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Study Design Comparative cross-sectional. Objective To measure the impact that COrona VIrus Disease-19 (COVID-19) has had on craniomaxillofacial (CMF) surgeons after 1 year and compare it with 2020 data by ( 1) measuring access to adequate personal protective equipment (PPE), ( 2) performance of elective surgery, and ( 3) the vaccination status. This should be investigated because most CMF surgeons felt that hospitals did not provide them with adequate PPE. Methods The investigators surveyed the international AO CMF membership using a 30-item online questionnaire and compared it to a previous study. The primary predictor variable was year of survey administration. Primary outcome variables were availability of adequate personal protective equipment (adequate/inadequate), performance of elective surgery (yes/no), and vaccination status (fully vaccinated/partly vaccinated/not vaccinated). Descriptive and analytic statistics were computed. Binary logistic regression models were created to measure the association between year and PPE availability. Statistical significance level was set at P < .05. Results The sample was composed of 523 surgeons (2% response rate). Most surgeons reported access to adequate PPE (74.6%). The most adequate PPE was offered in Europe (87.8%) with the least offered in Africa (45.5%). Surgeons in 2021 were more likely to report adequate PPE compared to 2020 (OR 3.74, 95% CI [2.59–4.39]). Most of the respondents resumed elective surgery (79.5% vs 13.3% in 2020) and were fully vaccinated (59.1%). Conclusions Most CMF surgeons now have access to adequate PPE, resumed elective surgery, and are either fully or partly vaccinated. Future studies should investigate the long-term impact of the fast-evolving COVID-19 pandemic on CMF surgeons.

The current standard of documenting and communicating frozen section margin results is inefficient. We present a novel method of generating 3D digital models of gross tumor specimens to more clearly visualize histopathological margin results.Fifty-five head and neck specimens were scanned and virtually "inked" using 3D software. These 3D specimen maps were displayed in the operating room to provide the surgeon with a real-time specimen-to-defect relationship by which further resections could be guided.Margin results were reported within an average of 34 min using the proposed workflow. The scanner rendered accurate models of specimens that exceeded 3.0 × 3.0 × 3.0 cm. Critical specimen features to consider were size, color, textural complexity, and the presence of discernible anatomic landmarks.Optical 3D scanning technology can improve the quality of head and neck margin documentation and the efficiency with which results are communicated between the pathologist and surgeon.

Study Design: case series. Objective: The restoration of defects in a single procedure with microvascular free flap reconstruction has become a mainstay of head and neck surgery. Yet in patients with complex defects and pre-existing comorbid medical conditions, a staged-reconstructive approach can enhance the safety of the procedure and improve the patient’s outcome. Methods: We present 3 representative case examples of a larger series of patients who underwent reconstruction of major defects and discuss the usefulness of a staged-reconstructive approach in the management of complex patients. Results: All 3 patients, with an existing composite defect in the setting of prior radiation therapy, underwent successful staged-reconstructive surgery using a variety of free tissue and regional flap transfers. Conclusions: A staged approach facilitates the reconstruction of complex composite defects, increases vessel availability, and mitigates the risk of flap failure. Although this approach commits the patient to multiple procedures and a more prolonged plan of care, it is preferable to 1 operation in specific complex situations with adverse, high-risk clinical features.

Purpose Successful orthognathic surgery is fundamentally based on accurately carrying out the intended surgical plan intraoperatively. The purpose of this study was to evaluate the accuracy of bone-borne patient-specific maxillary cutting guides and 3-dimensional (3D)–printed plates in repositioning the maxilla during bimaxillary orthognathic surgery. Materials and Methods This was a retrospective case series consisting of patients who had undergone Le Fort I osteotomy with a patient-specific cutting guide and 3D-printed plate as well as a bilateral sagittal split osteotomy and had 6-week postoperative cone-beam computed tomography studies. The primary outcome variable was the difference between the position of the postoperative maxilla and the virtually planned maxilla measured at 10 landmarks in 3 dimensions. Other study variables included the preoperative diagnosis and planned surgical movement at each landmark. Descriptive statistics were tabulated, and bivariate analyses were performed. Results A total of 10 patients were included in this study. The mean age was 25.7 ± 8.1 years, and there were 5 female patients. The median planned surgical movement was 0.350 mm on the x-axis (right-left), 3.750 mm on the y-axis (anterior-posterior), and 1.704 mm on the z-axis (superior-inferior). The median absolute discrepancy between the postoperative position and the planned position on the x-axis, y-axis, and z-axis was 0.638, 0.798, and 0.481 mm, respectively. There was no significant difference in the discrepancies between the x-axis and y-axis (P = .575), x-axis and z-axis (P = .332), and y-axis and z-axis (P = .114). Conclusions Using a patient-specific cutting guide and 3D-printed plate when performing Le Fort I osteotomy allows for accurate 3-dimensional positioning of the maxilla in accordance with the surgical plan.

Open-mouth deformity after mandibular resection presents a challenge for surgeons and patients, contributing to significant functional and cosmetic morbidity. We present an innovative surgical technique to prevent or correct open-mouth deformity. Tensor fascia lata slings were utilized in combination with maxillomandibular fixation to surgically correct or prevent open-mouth deformity in four patients who had previously undergone mandibulectomy or at the time of a contralateral mandibulectomy following prior hemimandibulectomy and reconstruction. Two patients achieved favorable outcomes, including oral competence and improved resting jaw position, while open-mouth deformity could not be corrected for one patient. Another patient remains in the early postoperative period following a secondary procedure to correct open-mouth deformity. Open-mouth deformity is a functional/aesthetic problem that has not been addressed in the literature. Use of tensor fascia lata slings to suspend the mandible is a novel approach to the surgical management of open-mouth deformity.

The COVID-19 pandemic is a global problem that has adversely and significantly impacted the safe practice of maxillofacial surgery. The risk lies in the heavy viral load in the oral/nasal/upper respiratory mucosal surfaces. Surgical procedures performed in this anatomic regional produce aerosalized viral particles which are highly infectious. Best practices and recommendations are outlined to mitigate the risk to the provider.

Study Design: The COrona VIrus Disease-19 (COVID-19) pandemic has disrupted craniomaxillofacial (CMF) surgeons practice worldwide. We implemented a cross-sectional study and enrolled a sample of CMF surgeons who completed a survey. Objective: To measure the impact that COVID-19 has had on CMF surgeons by (1) identifying variations that may exist by geographic region and specialty and (2) measuring access to adequate personal protective equipment (PPE) and identify factors associated with limited access to adequate PPE. Methods: Primary outcome variable was availability of adequate PPE for health-care workers (HCWs) in the front line and surgeons. Descriptive and analytic statistics were computed. Level of statistical significance was set at P < .05. Binary logistic regression models were created to identify variables associated with PPE status (adequate or inadequate). Results: Most of the respondents felt that hospitals did not provide adequate PPE to the HCWs (57.3%) with significant regional differences ( P = .04). Most adequate PPE was available to surgeons in North America with the least offered in Africa. Differences in PPE adequacy per region ( P < .001) and per country ( P < .001) were significant. In Africa and South America, regions reporting previous virus outbreaks, the differences in access to adequate PPE evaporated compared to Europe ( P = .18 and P = .15, respectively). Conclusion: The impact of COVID-19 among CMF surgeons is global and adversely affects both clinical practice and personal lives of CMF surgeons. Future surveys should capture what the mid- and long-term impact of the COVID-19 crisis will look like.

BACKGROUND Common in head and neck cancer patients, trismus can make speech and swallowing difficult and can compromise quality of life (QOL). Jaw range of motion exercise therapy may prevent or treat trismus in surgical patients. While the importance of these exercises is well-documented, there is little literature regarding the optimal timing of exercise initiation. METHODS A prospective pilot study investigated the effects of early vs late jaw exercise intervention on postoperative jaw opening and QOL measures, which were examined descriptively. RESULTS Timing of exercise intervention was not found to significantly impact the measured outcomes. However, provisional, descriptive findings showed that jaw opening was significantly associated with multiple QOL measures, with greater jaw opening associated with improved QOL. For certain QOL measures, this positive association was stronger at earlier time points than at later time points. CONCLUSIONS The exploratory findings of this pilot study support further research into possible benefits of early jaw exercise intervention.

IMPORTANCE: Incorporation of patient perspectives, or patient-reported outcomes, in functional outcome measures has been gaining prominence in the literature on reconstructive surgery. OBJECTIVE: To create and validate an instrument for measuring the main functional areas of concern for patients with head and neck cancer. DESIGN, SETTING, AND PARTICIPANTS: This 4-phase mixed-methods qualitative study was conducted from July 1, 2013, to June 30, 2016, in a quaternary head and neck oncology center in Edmonton, Alberta, Canada. Patients were recruited from 3 Head and Neck Research Network sites: University of Alberta (Edmonton, Canada), Mount Sinai Health Network (New York, New York), and University of Turku Hospital (Turku, Finland). The inclusion criteria included 18 years of age or older, diagnosis of squamous cell carcinoma involving the subsites of the head and neck (ie, oral cavity, oropharynx, hypopharynx, and larynx), and at least 1 year since treatment completion. Those patients who were undergoing additional active treatment or with evidence of disease recurrence were excluded. Data were analyzed from July 1, 2013, to June 30, 2016. MAIN OUTCOMES AND MEASURES: The primary outcome measures were the clinical correlation of the Edmonton-33 instrument scores with swallowing, speech, dry mouth, and chewing assessment outcomes. RESULTS: In total, 10 patients with head and neck cancer (mean age, 59.6 years; 6 men [60%]) were included in phase 1 of the study, 5 patients (mean age, 55.2 years) were included in phase 2, 10 patients were included in phase 3, and 25 patients with head and neck cancer (mean age, 62.6 years; 14 men [56%]) participated in the phase 4 validation. The Edmonton-33 instrument scores correlated strongly with the swallowing scores of the MD Anderson Dysphagia Inventory (r = 0.77; 95% CI, 0.49-1.0), the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire–Head and Neck 35 (EORTC QLQ–H&N35) (r = –0.73; 95% CI, –1.0 to –0.44), and the modified barium swallow test (r = –0.60; 95% CI, –0.94 to –0.25). The instrument scores were also strongly correlated with the Speech Handicap Index scores (r = –0.64; 95% CI, –0.97 to –0.31), word intelligibility scores (r = 0.61; 95% CI, 0.27-0.95), and sentence intelligibility scores (r = 0.55; 95% CI, 0.19-0.91). A moderate to strong correlation was observed between the Edmonton-33 instrument and the EORTC QLQ–H&N35 scores in the dry mouth (r = –0.54; 95% CI, –0.91 to –0.18) and chewing (r = –0.45; 95% CI, –0.84 to –0.06) domains. The factor loading values for the domains of swallowing, speech, dry mouth, and chewing were all greater than 0.3. The mean factor loading values for the items related to swallowing were 0.71 (95% CI, 0.62-0.80) and for the items related to speech were 0.76 (95% CI, 0.72-0.80). The mean factor loading values for the items related to dry mouth were 0.71 (95% CI, 0.59-0.83) and for those related to chewing were 0.77 (95% CI, 0.69-0.85). CONCLUSIONS AND RELEVANCE: The Edmonton-33 appears to be a validated instrument that will allow patients with head and neck cancer to assess and report their own functional outcomes. It could serve as a single comprehensive measure for functional outcomes.

Objective A subset of patients who undergo major palatomaxillary reconstruction do not initially achieve their intended oncologic and/or reconstructive goals and require additional surgery. We aim to detail the unique management considerations in this patient population. Methods We performed a retrospective review of patients who underwent palatomaxillary reconstruction by the senior author (m.l.u.) between 1998 and 2016. Results Twenty-one patients required multiple reconstructions. The median time to second reconstruction was 17 months. The most common reason for a second reconstruction was for recurrent disease (10 of 21), followed by functional/aesthetic reasons (7 of 21) and osteoradionecrosis (4 of 21). Four patients went on to have a third reconstruction, and two underwent a fourth. A total of 27 reconstructions were performed, consisting of 20 soft tissue free flaps, four vascularized bone free flaps, and three locoregional flaps. Conclusion This patient cohort represents unique oncologic and reconstructive challenges. With long-term follow-up, multiple reconstructions may be required to optimize oncologic and functional/aesthetic outcomes. This is the first series of its kind that details the reasons for, as well as the outcomes of, patients who required multiple reconstructive procedures following initial palatomaxillary reconstruction. Level of evidence 2B Laryngoscope, 130:2349-2353, 2020.

Purpose The purpose of this study was to describe the trends pertaining to the use of the fibula free flap for mandibular reconstruction during the past 10 years. Materials and Methods A systematic review for publications on the fibula free flap in mandibular reconstruction in the PubMed and Scopus databases was performed from January 1, 2005 until December 31, 2014. Publications were classified by topic, number of patients, and country of origin. The study period was split into 2 periods. The first 5-year period was compared with the second 5-year period. Results Eighty-five publications were identified. There was an increase in publications regarding restorative decision making (11 vs 9), surgical techniques (13 vs 6), outcomes (20 vs 10), and computer-aided design and computer-aided manufacturing (CAD-CAM; 8 vs 2) in the second 5-year period. The number of patients reported also increased in publications on surgical techniques (1,085 vs 59), outcomes (777 vs 254), bisphosphonate-related osteonecrosis of the jaw and osteoradionecrosis (165 vs 28), and CAD-CAM (65 vs 15) in the second 5-year period. The United States, India, China, and Europe produced most of the publications. Conclusions In the past 10 years, there was a surge in publications on the use of the fibula free flap for mandibular reconstruction. There was a 1.8-fold increase in the number of publications and a 3.4-fold increase in the number of patients undergoing this method of mandibular reconstruction in the second 5-year period. Publications from the United States, India, and China contributed to a large increase in the number of patients in the second 5-year period. More interest in CAD-CAM technology was seen in the second 5-year period that was not seen in the first 5-year period.

The management of benign, locally aggressive odontogenic tumors, namely, keratocystic odontogenic tumors (KOTs) and ameloblastomas, can be challenging. The purpose of this article is to briefly summarize important features of these lesions and review recent trends in the literature regarding their treatment.Currently, KOTs are frequently treated with a conservative approach consisting of enucleation and adjuvant decompression or local microablation with peripheral ostectomies, Carnoy's solution, or cryotherapy. Conversely, ameloblastomas generally require marginal or segmental resection followed by reconstruction using local bone regeneration techniques or vascularized osteocutaneous free flaps, respectively. Bone regeneration techniques have improved with the use of autogenous progenitor cells held in place by autogenous or alloplastic scaffolding. Esthetic results for free flap reconstruction have improved with the use of inconspicuous surgical approaches utilizing intraoral or rhytidectomy incisions. Molecular markers for both neoplasms are being investigated as potential targets for chemotherapeutic agents.Excluding hamartomas (i.e., odontomas), KOTs and ameloblastomas are the most common benign odontogenic lesions. Their management is often complicated by their locally infiltrative behavior, responsible for high rates of recurrence. Simple enucleation or excision of these lesions has proven insufficient. When left untreated, these lesions are capable of causing severe disfigurement and loss of function. Knowledge regarding current best practices and potential future therapeutics is imperative to well treated and effective disease management.

Objectives/Hypothesis The aim of this study was to present our experience with management of malignant lesions arising within the masticator space, and to describe a technique of en bloc resection and reconstruction. Study Design Case series and case report. Methods Eight cases of masticator space malignancies treated surgically with en bloc resection and free flap reconstruction were retrospectively reviewed. Results Tumor extirpation was carried out through a parotidectomy approach with mobilization and protection of the facial nerve. Primary reconstruction was accomplished with vascularized bone containing free flaps, fibula (n = 4), scapula (n = 2), and scapula with latissimus dorsi muscle (n = 2). Mean follow-up was 62.5 months (range, 18–132 months). Conclusions En bloc resection of masticator space malignancies can be consistently accomplished through an extended parotidectomy approach. The defect is best reconstructed with a vascularized bone and soft tissue free flap. Favorable functional and aesthetic outcomes can be successfully achieved using the techniques described in this series. Level of Evidence 4 Laryngoscope, 2015

Keywords: Mandibular reconstruction; oral cavity; double barrel fibular flap; transoral; quality of life

Reconstruction of bony craniofacial defects requires precise understanding of the anatomic relationships. The ideal reconstructive technique should be fast as well as economical, with minimal donor-site morbidity, and provide a lasting and aesthetically pleasing result. There are some circumstances in which a patient's own tissue is not sufficient to reconstruct defects. The development of sophisticated software has facilitated the manufacturing of patient-specific implants (PSIs). The aim of this study was to analyze the utility of polyether ether ketone (PEEK) PSIs for craniofacial reconstruction. We performed a retrospective chart review from July 2009 to July 2013 in patients who underwent craniofacial reconstruction using PEEK-PSIs using a virtual process based on computer-aided design and computer-aided manufacturing. A total of 6 patients were identified. The mean age was 46 years (16-68 y). Operative indications included cancer (n = 4), congenital deformities (n = 1), and infection (n = 1). The mean surgical time was 3.7 hours and the mean hospital stay was 1.5 days. The mean surface area of the defect was 93.4 ± 43.26 cm(2), the mean implant cost was $8493 ± $837.95, and the mean time required to manufacture the implants was 2 weeks. No major or minor complications were seen during the 4-year follow-up. We found PEEK implants to be useful in the reconstruction of complex calvarial defects, demonstrating a low complication rate, good outcomes, and high patient satisfaction in this small series of patients. Polyether ether ketone implants show promising potential and warrant further study to better establish the role of this technology in cranial reconstruction.

Background Palatomaxillary defects were historically restored with a prosthetic obturator; however, advances in local and free tissue transfer has provided a viable alternative for appropriately selected patients with palatomaxillary defects. Methods A retrospective chart review of patients who underwent palatomaxillary reconstruction by the lead author between 1998 and 2016 was conducted. Patients who were restored with a palatal obturator were excluded. Results One hundred forty patients were reconstructed with a total of 159 local, regional, and free flaps with a 96.7% success rate. Seventy-four patients (52.8%) underwent prosthodontic rehabilitation, with 183 implants placed and an 86% success rate. Conclusion Palatomaxillary reconstruction applying a systematic approach, using a multitude of techniques, is a safe and effective way to restore patients without compromising the ability to maintain surveillance. Prosthodontic rehabilitation can be achieved in a high percentage of patients using dental implants, leading to optimal aesthetic and functional results.

Background While aggressive treatment for oral cancer may optimize survival, decrements in speech and swallowing function and quality of life often result. This exploratory study investigated how patients recover their communicative function, swallowing ability, and quality of life after primary surgery [with or without adjuvant (chemo)radiation therapy] for tongue cancer over the course of the first year post-operation. Methods Patients treated for oral cancer at three institutions (University of Alberta Hospital, Mount Sinai Beth Israel Medical Center, and Turku University Hospital) were administered patient-reported outcomes assessing speech [Speech Handicap Index (SHI)], swallowing [(M.D. Anderson Dysphagia Inventory (MDADI)] and quality of life [European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC-H&N35)]. Outcome measures were completed pre-operatively and at 1-, 6-, and 12-months post-operatively. Results One hundred and seventeen patients undergoing partial glossectomy with reconstruction participated in this study. Results indicated no significant differences in swallowing function (MDADI and EORTC-H&N35 subscales) between baseline and 6 months post-surgery and no significant differences in speech function (SHI subscales) between baseline and 1 year post-surgery. Most quality of life domains (EORTC-H&N35 subscales) returned to baseline levels by 1 year post-operation, while difficulties with dry mouth and sticky saliva persisted. A clear time trend of adjuvant (chemo)radiation therapy negatively affecting dry mouth scores over time was identified in this study, while negative independent effects of chemoradiation on MDADI swallowing, and EORTC-H&N35 swallowing, eating, and opening mouth subscales were found. Conclusions Assessment time influenced patient-reported speech, swallowing, and quality of life outcomes, while treatment (by time) effects were found for only swallowing and quality of life outcomes. Results of the present study will help guide clinical care and will be useful for patient counseling on expected short and long-term functional and quality of life outcomes of surgical and adjuvant treatment for oral cavity cancer.

Background Review patient and defect factors in which this donor site is an optimal choice for reconstruction and to discuss strategies to overcome the perceived drawbacks of this system of flaps. Methods A retrospective medical chart review was conducted on all patients who underwent the subscapular system of free flaps for head and neck reconstruction. Results Ninety-eight reconstructions were performed for mandibular defects, 4 for maxillary defects alone and 3 for combined mandible-maxilla defects. The overall success rate was 98%. Conclusion The subscapular system of free flaps is an excellent option in patients for whom the alternative donor sites are either not usable or lack the associated soft tissue elements required for a successful reconstruction. This flap should also be considered as a first choice for patients with complex/extensive surgical defects requiring multiple, independently mobile, soft tissue components; in patients who will benefit from a large muscle flap placed over the vital structures in the neck; patients of advanced age; and patients in whom early mobilization is critical. © 2014 Wiley Periodicals, Inc. Head Neck 37: 1200–1206, 2015

This article presents a case of and reviews the literature involving the extraoral approach for surgical removal of an ectopic mandibular third molar tooth. Case reports describing extraction of the mandibular third molar using the extraoral approach are very limited. This article describes an unusual case of an impacted, infected, ectopic right mandibular third molar that was positioned at the inferior border and had caused an extraoral draining sinus. Furthermore, the roots were intimately involved with the inferior alveolar nerve (IAN) and had perforated the buccal cortex of the mandible. Surgical removal using a transcervical submandibular approach was deemed necessary to try to preserve the IAN and avoid fracture of the mandible in this 74-year-old patient.

Objectives: Surgical resection of oral cancer can result in altered speech, swallowing, and quality of life (QOL). To date, the oral outcome variables of tongue strength, tongue and jaw range of motion, and saliva production have not been extensively assessed. This pilot study was done to assess tongue strength along with other oral outcomes and their relationship to performance status for speech, swallowing, and QOL after partial glossectomy. Our aim was to create a norm for what should be considered a normal tongue strength value in this population. We hypothesized that patients with tongue strength of 30 kPa or greater would perform better on the performance status scale and various QOL measures than do patients with tongue strength of less than 30 kPa. Methods: We used a cross-sectional design in this study. The postoperative assessment included 1) Performance Status Scale and Karnofsky Performance Status Scale; 2) oral outcome variables of tongue strength, jaw range of motion, and saliva production; and 3) patient-rated QOL ratings via Eating Assessment Tool, M. D. Anderson Dysphagia Inventory, EORTC-H&N35, and Speech Handicap Index. Results: Patients with tongue strength of at least 30 kPa performed better on the performance status scales and various QOL measures. The cutoff score of 30 kPa for tongue strength measures revealed a trend in predicting performance on the scales and QOL measures. Conclusions: The oral outcome variables correlated with performance status for speech, swallowing, and QOL. We propose a norm for tongue strength in this population, based on the trend seen in this group of patients, as none previously existed. Future studies are under way that incorporate a larger sample size to further validate this norm. Future studies will also examine oral functional outcome measures in a larger population by including other oral and oropharyngeal sites to help predict speech and swallow performance status and QOL.

Importance Although a number of mandibular and occlusal problems may be addressed by orthodontic treatment alone, dentofacial osteotomies are often needed to achieve desired functional or cosmetic results. With the increased popularity of mandibular distraction osteogenesis in recent years, the role of the facial plastic and reconstructive surgeon is crucial in the multidisciplinary care of patients with such problems. Objective To review the history and evolution of mandibular osteotomies and distraction osteogenesis and to discuss indications, advantages, disadvantages, and recent advances of these techniques. Evidence Review MEDLINE and PubMed searches without date limits, confined to publications in English, German, and French languages were used to search for terms mandibular advancement, mandibular osteotomy, orthognathic surgery, mandibular distraction osteogenesis, prognathism, and retrognathism in the respective languages. References not found on the sources noted were found in print form in the New York Medical College Library when needed. Particular techniques, as originally described or relating to mandibular osteotomies and mandibular distraction osteogenesis, were critically reviewed. Findings The goal of surgical mandibular modification procedures is to correct a variety of craniofacial abnormalities for both functional and aesthetic purposes. Multiple techniques of both mandibular osteotomy and distraction osteogenesis have been shown to be effective. Their effectiveness and utility is primarily determined by the specific craniofacial defect and desired outcome, as well as surgeon preference and patient compliance. Conclusions While mandibular osteotomy has evolved tremendously, distraction osteogenesis continues to grow as a leading method of surgical correction for a variety of craniofacial defects. Current research shows significant strides in making distraction more effective and efficient to use for both the surgeon and the patient. With the growing popularity of these procedures, the up-to-date knowledge of the facial plastic and reconstructive surgeon in these advances is of utmost importance.

Background For patients who have extensive prior treatment, use of the internal mammary artery/vein (IMA/IMV) or cephalic vein has been shown to be a reliable option. Additionally, for those patients who require vascularized bone and extensive soft tissue reconstruction, the combined latissimus dorsi scapular free flap (mega-flap) is an excellent option. Methods We reviewed 3 cases in which extensive prior surgery and radiation precluded the use of traditional recipient vessels in the neck. Results Three patients with major jaw deformities were reconstructed using a mega-flap. In all cases, saphenous vein grafting succeeded in achieving arterial inflow from the IMA to the subscapular artery. Venous egress was achieved using a vein graft to the IMV in 1 patient and a transposed cephalic vein in the remaining 2 patients. Conclusions This approach of restoring large oral cavity defects for patients with extensive prior therapy and comorbid conditions has proven to be reliable and reproducible. © Wiley Periodicals Inc. Head Neck, 35: E328–E332, 2013

Osteoradionecrosis (ORN) of the mandible is a significant complication of radiation therapy for head and neck cancer. In this condition, bone within the radiation field becomes devitalized and exposed through the overlying skin or mucosa, persisting as a non-healing wound for three months or more. In 1926, Ewing first recognized the bone changes associated with radiation therapy and described them as "radiation osteitis". In 1983, Marx proposed the first staging system for ORN that also served as a treatment protocol. This protocol advocated that patients whose disease progressed following conservative therapy (hyperbaric oxygen (HBO), local wound care, debridement) were advanced to a radical resection with a staged reconstruction utilizing a non-vascularized bone graft. Since the introduction of Marx's protocol, there have been advances in surgical techniques (i.e. microvascular surgery), as well as in imaging techniques, which have significantly impacted on the diagnosis and management of ORN. High resolution CT scans and orthopantamograms have become a key component in evaluating and staging ORN, prior to formulating a treatment plan. Patients can now be stratified based on imaging and clinical findings, and treatment can be determined based on the stage of disease, rather than determining the stage of disease based on a patient's response to a standardized treatment protocol. Reconstructions are now routinely performed immediately after resection of the diseased tissue rather than in a staged fashion. Furthermore, the transfer of well-vascularized hard and soft tissue using microvascular surgery have brought the utility of HBO treatment in advanced ORN into question.

Objectives: Surgery for tumors of the parapharyngeal space (PPS) requires adequate exposure to identify and protect vital structures. Transcervical and transcervical-transparotid approaches to the PPS may be enhanced by mandibulotomy. However, midline mandibulotomy traditionally requires lip-splitting and extensive intraoral incisions, often necessitating tracheostomy and nasogastric feeding. We describe a new technique to gain exposure to the PPS while avoiding these consequences. Study Design: Case series. Methods: Five patients with PPS tumors underwent surgery using a new technique, the subcutaneous mandibulotomy approach (SMA). Each case was retrospectively assessed for tumor size, intraoperative access to the PPS, perioperative complications, and length of hospitalization. Results: In this series, the additional exposure achieved by SMA was adequate to safely remove large PPS tumors that could not be delivered through the transcervical-transparotid approach. All patients started oral diets on postoperative day 1 and were discharged within 3 days. There were no intraoperative complications, and postoperative complications were self-limited. The pathologic entities were a venous malformation, a paraganglioma, and three large, deep-lobe pleomorphic adenomas of the parotid. Conclusions: We introduce a new technique, the SMA, which affords excellent access to the PPS without the lip-split, chin-split, and floor of mouth incisions. The SMA avoids both nasogastric feeding and a tracheostomy and offers improved cosmesis compared with a traditional midline mandibulotomy. Our current stepwise approach to achieve exposure to the PPS includes use of the SMA as an intermediate step for extensive PPS lesions, which are inaccessible through the transcervical approach yet do not require full labiomandibulotomy for safe and complete removal.

The aim of this study was to present our experience with management of malignant lesions arising within the masticator space, and to describe a technique of en bloc resection and reconstruction.Case series and case report.Eight cases of masticator space malignancies treated surgically with en bloc resection and free flap reconstruction were retrospectively reviewed.Tumor extirpation was carried out through a parotidectomy approach with mobilization and protection of the facial nerve. Primary reconstruction was accomplished with vascularized bone containing free flaps, fibula (n = 4), scapula (n = 2), and scapula with latissimus dorsi muscle (n = 2). Mean follow-up was 62.5 months (range, 18-132 months).En bloc resection of masticator space malignancies can be consistently accomplished through an extended parotidectomy approach. The defect is best reconstructed with a vascularized bone and soft tissue free flap. Favorable functional and aesthetic outcomes can be successfully achieved using the techniques described in this series.4.

Palatomaxillary defects are inherently more complex than defects of the mandible due to the 3-dimensional shape and the location in the midface region, at a distance from most of the recipient vessels used in free tissue transfer. However, the same reconstructive principles that have been applied in oromandibular defects can be utilized for palatomaxillary defects. The prognosis for functional recovery in these reconstructions is outstanding due to the fact that the tongue is unaffected in midface tumors. The authors review the previously introduced staging system that assists in reporting and communication, and most importantly in treatment planning. The options for management of Class 1, 2, and 3 defects are discussed in detail. Dental restoration using dental implants for support and anchorage provides the foundation for functional dental rehabilitation.

The tongue provides well-vascularized tissue that can be used predictably in maxillofacial reconstruction. Pertinent surgical anatomy and the different designs and clinical applications of tongue flaps are presented. Clinical cases are discussed.

Pneumosinus dilatans (PD) represents a rare lesion of unknown etiology in which progressive enlargement of an air-filled paranasal sinus results in cosmetic and functional complications. The absence of pathologic mucosa has traditionally been considered a hallmark of this disorder. A 24-year-old man presented with 2 years of chronic rhinosinusitis and recurrent, acute episodes of severe forehead pain with worsening outward prominence of the frontal sinus during air travel. Computed tomography and findings at surgery were notable for diffuse nonpolypoid inflammatory changes of the paranasal sinuses, a type III frontal sinus cell, and PD of the frontal sinus with severe deformity and thinning of the anterior table. A bicoronal approach was used for frontal sinus obliteration and cranioplasty. Excellent cosmetic and functional results were noted at the last follow-up. To our knowledge, this is the first report of PD frontalis presenting in the setting of chronic rhinosinusitis. Surgical management of this disorder requires consideration of both the functional and cosmetic issues.