Predrag Knežević

Madelung syndrome (benign lipomatosis): clinical course and treatment

Madelung syndrome is a rare disease found predominantly in the Mediterranean area. It has a distinctive clinical appearance. Staged surgery is the treatment of choice, which produces substantial improvement in both functional and aesthetic appearance. Recurrences usually occur when it is impossible to resect the disease completely.

Complications of sevoflurane-fentanyl versus midazolam-fentanyl anesthesia in pediatric cleft lip and palate surgery: a randomized comparison study.

Careful choice of anesthetic agents in pediatric patients reduces the frequency of anesthesia-related complications. The frequency and type of intraoperative and postoperative complications of sevoflurane-fentanyl versus midazolam-fentanyl anesthesia were compared in 140 consecutive children (aged 3 months to 10 years) undergoing cleft lip and palate repair. Midazolam-fentanyl anesthesia was induced with midazolam (0.05 mg/kg), fentanyl (0.005 mg/kg) and vecuronium (0.1mg/kg), and maintained with the same agents according to the defined parametars. Sevoflurane-fentanyl anesthesia was induced and maintained with sevoflurane (5-8 vol% and 0.8-1 vol%, respectively) in an oxygen/air mixture and supplemented with fentanyl (0.005 mg/kg). Both groups were comparable in basic demographic data, hemodynamic and respiratory parameters. Difficult intubation occurred in 6 of 76 children (midazolam-fentanyl group) and 4 of 64 children (sevoflurane-fentanyl group) (P=0.754). Ventricular extrasystole and bronchospasm occurred in one patient each in the sevoflurane-fentanyl group. Postoperatively, emergence agitation was observed in the sevoflurane-fentanyl group (17 cases; P<0.001); postoperative nausea and vomiting occurred in 2 children (midazolam-fentanyl group) and 3 children (sevoflurane-fentanyl group) (P=0.660). Midazolam-based anesthesia in children is safer than sevoflurane-based anesthesia regarding occurrence of emergence agitation.

Brown class III maxillectomy defects reconstruction with prefabricated titanium mesh and soft tissue free flap.

BackgroundMidface reconstruction is one of the most challenging tasks for the reconstructive surgeon. We present a technique for the reconstruction of the midface after total maxillectomy with preservation of orbital contents. MethodsSkeletal reconstruction is achieved with a preoperatively bent titanium sheet mesh on a universal skeletal model. The alveolar ridge, the anterior wall of the maxillary sinus, the zygomatic prominence, the lower orbital rim, and the orbital floor are reconstructed with a titanium mesh. A soft tissue free flap, preferably anterolateral thigh free flap, is harvested as well. A part of the flap is deepithelized and put in front of the mesh to prevent exposure, and the other part is used for palatal reconstruction. ResultsFour male and 1 female patients were reconstructed with titanium mesh. Four free flaps were raised: 3 anterolateral thigh and 1 latissimus dorsi. All free flaps survived. All patients received postoperative irradiation with 64 Gy. Median follow-up was 12 months; no major complications occurred. Mesh was exposed in only 1 case, which was managed successfully with resuspension of the heavy latissimus dorsi myocutaneous flap. Midface projection and height, globe position, ocular movements, and vision where satisfactory in all cases. ConclusionsMidface reconstruction with titanium mesh and soft tissue free flap is a reliable and safe method for functional and aesthetic reconstruction after maxillectomy.

Soft tissue changes after mandibular setback and bimaxillary surgery in Class III patients

OBJECTIVE To evaluate the relationship between soft tissue and bone structure for Class III patients before and after bilateral sagittal split osteotomy (BSSO) and bimaxillary orthognathic surgery; to determine the impact of other factors on soft tissue change; and to evaluate correlations between thickness of tissue before surgery, SNA, SNB, and ANB angles, and soft tissue changes. MATERIALS AND METHODS The study included 78 Class III patients treated only with BSSO or with BSSO and Le Fort I osteotomy. Lateral cephalograms were taken before and 3 months to 1 year after surgery. After all points of the Zagreb82 and Legan and Burstone profile analysis were traced, the ratio of five soft tissue points before and after surgery was evaluated. RESULTS Soft tissue between points Sn and A and upper lip showed statistically significant changes for patients treated with bimaxillary surgery and BSSO. Only gender had an influence on soft tissue change. The correlation between soft tissue thickness and changes after surgery was significant. A change in SNB angle correlated with upper lip thickness for patients treated with BSSO but not for patients treated with BSSO and Le Fort I. SNA angle changes correlated with soft tissue changes between points Sn and A. CONCLUSION Results of this study show soft tissue changes after BSSO and BSSO and Le Fort I and eliminate the deficiencies that were indicated in the meta-analysis of soft tissue changes from a previous study.

Altered light-touch sensation after bilateral sagittal-split osteotomy A prospective study of 50 patients

OBJECTIVE To prospectively evaluate the incidence of change in light-touch sensation in the innervated area of the lower alveolar nerve after bilateral sagittal-split osteotomy (BSSO) with attention on the time it takes to rebuild the function of the inferior alveolar nerve. MATERIALS AND METHODS The sample consisted of 30 women and 20 men with a mean age of 22.14 ± 3.30 years. The neurosensory test was conducted with a 20-mm long monofilament of suture material Prolene (3-0) connected to a plastic holder. These tests were performed 1 day before surgery and every 2 weeks during first 2 months after surgery. After that, patients were tested once every month until the end of the first year. RESULTS All patients had a disturbance of light-touch sensation after BSSO, but none of these changes was permanent. The average duration of hypoesthesia was 6.6 ± 1.2 with a range from 4 to 9 months. The average duration of hypoesthesia for women was 6.27 ± 1.0 months, and men had hypoesthesia for 7.1 ± 1.2 months on average. This difference was statistically significant. The two oldest female patients, who were 33 and 37 years old at the time of the surgery, experienced altered sensitivity for only 4 months. CONCLUSIONS After BSSO, all patients experienced disturbed light-touch sensation in the innervated area of the lower alveolar nerve. A faster recovery in the oldest patients and a statistically significant difference between the sexes should be interpreted with caution.

Maxillary Fragment Stabilization After Le Fort I Fracture With 1 Screw Pair per Plate

PURPOSE The aim of the present study was to determine whether plates with only 1 screw pair can be used for Le Fort I fracture management. Good postoperative results motivated the direct application of mandible fixation principles to the fractured midface region without additional experimental research. However, the amount and distribution of the forces in the midface region is different from those on the mandible. MATERIALS AND METHODS Testing was conducted on plastic anatomic models. The validity of the experimental model was tested before the fixation techniques were compared. Standard miniplates and miniscrews were used for fixation of the maxilla. The model surface strain analysis was conducted using the noncontact object grating method, which enabled the surface strain measurement without direct influence on the measured model. RESULTS In 2 screw pair fixation, the outer screw pair has little effect on the local strain distribution, but it lowers the contact forces along the crack. One screw pair fixation is stable enough for fixation, but it has a greater strain peak at the crack edges. CONCLUSION Our results showed that 1 screw pair per plate was enough for stable fixation, and 2 or more screw pairs should only be used when the bone fragment at the fracture site cannot sufficiently transmit forces along the crack.

Protective intramedullary fixation after harvest of an osteocutaneous radial free flap

The osteocutaneous radial free flap, even after 30 years, is still considered to be the “workhorse“ for head and neck reconstruction. A high incidence of donor site fractures has remained a major problem, however. The technique described here is a method developed for the prophylaxis of fractures of the donor site of the harvested radial bone and is based on a modification of the intramedullary Rush nail fixation. The data were collected from 18 patients in whom the radial forearm free flap had been used during reconstruction. None of the prophylactically-nailed radii fractured. The complications experienced with this technique are general complications, such as scarring of the forearm and dehiscence of the wound. This technique is simple, and has given excellent results. Aesthetic and functional results were comparable to those of other flaps used for reconstruction. We recommend this technique because of its simplicity, vascular safety, and cost effectiveness.

Modifikacija klizno-rotirajućeg režnja napravljenog 1950. godine

The early techniques of cleft lip repair involved the straight-line technique, the triangular flap technique or some kind of geometric line (triangular, quadrangular closure). A turning point in cleft lip surgery was in 1955 when doctor. Millard presented his method: the rotation-advancement technique or flap, at the First International Congress of Plastic Surgery in Stockholm. Today, the technique, with or without some modifications, is used by more than 85% of cleft surgeons around the world. We are presenting a patient with complete unilateral cleft lip and palate who underwent surgery sixty-five years ago. The scar on his lip was similar to rotation advancement line. Cheiloplasty was performed by Professor Šercer in 1950, five years before Millards publication. Professor Ante Šercer was an internationally recognized Croatian scholar in the area of ear, nose and throat diseases. He also gave a significant contribution to surgical management of velopharyngeal insufficiency and plastic surgery of the nose and ear.

Modified Millard's technique in operations for unilateral cleft lip.

Abstract Many approaches have been described, but the rotation-advancement technique described by Millard remains one of the most popular repair techniques for correction of cleft lip. The technique described here is a modified method that can be used in primary cleft surgery but also for secondary correction, using the same incision with a small modification in design. Thirty-two patients were followed up for two years, all of whom had good postoperative results without secondary correction. The modification provides rotation and elongation of the lip where it is needed. This technique can be useful for all aspects of secondary cleft lip correction, but is also useful in primary surgery when the cleft side is too short.

Underestimated value of communicating vein between deep and superficial venous system of radial forearm free flap.

To the Editor: We read an article by Selber et al regarding the venous drainage of radial forearm free flap with great interest. The authors favor using only 1 venous system by performing anastomosis on a single vein, either cephalic vein (CV) or one of the venae comitantes (VC) (together almost 84% of the cases). In only 9 cases of 370, they performed single anastomosis using a common vein in which these 2 venous drainage systems coalesce together. This fact is interesting because practice in our Department is proportionally inverse. A small interconnecting vein between 2 venous systems of radial forearm free flap has been described by several authors and named as a profundus cubitalis vein, perforating vein, and communicating vein. We also favor performing single venous anastomosis. During harvest of radial forearm free flap, a communicating vein between deep and superficial venous system is included whenever possible. As a result of this, drainage of 2 venous systems is joined together and slow venous outflow is prevented; in fact blood outflow is even increased. After doing arterial anastomosis, observation of venous outflow on 3 free vein ends (2 VC and single CV) is performed for about a minute. The fastest draining vein end is used for anastomosis. There is no need for stopping blood flow again through the flap; the other 2 veins can be left open while doing venous anastomosis. This way ischemia time and reperfusion injury of the flap are decreased. After completion of microanastomosis, the other 2 vein ends are ligated and venous outflow is increased and redirected to the single vein that is used for venous anastomosis. By using both venous drainage systems conjoined only through single anastomosis, either a larger VC or CV, we did not experience significant problems in terms of venous congestion. In fact we believe it is a superior technique as compared with using only one venous system separately, either superficial or deep. In contrast, doing dual venous anastomosis prolongs the surgical time and could only lead to decrease in venous outflow and thrombosis. There have not been any problems in finding a communicating vein. The key is to dissect high enough in the cubital fossa. Usually it is found a bit more proximal than the level of division of brachial artery. Doing single or dual venous anastomosis has been an issue in the literature. We believe that doing single anastomosis is at least as safe as doing dual anastomosis, but with inclusion of a communicating vein in the flap it becomes more safe and reliable regarding venous congestion or thrombosis.