Prelamination of the Forearm Flap for Soft Palate Reconstruction: A Case Report.

Microsurgical reconstruction is nowadays the treatment of choice of several head and neck deformities that otherwise could be repaired with limited or unsatisfactory results. The forearm free flap has its own goals expecially the possibility to reconstruct small and extremely specialized anatomical structures such as the soft palate. The abuse of drugs like cocaine, generally taken by sniffing, can produce vascular impairment in nasal and oral tissues producing, as long as the abuse is kept, necrosis of facial anatomical structures and increase of the empty space in the depth of the face or nose. The consequences are generally represented by palatal fistulas or defect, leak of food or drink from the nose, and rhinolalia. Prelamination of the flap before microvascular transfer ensures not only preparation ofadequate tissue volume to resurface the defect but also optimization of the venous outflow. This two times approach, consisting first in preparation and then elevation/transfer of the flap, gives the chances to ensure viability of the flap itself and organize the surgical strategy several times to reduce forthcoming complications. The authors believe that this technical modification could be used for many other chronic defects in the head and neck region but could also be extended, with experience, to bigger defects. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03870-7.

Partial Parotidectomy under Local Anaesthesia without Regional Block Assisted by Electromyographic Facial Nerve Monitoring - A Case Report.

The Rationale: This study describes a partial parotidectomy (PP) under local anaesthesia (LA) without regional block (LAwRB) assisted by electromyographic monitoring of the facial nerve, to consolidate the feasibility, efficacy and safety of these procedures without general anaesthesia (GA). Patient Concerns: An 82-year-old with a lump in the left parotid gland suspected for non-Hodgkin lymphoma (NHL) needed a histological examination to start chemotherapy. Diagnosis and Treatments: Because of multiple comorbidities, the authors performed a PP under LAwRB electromyographically guided by the NIM Vital (Medtronic)™. Outcomes: The procedure was quick and did not require conversion to GA. The histopathological examination confirmed the NHL. No haematoma, sialocoele, earlobe numbness and transient or permanent facial palsy were observed. Take-Away Lessons: The electrophysiologic monitoring of the facial nerve improves the efficacy, safety and feasibility of parotid surgery under LA, avoiding adverse effects of GA, need of regional block and reducing hospital stay.

The superior eyelid crease approach with retroseptal dissection: A modified access to the superomedial intraconal space. Treatment of a cavernous hemangioma: Case report and literature review.

The orbit can be affected by primary intraconal lesions as well as cavernous hemangiomas. This article illustrates for the first time the retroseptal dissection (RD) route combined to the superior eyelid crease approach (SECA) to treat a symptomatic hemangioma inside the superomedial intraconal space. It also reviews the main studies about the argument. A 42-year-old woman affected by a mild painful proptosis and some accommodation difficulties in her right eye. The magnetic resonance imaging revealed a soft intraconal mass in the superomedial quadrant of the right orbit. The lesion was removed performing a SECA with RD through an incision inside a natural eyelid crease. Disappearance of pain with an improvement of accommodation was reported immediately. During the whole follow-up, the visual acuity, field examinations, and ocular motility did not reveal any impairment. Our approach represents a valid, quick, not technically demanding and mini-invasive method to access the superomedial intraconal space. Finally, it gives excellent functional and cosmetic results.

American Joint Committee on Cancer staging system 7th edition versus 8th edition: any improvement for patients with squamous cell carcinoma of the tongue?

OBJECTIVE: In this study, we evaluated the 8th edition of American Joint Committee on Cancer (AJCC) staging criteria and lymph node ratio (LNR) to identify patients affected by squamous cell carcinoma of the tongue (SCCT) with a poor prognosis. STUDY DESIGN: Seventy-three cases of SCCT were analyzed retrospectively. Tumor staging was revised according to the 7th and 8th editions of the AJCC criteria. Depth of invasion (DOI), extranodal extension (ENE), and LNR were evaluated. RESULTS: Twenty-five cases were reclassified: 17 patients received an upstage in the staging score, and in 8 cases in the same stage group, pT or pN was changed. In the pT-upstaged group, 7 patients experienced recurrence, and 8 died. In the pN-upstaged group, 9 patients developed recurrence, and 10 died. The number of disease recurrence or death was higher in the groups of patients who received an upstage in pN and in the staging score (P < .05). The pN-upstaged group showed worse disease-free survival (DFS) and overall survival (OS) (P < .05). LNR was higher in patients with recurrence, and among these, LNR was lower in patients with ENE (P <.05). CONCLUSIONS: The 8th edition of the AJCC criteria allows for better stratification of patients with SCCT. The implementation of ENE and LNR to pN classification seems to identify patients with worse DFS and OS.

Autologous Costal Cartilage Graft-A New Method to Treat Articular Cartilage Defects: Case Report and Note of Surgical Technique.

Full-thickness articular cartilage defects do not heal spontaneously. Several techniques have been developed to address this issue, but none resulted in the restitutio ad integrum of the articular cartilage. The most frequent sites of chondral lesion in the knee are medial femoral condyle and patella. The patellofemoral lesions are characterized by outcomes that are generally worse than those of tibiofemoral ones. To date, it has been well recognized the chondrogenic potential of rib perichondrium, and costal cartilage grafts have been extensively used in reconstructive surgery. Considering the need to find a gold standard technique to restore articular defect, we developed and here described a new technique to repair cartilage lesions of the knee using autologous costal cartilage graft with its perichondrium. This innovative surgical approach can be used to treat full thickness articular defects using autologous hyaline cartilage, making it possible to cover wide defects. This one step technique is low invasive, not technically demanding with minimal donor site morbidity and it has low costs. The long-term clinical efficacy of the method remains to be evaluated.

Combined supra-transorbital keyhole approach for treatment of delayed intraorbital encephalocele: A minimally invasive approach for an unusual complication of decompressive craniectomy.

BACKGROUND: Intraorbital encephalocele is a rare entity characterized by the herniation of cerebral tissue inside the orbital cavity through a defect of the orbital roof. In patients who have experienced head trauma, intraorbital encephalocele is usually secondary to orbital roof fracture. CASE DESCRIPTION: We describe here a case of a patient who presented an intraorbital encephalocele 2 years after severe traumatic brain injury, treated by decompressive craniectomy and subsequent autologous cranioplasty, without any evidence of orbital roof fracture. The encephalocele removal and the subsequent orbital roof reconstruction were performed by using a modification of the supraorbital keyhole approach, in which we combine an orbital osteotomy with a supraorbital minicraniotomy to facilitate view and access to both the anterior cranial fossa and orbital compartment and to preserve the already osseointegrated autologous cranioplasty. CONCLUSIONS: The peculiarities of this case are the orbital encephalocele without an orbital roof traumatic fracture, and the combined minimally invasive approach used to fix both the encephalocele and the orbital roof defect. Delayed intraorbital encephalocele is probably a complication related to an unintentional opening of the orbit during decompressive craniectomy through which the brain herniated following the restoration of physiological intracranial pressure gradients after the bone flap repositioning. The reconstruction of the orbital roof was performed by using a combined supra-transorbital minimally invasive approach aiming at achieving adequate surgical exposure while preserving the autologous cranioplasty, already osteointegrated. To the best of our knowledge, this approach has not been previously used to address intraorbital encephalocele.

A new operative open-wings technique to correct the frontoforehead unit in metopic synostosis.

The technology adoption and creation of a multidisciplinary team have helped to overcome the complexity associated. Craniofacial surgery has thus emerged from the valuable contributions of neurosurgery, maxillofacial surgery, plastic surgery, eyes, nose, and throat as well as head and neck surgery. A patient with trigonocephaly may present a prominent "keel" forehead, accompanied by recession of the lateral orbit rims, hypotelorism, and constriction of the anterior frontal fossa when the metopic suture fuses before 6 months of age. In a period between 2007 and 2011, in the Salesi Children's Hospital, were treated for nonsyndromic variety of metopic synostosis 11 infants; their ages ranged from 6 months to 9 months, and 7 were males and 4 females. The most important aims of our new surgical technique are the achievement of symmetry as well as normal proportion and reconstruction of the frontoforehead unit but remaining in a very conservative treatment. The morphology and position of the supraorbital ridge-lateral orbital rim region are key elements of upper facial esthetics. This new "open-wings" technique for the reconfiguration of the bilateral emisupraorbital bar requires a midline incomplete osteotomy that involves only the internal cortex of the frontonasal region. Hence, both lateral orbital walls are bent inwardly and tilting forward, as in computed tomographic scan planning, with a greenstick fracture pivoting on the preserved medial frontonasal region. This open-wings conservative technique allows the avoidance of the most important complication that may result in the traditional way such as dead space in the anterior cranial fossa, infections, and blood loss but with an achievement of satisfactory craniofacial form and aesthetic result.

The retromandibular transparotid approach: our clinical experience.

INTRODUCTION: Mandibular condylar fractures are very common. There is general agreement that an intracapsular fracture requires conservative treatment, but the treatment of extra-capsular fractures is controversial. Extraoral approaches have different advantages and disadvantages. The possibility of damage to the facial nerve is always present but, in our experience, always recovers in a short time. MATERIALS AND METHODS: From June 2008 to June 2009, we admitted 25 patients with mandibular condylar fractures to our department. Nineteen patients received a retromandibular transparotid approach to identify and stabilize the condylar fracture site. None of them developed infection. SURGICAL TECHNIQUE: A 2 cm incision extending in the retromandibular hollow is the first step. Initial dissection in a forward and upward in the direction of the SMAS layer is mandatory to gain good mobility of the soft tissue flaps. Blunt dissection through the parotid gland is performed between the marginal and buccal branches of the facial nerve. Periosteal elevation of all the lateral surface of the mandible provides good exposure of the bony surfaces and mobilization of the soft tissues. CONCLUSIONS: We believe that this approach is a safe and time sparing alternative to the intraoral endoscopic approach.

The venous flap - a safe alternative to the simple vein graft in a special situation.

The use of free tissue transfer has evolved to become the mainstay of treatment of tissue defects. The reconstructive surgeon can choose from a wide variety of flaps. Flaps are chosen based on the tissue defect and also on the characteristics of the pedicle in terms of calibre and vessel length. Occasionally situations arise necessitating the use of vein grafts. Vein grafts can be used primarily as part of a planned procedure to increase pedicle length or as a salvage technique following anastomotic complication. We report the use of venous flap instead of a conventional vein graft, for restoring continuity of the arterial flow in the pedicle of a free flap, following resection of a thrombosed segment. A venous flap harvested from the left leg with a cutaneous vein was used in a flow-through fashion to restore the continuity of the arterial inflow to the flap. The venous flap is an ideal option in selected cases instead of a vein graft. This is specifically indicated where there is a shortage of soft tissue to cover the anastomosis. The pedicle can then be covered in a tension-free manner. Thus in addition to extremity wounds, the venous flap can be used safely in salvage of difficult situations in the head and neck area.

A picture speaks a thousand words: the use of digital photography and the Internet as a cost-effective tool in monitoring free flaps.

Microsurgical free tissue transfer is progressing rapidly and is being used more frequently the world over. Monitoring these cases is crucial for a satisfactory outcome. More sophisticated methods are available for monitoring, though they are often expensive. We propose a novel technique using digital photography and the Internet to offer a reliable and cost-effective method to monitor free-tissue transfers. During an 8-month period, 163 microvascular procedures were monitored using this technique. Serial photographs taken were stored in a separate case folder and sent to the surgeon as deemed necessary. Analysis of the 67 cases is presented. Five reexplorations were done. The early diagnosis of venous congestion was possible using this technique. Timely intervention contributed to the success of the reexplorations, and these flaps could be salvaged. The file size of images was in the range of 1 MB to 6 MB. The file size of a set of photographs was usually around 7 MB to 9 MB. These were sent across the asymmetric digital subscriber line Internet lines. The use of the digital images and the Internet allows reconstructive surgeons to have a reliable picture of the state of their free-tissue transfers. This allows decreasing observer error and saves valuable time which otherwise needs to be spent to verify situations of doubt.