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Summary Background Persisting anastomotic leakage after oncological esophagectomy is a severe problem associated with high mortality and morbidity. Unfortunately, treatment options with promising results are scarce, especially when conventional operative and endoscopic methods have failed. Due to limitation of oral intake and the need for artificial nutrition, quality of life (QOL) is reduced. Microvascular myocutaneous and cutaneous free flap (MFF) reconstruction could be a promising alternative. Methods This retrospective case series presents 7 patients treated between March 2017 and November 2020 at our surgical department, with persisting postoperative anastomotic leakage without further feasible treatment options. All patients received anastomotic MFF reconstruction; used flaps and important intraoperative factors like microvascular anastomosis were evaluated. Complications and patient contentment was assessed. Results The included 7 male patients had median age of 65.15 years (range: 48–75). MFF function was adequate in 6/7 patients, one flap necrosis was encountered. Whereas 5 patients initially had good results, surgical revision was performed in 1 patient to ensure graft function. Postoperative complications appeared in 6/7 patients. Mean duration of inpatient care was 63 days (range: 24–156). At the time of evaluation, 1 patient has died of his malignant disease. No more additional nutrition was needed in 3/6 patients with adequate graft function. Most patients reported improved QOL after MFF. Conclusion MFF free flap can be an alternative treatment option for patients with terminal esophagostomy after complicated oncological esophagus resection without further treatment options. The renewed ability of oral food intake results in a significant improvement of QOL.

Different surgical techniques are available to adequately correct the primary cleft lip deformity; however, when compared, none of these techniques have proven superior with regard to achieving optimal aesthetic results. Thus, the aim of this retrospective study was to assess the nasolabial appearance in patients with unilateral cleft lip and palate (UCLP) at age five with reference to two techniques for primary cleft lip repair used in our service: Pfeifer’s wave-line procedure and Randall’s technique. A modified Asher–McDade Aesthetic Index was applied to appraise the nasolabial area by means of 2D photographs of non-syndromic five-year-old patients with a UCLP. In this context, three parameters were assessed: 1. nasal frontal view; 2. shape of the vermilion border and philtrum length; and 3. the nasolabial profile. Five professionals experienced in cleft care were asked to rate the photographs on two occasions. Overall, 53 patients were included in the final analysis, 28 of whom underwent lip repair according to Pfeifer; 25 were treated employing Randall’s technique. Statistically significant differences between the two techniques regarding philtrum length and vermilion border were found (p = 0.046). With reference to the other parameters assessed, no significant differences were determined. The results suggest that Randall’s cleft lip repair may allow for more accurate alignment of the vermilion border and more adequate correction of the cleft lip length discrepancy in comparison to Pfeifer’s wave-line technique.

The medial femoral trochlea flap has been described as a method of scaphoid proximal pole nonunion reconstruction when the proximal pole is deemed nonsalvageable. The lateral femoral trochlea (LFT) is an alternative donor site providing a comparable vascularized convex osteochondral flap. We describe the technique and outcomes of our first 17 cases of LFT flap reconstruction of the proximal scaphoid pole with a minimum follow-up of 14 months.Seventeen of the first 24 patients who underwent LFT scaphoid reconstruction at 3 institutions were able to be contacted for clinical follow-up and chart reviews. We recorded patient age and sex, duration of nonunion, number of previous surgical procedures, details of surgical technique, achievement of osseous union, complications, additional postoperative procedures, preoperative and postoperative pain, and range of motion. Preoperative and postoperative scapholunate and radiolunate angles were analyzed on x-rays and achievement of osseous union on computerized tomography scans.The average age of patients included was 35 years (range, 16-55 years). Follow-up data were recorded at an average of 33 months (range, 14-62 months). Ten patients had previous procedures (average, 1; range, 0-2). Median duration from trauma to LFT was 3.4 years (range, 8 months-12 years) among patients who had a recognized date of injury. Osseous healing was achieved in 16 of 17 patients and confirmed by computerized tomograpy scan. Twelve patients reported complete pain relief, while 5 reported partial pain relief. Final postoperative range of motion was 59°extension (range, 30°-85°) and 50° flexion (range, 10°-80°), which was comparable to preoperative values. Preoperative (59°) and postoperative (55°) scapholunate angles were similar to normal wrists.Vascularized LFT flaps provide an alternative donor site for vascularized osteochondral reconstruction of proximal pole scaphoid nonunion. Rate of union, range of motion, and pain relief are similar to reported results with medial femoral trochlea flap reconstruction.Therapeutic IV.

In cases of large defects of the limbs, post‐traumatic deformity and disability can have devastating effects on patients' quality of life. The purpose of this report is to describe the technique for raising a fasciocutaneous iliotibial perforator flap and present its application in the reconstruction of a complex soft tissue defect of the foot. The patient was a 13‐year‐old male who had suffered a crush injury to the foot in a motor vehicle accident 5 years earlier. Due to retraction of the skin, together with the extensor tendons of the digits, the patient could not flex the digits II, III, IV, and V. To reconstruct the defect, the authors harvested a fasciocutaneous flap based on a perforator branch of the superior lateral genicular artery and accompanying veins. The immediate postoperative course was uneventful, with progressive and complete recovery of power and range of motion in the foot and knee within 6 weeks. Despite the tendency to form hypertrophic scars again, the functionality of the operated foot was excellent 29 months after the reconstruction. According to the American Orthopedic Foot and Ankle Society scale, the patient scored 100 points on the midfoot section and 93 points on the section forefoot rays two to five. The iliotibial perforator flap could be a new tool for a state‐of‐the‐art functional reconstruction of soft tissues defects of the limbs and head and neck.

Persisting anastomotic leak after oncological esophagectomy is a severe problem associated with high mortality and morbidity. Unfortunately, treatment options with promising results are scarce especially when conventional operative and endoscopic methods have failed. Due to limitation of oral intake and need for artificial nutrition quality of life is reduced. Microvascular myocutaneous and cutaneous free flap (MFF) reconstruction could be a promising alternative. Methods This retrospective cohort study presents seven patients treated between March 2017 and November 2020 at our surgical department, with terminal esophagostomy after complicated oncological esophagus resection without further feasible treatment options. All Patients received anastomotic MFF reconstruction. We have examined postoperative outcomes, complications according to Clavien-Dindo-Classification and patient contentment with a questionnaire. Additionally, we described important procedure related facts. Results The included seven male patients had median age of 65.15 years (range: 48–75). MFF function was adequate in six out of seven patients, graft rejection appeared in one patient. Five patients initially had good results, surgical revision was performed in one patient to ensure graft function. Postoperative complications appeared in 6/7 patients (Table 1). Mean duration of inpatient care was 63 days (Range: 24–156). At time of evaluation, one patient has died cancer related. No more additional nutrition was needed in 3/6 patients with adequate graft function. The majority of patients reported an improved quality of life compared to preoperatively. Conclusion MFF free flap can be a safe and feasible treatment option for patients with terminal esophagostomy after complicated oncological esophagus resection without further treatment options or in patients with complicated postoperative course with complex combined defects. The renewed ability of oral food intake results in a significant improvement of quality of life for the patients. No procedure related mortality was observed. Number of patients with regained ability of oral intake is encouraging.

BackgroundPersisting anastomotic leakage after oncological esophagectomy is a severe problem associated with high mortality and morbidity. Unfortunately, treatment options with promising results are scarce especially when conventional operative and endoscopic methods have failed. Due to limitation of oral intake and need for artificial nutrition quality of life is reduced. Microvascular myocutaneous and cutaneous free flap (MFF) reconstruction could be a promising alternative. MethodsThis retrospective case series presents seven patients treated between March 2017 and November 2020 at our surgical department, with persisting postoperative anastomotic leakage without further feasible treatment options. All patients received anastomotic MFF reconstruction, we evaluated used flaps and important intraoperative factors like microvascular anastomosis. Complications were assessed by Clavien-Dindo-Score, patient contentment was evaluated with a questionnaire. ResultsThe included seven male patients had median age of 65.15 years (range: 48-75). MFF function was adequate in six out of seven patients, one flap necrosis was encountered. Five patients initially had good results, surgical revision was performed in one patient to ensure graft function. Postoperative complications appeared in 6 out of 7 patients, three patients had complications ranked in Clavien-Dindo IIIa (two patients received stenting, one patient endoscopic stenting and dilatation) and two patients needed surgical revision (Clavien-Dindo IIIb). Furthermore one patient had postoperative delirium with prolonged intensive care unit stay and one patient had no complications (Clavien-Dindo 0). Mean duration of inpatient care was 63 days (Range: 24-156). At time of evaluation, one patient has died because of his malignant disease. No more additional nutrition was needed in 3 out of 6 patients with adequate graft function. The majority of patients reported improved quality of life after MFF. Conclusion MFF free flap can be an alternative treatment option for patients with terminal esophagostomy after complicated oncological esophagus resection without further treatment options. The renewed ability of oral food intake results in a significant improvement of quality of life for the patients.

The authors report a patient with masticator space abscess due to an ascending infection following a wisdom tooth extraction. They administered antibiotics and did an incision and drainage; however, osteomyelitis of the mandible and compartment syndrome of the temporal muscle complicated the course. The authors suggest a physiopathology and discuss the management of this study.

The purpose of this study was to describe a newly developed procedure for temporary mandibulotomy and subsequent osteosynthesis. Clinical outcomes were evaluated, including complications and the impact on postoperative treatment, particularly postoperative radiotherapy. Twenty-four patients underwent temporary mandibulotomies for the surgical resection of malignancies located in the posterior oral or oropharyngeal region. All were treated with postoperative radiotherapy. An angulated median mandibulotomy was followed by osteosynthesis with three anchor screws directed towards the inferior aspect of the mandible. Anchor screws are modified conventional lag screws that include an additional biconcave washer. This modification prevents the screw heads from cracking into the cancellous bone during tightening, improving their biomechanical qualities considerably. Insertion of screws at any angle to the bony surface therefore becomes possible, which is a precondition for this technique. Minor complications occurred in two patients in the early postoperative period. However, complications causing bony non-union, leading to postponed postoperative radiotherapy were not noted in this cohort.

We deal regularly with patients who present with severe atrophy of the jaws, compromised soft tissue, or penetrating defects of the alveolar ridge that are not the result of malignant disease. For these patients we use microvascular bony flaps together with dental implants and implant-supported prostheses. The purpose of this retrospective study was to present our current management and the lessons we have learned over a 16-year period while treating 86 patients for these indications with 87 microvascular bone flaps. We used a transoral approach for the anastomosis in 60 flaps, thereby avoiding visible scars, and inserted 281 dental implants to support fixed or removable dental prostheses. Two femoral flaps developed partial necrosis, and seven implants were lost. Eighty-five of the 86 patients were satisfied with the improvement in their orofacial function and aesthetics. Poor oral hygiene, active osteomyelitis, and severe bruxism are absolute contraindications.

Supplemental Digital Content is available in the text., Background: It is anticipated that in due course the burden of emergency care due to COVID-19 infected patients will reduce sufficiently to permit elective surgical procedures to recommence. Prioritizing cleft/craniofacial surgery in the already overloaded medical system will then become an issue. The European Cleft Palate Craniofacial Association, together with the European Cleft and Craniofacial Initiative for Equality in Care, performed a brief survey to capture a current snapshot during a rapidly evolving pandemic. Methods: A questionnaire was sent to the 2242 participants who attended 1 of 3 recent international cleft/craniofacial meetings. Results: The respondents indicated that children with Robin sequence who were not responding to nonsurgical options should be treated as emergency cases. Over 70% of the respondents indicated that palate repair should be performed before the age of 15 months, an additional 22% stating the same be performed by 18 months. Placement of middle ear tubes, primary cleft lip surgery, alveolar bone grafting, and velopharyngeal insufficiency surgery also need prioritization. Children with craniofacial conditions such as craniosynostosis and increased intracranial pressure need immediate care, whilst children with craniosynostosis and associated obstructive sleep apnea syndrome or proptosis need surgical care within 3 months of the typical timing. Craniosynostosis without signs of increased intracranial pressure needs correction before the age of 18 months. Conclusions: This survey indicates several areas of cleft and craniofacial conditions that need prioritization, but also certain areas where intervention is less urgent. We acknowledge that there will be differences in the post COVID-19 response according to circumstances and policies in individual countries.

Objective We assessed the aetiology of idiopathic condylar resorption by examining the effects of oestrogen and compressive mechanical stress under a low systemic oestrogen condition in temporomandibular joints (TMJ) caused by an ovariectomy. Materials and methods Female rabbits were divided into non-ovariectomy (non-OVX) and ovariectomy (OVX) groups. A cortical osteotomy was performed with a custom device that was increased in length by 0.25 mm every 12 hr for 1 week after the operation, during which the TMJs in the rabbits received compressive mechanical stress. Samples from both groups were examined with micro-computed tomography and histological staining. Results Area and depth of bone resorption were both greater in the OVX group. Furthermore, a significantly earlier and greater prevalence of sub-condylar bone resorption was noted in that group, while cells positive for tartrate-resistant acid phosphatase were increased in the OVX group. Conclusions The present findings suggest that oestrogen induced a much greater amount of bone resorption on the anterior surface of the condylar head at an earlier stage in the TMJs of the present model rabbits. Thereafter, restoration of TMJ function appeared to occur in a normal manner.

We report the case of a patient presenting with severe headache and progressive aphasia due to a large brain abscess. End-stage peri-implantitis on a dental implant in the upper jaw with contact to the maxillary sinus floor causing maxillary and frontal sinusitis could be identified as the source of infection. Multidisciplinary treatment included broad-spectrum antibiotics, craniotomy for abscess drainage, sinus surgery, and the removal of the implant. Despite all the care taken, the patient died, underlining the importance of oral hygiene and a frequent recall in patients with dental implants. To the best of our knowledge, this is the first report of a brain abscess caused by peri-implantitis in the literature.

Arthrocentesis has an effect of washing out inflammatory products that accumulate in the joint compartment of a dysfunctional temporomandibular joint (TMJ). The procedure removes inflammatory cytokines, which are pain-causing substances, for early reduction of TMJ pain and quick recovery of jaw function, thus increasing the possibility of a successful rehabilitation. The aim of this study was to investigate the relationship between arthroscopy synovitis grade in patients with unilateral high condylar fractures and concentrations of the pro-inflammatory cytokines tumour necrosis factor (TNF)-alpha as well as of matrix metalloproteinases (MMPs) in washed-out synovial fluid (SF) samples obtained from those patients. A total of 26 patients with unilateral high condylar fractures who underwent arthrocentesis for a therapeutic purpose were examined. SF samples were collected before performing arthroscopy to determine synovitis grade. The detection rates and concentrations of TNF-alpha and MMPs were determined, and their association with synovitis grade was analysed. TNF-alpha was detected in 23 and MMP-3 in 22 of the TMJs. There was a correlation between synovitis grade and concentration of TNF-alpha in the fracture group. Furthermore, the concentrations of TNF-alpha and MMP-3 were significantly higher as compared to the control group, comprised of TMJs on the non-fracture side of the same patients, while a correlation was also noted between TNF-alpha concentration and synovitis grade in the fracture group. The present findings may provide a biological/biochemical rationale for arthrocentesis as a reasonable treatment modality for high condylar fractures.

In the abstract and in other parts of the manuscript the authors wrote that the mutation rs396991 causes a valine (V) to phenylalanine (F) substitution at position 157. However, the correct codon number is 158. These errors have not been fixed in the original Article.

Background: Anatomical knowledge of the facial vasculature is crucial for successful plastic, reconstructive, and minimally invasive procedures of the face. Whereas the majority of previous investigations focused on facial arteries, the precise course, variability, and relationship with adjacent structures of the facial vein have been widely neglected. Methods: Seventy-two fresh frozen human cephalic cadavers (32 male and 40 female cadavers;mean age, 75.2 +/- 10.9 years;mean body mass index, 24.2 +/- 6.6 kg/m(2);99 percent Caucasian ethnicity) were investigated by means of layer-by-layer anatomical dissection. In addition, 10 cephalic specimens were investigated using contrast agent-enhanced computed tomographic imaging. Results: The facial vein displayed a constant course in relation to the adjacent anatomical structures. The vein was identified posterior to the facial artery, anterior to the parotid duct, and deep to the zygomaticus major muscle. The angular vein formed the lateral boundary of the deep medial cheek fat and the premaxillary space, and the medial boundary of the deep lateral cheek fat and the suborbicularis oculi fat. The mean distance of the inferior and superior labial veins, of the deep facial vein, and of the angular vein from the inferior orbital margin was 51.6 +/- 3.1, 42.6 +/- 2.3, 27.4 +/- 3.0, and 4.2 +/- 0.7 mm, respectively. Conclusions: This work provides detailed information on the course of the facial vein in relation to neighboring structures. The presented clinically relevant anatomical observations and descriptions of landmarks will serve as helpful information for plastic, reconstructive, and aesthetic surgeons.

Summary Objective The aim of this study is to provide detailed information on the arterial variations of the descending geniculate artery (DGA) for the harvest of a cortico-periostal flap from the medial femoral condyle and a fascio-cutaneous perforator flap with its respective pedicles. Material and methods A total of 50 lower limbs from embalmed cadavers were dissected. The distribution pattern, length, and diameter of the DGA, saphenous artery (SA), muscular, periostal, and articular branches, and their concomitant veins were measured and evaluated. Results The DGA was present in 98% of the cases. In 80%, a Y-shaped distribution was identified where the SA branched from the DGA. Here, the mean lengths of DGA, SA, and the articular branch of the DGA were 3.2 ± 1.1, 7.18 ± 3.2, and 6.72 ± 2.07 cm, respectively. In 18%, an H-shaped distribution was noted, where the SA emerged directly from the femoral artery with a length of 10.2 ± 1.9 cm, whereas the length of the DGA (and its terminal articular branch) was 7.5 ± 1.5 cm. The mean length of the arterial pedicle for a cortico-periostal flap from the medial condyle was 9.92 cm, whereas for the fascio-cutaneous perforator flap, it was 9.46 cm in Y-shaped distribution and 10.2 cm for the H-shaped distribution. Conclusion Different arterial distribution patterns increase the need for routine preoperative vascular imaging when planning to harvest a cortico-periostal flap and a fascio-cutaneous perforator flap from the medial femoral condyle, especially when a double-chimeric flap is targeted. Level of evidence Level 4, case series.

The medial femoral condyle (MFC) flap is considered an ideal graft for bone reconstructions. This study was performed to evaluate donor site knee joint function and scar appearance after MFC flap procurement. Adult patients who had undergone facial reconstruction with an MFC flap between March 2011 and March 2017 at the University Hospital Salzburg were enrolled. Knee function was assessed postoperatively using two validated orthopaedic scores: Tegner Lysholm Knee Scoring Scale (TL) and Knee Society Score (KSS); both range from 0 to 100 (100 being no impairment). Scars were evaluated using the Patient and Observer Scar Assessment Scale (POSAS) (range 6–60). Thirty-eight patients were enrolled. The average postoperative TL score was 95.68 (range 66–100). The mean KSS clinical examination and function scores were 96.8 (range 58–100) and 97.11 (range 60–100), respectively. Flap type (osteocutaneous vs. non-osteocutaneous) did not correlate with TL or KSS scores. KSS and TL scores showed no association with vascular pedicle length or transplant volume. The average POSAS patient and observer scores were 6.84 and 15.24, respectively. POSAS observer scores were significantly higher for osteocutaneous flaps than for non-osteocutaneous flaps. The MFC flap causes minimal donor site morbidity. No knee joint instability or range of motion limitation was found. Postoperative TL and KSS scores indicated excellent knee function.

Purpose of review The aim of this article is to review the literature on medial femoral condyle (MFC) free flap in head and neck reconstruction. Recent findings The MFC flap is a superb material for head and neck reconstruction, especially in smaller bony defects. As an alternative to fibular free flap, it presents many advantages. Combining the periosteal bone with skin and/or muscle paddle, the MFC flap is suitable for complex reconstructions with favorable healing process. Even though this flap has a longer history of orthopedic and traumatologic reconstructions, a number of cases in head and neck surgery have been recently reported. Summary The MFC flap has been successfully used to reconstruct various head and neck sites, from the orbit, maxilla, and mandible, to the laryngeal and tracheal scaffolds.

Background/aim Maxillofacial trauma is frequent and represents a heavy burden for patients and society. The aim of this study was to investigate the characteristics and management of mandibular fractures caused by falls. Material and methods One hundred thirty-nine patients with 185 mandible fractures caused by falls were included in this retrospective study. The patients were grouped according to age, gender, fitness level (as classified by the American Society of Anesthesiology physical status classification), the month of the accident, sites of fractures and treatment methods. Results Most adult and fit patients were treated with open reduction and internal fixation, except for intracapsular condyle fractures. Conservative management was chosen for paediatric patients and in all cases deemed at high risk for lengthy procedures under general anaesthesia (physical status III according to the American Society of Anesthesiology). Young patients were mainly males, whereas geriatric patients were mainly females. In cases of single-site fracture, condylar fractures were the most prevalent. In cases with multiple sites, the association of condyle and symphysis fractures was the most frequent. Conclusions The results show an increasing trend in geriatric condyle fractures, especially in females. The epidemiology of fall-related mandibular fractures is subject to the influence of seasonal, historical, cultural and demographic factors.

We have assessed the role of the medial femoral condylar flap in 107 patients who had reconstructions of the head and neck. We retrospectively reviewed their medical records for indications, complications, and outcomes. The flap was primarily used for coverage of alveolar ridge defects (n=67), secondly for defects of the facial bone, calvaria, or skull base (n=35), and thirdly for partial laryngeal defects (n=5). Two flaps were lost. One patient fractured a femur 5 weeks postoperatively. The duration of follow up ranged from 6 months to 12 years. The medial femoral condylar flap is well-suited to individual reconstructions of the alveolar ridge, midface, calvaria, skull base, and part of the larynx with poor recipient sites. The flap does not replace other wellknown flaps, but offers new solutions for solving special problems in head and neck surgery.

Large airway reconstruction is difficult and requires a flap that will mirror the tissue variety. The main challenge is to keep the reconstruction stable and prevent collapse. In this report, we present a laryngotracheal reconstruction with a buccal mucosa–prefabricated medial femoral condyle free flap, after chondroma excision in a 1-step procedure. Functional results are promising and were confirmed by endoscopy and computed tomography examination 12 months postoperatively. This reconstruction-with-prefabrication technique, among others, may be used in the reconstruction of different regions like craniofacial bone defects, apart from larynx and trachea.

Septic arthritis of the temporomandibular joint (TMJ) is rare, but patients with this diagnosis are at high risk for significant morbidity. We present a case of a 15-year-old man who presented with increasing trismus for 3 days. He had only minimal discomfort and swelling of the right cheek and temporal region, and pericoronitis of an impacted wisdom tooth was suspected. Under intravenous antibiotics, pain subsided, but trismus and a slight swelling remained. CT scan showed septic arthritis of the TMJ with an abscess formation penetrating into the epidural space. Immediate drainage and craniotomy were performed. Under intravenous antibiotics, the patient made a full recovery. The source of infection remained undetermined. To our knowledge, this is the first reported case of septic arthritis of the TMJ spreading into the epidural space.

PubMedID: 29033290 Purpose: Subchondral perfusion of osteochondral grafts has been shown to be important in preventing long-term cartilage degeneration. In carpal reconstruction, subchondral perfusion from the graft bed is limited. This study's purpose was to compare the histological characteristics of cartilage in osteochondral grafts supported by synovial imbibition alone to cartilage of vascularized osteochondral flaps that have both synovial and vascular pedicle perfusion. Methods: Two adjacent osteochondral segments were harvested on the medial femoral trochlea in domestic 6- to 8-month-old pigs. Each segment measured approximately 12 mm × 15 mm × 17 mm. One segment was maintained on the descending geniculate artery vascular pedicle. The adjacent segment was separated from the pedicle to serve as a nonvascularized graft. A thin layer of methylmethacrylate cement was used to line the harvest site defect to prevent vascular ingrowth to the subsequently replaced specimens. The pigs were maintained on a high-calorie feed and returned to ambulation and full weight-bearing on the surgical legs. The animals were sacrificed after 6 months and the specimens were reharvested, sectioned, and examined. The cartilage was graded by 2 pathologists blinded to the origin of specimens as vascularized flaps or nonvascularized grafts. Results: All specimens were assigned scores utilizing the International Cartilage Repair Society grading system. Scoring for chondrocyte viability, cartilage surface morphology, and cell and matrix appearance was significantly higher in the vascularized osteochondral group than in the graft group. Conclusions: When deprived of subchondral perfusion from underlying bone, osteochondral vascularized flaps in an intrasynovial environment demonstrate superior cartilage quality and survival compared with nonvascularized grafts. Clinical relevance: In locations in which perfusion from surrounding bone may be limited (ie, proximal scaphoid or proximal lunate reconstruction), articular reconstruction using vascularized osteochondral flaps will yield superior cartilage organization and architecture than nonvascularized osteochondral grafts. The clinical and functional relevance of this finding requires further study. © 2018 American Society for Surgery of the Hand

The larynx is a complicated organ with very important functions. Reconstructive operations of the larynx often result in some function reduction caused by scars and stenoses. The aim of this report is to present the results of the one-stage reconstructive operation after a large excision of the chondrosarcoma of the larynx. The patient was male, aged 48 with the history of the operation of the highly mature cartilaginous sarcoma of the thyroid on the right side with tumor recurrence. The one-stage reconstructive surgery using medial condyle femur corticoperiosteal free flap which reshaped the cartilage scaffold and restored an inner layer as the mucosa was made. The flap survived without local and systemic complications. Six months follow-up revealed no local recurrence and good breathing results. There was no restriction of movement of the lower limbs. The patient returned to work previously performed. Results were shown in endoscopic examinations and computer tomography. The medial condyle femur corticoperiosteal free flap may be an option for reconstruction of large laryngeal defect with restoring its shape and inner layers.

Introduction Two-jaw surgery has become the standard procedure for correcting skeletal maxillo-mandibular discrepancies in adults. However, only a few studies have reported on the long-term stability of bimaxillary orthognathic surgery in patients with Class II malocclusion and transverse discrepancies. In this study, the long-term outcome of two-piece maxillary treatment during bimaxillary surgery in patients with skeletal Class II malocclusion was examined and the results are discussed. Material and methods Dental plaster casts and lateral cephalograms of 47 patients were collected in five phases of treatment: baseline (t1), preoperatively (t2), postoperatively (t3), at the end of orthodontic treatment (t4), and at the time of long-term follow-up (t5), and were retrospectively analyzed. Results At follow-up all patients showed a Class I occlusion. The maxillary width was, on average, enlarged by 2.7 mm surgically. During the following 8.8 years after treatment, 1.7 mm were lost. The cephalometric analyses showed no severe changes in the sagittal maxillary position for the duration of follow-up. The sagittal mandibular position (SNB) was changed significantly by the mandibular advancement from 75.4° to 77.8° and remained stable for 8.8 years postoperatively. Conclusion Bimaxillary surgery with two-piece maxillary treatment in patients with Class II malocclusion leads to stable long-term occlusal results in the sagittal plane. The transverse enlargement achieved by intraoperative widening does not remain stable over the years. A relapse of about 60% of the surgically expanded transverse width is seen. In Class II deformities without an open bite, where extended transverse enlargement is necessary, a two-step procedure with primary surgically-assisted rapid palatal expansion followed by one-piece surgery should be planned.

This article aims to give an overview on etiology, diagnosis and treatment options of osteonecrosis of the jaw bone among cancer patients receiving anti-resorptive drugs (ARDs). The physiologic bone function of continuous resorption and buildup is modified by the use of ARDs. Although ARDs proved to reduce pain and to improve the quality of life in patients with metastasizing bone disease, side effects such as medication related osteonecrosis of jaw bone (MRONJ) have been frequently reported since ARDs were firstly introduced. The new generation of ARDs such as Denosumab is associated with the same incidence of MRONJ among cancer patients. The etiology of MRONJ is not entirely understood and many hypotheses have been proposed. ARDs can modify the hard tissues directly by accumulation in the bone, or indirectly by suppression of the osteoclasts, inhibition of angiogenesis and vascularity. Some ARDs such as Bisphosphonates have reportedly the capacity to interfere directly and indirectly with the bone physiology. MRONJ can be a debilitating disease with non healing freely exposed bone in the oral cavity in patients, who already suffer from a primary cancerous disease. Knowledge of MRONJ as a potential side effect of ARDs is crucial for health professionals treating patients with bone modulating drugs.

In midface defects including the orbit (Brown class III and IV), no single flap can provide adequate reconstruction. In this technical note, the combination of vascularized iliac crest flap and vascularized medial femoral condyle flap (MFC) is described. The vascularized iliac crest flap is reported to be the gold standard for maxilla reconstruction. There is, however, no consensus on the best method for orbital and nasal wall reconstruction. The MFC flap can be harvested as a thin corticoperiosteal flap or as an osteomyocutaneous flap. Due to the periosteal blood supply, this flap can be customized for an individual defect of the upper hemi-midface. It is therefore of great benefit in orbital and nasal wall reconstruction. By combining the deep circumflex iliac artery (DCIA) bone flap and the MFC flap, the best standard reconstruction technique of the hemi-maxilla can be combined with a new anatomical precise microvascular reconstruction technique of the orbit. A nearly symmetric midface appearance can be achieved.

Background Tumour heterogeneity and clonal evolution within a cancer patient are deemed responsible for relapse in malignancies and present challenges to the principles of targeted therapy, for which treatment modality is often decided based on the molecular pathology of the primary tumour. Nevertheless, the clonal architecture in distant relapse of head and neck cancer is fairly unknown. Patients and methods For this project, we analysed a cohort of 386 patients within the Austrian Registry of head and neck cancer. We identified 26 patients with material from the primary tumour, the distant metastasis after curative first-line treatment and a germline sample for analysis of clonal evolution. After pathological analyses, these samples were analysed using a targeted massively parallel sequencing (MPS) panel of 257 genes known to be recurrently mutated in head and neck cancer plus a genome-wide SNP-set. Results Despite histological diagnosis of distant metastasis, no corresponding mutation in the supposed metastases was found in two of 23 (8.6%) evaluable patients suggesting a primary tumour of the lung instead of a distant metastasis of head and neck cancer. We observed a branched pattern of evolution in 31.6% of the analysed patients. This pattern was associated with a shorter time to distant metastasis, compared with a pattern of punctuated evolution. Structural genomic changes over time were also present in 7 of 12 (60%) evaluable patients with metachronous metastases. Conclusion Targeted MPS demonstrated substantial heterogeneity at the time of diagnosis and a complex pattern of evolution during disease progression in head and neck cancer. Copy number analyses revealed additional changes that were not detected by mutational analyses. Mutational and structural changes contribute to tumour heterogeneity at diagnosis and progression.

Summary Background The buccal space is an integral deep facial space which is involved in a variety of intra- and extra-oral pathologies and provides a good location for the harvest of the facial artery. The age-related anatomy of this space was investigated and compared to previous reports. Methods We conducted anatomic dissections in 102 fresh frozen human cephalic specimens (45 males, 57 females; age range 50–100 years) and performed additional computed tomographic, magnetic resonance and 3-D surface volumetric imaging studies to visualize the boundaries and the contents of the buccal space after injection of contrast enhancing material. Results The mean vertical extent of contrast agent injected into the buccal space was 25.2 ± 4.3 mm and did not significantly differ between individuals of different age (p = 0.77) or gender (p = 0.13). The maximal injected volume was 10.02 cc [range: 3.09–10.02] without significant influence of age (p = 0.13) or gender (p = 0.81). The change in surface volume was 3.64 ± 1.04 cc resulting in a mean surface-volume-coefficient of 0.87 ± 0.12 without being statistically significant influenced by age (p = 0.53) or gender (p = 0.78). Conclusions The facial artery was constantly identified within the buccal space whereas the facial vein was found to course within its posterior boundary. The buccal space did not undergo age-related changes in volume or size which highlights this space is a reliable and predictable landmark for various plastic, reconstructive and aesthetic procedures.

The lateral femoral condyle (LFC) flap is a new flap first reported in 2015 for the treatment of osteomyelitis in hand surgery. This paper introduces a technique of osteochondral LFC flap harvest for mandibular condyle reconstruction and reports on the use of this flap in temporomandibular joint reconstruction. For condyle resection, a pre-auricular approach saving the temporal artery and vein is performed. A step osteotomy technique is used for condyle resection. LFC harvesting starts with dissection of the popliteal artery and vein. The superior genicular artery and vein are identified and followed along their periosteal branches. An osteochondral flap according to the condyle defect is harvested from the anterior pole of the knee. The flap is banded according to the defect and fixed to the mandibular neck with three miniscrews. Follow-up computed tomography scans should be performed at 1 week, 6 months, and 1year after surgery. The case of a 58-year-old female patient with osteomyelitis of the left mandibular condyle after multiple preoperative therapies is reported. The LFC flap technique was used for left condyle reconstruction, resulting in good functional and morphological outcomes at the 6-month postoperative follow-up. In conclusion, the osteochondral LFC flap is a new and promising technique for mandibular condyle reconstruction for special indications.

Purpose To present a new technique for sandwich osteoplasty in the posterior mandible and to evaluate its feasibility as part of dental implant treatment. Materials and methods A retrospective study of sandwich osteoplasty in the posterior mandible was conducted. No osteosynthetic material was used to stabilize the osteotomy. Fixation was achieved with the interposition of two bone blocks harvested from the retromolar region. Results Eighteen patients with 26 sites of severe atrophy of the posterior mandible were treated. After a healing period of 4 months, 53 dental implants were inserted into the augmented region. The implants were loaded with single crowns or fixed dental prostheses 3 months after placement. The mean vertical bone gain after 4 months of healing was 4.2 mm (standard deviation 1.4 mm). The average bone loss between augmentation and implantation was 2.3 mm (35.4%). All implants osseointegrated and showed no clinical signs of peri-implantitis. In three subjects, the elevated bony segment perforated the lingual mucosa near the adjacent teeth after excessive elevation (> 6 mm) but healed without any sequelae. Conclusion An alternative method for vertical alveolar ridge augmentation of the posterior mandible is presented. No osteosynthetic material is required for fixation, and related complications can be avoided. Further prospective clinical studies are required to demonstrate the feasibility of this technique versus the conventional sandwich osteoplasty.

he dorsum of the nose can be reconstructed in many ways, sually with satisfactory results.1 Many patients require corection of the upper lateral cartilages to improve the shape rom the anteroposterior view and in profile. Care must be aken with the horizontal and vertical reduction of the upper ateral cartilages. To avoid over-resection, it should be begun fter the osteotomies have been completed, as the upper latral cartilages will drop down after the nasal bones have been epositioned.2 Substantial reduction of the upper lateral carilages may result in the roof of the nose requiring spacer rafts at the rhinion to fill the gap. Spreader grafts may also be equired to lateralise the upper lateral cartilages from the sepum either to widen the nose aesthetically or support the upper ateral cartilages, which may narrow the internal valve.2 Over-resection of the dorsum has been reported to be one f the main complaints that lead to revision rhinoplasty,3 hich may be demanding when the dorsum has been altered nd scarred after the primary operation.4 We present what s to our knowledge a new technique for preservation of the riginal structures of the dorsum of the nose in open rhinolasty.

Purpose The descending geniculate artery's branching pattern includes periosteal vessels supplying the cartilage-bearing trochlea of the medial patellofemoral joint. Previous cadaveric studies described anatomic similarities between the greater curvature of the proximal scaphoid and the convex surface of the medial femoral trochlea (MFT). We describe the technique and report our first 16 consecutive cases of vascularized osteocartilaginous arthroplasty for chronic scaphoid proximal pole nonunions using the MFT, with a minimum of 6 months of follow-up. Methods Chart reviews of 16 consecutive cases of osteocartilaginous MFT flap transfers for scaphoid reconstruction were performed at 2 institutions. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months (range, 6–72 mo). Patient age and sex, duration of nonunion, number of previous surgical procedures, surgical technique, achievement of osseous union, preoperative and postoperative scapholunate angles, preoperative and postoperative range of motion, and pain relief were recorded. Results Computed tomography imaging confirmed healing in 15 of 16 reconstructed scaphoids. Mean patient age was 30 years (range, 18–47 y). The average number of previous surgical procedures was 1 (range, 0–3). All patients experienced some wrist pain improvement (12/16 complete relief, 4/16 incomplete relief). Wrist range of motion at follow-up averaged 46° extension (range, 28° to 80°) and 44° flexion (range, 10° to 80°), which was similar to preoperative measurements (average 46° extension and 43° flexion). Scapholunate relationship remained unchanged with average scapholunate angles of 52° before surgery and 49° after surgery. Conclusions Osteochondral vascularized MFT flaps provide a reliable means of achieving resolution of difficult proximal pole scaphoid nonunions. These flaps allow resection of the proximal portion of the unhealed scaphoid and reconstruction with an anatomically analogous convex segment of cartilage-bearing bone. This technique provides the advantages of vascularized bone and ease of fixation. Early follow-up demonstrates a high rate of union with acceptable motion and pain relief. Clinical relevance Early follow-up suggests that the vascularized MFT osteocartilaginous flap is a valuable tool for treating challenging proximal pole scaphoid nonunions.

In arterialized venous flaps (AVFs) the venous network is used to revascularize the flap. While the feasibility of AVFs in soft tissues has been reported there is no study on osseous AVFs. In this study we aim to assess the flap survival of osseous AVFs in a pig model. Medial femoral condyle flaps were elevated in 18 pigs. Three groups were created: AVF (n = 6), conventional arterial flap (cAF, n = 6) and bone graft (BG, n = 6). The AVFs were created by anastomosis of genicular artery with one vena comitans while leaving one efferent vein for drainage. After 6 months the specimens were harvested. The histology and histomorphometry of of the bone in cAF and AVF was significantly superior to bone grafts with a higher bone volume in AVFs (p = 0.01). This study demonstrates that osseous free flaps may be supported and survive using the technique of arterialization of the venous network. The concept of AVFs in osseous flaps may be feasible for revascularization of free flaps with an inadequate artery but well developed veins. Further experimental and clinical studies are needed to assess the feasibility of clinical use of arterialized venous bone flaps.