Federico Biglioli

Mini-retromandibular approach to condylar fractures

INTRODUCTION Among maxillofacial surgeons, a general agreement exists that the therapeutic strategy for intracapsular condylar fractures is conservative, while the treatment of extracapsular fractures of the mandibular condyle is extremely controversial. The indications and choice of treatment are less than uniform, often relying on the surgeons personal experience and beliefs. The literature increasingly suggests that the surgical management of these fractures is superior to conservative management in functional terms. Nonetheless, the indications for surgically treating condylar fractures are limited by fear of potential pitfalls related to the access. Extraoral routes to the condyle involve the risk of facial nerve injuries or visible scars; transoral access is free from these pitfalls but is demanding technically, especially for higher neck fractures. In our experience, a 2-cm-long retromandibular access allows straightforward management of condylar fractures, providing as a result a well concealed scar. MATERIALS AND METHODS From 2006 to 2007, 21 patients with 25 condylar fractures were treated surgically using the mini-retromandibular access. The mean operating time was 32 min (range 17-55 min). No facial nerve injuries were observed. The first two patients developed postoperative infections. One patient, in whom the first intervention resulted in malreduction of the fracture because the access was insufficient (15 mm incision), required a second operation to achieve correct reduction and rigid fixation of the condyle. RESULTS In all cases, good anatomical stump reduction was achieved. All the patients obtained good articular function, since the access was exclusively extra-articular. CONCLUSIONS Condylar fracture reduction, fixation and healing can be managed comfortably using a limited retromandibular approach. Moreover, the risk of facial nerve injury is limited as the nerve fibres are viewed directly.

Masseteric–facial nerve anastomosis for early facial reanimation

OBJECTIVE Early repair of facial nerve paralysis when cortical neural input cannot be provided by the facial nerve nucleus, is generally accomplished anastomozing the extracranial stump of the facial nerve to a motor donor nerve. That is generally the hypoglossus, which carries a variable degree of morbidity. The present work aims to demonstrate the effectiveness of the masseteric nerve as donor for early facial reanimation, with the advantage that harvesting is associated with negligible morbidity. METHODS Between October 2007 and August 2009, 7 patients (2 males, 5 women) with unilateral facial paralysis underwent a masseter-facial nerves anastomosis with an interpositional nerve graft of the great auricular nerve. The interval between the onset of paralysis and surgery ranged from 8 to 48 months (mean 19.2 months). All patients included in the study had signs of facial mimetic muscle fibrillations on electromyography. The degree of preoperative facial nerve dysfunction was grade VI following the House-Brackmann scale for all patients. RESULTS At the time of the study, all the patients with a minimum follow-up time of 12 months after the onset of mimetic function had recovered facial animation. Facial muscles showed signs of recovery within 2-9 months, mean 4.8 months, with the restoration of facial symmetry at rest. Facial movements appeared while the patients activated their chewing musculature. Morbidity related to this intervention is only the loss of sensitivity of earlobe and preauricular region. CONCLUSION The present technique seems to be a valid alternative to classical hypoglossal-facial nerve anastomosis because of similar facial nerve recovery and lower morbidity.

Reconstruction of the orbital walls in surgery of the skull base for benign neoplasms

Surgery for benign neoplasm extending into the orbital roof requires immediate reconstruction to avoid complications, which include transmission of the cerebral pulse to the globe, bulbar dystopia, diplopia, and fibrosis of the oculomotor muscles. Many alloplastic materials have been employed for such reconstruction, but currently most authors agree that autologous bone graft is the best option. Using calvarial bone in adults and split ribs in children, we have operated on eight patients for fibrous dysplasia (five cases), neurofibroma (two cases), or meningioma (one case). After a median follow-up period of two years and six months, good morphology of the orbit was maintained with no ocular symptoms.

Intraoral approach to large dermoid cysts of the floor of the mouth: a technical note

An intraoral approach to dermoid cysts of the floor of the mouth is described. With this technique, it is possible to obtain adequate surgical access in cases of very large dermoid cysts involving simultaneously the floor of the mouth and the submental space, thus avoiding a skin incision in the submental fold.

Double innervation in free-flap surgery for long-standing facial paralysis

OBJECTIVE One-stage free-flap facial reanimation may be accomplished by using a gracilis transfer innervated by the masseteric nerve, but this technique does not restore the patients ability to smile spontaneously. By contrast, the transfer of the latissimus dorsi innervated by the contralateral facial nerve provides the correct nerve stimulus but is limited by variation in the quantity of contraction. The authors propose a new one-stage facial reanimation technique using dual innervation; a gracilis muscle flap is innervated by the masseteric nerve, and supplementary nerve input is provided by a cross-face sural nerve graft anastomosed to the contralateral facial nerve branch. METHODS Between October 2009 and March 2010, four patients affected by long-standing unilateral facial paralysis received gracilis muscle transfers innervated by both the masseteric nerve and the contralateral facial nerve. RESULTS All patients recovered voluntary and spontaneous smiling abilities. The recovery time to voluntary flap contraction was 3.8 months, and spontaneous flap contraction was achieved within 7.2 months after surgery. According to Terzis and Noahs five-stage classification of reanimation outcomes, two patients had excellent outcomes and two had good outcomes. CONCLUSIONS In this preliminary study, the devised double-innervation technique allows to achieve a good grade of flap contraction as well as emotional smiling ability. A wider number of operated patients are needed to confirm those initial findings.

Sinonasal complications resulting from dental treatment: outcome-oriented proposal of classification and surgical protocol.

Background Odontogenic sinusitis is a relevant infectious condition of the paranasal sinuses. The widespread use of dental implants and reconstructive procedures for dental implant placement has led to new types of complication. To the authors’ knowledge, no publication has extensively examined sinonasal complications resulting from dental treatment, and no classification system allowing standardization and comparison of results is currently available. This study was designed to (a) analyze the results obtained from surgical treatment of complications resulting from dental procedures combining functional endoscopic sinus surgery (FESS) and an intraoral approach and (b) propose a new classification system and standardized treatment protocols for sinonasal complications resulting from dental procedures. Methods A total of 257 patients consecutively treated with FESS (136 in conjunction with oral surgery) were included in the study. Different clinical situations were integrated into a new classification system based on the pathogenesis and clinical aspects of each case, with the aim of identifying homogenous treatment groups. Results were evaluated for each class. Results Of the 257 patients, 254 were successfully treated with surgery performed according to the proposed protocols. Three of 257 patients required a second surgery, after which they completely recovered. Complications of implant and preimplant surgery (maxillary sinus floor elevation) showed longer recovery times. Conclusion The results obtained are very encouraging. The majority of patients (254/257; 98.8%) were successfully treated with the proposed protocols. These results seem to indicate that the rationalization of surgical treatment protocols according to the initial clinical situation may significantly improve the clinical outcome.

Pilomatrix carcinoma with visceral metastases: case report and review of the literature.

Pilomatrix carcinoma, the malignant equivalent of pilomatrixoma, is rare among skin cancers. In the literature, there have been 80 cases of pilomatrix carcinoma reported, and among them nine were with metastases. The clinical presentation of this case is suggestive for the biology and of the usual history of this neoplasm. The patient was a 53-year-old male who had been treated 2 years earlier for a pilomatrix carcinoma located in the posterior part of the neck. The clinical presentation had been characterised by sudden paraplegia caused by vertebral collapse at T4 due to bone metastases. The patient underwent a first surgery for vertebral stabilisation and medullary decompression; then, he had a second operation for the resection of the local relapse of the tumour. Literature review and analysis of this case show that the pilomatrix carcinoma should be regarded as a highly locally aggressive tumour, with a high rate of local recurrence as well as metastases.

Single-stage facial reanimation in the surgical treatment of unilateral established facial paralysis.

Background: Surgical treatment of unilateral long-standing facial paralysis requires transposition of new musculature to restore the function of the atrophied mimetic musculature. Facial reanimation with free neuromuscular flaps is actually the accepted standard treatment. Two-stage procedures have been used for years, with a total flap recovery time of 18 to 24 months. In 1998, Harii proposed single-stage facial reanimation using the latissimus dorsi flap, showing a faster recovery compared with two-stage procedures. The present study evaluated the results of the authors’ center applying the single-stage facial reanimation. Methods: From April of 1999 to April of 2006, 33 patients with unilateral established facial paralysis underwent single-stage facial reanimation via latissimus dorsi free flap transplantation. Time from the onset of paralysis ranged from 20 months to 64 years (mean, 11.6 years). Patients were followed postoperatively for at least 24 months. Results were studied and compared using Terzis and Noah’s 1997 classification. Results: Among the 33 patients included in the study, there was an average reinnervation time of 8.9 months. According to Terzis and Noah’s classification system, 12 patients (36.3 percent) were considered grade V, 12 (36.3 percent) were grade IV, four (12.2 percent) were grade III, two (6.1 percent) were grade II, and three (9.1 percent) were grade I. Conclusions: Single-stage facial reanimation with a latissimus dorsi flap achieved morphofunctional results similar to those obtained with the classic two-stage technique. In addition, the authors were able to reduce the morbidity associated with treatment and the time required for recovery.

Fibrous dysplasia of the orbital region: Current clinical perspectives in ophthalmology and cranio-maxillofacial surgery

Purpose: To describe the multidisciplinary diagnosis and treatment of patients with orbital fibrous dysplasia, a slowly progressive disease that may lead to asymmetry, disfigurement, and functional ocular problems. Methods: Ten patients with orbital fibrous dysplasia underwent bifrontal craniotomy through a coronal flap, with the removal of the supraorbital arch and dysplastic process involving the anterior and middle base of the skull. Four patients underwent superior orbital fissure and optic nerve canal decompression. Reconstruction was performed by using an autologous bone graft for both the adults and children, in whom a rib graft was preferred. The mean follow-up was 53.2 ± 18.3 months (range, 14 to 94 months). The patients’ preoperative status and postoperative status were compared. Results: The immediate and long-term morphologic and aesthetic results were good in all cases. All of the patients complained of some degree of diplopia during the immediate postoperative period, but the problem spontaneously resolved within 1 to 6 months in all but one case. No postoperative reduction in visual function was observed in the patients who underwent optic nerve decompression. The only reported complication was the irregular reabsorption of regrafted dysplastic bone in one patient. Conclusions: A multidisciplinary approach to orbital fibrous dysplasia is fundamental for treatment planning and execution.

Facial movement before and after masseteric-facial nerves anastomosis: A three-dimensional optoelectronic pilot study ☆

To quantify the effects of facial palsy reanimation, 14 patients aged 17-66 years were analysed. All patients had unilateral facial paralysis, and were candidates for surgical masseteric to facial nerve anastomosis. Two patient groups were measured: seven patients were waiting for surgery, the other seven patients had already been submitted to surgery, and had regained facial mimicry. Each patient performed three facial animations: brow raise; free smile; lip purse. These were recorded using an optoelectronic motion analyser. The three-dimensional coordinates of facial landmarks were obtained, their movements were computed, and asymmetry indices calculated (differential movements between the two hemi-faces: healthy and paretic/rehabilitated). Before surgery, mobility was larger in the healthy than in the paretic side; after surgery, the differences were reduced (brow raise and lip purse), or even reversed (smile). Before surgery, lip purse was performed with significant labial asymmetry (p=0.042; larger healthy side movement). After surgery, asymmetry indices reduced. Total labial asymmetry during smiling was significantly different from 0 before surgery (p=0.018, larger healthy side movement). After surgery, all asymmetry indices became non-significant. Before surgery the lateral displacements of all labial landmarks were towards the healthy side, while they normalized after surgery.