Thrombotic Complications in Venous Malformations: Are There Differences Between Facial and Other Localizations?

Venous thrombosis (VT) is a frequent complication in venous malformations (VM) in relation with blood stasis and localized intravascular coagulopathy (LIC). Our aim was to describe the clinical characteristics and the treatment of patients with facial and non facial VM with VT. We implemented an observational retrospective study of patients with VM followed between 2002 and 2017. We compared features of facial and non facial VM. Descriptive and bivariate statistics were computed and the P value was set at 0.05. Fifty patients were included between 2002 and 2017. 24 of them were women (44%). The median age of the patients at diagnosis was 16,5 [8-31] years. The median follow up was 2 [2; 4] years. In non facial VM venous thrombosis occurred in 12 cases. In facial VM, 3 patients had thrombotic complication (15%). We demonstrate no difference of VT between facial VM and other localization. No patients had clinical risk factors for VT at diagnosis. Our study showed that VT is a frequent complication of VM and its proportion is not different between facial and non facial VM. Studies are needed to confirm the role of LIC in VT in VM, particularly in facial VM.

Second metatarsal free transfer in total temporomandibular joint reconstruction for ankylosis in a child: 10-year follow-up

The management of temporomandibular joint (TMJ) ankylosis requires complete removal of the ankylosed block and the prevention of recurrence. For this purpose, the ramus-condyle unit can be reconstructed with a second metatarsal free flap. This article reports the use of this flap in a young patient treated for left TMJ ankylosis, post costochondral graft for the treatment of hemifacial microsomia. Data from the 10-year follow-up are reported. The glenoid fossa was reconstructed with a graft of the second metatarsal base, enabling the juxtaposition of two cartilaginous joint surfaces, with the aim of optimizing the functional result and preventing the recurrence of ankylosis. At the 10-year follow-up after this surgery, there was no recurrence of the ankylosis and no articular disorder, and the morphological result was satisfactory. Bone fixation was stable over the 10-year period and the metatarsal head was still in place. Quantitative measurements obtained by computed tomography scan did not show any growth of the second metatarsal free flap compared to the right unaffected condylar process.

TRIM37 is highly expressed during mitosis in CHON-002 chondrocytes cell line and is regulated by miR-223

Multiple molecular disorders can affect mechanisms regulating proliferation and differentiation of growth plate chondrocytes. Mutations in the TRIM37 gene cause the Mulibrey nanism, a heritable growth disorder. Since chondrocytes are instrumental in long bone growth that is deficient in nanism, we hypothesized that TRIM37 defect could contribute to dysregulation of the chondrocyte cell cycle. Western blotting, confocal microscopy and imaging flow cytometry determined TRIM37 expression in CHON-002 cell lineage. We showed that TRIM37 is expressed during mitosis of chondrocytes and directly impacted their proliferation. During the chondrocyte cell cycle, TRIM37 was present in both nucleus and cytoplasm. During M phase we observed an increase of the TRIM37-Tubulin co-localization in comparison with G1, S and G2 phases. TRIM37 knock down inhibited proliferation, together with cell cycle anomalies and increased autophagy, while overexpression accordingly enhanced cell proliferation. We demonstrated that microRNA-223 directly targets TRIM37, and suggest that miR-223 regulates TRIM37 gene expression during the cell cycle. In summary, our results give clues to explain why TRIM37 deficiency in chondrocytes impacts bone growth. Modulating TRIM37 using miR-223 could be an approach to increase chondrogenesis.

Use of an occlusal splint and intraoperative imaging with an intraoral approach in the management of mandibular subcondylar fractures

INTRODUCTION

To evaluate the feasibility of safely managing subcondylar fractures using an original surgical procedure combining an intraoral approach, the use of a custom-made occlusal overlay splint, and intraoperative imaging.

MATERIALS AND METHODS

Condylar fragment was freed from surrounding soft tissues, was laterally exposed to the ramus, and a miniplate was fixed in place for osteosynthesis. An overlay splint maintaining the dental occlusion was used to facilitate reduction and stabilization during fixation. Intraoperative monitoring by cone-beam computed tomography (CBCT) was performed before completing the fixation.

RESULTS

Between November 2018 and June 2019, 10 patients were treated using this procedure. The median length of the proximal condylar fragment was 29 mm (range 24-39 min). Five patients had an associated mandibular fracture. The median duration of the condylar fracture surgery was 54.5 min (range 38-79 min). All patients had satisfactory reduction and osteosynthesis with no complications.

CONCLUSION

It is feasible to safely manage subcondylar fractures with this surgical procedure that could facilitate open reduction using intraoral approaches. Occlusal splints maintain downward pressure on the rami bilaterally and symmetrically, helping to anatomically reposition condylar process fractures. Intraoperative imaging is used to monitor this step.

Management of the clinically N0 neck in early-stage oral squamous cell carcinoma (OSCC). An EACMFS position paper

Metastasis of oral squamous cell carcinoma (OSCC) to the cervical lymph nodes has a significant impact on prognosis. Accurate staging of the neck is important in order to deliver appropriate treatment for locoregional control of the disease and for prognosis. The management of the neck in early, low volume disease (clinically T₁/T₂ oral cavity tumours) has long been debated. The risk of occult nodal involvement in cT₁/T₂ OSCC is estimated around 20-30%. We describe the natural evolutionary history of OSCC and its patterns of spread and metastasis to the local lymphatic basins. We discuss most published literature and studies on management of the clinically negative neck (cN₀). Particular focus is given to prospective randomized trials comparing the outcomes of upfront elective neck dissection against the observational stance, and we summarize the results of the sentinel node biopsy studies. The paper discusses the significance of the primary tumour histological characteristics and specifically the tumour's depth of invasion (DOI) and its impact on predicting nodal metastasis. The DOI has been incorporated in the TNM staging highlighting its significance in aiding the treatment decision making and this is reflected in world-wide oncological guidelines. The critical analysis of all available literature amalgamates the existing evidence in early OSCC and provides recommendations in the management of the clinically N₀ neck.

Fraser syndrome: review of the literature illustrated by a historical adult case

Fraser syndrome (cryptophthalmos-syndactyly syndrome) is a rare autosomal recessive malformation disorder. The first description of the syndrome was reported by George Fraser in 1962. Diagnosis is based on the major and minor criteria established by van Haelst et al. in 2007. Unilateral or bilateral cryptophthalmos, syndactyly, unilateral renal agenesis, and genital anomalies are the most frequent anomalies. Several maxillofacial, oro-dental, ear-nose-throat, hormonal, and anorectal disorders are reported. Cardiac malformations and musculoskeletal anomalies are uncommon. The syndrome is related to mutations in three different genes (FRAS1, FREM2, and GRIP1) resulting in failure of the apoptosis program and disruption of the epithelial-mesenchymal interactions during embryonic development. Prenatal diagnosis is based on the detection of renal agenesis and laryngeal atresia, together with a family history. Most foetuses with severe anomalies are terminated or are stillborn. All patients or pregnancies with a diagnosis of Fraser syndrome should be referred to expert centres. A collaborative approach including anaesthetists, ENT specialists, maxillofacial surgeons, and geneticists is necessary for the management of this syndrome. In vivo and in vitro research models are available to better understand the underlying aetiology.

Co-transplantation of Wharton's jelly mesenchymal stem cell-derived osteoblasts with differentiated endothelial cells does not stimulate blood vessel and osteoid formation in nude mice models

A major challenge in bone tissue engineering is the lack of post-implantation vascular growth into biomaterials. In the skeletal system, blood vessel growth appears to be coupled to osteogenesis-suggesting the existence of molecular crosstalk between endothelial cells (ECs) and osteoblastic cells. The present study (performed in two murine ectopic models) was designed to determine whether co-transplantation of human Wharton's jelly mesenchymal stem cell-derived osteoblasts (WJMSC-OBs) and human differentiated ECs enhances bone regeneration and stimulates angiogenesis, relative to the seeding of WJMSC-OBs alone. Human WJMSC-OBs and human ECs were loaded into a silicate-substituted calcium phosphate (SiCaP) scaffold and then ectopically implanted at subcutaneous or intramuscular sites in nude mice. At both subcutaneous and intramuscular implantation sites, we observed ectopic bone formation and osteoids composed of host cells when WJMSC-OBs were seeded into the scaffold. However, the addition of ECs was associated with a lower level of osteogenesis, and we did not observe stimulation of blood vessel ingrowth. in vitro studies demonstrated that WJMSC-OBs lost their ability to secrete vascular endothelial growth factor and stromal cell-derived factor 1-including when ECs were present. In these two murine ectopic models, our cell-matrix environment combination did not seem to be optimal for inducing vascularized bone reconstruction.

Intraosseous microdialysis for bone free flap monitoring in head and neck reconstructive surgery: A prospective pilot study

BACKGROUND

Although some researchers have positioned microdialysis catheters in the soft tissue surrounding bone, the results did not accurately reflect bone metabolism. The present study's objective was to establish the feasibility of microdialysis with a catheter positioned directly in bone.

METHODS

Thirty-four patients (19 males, 15 females; median age: 59) were included in a prospective, nonrandomized clinical trial in the Department of Maxillofacial Surgery at Amiens-Picardie University Hospital (Amiens, France). Fibula or iliac crest free flaps were used in reconstructive head and neck surgery (for cancer, osteoradionecrosis, trauma, or ameloblastoma) and monitored with microdialysis catheters positioned in a hole drilled into the bone. Glucose, lactate, pyruvate, and glycerol concentrations were analyzed for 5 days.

RESULTS

All catheters were positioned successfully, and thrombosis did not occur during the monitoring. In two patients, an increase in the lactate concentration and a glucose level close to 0 were associated with signs of flap necrosis, with removal on Days 9 and 50. In viable flaps, the mean glucose level was 2.02 mmol/L, the mean lactate level was 8.36 mmol/L, and the mean lactate/pyruvate ratio was 53. Forty percent of the glucose values were below 1 mmol/L, and 50% of the lactate/pyruvate ratio values were above 50-suggesting a specific metabolic pattern because these values would be considered as alert values in soft tissue.

CONCLUSION

Monitoring bone free flaps with intraosseous microdialysis is feasible. This technique specifically assesses bone viability, and further studies are now necessary to define the alert values in bone.

Treatment of mandibular osteoradionecrosis by periosteal free flaps

Mandibular osteoradionecrosis (ORN) is one of the most serious complications of radiotherapy of the head and neck, and is characterised by hypoxia, hypovascularisation, and hypocellularity. Periosteal free flaps have intrinsic osteogenic, and extrinsic neoangiogenic, properties that are related to the periosteum. Our objective was to present our experience with the use of periosteal free flaps in the treatment of ORN (Notani class I or II) that are refractory to conservative management or have a large area of bone (≥2 cm) exposed. We organised a single-centre, retrospective study between 2003 and 2013 and describe the management of 11 patients (4 women and 7 men) who were being treated for refractory mandibular ORN. Thirteen periosteal free flaps were used: inner femoral condylar periosteum (n = 4), iliac crest (n = 1), external brachial with humeral periosteum (n = 1), and forearm with radial periosteum (n = 7). During follow-up we found three acute complications (haematoma, partial necrosis, and total vascular necrosis) that required immediate construction of a second periosteal free flap. There were also two chronic complications (fistula and post-traumatic fracture). With only one progressive lesion identified, the ORN was stopped in 11/12 patients. Two examples of osteoconduction were identified on postoperative images at six months and two years. Because of its osteoconductive and neoangiogenic capacities, the periosteal free flap seems to offer a real biological dimension to the treatment of ORN, and its efficiency favours its early revascularisation.

A multi-layered nerve guidance conduit design adapted to facilitate surgical implantation

BACKGROUND AND AIMS

The gold standard procedure after a severe nerve injury is the nerve autograft, yet this technique has drawbacks. In recent years, progress has been made in the development of artificial nerve guides to replace the autograft, but no device has been able to demonstrate superiority. The present study introduces an adaptable foundation design for peripheral nerve regeneration.

METHODS

Silk fibroin was electrospun, creating a tri-layered material with aligned fiber surfaces and a randomly deposited fiber interior. This material was rolled into a micro-channeled conduit, which was then enveloped by a jacket layer of the same tri-layered material.

RESULTS

The proposed implant design succeeds in incorporating various desirable aspects of synthetic nerve guides, while facilitating the surgical implantation process for medical application. The aligned fiber surfaces of the conduit support axon guidance, while the tri-layered architecture improves its structural integrity compared with a fully aligned fiber material. Moreover, the jacket layer creates a small niche on each end which facilitates surgical implantation. An in vivo study in rats showed that nerve regeneration using this device was comparable to results after direct suture.

CONCLUSION

This proof-of-principle study, therefore, advances the development of tissue engineered nerve grafts by creating an optimized guidance conduit design capable of successful nerve regeneration.

Quantitative assessment of the flow distribution in the branches of the external carotid by non-injected flow MRI

Owing to the lack of databases of blood flow distributions in the external carotid branches, surgeons currently rely on per-operative imaging and on their experience to choose the recipient vessels for microsurgical facial reconstructions. But, thanks to three-dimensional phase contrast angiography (PCA) and kinematic CINE phase contrast (PC) sequences, MRI technologies have the potential to provide quantitative anatomical and hemodynamic information without injection of contrast agent. Having developed and optimized PC-MRI sequences for the small facial vessels, our objective was to investigate the haemodynamic and blood flow distribution in the external carotid branches. We included 31 healthy volunteers in an MRI prospective study. Two-dimensional CINE PC-MRI sequences (average duration time of 2 min 40 s ± 24 s) were performed in the external carotid collaterals (n = 290). A statistical analysis of the flow measurements showed that, despite large interpersonal variabilities, a general flow distribution pattern was obtained by dividing the vessel flow rates by the external carotid artery one (providing local percentages of the incoming flow). The vessels could then be classified in three haemodynamic groups (p < 0.05 Student's test): "low flow" group (lingual artery-12.5 ± 5% of incoming flow), "intermediate flow" group (superior thyroid artery-16.5 ± 10%, internal maxillary artery-20.5 ± 11%, superficial temporal artery-18.4 ± 6%), "high flow" group (facial artery -26.6 ± 10%). Thanks to this general flow distribution mapping, it is now possible to estimate the flow rates in the distal branches of any individual from a single blood flow measurement in the external carotid artery.

Phenotypic spectrum of Tessier facial cleft number 5

INTRODUCTION

Craniofacial clefts belong to the most disfiguring and rare congenital malformations of the face and among these, orbito-facial clefts constitute approximately 0.22 % of the cases with Tessier cleft number 5 being the least common. Our aim was to define the phenotypic spectrum for this subgroup to improve clinical management.

METHODS

Our study group consisted of four patients which were treated at two different cleft centers. Retrospective chart review and anatomical analysis were conducted for each patient based on clinical evaluation and imaging studies. Morphological anomalies including soft tissue, bone and oral components were recorded.

RESULTS

Based on our analysis and literature review, we could define two subtypes of Tessier facial cleft number 5. (1) Medial clefts are the more severe subtype, creating a significant soft tissue and bone defect that runs vertically, through the eyelid, infraorbital rim, maxillary sinus and cheek. They have the poorer esthetic and functional prognosis, due to orbital dystopia and absence of lower eyelid. (2) Lateral clefts are a less severe subtype characterized by the presence of a vertical furrow of the cheek running laterally to the maxillary sinus.

CONCLUSIONS

We identified two subtypes of facial cleft number 5 which require an individualized surgical management.

Face Transplantation: Partial Graft Loss of the First Case 10 Years Later

Ten years after the first face transplantation, we report the partial loss of this graft. After two episodes of acute rejection (AR) occurred and completely reversed in the first posttransplantation year, at 90 months posttransplantation the patient developed de novo class II donor-specific antibodies, without clinical signs of AR. Some months later, she developed several skin rejection episodes treated with steroid pulses. Despite rapid clinical improvement, some months later the sentinel skin graft underwent necrosis. Microscopic examination showed intimal thickening, thrombosis of the pedicle vessel, and C4d deposits on the endothelium of some dermal vessels of the facial graft. Flow magnetic resonance imaging of the facial graft showed a decrease of the distal right facial artery flow. Three steroid pulses of 500 mg each, followed by intravenous immunoglobulins (2 g/kg), five sessions of plasmapheresis, and three cycles of bortezomib 1.3 mg/m² , were administered. Despite rescue therapy with eculizumab, necrosis of the lips and the perioral area occurred, which led to surgical removal of the lower lip, labial commissures, and part of the right cheek in May 2015. In January 2016, the patient underwent conventional facial reconstruction because during the retransplantation evaluation a small-cell lung carcinoma was discovered, causing the patient's death in April 2016.