Secondary Microsurgical Reconstruction of the Cervical Esophagus: Safer Flaps and Practical Tips in a Challenging Situation.

Background: Cervical esophageal reconstruction is vital to improve the quality of life in cancer surgery patients. Microsurgery is crucial in providing vascularized tissue for defect repair, particularly in secondary cases with a higher risk of failure due to larger defects and damage from previous surgery and radiotherapy. The purpose of this study was to describe the clinical characteristics of a series of patients who underwent secondary repair of esophageal defects and provide practical information for the management and treatment of such cases based on the authors' experience and the literature review. Methods: We retrospectively reviewed the electronic medical records of the Plastic Surgery Clinic at the University of Trieste to identify cases of patients who underwent secondary esophageal microsurgical reconstructions following oncological surgery. Patient demographics, the etiology of esophageal defects, previous surgical history, and preoperative assessments were collected from medical records. Surgical techniques utilized for reconstruction, such as pedicled flaps or free tissue transfers, were documented along with intraoperative information. Postoperative outcomes, including complications, graft viability, and functional outcomes, were evaluated during follow-up. Results: We treated 13 cases of secondary esophageal reconstructions between 2011 and 2022. Most commonly, Antero-Lateral Thigh (ALT) flaps were used in 10 cases, while 2 cases employed a radial forearm flap (RFF), and 1 case employed a chimeric parascapular flap. No flap failures occurred during a median 50-month follow-up. One ALT flap patient experienced postop stricture but maintained swallowing ability. A single tracheoesophageal fistula occurred in an RFF patient with a history of radiotherapy and complete lymph node dissection. Conclusions: Cervical esophageal reconstruction significantly impacts patients' quality of life by restoring oral feeding and phonation. When local flaps fall short, microsurgical reconstruction with intestinal flaps is valuable but is burdened by limitations. For challenging secondary cases, ALT or RFF flaps emerge as safer options due to their robust pedicles, yielding low complication rates and positive functional outcomes.

Is the LICOX® PtO2 system reliable for monitoring of free flaps? Comparison between two cohorts of patients.

BACKGROUND: Licox® PtO2 is a minimally invasive monitoring system for continuous measurement of tissue oxygen tension in all types of free tissue transfers. Our study compares two consecutive series of patients undergoing microsurgical reconstruction monitored with standard clinical bedside surveillance and with the Licox® PtO2 system regarding flap loss and flap salvage, the sensitivity, specificity, and cost-effectiveness. METHODS: We performed a longitudinal observational prospective study of all patients undergoing microsurgical reconstructions between 2016 and 2017. Group 1 included 43 patients that underwent standard clinical bedside postoperative flap monitoring whereas group 2 included 44 consecutive patients also monitored with Licox® PtO2 system. Flap complications such as return to theater for vascular compromise, partial and total flap loss and flap salvage rate were analyzed. RESULTS: We recorded no significant difference between the two groups regarding the rate of vascular complications (P = .31), return to the theater (P = .31), flap salvage (P = .9), partial and total flap loss (P = .36 and P = .49, respectively). When analyzing the Licox® PtO2 system monitoring group, we documented six false-positive results (13.6%) and 0 false negatives with an accuracy of 0.86, a sensibility of 1.00, and a specificity of 0.85. CONCLUSIONS: This is the first study that provides statistical data about the comparison of postoperative free flap monitoring by standard clinical bedside method and Licox® PtO2 system. For the monitoring of buried flaps, the Licox® PtO2 monitoring can be used only as a supplement to other systems. Its use, compared to near-infrared spectroscopy or clinical bedside monitoring, was not found cost-efficient.

Triple-Cut Computer-Aided Design-Computer-Aided Modeling: More Oncologic Safety Added to Precise Mandible Modeling.

PURPOSE: Computer-aided design-computer-aided modeling (CAD-CAM) has become standard in mandibular reconstruction because it offers better outcomes. Occasionally, the reconstructive plans need to be changed intraoperatively and the custom-made prefabricated devices may become inadequate. We present an efficient adjunct to the standard CAD-CAM technique that resolves this problem. MATERIALS AND METHODS: Customized surgical devices with our "triple-cut" concept were used in 5 patients for mandibular reconstruction with free fibula flap (4 after mandibular resection for squamous cell carcinoma and 1 after mandibular osteoradionecrosis). In all patients the mandibular and fibular cutting guides were provided with 3 different cutting levels per side. RESULTS: Three different cutting levels on the mandible permitted an accurate resection based on the intraoperative needs. The corresponding 3 "cutting levels" on the fibula created perfectly matching segments of vascularized bone. Good contact of bony segments was obtained in all patients. CONCLUSIONS: The prefabricated triple-cut cutting guides make changing the dimensions of bony resection, while still using the prefabricated CAD-CAM reconstructive plate, possible.

Treatment of a double-giant Rhinophyma with electrocautery and Versajet hydrosurgery system.

Rhinophyma is a disfiguring condition etiologically related to rosacea and due to hypertrophy of the sebaceous glands of the nose. It leads to a progressive thickening of the skin up to the development, in some cases, of severe deformities that result in significant functional deficits and serious cosmetic damage. We report a case of giant rhinophyma consisting of 2 large masses that interfered with feeding and respiration of the patient, and we describe the surgical treatment by resection with electrosurgery and razor-thin saline jet (Versajet Hydrosurgery System). This combined approach is simple and effective for the treatment of severe cases of rhinophyma.

How we fix free flaps to the bone in oral and oropharyngeal reconstructions.

PURPOSE: The use of suture anchors has been described in orthopedic, hand, oculoplastic, temporomandibular joint and in aesthetic surgery, but no study reports the use of the Mitek® anchors (Depuy Mitek Surgical Products, Inc. Raynham, Massachusetts) for fixing the free flaps used in oncologic oral and oropharyngeal reconstruction. MATERIALS AND METHODS: In this prospective non-randomized study, 9 patients underwent surgical resection of oral or oropharyngeal cancer followed by a free flap reconstruction; mini anchors were used to fix the flap directly to the bone. We collected data regarding the patients, the tumor stage, the surgical procedure, the radiotherapy and the number of anchors used. RESULTS: The average follow-up was 28months (range 24-38).We observed no complications with trans-oral, sub-mandibular and trans-mandibular approach in both oral and oropharyngeal reconstructions. All anchors became osteo-integrated and no complications occurred after radiotherapy. CONCLUSIONS: In our opinion this device favors free flap adhesion to the bone. We registered no postoperative complications related to the use of the device which looks suitable for use in irradiated tissues. The radiotherapy did not cause any long-term complications related to the use of Mitek® mini bone anchors.

Elastofibroma dorsi. Our experience with 11 lesions.

Elastofibroma is a rare benign lesion that typically arises on the posterior chest wall beneath the scapula. The etiopathogenesis is still unclear and the knowledge about its diagnosis and management mainly comes from small case series. We collected all the data related to 11 Elastofibroma Dorsi treated at our institution between January 2003 and July 2014. The definitive diagnosis was made by histological examination of the mass. We analyzed the characteristic of the patients, (i.e. age, sex, dominant hand, and occupation), the presenting symptoms and signs, the preoperative investigations, surgical management and complications comparing our findings with the current medical literature on the subject. We found that preoperative investigations are of limited value and when clinical presentation is typical the diagnosis could be made presumptively. Surgery should be performed under general anaesthesia since local anaesthetic infiltration and sedation are often inadequate to reduce intraoperative discomfort.