Eric J. Dierks

Computer Planning and Intraoperative Navigation for Palatomaxillary and Mandibular Reconstruction With Fibular Free Flaps

a m The loss of mandibular continuity or palatal integrity as a result of ablative tumor therapy or severe trauma is physiologically and psychologically debilitating. The utility of the free fibular osteocutaneous flap (FFOF) for mandibular reconstruction was recognized and subsequently popularized by Hidalgo in 1989. Since that time, the FFOF has been shown to be a highly reliable flap for the reconstruction of mandibular continuity defects and is an important option for alatomaxillary reconstruction. The fibula has a thick outer cortex that provides up to 22 to 25 cm of bone for use in re-establishing continuity of the mandible and can be transferred as an osteocutaneous or osteofascial flap. The advantage of the fibular osteocutaneous flap is that its constant topography provides ease of harvest that can be performed simultaneously with head and neck extirpative procedures with little do-

Analysis of Microvascular Free Flaps for Reconstruction of Advanced Mandibular Osteoradionecrosis: A Retrospective Cohort Study

PURPOSE Previous studies have suggested that radiation therapy does not impact local complication rates after microvascular free flap (MVFF) reconstruction for head and neck cancer. There is little data, however, indicating whether or not the presence of osteoradionecrosis (ORN) affects treatment outcome. The purpose of this retrospective cohort study is to review the outcome of patients undergoing MVFF reconstruction for ORN and to determine if there is a difference in outcome and/or complications when compared to similarly reconstructed patients who received radiation therapy but did not develop ORN, as well as un-radiated controls. PATIENTS AND METHODS The records of 305 consecutive patients who underwent MVFF reconstruction for a variety of cancer-related therapies or post-traumatic craniofacial defects from 1994 to 2004 were reviewed. Of these, all patients who underwent surgery for Marx stage III ORN involving the mandible were identified (n = 21). For purposes of comparison, patients who received preoperative radiation therapy (XRT) and underwent similar reconstruction but did not have ORN were identified and included in the study group. Similarly matched patients who never received XRT served as controls. Patients were reconstructed with a variety of MVFFs harvested from the fibula (n = 48), radial forearm (n = 11), rectus abdominus (n = 3), latissimus dorsi (n = 3), serratus anterior (n = 1) and iliac crest (n = 1). The study cohort was divided according to XRT status: group 1 (ORN), patients that received XRT and developed ORN (n = 21); group 2 (no ORN), patients that received XRT but did not develop ORN (n = 21); and group 3 (control), patients that never received XRT (n = 25). The following data were collected: age, gender, diagnosis, recipient site, donor site, hyperbaric oxygen therapy (HBO), flap complications, flap survival, patient survival. Outcome measures were defined as flap survival, complications and resolution of ORN. Descriptive statistics were recorded and an analysis of variance was calculated to evaluate differences between the 3 groups. The Fishers exact test was used to evaluate whether a complication occurred more frequently in any one particular group. RESULTS The mean age of the 67 patients included in the study was 57 years (SD = 15.4) years (M = 32, F = 35) and there were no significant demographic differences between the 3 groups (P = .8528). All patients were successfully reconstructed although 21% required reoperation for various reasons. Overall flap survival was 88% (ORN = 86%, no ORN = 87%, control = 90%) and there was no difference between the 3 groups studied (P = 1.0). Complications were evenly distributed among the 3 groups (50% overall) and included skin necrosis (P = .824), wound infection (P = .6374), salivary fistula (P = .1178), and partial flap loss (P = 1.0). Carotid blowout occurred in 2 patients in the ORN group, however, this was not statistically significant (P = .1844). Fourteen of the 21 patients in the ORN group had received preoperative HBO. CONCLUSION Overall MVFF survival and complication rates among patients with ORN versus control groups are the same in this study cohort. Free tissue transfer is a viable option for advanced mandibular ORN.

Survival analysis and risk factors for recurrence in oral squamous cell carcinoma: does surgical salvage affect outcome?

PURPOSE The purpose of this retrospective study was to review the outcomes and recurrence rates of subjects with oral cavity squamous cell carcinoma treated at a single institution by primary surgical resection, with or without adjuvant radiation or chemotherapy, to identify factors that affect locoregional control and determine whether surgical salvage affects survival. MATERIALS AND METHODS The records of 157 subjects diagnosed with oral cavity squamous cell carcinoma treated at a single institution from 1997 to 2007 were identified. Data on demographics, site, clinical stage, pathologic stage, treatment, recurrence, and survival were collected. Defined outcome measures were overall survival, disease-free survival, and length of survival after recurrence. Analysis of the data was performed by use of the Cox proportional hazards model. Kaplan-Meier survival curves were created for disease-free survival, as well as survival by histologic grade, nodal status, recurrence, and tumor stage. RESULTS We identified 157 subjects, with 155 meeting the inclusion criteria. The overall 5-year survival rate was 48%, with a disease-free survival rate of 42% (95% confidence interval, 36%-53%). Survival was found to be influenced by stage (P = .0001), nodal status (P = .0025), and histologic grade (P = .04). There were 24 subjects with recurrence (15%). Of these, 11 had local recurrence (46%), 9 had regional recurrence (37%), 2 had distant recurrence (8%), 1 had both local and regional recurrence (4%), and 1 had both local and distant metastasis (4%). Recurrence was not found to be significantly affected by pathologic stage (P = .71), clinical stage (P = .6), histologic grade (P = .178), postoperative radiation therapy (P = .54), postoperative chemotherapy (P = .66), N-positive status (P = .71), or whether the subject underwent a neck dissection (P = .984). Surgery significantly increased both overall survival time (P = .009) and survival time after recurrence (P = .006). Radiation therapy (P = .4) and chemotherapy (P = .82) did not have a survival benefit as therapy for recurrence. CONCLUSIONS Survival is influenced by stage at presentation, nodal status, and histologic grade. No variables were found to influence recurrence rates. Surgery significantly increased overall survival time, and salvage surgery increased survival after recurrence.

Congenital Neck Masses

Congenital neck lesions reflect abnormal embryogenesis in head and neck development. A thorough knowledge of embryology and anatomy is critical in the diagnosis and treatment of these lesions. The appropriate diagnosis of these lesions is necessary to provide appropriate treatment and long-term follow up, because some of these lesions may undergo malignant transformation or be harbingers of malignant disease.

Oral maxillary squamous carcinoma: An indication for neck dissection in the clinically negative neck

This multicenter study was undertaken to characterize the metastatic behavior of oral maxillary squamous carcinoma and to determine the role of selective neck dissection.

Does intraoperative navigation restore orbital dimensions in traumatic and post-ablative defects? ☆

BACKGROUND The outcomes of the reconstruction of post-ablative and post-traumatic orbital defects are often unpredictable when considering the restoration of the orbital dimensions. Intraoperative navigation offers the surgeon visualization of bony landmarks via comparison to preoperative computed tomography, aiding in bony reduction and implant placement. The purpose of this study was to assess whether intraoperative navigation-guided orbital reconstruction re-establishes orbital volume and globe projection in subjects with post-ablative and post-traumatic orbital defects. MATERIAL AND METHODS The investigators initiated a retrospective cohort study and enrolled a sample of subjects that underwent primary or secondary reconstruction for unilateral orbital deformities secondary to traumatic injury or tumour surgery. Pre- and post-operative orbital volume and globe projection were measured using Analyze (Mayo Clinic Biomedical Imaging Resource, Rochester, MN, USA). A matched pairs t-test was used to assess the difference in pre- and post-operative orbital volume and globe projection. RESULTS Twenty-three subjects underwent intraoperative navigation-guided orbital reconstruction. The mean difference in orbital volume and globe projection between the non-operated orbit and operated orbit in the post-operative period was -1.3 cm(3) and 2.4mm respectively. Both final measurements were within the margin of error of clinically noticeable enophthalmos. The mean absolute difference in orbital volume and globe projection between the pre- and post-operative period was 5.1 cm(3) (p=<0.001) and 4.1mm (p=<0.001) respectively. CONCLUSION The results of this study suggest that orbital reconstruction using intraoperative navigation is effective in establishing normal orbital volume and globe projection in post-traumatic and post-ablative defects, therefore restoring the orbit and globe to pre-traumatic and pre-ablative conditions.

Treatment options for the recurrent odontogenic keratocyst

The odontogenic keratocyst (OKC) is a cystic disease with no real metastatic potential. As long as lesion of odontogenic origin that demonstrates the behavioral characteristics of a benign neoplasm and has a propensity to recur after surgical treatment. Studies published over the last three decades have reported recurrence rates after initial treatment with various procedures that ranged from 2.5% to 62.5% [1–21]. Myriad surgical strategies have been proposed to facilitate complete removal of the lesion and minimize recurrent or residual disease [1,4,10,12,18, 22–27]. A greater understanding of the clinical behavior of the OKC has prompted more meticulous surgery with or without peripheral ostectomy, tissue fixation methods, soft tissue excision, radical treatment when necessary, and more conscientious follow-up. The optimum treatment modality has yet to be realized. The aggressive nature of keratocysts has been documented in numerous case reports and is illustrated by cortical erosion [28], soft tissue involvement [29], and extension into the skull base [30,31], orbit [11], and infratemporal fossa [32]. Research has suggested that the OKC should be regarded as a benign cystic neoplasm, and evolving evidence supports this contention [33–36]. It seems that the OKC should be managed with the same respect given to other odontogenic and nonodontogenic jaw tumors. Resection has proved to be the most predictable treatment, but the morbidity associated with reconstructing continuity defects of the mandible or ablative defects of the maxilla seems unwarranted in most instances for a

Vascularized Options for Reconstruction of the Mandibular Condyle

The temporomandibular joint is elegant in its design, which may make it difficult if not impossible to comprehensively reconstruct. Although a broad range of nonvascularized options exists for reconstruction of degenerative conditions of the temporomandibular joint, vascularized reconstructions such as the fibula or the second metatarsal phalangeal joint are more appropriate for defects resulting from oncologic resection or in patients with compromised soft tissue. An anatomically based classification system for these defects is presented.

Reliability of Intraoperative Navigation in Restoring Normal Orbital Dimensions

PURPOSE To assess the reliability and effectiveness of intraoperative navigation in restoring normal orbital and globe dimensions in traumatic and postablative orbital defects. MATERIALS AND METHODS To address the research purpose, the investigators initiated a retrospective cohort study and enrolled a sample of subjects that underwent primary or secondary reconstruction for unilateral orbital deformities secondary to traumatic injury or tumor surgery during the study enrollment period. Using computed tomographic datasets, pre- and postoperative orbital volume and globe projection were measured using Analyze software (Mayo Clinic Biomedical Imaging Resource, Rochester, MN). Intraclass correlation coefficient (ICC) was used to evaluate the reliability between preoperative unaffected orbit and the postoperative affected orbital and globe dimensions. A matched pairs t test was used to assess the difference in pre- and postoperative orbital volume and globe projection. RESULTS The sample was composed of 23 subjects that underwent orbital reconstruction secondary to traumatic of postablative defects. There was a linear and reliable relationship between preoperative unaffected and postoperative affected orbital volumes (ICC, 0.67; 95% CI, 0.37 to 0.86), and preoperative unaffected and postoperative affected globe projections was high (ICC, 0.87; 95% CI, 0.69 to 0.94). There was a significant difference in pre- and postoperative mean orbital volume (30.6 vs 25.5 cm(3), P ≤ 0.001), and pre- and postoperative globe projection (51.2 vs 53.6 mm, P ≤ 0.001). CONCLUSIONS The results of this study suggest that intraoperative navigation-assisted orbital reconstruction is reliable in restoring orbital volume and globe projection to pretraumatic and preablative conditions.

Management of Laryngeal Trauma

Fractures of the larynx are uncommon injuries that may be associated with maxillofacial trauma. Clinicians treating maxillofacial injuries should be familiar with the signs and symptoms of laryngeal fractures and with proper airway management. A timely evaluation of the larynx, rapid airway intervention, and proper surgical repair are essential for a successful outcome.