Screw-wire osteo-traction: an adjunctive or alternative method of anatomical reduction of multisegment midfacial fractures? A description of technique and prospective study of 40 patients.

Stable anatomical fracture reduction and segment control before miniplate fixation can be difficult to achieve in comminuted midfacial fractures. Fracture mobilization and reduction methods include Gillies elevation, malar hook, and Dingman elevators. No single method is used universally. Disadvantages include imprecise segment alignment and poor segment stability/control. We have employed screw-wire osteo-traction (SWOT) to address this problem. A literature review revealed two published reports. The aims were to evaluate the SWOT technique effectiveness as a fracture reduction method and to examine rates of revision fixation and plate removal. We recruited 40 consecutive patients requiring open reduction and internal fixation of multisegment midfacial fractures (2009-2012) and employed miniplate osteosynthesis in all patients. SWOT was used as a default reduction method in all patients. The rates of successful fracture reduction achieved by SWOT alone or in combination and of revision fixation and plate removal, were used as outcome indices of the reduction method effectiveness. The SWOT technique achieved satisfactory anatomical reduction in 27/40 patients when used alone. Other reduction methods were also used in 13/40 patients. No patient required revision fixation and three patients required late plate removal. SWOT can be used across the midface fracture pattern in conjunction with other methods or as a sole reduction method before miniplate fixation.

A presentation of facial necrotizing fasciitis with orbital involvement.

Necrotizing fasciitis is a rare, severe, life-threatening soft tissue infection. Rapid progression and systemic illness are recognized features of the condition in which a high index of suspicion is essential to prompt early diagnosis and ensure a favourable outcome. Management necessitates immediate and aggressive surgical and antimicrobial treatment. This case report describes the rare presentation of facial necrotizing fasciitis with orbital involvement that required initial and subsequent widespread surgical resection within the first 24 h of admission, including unilateral enucleation of infected orbital contents.

Tumour recurrence after surgical removal of parotid pleomorphic salivary adenoma using a retrograde facial nerve dissection technique.

Recurrence after surgical removal of parotid pleomorphic salivary adenoma using retrograde facial nerve dissection is not well researched. We adopted retrograde nerve dissection for parotid surgery for benign disease as a standard procedure in 1995. The objective of this study was to establish the rate of recurrence of primary tumours associated with the technique after removal of parotid pleomorphic salivary adenoma. We recruited 59 patients over a 16-year (1995-2011) period and collected the data prospectively. Eight patients were excluded as they had died or had been lost to follow up. Male:female ratio was 16:35 and age range was 15-69 years. The mean tumour size as measured on magnetic resonance imaging (MRI) was 27.4mm. Thirty-eight patients had superficial parotidectomy, 8 had total parotidectomy, and 5 had partial superficial parotidectomy. Mean follow up from the date of operation was 104 months (median 98, range 17-171). All patients were reviewed and examined in 2011 to establish whether the tumour had recurred. One patient had developed a solitary nodular recurrence 8 years after the initial procedure. Recurrence was 2%. The rate of clinically apparent recurrence after parotidectomy for pleomorphic salivary adenoma in this study is low and is comparable with others reported.

Comparison of facial nerve injury and recovery rates after antegrade and retrograde nerve dissection in parotid surgery for benign disease: prospective study over 4 years.

The facial nerve can be dissected using an antegrade or retrograde approach. Antegrade dissection is the established technique and retrograde dissection is used less often. Recent publications have drawn attention to the potential value of the retrograde technique particularly if direct identification of the nerve trunk is difficult, and in revision procedures. We prospectively studied 43 consecutive procedures in 40 patients who had parotidectomy over a 4-year period, and evaluated and compared rates of temporary and permanent nerve injury, and nerve recovery after antegrade and retrograde dissection in operations for benign parotid disease. Each patient was allocated randomly to the antegrade (n=20) or retrograde (n=20) groups. Three patients were excluded. All patients had peroperative nerve monitoring and were followed up at 1 week, 1 month, 3 months, or to full recovery of the nerve. The House-Brackmann (HB) grading system was used to assess the degree of injury to the nerve. A high rate of serious nerve injury (HBIII or above) was associated with retrograde dissection at 1 week. Serious nerve injuries (HBIII or above) were slow to recover after the antegrade technique at 3 months. There was no difference between groups in the rates of full nerve recovery at 6 months.

Provision of oral medicine in departments of oral and maxillofacial surgery in the UK: national postal questionnaire survey 2009.

We investigated the current provision of oral medicine in oral and maxillofacial (OMF) departments in the UK. We examined the number of specialists in oral medicine in OMF departments, the training given to OMF consultants in oral medicine, and the estimated time dedicated to treating patients with oral medical conditions in outpatient clinics. We also examined the pattern and reasons for onward referrals to departments of oral medicine. A postal questionnaire was sent to 300 OMF consultants and was returned by 183 (61%). Sixteen (9%) of the responding consultants had a registered specialist qualification in oral medicine with the General Dental Council (GDC), 15 (8%) had a degree in oral medicine, and 4 (2%) had a diploma. One hundred and eighteen (64%) consultants had been given formal training in oral medicine during their training as registrars. Time dedicated to oral medicine in outpatient clinics varied between less than 20% and more than 40% of total outpatient time. Sixteen surgeons (9%) referred 1-2 patients/week to departments of oral medicine, and 19 (10%) referred 2-4/month. Reasons for referral included need for specialist expertise, failure of treatment, and lack of time in outpatients. The proposal for a dentally qualified consultant-led oral medicine service was supported by 70 responding surgeons (38%).

Ipsilateral removal of sublingual gland after excision of submandibular gland for benign disease: 10-year prospective study and comprehensive review 1978-2008.

The removal of the submandibular salivary gland for non-neoplastic disease is a common procedure that has well documented risks and postoperative complications. Persistent symptoms of pain and swelling in the floor of the mouth that can occur after excision of the submandibular gland may require removal of the sublingual gland, but a causative association between the two has not, to our knowledge, been comprehensively established. We prospectively studied 77 patients who had had excision of the submandibular gland for benign disease, six of whom (8%) returned to theatre for ipsilateral sublingual sialadenectomy within a 5-year period after the initial operation (mean 24 months). These findings suggest that the association is under-reported, and may need to be considered during the consent process for excision of the submandibular salivary gland.

Incidence of hypertrophic and keloid scars after N-butyl 2-cyanoacrylate tissue adhesive had been used to close parotidectomy wounds: a prospective study of 100 consecutive patients.

Suturing is the usual technique for cutaneous wound closure after parotidectomy and gives a satisfactory aesthetic appearance for most patients. Late complications include the development of hypertrophic and keloid scars, the incidence of which ranges from 5% to 16% in elective cases. We studied the use of N-butyl 2-cyanoacrylate (Indermil) for closure of parotid wounds in 100 consecutive patients over a period of 7 years, our main aim being to establish the incidence of hypertrophic and keloid scars after the use of Indermil. We also wanted to explore the potential advantages of this technique as an alternative method of wound closure. The incidence of hypertrophic and keloid scars was 8 and 9, respectively. The technique is simple and safe, and the incidence of hypertrophic and keloid scars within the accepted range for sutures.

Techniques for dissection of the facial nerve in benign parotid surgery: a cross specialty survey of oral and maxillofacial and ear nose and throat surgeons in the UK.

We investigated techniques of dissection of the facial nerve currently being used in parotid surgery for benign disease in oral and maxillofacial (OMF) and ear, nose and throat (ENT) surgery. A postal questionnaire was sent to 300 OMF and 300 ENT consultants and 49% were returned(171(57%) OMF and 123 (41%) ENT. The antegrade technique was used routinely by 209 surgeons (87%), the retrograde technique by 9 (4%), and both techniques combined by 21 surgeons (9%). The antegrade technique was used by 135 surgeons (56%) for revision parotidectomy, by 193 (81%) for limited superficial parotidectomy, by 173 (72%) for obese patients with large tumours and by 75 (31%) for injury to the facial nerve. The retrograde technique was used by 21 surgeons (9%) for revision parotidectomy, by 22 (9%) for limited superficial parotidectomy, by 15 (6%) for obese patients with large tumours and by 29 surgeons (12%) for injury to the facial nerve. A combination of techniques was chosen by 83 surgeons (35%) in revision parotidectomy, by 24 surgeons (10%) in limited superficial parotidectomy, by 51 surgeons (21%) in obese patients with large tumours and by (56%) surgeons 135 for injury to the facial nerve.

Prospective study of the incidence of serious posterior maxillary haemorrhage during a tuberosity osteotomy in low level Le Fort I operations.

The incidence of serious haemorrhage in Le Fort I osteotomy is low and attempts to reduce this further have led to the development of various techniques to minimise vascular injury. This includes the tuberosity osteotomy and was published over two decades ago. This technique has not been widely adopted as shown by a recent UK survey of consultants, which suggested that only 12 (7%) of the 175 surgeons who responded, routinely use tuberosity osteotomy in non-cleft low level Le Fort I procedures. The aim of the study was to examine prospectively the incidence of serious haemorrhage from the posterior maxilla during tuberosity osteotomy. We report 35 consecutive patients who have had no operative or postoperative vascular complications.

Facial nerve morbidity after retrograde nerve dissection in parotid surgery for benign disease: a 10-year prospective observational study of 136 cases.

We evaluated the facial nerve function in 136 patients who had had retrograde nerve dissection during parotidectomy for benign disease. One week after the operation 90 patients (66%) had some weakness of the facial nerve. After 1 month 52 (38%) had facial nerve paresis. After 3 months 114 (84%) had recovered fully and 21 (16%) had minor nerve paresis. After 6 months 135 (99%) had normal nerve function. One patient had persistent marginal mandibular nerve paresis.

Sclerosing polycystic adenosis of the parotid gland.

Sclerosing polycystic adenosis of the major salivary glands is rare and can simulate a slow growing tumour. It is pseudoencapsulated and includes tubuloacinar adenosis with dilated ducts, apocrine metaplasia, epithelial hyperplasia, and cystic changes associated with fibrosis. The histological appearance of the lesion is similar to that of fibrocystic disease of the breast. The multifocal nature of the lesion makes its management difficult. We report a case of sclerosing polycystic adenosis in a 45-year-old white woman.

Pterygomaxillary separation in Le Fort I osteotomy UK OMFS consultant questionnaire survey.

Pterygomaxillary osteotomy or leverage alone is commonly used to achieve separation of the posterior maxilla from the pterygoid process in the Le Fort I osteotomy. An osteotomy of the tuberosity is less often used. No published data exist on the extent to which surgeons in the UK have adopted these techniques or on the incidence of technique-related vascular complications. We aimed to investigate techniques that are currently used for pterygomaxillary separation and maxillary mobilisation, and the incidence of serious vascular complications among orthognathic surgeons in the UK in 2004. A questionnaire was sent to 301 oral and maxillofacial (OMFS) consultant surgeons in the UK and 205 were returned (response rate 68%). Most of these surgeons (78%) reported that they use an osteotome or a micro-oscillating saw for pterygomaxillary separation. The others use leverage alone or osteotomy of the tuberosity. Eleven (8%) of the surgeons who use a pterygomaxillary osteotome reported that they had had a serious vascular complication in the past year. There were no vascular complications reported by surgeons who use leverage alone or osteotomy of the tuberosity.