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.

Central Mound Technique in Oncoplastic Surgery: A Valuable Technique to Save Your Bacon.

INTRODUCTION: Breast-conserving surgery (BCS) is a valid method for the reconstruction of partial breast defects, however, there is a great variety of final aesthetic outcomes depending on the location of the tumor in the breast and also on the initial breast volume and the degree of ptosis. Specifically, defects affecting the upper inner/central quadrant represent a reconstructive challenge with not always satisfactory final results. For this purpose, the authors investigated the use of the central mound technique in breast-conserving surgery. The aim of the study was to apply the central mound as an oncoplastic technique and assess the satisfaction rate of the patients. MATERIALS AND METHODS: This was a retrospective study that involved 40 patients (80 breast) underwent breast conserving surgery and contextual bilateral breast remodeling with central mound technique. A pre- and postoperative Breast-Q questionnaire (breast conserving therapy module) was given to all the patients before the surgery, 3 months and 9 months after. The statistical analysis with chi-square test was performed. RESULTS: After 9 months the author found a major increase of all BREAST-Q parameters; the most valuable increments concerned the "Satisfaction with breast" and "Psychosocial well-being." None of the patients experienced a decreased in the quality of life related to the surgical procedure. CONCLUSION: The authors believe that this technique has useful functional and aesthetic results particularly appreciated by patients with upper pole lesion who have a slightly or moderately breast ptosis and a small cup size.

5% Lidocaine Hydrochloride Cream for Wound Pain Relief: A Multicentre Observational Study.

BACKGROUND: Lidocaine hydrochloride is frequently used for management of painful wounds. This prospective, multicentre study examined the effects of 5% lidocaine cream on wound pain relief. MATERIAL AND METHODS: The study included 78 patients with painful wounds treated with 5% Lidocaine cream for two weeks in two Italian Hospitals. Patients' perception of pain was recorded by, using the 5-point Visual Rate Scale and the 11-point Numerical Pain Rating Scale. All medications and adverse events were evaluated in a daily diary. The primary outcome of the study was establishing the wound pain relief based on the results of 5-VRS and pain intensity based on the 11-NPRS testing from baseline to the end of treatment. Clinical aspects and adverse events were also collected. RESULTS: Seventy-eight patients had a median age of 67.5 years (range 18-96 years). 62.8% were women. The wounds included traumatic wounds (n = 39), venous ulcers (n = 25), post-surgical wounds (n = 6) pyoderma gangrenosum (n = 6), vasculitis (n = 1) and pressure ulcer (n = 1). The intensity of pain significantly decreased from the baseline level established at the beginning of treatment (mean score 6.7 - 1.90) - to the level at end of treatment (3.0 - 2.23-; p < 0.0001). 9 patients prematurely stopped the treatment for healing (n = 4), wound improvement (n = 2) and adverse events related to the treatment. (n = 3). 13 patients presented a total of 25 adverse events, 4 of them were related to the treatment. CONCLUSION: The treatment of painful wounds with 5% Lidocaine Cream for 14 days resulted in reduced pain intensity, and showed high safety and tolerability.

Prognostic significance of unexplained left ventricular hypertrophy in patients undergoing carpal tunnel surgery.

AIMS: Carpal tunnel (CT) syndrome is a recognized red-flag of cardiac amyloidosis (CA) and increased cardiovascular (CV) morbidity. We designed this study to characterize the CV profile of patients with CT syndrome at the time of first surgery and to identify high-risk presentations. METHODS AND RESULTS: We retrospectively reviewed 643 patients who underwent CT surgery between 2007 and 2019. Of them, 130 patients (77 years, 45% male patients, left ventricular ejection fraction 62%) with available CV characterization within ±12 months from CT surgery were included. Abnormal loading conditions causing cardiac left ventricular hypertrophy (LVH) were investigated to distinguish explained LVH (Ex-LVH) from unexplained LVH (Un-LVH). LVH was found in 66 (51%) patients, 33% of them presented Un-LVH. Compared with the others, Un-LVH patients were older (77 and 75 vs. 70 years in Un-LVH, Ex-LVH, and non-LVH, respectively; P = 0.002), had higher rates of electrocardiogram-echo discrepancy (70%, 14.3%, and 1.6%, respectively; P < 0.001) and of echocardiographic findings of CA (24%, 7%, and 0%, P < 0.001). Among Un-LVH patients, 9 (43%) experienced death and 7 (33%) developed heart failure (HF) at 3.8 and 2.4 years from CT surgery, respectively. Compared with the others, death and HF development rates were higher in Un-LVH patients both at unadjusted (P = 0.01 and P = 0.02, respectively) and adjusted analysis for age, gender, and renal insufficiency (P = 0.00038 and P = 0.050, respectively). CONCLUSIONS: At the time of CT surgery, Un-LVH was found in more than 30% of patients with LVH, and 24% of them showed echocardiographic features suggesting an underdiagnosed CA. Un-LVH was associated with higher all-cause mortality and HF development.

Protocol for Prevention and Monitoring of Surgical Site Infections in Implant-Based Breast Reconstruction: Preliminary Results.

Surgical site infection in implant-based breast reconstruction is a complication with variable incidence reported in the literature. Due to potential loss of implant and reconstruction, it can have a strong psychological impact on patients. Background and objectives: This study aimed primarily at analyzing the current status of the surgical site infection (SSI), (type, time of onset, clinical presentation, pathogens and management) in patients who underwent implant-based breast reconstruction at our Breast Unit. Secondarily, we wanted to establish whether introduction of a new, updated evidence-based protocol for infection prevention can reduce SSI in implant-based breast reconstruction. Materials and Methods: A single-center retrospective study was performed primarily to evaluate the incidence and features of SSI after implant-based breast reconstruction from 2007 to 2020. In June 2020, a protocol for prevention of SSI in implant-based breast reconstruction was introduced in clinical practice. Secondarily, a data analysis of all patients who underwent implant-based breast reconstruction in compliance with this protocol was performed after preliminarily assessing its efficacy. Results: 756 women were evaluated after mastectomy and implant-based breast reconstruction for breast cancer. A total of 26 surgical site infections were detected. The annual incidence of SSI decreased over time (range 0-11.76%). Data relating to infections' features, involved pathogens and implemented treatments were obtained. Since the introduction of the protocol, 22 patients have been evaluated, for a total of 29 implants. No early infections occurred. Conclusions: Surgical site infection rates at our Breast Unit are comparable to those reported in the literature. The SSI rates have shown a decreasing trend over the years. No SSI has occurred since the introduction of the prevention protocol for surgical site infection in June 2020.

Middle-retroauricular Island Flap: A New Axial Flap for Reconstruction of Non-helical Ear Defects.

Surgical treatment of ear carcinomas needs the selection of the appropriate reconstructive techniques, which depends on the location and the dimensions of the defect after excision of the cancer and the quality of blood supply to the peri-lesional skin. The aim of this study was to evaluate the efficacy and reliability of a new axial island retroauricular flap (middle-retroauricular island flap M-RIF) for coverage of non-helical ear defects with direct donor site closure. METHODS: All patients, from January 2013 to January 2020, with skin tumors of the non-helix region and undergoing a combined skin-cartilage excision with M-RIF local flap reconstruction under local anesthesia, were enrolled in the study. RESULTS: 18 patients (14 men and 4 women) underwent auricle skin-cartilage excision and M-RIF flap reconstruction. The mean age was 65 years (range, 60-85); the type of primary lesions were 12 BCC and 6 SCC. One flap wound dehiscence and one donor site infection and partial necrosis of the posterior auricular skin occurred; no other complications were recorded. CONCLUSIONS: The M-RIF flap is a valid surgical option when dealing with non-helical defects of the anterior pinna. It allows the reconstruction of the defect of the entire anterior surface of the auricle apart from the helix and the lobe and primary donor site closure.

New Algorithm for Chest-wall Surgery and Quality of Life Assessment in Female-to-male Reassignment Patients.

BACKGROUND: Chest-wall contouring surgery (chest-wall reconstructive surgery) is often the first surgical procedure in female-to-male (FtM) gender reassignment surgery (GRS). The main goal of this procedure is to create an aesthetically pleasing male-like chest contour. No universally accepted algorithm exists for detection of the appropriate surgical technique. Also, there is no tool for objective evaluation of the quality of life and satisfaction of these patients after the operation. METHODS: This study involves a single-center clinical trial assessing the patients who underwent subcutaneous mastectomy in FtM GRS between 2003 and 2019. The selection of patients was based on the new "simplified" algorithm consisting of 2 different surgical techniques: the semicircular and the double-incision with free nipple grafting. The selection was based on 3 criteria: breasts size, breast ptosis, and skin elasticity. The outcomes and complication rates were collected and analyzed. The patients' satisfaction and Quality of Life was assessed with a 5-point Likert scale questionnaire, specifically conceived for FtM patients. The aesthetic evaluation was performed using a 5-point Likert scale dealing with the 5 items featuring as the main goals of GRS. RESULTS: 184 mastectomies were performed in 92 FtM GRS patients. The overall reoperation rate was 11.9%. The patient survey revealed both a high satisfaction rate and a good aesthetic result (4.4/5). CONCLUSIONS: The proposed algorithm facilitates the selection of the most suitable technique for top surgery. The patient satisfaction rate evaluated by the proposed Health-Related Quality of Life questionnaire confirmed the outcomes of the use of the algorithm. Further studies to validate the proposed evaluating tools are needed.

Reconstruction of penile skin loss using a combined therapy of negative pressure wound therapy, dermal regeneration template, and split-thickness skin graft application.

This study evaluates the use of acellular dermal matrix (ADM) in conjunction with negative pressure wound therapy (NPWT) and delayed split-thickness skin graft (STSG) application as an alternative to free tissue transfer for defect coverage of the penile shaft. Five patients with genital lymphedema and one with penile skin deficiency underwent penile shaft reconstruction with a two-stage surgical procedure. The first procedure aimed to the correction of skin defect and to neodermis regeneration through the use of an ADM (Integra®, Integra Lifesciences Corp., Plainsboro, NJ, USA) and NPWT. The second procedure 3 weeks later aimed to the covering of the skin defect with an unmeshed STSG. Both the Integra and skin graft showed completely taking at 7 days postop. No major complications occurred. At 6 months grafts gained sufficient elasticity to allow the sliding of the epidermis over the dermal layer, similarly the physiological penile shaft skin. Our results suggest that combined therapy might be an alternative to free tissue transfer for defect coverage of the penile shaft, leading to a good esthetic result, an optimal shaft coverage and providing adequate extensibility during erections. For best results we advise that in these cases urologists should collaborate with plastic surgeons.

Reconstruction of the Weightbearing Area of the Foot with Vascularized Chimeric Osteocutaneous Fibular Flap: A Case Report.

Damage to the weightbearing surface of the foot is a challenge for the reconstructive surgeon. The aim is to reconstruct the skeletal tripod and soft tissue, allowing the patient to walk normally. We report the case of a patient admitted with an acute right foot open fracture of the second, third, fourth, and fifth metatarsal bones. After debridement of all nonvital tissues, the patient required reconstruction of the metatarsal heads (third, fourth, and fifth) plus soft tissue coverage. We then performed a reconstruction with a free osteocutaneous fibular flap, insetting the bone perpendicular to the long axis of the metatarsal bones. This configuration allowed the reconstruction of the foot skeletal tripod. A second free flap, a thin radial forearm flap, was added during the revision surgery to improve the venous drainage of the skin paddle of the fibular flap and avoid tension after skin closure. At 1-year follow-up, the patient was able to walk entirely weightbearing on the forefoot, returning to her previous employment with no limitation in physical and recreational activities. To our knowledge, this is the first description of the use of a chimeric osteocutaneous fibular flap, oriented transversely, to reconstruct a complex bone/soft tissue defect after a traumatic loss of multiple metatarsal heads.

How to Make Your Life Easier: Blepharoplasty Markings with Microsurgical Clamps.

Preoperative blepharoplasty markings might be challenging, especially for young surgeons. It takes experience to carefully evaluate the amount of skin excess that can be safely removed. In the current study, we explored the use of microsurgical vascular clamps as a novel and useful tool in the preoperative upper blepharoplasty markings; they made it possible to directly visualize the amount of skin to be removed, facilitating the surgeon (especially the young surgeon) preoperative markings process. In our series, 30 patients underwent upper blepharoplasty with preoperative application of microvascular clamps with satisfactory results.

Prognostic indicators of improved survival and quality of life in surgically treated oral cancer.

OBJECTIVE: No published study has analyzed the prognostic factors of surgically treated oral squamous cell carcinoma (OSCC) in relation to both survival and quality of life (QoL). The aim of this study was to analyze postoperative QoL in relation to survival to identify which parameters can predict the long-term outcome allowing the best QoL. STUDY DESIGN: This retrospective cohort study considered 167 patients affected by OSCC treated surgically at the Otolaryngology Department of Cattinara Hospital (Trieste, Italy) by a single surgeon. We collected data about the main prognostic factors and the postoperative QoL 12 month after surgery. RESULTS: The 5-year overall survival rate was equal to 68.1%, and the 5-year disease-specific survival was 77.8%. In this sample, 32% of patients also underwent adjuvant chemoradiotherapy. On stepwise Cox regression, the best predictors of disease-specific survival were the N stage (P < .001) and tumor depth of invasion (P < .001). QoL was affected by N stage, depth of invasion, invasive surgical approach, radiotherapy, and neck dissection (P < .05). CONCLUSION: The prognostic factors that affect both survival rates and residual QoL are the surgical approach, the neck stage, and the depth of invasion, all of which can be minimized by early diagnosis.

Leeching as Salvage Venous Drainage in Ear Reconstruction: Clinical Case and Review of Literature.

BACKGROUND: Ear avulsion is a rare complication of different traumas, such as car accidents, human or animal bites and stab wounds, and can result in dramatic cosmetic consequences for the patient. Ear replantation, revascularization, and reattachment are the options offering best aesthetic results. But venous outflow insufficiency is responsible for a high rate of failures. Leeching is one the most efficient methods to relieve venous congestion. It has been used as an alternative venous outflow in case of severe impairment of the physiologic one. METHODS: We present a case of successful rescue of a congested reattached ear by leeching after subtotal avulsion, along with a review of the literature on cases of avulsed auricle reconstruction salvaged by hirudotherapy. Data were collected and analyzed to identify a best regimen to deal with venous congestion. RESULTS: More than 130 cases of avulsed auricle savage are described in the literature, in a fourth of which leech therapy was used in the management of venous congestion. DISCUSSION: In case of both venous outflow deficit or absence, leeches are a potentially successful option to correct the congestion while new veins reestablish normal physiology. The need for anticoagulant/antiaggregant therapy, antibiotics, and often blood transfusion are the main pitfalls of leeching. CONCLUSION: Leeches can be considered a salvage method for ear replantation and reattachment in those cases that lack venous outflow in the presence of valid arterial inflow.

Is it possible to calculate surface areas of intraoral structures from preoperative CT scan?

Microsurgical reconstruction of intraoral structures requires accurate planning of flap shape and dimensions. The goal of this study is to describe a method that allows to calculate surfaces of oral structures from preoperative CT-scan in order to determine a precise flap design before the surgery. We created casts of the human mouth from cadavers with a head and neck CT-scan available using an impression material. We digitalized the mouth casts and unwrapped the surfaces of the different structures of the mouth in a bi-dimensional plane in order to measure the area. Furthermore, we measured distances from pre-determined bony landmarks using the CT-scan 3D reconstruction model and we correlated the two type of measurements. We performed a simple regression analysis and afterwards a multivariate analysis using the more statistically correlated measurements. We found a statistical correlation between the surface of the tongue and the surface floor of the mouth with three bone distances that let us to create three mathematical formulas. With those formulas, we can calculate the surfaces of the tongue and the floor of the mouth using simple bony distances that can be easily measured from the head and neck preoperative CT scan. Using standard template's layouts, we can create a precise preoperative flap design in the reconstruction of the tongue and of the floor of the mouth.