Publications by authors named "Zach Zhang"

15 Publications

  • Page 1 of 1

Acute Thumb Reconstruction With Medial Femoral Condyle and Radial Forearm Free Flaps: A Case Report.

Hand (N Y) 2022 Jun 6:15589447221096705. Epub 2022 Jun 6.

Division of Plastic Surgery, University of British Columbia, Vancouver, Canada.

Traumatic thumb injuries often result in significant functional disability. With segmental bone loss, reconstructive options include antibiotic cement with delayed bone graft, revision amputation with webspace deepening, metacarpal distraction osteogenesis, index pollicization, bone flap, and free toe transfer. We present a case of a subtotal thumb amputation just distal to the metacarpal phalangeal joint resulting in loss of both soft tissue and a segmental bone defect of the proximal and distal phalanx. Reconstruction was initially performed with a chimeric bone free flap from the medial femoral condyle with a vastus medialis muscle cuff to provide soft tissue coverage. A revision soft tissue coverage procedure was required and a radial forearm free flap was utilized. His reconstruction restored his missing bone and soft tissue, and provided stability with sufficient grip strength and metacarpophalangeal function resulting in a satisfactory functional outcome.
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http://dx.doi.org/10.1177/15589447221096705DOI Listing
June 2022

Safety and Cost-Effectiveness of Outpatient Surgery in Acute Burn Care.

J Burn Care Res 2022 01;43(1):37-42

Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada.

Outpatient burn surgery is increasingly used in acute burn care. Reports of its safety and efficacy are limited. This study aims to evaluate the safety and cost reduction associated with outpatient burn surgery and to describe our center's experience. This was a single-center, retrospective cohort study of consecutive patients who underwent outpatient burn surgery requiring split-thickness skin graft or dermal regenerative template from January 2010 to December 2018. Patient demographics, comorbidities, burn etiologies, operative data, and postoperative care were reviewed. The primary outcome is complications involving major graft loss requiring reoperation. One hundred and sixty-five patients and 173 procedures met the inclusion criteria. The average age was 44 years and 60.6% (100/165) were male. Annual outpatient procedure volume increased 48% from 23 to 34 cases over the 9-year period. The median (interquartile range) grafted percentage total body surface area was 1.0 (1.0)%. Rate of major graft loss requiring reoperation was 5.2% (9/172) and the most common site was the lower extremity (8/9, 88.9%). Age, sex, comorbidities, total body surface area, and procedure types were not significantly associated with postoperative complication rates. The outpatient burn surgery model was estimated to save CA$8170 per patient from inpatient costs. Demonstration of the safety and cost savings associated with outpatient acute burn surgery is compelling for further utilization. Our experience found the adoption of improved dressing care, appropriate patient selection, increased patient education, adequate pain control, and regimented outpatient multidisciplinary care to be fundamental for effective outpatient surgical burn care.
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http://dx.doi.org/10.1093/jbcr/irab183DOI Listing
January 2022

Medico-legal Closed Case Trends in Canadian Plastic Surgery: A Retrospective Descriptive Study.

Plast Reconstr Surg Glob Open 2021 Aug 13;9(8):e3754. Epub 2021 Aug 13.

Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.

To enhance patient safety and prevent medico-legal complaints, we need to understand current trends and impacts. We aimed to characterize Canadian plastic surgery medico-legal patterns in many dimensions.

Method: This retrospective descriptive analysis of Canadian Medical Protective Association data between January 1, 2013 and December 31, 2017 included closed regulatory body complaints and civil-legal actions involving plastic surgeons. We excluded class action legal cases and hospital complaints. We collected data on patient allegations, procedure types, healthcare-related patient harms, and peer expert criticisms. The primary outcome of interest was physician medico-legal outcome.

Results: We found 414 cases that met the inclusion criteria: 253 (61.1%) cases involved cosmetic procedures and 161 (38.9%) noncosmetic procedures. The annual incidence among plastic surgeon members of regulatory body complaints and civil-legal actions was 12.1% and 6.7%, for a combined incidence of 18.8%. The most common allegations were deficient clinical assessment, inadequate informed consent, delayed or misdiagnosis, and inadequate monitoring. Leading contributing factors were physician-patient communication breakdown, deficient clinical judgments, and inadequate documentation. The top procedural complications included cosmetic deformity, poor scarring, upper extremity stiffness or deficit, major structural injury, and mental health disorder. Less than half of cases (198/414, 47.8%) had unfavorable medico-legal outcomes for the surgeon. Patients were compensated in 86/198 (43.4%) of civil-legal cases.

Conclusions: Plastic surgeons experience more medico-legal complaints for cosmetic versus noncosmetic procedures. To minimize medico-legal risks, plastic surgeons should focus on strong physician-patient communication, patient education/consent, thorough clinical assessment, minimizing potentially preventable complications, and maintaining relevant documentation.
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http://dx.doi.org/10.1097/GOX.0000000000003754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8367055PMC
August 2021

Reply: Evaluation of Intrinsic Hand Musculature Reinnervation following Supercharge End-to-Side Anterior Interosseous-to-Ulnar Motor Nerve Transfer.

Plast Reconstr Surg 2021 09;148(3):500e-501e

Division of Plastic and Reconstructive Plastic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.

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http://dx.doi.org/10.1097/PRS.0000000000008248DOI Listing
September 2021

Canadian Postoperative Dependency Protocols Following Lower Limb Microvascular Reconstruction: A National Survey and Literature Review.

Plast Surg (Oakv) 2021 May 14;29(2):122-127. Epub 2020 Oct 14.

Division of Plastic Surgery, Department of Surgery, University of Ottawa, Ontario, Canada.

Introduction: Microsurgical free tissue transfer for lower limb reconstruction presents unique challenges in the postoperative period where dependency promotes interstitial fluid diffusion and reduced tissue perfusion. Management of flap edema, venous congestion, and ischaemic conditioning is critical for flap survival. Little evidence exists to guide postoperative protocols in the initiation and progression of lower extremity dangle, monitoring, and anticoagulation. We aim to describe current trends for postoperative dependency protocols by surveying Canadian microsurgeons.

Methods: Plastic surgeons performing lower limb microvascular reconstruction at Fellow of The Royal College of Surgeons of Canada approved teaching institutions were administered a 17-question anonymous electronic survey. A literature review was conducted to identify protocols and consensus opinions in other jurisdictions.

Results: All respondents (n = 16) monitored flaps clinically, with conventional Doppler used by 13 respondents. Anticoagulation was employed by 15 of 16 respondents, and 9 of 16 used 2 or more agents. The most common agents were aspirin, followed by low-molecular-weight heparin. Significant variability existed in dangling protocols. Dependency was initiated at postoperative day (POD) 3 to 10 (mean POD: 6 ± 1.64 standard deviation), with intervals ranging from 5 to 20 minutes and frequencies ranging from 1 to 6 times per day. Nearly half allowed both increasing duration and frequency of dependency. Flap success rates were above 90%, and the median length of stay was 10 to 12 days.

Conclusion: While flap success rates across the country are similar, no consensus exists for postoperative dependency protocols amongst Canadian microsurgeons. Prospective randomised controlled trials are warranted to evaluate early aggressive dependency protocols to reduce length of stay and cost.
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http://dx.doi.org/10.1177/2292550320954093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8120563PMC
May 2021

Correction to: Postoperative Adverse Events are Associated with Oncologic Recurrence Following Curative‑intent Resection for Lung Cancer.

Lung 2020 Dec;198(6):983

Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada.

The original version of this article unfortunately contained a mistake in author names. The given and family names of all the authors was transposed. The author names are corrected with this correction. The original article has been corrected.
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http://dx.doi.org/10.1007/s00408-020-00409-3DOI Listing
December 2020

Postoperative Adverse Events are Associated with Oncologic Recurrence Following Curative-intent Resection for Lung Cancer.

Lung 2020 12 9;198(6):973-981. Epub 2020 Oct 9.

Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada.

Background: Up to 50% of patients suffer short-term postoperative adverse events (AEs) and metastatic recurrence in the long-term following curative-intent lung cancer resection. The association between AEs, particularly infectious in nature, and disease recurrence is controversial. We sought to evaluate the association of postoperative AEs on risk of developing recurrence and recurrence-free survival (RFS) following curative-intent lung resection surgery.

Methods: All lung cancer resections at a single institution (January 2008-July 2015) were included, with prospective collection of AEs using the Thoracic Morbidity & Mortality System. Cox proportional hazards models were used to estimate the effect of AEs on recurrence, with results presented as hazard ratio (HR) with 95% confidence interval (CI). An a priori, clinically driven approach to predictor variable selection was used. Kaplan-Meier curves were used examine the relationship between AE and RFS. p < 0.05 was considered statistically significant.

Results: 892 patients underwent curative-intent resection. 342 (38.3%) patients experienced an AE; 69 (7.7%) patients developed infectious AEs. 17.6% (n = 157) of patients had disease recurrence after mean follow-up of 26.5 months. Severe (Grade IV) AEs were associated with increased risk of recurrence (3.40; 95% CI 1.56-7.41) and a trend to decreased RFS. Major infectious AEs were associated with increased risk of recurrence (HR 1.71; CI 1.05-2.8) and earlier time to recurrence (no infectious AE 66 months, minor infectious 41 months, major infectious 54 months; p = 0.02).

Conclusion: For patients undergoing curative-intent lung cancer resection, postoperative AEs associated with critical illness or major infection were associated with increased risk of oncologic recurrence.
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http://dx.doi.org/10.1007/s00408-020-00395-6DOI Listing
December 2020

Evaluation of Intrinsic Hand Musculature Reinnervation following Supercharge End-to-Side Anterior Interosseous-to-Ulnar Motor Nerve Transfer.

Plast Reconstr Surg 2020 07;146(1):128-132

From the Division of Plastic and Reconstructive Plastic Surgery, Department of Surgery, the Faculty of Medicine, and the Division of Physical Medicine and Rehabilitation, University of Ottawa; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia.

Supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer is commonly performed in the authors' institution to augment intrinsic hand function. Following observations of recovery patterns, the authors hypothesized that despite its more distal innervation, the first dorsal interosseous muscle recovers to a greater extent than the abductor digiti minimi muscle. The objective of this work was to evaluate the clinical and electrodiagnostic pattern of reinnervation of intrinsic hand musculature following supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer. A retrospective cohort of prospectively collected data included all patients who underwent a supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer. Two independent reviewers performed data collection. Reinnervation was assessed with two primary outcome measures: (1) clinically, with serial Medical Research Council strength assessments; and (2) electrodiagnostically, with serial motor amplitude measurements. Statistical analysis was performed using nonparametric statistics. Seventeen patients (65 percent male; mean age, 56.9 ± 13.3 years) were included with a mean follow-up of 16.7 ± 8.5 months. Preoperatively, all patients demonstrated clinically significant weakness and electrodiagnostic evidence of denervation. Postoperatively, strength and motor amplitude increased significantly for both the first dorsal interosseous muscle (p = 0.002 and p = 0.016) and the abductor digiti minimi muscle (p = 0.044 and p = 0.015). Despite comparable preoperative strength (p = 0.098), postoperatively, the first dorsal interosseous muscle achieved significantly greater strength when compared to the abductor digiti minimi muscle (p = 0.023). Following supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer, recovery of intrinsic muscle function differs between the abductor digiti minimi and the first dorsal interosseous muscles, with better recovery observed in the more distally innervated first dorsal interosseous muscle. Further work to elucidate the underlying physiologic and anatomical basis for this discrepancy is indicated. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000006903DOI Listing
July 2020

Clinicopathological overlap of neurodegenerative diseases: A comprehensive review.

J Clin Neurosci 2020 Aug 27;78:30-33. Epub 2020 Apr 27.

Department of Pathology and Laboratory Medicine, Western University, London, Canada.

Clinical and neuropathological overlap of two or more neurodegenerative diseases (ND) is not an uncommon occurrence yet is still underdiagnosed in clinical neurological and neuropathological. The authors present a clinicopathological overview of the current understanding of overlapping ND's with the hope that this review will encourage further studies that are required to investigate the effect of such overlaps on clinical presentations and how often clinical presentations raise the suspicion of multiple ND's. The authors suggest that as more patients with overlapping ND's come to light, traditional classification system of ND's may need to be modified.
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http://dx.doi.org/10.1016/j.jocn.2020.04.088DOI Listing
August 2020

Determining postoperative outcomes after cleft palate repair: A systematic review and meta-analysis.

J Plast Reconstr Aesthet Surg 2019 Jan 5;72(1):85-91. Epub 2018 Sep 5.

Department of Plastic Surgery, University of Ottawa, Canada. Electronic address:

Background: A lack of high-level evidence exists on the outcomes of different cleft palate repair techniques. A critical appreciation for the complication rates of common repair techniques is paramount to optimize cleft palate care.

Methods: A literature search was conducted for articles on the measurement of fistula and velopharyngeal insufficiency (VPI) rates following cleft palate repair. Study quality was determined using validated scales. The heterogeneity between studies was evaluated using the I statistic. Random-effect model analysis and forest plots were used to report pooled relative risks (RRs) with 95% confidence intervals for treatment effect. P-values of 0.05 were considered statistically significant.

Results: Of 2386 studies retrieved, 852 underwent screening and 227 met inclusion criteria (130 studies (57%) on fistulas and 122 studies (54%) on VPI). Meta-analyses were performed using 32 studies. The Furlow technique was associated with less postoperative fistulae than the von Langenbeck and Veau/Wardill/Kilner techniques (RR = 0.56 [0.39-0.79], p < 0.01 and RR = 0.25 [0.12-0.52], p < 0.01, respectively). One-stage repair was associated with less fistulae compared to two-stage repair (RR = 0.42 [0.19-0.96], p = 0.04). The Furlow repair was also associated with a less VPI than the Bardach palatoplasty (RR = 0.41 [0.23, 0.71], p < 0.01), and the one-stage repair was associated with a reduction in VPI rates compared to two-stage repair (RR = 0.55 [0.32, 0.95], p = 0.03).

Conclusion: The Furlow repair is associated with less risk of fistula formation than the von Langenbeck and Veau/Wardill/Kilner techniques and less VPI compared to the Bardach repair. One-stage repair is associated with less risk of fistula formation and VPI than two-stage repair.
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http://dx.doi.org/10.1016/j.bjps.2018.08.019DOI Listing
January 2019

Students working against tobacco: A novel educational program to improve Canadian medical students' tobacco counselling skills.

Can Med Educ J 2018 May 31;9(2):e72-e78. Epub 2018 May 31.

Faculty of Medicine, University of Ottawa, Ontario, Canada.

Background: Medical professionals should be appropriately trained in the field of smoking cessation counseling and be familiar with related tobacco-control issues. Sadly, Canadian medical students receive little education regarding smoking cessation.

Methods: University of Ottawa medical students created Students Working Against Tobacco (SWAT), a program that provides its members with tobacco education and opportunities to discuss tobacco use, smoking prevention and cessation with elementary-school students. Surveys assessing student knowledge and confidence in addressing tobacco issues were administered to the participating students at the start of the program and following their delivery of a school presentation.

Results: Students initially lacked knowledge, skills and experience in addressing tobacco issues and discussing smoking prevention and cessation counselling. Following their involvement in the SWAT program, students' smoking cessation counselling knowledge and skills improved, and they expressed confidence in becoming more engaged in this important preventive health issue.

Conclusion: Until smoking cessation is incorporated into undergraduate medical education programs, gaps will remain in the preparation of tomorrow's physicians regarding the provision of effective smoking cessation counselling and their broader understanding of this important health issue. Currently, there are constraints limiting the number of medical undergraduates that SWAT is able to involve and influence.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6044310PMC
May 2018

All grades of severity of postoperative adverse events are associated with prolonged length of stay after lung cancer resection.

J Thorac Cardiovasc Surg 2018 02 28;155(2):798-807. Epub 2017 Sep 28.

Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology, Public Health, and Preventative Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada. Electronic address:

Objective: To determine whether all grades of severity of postoperative adverse events are associated with prolonged length of stay in patients undergoing pulmonary cancer resection.

Methods: This was a retrospective cohort study of all patients who underwent pulmonary resection with curative intent for malignancy at The Ottawa Hospital, Division of Thoracic Surgery (January 2008 to July 2015). Postoperative adverse events were collected prospectively with the Thoracic Morbidity & Mortality System, based on the Clavien-Dindo severity classification. Patient demographics, comorbidities, preoperative investigations, cardiopulmonary assessment, pathologic staging, operative characteristics, and length of stay were retrospectively reviewed. Prolonged hospital stay was defined as >75th percentile for each procedure performed (wedge resection 6 days, segmentectomy 6 days, lobectomy 7 days, extended lobectomy 8 days, pneumonectomy 10 days). Univariable and multivariable logistic regression analyses were conducted to identify factors associated with prolonged hospital stay.

Results: Of 1041 patients, 579 (55.6%) were female, 610 (58.1%) were >65 years old, 232 (22.3%) experienced prolonged hospital stay, and 416 (40.0%) patients had ≥1 postoperative adverse event. Multivariable analyses identified significant (P < .05) factors associated with prolonged hospital stay to be (odds ratio; 95% confidence interval): lower diffusion capacity of the lung for carbon monoxide (0.99; 0.98-0.99), surgical approach: open thoracotomy (1.8; 1.3-2.5), and presence of any postoperative adverse event: Grade I (5.8; 3.3-10.2), Grade II (6.0; 4.0-8.9), Grade III (11.4; 7.0-18.7), and Grade IV (19.40; 7.1-55.18).

Conclusions: Lower diffusion capacity of the lung for carbon monoxide, open thoracotomy approach, and the development of any postoperative adverse event, including minor events that required no additional therapy, were factors associated with prolonged hospital stay.
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http://dx.doi.org/10.1016/j.jtcvs.2017.09.094DOI Listing
February 2018

Impact of Adverse Events and Length of Stay on Patient Experience After Lung Cancer Resection.

Ann Thorac Surg 2017 Aug 29;104(2):382-388. Epub 2017 Jun 29.

Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada. Electronic address:

Background: Postoperative adverse events (AEs), prolonged length of stay (PLOS), and patient experience are common quality measures after thoracic surgical procedures. Our objective was to investigate the relationship of postoperative AEs on patient experience and hospital length of stay (LOS) after lung cancer resection.

Methods: AEs (using Thoracic Morbidity and Mortality system based on Clavien-Dindo schema) and LOS were prospectively collected for all patients undergoing lung cancer resection. A 21-item questionnaire, retrospectively asking about patient experience, was mailed to patients twice (October 2015 and January 2016). The impact of AEs on experience was investigated and stratified by hospital LOS, with PLOS defined as the 75th percentile. Univariate analysis used parametric (t test) and nonparametric (Mann-Whitney) tests according to test conditions.

Results: Of 288 patients who responded to the survey (70% response rate), 175 (61%) had no AEs, 113 (39%) had experienced at least one AE, and 52 (18%) had experienced PLOS. Lung cancer patients who experienced PLOS showed significantly decreased experience on several questionnaire items, including their impression of comprehensiveness of surgeons information provision during inpatient period (p = 0.008), inpatient recovery from operation (p = 0.001), quality of life 30 days after operation (p = 0.032), follow-up care, (p = 0.022), and satisfaction with outcome 1 year after operation during follow-up care (p = 0.022). The presence of postoperative AEs led only to reduced impression about inpatient recovery from the operation (p = 0.01).

Conclusions: In this cohort, postoperative AEs were minimally associated with negative patient experience. However, patients who experienced PLOS demonstrated a marked reduction in experience after thoracic surgical procedures.
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http://dx.doi.org/10.1016/j.athoracsur.2017.05.025DOI Listing
August 2017

Post-operative outcomes after cleft palate repair in syndromic and non-syndromic children: a systematic review protocol.

Syst Rev 2017 03 9;6(1):52. Epub 2017 Mar 9.

Division of Plastic Surgery, University of Ottawa, Ottawa, Canada.

Background: There is a lack of high-level evidence on the surgical management of cleft palate. An appreciation of the differences in the complication rates between different surgical techniques and timing of repair is essential in optimizing cleft palate management.

Method: A comprehensive electronic database search will be conducted on the complication rates associated with cleft palate repair using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. Two independent reviewers with expertise in cleft pathology will screen all appropriate titles, abstracts, and full-text publications prior to deciding whether each meet the predetermined inclusion criteria. The study findings will be tabulated and summarized. The primary outcomes will be the rate of palatal fistula, the incidence and severity of velopharyngeal insufficiency, and the rate of maxillary hypoplasia with different techniques and also the timing of the repair. A meta-analysis will be conducted using a random effects model.

Discussion: The evidence behind the optimal surgical approach to cleft palate repair is minimal, with no gold standard technique identified to date for a certain type of cleft palate. It is essential to appreciate how the complication rates differ between each surgical technique and each time point of repair, in order to optimize the management of these patients. A more critical evaluation of the outcomes of different cleft palate repair methods may also provide insight into more effective surgical approaches for different types of cleft palates.
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http://dx.doi.org/10.1186/s13643-017-0438-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5345151PMC
March 2017

The Use of Neuronavigation as an Adjunct in Facial Reconstructive Surgery.

J Craniofac Surg 2016 Jun;27(4):e394-7

*Faculty of Medicine †Division of Plastic Surgery, Department of Surgery and Telfer School of Management ‡Division of Plastic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada.

Neuronavigation, a ubiquitous tool used in neurosurgery, is rarely used in maxillofacial reconstructive surgery despite it offering many advantages without any disadvantage to the patient. The present report describes one patient with complex gun-shot wound facial injury and one patient with a rare malignant peripheral nerve sheath tumor involving the skull base, in which neuronavigation was used to improve the accuracy of bony reduction and minimize surgical invasiveness. Although neuronavigation is not necessary for all maxillofacial surgery, it can be a useful adjunct in complex maxillofacial reconstruction and maxillofacial tumor resection.
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http://dx.doi.org/10.1097/SCS.0000000000002669DOI Listing
June 2016
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