Faculty Bibliography

Reconstruction of large maxillary and mandibular defects following ablative surgery has posed a challenge to the head and neck surgeon due to the high functional and esthetic demands requiring precise three-dimensional reconstruction. Previous issues with maxillofacial reconstruction have included poor facial contour, unfavorable orthognathic relationships, and inability to provide adequate dental rehabilitation. The advent of the fibula flap along with (3D) facial analysis and virtual surgical simulation has revolutionized surgical interventions of the head and neck. Recent reports on the long-term success of dental implants in fibula reconstructions have made dental rehabilitation a reality. However, the loading and restoration of these implants are usually delayed prior to final prosthodontic rehabilitation leading to adverse functional, esthetic and psychological effects. Rohner et al. has documented the success of a two-stage surgery of fibula harvest and dental implant placement (Stage 1) followed by ablative surgery, inset and immediate loading with a dental prosthesis (Stage 2)⁽²⁾; this procedure is a two stage process that involves a 10-week delay between each surgery and will leave the patient edentulous. At our institution, computer-aided surgery and CAD/CAM technologies have enabled us to virtually plan complex surgery and have afforded our group the opportunity of providing a "Jaw in a Day '¹ This technique is a one-stage complete surgery including ablation, free flap, implant, and prosthetic reconstruction. A retrospective chart review was conducted for all patients who received immediate dental implants with a dental prosthesis in a fibular free flap following mandibular resection due to benign tumors. "Jaw in a Day 'procedures were completed at two of our affiliated hospitals (Bellevue Hospital Center and NYU Langone Medical Center) from January 2011 to January 2015. We looked at success rate of flaps, implants, and prostheses. We also looked at primary and long-term complications. Of the 8 patients who underwent the above procedure, a total of 35 immediate implants were placed along with a fixed prosthesis. Patients received maxillary/mandibular resection, fibula free flap reconstruction with immediate implant and dental prosthesis placement. All patients treated were diagnosed with benign mandibular (7) and maxillary (1) tumors, including ameloblastoma (6), odontogenic myxoma (1), and AV malformation (1). Of the 35 implants placed, 1 implant failed and was removed. The cumulative survival of fibular-free flaps was 100%. The cumulative implant success rate was 97%. Complications included soft tissue perimplantitis (2), plate exposure (2), and (1) prosthesis that did not adequately fit. The followup of the 8 patients was from January 2011 to January 2015. Single-stage maxillofacial reconstruction with virtual surgical planning has greatly impacted the field of maxillofacial reconstruction allowing for precision and accuracy while improving patient's function and quality of life. The above study shows its feasibility and low complication rates. Immediate implant and dental prosthesis placement has helped reduce the time for dental prosthetic rehabilitation and avoid the traditional 3- to 6-month delay period. Reconstruction with a MVFFF and immediate dental rehabilitation has revolutionized the treatment of benign tumor following ablative surgery

Carcinoma ex pleomorphic adenoma is a rare malignancy of the head and neck, particularly in the minor salivary glands. Most cases arise in the major salivary glands, most commonly in the parotid gland, followed by the submandibular gland. The malignant component of the tumor varies, but can be salivary duct carcinoma, adenoid cystic carcinoma, mucoepidermoid carcinoma, squamous cell carcinoma, or adenocarcinoma, not otherwise specified. Primary salivary duct carcinoma is also a rare malignancy of the head and neck. Similar to carcinoma ex pleomorphic adenoma, it is more common in the major salivary glands, with the parotid gland accounting for 88% and the submandibular gland for 10% of cases. To date, only 25 known cases of primary salivary duct carcinoma arising in the minor salivary glands have been documented, with most arising in the palate. Salivary duct carcinoma ex pleomorphic adenoma of the minor salivary glands appears to be even rarer. Our case of salivary duct carcinoma ex pleomorphic adenoma of the palate is the first complete report, to our knowledge, in the English-language scientific literature.

BACKGROUND: The free fibula osteocutaneous flap has become the criterion standard for reconstruction of complex mandibular defects. The authors present their institutional experience with optimization of flap contouring and inset using virtual planning and prefabricated cutting jigs. METHODS: All free fibula-based mandible reconstructions performed at the authors' institution using virtual planning technology between 2009 and 2012 were retrospectively analyzed. The authors evaluated a variety of patient and procedural variables and outcomes. A series of cases performed before virtual planning was reviewed for comparison purposes. RESULTS: Fifty-four reconstructions were performed in 52 patients. Patients were divided evenly between a private university-affiliated medical center and a large county hospital. The most common indications were malignancy (43 percent), ameloblastoma (26 percent), and osteonecrosis/osteomyelitis (23 percent). Thirty percent of patients had irradiation of the recipient site and 38 percent had previous surgery. Sixty-three percent of patients received dental implants, with 47 percent achieving functional dentition. Twenty-five percent of patients had immediate dental implant placement, and 9 percent had immediate dental restoration. Postoperative imaging demonstrated excellent precision and accuracy of flap positioning. Comparison with cases performed before virtual planning demonstrated increased complexity of flap design along with reduced operative time in the virtually planned group. CONCLUSIONS: Preoperative virtual planning along with use of prefabricated cutting jigs allows for precise contouring and positioning of microvascular fibula free flaps in mandibular reconstruction. Using this technique, the authors have achieved unprecedented rates of dental rehabilitation along with reduced operative times. The authors believe that virtual planning technologies are an emerging criterion standard in mandible reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Background: The use of osteocutaneous fibular free flaps in adults has been well described in the literature, but the data on their use in the pediatric population is lacking. Free fibular transfer allows for reconstruction of skeletal defects greater than 6cm and offers a skin paddle for intraoral coverage. The fibula dissection can be accomplished with relative ease and with little donor site morbidity making it an ideal option for pediatric patients.1 Materials & Methods: This retrospective study reviewed patients treated at either Bellevue Hospital Center or NYU Langone Medical Center by the Department of Oral & Maxillofacial Surgery from 2006 to 2013. Patients were included in the study if they were age 21 or younger and had undergone reconstruction with free fibular transfer. Method of Data Analysis: 12 participants were found to fit the inclusion criteria and were followed for an average of 16 months (range 1-42 months). Results: The mean age was 16.5 years (range, 10-21 years) including both males (n=7) and females (n=5). Indications included Ameloblastoma (n=6), Hemifacial microsomia (n=3), Ectodermal dysplasia (n=1), Osteoradionecrosis (n=1) and Arteriovenous malformation (n=1). Locations included the mandible (n=9), maxilla (n=2), and orbit (n=1) with immediate endosseous implant placement in 9 of 12 cases. Two patients had infectious complications, one requiring removal of hardware and one requiring removal of non-vital bone with an overall success rate of 92%. Conclusions: In adults, immediate reconstruction with free fibular transfer, most commonly due to malignancy, has improved post-operative rehabilitation and functional status. At our institution, this procedure has been tolerated well in the pediatric population with success rates consistent with those previously reported.2 Though our follow up time is somewhat limited, both donor and recipient site morbidity have been low. In our experience, children appear to be ideal candidates for free fibular transfer due to their lack o!

Statement of the Problem: Osseous microvascular free flap reconstruction is a long accepted treatment following resection of the jaws. Different vascularized osseous free flaps allow for adequate tissue and bone for reconstruction of defects from various causes and sizes.1 Continued improvements in both surgical techniques and treatment planning, such as computer modeling and template design, improve the success of osseous microvascular flaps for facial reconstruction.2 Although success rates of osseous free flaps are high, at our institution we have noted multiple instances of hardware failures occurring at different time periods from the original reconstruction. Plate failures in osseous flaps require removal, adding morbidity in an already fragile patient population. We seek to review the instances of hardware failure in microvascular osseous free flap reconstruction in order to identify causes and possible areas of improvement in order to prevent plate failure. Methods: Retrospective chart review was performed on all patients treated with mandibular osseous microvascular free flap reconstructions in the Department of Oral and Maxillofacial Surgery at Bellevue and NYU Medical Center Hospitals from June 2006 to June 2012. This included patients with osteonecrotic disease, osteomyelitis, benign and malignant neoplasms. Patient diagnosis, treatment, age, sex, and follow-up time were collected. Patients who had additional surgical procedures to remove reconstruction plates, for reasons other than complete microvascular flap failure in the immediate perioperative period, were considered plate failures. Results: A total of 72 cases of patients receiving osseous free flaps were reviewed. 7 cases were found to have had plate failures requiring removal of the plate (9.7%). Preoperative diagnosis of the patients involved were 1 case of osteoradionecrosis, 2 case of bisphosphonate induced osteonecrosis, and 4 cases of squamous cell carcinoma (all had radiation). The age of the patients experiencing pla!

Statement of the Problem: Lymphomas comprise of a heterogeneous group of malignancies that can arise in different nodal and extranodal sites in the head and neck and are generally divided into Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL)1. Lymphoma is the fifth most common malignancy in the US and the second most common malignancy in the head and neck. More importantly, the incidence of NHL has risen over the last several decades.1 The most common presentation of lymphomas in the head and neck is enlarging or persistent painless cervical lymphadenopathy with/without constitutional symptoms. Other extranodal locations of lymphoma in the head and neck include Waldeyer's ring, oral cavity, nasal cavity, salivary glands, thyroid, maxilla and mandible.2 Early diagnosis of lymphomas of the head and neck and proper referral to Medical Oncology and Hematology is essential in prolonging survival in these patients since chemotherapy is the mainstay of treatments for lymphomas of the head and neck. Materials/Methods: Retrospective chart review was performed for patients from Bellevue Hospital and NYU Langone Medical Center from January 2006 till January 2013. Patient diagnosis, type, location and stage of lymphoma, time elapsed till treatment, and course of treatment was recorded for each patient. A total of 28 patients were diagnosed with lymphoma of the head and neck with FNA and/or biopsy. CT with contrast and/or MRI were performed and referral to Hem/Medical oncology was made for all patients. Results: The age of the patients ranged from 20 year old to 90 year old with an average of 48.1 years old at diagnosis. Sixty-seven percent of patients were male. Ninety-six percent of patients presented with Stage I-III Non-Hodgkin Lymphoma of varying forms including Burkitt's, Diffuse Large Cell B cell, small cell B cell, marginal zone B-cell, follicular B-cell, mature T-cell lymphoma, NK T-cell. Of the patients diagnosed with NHL, fifty-nine percent presented with lymphoma of B-cell origin. Eighty-nin!

Statement of the Problem: Reconstruction of the atrophic edentulousmaxilla canbe a challenge, particularly in individuals where extensive bone grafting is required prior to dental implant placement or in patients where bone grafts have been tried and failed. Likewise, dental rehabilitation after tumor ablation and reconstruction can be problematic if there is inadequate maxillary bone to support traditional dental implants. Zygomaticus implants, which make use of the dense type I-II bone of the zygoma, are one solution that allows for dental implant reconstruction of the atrophic or reconstructed maxilla. Materials and Methods, Data Analysis: We performed a retrospective chart review of all patients who received dental implants in the operating room at two of our affiliated hospitals from June 2007 to March 2013. We identified those patients who received either unilateral or bilateral zygomaticus implants.We then collected available data including gender, diagnosis, adjunctive surgical procedures, and indication for zygomaticus implants. Patients receiving zygomaticus implants following maxillectomy procedures were compared to a cohort of patients who did not receive implants following maxillectomy to determine which variables may have influenced surgeon choice of zygomaticus implants. In addition, we report on two recent cases of zygomaticus implants placed followingenucleation of maxillary bone cysts. Follow-up was available for all patients and ranged from one month to five years. All implants were placed by and with the supervision of a single attending surgeon, DLH. Results: From 2007 to 2013, a total of 25 zygomaticus implants were placed in 12 patients at two affiliated hospitals. Indications for zygomatic implants were varied. Patients received zygomatic implantation for cleft reconstruction, maxillectomy defect with and without free tissue transfer, and atrophic maxilla not amenable to traditional implant surgery. Two patients received bilateral zygomaticus implants for a diagnosis of !

Statement of Problem: Traditionally, pediatric craniomaxillofacial reconstruction was driven by nonvascularized bone grafts and then later, distraction osteogenesis. Although beneficial, these techniques were prone to problems, particularly relapse and graft resorption. Oftentimes, patients reconstructed primarily with costochondral grafts required multiple subsequent operations to reconstruct the mandible and temporomandibular joint secondary to near total graft resorption. We propose the use of the free fibula flap in conjunction with adjunctive procedures (orthognathic surgery, temporomandibular joint reconstruction or maxillofacial prosthetics) to successfully treat young patients with complex craniofacial asymmetries who have failed previous operations. Methods: A retrospective chart review at NYU Langone Medical Center was completed to identify patients under 18 years of age who underwent free fibula flap reconstruction for congenital or acquired asymmetric craniofacial deformities from 2010-2013. All patients were previously treated with non-vascularized grafts prior to free tissue transfer. A total of seven patients were treated for hemifacial microsomia, Pruzansky III (HFM) (n=4), Treacher Collins syndrome (n=1), Ectodermal dysplasia (n=1), and orbital osteoradionecrosis (n=1). Computer aided design and virtual surgical planning was implemented in all cases. For the four patients with HFM, reconstruction of the hypoplastic mandible with the fibula flap was performed in conjunction with maxillary and/or mandibular orthognathic surgery. One of those patients also underwent concomitant total prosthetic replacement of the contralateral TMJ. Five patients underwent concomitant dental implant placement into the fibula, while one patient received a post operative orbital prosthesis. Frameless stereotaxy was used in three cases to aid in placement of the proximal fibula. Postoperative physical examination and computed tomography was used to evaluate flap position and correction of asymmetry. R!

Statement of the Problem: The use of free osseous flaps has become the gold standard for reconstruction of complex mandibular defects. Popularized by Hidalgo1 in 1989, the free fibula transfer has become the operation of choice for these indications. While this operation has become routine; contouring of the flap using wedge osteotomies, as well as its inset remain operator dependent and imprecise. At our institution we have attempted to make this process more uniform and reproducible through the use of virtual planning and pre-fabricated cutting jigs. We have previously reported our experience on computer-aided design and manufacturing;2 however the purpose of this study was to review our series of free fibula mandibular reconstructions using these adjunctive technologies. Methods: Prior to surgery all patients underwent CT scanning of the face and bilateral lower extremities. These images were then transmitted to an outside vendor. In consultation with both the ablative and reconstructive teams, a surgical plan was devised and performed virtually, cutting jigs for both creation of the mandibular defect and for fibular osteotomies were fabricated, and a stereolithicmodel that allows for precise pre-surgical bending of a reconstruction platewas created. The rest of the surgical procedure was performed in standard fashion. Following IRB approval, all cases between 2009 and 2012 were identified and retrospectively reviewed. In addition to patient demographics, the charts were reviewed for surgical indications, microvascular anastomoses, use of a skin paddle, use of a "double barrel", timing of dental implant placement (immediate versus delayed), and timing of dental prosthetic rehabilitation (immediate versus delayed). Methods of Data Analysis: This was a retrospective chart review from 2009 to the present. Fifty-four reconstructionswere identified as having undergone presurgical virtual planning and subsequent surgery for mandibular reconstruction with microvascular free fibula transfer. Patient!