Piet E. Haers

Biodegradable polylactide plates and screws in orthognathic surgery: technical note

In orthognathic surgery, the bone fragments are usually fixed with metallic plates and screws. Metallic devices other than titanium plates are usually removed after the osteotomy has consolidated, which often requires general anaesthesia. Titanium plates, supposed to be biotolerable, have been introduced in order to overcome this need for secondary intervention. However, due to corrosion, titanium particles have been found in scar tissue covering these plates and in locoregional lymph nodes. Therefore, their removal is also advocated. Self-reinforced poly (L-lactide) homopolymer (PLLA) and poly (L/D-lactide) stereocopolymers with a L/D molar ratio up to 85/15 have sufficient strength to overcome the need for additional support for the fixation of fractures. The plates can be bent at room temperature. The surgical technique and early results of a case of bimaxillary surgery and genioplasty fixed with bioresorbable material without postoperative rigid maxillomandibular fixation are reported.

Mandibular resorption due to systemic sclerosis: Case report of surgical correction of a secondary open bite deformity

Systemic sclerosis (SSc) is a connective-tissue disorder of unknown origin causing a multisystem disease. While erosions of the distal phalanges are commonly described, resorption of the mandible has been considered an unusual finding. However, systematic radiographic screening of different groups of patients suffering from SSc revealed a resorption incidence of 20-33% of the examined mandibles. Women especially seem to be affected, and the male/female ratio is 1/7. Bilateral condylysis due to SSc has been described in seven cases, or 13.7% of the reported cases. To the best of our knowledge, this is the fourth report of surgical correction of secondary dysgnathia due to systemic sclerosis and the first with a 2-year follow-up period.

The Le Fort I osteotomy as a surgical approach for removal of tumours of the midface

Tumours of the midface and maxillary sinuses have been removed via multiple approaches. The most common approaches are those using incisions in the facial skin, especially in the case of malignant tumours. The Le Fort I procedure via an intraoral incision as described by Sailer in 1986 is a versatile alternative. Combined with a coronal approach and various osteotomies of the upper face it also allows removal of tumours extending into the orbits, the nasoethmoidal complex and the skull base. The versatility of the Le Fort I osteotomy as a surgical approach was analysed in 17 cases. This method is reliable and gives excellent access. Further advantages are the wide surgical exposure and the clear visibility of the resection margins, the absence of visible scars, the feasibility of combining this approach with reconstruction using the buccal fat pad and the possibility of simultaneous placement of bone grafts, insertion of endosseous implants or other preprosthetic procedures via the same incision.

Multimodal strategy for reduction of homologous transfusions in cranio-maxillofacial surgery

The transfusion of homologous blood carries well-known risks that have prompted efforts to develop alternative techniques. Such measures are of particular interest to patients undergoing elective procedures. A total of 204 patients, out of 1470 patients who consecutively underwent major craniomaxillofacial procedures under general anesthesia over a two-year period, were enrolled in a prospective protocol to reduce homologous transfusion requirements when a blood loss in excess of 500 ml was anticipated. The data were compared with the results of a retrospective control group (n=2890) covering major procedures during the previous four years, when blood-saving measures were applied occasionally, but not based on a global strategy. Techniques for the reduction of homologous transfusions were acute normovolemic hemodilution, controlled moderate hypotension, cell saver and predeposit autologous blood. In addition, preoperative administration of human recombinant erythropoietin was introduced during the last year of the study. These techniques were applied individually or in combination, depending on contraindications specific for each technique, using invasive monitoring in order to maintain intraoperative hemodynamic stability. The goal of this study was to examine the extent to which homologous transfusions may be reduced with the systematic application of transfusion-sparing techniques. Of 204 patients qualifying for the transfusion-sparing protocol, 30 received homologous transfusions. In comparison to the control group, utilization of transfusion-sparing techniques had doubled. The overall reduction in the use of homologous transfusions was highly significant. When acute normovolemic hemodilution, controlled moderate hypotension and the cell saver were used in combination, a greater reduction in homologous transfusions was achieved than with the use of either a single modality or combination of any two. No transfusions were required in patients pretreated with erythropoietin.

Development of the frontal sinus following bilateral fronto-orbital osteotomies

The presence of frontal sinuses following bilateral fronto-orbital advancement is discussed controversially in the literature. In a retrospective study, 33 patients (18 male and 15 female) were operated on between 1982 and 1993, with at least one year postoperative follow-up and with a minimum age of 6 years at the end of the follow-up period following bilateral fronto-orbital remodelling, were included. The average age at which the procedure was performed was 29 months with a minimum of 3 months and a maximum of 7.8 years. The study presented shows a pneumatization of the frontal sinus in 72.7% of 33 patients following bilateral fronto-orbital advancement. The first radiographic signs of sinus development were detected between the ages of 4 and 11, average 8.3 years. There were no statistically proven correlations between frontal sinus pneumatization and age at operation or the amount of advancement or sex of the patients. Surgical enlargement of the cranium by frontal advancement with adequate stabilization results in an enlargement of the neurocranium, thereby decreasing pressure on the inner frontal cortex and allowing frontal sinus pneumatization to proceed normally. Hence, the development of a frontal sinus may be a reflection of the effectiveness of the surgical therapy.

The bilobed myocutaneous pectoral is major flap in closure of combined intra- and extraoral defects

Oral carcinomas may eventually invade the perioral soft tissues. In such cases, tumor resection creates through and through defects. Similar defects are seen in patients with gunshot wounds. The versatility of the bilobed myocutaneous pectoralis major flap in closure of these defects is emphasized. The results in nine patients treated by this method are discussed.

Microsurgical reconstruction of the head and neck region: Current concepts of maxillofacial surgery units worldwide

INTRODUCTION Microvascular surgery following tumor resection has become an important field of oral maxillofacial surgery (OMFS). Following the surveys on current reconstructive practice in German-speaking countries and Europe, this paper presents the third phase of the project when the survey was conducted globally. METHODS The DOESAK questionnaire has been developed via a multicenter approach with maxillofacial surgeons from 19 different hospitals in Germany, Austria and Switzerland. It was distributed in three different phases to a growing number of maxillofacial units in German-speaking clinics, over Europe and then worldwide. RESULTS Thirty-eight units from Germany, Austria and Switzerland, 65 remaining European OMFS-departments and 226 units worldwide responded to the survey. There is wide agreement on the most commonly used flaps, intraoperative rapid sections and a trend towards primary bony reconstruction. No uniform concepts can be identified concerning osteosynthesis of bone transplants, microsurgical techniques, administration of supportive medication and postoperative monitoring protocols. Microsurgical reconstruction is the gold standard for the majority of oncologic cases in Europe, but worldwide, only every second unit has access to this technique. CONCLUSION The DOESAK questionnaire has proven to be a valid and well accepted tool for gathering information about current practice in reconstructive OMFS surgery. The questionnaire has been able to demonstrate similarities, differences and global inequalities.

The unilateral hockey-stick incision for neck dissection in oral carcinoma. Technical note

In 42 patients, a hockey-stick incision was used as standard approach in unilateral neck dissection. This approach permits a good overview of all structures in the neck and allows en bloc resection with intraoral tumor removal. The incision does not interfere with simultaneous reconstruction by pedicled or free flaps, and results in a scar which is barely visible and easily covered.

A worldwide comparison of the management of T1 and T2 anterior floor of the mouth and tongue squamous cell carcinoma – Extent of surgical resection and reconstructive measures

INTRODUCTION Microvascular surgery following tumor resection has become an important field of oral maxillofacial surgery (OMFS). Following the results on general aspects of current reconstructive practice in German-speaking countries, Europe and worldwide, this paper presents specific concepts for the management of resection and reconstruction of T1/T2 squamous cell carcinoma (SCC) of the anterior floor of the mouth and tongue. METHODS The DOESAK questionnaire was distributed in three different phases to a growing number of maxillofacial units worldwide. Within this survey, clinical patient settings were presented to participants and center-specific treatment strategies were evaluated. RESULTS A total of 188 OMFS units from 36 different countries documented their treatment strategies for T1/T2 anterior floor of the mouth squamous cell carcinoma and tongue carcinoma. For floor of mouth carcinoma close to the mandible, a wide variety of concepts are presented: subperiosteal removal of the tumor versus continuity resection of the mandible and reconstruction ranging from locoregional closure to microvascular bony reconstruction. For T2 tongue carcinoma, concepts are more uniform. CONCLUSION These results demonstrate the lack of evidence and the controversy of different guidelines for the extent of safety margins and underline the crucial need of global prospective randomized trials on this topic to finally obtain evidence for a common guideline based on a strong community of OMFS units.

A worldwide comparison of the management of surgical treatment of advanced oral cancer

INTRODUCTION Microvascular surgery following tumor resection has become an important field of oral and maxillofacial surgery (OMFS). Following the results from management of T1/T2 floor-of-mouth and tongue squamous cell carcinoma (SCC) in German-speaking countries, Europe, and worldwide, this paper presents specific concepts for the management of resection and reconstruction of T3/T4 SCC of the maxillary and mandibular alveolar process and tongue. METHODS The DÖSAK questionnaire was distributed in three different phases to a growing number of maxillofacial units worldwide. Within this survey, clinical patient settings were presented to participants and center-specific treatment strategies were evaluated. RESULTS A total of 188 OMFS units from 36 different countries documented their treatment strategies for T3/T4 maxillary and mandibular alveolar process and tongue SCC. The extent of surgical resections and subsequent reconstructions is more consistent than with T1/T2 tumors, although the controversy surrounding continuity resections and mandible-sparing procedures remains. For continuity resection of the mandible the fibula free flap is the most frequently used bone replacement, whereas maxilla reconstruction concepts are less consistent, ranging from locoregional coverage concepts and different microvascular reconstruction options to treatment via obturator prosthesis. CONCLUSION Results from treatment strategies for T3/T4 tumors underline the limited evidence for the appropriate amount of resection and subsequent reconstruction process, especially in cases involving the mandible. Prospective randomized trials will be necessary in the long term to establish valid treatment guidelines.