Utility of the Glabellar Flap in the Reconstruction of Medial Canthal Tumors after Mohs Surgery

The goals of periorbital region reconstruction are to obtain both functional and esthetic results. Medial canthus is the second most common periorbital location for basal cell carcinoma. If left untreated, it is locally destructive but rarely metastasizes. Incompletely resected medial canthal tumors recur or penetrate along the lacrimal path and expand to wider lesions. A safety margin is necessary to ensure a complete lesion resection. Since it was introduced in 1941, Mohs surgery has been promoted as an efficient method of dealing with infiltrative periorbital skin tumors. It has been shown to have high rates of complete cancer removal during surgery, minimizing the amount of normal tissue loss and securing better functional and cosmetic outcomes. Due to its concave contour and convergence of skin units with variable thickness, texture and mobility, reconstruction of the medial canthal region (MCR) remains challenging. Reconstructive methods such as free full-thickness skin grafts and glabellar flaps have been used alone or in combination with other techniques. The concavity of the canthus must be achieved, but the maintenance of the normal contour and symmetry of the surrounding tissue is critical. The glabellar flap (GF) is a triangular advancement flap that adequately restores the volume in deeper defects, guaranteeing sufficient vascular support without complex or undesirable scars. We present two cases of basal cell carcinoma affecting the MCR that was successfully reconstructed using a GF alone in one case and together with a cheek advancement flap in the second one. In both cases, tumor excision was performed using Mohs surgery.

Trends in flap reconstruction of pelvic oncologic defects: Analysis of the national inpatient sample.

BACKGROUND: Flap reconstruction of radiated pelvic oncologic defects decreases perineal wound-healing complications. How widely and how often reconstructions are performed, and how technical mastery and improved perioperative care has affected outcomes, is unknown. Our objective is to 1) provide a comprehensive evaluation of national trends in flap reconstruction of pelvic oncologic defects and 2) compare complications and length of stay (LOS) in patients with/without reconstruction. METHODS: The National Inpatient Sample (NIS) database was queried (1998-2014) for patients diagnosed with cancer, primarily of the rectum and anus, who underwent abdominoperineal resection (APR) or pelvic exenteration (PE). Differences in complications and LOS were compared between patients with flap reconstruction versus primary closure. Regional and hospital outcomes were also analyzed. RESULTS: The cohort included 117,923 adult patients; 3,673 (3.1%) underwent flap reconstruction. Flap reconstruction rates increased from 0.8% in 1998 to 9.8% in 2014. Extirpative procedures decreased 37.4% from 1998 to 2014. Flap reconstruction decreased risk of wound breakdown (OR 0.87; p = 0.0029) and need for secondary closure of dehiscence (OR 0.82; p = 0.0023) between periods 1998-2009 and 2010-2014. Median LOS was higher for flap patients (median [IQR] of 9.8 [7.2,14.8] vs. 7.9 [6.1-11.0; p < 0.0001) and decreased over time. CONCLUSIONS: The use of flap reconstruction for pelvic oncologic defects increased from 1998 to 2014, with a reduction in LOS. Following flap reconstruction, overall complications are higher, but wound breakdown and dehiscence requiring reclosure are decreasing, suggesting technique maturation. We anticipate flap reconstruction rates will increase with further improvement in patient outcomes.

Continuous dural suturing for closure of grade 3 leaks after tumor removal via an endoscopic endonasal approach.

Cerebrospinal fluid (CSF) leakage is a major complication after extended endonasal transsphenoidal surgery (EETSS), which is commonly used in the treatment of anterior skull base tumors. Dural suturing and graded reconstruction are promising techniques to further decrease the incidence of postoperative CSF (poCSF) leakage. The effect of continuous dural suturing in endoscopic surgery was investigated in this retrospective study. A total of 79 EETSS patients were included; the procedures were performed for subdural tumor removal by a single endoscopic neurosurgical team. Comparisons were applied between patients who did and did not undergo endoscopic dural suturing after tumor removal. Multivariate logistic regression analysis was performed to identify variables that significantly influenced the incidence of poCSF leakage. In all, 79 adult patients developed Esposito's grade 3 intraoperative high-flow CSF leakage. Ten patients (12.7%) experienced poCSF leakage. One of the 36 patients who underwent intraoperative dural suturing developed poCSF leakage, compared with nine of 43 patients who did not undergo dural suturing (p = 0.016). Regression analysis showed that dural suturing could significantly decrease the incidence of poCSF leakage (p = 0.049, OR 0.108, 95% CI 0.013-0.899). Prophylactic lumbar drainage could also help decrease the CSF leakage rate. Dural suturing under endoscopy is a promising and effective method for application in skull base reconstruction after subdural skull base tumor removal. With future progress, lumbar drainage and even nasoseptal flap placement could be replaced in certain groups of patients undergoing EETSS.

Long-term complications and implant survival rates after cranioplastic surgery: a single-center study of 392 patients.

Cranioplasty (CP) is a standard procedure in neurosurgical practice for patients after (decompressive) craniectomy. However, CP surgery is not standardized, is carried out in different ways, and is associated with considerable complication rates. Here, we report our experiences with the use of different CP materials and analyze long-term complications and implant survival rates. We retrospectively studied patients who underwent CP surgery at our institution between 2004 and 2014. Binary logistic regression analysis was performed in order to identify risk factors for the development of complications. Kaplan-Meier analysis was used to estimate implant survival rates. A total of 392 patients (182 females, 210 males) with a mean age of 48 years were included. These patients underwent a total of 508 CP surgeries. The overall complication rate of primary CP was 33.2%, due to bone resorption/loosening (14.6%) and graft infection (7.9%) with a mean implant survival of 120 ± 5 months. Binary logistic regression analysis showed that young age (< 30 years) (p = 0.026, OR 3.150), the presence of multidrug-resistant bacteria (p = 0.045, OR 2.273), and cerebrospinal fluid (CSF) shunt (p = 0.001, OR 3.137) were risk factors for postoperative complications. The use of titanium miniplates for CP fixation was associated with reduced complication rates and bone flap osteolysis as well as longer implant survival rates. The present study highlights the risk profile of CP surgery. Young age (< 30 years) and shunt-dependent hydrocephalus are associated with postoperative complications especially due to bone flap autolysis. Furthermore, a rigid CP fixation seems to play a crucial role in reducing complication rates.

CSF disturbances and other neurosurgical complications after interdisciplinary reconstructions of large combined scalp and skull deficiencies.

Combined scalp and skull deficiency due to malignant scalp tumors or sequelae of intracranial surgery present challenging entities for both neurosurgeons and reconstructive treatment. In complex cases, an interdisciplinary approach is needed between neurosurgeons and cranio-maxillofacial surgeons. We present a considerably large series for which we identify typical complications and pitfalls and provide evidence for the importance of an interdisciplinary algorithm for chronic wound healing complications and malignomas of the scalp and skull. We retrospectively reviewed all patients treated by the department of neurosurgery and cranio-maxillofacial surgery at our hospital for complex scalp deficiencies and malignant scalp tumors affecting the skull between 2006 and 2019, and extracted data on demographics, surgical technique, and perioperative complications. Thirty-seven patients were treated. Most cases were operated simultaneously (n: 32) and 6 cases in a staged procedure. Nineteen patients obtained a free flap for scalp reconstruction, 15 were treated with local axial flaps, and 3 patients underwent full thickness skin graft treatment. Complications occurred in 62% of cases, mostly related to cerebrospinal fluid (CSF) circulation disorders. New cerebrospinal fluid (CSF) disturbances occurred in 8 patients undergoing free flaps and shunt dysfunction occurred in 5 patients undergoing local axial flaps. Four patients died shortly after the surgical procedure (perioperative mortality 10.8%). Combined scalp and skull deficiency present a challenging task. An interdisciplinary treatment helps to prevent severe and specialty-specific complications, such as hydrocephalus. We therefore recommend a close neurological observation after reconstructive treatment with focus on symptoms of CSF disturbances.

Timing of cranial reconstruction after cranioplasty infections: are we ready for a re-thinking? A comparative analysis of delayed versus immediate cranioplasty after debridement in a series of 48 patients.

The optimal management of cranioplasty infections remains a matter of debate. Most authors have suggested that the infected bone/implant removal is mandatory, combined with prolonged antibiotic therapy before reconstruction. However, failures can occur, even with 12-18-month intervals between the surgeries. Longer wait times before cranial reconstruction increase the risks of socioeconomic burdens and further complications, as observed in decompressed patients hosting shunts. In our department, we treated 48 cranioplasty infections over a period of 8 years, divided into two groups. For Group A (n = 26), the treatment consisted of cranioplasty removal and debridement, followed by a delayed reconstruction. Group B (n = 22) received 2 weeks of broad-spectrum antibiotics, followed by an "aggressive" field debridement and immediate cranioplasty. All patients received a minimum of 8 weeks of post-operative antibiotic therapy and were scheduled for clinic-radiological follow-ups for at least 36 months. Significant differences were observed between Groups A and B with respect to the number of failures (respectively 7 versus 1), the global operative time (significantly longer for Group B), germ identification (respectively 7 versus 13), and the overall length of hospital stay (on average, 61.04 days in Group A versus 47.41 days in Group B). Three shunted patients in Group A developed sinking flap syndrome. Shunt resetting allowed symptom control until cranioplasty in one subject, whereas two did not improve, even after reconstruction. In selected patients, an aggressive field debridement, followed by the immediate replacement of an infected cranioplasty, may represent a safe and valuable option.

Prior smoking and nasoseptal flap usage adversely impact quality of life and healing after endoscopic pituitary surgery.

OBJECTIVE: Endoscopic pituitary surgery (EPS) via the endonasal transsphenoidal approach is well established as an effective treatment modality for sellar masses. The objective of this study was to determine the relationship between key patient and operative variables and rhinological outcomes as determined by the 22-item Sino-Nasal Outcome Test (SNOT-22) and endoscopic scores following EPS. METHODS: Prospectively collected SNOT-22 scores and objective endoscopic data were analyzed from a cohort of 109 patients who underwent EPS and had at least 90 days of postoperative follow-up. Trends in postoperative SNOT-22 scores were analyzed using linear mixed-effects models. Time to return to baseline endoscopic score was analyzed using Cox regression. RESULTS: After adjusting for age and sex, the authors found that prior smokers had higher total and rhinological subdomain SNOT-22 scores (p < 0.01, 95% CI 5.82-16.39; p = 0.01, 95% CI 1.38-5.09, respectively) following EPS. Nasoseptal flap use also showed higher total and rhinological subdomain SNOT-22 scores (p = 0.01, 95% CI 1.62-12.60; p = 0.02, 95% CI 0.42-4.30, respectively). Prior sinonasal surgery and concurrent septoplasty did not affect the change in SNOT-22 total scores over time (p = 0.08, 95% CI -0.40 to 0.02; p = 0.33, 95% CI -0.09 to 0.29). CONCLUSIONS: The findings suggest that the evolution of healing and patient-reported quality of life (QOL) measures are multifaceted with contributions from two key variables. Nasoseptal flap usage and prior smoking status may adversely impact postoperative QOL. No variables were found to be associated with objective postoperative endoscopic findings.

An investigation of factors associated with the development of postoperative bone flap infection following decompressive craniectomy and subsequent cranioplasty.

OBJECTIVE: After a decompressive craniectomy (DC), a cranioplasty (CP) is often performed in order to improve neurosurgical outcome and cerebral blood circulation. But even though the performance of a CP subsequent to a DC has become routine medical practice, patients can in fact develop many complications from the surgery that could prolong hospitalization and lead to unfavorable prognoses. This study investigates one of the most frequent complications, bone flap infection, in order to identify prognostic factors of its development. PATIENTS AND METHODS: In this single-center study, we have retrospectively examined 329 CPs performed between 2002 and 2017. Multiple categorical and metric parameters (e.g., timing of CP, bone flap material, specific laboratory signs of infection and reason for DC) were analyzed applying unadjusted and multivariable testing. RESULTS: Bone flap infection occurred in 24 patients (7.3%). A CP performed more than six months after a DC is associated with a significantly increased risk of infection (OR = 0.308 [0.118; 0.803], p = 0.016). However, with CPs performed after twelve months, the incidence decreases, but without provable statistical impact. In addition, bone flap infection is strongly related to the neurological outcome and the material used for the skull implant, with the use of synthetic bone flaps leading to a marked increase in the rate of infection (p < 0.001). CONCLUSIONS: This study supports the hypothesis that the risk of infection is higher the longer the elapsed time between DC and CP, especially if more than six months. Based on our results, the best DC-CP time frame for keeping the infection rate low is performing the CP within the first six months after the DC. In the event that the CP cannot be performed within the first six months, a CP performed twelve months or more after the DC seems to have a favorable outcome as well.

Volume of Brain Herniation After Decompressive Craniectomy in Patients with Traumatic Brain Injury.

BACKGROUND: The decompressive hemicraniectomy operation is highly effective in relieving refractory intracranial hypertension. However, one limitation of this treatment strategy is the requirement to perform a subsequent cranioplasty operation to reconstruct the skull defect-an expensive procedure with high complication rates. An implant that is capable of accommodated post-hemicraniectomy brain swelling, but also provides acceptable skull defect coverage after brain swelling abates, would theoretically eliminate the need for the cranioplasty operation. In an earlier report, the concept of using a thin, moveable plate implant for this purpose was introduced. METHODS: Measurements were obtained in a series of stroke patients to determine whether a plate offset from the skull by 5 mm would accommodate the observed post-hemicraniectomy brain swelling. The volume of brain swelling measured in all patients in the stroke series would be accommodated by a 5-mm offset plate. In the current report, we expanded our analysis to study brain swelling patterns in a different population of patients requiring a hemicraniectomy operation: those with traumatic brain injuries (TBI). RESULTS: We identified 56 patients with TBI and measured their postoperative brain herniation volumes. A moveable plate offset by 5 mm would create sufficient additional volume to accommodate the brain swelling measured in all but one patient. That patient had malignant intraoperative brain swelling and died the following day. CONCLUSIONS: These data suggest that a 5 mm offset plate will provide sufficient volume for brain expansion for almost all hemicraniectomy operations.

Rate of Craniotomy Fusion After Free Bone Flap.

BACKGROUND: Craniotomy has been performed in neurologic surgery for over a century. Replacement of free bone flaps in routine craniotomies is widely practiced, however, the rate of fusion after free flap replacement is unknown. OBJECTIVE: To assess timing and rate of fusion after routine craniotomies. METHODS: A retrospective cohort study of 2200 patients who underwent craniotomies from 2002 to 2005. Fusion rates and time to fusion were evaluated. When time to fusion was taken into consideration, univariate and multivariate analyses of the impact of clinical factors on fusion rate were also examined. RESULTS: Of 171 patients with postoperative computed tomography of over 2200 patients undergoing craniotomy, 103 (60%) demonstrated solid fusion, 26 (15%) had probable fusion, and 42 (25%) had not achieved fusion. There were no significant differences when fusion was compared with demographics such as age, sex, body mass index, and history of tobacco use. Radiation therapy had a significant impact on fusion: those receiving radiation were less likely to achieve fusion (P = 0.0082). The fusion rates at 12, 24, and 36 months after surgery were 15%, 41%, and 54%, respectively. CONCLUSION: As expected, craniotomy fusion rates after free flap replacement increased steadily over time. We were not able to demonstrate that clinical factors such as age, sex, body mass index, diagnosis, fixation material, and radiation had an impact on fusion rate when time to fusion was accounted for. Patients receiving radiation, however, experienced fusion less frequently. Because of the scarcity of previous studies in this area, this current study serves as a platform for future studies on fusion rates after free flap replacement.

Autologous Flap Transfer for Esophageal Stricture Prevention After Endoscopic Submucosal Dissection in a Porcine Model.

BACKGROUND: Esophageal stricture caused by endoscopic submucosal dissection for a mucosal defect that covers more than three quarters of the circumference of the esophagus has a high incidence. To date, no method for preventing such strictures has been widely recognized as effective in clinical practice. AIMS: We examined whether esophageal stricture caused by circumferential endoscopic submucosal dissection could be prevented by autologous flap transfer. METHODS: Six pigs (N = 6) underwent circumferential esophageal endoscopic submucosal dissection under general anesthesia. For animals in the flap group (N = 3), an autologous flap was constructed and then placed at the resection site and secured with metal clips. Animals in the control group (N = 3) underwent endoscopic submucosal dissection only. Endoscopy was performed 3 weeks postoperative to evaluate the effects of flap transfer. RESULTS: Animals in the flap group gained more weight than animals in the control group. At 3 weeks postoperative, animals in the flap group developed clinically slight stricture; in these animals, an endoscope could be passed through the stricture with slight resistance. In contrast, in the control group, significant stricture was observed, and the stricture was difficult to cross with an endoscope. CONCLUSION: Autologous flap transfer after circumferential esophageal endoscopic submucosal dissection is a novel approach that remarkably decreases the degree of esophageal stricture that arises.

Endoscopic Endonasal Reconstruction of Anterior Skull Base Defects: What Factors Really Affect the Outcomes?

OBJECTIVE: Endoscopic endonasal surgery has evolved in recent decades, requiring comparable advances in reconstructive techniques. This study aimed to retrospectively review outcomes of endoscopic anterior skull base reconstruction and to analyze factors associated with failures. METHODS: Data from patients who underwent endoscopic endonasal anterior skull base reconstruction in a single institution between 1998 and 2017 were collected. Patients were stratified according to selected risk factors: sex; age; previous surgery; disease treated (cerebrospinal fluid leaks, benign tumors, malignant tumors); single or multiple defects; defect dimension (<1 cm2, 1-2 cm2, 2-6 cm2, >6 cm2) and site (olfactory cleft, ethmoidal roof, planum sphenoidalis, posterior wall of frontal sinus); reconstruction technique (overlay graft, multilayer grafts, pedicled flap) and materials used; postoperative radiotherapy; and year of surgery. Statistical significance was assessed using Fisher exact test. Univariate logistic regression was implemented to analyze the association between risk factors and failures. RESULTS: Inclusion criteria were met by 513 cases with median follow-up of 96 months (range, 12-257 months). Success rate for initial repair was 95% (487/513), with 100% success rate for secondary closure after revision surgery. Failures were not significantly related to sex (P = 0.54), reconstruction technique (P = 0.28), location of defect (P = 0.65), dimension (P = 0.69), disease (P = 0.83), or postoperative radiotherapy (P = 0.83). Year of surgery, considered as a continuous variable, was associated with a statistically significant reduction of failures (odds ratio = 0.89, P = 0.005). CONCLUSIONS: Endoscopic surgery is safe and effective for anterior skull base reconstruction. Refinements in surgical technique and increasing experience have contributed to improved success rates.

Aseptic Bone Flap Resorption after Cranioplasty with Autologous Bone: Incidence, Risk Factors, and Clinical Implications.

OBJECTIVES: Aseptic bone flap resorption (ABFR) is a known complication of cranioplasty (CP) with an autologous bone flap. The incidence of ABFR has been reported to be as high as 34.2% in the literature; however, it is underestimated in clinical fields. We retrospectively reviewed 13 years of clinical cases of patients who underwent CP after decompressive craniectomy (DC) to investigate the incidence and risk factors of ABFR. METHODS: Ninety-one patients who underwent DC and CP in Guro Hospital, Korea University Medical Center, were enrolled. ABFR was defined using serial brain computed tomography. To identify possible risk factors for ABFR, univariate and multivariate Cox regression and receiver operating characteristic curve analyses were performed. RESULTS: Of the 91 patients enrolled, ABFR was diagnosed in 32 patients (35.1%). Bone flap size, existence of a shunting system, and the DC-CP interval were significant in the univariate analysis. Bone flap size was statistically significant in the multivariate analysis (P = 0.0189). The cutoff points of the DC-CP interval and bone flap size were 44 days and 110 cm2, respectively. CONCLUSIONS: The incidence of ABFR was remarkably high. Bone flap size, the existence of a shunting system, and the DC-CP interval were shown to be potential risk factors of ABFR after CP.

Early Cranioplasty Benefits Patients with Obvious Bilateral Frontotemporal Bone Window Collapse After Decompressive Craniectomy.

OBJECTIVE: Obvious skin flap collapse is often accompanied by reduced neurologic recovery after decompressive craniectomy. This study explored the feasibility of early cranioplasty (EC) in patients with obvious bilateral frontotemporal bone window (BFBW) collapse after decompressive craniectomy. METHODS: Patients with obvious BFBW collapse who underwent EC or traditional cranioplasty (TC) were divided into 3 groups according to their preoperative Glasgow Coma Scale (GCS) scores. The indexes, including postoperative incision healing, salivation symptoms, postoperative infection, and 6-month postoperative follow-up after EC or TC, were compared in each group. RESULTS: Two of 32 patients with GCS scores of 3 to 8 points experienced poor healing of the scalp incision after EC, whereas no TC patients had poor healing. Incision healing significantly differed between these 2 groups (P > 0.05), and long-term prognoses based on GOS scores were the same after a 6-month postoperative follow-up (P > 0.05). In patients with GCS scores of 9 to 12 points, salivation improved by 84.2% and 17.6% in the EC and TC groups, respectively (P < 0.05) after a mean follow-up time of 6 months. Similarly, positive neurologic recovery rates (GOS score 4-5 points) were higher in the EC group (88.9%) than in the TC group (60.0%) (P < 0.05) and did not differ between the EC (79.3%) and TC (80.6%) groups in patients with GCS scores of 13 to 15 points (P > 0.05). However, salivation improved by 86.7% in the EC group but by only 12.5% in the TC group (P < 0.05). CONCLUSION: We therefore recommend EC for patients with obvious BFBW collapse and GCS scores ≥9.

Breast Reconstruction: A Century of Controversies and Progress.

Breast cancer treatment has dramatically changed over the past century. Since Halsted's first description of radical mastectomy in 1882, breast reconstruction has evolved slowly from being considered as a useless or even dangerous procedure by surgeons to the possibility nowadays of reconstructing almost any kind of defect. In this review on the development of breast reconstruction, we outline the historical milestone innovations that led to the current management of the mastectomy defect in an attempt to understand the economic, social and psychological factors, which contributed to slow down its acceptance for several decades.

Stentless mirrored L-shaped septonasal flap versus stented flapless technique for endoscopic endonasal repair of bilateral congenital choanal atresia: a prospective randomised controlled study.

OBJECTIVES: To compare the outcomes of endoscopic repair of bilateral congenital choanal atresia using a flap technique without stenting versus endoscopic repair using stenting without a flap. METHODS: A prospective randomised controlled study was conducted, comprising 72 patients with bilateral congenital choanal atresia. The patients were randomised into two groups. Group A (42 patients) underwent endoscopic repair using a mirrored L-shaped flap without stenting, and group B (30 patients) underwent endoscopic repair using stenting without a flap. RESULTS: At a mean follow-up period of 18.2 months, endoscopic assessment revealed a patent posterior choana in 81 per cent and 83.33 per cent of patients in group A and group B respectively. Choanal stenosis occurred in 21.40 per cent and 33.33 per cent of patients in group A and group B respectively. Granulation tissue was observed in 28.6 per cent and 53.3 per cent of patients in group A and group B respectively. CONCLUSION: The endoscopic approach utilising a flap without stenting is safe and effective, with a high success rate.