The Amsterdam UMC protocol for computer-assisted mandibular and maxillary reconstruction; A cadaveric study.

OBJECTIVES: In this cadaveric study, the accuracy of CAS guided mandibular and maxillary reconstruction including immediate dental implant placement in different Brown defect classes is assessed. MATERIALS AND METHODS: The virtual planning and surgical procedure was conducted according to a newly proposed Amsterdam UMC reconstruction protocol. Postoperative evaluation was performed according to a previously proposed evaluation guideline. RESULTS: Fourteen mandibular and 6 maxillary reconstructions were performed. Average mandibular angle deviations were 1.52°±1.32, 1.85°±1.58, 1.37°±1.09, 1.78°±1.37, 2.43°±1.52 and 2.83°±2.37, respectively for the left and right axial angles, left and right coronal angles and left and right sagittal angles. A total of 62 dental implants were placed in neomandibles with an average dXYZ values of 3.68 ± 2.21 mm and 16 in neomaxillas with an average dXYZ values of 3.24 ± 1.7 mm. CONCLUSION: Promising levels of accuracy were achieved for all mandibular angles. Dental implant positions approached the preoperative preferred positions well, within the margin to manufacture prosthetic devices.

Near-Infrared Fluorescence with Indocyanine Green to Assess Bone Perfusion: A Systematic Review.

Background: Adequate perfusion of a bone flap is essential for successful reconstruction of osseous defects. Unfortunately, complications related to inadequate bone perfusion are common. Near-infrared fluorescence (NIRF) imaging enables intraoperative visualization of perfusion. NIRF has been investigated in reconstructive surgery to aid the surgeon in clinical perioperative assessment of soft tissue perfusion. However, little is known on the beneficial use of NIRF to assess bone perfusion. Therefore, the aim of this review was to search for studies evaluating NIRF to assess bone perfusion. Methods: A systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, was performed. Studies up to October 2021 were included. We extracted data regarding the study population, size and design, reported objective fluorescence parameters and the methodology used for fluorescence imaging and processing. Results: Ten articles were included. Studies reported unevenly on the protocol used for NIRF imaging. Five studies reported objective parameters. Absolute and relative perfusion parameters and parameters derived from maximum fluorescence were reported. The clinical significance of these parameters has not been evaluated in humans. Conclusion: The evidence on bone perfusion as measured with NIRF is limited. More clinical studies are required.

Long-term outcomes of implant-based dental rehabilitation in head and neck cancer patients after reconstruction with the free vascularized fibula flap.

The study aimed at evaluating, comprehensively, implant-based dental rehabilitation in head and neck cancer patients after maxillofacial reconstruction with a vascularized free fibula flap (FFF). Data were obtained by retrospectively reviewing the medical records of patients treated in Amsterdam UMC-VU Medical Center. Dental implant survival and implant success according to the Albrektsson criteria were analyzed. Additionally, prosthetic-related outcomes were studied, with a focus on functional dental rehabilitation. In total, 161 implants were placed in FFFs, with a mean follow-up of 4.9 years (range 0.2-23.4). Implant survival was 55.3% in irradiated FFFs and 96% in non-irradiated FFFs. Significant predictors for implant failure were tobacco use and irradiation of the FFF. Implant success was 40.4% in irradiated FFFs and 61.4% in non-irradiated FFFs, mainly due to implant failure and non-functional implants. Implant-based dental rehabilitation was started 45 times in 42 patients, out of 161 FFF reconstructions (27.9%). Thirty-seven patients completed the dental rehabilitation, 29 of whom achieved functional rehabilitation. Irradiation of the FFF negatively influenced attainment of functional rehabilitation. For patients with functional rehabilitation, the body mass index varied at different timepoints: FFF reconstruction, 24.6; dental implantation 23.5; and after placing dental prosthesis, 23.9. Functional implant-based dental rehabilitation, if started, can be achieved in the majority of head and neck cancer patients after FFF reconstruction. Actively smoking patients with an irradiated FFF should be clearly informed about the increased risk for implant and prosthetic treatment failure.

Accuracy of Computer-Assisted Surgery in Maxillary Reconstruction: A Systematic Review.

Computer-assisted surgery (CAS) in maxillary reconstruction has proven its value regarding more predictable postoperative results. However, the accuracy evaluation methods differ between studies, and no meta-analysis has been performed yet. A systematic review was performed in the PubMed, Embase, and Cochrane Library databases, using a Patient, Intervention, Comparison and Outcome (PICO) method: (P) patients in need of maxillary reconstruction using free osteocutaneous tissue transfer, (I) reconstructed according to a virtual plan in CAS software, (C) compared to the actual postoperative result, and (O) postoperatively measured by a quantitative accuracy assessment) search strategy, and was reported according to the PRISMA statement. We reviewed all of the studies that quantitatively assessed the accuracy of maxillary reconstructions using CAS. Twelve studies matched the inclusion criteria, reporting 67 maxillary reconstructions. All of the included studies compared postoperative 3D models to preoperative 3D models (revised to the virtual plan). The postoperative accuracy measurements mainly focused on the position of the fibular bony segments. Only approximate comparisons of postoperative accuracy between studies were feasible because of small differences in the postoperative measurement methods; the accuracy of the bony segment positioning ranged between 0.44 mm and 7.8 mm, and between 2.90° and 6.96°. A postoperative evaluation guideline to create uniformity in evaluation methods needs to be considered so as to allow for valid comparisons of postoperative results and to facilitate meta-analyses in the future. With the proper validation of the postoperative results, future research might explore more definitive evidence regarding the management and superiority of CAS in maxillary and midface reconstruction.

Collaboration Around Rare Bone Diseases Leads to the Unique Organizational Incentive of the Amsterdam Bone Center.

In the field of rare bone diseases in particular, a broad care team of specialists embedded in multidisciplinary clinical and research environment is essential to generate new therapeutic solutions and approaches to care. Collaboration among clinical and research departments within a University Medical Center is often difficult to establish, and may be hindered by competition and non-equivalent cooperation inherent in a hierarchical structure. Here we describe the "collaborative organizational model" of the Amsterdam Bone Center (ABC), which emerged from and benefited the rare bone disease team. This team is often confronted with pathologically complex and under-investigated diseases. We describe the benefits of this model that still guarantees the autonomy of each team member, but combines and focuses our collective expertise on a clear shared goal, enabling us to capture synergistic and innovative opportunities for the patient, while avoiding self-interest and possible harmful competition.

The Effectiveness of Burn Scar Contracture Release Surgery in Low- and Middle-income Countries.

Worldwide, many scar contracture release surgeries are performed to improve range of motion (ROM) after a burn injury. There is a particular need in low- and middle-income countries (LMICs) for such procedures. However, well-designed longitudinal studies on this topic are lacking globally. The present study therefore aimed to evaluate the long-term effectiveness of contracture release surgery performed in an LMIC. METHODS: This pre-/postintervention study was conducted in a rural regional referral hospital in Tanzania. All patients undergoing contracture release surgery during surgical missions were eligible. ROM data were indexed to normal values to compare various joints. Surgery was considered effective if the ROM of all planes of motion of a single joint increased at least 25% postoperatively or if the ROM reached 100% of normal ROM. Follow-ups were at discharge and at 1, 3, 6, and 12 months postoperatively. RESULTS: A total of 70 joints of 44 patients were included. Follow-up rate at 12 months was 86%. Contracture release surgery was effective in 79% of the joints (P < 0.001) and resulted in a mean ROM improvement from 32% to 90% of the normal value (P < 0.001). A predictive factor for a quicker rehabilitation was lower age (R 2 = 11%, P = 0.001). Complication rate was 52%, consisting of mostly minor complications. CONCLUSIONS: This is the first study to evaluate the long-term effectiveness of contracture release surgery in an LMIC. The follow-up rate was high and showed that contracture release surgery is safe, effective, and sustainable. We call for the implementation of outcome research in future surgical missions.

The Baker Classification for Capsular Contracture in Breast Implant Surgery Is Unreliable as a Diagnostic Tool.

BACKGROUND: Breast implants are frequently used in cosmetic and reconstructive breast surgery. Capsular contracture, the most common long-term complication, is usually graded using the Baker classification. Despite its widespread use, the reliability of the Baker classification has never been established. The aim of this study was to determine the interobserver reliability and agreement of the Baker classification. METHODS: Sixty women who had undergone cosmetic breast augmentation were included. They were examined independently by two plastic surgeons from an observer pool. The Baker score was determined, along with firmness, dislocation, symmetry, and pain using four-point scales. Patients were asked to complete the BREAST-Q postaugmentation module. The interobserver reliability and agreement were calculated for all variables with a quadratic weighted kappa. RESULTS: The interobserver reliability of the Baker classification was poor (kappa, 0.55; 95 percent CI, 0.37 to 0.72). Interobserver reliability of the clinical parameters firmness (0.64; 95 percent CI, 0.49 to 0.79), dislocation (0.49; 95 percent CI, 0.26 to 0.73), and symmetry (0.61; 95 percent CI, 0.34 to 0.88) was also poor. Pain scores seemed more reliable (0.72; 95 percent CI, 0.56 to 0.89); however, most patients had no pain. The interobserver agreement for the Baker score was 48 percent; in 43 percent, the observers differed one category; and in 12 percent, the difference was more than one category. CONCLUSIONS: Interobserver reliability and observer agreement of the Baker classification for capsular contracture were poor. Consensus about how to adequately rate the symptoms of capsular complaints is lacking. A more reliable method of measurement or description is needed, especially for scientific research purposes, to assess the long-term problems associated with breast implants. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

A Postoperative Evaluation Guideline for Computer-Assisted Reconstruction of the Mandible.

Valid comparisons of postoperative accuracy results in computer-assisted reconstruction of the mandible are difficult due to heterogeneity in imaging modalities, mandibular defect classification, and evaluation methodologies between studies. This guideline uses a step-by-step approach guiding the process of imaging, classification of mandibular defects and volume assessment of three-dimensional (3D) models, after which a legitimized quantitative accuracy evaluation method can be performed between the postoperative clinical situation and the preoperative virtual plan. The condyles and the vertical and horizontal corners of the mandible are used as bony landmarks to define virtual lines in the computer-assisted surgery (CAS) software. Between these lines the axial, coronal, and both sagittal mandibular angles are calculated on both pre- and postoperative 3D models of the (neo)mandible and subsequently the deviations are calculated. By superimposing the postoperative 3D model to the preoperative virtually planned 3D model, which is fixed to the XYZ axis, the deviation between pre- and postoperative virtually planned dental implant positions can be calculated. This protocol continues and specifies an earlier publication of this evaluation guideline.

Combined Massive Allograft and Intramedullary Vascularized Fibula as the Primary Reconstruction Method for Segmental Bone Loss in the Lower Extremity: A Systematic Review and Meta-Analysis.

BACKGROUND: Reconstruction of segmental bone loss due to malignancy, infection, or trauma is a challenge for the reconstructive surgeon. The combination of a vascularized fibular flap with a cortical allograft provides a reliable reconstructive option in the lower extremity. In this systematic review, we describe the outcome of this technique for the treatment of segmental bone loss. METHODS: A systematic review was performed on the use of a combined massive allograft and intramedullary vascularized fibula as a reconstruction method for large bone defects. We used PubMed, Embase, and the Wiley Cochrane Library. RESULTS: Seventeen clinical articles were included between 1997 and 2017, reporting 329 cases of lower-extremity reconstructions. A meta-analysis was performed on primary union rates. The main outcome measures were primary union rate, complication rate, reintervention rate, and function after reconstruction. All publications showed relatively high complication (5.9% to 85.7%) and reintervention rates (10% to 91.7%) with good primary union rates (66.7% to 100%) and functional outcome (range of mean Musculoskeletal Tumor Society [MSTS] scores, 24 to 29 points). CONCLUSIONS: The combination of a massive allograft with intramedullary vascularized fibula provides a single-step reconstruction method for large bone defects (>6 cm) in the lower extremity, with good long-term outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Impact of short-term reconstructive surgical missions: a systematic review.

INTRODUCTION: Short-term missions providing patients in low-income countries with reconstructive surgery are often criticised because evidence of their value is lacking. This study aims to assess the effectiveness of short-term reconstructive surgical missions in low-income and middle-income countries. METHODS: A systematic review was conducted according to PRISMA guidelines. We searched five medical databases from inception up to 2 July 2018. Original studies of short-term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients and sustainability. Data were combined to generate overall outcomes, including overall complication rates. RESULTS: Of 1662 identified studies, 41 met full inclusion criteria, which included 48 546 patients. The overall study quality according to Oxford CEBM and GRADE was low. Ten studies reported a minimum of 6 months' follow-up, showing a follow-up rate of 56.0% and a complication rate of 22.3%. Twelve studies that did not report on duration or follow-up rate reported a complication rate of 1.2%. Fifteen out of 20 studies (75%) that reported on follow-up also reported on sustainable characteristics. CONCLUSIONS: Evidence on the patient outcomes of reconstructive surgical missions is scarce and of limited quality. Higher complication rates were reported in studies which explicitly mentioned the duration and rate of follow-up. Studies with a low follow-up quality might be under-reporting complication rates and overestimating the positive impact of missions. This review indicates that missions should develop towards sustainable partnerships. These partnerships should provide quality aftercare, perform outcome research and build the surgical capacity of local healthcare systems. PROSPERO REGISTRATION NUMBER: CRD42018099285.

Accuracy of computer-assisted surgery in mandibular reconstruction: A postoperative evaluation guideline.

Comparing accuracy results for mandibular reconstructions using computer-assisted surgery (CAS) is limited due to heterogeneity in image acquisition, extent of mandibular resection, and evaluation methodologies between studies. We propose a practical, feasible and reproducible guideline for standardizing evaluation methods to allow valid comparisons of postoperative results and facilitate meta-analyses in the future. It offers a guide to imaging, data comparison, volume assessment of 3-dimensional models, classification of defects, and it also contains a quantitative accuracy evaluation method.

Accuracy of computer-assisted surgery in mandibular reconstruction: A systematic review.

Computer-assisted surgery (CAS) for mandibular reconstruction was developed to improve conventional treatment methods. In the past years, many different software programs have entered the market, offering numerous approaches for preoperative planning and postoperative evaluation of the CAS process of mandibular reconstruction. In this systematic review, we reviewed planning and evaluation methods in studies that quantitatively assessed accuracy of mandibular reconstruction performed with CAS. We included 42 studies describing 413 mandibular reconstructions planned and evaluated using CAS. The commonest software was Proplan/Surgicase CMF (55%). In most cases, the postoperative virtual 3-dimensional model was compared to the preoperative 3-dimensional model, revised to the virtual plan (64%). The commonest landmark for accuracy measurements was the condyle (54%). Accuracy deviations ranged between 0 mm and 12.5 mm and between 0.9° and 17.5°. Because of a lack of uniformity in planning (e.g., image acquisition, mandibular resection size) and evaluation methodologies, the ability to compare postoperative outcomes was limited; meta-analysis was not performed. A practical and simple guideline for standardizing planning and evaluation methods needs to be considered to allow valid comparisons of postoperative results and facilitate meta-analysis in the future.

Double flap phalloplasty in transgender men: Surgical technique and outcome of pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction.

INTRODUCTION: Radial forearm free flap (RFFF) tube-in-tube phalloplasty is the most performed phalloplasty technique worldwide. The conspicuous donor-site scar is a drawback for some transgender men. In search for techniques with less conspicuous donor-sites, we performed a series of one-stage pedicled anterolateral thigh flap (ALT) phalloplasties combined with RFFF urethral reconstruction. In this study, we aim to describe this technique and assess its surgical outcome in a series of transgender men. PATIENTS AND METHODS: Between January 2008 and December 2015, nineteen transgender men (median age 37, range 21-57) underwent pedicled ALT phalloplasty combined with RFFF urethral reconstruction in one stage. The surgical procedure was described. Patient demographics, surgical characteristics, intra- and postoperative complications, hospitalization length, and reoperations were recorded. RESULTS: The size of the ALT flaps ranged from 12 × 12 to 15 × 13 cm, the size of the RFFFs from 14 × 3 to 17 × 3 cm. Median clinical follow-up was 35 months (range 3-95). Total RFFF failure occurred in two patients, total ALT flap failure in one patient, and partial necrosis of the ALT flap in one patient. Long-term urinary complications occurred in 10 (53%) patients, of which 9 concerned urethral strictures. CONCLUSIONS: In experienced hands, one-stage pedicled ALT phalloplasty combined with RFFF urethral reconstruction is a feasible alternative surgical option in eligible transgender men, who desire a less conspicuous forearm scar. Possible drawbacks comprise flap-related complications, difficult inner flap monitoring and urethral complications.

The effect of flexor hallucis longus harvest on hallux function: a retrospective cross-sectional cohort study.

BACKGROUND AND AIM: Our aim was to evaluate the long-term morbidity of the hallux function after harvesting a free fibula flap. Special attention was given to the differences between patients who underwent the dissection of an osteo-cutaneous flap (without inclusion of the flexor hallucis longus (FHL) muscle) and patients who were treated with an osteo-myo-cutaneous (with inclusion of the FHL muscle). METHODS: During the period 1995-2009, 167 patients underwent an autologous mandible reconstruction using a free fibula flap. By the time of our investigation, 64 patients were deceased, 29 patients were lost to follow-up, 14 patients did not meet the inclusion criteria and 28 patients were unable or unwilling to come to the hospital. Thus, 32 patients were examined in this study. Combined flexion strength of the hallux flexors and range of motion (ROM) of the metatarsophalangeal (MTP) and interphalangeal (IP) joints were measured. RESULTS: Hallux flexion strength tests showed a significant decrease in strength in the operated leg versus control, 28±16.6 versus 37±19.2 N/s (p=0.003). The ROM for the MTP was significantly lower for the donor leg than for the control leg: 26±12° versus 30±10° (p=0.024) for plantar flexion and 30±13° versus 37±11° (p<0.001) for dorsal flexion. In addition, the ROM for plantar flexion in the IP joint was significantly lower in the donor group. No significant differences were found when comparing reduction of flexion strength or reduction of ROM in the osteo-cutaneous versus osteo-myo-cutaneous harvest. CONCLUSIONS: The main conclusion to be drawn from our results is that free fibula flap donor site morbidity in terms of hallux function is independent of the inclusion or exclusion of the FHL muscle in the flap. LEVEL OF EVIDENCE III: Retrospective cohort or comparative study; case-control study; or systematic review of these studies.

A systematic review of oncoplastic breast-conserving surgery: current weaknesses and future prospects.

OBJECTIVE: The primary objectives of this systematic review on oncoplastic breast surgery (OPBS) were to evaluate the oncological and cosmetic outcomes of OPBS. The secondary objectives were to assess morbidity, quality of life, and applied algorithms. BACKGROUND: Breast-conserving therapy (BCT) has become the standard of care, and survival is now excellent. Consequently, the focus of BCT has increasingly shifted to cosmetic outcome, quality of life, and patient satisfaction. Nonetheless, excision of certain tumors still presents a considerable challenge. Specialized approaches combining oncological surgery and plastic surgery techniques are collectively referred to as OPBS. A summary of OPBS outcomes would facilitate decision-making and best treatment selection by both clinicians and patients. METHODS: Using specific inclusion and exclusion criteria to analyze 2090 abstracts on the topic of OPBS published between 2000 and 2011, the authors evaluated each study with respect to design and outcomes. RESULTS: A total of 88 articles were identified for potential inclusion and reviewed in detail by the lead authors. No randomized controlled trials were identified. Eleven prospective observational or comparative studies fulfilled inclusion criteria and were selected. In these studies, 80% to 93% of the tumors were invasive. Tumor-free resection margins were observed in 78% to 93%, resulting in a 3% to 16% mastectomy rate. Local recurrence was observed in 0% to 7% of the patients. Good cosmetic outcome was obtained in 84% to 89% of patients. However, most studies showed significant weaknesses including lack of robust design and important methodological shortcomings, negatively influencing generalizability. CONCLUSIONS: This systematic review reveals that current evidence supporting the efficacy of OPBS is based on poorly designed and underpowered studies. Given the increasing importance and application of OPBS, there is a pressing need for robust comparative studies, including both randomized controlled trials and well-designed, multicenter prospective longitudinal studies.

Ultrasound-guided breast-sparing surgery to improve cosmetic outcomes and quality of life. A prospective multicentre randomised controlled clinical trial comparing ultrasound-guided surgery to traditional palpation-guided surgery (COBALT trial).

BACKGROUND: Breast-conserving surgery for breast cancer was developed as a method to preserve healthy breast tissue, thereby improving cosmetic outcomes. Thus far, the primary aim of breast-conserving surgery has been the achievement of tumour-free resection margins and prevention of local recurrence, whereas the cosmetic outcome has been considered less important. Large studies have reported poor cosmetic outcomes in 20-40% of patients after breast-conserving surgery, with the volume of the resected breast tissue being the major determinant. There is clear evidence for the efficacy of ultrasonography in the resection of nonpalpable tumours. Surgical resection of palpable breast cancer is performed with guidance by intra-operative palpation. These palpation-guided excisions often result in an unnecessarily wide resection of adjacent healthy breast tissue, while the rate of tumour-involved resection margins is still high. It is hypothesised that the use of intra-operative ultrasonography in the excision of palpable breast cancer will improve the ability to spare healthy breast tissue while maintaining or even improving the oncological margin status. The aim of this study is to compare ultrasound-guided surgery for palpable tumours with the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumour-free margins, cosmetic outcomes and quality of life. METHODS/DESIGN: In this prospective multicentre randomised controlled clinical trial, 120 women who have been diagnosed with palpable early-stage (T1-2N0-1) primary invasive breast cancer and deemed suitable for breast-conserving surgery will be randomised between ultrasound-guided surgery and palpation-guided surgery. With this sample size, an expected 20% reduction of resected breast tissue and an 18% difference in tumour-free margins can be detected with a power of 80%. Secondary endpoints include cosmetic outcomes and quality of life. The rationale, study design and planned analyses are described. CONCLUSION: The COBALT trial is a prospective, multicentre, randomised controlled study to assess the efficacy of ultrasound-guided breast-conserving surgery in patients with palpable early-stage primary invasive breast cancer in terms of the sparing of breast tissue, oncological margin status, cosmetic outcomes and quality of life. TRIAL REGISTRATION NUMBER: Netherlands Trial Register (NTR): NTR2579.

Management of recurrent ameloblastoma of the jaws; a 40-year single institution experience.

Ameloblastoma is a histologically almost always benign odontogenic tumor with a high rate of recurrence if not removed completely. Therefore, radical surgery is the treatment of choice of a primary ameloblastoma. Of 18 patients with a recurrent ameloblastoma, previously treated by enucleation, radical surgery was deemed impossible in three because of the extent of the tumor or because of a poor general condition of the patient. Of the remaining 15 patients three refused to undergo radical surgery and have been treated for their recurrence by enucleation again. In none of the twelve remaining patients treated by radical surgery a recurrence was observed in a mean follow-up period of 10.5 years. In one of these patients a metastatic cervical lymph node was detected during the primary reconstruction of the mandibular defect. The absence of recurrences in patients treated by radical surgery should be looked at with some reservation, since recurrences may still show up after 10.5 years. The three patients who refused radical surgery all developed one or more new recurrences.

Internal thoracic vessels used as pedicle graft for anastomosis with vascularized bone graft to reconstruct C7-T3 spinal defects: a new technique.

STUDY DESIGN: A report of 4 cases of primary bone tumors (3 cases) or infection (1 case) at the cervicothoracic junction treated with resection-reconstruction. OBJECTIVES: To document a new technique using the internal thoracic vessels as recipient vessels for reconstruction of the cervicothoracic spine with free vascularized fibula grafts. SUMMARY OF BACKGROUND DATA: The cervicothoracic junction is a difficult region in reconstructive spinal surgery. Although nonvascularized fibula grafts can be used to reconstruct the osseous defect, compared with free vascularized fibula grafts they are biomechanical weaker, incorporate less well, are less resistant to infection, and remodel incomplete in time. However, when using free vascularized bone grafts, the selection of suitable recipient vessels remains one of the most critical decisions. MATERIALS AND METHODS: Four patients who had a primary tumor (3 cases) or a severe progressive kyphotic deformity and progressive neurologic symptoms due to tuberculosis (1 case) were treated by resection and vascularized reconstruction. In 3 patients, a staged anteroposterior en bloc resection of T1-T3 (2 cases) or T1-T2 (1 case) was performed; the ventral reconstruction of the osseous defect consisted of a vascularized fibula graft interposition between C7-T4 (2 cases) or C7-T3 (1 case). In another case, an axial slot was milled through the T1-T2 vertebral bodies to accept an osteotomized vascularized fibular graft. In all cases, a free vascularized fibula graft was used: the vascular anastomosis was performed between the peroneal and the dissected and rerouted internal thoracic vessels. The anterior construction was strengthened by a ventral plate-screw system. RESULTS: The resection-reconstruction procedures, including the dissection, rerouting, and anastomosis between the internal thoracic vessels and the peroneal vessels, were successfully performed. At present, all patients are alive, and there is no evidence of recurrent disease, unchanged, or improved neurologic with a mean follow-up of 28 months. All grafts are well incorporated. CONCLUSIONS.: A combined low anterolateral cervical and midsternal approach or a midline sternotomy allows not only a safe and excellent exposure to the cervicothoracic junction but also to the internal thoracic vessels. The internal thoracic vessels are appropriate donor vessels: its longevity, diameter, length, and rerouting capacity allow vascularized graft reconstruction of vertebral column defects of the low cervical (C6-C7) and/or upper thoracic (T1-T3) region.

Low prevalence of (pre) malignant lesions in the breast and high prevalence in the ovary and Fallopian tube in women at hereditary high risk of breast and ovarian cancer.

To analyse the prevalence of (pre) malignant lesions occurring in breast and adnexal tissue at prophylactic surgery in women at hereditary high risk of breast and/or ovarian cancers. Tissue was obtained from 85 women who underwent prophylactic bilateral salpingo-oophorectomy (pBSO) and from 59 women who underwent prophylactic mastectomy (pM). Control tissue samples were obtained from women undergoing breast reduction surgery (N = 99) or adnexal surgery for benign reasons (N = 72). In women with a BRCA1/2 mutation, the prevalence of a (pre) malignant adnexal lesion was 50% (95% CI 26-74) if older than 40 years and 14% (95% CI 0-58) if younger. The prevalences of (pre) malignant breast lesions in women older than 40 years, with and without a BRCA1/2 mutation, were 0% (95% CI 0-16) and 47% (95% CI 21-73), respectively. No association was found between (pre) malignant lesions in breast and adnexal tissue occurring in 28 women who underwent surgery on both organs (R = 0.155, p = 0.432), but the prevalence of lesions was significantly higher in adnexal tissue than in the breast (p = 0.023). Compared to controls, women at hereditary high risk had a higher chance of (pre) malignant lesions in the breast and an even higher chance of such lesions in the adnexal tissue. There was no indication for concomitant presence of such lesions in both organs at the time of prophylactic surgery. The high frequency of (pre) malignant lesions in the adnexal tissue stresses further the importance of pBSO from the age of 40 onwards in women at hereditary high risk.