Awake Breast Conservative Surgery: A Strategy to Shorten Surgical Waiting Lists During and Post COVID-19 Emergency.

BACKGROUND/AIM: SARS-CoV-2 with a dramatical worldwide spread, impacted greatly daily life and healthcare. In order to avoid delay in cancer treatment, many strategies and measures were implemented. The Awake breast surgery was a strategy implemented in our Unit during the pandemic, aimed to reduce operatory room occupancy and increase the number of procedures performed during the daily surgical session. The aim of the study was to evaluate how the use of this strategy has changed before and after the advent of the COVID-19 pandemic, and its relative benefits. PATIENTS AND METHODS: This was a retrospective study analysing all patients subjected to breast conservative surgery for oncological disease from July 2018 to December 2021. RESULTS: Out of 498 patients enrolled in the study, 253 (50.8%) cases were treated before the pandemic and were designated as "pre-COVID-19" group. The remaining 245 (49.1%) cases were considered the "COVID-19" group. Cases of awake surgery in COVID-19 group were 141 (54.7%) vs. 84 (33.2%), p<0.001. Length of hospitalization and surgical time were comparable between the groups: relative p=0.188 and 0.264, respectively. Differently, operation room occupation was significantly shorter in the COVID-19 group, p<0.001; and number of outpatient surgical procedures was higher, p=0.0304. Multivariate analysis identified the period of surgery (OR=1.47) as a statistically significant factor, p=0.011, predictive of prolonged operatory room occupancy. CONCLUSION: Awake surgery was one of the strategies which made more operating rooms available and allowed avoiding further delays.

Combined surgical approach retromandibular and intraoral to subcondylar mandibular fractures.

BACKGROUND: Condylar and subcondylar fractures are very common and account for at least one third of all mandibular fractures. In literature, little agreement exists about the management of extracapsular condylar and subcondylar fractures in adults. Some studies provide better results of occlusion, masticatory function, mouth opening, and bone morphology with surgical treatment. Conversely, other studies report excellent results with conservative treatment avoiding complications such as facial nerve injury and unsightly scar. METHODS: In this study, we report our experience of 25 condylar/subcondylar fractures. We report the case of a man with bilateral subcondylar fractures treated by a double surgical approach, intraoral and retromamdibular. Intraoral approach lets us dissect the masseter and disconnect the temporal muscle tendon, thus favoring further reduction of fracture stumps, whereas retromandibular approach favors a good operative field and the positioning of titanium microplate. RESULTS: Postoperative monitoring reported good results of occlusion. Postoperative computed tomographic scans show the good reduction and positioning of titanium miniplate.

Treatment of N in the upper maxillary tumors.

From 2002 to 2008, 86 patients have undergone surgical treatment of malignant upper maxillary tumors at the Maxillo-Facial Surgery Department, Tor Vergata University, Rome. All the N-positive patients at the time of the T therapy have undergone lymph node surgical emptying. In 6 patients, a laterocervical emptying was performed when laterocervical metastases were found. In the remaining 68 patients, with no evidence of N, we did not perform laterocervical emptying. We found in our patients a high percentage of cervical metastasis in T2 squamous cell carcinoma of the maxilla (32.1%). In this article, the authors present the results of their experience in treating N in upper maxillary tumors. This research study highlights some important aspects that have to be considered. Squamous cell carcinoma of the maxilla extending to the oral cavity (T1-T2) shows a higher laterocervical lymphophily than the superoposterior ones (T3-T4). Presence or appearance of lymph node metastases is a high-malignancy index, with a subsequently very negative prognosis. Considering the large percentage of cervical recurrences in T1-T2 squamous cell carcinoma of the maxilla that spread up in the hard palate mucosa and upper gum and the consequently high morbidity, performing a prophylactic laterocervical emptying in these patients could be advisable. Even in the recent literature, we found opinion in favor of this behavior.

Central giant cell granuloma of the jaws.

Central giant cell granuloma was classified by the World Health Organization in 2005 as a rarely aggressive idiopathic benign intraosseous lesion that occurs almost exclusively in the jaws. It occurs most frequently in young women (aged <30 y). This osteolytic lesion histologically consists of proliferation of fibrous tissue, hemorrhagic focuses, hemosiderin deposits, osteoclast-like giant cells, and reactive bone formation. Differential diagnosis has to be made with other osteolytic neoformations of the jaws, both unicystic and multicystic (odontogenic tumors, fibrous dysplasia, cysts, etc). From 2002 to 2008, we surgically treated 8 cases of giant cell granuloma. Our article focuses on a 59-year-old woman who came to our department with a swelling on the right side of the face. Computed tomography examination showed an osteolytic and expansive neoformation spreading up from the lateral wall of the nose to the anterior wall of maxillary sinus and above up to the inferior margin of the eye socket. Besides, it was contiguous to the canine root apex, the first and second bicuspids. Intraoral incisional biopsy confirmed the histologic picture of central giant cell granuloma. After a few days, she underwent surgical excision of the neoformation, preserving the lateral wall of the nose, the anterior wall of maxillary sinus, the eye socket, and the dental elements, respectively. Results of the histopathologic examination confirmed the previous biopsy. A follow-up at 30 months excluded any relapse.

Intraosseous hemangiomas.

Intraosseous hemangiomas are classified as benign tumors of vascular nature. Some authors describe them as hamartomas. They originate and expand inside bone structures. They are usually congenital, rarely of posttraumatic origin. In the Maxillo-Facial Surgery departments of the Universities of Rome "La Sapienza" and "Tor Vergata," from 1990 to 2004, 11 cases of intraosseous hemangioma have been diagnosed. In 6 cases, the neoplasm localized in the zygomatic region; in 3 cases, at the mandible level; in 1 patient, in the maxillary site; and in 1 patient, in the frontal bone. Literature review and the case of a male patient affected by left orbitozygomatic hemangioma are described.

Reconstruction of premaxilla with fibula free flap.

The reconstruction of the maxilla after surgical excision of malignant neoplasms has always presented significant difficulties. The excision of the premaxillary region involves considerable aesthetic and functional problems and, thus, presents particular reconstructive difficulties. The difficulties in the reconstruction of this area are related to the advanced anterior position and to the structural complexity of the premaxilla. In addition, soft tissue reconstructions, which might be used potentially to create an oral-nasal diaphragm, are often functionally and aesthetically unsatisfactory. Microvascular options have dramatically improved the reconstructive possibilities. Among free flaps, the fibula, scapula, and iliac crest are most used in the reconstruction of the upper jaw because of their advantageous compositional characteristics and plasticity. In our experience, however, the fibula free flap has emerged as the best reconstructive option for the premaxillary region because of the length of the pedicle, the flexibility and good quality of the bone, the reduced bulk of the soft tissue, and the low potential for problems at the donor site.

Use of microvascular free flaps in the reconstruction of the anterior and middle skull base.

Different reconstruction techniques of the anterior and middle skull base as consequence of a defect after surgical treatment of neoplastic pathologies are described in the literature. The aim of the present study is to present our experience regarding the use of microvascular free flaps for reconstruction of the anterior or middle skull base after large defects caused by removal of malignant neoplasms. From 2000 to 2004, in the Department of Maxillo-Facial Surgery of the University of Rome "La Sapienza" and "Tor Vergata," 13 surgical procedures for reconstruction of anterior and middle skull base defects by free flaps were performed in 11 patients. Data on patient demographics, histopathology, location and size of defect, type of reconstruction, and postoperative complications were obtained from medical record charts. A safe soft tissue closure of the intracranial space was achieved in all patients. Defect repair was accomplished by revascularized transfer of rectus abdominis flaps in seven cases, latissimus dorsi muscle flaps in two patients, radial forearm flap in one case, and fibula flap in one case. There were two total flap losses; the secondary defect repair was accomplished in both cases by revascularized transfer of latissimus dorsi muscle flap. No donor site complications were observed in all the flaps. The mean operation time was 85 hours; patients were hospitalized for a mean period of 14 days. The method of choice for the reconstruction of anterior or middle skull base defect should be based upon careful evaluation of the single case and, particularly, the localization and entity of the residual defect. For defects that require large amounts of soft tissue, the latissimus dorsi free flap and the rectus abdominis free flap are the best appropriate choices for reconstructive procedures for anterior and middle skull base tumors.

Surgical treatment of recurrent orbital hemangiopericytoma.

Hemangiopericytoma is a rare vascular tumor featuring the uncontrolled proliferation of pericytes. This tumor tends to develop in subcutaneous tissue and skeletal muscle. The localization of hemangiopericytoma in the orbit is particularly rare. Clinical signs and symptoms are, in order of frequency, proptosis, perception of an intraorbital mass, pain, diplopia, reduction of visus, tumescence, and ecchymoses of the eyelids. Hemangiopericytomas have higher potential of relapse, local invasiveness, and the possibility of producing distant metastases. Surgery must be as radical as possible to avoid incomplete tumor resection and high frequency of relapse together with increased duration of the disease and a higher risk of malignant development. The current report is a study of two cases of hemangiopericytoma in the orbital cavity treated at the Unit of Maxillo-Facial Surgery of the University of "La Sapienza" in Rome. The present data demonstrate that complete en bloc excision of the mass with its capsule is important to avoid the risk of relapse. To this end, an appropriate first surgical treatment should be chosen so as to obtain a wide "surgical light" and complete view of the mass. In the reported cases, the use of a combined anterolateral approach was preferred to attack the tumor from different sides. Indeed, such an approach allows one to obtain optimal exposition of the orbital region and temporal and infratemporal fossae contemporaneously.

Surgical approach to the third area of the internal carotid artery through vertical osteotomy of the mandibular ramus: case report.

Internal carotid artery (ICA) reparative techniques are nowadays widely standardized in traumatic as well as degenerative pathological conditions; therefore, the greatest difficulty encountered in the treatment of lesions at the expense of the most distal segment of the ICA is not a result of the application of these techniques as much as the difficulty in obtaining adequate exposure of the vessel and a sufficiently wide surgical field. In the past, lesions localized more toward the skull were considered to be surgically unreachable. During the last 20 years, however, various techniques have been suggested and attempted for the exposure of this difficult area. This article suggests a type of approach already carried out by the Department of Maxillofacial Surgery of the University of Rome "La Sapienza" in collaboration with the II Department of Vascular Surgery of the same university, which offers the advantage of being of simple and rapid execution with minimum repercussions on the intrasurgical time required and guarantees an excellent exposure of the most distal tract of the ICA with an adequate widening of the surgical field.