nerve. MATERIALS AND METHODS: The sample consisted of 30 women and 20 men with a mean age of 22.14 ± 3.30 years. The neurosensory test was conducted with a 20-mm long monofilament of suture material Prolene (3-0) connected to a plastic holder. These tests were performed 1 day before surgery and every 2 weeks during first 2 months after surgery. After that, patients were tested once every month until the end of the first year. RESULTS: All patients had a disturbance of light-touch sensation after BSSO, but none of these changes was permanent. The average duration of hypoesthesia was 6.6 ± 1.2 with a range from 4 to 9 months. The average duration of hypoesthesia for women was 6.27 ± 1.0 months, and men had hypoesthesia for 7.1 ± 1.2 months on average. This difference was statistically significant. The two oldest female patients, who were 33 and 37 years old at the time of the surgery, experienced altered sensitivity for only 4 months. CONCLUSIONS: After BSSO, all patients experienced disturbed light-touch sensation in the innervated area of the lower alveolar nerve. A faster recovery in the oldest patients and a statistically significant difference between the sexes should be interpreted with caution.

Maxillary fragment stabilization after Le Fort I fracture with 1 screw pair per plate.

PURPOSE: The aim of the present study was to determine whether plates with only 1 screw pair can be used for Le Fort I fracture management. Good postoperative results motivated the direct application of mandible fixation principles to the fractured midface region without additional experimental research. However, the amount and distribution of the forces in the midface region is different from those on the mandible. MATERIALS AND METHODS: Testing was conducted on plastic anatomic models. The validity of the experimental model was tested before the fixation techniques were compared. Standard miniplates and miniscrews were used for fixation of the maxilla. The model surface strain analysis was conducted using the noncontact object grating method, which enabled the surface strain measurement without direct influence on the measured model. RESULTS: In 2 screw pair fixation, the outer screw pair has little effect on the local strain distribution, but it lowers the contact forces along the crack. One screw pair fixation is stable enough for fixation, but it has a greater strain peak at the crack edges. CONCLUSION: Our results showed that 1 screw pair per plate was enough for stable fixation, and 2 or more screw pairs should only be used when the bone fragment at the fracture site cannot sufficiently transmit forces along the crack.

Protective intramedullary fixation after harvest of an osteocutaneous radial free flap.

The osteocutaneous radial free flap, even after 30 years, is still considered to be the "workhorse" for head and neck reconstruction. A high incidence of donor site fractures has remained a major problem, however. The technique described here is a method developed for the prophylaxis of fractures of the donor site of the harvested radial bone and is based on a modification of the intramedullary Rush nail fixation. The data were collected from 18 patients in whom the radial forearm free flap had been used during reconstruction. None of the prophylactically-nailed radii fractured. The complications experienced with this technique are general complications, such as scarring of the forearm and dehiscence of the wound. This technique is simple, and has given excellent results. Aesthetic and functional results were comparable to those of other flaps used for reconstruction. We recommend this technique because of its simplicity, vascular safety, and cost effectiveness.

Latissimus dorsi-scapula free flap for reconstruction of defects following radical maxillectomy with orbital exenteration.

A total of 21 patients with latissimus dorsi-scapula free flap reconstruction immediately following radical maxillectomy together with orbital exenteration are presented. Orbital exenteration was performed in all patients due to tumour invasion at the time of diagnosis. There was no total flap failure. Two tissue components subdivided into separate flap units with individual vascular pedicles linked by a single vascular source provide an ideal reconstructive solution for massive defects of the mid-face and orbit. Separate arcs of rotation of each flap unit permit greater mobility necessary for complex three-dimensional reconstruction. A vertically positioned angle of the scapula enables simultaneous reconstruction of the malar eminence and alveolar ridge whereas spontaneous intraoral epithelialisation of the latissimus dorsi muscle requires no additional procedure. For these reasons, in our opinion, combined latissimus dorsi-scapula free flap should be considered the first choice in reconstruction of defects following total maxillectomy with orbital exenteration.

The pectoralis major flap in head and neck reconstruction: first 500 patients.

AIM: The aim of this study was to evaluate almost 20 years of using the pectoralis major flap in head and neck reconstruction at the Department of Maxillofacial Surgery, Zagreb. PATIENTS: In the period from 1981 to 1999, a total of 506 pectoralis major flaps were used for head and neck reconstruction in 500 patients. In all cases the flap was used after surgical resection of an advanced malignant tumour of the head and neck. RESULTS: The tumours were intraoral in 387 cases (77%), pharyngeal in 78 cases (15%) and on the skin in 10 cases (5%). The defect was located in the mucosal lining in 407 (81%), skin in 43 (8%), both intra- and extraoral in 53 (10%) patients. Bone defects occurred in 65 patients. In 31 patients (6%), the pectoralis major flap was used in combination with other flaps (deltopectoral, tongue, trapezius and free flaps). Complications occurred with 168 flaps (33%), but total flap necrosis was only seen in 10 patients (2%). Surgical treatment of complications was necessary in 87 patients (17%). CONCLUSION: Despite the increasing use of microvascular reconstruction, the pectoralis major myocutaneous flap continues to be the most universal major flap in head and neck reconstruction.

Madelung syndrome (benign lipomatosis): clinical course and treatment.

Madelung syndrome is a rare disease found predominantly in the Mediterranean area. It has a distinctive clinical appearance. Staged surgery is the treatment of choice, which produces substantial improvement in both functional and aesthetic appearance. Recurrences usually occur when it is impossible to resect the disease completely.