Early Postoperative Malignant Subcutaneous Emphysema: Report and Review

Background

Subcutaneous emphysema is defined as presence of air or gas in subcutaneous tissue layer. It may be localized or generalized due to various aetiological factors. Although SE and pneumomediastinum are self-limiting conditions, life-threatening complications may develop. Escape of air into both pleural cavity causing bilateral pneumothorax and tension pneumothorax can be termed as malignant emphysema.

Purpose

To report a case of malignant generalized subcutaneous emphysema in early postoperative phase following palatoplasty.

Case Report

A 25 year old female patient was operated for closure of residual oronasal communication using an anteriorly based tongue flap. The patient was reversed from general anesthesia and shifted to the post-operative room with the endotracheal tube in situ. Sudden swelling of the face and periorbital area was noticed which spread all over the body. A diagnosis of malignant post-operative subcutaneous emphysema was made and the patient was shifted back to the operation theatre. She was managed successfully by bilateral tube thoracotomy and tracheostomy.

Conclusion

Close observation of the patient in early postoperative stage having endotracheal tube in situ is crucial to avoid such complication. Regardless of aetiology, early recognition of the clinical features of tension pneumothorax and timely intervention are necessary for the survival of the patient.

     

Pierre-Robin-Sequenz — postoperative Komplikationen nach Gaumenspaltverschluss

Background

In a 25-year retrospective review of 1976–2000, the postoperative course after cleft palate surgery and pharyngeal flap surgery in 87 children with Pierre Robin sequence was studied.

Patients and methods

The study comprised 114 interventions with 87 primary palatoplasties; 17 patients required palatal fistulae repair and 10 children were treated with secondary pharyngoplasty procedures. All children were divided into three postnatal risk groups according to the severity of their symptoms at birth and in the course of the early months of life.

Results

A direct correlation was seen between the incidence of early postnatal difficulties and the postoperative obstructive complications after cleft palate surgery and pharyngeal flap surgery. Thus, children experiencing obstructive problems at birth (high postnatal risk group) displayed more severe complications at the time after cleft palate repair. In children undergoing pharyngeal flap surgery not only early postoperative obstruction but also late obstructive sleep apnea can occur.

     

Preservation of Aesthetics of Breast in Pectoralis Major Myocutaneous Flap Donor Site in Females

Background and Objectives

In females, raising a pectoralis major myocutaneous flap is challenging and primary closure of flap donor site causes breast deformity with medial displacement of nipple areola complex. To avoid this distortion, a new method of donor site closure is devised.

Methods

A parasternal skin paddle which has better vascularity is planned while doing a pectoralis major myocutaneous flap in females and a lateral flap planned along the lateral breast curve is used to cover the donor site. The lateral flap donor site is primarily closed. This prevents medial displacement of nipple areola complex.

Results

A total of 47 patients underwent donor site flap closure technique. Minor complications in form of marginal necrosis near the tip of the flap were observed in 10.6 % patients. The donor breast of all these PMMC flaps had good contour and aesthetic positioning of nipple areola complex.

Conclusion

Donor site morbidity with respect to breast distortion has not been studied so far in case of females so our study stands unique in this aspect. Using this technique of planning PMMC in females ensures a skin paddle of better vascularity and restores the breast aesthetics.

     

Early postoperative healing following buccal <Emphasis Type="Italic">single flap approach</Emphasis> to access intraosseous periodontal defects

Aim

This study aims to evaluate the early postoperative healing of papillary incision wounds and its association with (1) patient/site-related factors and technical (surgical) aspects as well as with (2) 6-month clinical outcomes following buccal single flap approach (SFA) in the treatment of intraosseous periodontal defects.

Methods

Forty-three intraosseous defects in 35 patients were accessed with a buccal SFA alone or in combination with a reconstructive technology (graft, enamel matrix derivative (EMD), graft + EMD, or graft + membrane). Postoperative healing was evaluated at 2 weeks using the Early Wound-Healing Index (EHI).

Results

EHI ranged from score 1 (i.e., complete flap closure and optimal healing) to score 4 (i.e., loss of primary closure and partial tissue necrosis). SFA resulted in a complete wound closure at 2 weeks in the great majority of sites. A significantly more frequent presence of interdental contact point and interdental soft tissue crater, and narrower base of the interdental papilla were observed at sites with either EHI?>?1 or EHI?=?4 compared to sites with EHI = 1. No association between EHI and the 6-month clinical outcomes was observed.

Conclusions

At 2 weeks, buccal SFA may result in highly predictable complete flap closure.

Clinical relevance

Site-specific characteristics may influence the early postoperative healing of the papillary incision following SFA procedure. Two-week soft tissue healing, however, was not associated with the 6-month clinical outcomes.

     

A Protocol for Management of the Hairs Problem in Oral Cavity Reconstruction by Submental Flap

Background

Submental flap is a useful aid in maxillofacial reconstruction. For intraoral usage the hairs in male patients will create some problems.

Materials and Methods

In a retrospective study, patients in whom submental flap had been used for reconstruction of orofacial region between 2007 and 2013, in the Mashhad University, Ghaem Hospital, were included. The ways in which the problem of hairs was solved in male patients were evaluated.

Results

There were 42 patients in whom submental flap was used for orofacial reconstruction. Sixty percent were males. Three ways had been used for management of intraoral hairs: radiotherapy (9 patients), second surgery (2 patients) and flap de-epithelialization (13 patients).

Conclusion

Deepithelialized variant of submental flap is the best option when submental flap is used for oral cavity reconstruction in male patients. Flap thickness, age, race and postoperative radiotherapy can have strong influence on this strategy.

     

Compartmental tongue resection with submental island flap reconstruction for large carcinoma of the oral tongue

Background

Tongue resection is a surgical challenge because of its adverse effects on language articulation, swallowing, respiration, the eventual quality of life, and poor prognosis of advanced disease. To date, the currently accepted standard treatment has been based on excision of the primary lesion with a 1.5–2-cm circumferential macroscopic margin. Compartmental tongue surgery (CTS) is a surgical technique that removes an anatomo-functional compartment containing the primary tumor.

Methods and techniques

This is a prospective study that was carried out from June 2012 to January 2015 for patients with carcinoma affecting oral tongue. We enrolled all cases with ≥T2 tongue cancer with or without infiltration of floor of the mouth. Patients underwent compartmental tongue resection with reconstruction using island submental flap.

Results

Pharyngeal tear occurred in two cases that were repaired by simple suture. Bleeding occurred in two cases with control of the affected vessels. Loco-regional recurrence was detected only in two cases that underwent CTS, while 18 patients who underwent traditional tongue resection had local recurrence.

Conclusion

CTS via pull through technique with submental island flap reconstruction for large tongue cancer has been evolved to improve oncologic resections, obtaining a better local control of disease and increased survival rate with concomitant successful functional and esthetic outcomes especially in elderly patients with serious comorbidities.

     

Comparative study of primary and secondary closure of the surgical wound after removal of impacted mandibular third molars

Aim

Aim of the study is to compare the primary and secondary healing after surgical removal of impacted mandibular third molars, in terms of swelling, severity of pain, trismus, and periodontal healing between two types of closure.

Materials and methods

A total of 60 patients, divided into two groups randomly: group A, with 30 patients in which primary closure was done; group B, with 30 patients in which secondary closure was done. A comparison between two groups was done in terms of postoperative pain, swelling, trismus at first, third, and seventh postoperative days, and periodontal healing near adjacent second molar after 6 months.

Results

The swelling and pain in group A were greater than that in group B, with a statistically significant difference (p <?0.05). Mouth opening is greater in group B compared to group A. There is no significant difference in periodontal healing in between two groups after 6 months. Complication like alveolar osteitis was noted in 1 patient (3.3%) in group B.

Conclusion

We conclude that secondary closure was better than primary closure in terms of postoperative pain, swelling, and trismus. Irrespective of any closure technique, there is no difference in terms of periodontal healing.

     

Comparison between primary closure and skin grafts of the free fibula osteocutaneous flap donor site

Purpose

This study aimed to compare the size of skin paddles, the postoperative course, and donor site complications between primary closure and skin grafts of the free fibula flap donor site.

Methods

Thirty-five consecutive patients were enrolled. Medical records were retrospectively reviewed for risk factors for delayed healing, size of skin paddles, time to resumption of gait with a mobility aid and self-ambulation, early donor site morbidity, and late donor site complaints.

Results

The harvested skin paddles were significantly wider in the skin graft group than in the primary closure group (P?=?0.02), with no difference in length (P?=?0.1). The difference in time to resuming gait with a mobility aid was also significant (P?=?0.01), but not the time to self-ambulation (P?=?0.9). Two early donor site morbidities (5.7 %) and 12 late donor site complaints (34.3 %) were found. No significant difference in the incidence of early donor site morbidity was observed between two groups. Occurrence of late donor site complaints was not affected by any risk factors.

Conclusions

The width of the harvested skin paddle, but not the length, is one of factors involved in donor site closure. Resumption of gait with a mobility aid, but not self-ambulation, may be delayed in skin graft patients.

     

Prevalence of Functional Problems After Oral Cavity Malignancy Treatment at a Tertiary Center: Utilizing PSS HN (Performance Status Scale for Head and Neck) Scale

Background

Oral cancer is the most common type of cancer occurring in India and it is equally important to assess morbidities after treatment for optimal utilization of resources. Utilizing PSS HN we try to identify the patient population who are severely impaired and need aggressive rehabilitation.

Method and Material

The PSSHN questionnaire was administered by the treating physician to 100 consecutive oral cancer patients who completed their index treatment at least 6 months prior to accrual. Functional morbidities with score ≤50 were considered as significant.

Results

Prevalence of functional deficit of eating in public; deficit of understandability of speech and deficit of normalcy of diet were 28, 13 and 38 % respectively.

Conclusion

Type of resection either segmental mandibulectomy or major glossectomy, had most significant impact on concerned functional deficits and surgeries involving these defects should be carefully planned to involve free flap reconstruction and proper postoperative rehabilitation.

     

Clinical observation of tongue coating of perioperative patients: factors related to the number of bacteria on the tongue before and after surgery

Background

Increased amount of tongue coating has been reported to be associated with increased bacteria count in the saliva and aspiration pneumonia in elderly people. However, the implications of tongue coating for prevention of postoperative complications in patients undergoing major oncologic or cardiac surgery has not been well documented. The purpose of this study is to investigate the number of bacteria on the tongue before and after surgery and factors affecting it.

Methods

Fifty-four patients who underwent oncologic or cardiac surgery under general anesthesia at Nagasaki University Hospital were enrolled in the study. Various demographic, tumor-related, treatment-related factors, and the number of bacteria on the tongue and in the saliva were examined, and the relationship among them was analyzed by Mann-Whitney U test, Spearman rank correlation coefficient, or multiple regression.

Results

Before surgery, no significant factors were correlated with the number of bacteria on the tongue, and there were no relationship between bacteria count on the tongue and that in the saliva. On the next day after surgery, bacteria on the tongue increased, and sex, periodontal pocket depth, feeding condition, dental plaque, blood loss, and bacteria in the saliva were correlated with bacteria on the tongue by a univariate analysis. A multivariate analysis showed that feeding condition, and amount of dental plaque were correlated with the number of bacteria.

Conclusions

Increased number of bacteria on the tongue was associated with feeding condition and amount of dental plaque. Further studies are necessary to clarify the clinical significance of dental coating in perioperative oral management of patients undergoing oncologic or cardiac surgery.

     

Surgical defect coverage in oral submucous fibrosis patients with single-stage extended nasolabial flap

Purpose

Long standing oral submucous fibrosis (OSMF) is associated with involvement of the oral submucosa and the muscles of mastication leading to difficulty in mouth opening. Various surgical modalities are mentioned for release but each has its own limitations. The aim of the study was to evaluate the postoperative mouth opening in patients of OSMF after excision of fibrous bands followed by coronoidotomy and surgical defect coverage by extended nasolabial flap.

Methods

We evaluated the use of extended nasolabial flaps and coronoidectomy in the management of 11 randomly selected patients with histologically confirmed oral submucous fibrosis. They all had interincisal opening of less than 25 mm and were treated by bilateral release of fibrous bands, coronoidectomy or coronoidotomy, and extended grafting with a nasolabial flap.

Result

Their interincisal opening improved significantly from a mean of 8.68±7 mm to a mean of 36.75±4.05 mm at 6-month follow-up.

Conclusion

The procedure was effective in the management of patients with oral submucous fibrosis, the main disadvantage being the extraoral scars.

     

Subcuticular Suture Technique: Alternative to Frost Suture to Prevent Ectropion After Transcutaneous Incision of Lower Eyelid

Introduction

An ectropion is a complication that can arise from reconstruction in the infraorbital region. Often, this complication occurs despite proper positioning of the lower lid at the time of closure. Various transcutaneous approaches to orbit skeleton have investigated in view of complication arising from them. A subtarsal approach with a postoperative Frost suture gives an advantage to reduce the occurrence of ectropion especially after treatment of orbital floor fractures.

Material and methods

This case describes a method of subcuticular suturing technique for subtarsal incision of lower lid which can be used to support the lid during healing period, thus decreasing the rate of ectropion.

Conclusion

The technique described here is an alterative method for frost suturing with certain advantages.

     

“Sodium bicarbonate”: an adjunct to painless palatal anesthesia

Purpose

It is believed that whenever we inject local anesthesia into the palate it is a painful experience for the patients. The aim of this study was to make palatal anesthesia painless by adding 7.4% sodium bicarbonate as an adjunct in local anesthesia.

Methods

Fifty subjects requiring extraction of maxillary bilateral premolar teeth for orthodontic purpose free from periapical infections. These extractions were divided in such a way that all right-sided extractions were done under 2% lignocaine with 1:80,000 adrenaline; and all left-sided extractions were done under 2% lignocaine with 1:80,000 adrenaline with 7.4% sodium bicarbonate added. All extractions were performed using a consistent intra-alveolar technique by a single operator. Both the patient and the operator were blinded to the contents of the local anesthetic solution. Data records of these patients were procured on the basis of VAS and VRS, requirement of repeated injection, and onset and duration of anesthesia.

Results

Clinical and statistical data confirmed that the addition of sodium bicarbonate in local anesthetics reduces pain and decreased the onset and increased duration of local anesthesia in the palatal site, as compared to injection of local anesthetic without sodium bicarbonate.

Conclusion

Effect of sodium bicarbonate on reducing pain while injecting into the palatal aspect was noted in this study.

     

Sub-Periosteal Dissection with Denture-Guided Epithelial Regeneration: A Novel Method for Peri-Implant Soft Tissue Management in Reconstructed Mandibles

Background

In patients with reconstructed mandibles using free fibula flaps, management of soft tissues around implants supporting dental rehabilitation, is often a clinical problem.

Aim

The aim of this paper is to describe a new technique, namely "Sub-periosteal dissection and denture-guided epithelial regeneration (SD-DGER)", as a method of peri-implant soft tissue management in these patients.

Materials and methods

The technique consists of performing a subperiosteal dissection with creation of buccal and lingual flaps. These flaps form the buccal and lingual vestibule. Implants are placed and an interim denture is immediately loaded onto the implants to guide the regenerated epithelium. A keratinized mucosal layer is formed on the bare fibula bone in six months time.

Results

This technique was successful in producing fixed keratinized epithelial tissue around implants in patients with mandibles reconstructed using the free fibula flap in patients who did not undergo radiotherapy.

Conclusion

The sub-periosteal dissection with denture guided epithelial regeneration is a predictable form of peri-implant soft tissue management in selected patients with reconstructed jaws.

     

Efficacy of nasolabial flap in reconstruction of fibrotomy defect in surgical management of oral submucous fibrosis: a prospective study

Purpose

Various surgical modalities have been used in the surgical management of oral submucous fibrosis with variable results. This prospective study evaluates the efficacy of nasolabial flap in the reconstruction of fibrotomy defect in surgical treatment of oral submucous fibrosis in terms of functional and esthetic outcomes.

Material and method

In this prospective study, we treated 20 patients of oral submucous fibrosis surgically. The surgical protocol was consisting of bilateral fibrotomy, temporal myotomy, and coronoidotomy or coronoidectomy followed by reconstruction of fibrotomy defect with bilateral extended nasolabial flaps. All patients were prescribed with nutritional supplements and antioxidants. Vigorous mouth opening exercise was made compulsory for every patient. Preoperative and postoperative evaluation was done for interincisal mouth opening, function of mastication, and cosmetic results. Patient’s regular follow-up was done for 2 years.

Results

Postoperatively, we noted excellent increase in the interincisal mouth opening relieving trismus. Patient’s ability to chew solid food was increased significantly. Extraoral scar was minimal and well accepted by all the patients. There was no morbidity of the donor site. There was no injury to the facial nerve in all cases. The only drawback was intraoral hair growth which went on reducing with mucosalization of the graft tissue.

Conclusion

Random pattern nasolabial flap is a very good option for intraoral reconstruction of fibrotomy defect in surgical treatment of oral submucous fibrosis with excellent functional and cosmetic results with minimal complications.

     

Reduction of Palatal Midline and Para-Midline Fractures Using Intra-arch Wire Fixation Versus Transmucosal Miniplate Stabilization: Prospective Randomized Clinical Study to Evaluate Postoperative Occlusion

Purpose

The aim of the study is to compare the post reduction squealae of transmucosal miniplate fixation technique for stabilization of palatal fractures with intra-arch wiring technique.

Materials and Method

This study was prospectively undertaken on 16 patients, dividing them into two treatment arms based on random sampling methodology (Group A & B). For patients in Group A, intra-arch wire stabilization technique and in Group B trans-mucosal miniplate stabilization technique was used. The pre-operative and post-operative occlusion and time taken for stabilization in both the techniques was compared.

Results

The mean time taken for reduction and stabilization of palatal fracture in group A was 10.9 ± 2.21 min and in group B was 14.2 ± 1.13 min. Four out of eight study patients in group A required post reduction interception to stabilize occlusion postoperatively, whereas none of the patients in group B needed any post operative intervention.

Conclusion

The post operative occlusal stability was found better in study patients included in group B when compared to group A patients, although satisfactory post-operative occlusion was obtained even in group A with post-operative interception for occlusal stability.

     

Behavior of C-reactive protein in association with surgery of facial fracture and the influence of dexamethasone

Purpose

To clarify pre- and postoperative C-reactive protein (CRP) levels in patients with facial fractures and to investigate the influence of perioperatively administered dexamethasone on postoperative CRP levels.

Patients and methods

Facial fracture patients were randomized to receive perioperatively a total dose of 30 mg of dexamethasone (Oradexon®), whereas patients in the control group received no glucocorticoid. The analysis included patients who had CRP measured pre- and postoperatively.

Results

A total of 73 adult patients with facial fractures were included in the final analysis. Mean CRP level was elevated preoperatively and the level increased further after surgery. However, postoperative CRP rise was significantly impeded by dexamethasone (p?<?0.001), regardless of gender, age, treatment delay, site of fracture, surgical approach, and duration of surgery. CRP rise halved on the 1st postoperative day when dexamethasone was used. In addition, dexamethasone resulted in a CRP decrease on the 2nd postoperative day, whereas the CRP rise continued in the control group.

Conclusions

CRP rise is a normal body response after facial fracture and surgery that can be markedly reduced with dexamethasone. CRP changes should be considered with caution if perioperative dexamethasone is used.

     

A Comparative Study on Microvascular Anastomosis of Vascularised Free Fibular Flap with Couplers and Suturing in Mandibular Reconstruction

Introduction

Successful outcome of any vascularised free flap basically depends upon the successful restoration of circulation in the flap after anastomosis. As the flap ischemic time is the significant factor which determines the outcome of any free flaps, due consideration is given to reduce the time for anastomosis for reperfusion. The present study compares and evaluates whether the usage of microvascular couplers with the conventional suturing reduce the ischemic time of the free flaps.

Materials and Methods

Thirty patients were randomly divided into two groups (each group consisting of 15 patients) for mandibular reconstruction using free fibular microvascular flap. In group 1, microanastomosis was done with conventional suturing whereas microvascular couplers were used in group 2. Intraoperatively, patency, leakage and tissue perfusion were assessed. The time taken for anastomosis (time taken for suturing and applying couplers) and flap ischemic time (from the time of flap division from the donor site till the flap is reperfused after anastomosis) were calculated for both the groups.

Results

Significant decrease in time for anastomosis was observed in group 2, which resulted in decrease in flap ischemic time and in overall operating time.

     

Rational and simplified nomenclature for buccinator myomucosal flaps

Background

Reconstruction of moderate-sized mucosal defects of the oral cavity or oropharynx represents a surgical challenge. Buccinator myomucosal flaps seem to provide “ideal reconstruction” of oral/oropharyngeal defects because they carry a thin, mobile, well-vascularized, and sensitive tissue, like that excised or lost. Nevertheless, these flaps are not immediately popular because of confusion surrounding the complex terminology used to name them.

Methods

After a retrospective study on our experience and a literature review, the authors propose a new rational and simplified nomenclature for the classification of buccinator myomucosal flaps, which clarifies the source vessel, the composition of the flap, and the type of transfer.

Results

According to this nomenclature, six types of buccinator myomucosal flaps are described.

Conclusions

This proposed nomenclature may bring a consensus on the classification of buccinator myomucosal flaps and can help their spread.

     

Incidental finding of subgemmal neurogenous plaque upon retrospective evaluation of oral lymphoepithelial cysts

Purpose

We aimed to compare the histomorphological features of oral lymphoepithelial cysts (OLC) in different locations of the oral cavity and to verify the association between oral lymphoepithelial cysts and subgemmal neurogenous plaque (SNP) on biopsies from the lateral border of the tongue.

Methods

All cases diagnosed as OLC from the Oral Pathology Service at the School of Dentistry/University of São Paulo were retrieved. For all the cysts located in the tongue, their association to SNP was analyzed. Immunohistochemical staining against S100 was performed to confirm the diagnosis of SNP.

Results

Thirty-one cases were selected for morphological analysis and SNP was identified in 40% of cases, all of them positive for S100. In these cases, macroscopic analysis demonstrated two independent fragments. Microscopic analysis showed that cysts located in the floor of the mouth and ventral surface of the tongue showed less intense exocytosis, less formation of lymphoid follicles, and predominantly a moderate inflammatory infiltrate.

Conclusions

OLC have a similar histological pattern regardless the location within the oral cavity and. In some cases, the biopsy specimen may be accompanied by a SNP as an adjacent independent structure.