Eugenia Popescu

A new approach to aesthetic maxillofacial surgery: surgical treatment of unilateral exophthalmos due to maxillary sinus mucocele.

AbstractMaxillary sinus mucocele, known as a rare condition, can cause major therapeutic difficulties, especially when it invades the orbit leading to exophthalmia. Treatment is very difficult because the eye globe has to be repositioned, and the facial symmetry needs to be reconstructed as a result of malar bone invasion. This article reports the case of a 54-year-old patient with unilateral exophthalmia caused by the evolution of a maxillary mucocele that extended toward the orbit after destroying the malar bone and the orbital floor. The treatment consisted of a 1-step restoration of both the orbit floor and the malar bone using a temporomandibular flap composed of 2 bone fragments. Lipostructure and a titanium mesh to reconstruct the calvarial defect were necessary to restore facial aesthetics after placing back the eye globe in its initial site. After surgery, the patient followed a complex rehabilitation program including massage kinesiotherapy and psychological consultation and support. These had an essential contribution to the successful final outcome in terms of psychological impact, functionality, and aesthetics.

Role of mucosal high-risk human papillomavirus types in head and neck cancers in Romania

Background Limited information is available about the involvement of human papillomavirus (HPV) in head and neck squamous cell carcinomas (HNSCCs) in Romanian patients. Objective To evaluate the HPV-attributable fraction in HNSCCs collected in Northeastern Romania. Materials and methods In total, 189 formalin-fixed paraffin-embedded tissue samples (99 oral cavity tumors, 28 oropharynx, 48 pharynx, and 14 larynx/hypopharynx) were analyzed for HPV DNA and RNA using Luminex-based assays, and for overexpression of p16INK4a (p16) by immunohistochemistry. Results Of the 189 cases, 23 (12.2%) were HPV DNA-positive, comprising half of the oropharyngeal cases (14/28, 50.0%) and 9/161 (5.6%) of the non-oropharyngeal cases. HPV16 was the most prevalent HPV type (20/23, 86.9%), followed by HPV18 (5/23, 21.7%) and HPV39 (1/23, 4.3%). Only two (2/189, 1.1%) HNSCC cases were HPV-driven, i.e. positive for both HPV DNA and RNA. Conclusion A very small subset of HNSCC cases within this cohort from Northeastern Romania appeared to be HPV-driven.

The Use of Radial Free Flap to Reconstruct Defects After Extended Parotidectomy

The use of forearm free flap for reconstruction after extended parotidectomy is suitable for large superficial defects which may involve the skin, external and medial ear, zygomatic arch, and lateral part of malar bone. Due to its big surface and pliability, this flap is useful for extended and irregular skin defects. It is not ideal for deep defects with mandible or skull base resection in which cases we cannot achieve a good functional and aesthetic result. Not all patients with extended parotid tumors need resection of the facial nerve, but due to tumor status, such as extension, perineural spreading, histological pattern, and grading, most of them will undergo postoperative irradiation. For these cases, the flap ensures a good protection of the facial nerve against radiotherapy. A major disadvantage of this flap is the aesthetical appearance of donor site. In some cases, depending on the resected structures, such as bones, there might be postoperative facial asymmetry, which can be addressed later with lipostructure, leading to good aesthetic and functional outcome. Another immediate postoperative inconvenience is the color difference between the flap and recipient site, but later this will fade away.

Extended Metastatic Tumours to the Parotid Gland

The parotid gland’s unique characteristic among other glands is the presence of lymph nodes within the glandular tissue. This contributes greatly to the variety of the tumours that can be found here, by either primary malignancy arising in the parotid nodes or by the presence of lymphatic metastasis that exhibits the characteristics of the tissue of origin. The most common type of malignancy that can lead to lymph node metastasis with this location is represented by skin cancer in the territory of drainage, especially high-risk squamous cell carcinoma.

Attitude Toward the Facial Nerve in Extended Parotidectomy

The facial nerve crosses the parotid tissue and considering the initial location malignancies can grow to engulf one or several branches of the nerve on different lengths or even the main trunk of the nerve, and removal of the involved segments must be performed together with the tumor. The functional sequelae following interruption can be quite debilitating for the patient, and reconstruction of the nerve should be performed whenever possible in order to ensure a good quality of life. The outcomes of the reconstruction are different depending on the moment of reconstruction and the chosen method. A wide range of reconstructive techniques are available and must be carefully selected in order to suit each case and ensure acceptable restoration of nerve function.

Arising Problems in Extended Parotidectomy

The extended parotidectomy is a complex surgery reserved, generally, for the advanced parotid malignant lesions that interest several anatomical structures, with the objective of eradicating malignancy by en bloc resection of all tumor involved tissue. Besides the problem of the extent of tissues that will be removed in order to ensure oncological safety limits (with radical neck dissection usually performed at the same time), the reconstructive surgery techniques addressed to these cases are of particular interest, because they must correct both the aesthetic deficit (depression of the parotid and superior laterocervical regions due to the missing tissues surgically removed) and the functional one (the facial nerve palsy and Frey’s syndrome), for optimal results of the postoperative survival. In large defects following extended parotidectomy, the use of the thicker free transferred soft tissue flaps or, better, the radial forearm fasciocutaneous flaps (but usually followed by lipostructure in the latter cases, from our experience) is recommended, allowing a proper restoration of the facial contours and skin coverage and also avoid Frey’s syndrome. The paralytic lagophthalmos consecutive to total or extended parotidectomy for malignancy requires a special attention, due to the risk of developing a keratopathy, corneal abrasions or ulcers, or even blindness, due to the absence of the long-term protection provided by the ocular conjunctiva.

Direct Closure After Extended Parotidectomy

The extended parotidectomy does not necessarily imply large defects but also complex defects that involve more than the parotid gland itself.

Extended Parotid Tumors with Origin in the Parotid Tissue

Primary tumors of the parotid gland arise either in the superficial lobe, deep lobe, isthmus, accessory lobe, or Stensen’s duct, which will result in different behaviors concerning local spread and different clinical presentations. The various topographic and histologic possibilities, especially in the presence of extended tumors, will lead to a difficult differential diagnosis. Primary tumors must be differentiated from involvement of the parotid gland by direct invasion from tumors in neighboring areas and from metastatic disease to the parotid gland. Clinical suspicion is extremely important in order to properly address unusual individual cases and avoid the trap of approaching all parotid masses in the same manner that could eventually lead to either unnecessary or incomplete treatment. The suspicion is raised first by clinical examination and will be strengthened by further imaging studies, and eventually the final diagnosis will be confirmed by pathology. A great variety of histological types have been described in primary as well as secondary tumors to this area. Although statistical data suggests a great prevalence of certain malignant parotid tumors over others, the surgeon must not underestimate the possibility of rare tumors arising in this area that may require a different therapeutic approach. It is a challenge for the surgeon to manage certain complex tumors encountered in the parotid area. The aim of establishing the origin of the extended parotid gland tumor is to tailor the treatment according to the known behavior of tumors originating in the parotid tissue and to avoid the danger of under- or overtreatment.

Autologous Fat Transfer to Reconstruct Facial Defects After Parotidectomy

Parotidectomy (superficial, total, or extended) is a surgical procedure that may be associated with a number of aesthetic and functional complications. Some of them (like facial asymmetry due to the presence of tissue depression following the removal of invaded structures, and Frey syndrome) particularly requested the attention of researchers aiming to find the optimal correction methods. A widely used technique in aesthetic and reconstructive surgery – autologous fat transfer – may be a great option for compensating the defect caused by extended parotidectomy, demonstrating good and very good results over time, from both aesthetic and functional points of view. Autologous fat grafting is a technique used in reconstructive surgery to reshape the soft parts, as recommended by a lot of advantages: it can be performed under local anesthesia, requires short execution time, has unlimited availability of reconstruction material, no additional scars, no morbidity at the donor site, it can be repeated to achieve the desired effect with minimum discomfort for the patient, and has good aesthetic and functional results stable over time. Additionally, the multipotent mesenchymal cells associated to the fat cells significantly contribute to the improvement in texture and nutrition of the tissues in the area where lipostructure is performed, tissues that are often altered by previous surgery for tumor excision or by additional treatment procedures (radio- and chemotherapy).

Platysma Myocutaneous Flap: A Solution for Reconstruction of Defects After Extended Parotidectomy

In order to cover postoperative defects after removal of extended parotid tumors, the surgeon can use local flaps (rotated or translated random fasciocutaneous flaps or platysma myocutaneous flap), locoregional (major pectoralis myocutaneous flap), or microvascular free flaps (radialis or latissimus dorsi). The most suitable technique depends on local factors, such as size of the defect, structures involved by tumor resection, previous neck surgery or irradiation, the need to perform neck dissection, and general factors, such as preoperative status and treatment compliance of the patients.