Segmental Mandibulectomy and Mandibular Reconstruction with Fibula-Free Flap Using a 3D Template.

INTRODUCTION: The present study evaluates the influence of virtual surgical planning with a preoperative 3D resin model on aesthetic and functional outcomes in patients treated by segmental mandibulectomy and reconstruction with fibula-free flap for oral cancer. METHODS: All consecutive patients who underwent segmental mandibulectomy and mandibular reconstruction with a fibula-free flap using a 3D template at our department from January 2021 to January 2023 were included in the study. "Patients control" were patients treated by reconstruction with a fibula-free flap without using a 3D template. Three-dimensional modeling was performed by converting from preoperative computed tomography to a stereolithography format to obtain the resin 3D models. Qualitative analysis of anatomical and aesthetic results consisted of the evaluation of the patients' aesthetic and functional satisfaction and the symmetry of the mandibular contour observed at clinical examination. Quantitative analysis was based on the assessment of the accuracy and precision of the reconstruction by comparing preoperative and postoperative computed tomograms as objective indicators. RESULTS: Seven patients (five males and two females, mean age of 65.1 years) were included in the study. All patients showed a symmetric mandibular contour based on the clinical examination. After recovery, six patients (85.7%) considered themselves aesthetically satisfied. The quantitative analysis (assessed in six/seven patients) showed that the mean difference between preoperative and postoperative intercondylar distance, intergonial angle distance, anteroposterior dimension, and gonial angle improved in the 3D template-assisted group. CONCLUSION: The 3D-printed template for mandibular reconstruction with microvascular fibula-free flap can improve aesthetic outcomes in comparison with standard approaches.

Insights on the Choice and Preparation of the Donor Nerve in Corneal Neurotization for Neurotrophic Keratopathy: A Narrative Review.

The article introduces neurotrophic keratopathy (NK), a condition resulting from corneal denervation due to various causes of trigeminal nerve dysfunctions. Surgical techniques for corneal neurotization (CN) have evolved, aiming to restore corneal sensitivity. Initially proposed in 1972, modern approaches offer less invasive options. CN can be performed through a direct approach (DCN) directly suturing a sensitive nerve to the affected cornea or indirectly (ICN) through a nerve auto/allograft. Surgical success relies on meticulous donor nerve selection and preparation, often involving multidisciplinary teams. A PubMed research and review of the relevant literature was conducted regarding the surgical approach, emphasizing surgical techniques and the choice of the donor nerve. The latter considers factors like sensory integrity and proximity to the cornea. The most used are the contralateral or ipsilateral supratrochlear (STN), and the supraorbital (SON) and great auricular (GAN) nerves. Regarding the choice of grafts, the most used in the literature are the sural (SN), the lateral antebrachial cutaneous nerve (LABCN), and the GAN nerves. Another promising option is represented by allografts (acellularized nerves from cadavers). The significance of sensory recovery and factors influencing surgical outcomes, including nerve caliber matching and axonal regeneration, are discussed. Future directions emphasize less invasive techniques and the potential of acellular nerve allografts. In conclusion, CN represents a promising avenue in the treatment of NK, offering tailored approaches based on patient history and surgical expertise, with new emerging techniques warranting further exploration through basic science refinements and clinical trials.

The profunda artery perforators: Anatomical study and radiological findings using computed tomography angiography in patients undergoing PAP flap breast reconstruction.

BACKGROUND: The popularity of the profunda femoris artery perforator (PAP) flap is increasing; however, knowledge concerning the standardization of radiological findings and their clinical implications is limited. We evaluated the radiological architecture of posterior thigh perforators using Computed Tomography Angiography (CTA) to identify landmarks to facilitate flap dissection. METHODS: A retrospective study was conducted on 35 patients who underwent unilateral breast reconstruction with a PAP flap. The preoperative CTA scans were analyzed, and the perforator characteristics were evaluated. The perforators were mapped using a Cartesian coordinate system. Data were normalized by anatomical landmarks and overlapped. Perioperative and postoperative results were analyzed. Radiological and intraoperative were compared. RESULTS: Two CTA scans were excluded; 66 thighs were examined. The mean perforator number was 3.2. The mean diameter of chosen perforators was 2.7 mm (DS ± 0.6 mm) at the origin, 2.2 mm (DS ± 0.4 mm) at the adductor space midpoint, and 1.7 mm (DS ± 0.3 mm) at the deep fascia. The mean adipose tissue thickness was 3.35 cm (DS ± 0.94) at the deep fascia and 3.59 cm (DS ± 1.19) at the adductor space midpoint. Intraoperatively, the perforator was located 3.22 cm (DS ± 0.87) from the posterior border of the gracilis muscle and 8.98 cm (DS ± 1.44) from the inferior gluteal crease. A radiological area located 9.33 cm (DS ± 4.81) from the y-axis and 7.48 cm (DS ± 1.88) from the x-axis was identified. CONCLUSIONS: CTA using the volume-rendering technique is a valuable method to study in vivo the radiological anatomy of the posterior thigh perforators.

Superficial outside-flap shunt (SOS) is associated with a low incidence of postoperative DIEP flap venous congestion: A single-institution retrospective cross-sectional study.

INTRODUCTION: Venous congestion burdens up to 15% of deep inferior epigastric artery perforator (DIEP) flap breast reconstructions. For these cases, venous augmentation by superficial outside shunt (SOS) is associated with 100% success in secondary salvage surgeries. Intraoperative venous augmentation using other techniques yields a 0.3% rate of return to theater due to venous congestion, but there is no evidence assessing the effectiveness of the SOS technique applied preventively. Comparing this preventive approach to data prior to its implementation, we expect to find a reduced number of venous congested flaps with reduced flap losses and revision surgeries. PATIENTS AND METHODS: This retrospective cross-sectional study involved DIEP flap breast reconstructions performed between 2011 and 2020. The control group included patients receiving additional venous anastomosis as a secondary salvage procedure. The "preventive SOS group" included patients who received preventive SOS during the main surgery. Age, body mass index (BMI), pregnancies, perioperative treatments (neoadjuvant or adjuvant chemo or radiotherapy), follow-up complications (arterial ischemia, venous congestion, hematomas, partial/total flap loss), and revision surgeries (breast debridement, flap remodeling) were recorded and compared. RESULTS: Within 695 flaps performed, 397 flaps were included in the control group, and 298 flaps were included in the preventive SOS group. The groups were homogeneous for age (p = 0.418), BMI (p = 0.747), and flap weight (p = 0.064). Fifty-one flaps (12.8%) in the control group compared to zero (0.0%) in the preventive SOS group required return to theater (p < 0.001). CONCLUSIONS: We reported encouraging preliminary results for SOS to prevent DIEP flap venous congestion. These results must be validated prospectively.

White matter abnormalities in 15 subjects with SPG76.

BACKGROUND AND OBJECTIVES: Hereditary spastic paraplegias (HSPs) are heterogenous genetic disorders characterized by progressive pyramidal tract involvement. SPG76 is a recently identified form of HSP, caused by biallelic calpain-1 (CAPN1) variants. The most frequently described MRI abnormality in SPG76 is mild cerebellar atrophy and non-specific white matter abnormalities were reported in only one case. Following the identification of prominent white matter abnormalities in a subject with CAPN1 variants, which delayed the diagnosis, we aimed to verify the presence of MRI patterns of white matter involvement specific to this HSP. METHODS: We performed a retrospective radiological qualitative analysis of 15 subjects with SPG76 (4 previously unreported) initially screened for white matter involvement. Moreover, we performed quantitative analyses in our proband with available longitudinal studies. RESULTS: We observed bilateral, periventricular white matter involvement in 12 subjects (80%), associated with multifocal subcortical abnormalities in 5 of them (33.3%). Three subjects (20%) presented only multifocal subcortical involvement. Longitudinal quantitative analyses of our proband revealed increase in multifocal white matter lesion count and increased area of periventricular white matter involvement over time. DISCUSSION: SPG76 should be added to the list of HSPs with associated white matter abnormalities. We identified periventricular white matter involvement in subjects with SPG76, variably associated with multifocal subcortical white matter abnormalities. These findings, in the presence of progressive spastic paraparesis, can mislead the diagnostic process towards an acquired white matter disorder.

Effective Surgical Management of a Large Serous Ovarian Cyst in a Morbidly Obese Middle-Aged Woman: A Case Study and Literature Review.

BACKGROUND In contemporary gynecological practice, encountering giant ovarian tumors is a rarity. While most are benign and of the mucinous subtype, the borderline variant only accounts for approximately 10% of these cases. This paper addresses the paucity of information about this specific subtype, emphasizing critical elements of managing borderline tumors that can pose life-threatening complications. Additionally, a review of other documented cases of the borderline variant in the literature is also included to foster a deeper understanding of this uncommon condition. CASE REPORT We present the multidisciplinary management of a 52-year-old symptomatic woman with a giant serous borderline ovarian tumor. Preoperative assessment showed a multiloculated pelvic-abdominal cyst responsible for compression of the bowel and retroperitoneal organs, and dyspnea. All tumor markers were negative. Together with anesthesiologists and interventional cardiologists, we decided to perform a controlled drainage of the cyst of the tumor, to prevent hemodynamic instability. Subsequent total extrafascial hysterectomy, contralateral salpingo-oophorectomy, and abdominal wall reconstruction, followed by admission to the intensive care unit, were also conducted by the multidisciplinary team. During the postoperative period, the patient experienced a cardiopulmonary arrest and acute renal failure, which were managed by dialysis. After discharge, the patient underwent oncologic followup, and after 2 years, she was found to be completely recovered and disease free. CONCLUSIONS Intraoperative controlled drainage of Giant ovarian tumor fluid, planned by a multidisciplinary management team, constitutes a valid and safe alternative to the popular choice of "en bloc" tumor resection. This approach avoids rapid changes in body circulation, which are responsible for intraoperative and postoperative severe complications.

Survival in Patients with Primary Parotid Gland Carcinoma after Surgery-Results of a Single-Centre Study.

This study aims to analyse a single-centre cohort series of patients who underwent parotidectomy for primary malignant parotid tumours. A retrospective chart review of 64 consecutive patients treated from November 2010 to March 2022 was performed. Outcomes were analysed by Kaplan-Meier curves. Sixty-four patients with a primary parotid malignancy were included in the study, with one bilateral case in this cohort. Patients were classified as stage I-II in 39 cases and stage III-IV in 26 cases. The five-year overall survival (OS), disease-specific survival (DSS), local relapse-free survival (LRFS), and distant metastasis-free survival (DMFS) rates were 78.4%, 89%, 92.5%, and 87.1%, respectively. Univariate analysis showed that high-risk histology, stage IV disease, lymphovascular invasion, perineural invasion, node metastasis, skin involvement, facial nerve involvement, and positive or close margins were risk factors associated with poorer outcomes. At present, the best evidence suggests that radical surgery should be the standard approach, and adjuvant therapy, in terms of radiotherapy/chemoradiotherapy, is recommended in patients with risk factors.

Brachioplasty with Extended Incision at the Elbow: A Comparison with the Traditional Short Technique.

BACKGROUND: The elbow area is frequently affected by excessive sagging skin post-massive weight loss. The aim of this study is to present a brachioplasty with distal extension of incision to the anticubital surface, in order to make the transition from middle arm to distal arm/elbow more nuanced and aesthetically pleasing. MATERIAL AND METHODS: An observational retrospective comparative study was performed confronting two groups of female patients. All patients treated with brachioplasty between January 2015 and December 2020 due to brachial laxity following massive weight loss were included in the study. Group A consisted of patients who underwent the novel procedure and Group B comprised subjects with the standard brachioplasty technique. Demographics, including age, BMI and comorbidities were taken into account. The mean outcome measure was the Body-QTM-satisfaction with upper arms score, which was administered preoperatively and one year postoperatively. RESULTS: In the period considered, Group A consisted of 92 patients and Group B of 78. No difference was found between groups concerning BMI and age. The groups were comparable also based on the Body-Q pre-surgery levels. The Body-Q scores at one year postoperatively were 22.80 ± 2.28 in group A and 19.50 ± 2.42 in group B. The postoperative Body-Q scores across the two groups were a higher in group A, and the result is statistically significant (p < 0.05). CONCLUSION: The utilization of the proposed elbow-extended technique allows an improvement of the upper limb profile, with far higher satisfaction of patients, at the price of minimal sequelae in terms of scar. The elbow area is a critical part in post-obese deformities of the brachium, and is frequently neglected. In case of skin laxity and redundancy an elbow extension of the brachioplasty incision is indicated. Results of elbow-extended brachioplasty are p valid and the additional scar well concealed and accepted by patients. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Perforator-based chimeric anterolateral thigh flap U-shaped insetting for total pharyngoesophageal reconstruction: Surgical technique and functional outcomes.

BACKGROUND: Pharyngoesophageal reconstruction with the tubed anterolateral thigh (ALT) flap is burdened by possible strictures and pharyngocutaneous fistulae (PCF). We present our experience with the U-shaped insetting of perforator-based chimeric ALT flap focusing on surgical technique, complications and functional outcomes. METHODS: We retrospectively included 10 patients with a total circumferential defect of the hypopharynx undergoing reconstruction with ALT flap. A perforator-based chimeric ALT flap with two independent skin paddles was harvested: the trapezoid paddle with the greater base cranially and the height oriented vertically was used for pharyngoesophageal reconstruction while the second paddle was exteriorized and used for flap monitoring and reducing tension on skin closure. Mean age was 56.4 years. Eight patients were affected by squamous cell carcinoma. Modified barium swallow radiogram and fiberoptic laryngoscopy were performed to assess strictures and PCFs. Swallowing and speech outcomes were evaluated through the Deglutition Handicap Index (DHI), M.D. Anderson Dysphagia Inventory (MDADI) and Voice Handicap Index (VHI) questionnaires. RESULTS: Mean flap dimension was 7.9 × 6 × 9.2 cm. Mean ischemia time was 58.2 min (range 42-80). No flap loss nor flap-related complications were reported. Two PCFs were observed. Fiberoptic laryngoscopy documented a complete integration of the flap with no strictures or stenosis. Mean follow-up was 13.6 months (range 1-45 months). Mean DHI score was 33.8, mean MDADI score was 62.5, mean VHI score was 32.2. CONCLUSIONS: The ALT flap U-shaped insetting is a reliable option for pharyngoesophageal reconstruction yielding a high success rate, low number of strictures and fistulae and good swallowing and voice outcomes.

Clostridium Histolyticum Collagenase Underdosed for Multicord Injection in Dupuytren's Disease: A Retrospective Cohort Study.

An underdosing of collagenase clostridium histolyticum (0.32 mg) is proposed as a potentially effective option in patients with additional cords in the same hand, after the first cord has been treated with the regular dose of 0.58 mg. The aim of this study was to analyze whether this additional dose is tolerated and effective. Methods: Patients with Dupuytren's disease affecting MCP joints with at least two independent pathological cords, causing deformity of two digits, were considered, with their written informed consent, for a simultaneous injection of the two cords with a single vial of collagenase. Digits treated with the standard dose of 0.58 mg were compared with digits injected with the smaller dose of 0.32 mg. Passive extension deficit and range of motion were evaluated after injection. Complications were also compared. Results: A total of 26 patients (29 hands) were included in the study. Of these, nine patients had two independent cords within one hand, and 17 patients had a single cord (three of these with a cord in each hand). Thirty-five digits were injected, 23 with 0.58 mg and 12 with 0.32 mg. Apart from a smaller mean percentage variation in passive extension deficit within 24 hours in the 0.58-mg dose compared with 0.32 mg (29% versus 40%, P = 0.031), no other differences emerged if a dose of 0.32 mg is used instead of 0.58 mg, in terms of selected outcome measures and rate of complications (P > 0.05). Conclusion: Underdosing collagenase clostridium histolyticum is equally effective in the treatment of Dupuytren's disease.

Unilateral immediate deep inferior epigastric artery perforator flap breast reconstruction following skin sparing mastectomy: A comparative study on revision surgeries to improve breast symmetry.

BACKGROUND: The number of revision surgeries to improve breast asymmetry after deep inferior epigastric perforator (DIEP) flap breast reconstruction is still high worldwide with impact on both patients and healthcare systems. These procedures include fat grafting, contralateral breast symmetrization, scar revision, flap repositioning and remodeling. A previously published DIEP flap insetting algorithm has proven to be effective in selecting patient-tailored strategies to achieve excellent aesthetic outcomes. This study investigated whether this insetting algorithm was effective in reducing revision surgeries in patients undergoing SSM and immediate DIEP flap breast reconstruction to achieve the goal of a one-stage reconstruction. METHODS: This retrospective case-control study included 60 patients (group A) treated without the DIEP flap standardized insetting algorithm and 60 patients (group B) treated with the standardized insetting algorithm, which considers among its variables the type of breast to be reconstructed, abdominal tissue thickness, rotation due to harvesting side. Demographic data, operative data, complications and number of revision surgeries were recorded. RESULTS: One hundred and twenty primary and 106 revision surgeries were performed. Groups were homogenous for age (p = .32), body mass index (p = .77), flap weight (p = .7), operative time (p = .87) and early complications (p = .78). When excluding isolated nipple reconstruction from the revision surgeries, one-stage reconstruction was successfully performed in 26 patients in group A (43.3%) and 39 patients (65.0%) in group B, with a statistically significant difference between the groups (p = .003). CONCLUSIONS: The introduction of a standardized insetting algorithm for immediate unilateral DIEP flap breast reconstruction can be effective in reducing the number of revision surgeries for breast asymmetry, making a one-stage reconstruction an achievable and reliable target.

The profunda artery perforator flap for upper limb reconstruction: A case report and literature review on the flap applications in reconstruction.

The profunda femoris artery perforator (PAP) flap has been recently popularized as an alternative option for microsurgical reconstruction. The use of PAP flap has never been reported and described for reconstruction of the upper extremities, in particular the forearm. The purpose of this case report is to describe a case suggesting the PAP flap as a further reconstructive option in the upper limb. A 16-year-old girl who sustained a traumatic injury to her right dominant forearm resulting in subtotal circumferential tissue loss following a road traffic accident was referred to the authors' department 2 years post-trauma. The disabling fibrotic sequelae on her volar forearm (15 × 10 cm) resulted in a nonfunctional hand. She was unable to perform any active movement of her wrist or digits. Passive movements in the finger joints were preserved. Following debridement and reconstruction of nerves and tendons, soft tissues were resurfaced with a PAP flap. The transverse skin paddle, 12 × 7 cm, was placed distally with the adipofascial portion positioned proximally above the muscle bellies and anastomoses site. A small raw area (4 × 3 cm) was covered with an acellular dermal matrix (ADM). The postoperative course was uneventful. At 9 months postoperatively, the patient demonstrated active flexion and extension of the fingers with independent function. The patient reported satisfaction with the flap donor site and forearm resurfacing. The PAP flap can be a further option for areas requiring soft tissue coverage in patients refusing visible scars. This flap had both the advantage of reducing the morbidity and visibility of the donor site, as well as the ability to resurface a large recipient site with soft and pliable tissue, covering exposed nerves and tendons.

Breast reconstruction using the profunda artery perforator (PAP) flap: Technical refinements and evolution, outcomes, and patient satisfaction based on 116 consecutive flaps.

INTRODUCTION: When a deep inferior epigastric artery flap is not suitable, the profunda artery perforator (PAP) flap can be a good alternative for autologous breast reconstruction. Popularity of the PAP flap is expanding, but it is still only slowly being adopted worldwide. We report our experience with 116 consecutive PAP flaps showing refinements and evolution of the technique towards improvement in outcomes and patients' satisfaction. METHODS: We prospectively collected data from consecutive PAP flap breast reconstructions performed from 2016 to 2019. Patients' demographics, pre-, intra-, postoperative data, and revision procedures were analyzed. The BREAST-Q and a specific questionnaire investigating outcomes at the donor site were completed preoperatively and 12 months postoperatively. RESULTS: One-hundred and sixteen PAP flaps were performed in 86 patients, 64 unilateral and 22 bilateral breast reconstructions. Mean body mass index was 24.72 kg/m2 (range 18.9-29.2) and mean flap weight was 251.30 g (range 152-455 g). Complications included donor site hematoma (1.7%), seroma (2.6%), fat necrosis (1.7%), and wound dehiscence (2.6%). No arterial/venous thrombosis nor flap losses were recorded. Patients reported high satisfaction in all BREAST-Q domains, with mean postoperative scores being higher than preoperative ones, suggesting a positive effect in quality of life and satisfaction. Scores were significant in the satisfaction with breast domain (p = 0.0016). CONCLUSIONS: Breast reconstruction with PAP flap yields a high success, low complications, and excellent cosmetic outcomes in the breast and donor sites. It improves patients' satisfaction and quality of life; hence, it can be considered an excellent option for autologous breast reconstruction.

Inferior gluteal artery perforator (IGAP) flap versus profunda artery perforator (PAP) flap as an alternative option for free autologous breast reconstruction.

BACKGROUND: When patients are unsuitable for deep inferior epigastric perforator (DIEP) flap breast reconstruction, the inferior gluteal artery perforator (IGAP) flap has been used as an alternative option. However, the profunda artery perforator (PAP) flap is also gaining popularity as an alternative to the DIEP flap for several reasons. This retrospective cohort study compares baseline characteristics, peri- and post-operative outcomes following IGAP flap and PAP flap breast reconstructions after mastectomy for cancer. METHODS: In a single center in the UK, from September 2008 through December 2016, 43 women underwent IGAP Flap(s) breast reconstruction and 51 received PAP flap(s) breast reconstructions. Statistical analysis was performed to compare baseline, peri-operative and post-operative variables between the two reconstruction methods. RESULTS: Perioperative complications requiring reoperation were experienced in women undergoing IGAP flap breast reconstructions only (21% versus 0%, p = 0.001), principally due to the risk of total flap failure (12% versus 0%, p = 0.01). Women undergoing IGAP flap breast reconstructions were at significantly higher odds of revision surgery (OR 17 [95% CI: 5.5-53], p < 0.001), which was unchanged after adjusting for bilateral reconstructions (adjusted OR 18 [95% CI: 5.3-58], p < 0.001). CONCLUSIONS: PAP flaps appear to be associated with significantly fewer complications and revision surgeries than IGAP flaps for breast reconstruction in women undergoing mastectomy for cancer and who are unsuitable for a DIEP flap breast reconstruction.

Safety of Reconstructive Microsurgery in the Elderly Population: a Multicentric Prospective Study.

BACKGROUND: Safety of reconstructive microsurgery in elderly patients is still a topic of debate, because no conclusive evidence exists that provides indications and risk evaluation in elderly patients. The purpose of this study, which the Italian Society for Plastic, Reconstructive, and Aesthetic Surgery (SICPRE) has promoted, is to evaluate the safety and the complication risk of elective reconstructive microsurgery in elderly patients as well as to identify patient- or procedure-related risk factors. The secondary aim is to evaluate the predictive role for complications of the Geriatric 8 score (G8). METHODS: A total of 194 consecutive patients from 18 centers, aged 65 or older, who received an elective microsurgical flap between April 2018 and April 2019 were prospectively evaluated. Patient-related, treatment-related, and outcomes data were recorded and statistically analyzed through multiple-adjusted logistic regression models. RESULTS: Our study showed an increased risk of complications and a longer hospitalization in patients aged ≥75 years with the American Society of Anesthesiologists (ASA) score ≥3 (or G8 score ≤11) as compared to patients >65 years of age and <75 years of age who undergo reconstruction with a microsurgical flap. Instead, flap survival did not significantly vary with age, but was associated only with ASA score ≥3 (or G8 score ≤11) and surgeries that last longer than 480 min; however, flap survival (92.3%) was slightly lower than that commonly reported for in the general population. CONCLUSIONS: Reconstructive microsurgery in the elderly is generally safe. The ASA score is easier and quicker than the G8 score and equally useful for risk stratification.

Superficial peroneal nerve accessory artery (SPNAA) flap for head and neck reconstruction: A cadaveric anatomical study and retrospective case series review.

BACKGROUND: Several different flaps can reconstruct intraoral defects or lower limb deficits after free fibula osteo-cutaneous flap harvesting for jaw reconstructions. However, commonly used options may not be available for various reasons and can be associated with significant morbidity. We hypothesized that flaps supplied by the superficial peroneal nerve accessory artery (SPNAA) could be a viable alternative reconstructive option. METHODS: We describe the SPNAA's anatomy using 20 human cadaveric leg dissections and report eight cases involving SPNAA-based perforator flap reconstructions (six propeller flaps and two free flaps) in a retrospective case series. Patient-specific baseline variables and intraoperative and postoperative outcomes are described. RESULTS: Cadaveric dissection suggests that the location of the SPNAA is reliable but its origin varies, with 40% (N = 8) of SPNAAs being of type I origin, 20% type II (N = 4), and 40% (N = 8) type III in our series. All reconstructions were successful. No intraoperative complications occurred during propeller or free-flap reconstructions. No flap failures occurred. One propeller reconstruction showed distal superficial skin necrosis and one donor site wound dehisced; both were successfully managed conservatively. No other short-term or long-term complications occurred. CONCLUSIONS: Flaps based on SPNAA perforators appear effective, reliable, and safe reconstructive methods for covering fibula osteocutaneous donor site defects and for intraoral reconstructions. Controlled trials are required to compare its effectiveness and safety with other reconstructive methods.

Compartmental Surgery With Microvascular Free Flap Reconstruction in Patients With T1-T4 Squamous Cell Carcinoma of the Tongue: Analysis of Risk Factors, and Prognostic Value of the 8th Edition AJCC TNM Staging System.

Compartmental surgery and primary reconstruction with microvascular free flaps represent the gold-standard in the treatment of oral tongue squamous cell carcinoma (OTSCC). However, there are still unclear clinical features that negatively affect the outcomes. This retrospective study included 80 consecutive patients with OTSCC who underwent compartmental surgery and primary reconstruction by free flap. The oncologic outcomes, the reliability of the 8th edition American Joint Committee on Cancer (AJCC) staging system and the prognostic factors were evaluated. Fifty-nine males and 21 females (mean age 57.8 years, range 27-81 years) were treated between November 2010 and March 2018 (one patient had two metachronous primaries). Seventy-one patients (88.75%, 52 males, 19 females, mean age of 57.9 years, range of 27-81 years) had no clinical history of previous head and neck radiotherapy and were considered as naive. Histology showed radical surgery on 80/81 lesions (98.8%), with excision margins >0.5 cm, while in 1 case (1.2%), a close posterior margin was found. According to the 8th AJCC classification, 37 patients (45.7%) were upstaged shifting from the clinical to the pathological stage, and 39 (48.1%) showed an upstaging while shifting from the 7th to the 8th AJCC staging system (no tumors were downstaged). Nodal involvement was confirmed in 33 patients (40.7%). Perineural and lymphovascular invasion were present in 9 (11.1%) and 11 (13.6%) cases, respectively. Twenty-two patients (27.1%) underwent adjuvant therapy. The 5-years disease-specific, overall, overall relapse-free, locoregional relapse-free and distant metastasis-free survival rates were 73.2, 66.8, 62.6, 67.4, and 86%, respectively. Patients with a lymph node ratio >0.09 experienced significantly worse outcomes. Univariate analysis showed that patients with previous radiotherapy, stage IV disease, nodal involvement, and lymphovascular invasion had significantly worse outcomes. Multivariate analysis focused naive patients and showed that lymphovascular invasion, advanced stage of disease, and node involvement resulted reliable prognostic factors, and patients with the same tumor stage and histological risk factors who did not undergo adjuvant therapy experienced significantly worse outcomes. In our series, surgery played a major role in the treatment of local extension; adjuvant therapy resulted strictly indicated in patients with advanced-stage disease associated with risk factors.

New Keystone flap application in vulvo-perineal reconstructive surgery: A case series.

OBJECTIVE: This study aimed to evaluate the application of the Keystone flap technique and the long-term results of vulvovaginal reconstruction after vulvar surgery. METHODS: This is the first case series describing the application of the Keystone perforator island flaps (KPIF) technique to close a wide defect after radical vulvectomy. We prospectively collected patient demographics, operative times, complications, pathologic results, and length of stay on all patients. The benefits, cosmetic results and satisfaction of patients were analyzed in the follow up. RESULTS: Five patients were selected for the study: four underwent radical vulvectomy for squamous cell vulvar cancer, and one underwent vulvar wide excision for Paget disease followed by reconstruction with the Keystone flap technique. The defects were successfully covered by the Keystone flap technique in all patients. CONCLUSIONS: Keystone flaps seem to be easy to design and elevate, and it offers rapid fasciocutaneous closure in wide vulvo-perineal defects with excellent long-term results.