Surgical Techniques for Closure of a Scalp Defect After Resection of Skin Malignancy.

BACKGROUND: Surgery for scalp malignancies is aimed at the complete resection and a good aesthetic outcome. The goal was to develop an algorithm for scalp reconstruction based on the authors' surgical experience. METHODS: This is a retrospective analysis of 123 procedures of scalp malignancies in 105 patients. Twenty eight procedures were for resection of squamous cell carcinoma, 54 for basal cell carcinoma, and 41 for suspected melanomas. RESULTS: Primary closure (27 procedures), local flap (LF; 19), split-thickness skin graft (SG; 64), rotated LF and SG (9), and free vascularized flaps (4) were used. Complications were partial (4) and total (1) necrosis of SG, free-flap atrophy (1), infection (2), wound dehiscence (1), and death due to cardiovascular complications (1). During follow-up, recurrence occurred in 22 patients (21%) and metastases to lymph nodes in 3 (3%). CONCLUSION: Surface area size and the presence of the periosteum as well as a bone infiltration are important factors that can guide selection of a reconstruction method after resection of scalp malignancy.

Small Biopsy Samples: Are They Representative for Biphenotypic Sinonasal Sarcoma?

(1) Background: Biphenotypic sinonasal sarcoma (BSNS) is a rare low-grade neoplasm of the sinonasal tract. It is characterized by specific PAX3 gene rearrangements and both myogenic and neural differentiation. The purpose of the study was to describe the histologic, immunohistochemical and molecular features of BSNS and indicate important clues for small incisional biopsy diagnostics. (2) Methods: Archival samples from patients with nasal cavities or ethmoid sinuses tumors were searched for BSNS cases. Inclusion criteria were the presence of spindle cell morphology and low-grade appearance. Both biopsy and resection specimens were stained for identical IHC panels including, i.a., S100, SMA, SOX10 and PAX3. FISH for PAX3 and SS18 was performed on biopsy specimens. (3) Results: BSNS diagnosis was made in 6 cases included in the study and confirmed by PAX3 rearrangement by FISH in 5 specimens. The pattern of IHC expression was identical for paired biopsy and resection samples apart from one BSNS case. (4) Conclusions: Incisional biopsy seems to be a sufficient method to establish BSNS diagnosis in most cases. Characteristic morphological features together with S100, SOX10 and SMA as the screening markers are useful for confirming the diagnosis. In cases of divergent morphology and immunoprofile evaluation of PAX3 rearrangement is vital.

[Anatomy and surgical approaches to the parapharyngeal space]. / Anatomia i dostepy chirurgiczne do przestrzeni przygardlowej.

PURPOSE: Analysis of surgical approaches to primary tumors localized in parapharyngeal space used in Head & Neck Cancer Department, Cancer Center Institute in Warsaw. Description of differences in terminology used to describe fascial compartments of the neck. MATERIAL AND METHODS: Retrospective analysis of medical records of 8 selected patients who had an operation for primary parapharyngeal space neoplasm. Analysis has been done of operation protocols, diagnostic images, tumor size and histopathology. RESULTS: Transcervical, transparotid and transmandibular approaches were used with additional rhinotomy and craniotomy in selected cases. Selection of approach should take into account tumor localization, its size and histopathology. CONCLUSIONS: Planning of surgical procedure for parapharyngeal space tumor should be based upon analysis of diagnostic images and selection of the approach depends on tumor localization, size and histopathology. Differences in terminology of superficial and middle cervical fascial compartments can lead to inappropriate clinical decisions.

Differences in free flaps' reconstructions with and without coupling device for venous anastomosis.

<br><b>Introduction:</b> Introduction of the coupler devices for anastomoses of neck vessels changes planning and performance of the surgical procedures. The Rigid ring of the coupling devices keeps a vein open and less prone to occlusion. Therefore, this should improve the flap survival rate and surgery duration.</br> <br><b>Aim:</b> The aim of the study was to point out the differences in surgery planning between couplers and sutures for venous microsurgical anastomoses.</br> <br><b>Methods:</b> The medical records of 209 patients who underwent 212 microvascular free flap reconstructions from January 2011 till December 2017 were retrospectively analyzed; 103 received radial forearm free flap (RFFF); 43 - anterolateral thigh flap (ALTF); 51 - fibula free flap (FFF); 15 - iliac crest free flap (ICFF). In 189 cases, reconstruction was performed simultaneously with tumor resection and in 23 cases, reconstruction was secondary, after previous oncological treatment. Among 443 anastomoses, suturing was used for 212 arteries and 127 venous anastomoses, while coupling was used for 104 venous anastomoses.</br> <br><b>Results:</b> The mean surgery duration for suturing was 452.82 min vs 358.88 min for coupling (P<0.05). Differences in flap survival and partial necrosis rates between coupling and suturing groups were not statistically significant (P>0.05). Donor vessel distribution in the neck was significantly different in both groups. Estimated costs of the surgical procedures performed with and without coupler devices were not equal.</br> <br><b>Conclusions:</b> The use of couplers for venous anastomosis in free flap head and neck reconstructions impacts the surgery process by shortening surgery duration which leads to cost reduction.</br>.

Comparison of criteria for elective tracheostomy in head and neck cancer surgery.

OBJECTIVES: Elective tracheostomy before resection of a malignancy in head and neck region assures unobstructed ventilation during postoperative period but is associated with an increased risk of complications. We aimed to evaluate retrospectively, how application of elective tracheostomy scales would influence frequency of tracheostomy in comparison with preoperative clinical judgement. METHODS: In 205 patients operated from 2013 till 2017 resection of a malignancy involved suprahyoid or pharyngeal muscles, neck dissection and flap reconstruction. Elective tracheostomy decision was made on clinical basis. Score for each patient in 3 published scales has been calculated. RESULTS: In the study group 76 patients had an elective tracheostomy at the outset of a resection procedure. Among 129 patients without elective tracheostomy 9 had a tracheostomy in postoperative period. Indications for elective tracheostomy were calculated for scale I, II and III. Only in 120 patients the decision to perform elective tracheostomy or not would be identical in each scale. CONCLUSION: Our results suggest that decisions to perform an elective tracheostomy based on the 3 scales has low specificity. The factors used in the published scales should be evaluated in a prospective multicenter study.

Vasculature of a Medial Femoral Condyle Free Flap in Intact and Osteotomized Flaps.

BACKGROUND: A small size and difficulties with shaping a medial femoral condyle corticocancellous bone flap are factors limiting its use. The goal of this study was to evaluate range of vascular supply to a medial femoral condyle corticocancellous bone flap to determine whether harvesting of larger flaps and performing a flap osteotomy would compromise the vasculature of a flap's bone. METHODS: Twenty-four limbs were dissected and medial femoral condyle corticocancellous bone flaps were harvested with skin paddles. Thirteen of 24 flaps had subperiosteal osteotomies simulating shaping a bone for reconstruction. A pedicle artery was perfused with red latex. Medial femoral condyle corticocancellous bone flap vascularization was evaluated by cutting the bone into 1-cm blocks and assessing the number of Haversian canals filled with red latex. RESULTS: Length of harvested flaps was 7 to 13 cm, thickness was 0.5 to 3 cm, and width was 1 to 3 cm. Pedicle length was between 3.5 and 9 cm (mean ± SD, 6.6 ± 1.6 cm). Red latex filled bone vessels at a distance of 6 to 11.5 cm from the distal end of a flap (8.2 ± 1.4 cm). Skin paddles were filled with latex in all cases. CONCLUSION: A medial femoral condyle corticocancellous bone flap had sufficient blood supply, allowing for harvesting flaps up to 11 cm long, and subperiosteal osteotomy did not compromise the vasculature of the flap's bone.

Leiomyosarcoma of the external ear--case report.

In head and neck region leiomyosarcoma is a very rare finding. This tumor is usually located in abdominal cavity. We report a case of 78-year-old man with tumor of the auricle that was resected with 0.7 cm margin. Histological and immunohistochemical analysis revealed the leiomyosarcoma. Adjuvant therapy was not advised. During 3 years of follow-up there are no signs of recurrence. Review of the literature shows that the survival of patients with leiomyosarcoma in head and neck region seems to be similar to other kinds of sarcomas in this localization. It is not clear, how large surgical margins should be to achieve satisfactory local control.

Contamination of the surgical field in head and neck oncologic surgery.

BACKGROUND: The purpose of this study was to determine the timing and type of surgical field contamination in 50 consecutive resections for advanced head and neck cancer with same-stage tissue reconstruction and to analyze the relationship between contamination and the surgical site infection. METHODS: Swabs from the surgical field and from surgical drapes close to the field were taken every 2 hours (at 0 hour, 2 hours, 4 hours, and 6 hours) and sent for a standard microbiological diagnostic procedure. Results were recorded in Microsoft Excel and analyzed with SPSS. RESULTS: We collected 336 swabs of which 71% were contaminated. Polymicrobial contamination was observed in 153 samples (45%). Twenty-six species of pathogens were found, the most frequent was Streptococcus species. Surgical site infection with positive culture occurred in 3 patients. CONCLUSION: In head and neck surgery for advanced cancer, standard aseptic procedures do not prevent contamination of the surgical field with physiological bacterial flora of the skin and oral cavity. Although contamination was common, surgical site infection was rare.