Intraoral Hirudotherapy for Venous Congestion following Free Flap Head and Neck Reconstruction: Novel Intraoral Technique.

Intraoral hirudotherapy is traditionally used for venous congestion following head and neck free flap reconstruction. Many institutions and healthcare teams have been reluctant to use intraoral leech therapy due to risks such as migration into the airway, increased infection from intraoral manipulation, and patient discomfort. Several protocols recommend blocking the path to the oropharynx via gauze or leaving a tracheotomy in place to protect the airway. This report pre-sents a novel technique for intraoral hirudotherapy that is safe and simple for treatment of free flap venous congestion. The base of a clear cup or a plastic lid is utilized, and the leech is attached onto the inside of the lid with 2 sutures near each end. Several cups with leeches attached are made at a time to reduce delay and difficulty of application by less experienced clinical staff. The leech is then applied onto the compromised flap and then simply removed once it has unlatched from the flap. This method allows the leech to be applied with ease by multiple members of the healthcare team, decreases the need for intraoral manipulation, and reduces the risk of migration into the aerodigestive tract. Future prospective studies are warranted to assess the efficacy of this technique.

The success of salvage procedures for failing digital replants: A retrospective cohort study.

BACKGROUND: The success of salvage procedures for failing digital replants (FR) is poorly documented. We sought to evaluate the success of salvage procedures for FR and factors contributing to successes and failures of replants. METHODS: Adult patients who presented to our center between January 1, 2000 and December 31, 2015, suffered ≥1 digital amputation(s), and underwent digital replantation were included. Preoperative, perioperative, and postoperative details were recorded. Digits were monitored postoperatively via nursing and physician assessments. The presumed reason for failure, details, and outcomes of salvage attempts were recorded for FR. Length of hospital stay and complications were also recorded. RESULTS: Fifty-two patients and 83 digits were included. Fifty-two digits (63%) were compromised (arterial ischemia in 15 digits; venous congestion in 37 digits) and 48 digits had salvage therapy. Twenty-one FR (44%) were salvaged via operative (1 of 2; 50%), nonoperative (19 of 43; 44%), and combined (1 of 3; 33%) therapies. FR patients were more likely than those with successful replants to receive a blood transfusion (52 vs. 23%; p = .009) with more transfused units (3.45 ± 3.30 vs. 0.86 ± 0.95; p = .001). Length of stay was prolonged for FR patients (9 [range: 2-22] vs. 7 [range: 3-19] days; p = .039). Ultimately, 59% (49 of 83) of replants were successful, where 25% (21 of 83) were successfully salvaged. CONCLUSION: Nonoperative and operative salvage therapies improve the rate of replant survival. We suggest close postoperative monitoring of all replants and active salvage interventions for compromised replants in the postoperative period.

Experience with pharmacologic leeching with bivalirudin for adjunct treatment of venous congestion of head and neck reconstructive flaps.

OBJECTIVES: The goal of this study was to review the feasibility of local bivalirudin injection for adjunct treatment of venous congestion of head and neck reconstructive flaps. METHODS: A retrospective chart review of patients who underwent bivalirudin treatment for venous congestion of head and neck reconstructive flaps in a single institution from September 1, 2012 to September 1, 2015 was undertaken. Individuals were treated with variable number of intradermal injections directly into the flap followed by a small skin incision to allow extended passive bleeding. The main outcome measure was improvement of flap congestion. RESULTS: Ten patients with free flap reconstruction (4 anterolateral thigh flaps, 2 pectoralis major flaps, 2 fibula osseocutaneous flaps, 1 supraclavicular flap, and 1 radial forearm free flap) of various head and neck defects underwent treatment with bivalirudin. Bivalirudin injections were utilized as adjunct therapy in 6 patients. Two individuals underwent alternate therapy for venous congestion immediately following injection and therefore the efficacy could not be assessed. Of the 8 remaining flaps, 4 developed partial necrosis, and 1 developed complete necrosis requiring additional reconstruction. Two individuals required blood transfusions during bivalirudin treatment. CONCLUSIONS: Bivalirudin is a safe and feasible adjunct therapy for treatment of flap congestion. It may serve as a useful alternative to traditional leech therapy, as bivalirudin negates the need for antibiotic prophylaxis, eliminates the psychological aversion associated with leech therapy, and avoids the potential for leech migration. Further work to determine the efficacy of bivalirudin to standard leech therapy is warranted.

Successful replantation of an amputated earlobe by microvascular anastomosis.

In the microsurgical area, replantation of ear amputation by microvascular anastomosis is considered to be the best method in terms of texture, color, and shape. Only a few cases of successful ear replantation with microvascular anastomosis have been reported because the size of the vessels is very small, and identifying appropriate vessels for anastomosis is difficult. Furthermore, most cases were total or subtotal (upper two thirds of the ear) amputations, and they were successfully reconstructed by replantation.To the best of our knowledge, this is the first case of a patient with ear lobe avulsion who underwent successful replantation by single arterial anastomosis. We report our case with a brief review of the literature.

Efficacy of arthroscopic surgery and midlaser treatments for chronic temporomandibular joint articular disc derangement following motor vehicle accident.

As a result of motor vehicle accident soft-tissue injury, temporomandibular joint articular disc derangement may develop and persist despite symptomatic treatment and medication. This study reports the effectiveness of management directed at controlling the TMJ and masticatory neuromuscular pain dysfunction with a TMJ/interocclusal stabilization appliance, specific biofeedback and ultrasound therapy. Following these conservative measures residual articular disc derangement was present in some subjects who were offered arthroscopic surgery and infrared midlaser with TMJ/occlusal stabilization. Twenty subjects with residual disc derangement were randomly selected into two groups with and without arthroscopic surgery, and analyses of variance made before treatment, 12 months after conservative procedures, 3 months following arthroscopic surgery and midlaser therapy and 3 years since commencement of management. Dependent variables compared were pain-discomfort, Clinical Dysfunction Index, articular disc derangement and maximal voluntary jaw opening. Conservative management alone provided significant reduction of pain-discomfort and clinical dysfunction, while arthroscopic surgery resulted in significant reduction in articular disc derangement. The midlaser with TMJ/occlusal stabilization maintained significant improvement in the variables (p < 0.01) for both groups. The common articular deviations in form found at arthroscopy were soft tissue alteration with hyperaemia, synovitis, synovial membrane and posterior attachment folding with connective tissue hyperplasia, and disc displacement with fibrous adhesions. The Global Status Score of pain behaviour compared with residual function, confirmed the presence of greater pain before treatment commenced.