Case series: non vascular considerations in trigeminal neuralgia.

An abnormal vascular course of the superior cerebellar artery is often cited as the cause for trigeminal neuralgia. However, among patients with TN-like symptoms, 6% to 16% are variously reported to have intracranial tumours. Aneurysms, tumours, or other lesions may impinge or irritate the trigeminal nerve along its course. Uncommonly, an area of demyelination from multiple sclerosis may be the precipitant. We would like to present a series of unusual lesions, all of which initially presented with neuralgic-like symptoms and were refractory to treatment. Collated case series with photographs and imaging are reviewed in this paper. Discussion of case presentation and management are done for evaluation. A wide range of other compressive lesions can cause trigeminal neuralgia. This paper illustrates the clinical presentation of atypical trigeminal neuralgia and emphasises the value of diagnostic imaging in trigeminal neuralgia patient. Suggested algorithm for management of trigeminal neuralgia.

The vascular anatomy of the rat superficial epigastric flap by vascular corrosion casting and technical refinement for the study of choke vessels in cadaveric flap models.

Accurate depiction of cutaneous vascular microanatomy is of relevance to plastic surgical flap research, and to descriptive anatomy. Yet current techniques have not permitted full visualization of the subdermal plexus, or potential angiosomal connections. Nor has endothelial visualization been facilitated. Vascular corrosion casting techniques are promising in that regard, and were applied in an extended lateral thoracoabdominal suprafascial adipocutaneous flap in the rat (based on the superficial epigastric bundle). Technical refinements for application to further study of human cadaveric flap models are presented. The intraflap vascular branching pattern of the superficial epigastric artery is described, with filling of the lateral thoracic, intercostals, and iliolumbar angiosomes found when coagulation of vessels at the periphery was delayed until after clearance. The vascular casting protocol presented is an effective and promising tool for the study of macro- and microvascular anatomy.

Vacuum-assisted closure for the treatment of Fournier's gangrene.

BACKGROUND: Fournier's gangrene (FG) is a very aggressive necrotizing fasciitis involving subcutaneous fat and skin of scrotal and perineal regions. Vacuum-assisted closure (VAC) is a well-known method used to treat complex wounds. The authors for the first time enhance a multimodal strategy to treat the FG using VAC, reducing the number of surgical debridements, allowing a one-step surgical reconstruction with locoregional fasciocutaneous flap. METHODS: Six patients with the diagnosis of FG were reviewed retrospectively at our institution. All patients were affected by very extensive FG. The FG Severity Index (FGSI) was used to evaluate the prognosis of the case at admission. Following the acute phase (24-48 h), VAC was used to achieve wound cleaning and prepare the area to a single-stage reconstruction with superomedial thigh flap. Hyperbaric oxygen therapy was also used before final reconstruction. RESULTS: The average FGSI was 10.5, ranging from 8 to 12. All patients survived and were completely healed at the mean follow-up time of 9 months (range 3-30 months). CONCLUSIONS: VAC therapy is effective to clean and prepare the wounds, cutting off the fasciitis process and reducing the hospital stay and patient discomfort. Multidisciplinary treatment is mandatory during this devastating infection.

The distally based sural flap for lower leg reconstruction: versatility in patients with associated morbidity.

INTRODUCTION: Coverage of soft tissue defects in the lower leg is often made by use of free flap, also because of the improving of anaesthesiology techniques in the last decades. However, there are disadvantages in the use of free flaps like the need for a remote donor site, increased operative time, use of a major vessel to the leg, and microsurgical skills. Besides these, trauma in the lower limb are often cause of damage for a major vessels of the leg, so the use of free flaps in these patients may be related to an higher incidence of complications; also associated pathologies, like diabetes and vascular pathology, can increase the incidence of complications when a free flap is utilized. In all these cases local fascio-cutaneous flaps, like the sural reverse flap, because of their easy and short time harvesting, can be a very good alternative to free flaps. Superficial sural artery flap is a adipofasciocutaneous flap based on the vascular axis of the sural nerve, which gets reverse blood flow through communication with the perforating branch of the peroneal artery, situated in the region of lateral malleolar gutter. PATIENTS AND METHODS: Between 2000 and 2005, 11 patients, mean age 68 (range 58-78 years), were treated at the Plastic and Reconstructive Surgery Unit of Messina University, for soft tissue defects of lower limb and foot, using the distally based sural artery flap. The defects were related to post-traumatic damage of soft tissue, diabetic and vascular ulcers, osteomyelitis and oncological resection. Mean follow-up time was 20 months (range 6-55 months). All patients were pre-operatively assessed for vascular patency of peroneal axis and associated morbidity that could increase risk offlap necrosis. This included diabetes mellitus type II, osteomyelitis and peripheral arterial diseases. RESULTS: All flaps survived with the exception of one that sustained partial skin necrosis, in the ratio of 25% of the skin island. All defects were covered with no major complications and none of the patients required a blood transfusion. Moreover aesthetic results were good with satisfaction of all the patients. CONCLUSION: In our cases we found the sural reverse flap to have a good reliability with low incidence of complication and surgical outcomes. This flap is an excellent option for covering defects of minor deficiency of skin in the third distally of lower limb, ankle and heel. It allows rapid, reliable coverage of defects extending as far distally as the forefoot. Because of the sparing of major vessels, the short surgery time in harvesting the flap, and the good vascular pattern of the flap, we retain the flap a first choose technique for reconstruction in lower leg, especially in politrauma and in patients with associated pathology as vascular diseases or diabetes.

Factors affecting swallow outcome following treatment for advanced oral and oropharyngeal malignancies.

BACKGROUND: Treatment for tumors of the oral cavity and the oropharynx disrupts normal swallow function. The ability for oral diet postoperatively varies and may be influenced by surgery and patient-related factors. METHODS: In all, 114 patients treated with surgery with and without chemoradiotherapy for advanced oral/oropharyngeal cancer were recruited. Clinicopathologic tumor parameters and reconstruction modalities were recorded. Swallow function was determined by oral intake, using the Functional Oral Intake Scale (FOIS) pretreatment and posttreatment. RESULTS: The median time to first attaining swallow function was 14 days. Patients were less likely to attain tube independence within 1 year of surgery if they received radiotherapy or had a low FOIS score preoperatively. Patients' time to first attaining swallow function postsurgery was inversely related to the FOIS score presurgery. CONCLUSIONS: Swallow function recovery postsurgery is better in patients with higher FOIS presurgery, smaller tumors, and no requirement for radiotherapy.

A functional magnetic resonance imaging paradigm to identify distinct cortical areas of facial function: a reliable localizer.

BACKGROUND: Irreversible facial paralysis can be surgically treated by importing both a new neural and a new motor muscle supply. Various donor nerves can be used. If a nerve supply other than the facial nerve is used, the patient has to adapt to generate a smile. If branches of the fifth cranial nerve are used, the patient has to learn to clench teeth and smile. Currently, controversy exists regarding whether a patient develops a spontaneous smile if a nerve other than the facial nerve is used. The authors postulate that brain adaptation in facial palsy patients can occur because of neural plasticity. The authors aimed to determine whether functional magnetic resonance imaging could topographically differentiate activity between the facial nerve- and the trigeminal nerve-related cortical areas. METHODS: A new paradigm of study using functional magnetic resonance imaging based on blood oxygen level-dependent signal activation was tested on 15 voluntary healthy subjects to find a sensitive localizer for teeth clenching and smiling. Subjects smiled to stimulate the facial nerve-related cortex, clenched their jaws to stimulate the trigeminal nerve-related cortex, and tapped their finger as a control condition. RESULTS: Smiling and teeth clenching showed distinct and consistent areas of cortical activation. Trigeminal and facial motor cortex areas were found to be distinct areas with minimal overlapping. CONCLUSIONS: The authors successfully devised a functional magnetic resonance imaging paradigm effective for activating specific areas corresponding to teeth clenching and smiling. This will allow accurate mapping of cortical plasticity in facial reanimation patients.

Topographic anatomy of the nerve to masseter: an anatomical and clinical study.

BACKGROUND: The use of the motor nerve to masseter has proved to be a reliable and sensible solution in facial reanimation as a donor for free muscle transfer. In this paper we describe the topographic anatomy of the nerve to masseter and our original technique for its quick and safe harvesting. METHODS: This anatomical study is based on the dissection of the nerve to masseter in 17 embalmed cadaverous sites and is focused on the anatomical relations between the nerve and the surrounding structures. Also buccal and zygomatic branches of the facial nerve were dissected and assessed and the resulting data are compared. RESULTS: The nerve to masseter has a predictable track inside the muscle which can be identified topographically within a square area under the zygomatic arch. This area is different between males and females and its accuracy has been tested on six patients at the Canniesburn Unit. CONCLUSIONS: The nerve to masseter emerges in a very predictable point from the mandibular notch - immediately below the zygomatic arch - to run within the muscle belly. The approach here described allows safer and faster harvesting of the nerve to masseter with minimal dissection through the muscle.