Cavernous sinus metastasis in head and neck cancer: Focus on oral squamous cell cancer.

Intracranial metastatic disease is rarely found in head and neck cancer (HNC), in particular, cavernous sinus (CS) involvement is difficult to recognize, because of its rarity, not specific symptoms associated and challenging imaging features. We report our experience in 4 cases, reviewing also the English literature. We analysed data from 21 patients showing that CS metastasis is a dramatic event, with rapid onset, usually starting with neurological manifestations (ophthalmoplegia, headache and trigeminal dysesthesia) and almost unavoidable outcome (DOD in 18/21 patients). Furthermore, we assessed that the diagnostic confirmation could be difficult to perform because of the need for multiple exams and time consuming procedures. Unfortunately, usual antineoplastic therapies seem to be not effective in prolonging survival, also because patients are already weakened by primary tumour treatments. The only option that seems useful in improving outcomes is immunotherapy.

Impact of COVID-19 epidemic on maxillofacial surgery in Italy.

Maxillofacial departments in 23 surgical units in Italy have been increasingly involved in facing the COVID-19 emergency. Elective surgeries have been progressively postponed to free up beds and offer human and material resources to those infected. We compiled an inventory of 32 questions to evaluate the impact of the SARS-COV2 epidemic on maxillofacial surgery in 23 selected Italian maxillofacial departments. The questionnaire focused on three different aspects: the variation of the workload, showing both a reduction of the number of team members (-16% among specialists, -11% among residents) due to reallocation or contamination and a consistent reduction of elective activities (the number of outpatient visits cancelled during the first month of the COVID-19 epidemic was about 10 000 all over Italy), while only tumour surgery and trauma surgery has been widely guaranteed; the screening procedures on patients and physicians (22% of maxillofacial units found infected surgeons, which is 4% of all maxillofacial surgeons); and the availability of Personal Protective Equipment, is only considered to be partial in 48% of Maxillofacial departments. This emergency has forced those of us in the Italian health system to change the way we work, but only time will prove if these changes have been effective.

Clinical and functional outcomes of cad/cam mandibular reconstruction with free fibular flap comparing traditional versus micro-invasive intraoral surgical approaches.

The surgical incision plays a pivotal role in any surgical procedure. A good surgical approach should allow optimal visualization, respect the anatomy and ensure the best aesthetic outcome possible, especially when the lesions involve the face. In this retrospective study, carried out from June 2014 to April 2018, different types of surgical approaches to perform mandibular reconstruction were compared. Twentyone patients who underwent mandibular reconstruction with free fibular flap (FFFs) using CAD-CAM technology and Virtual Surgical Planning (VSP) were included in the study, regardless the condition, the timing of reconstruction (primary vs secondary), the number of fibular segments or the type and size of the mandibular defect. The patients were treated for mandibular defects secondary to benign or low-grade oncological lesions and different non-oncological conditions. However, patients requiring neck dissection were excluded from the study. Patients were divided into two groups according to the type of surgical approach used: 7 patients received a traditional transcervical approach together with an intraoral approach, while 14 patients were operated through an intraoral approach combined with different microinvasive approaches, including the sub-mandibular, the retro-mandibular and the preauricular approaches. Different factors were statistically compared: characteristics of the harvested fibula, surgical timing, days of hospitalization, as well as complication, functional and aesthetic outcomes. According to this study, no statistically significant differences were observed between the two groups in any of the features considered. These results support the hypothesis that the combination of different microinvasive approaches and the traditional approach are superimposable, and they can be safely exchanged when the underlying defects allow it.

Three-dimensional longitudinal evaluation of facial mimicry in orthognathic class III surgery.

The effect of bimaxillary orthognathic surgery on facial mimicry was assessed longitudinally in 15 patients with dentoskeletal class III facial dysmorphism (seven men, eight women, mean age 28 years). The patients were analysed pre-surgery and at 6, 12, and 24 months post-surgery while performing verbal (five vowels) and non-verbal (open and closed mouth smile, lip purse) soft tissue facial movements. The three-dimensional motions of right and left nasogenian, crista philtri, cheilion, and lower lip landmarks were detected by an optoelectronic instrument, and a total mobility index was obtained. Differences between the sides were quantified by the symmetry index. Patient values were compared to those collected previously from healthy volunteers by computing z-scores. On average, no significant differences were found in the mobility of the buccal soft tissues at 24 months after surgery (ANOVA P-value, range 0.075-0.808), with positive median z-scores (pooled mean value close to 0.6). Symmetry indices ranged around the control reference values, showing no stage-related differences (Friedman test P-value, range 0.252-0.937), and exceeding 90% for all movements at 24 months after surgery. Bimaxillary osteotomy does not compromise facial mimicry in either verbal or non-verbal facial movements.

Impact of reconstructive microsurgery on patients with cancer of the head and neck: a prospective study of quality of life, particularly in older patients.

Treatment of cancer of the head and neck often requires extended resection and major reconstructive surgery, both of which can have great functional and emotional impact. It is fundamental to evaluate the outcome with respect not only to the clinical aspects but also to the quality of life (QoL) perceived by the patients. In the light of the reported increasing incidence of oral cancer in older patients, we decided to see if there was an association between QoL and age. Between June 2015 and December 2016 we submitted the Italian version of the 36-item Short Form Health Survey (SF-36) to 30 patients (mean (range) age 65.5 (23-87) years) who had had resection and microsurgical reconstruction at the Ospedale Maggiore Policlinico of Milan. The questionnaires were completed before operation, and 12 months afterwards, and clinical and personal data were also collected. From the results of SF-36 we obtained the Short Form 12 (SF-12), Physical Health Composite Score (PCS), and Mental Health Composite Score (MCS) and looked at how age influences the variation in QoL scores. The variation between SF-36 and SF-12 results (preoperatively and postoperatively) did not seem to correlate with age. Our study confirmed that reconstructive microsurgery can be realistically proposed to older as well as younger patients because, according to the QoL index, older patients are able to manage (and therefore take advantage of) this complex surgical technique.

Use of the orbital fat pad in eyelid reconstruction.

Eyelid reconstruction, though challenging, can produce a functional, esthetically pleasing lid. This should preferably be accomplished with a one-stage procedure, using robust, well-vascularized tissues similar to those being replaced, with minimal associated donor morbidity. According to the experience with Bichat pedicled flap in oral reconstruction, the authors propose the use of pedicle infraorbital fat pad for repair of conjunctival defect. Seven patients underwent eyelid reconstruction of full-thickness oncological or post-traumatic defects. In all cases, the reconstruction involved an orbital fat pad flap for the posterior lamella in addition to local flaps for the anterior lamella. All of the flaps survived. The transferred fat flap had a complete epithelization, histologically documented. No tumor relapse occurred in oncological cases. The results have been satisfactory both for clinical evaluation and for the patients. Reconstruction of the palpebral inner lamella with the orbital fat pad is a simple and low-morbidity procedure that has good morphological and functional results.

Parry Romberg Syndrome and linear facial scleroderma: management in pediatric population.

Among all different types of cutaneous scleroderma, Parry Romberg syndrome and linear scleroderma "en coup de sabre" typically involve the visage. Gradual degeneration of the tissues, from the skin up to the bone, is the stigmata of the diseases and the range of clinical manifestations is wide. They typically start during childhood and slowly progress before stabilizing. Considering the gravity of the associated deformity and its impact on facial function and appearance, we strongly advocate a prompt intervention that however must be tailored on paediatric patients. There is not a general consensus on hemifacial atrophy treatment, but autologous fat grafting has been proved to be a suitable technique, due to its low morbidity, repeatability and efficacy in correcting volume defects and in improving skin texture. Following the same concept of safeness and non-invasiveness we propose 3D stereophotogrammetric acquisitions as a possible tool for the pre- and post-surgical follow up, indispensable to evaluate the surgical results. We present our case series composed of 8 paediatric patients, aged between 11 and 17 years, who underwent several lipofilling procedures, from 2012 to 2016. Starting from 2015, 3D stereophotgrammetric data has been obtained.

Oral melanoma with osteocartilagineous differentiation: a case report and literature review.

Osteocartilagineous differentiation within malignant melanoma is a rare occurrence with several implications for diagnosis. Most of the reported cases have occurred in acral lentiginous malignant melanomas. In this paper, the authors describe the clinical, morphological, immunohistochemical features and surgical treatment of a case of primary oral mucosal melanoma with osteocartilaginous differentiation and they review the existing literature. The clinical history of a 67-year-old man affected of oral malignant melanoma was described from the first presentation to the second recurrence. FISH analysis on primary lesion and on relapses showed positive results both in epithelioid and in osteocondroblastic areas. Because of the scarcity of literature in osteogenic melanoma, histological identification may be problematic and prognostic factors and therapeutic protocols are nor well established. Immunohistochemical and molecular techniques can help to diagnosis this rare lesion.

Bacterial colonization of the implant-abutment interface of conical connection with an internal octagon: an in vitro study using real-time PCR.

Bacterial leakage at the implant-abutment connection of a two-piece implant system is considered the main cause of peri-implantitis. Prevention of bacterial leakage at the implant-abutment connection is mandatory for reducing inflammation process around implant neck and achieving bone stability. Micro-cavities at implant-abutment connection level can favour bacterial leakage, even in modern two-piece implant systems. The conical connection with an internal octagon (CCIO) is considered to be more stable mechanically and allows a more tight link between implant and abutment. As P. gingivalis and T. forsythia penetration might have clinical relevance, it was the purpose of this investigation to evaluate molecular leakage of these two bacteria in a new two-implant system with an internal conical implant-abutment connection with internal octagon (Shiner XT, FMD Falappa Medical Devices S.p.A. Rome, Italy). To verify the ability of the implant in protecting the internal space from the external environment, the passage of genetically modified Escherichia c oli across implant-abutment interface was evaluated. Four Shiner XT implants (FMD, Falappa Medical Devices®, Rome, Italy) were immerged in a bacterial culture for 24 h and bacteria amount was measured inside implant-abutment interface with Real-time PCR. Bacteria were detected inside all studied implants, with a median percentage of 6% for P. gingivalis and 5% for T. forsythia. Other comparable studies about the tightness of the tested implant system reported similar results. The gap size at the implant-abutment connection of CCIOs was measured by other authors discovering a gap size of 1­2µm of the AstraTech system and of 4µm for the Ankylos system. Bacterial leakage along implant-abutment connection of cylindrical and tapered implants, Shiner XT, (FMD Falappa Medical Devices S.p.A. Rome, Italy) showed better results compared to other implants. Additional studies are needed to explore the relationship in terms of microbiota of the CCIO. In addition, the dynamics of internal colonization needs to be thoroughly documented in longitudinal in vivo studies.

Nasal reconstruction: our experience.

The nose is a critically important aesthetic and functional portion of the face. We can explore nasal defects following trauma or tumor resections. Reconstructive techniques based on primary closure, skin graft, local flap, regional flap and microvascular free tissue transfer provides an algorithmic framework applicable to any reconstructive problem. From 2010 to 2016, 33 patients were treated with nasal reconstruction. Malignant tumor resection was the main cause of nasal defect. The most common tumor resected was BCC (basal cell carcinoma) followed by SCC (squamous cell carcinoma). Recurrence of malignant tumor were also treated. As described in the literature, we used the most common reconstructive techniques to handle post-resection defects. Most of the defects involved the dorsum and the ala of the nose, only rarely had the skeleton been affected by the resection. When the cartilage had been sacrificed, a graft from the septum or from the ear flap was harvested. All patients resulted in optimal reconstruction. In any case, a second surgery was needed. All the surgical procedures were performed in one single stage except for the paramedian forehead flap that required a second stage for division and inset of the flap. All donor sites did not show functional and aesthetic damage. All patients resulted in a morpho-functional restoration of the area affected by the resection with a high success rate. Following the algorithm when restoring the anatomical subunit is the base purpose has determined satisfactory results.

Genetic effects of BIOPAD® on fibroblast primary culture.

BIOPAD® is an ivory-white soft sponge, made exclusively of lyophilized type I native heterologous collagen extracted from horse flexor tendon, gelatine free, that keeps its native structure specific to the body's skin tissue. BIOPAD® is an active dressing, playing an active role in all stages of wound healing process, stimulating granulation tissue growth and enhancing regeneration tissues. It ensures balance between absorption and humidity at wound surface, gaseous exchange of soft tissues during healing process, barrier to prevent bacterial infections and it is completely non-adherent. The use of BIOPAD® is painless for the patient and does not require removal or change of dressing. In this work, we evaluated the effect of BIOPAD® on fibroblasts behavior in term of cell viability, survival and growth and collagen production. The expression levels of some adhesion and traction-resistance related genes (ELN, DSP, FN1, FBN1, ITGB1, ITGA1, ITGA5, ITGA2, COL1A1, COL3A1) were analyzed using real time Reverse Transcription-Polymerase Chain Reaction (real time RT-PCR). All genes, except for ELN, DSP, ITGB1 and ITGA1 are up-regulated after 48 h of treatment. Altogether, our results point out the good potential of BIOPAD® as a biocompatible and regenerative tool in medicine.

Genetic effects of Vicryl® on fibroblast primary culture.

Vicryl® (polyglactin 910) is an absorbable, synthetic, usually braided suture, indicated for soft tissue approximation and ligation. Vicryl® has a special coating for minimizing friction, easing passage through tissue and easy knot tie down. It is synthetic for minimal tissue reaction. Fibroblasts are the main cells of connective tissue that synthesize extracellular matrix. In this work, we tried to judge the action of Vicryl® on fibroblasts behaviour. We evaluated the expression levels of some adhesion and traction-resistance related genes (ELN, DSP, FN1, FBN1, ITGB1, ITGA1, ITGA5, ITGA2, COL1A1, COL3A1) by using real time Reverse Transcription-Polymerase Chain Reaction (real time RT-PCR). All but 2 genes resulted up-regulated after 48 h of treatment. Our preliminary results point out the potential of Vicryl® as a biocompatible and regenerative tool in medicine.

Extended-pedicle peroneal artery perforator flap in intraoral reconstruction.

The peroneal artery perforator (PNAP) flap is a good choice for reconstruction in intraoral soft-tissue rehabilitation. In this article, the authors propose the use of a modified PNAP flap with pedicle extension.

The park-bench position in cervico-facial reconstructive surgery: a technical note.

Resection and simultaneous reconstruction with free flaps of wide tumours of the scalp and posterior neck region are difficult to perform through a single surgical approach. In such cases, the park-bench position - a lateral oblique position - could allow simultaneous resection and reconstruction of tumours of the scalp and occipital region without changing the patient's position. In the case described here, this position was used to treat microcystic adnexal carcinoma in a patient who presented with three scalp lesions and a lesion of the right scapular region. This arrangement allowed both resection and reconstruction with a microvascular flap without changing the patient's position, as a result of being able to find neck vessels suitable for microanastomosis. Reconstruction was carried out using a right latissimus dorsi myogenous and subcutaneous flap, and anastomoses were created between the thoracodorsal artery and vein, and the transverse cervical artery and vein. In this position, transverse cervical vessels are well placed, with good exposure, and are in an optimal location for use in microvascular surgery. At 8 months post-reconstruction, the patient was in good condition without local recurrence or distant metastases, and the flap showed a good lining and contour. In conclusion, the park-bench position facilitates surgical excision, flap harvesting and microsurgery in the same patient position.

Bilateral SMAS rhytidectomy in parotid recurrent pleomorphic adenoma.

A case is presented of a young female with parotid recurrent pleomorphic adenoma and skin infiltration treated with subtotal parotidectomy combined with a bilateral superficial muscular aponeurotic system rhytidectomy.

Vascularized fibula free flap for implant rehabilitation in the case of extreme atrophy.

The skeletal reconstruction in cases of extreme atrophy like a class VI Cawood classification can be carried out using free bone flaps. They represent a valid option for preprosthetic rehabilitation of atrophic maxillas. Over the last 5 years, the use of vascularized bone transplants, aimed at implant-prosthetic rehabilitation, has become a practice, which has gradually found the right indications and the range of applications, which are now widely acknowledged. The key to success in the use of free flaps lies in the identification of the correct indications for use, in meticulous programming and the particular motivation that this type of patient has for reacquiring optimum masticatory functions. The final prosthetic implant rehabilitation must be prosthetically guided and an accurate preoperative planning is of fundamental importance for restoring masticatory functions and esthetic harmony to the patient through a fixed prosthesis. The authors present a case of a rehabilitation of an extreme maxillary and mandibular atrophy.

Microcystic adnexal carcinoma of the centrofacial region: a case report.

Microcystic adnexal carcinoma is a rare, locally aggressive neoplasm with both eccrine and follicular differentiation and a high probability of perineural invasion of the centrofacial region. Given the histopathological features of this tumour, early diagnosis is essential for adequate management. This report refers to a case of microcystic adnexal carcinoma of the nasogenial region, with infiltration of the deep planes extending to the anterior wall of the maxillary sinus. Surgical treatment involved wide demolition of the centrofacial region followed by reconstruction using four locoregional flaps: an Indian flap and a Mustardé flap were used for cutaneous reconstruction; a septal flap to support the maxillogenial region; a mucosal flap to separate the nasal cavities.

Severe mandibular interforaminal atrophies: bone reconstruction and immediate implant placement via endermic access.

The authors present a case of prosthetic-implant intraforaminal mandibular reconstruction surgery to correct severe atrophy using the application of autologous bone transplants with submental endermic access. The prosthetic-implant method applied in this case study with the close collaboration between the surgeon and prosthodontist, represents, if scrupulously executed in selected cases only, a valid alternative to the implant protocols used on a daily basis in the intraforaminal mandibular sector.

Use of porous polyethylene for correcting defects of temporal region following transposition of temporalis myofascial flap.

Transposition of the temporalis myofascial flap results in permanent aesthetic stigma in the donor site. Reconstruction of this deformity is desirable. The Authors present personal experience in the use of a porous polyethylene prosthesis to camouflage the temporal defects following transposition of the temporalis myofascial flap. From 2002 to 2005, 12 patients (5 male, 7 female, age range 36-84 years, mean 60), following the transposition of the temporalis myofascial flap, underwent reconstruction of the temporal region defect using porous high-density polyethylene temporal implants. The majority of the neoplasms removed proved to be squamous cell carcinomas of the alveolar crest or of the sinusal antrum. The standard surgical technique was used, namely, hemicoronal access and placement of 12 porous high-density polyethylene prostheses (5 left, 7 right). The size of the implants to be used (small, medium, large) was decided during the surgical operation. Of the 12 patients, 2 underwent post-operative radiotherapy, 6 weeks after the implantation of the prosthesis, without adopting any particular precautions to protect the area directly involved in the prosthesis implant. All patients are alive and free from disease, and implant placement appears to be free from post-operative complications. During the period of radiotherapy no complications. directly or indirectly related to the prosthetic implant, arose. Placement of the high-density polyethylene prosthesis fulfilled its filling effect on the deficit with a cosmetic success rate of 90%, as it was well integrated with no evident discontinuity between the edges of the prosthesis and the surrounding tissue or any alteration in the physiological convexity of the treated region. There were no incidents of pain or dysaesthesia of the skin covering the prosthesis. In conclusion, reconstruction of the temporal defect after temporalis myofascial flap transposition with the use of high-density polyethylene implants is an easy and safe method, with excellent functional and aesthetic results.