Rethinking Oncologic Facial Nerve Reconstruction in the Acute Phase Through Classification of the Level of Injury.

Early facial nerve reconstruction should be offered in every patient with oncological resections of the facial nerve due to the debilitating functional and psychosocial consequences of facial nerve palsy. Oncologic pathology or oncologic resection accounts for the second most common cause of facial nerve palsy. In the case of these acute injuries, selecting an adequate method for reconstruction to optimize functional and psychosocial well-being is paramount. Authors advocate consideration of the level of injury as a framework for approaching the viable options of reconstruction systematically. Authors breakdown oncologic injuries to the facial nerve in three levels in relation to their nerve reconstruction methods and strategies: Level I (intracranial to intratemporal), Level II (intratemporal to extratemporal and intraparotid), and Level III (extratemporal and extraparotid). Clinical features, common clinical scenarios, donor nerves available, recipient nerve, and reconstruction priorities will be present at each level. Additionally, examples of clinical cases will be shared to illustrate the utility of framing acute facial nerve injuries within injury levels. Selecting donor nerves is critical in successful facial nerve reconstruction in oncological patients. Usually, a combination of facial and nonfacial donor nerves (hybrid) is necessary to achieve maximal reinnervation of the mimetic muscles. Our proposed classification of three levels of facial nerve injuries provides a selection guide, which prioritizes methods for function nerve reconstruction in relation of the injury level in oncologic patients while prioritizing functional outcomes.

Nipple-sparing mastectomy with immediate breast reconstruction with a deep inferior epigastric perforator flap without skin paddle using delayed primary retention suture.

BACKGROUND: This study investigated the outcomes of nipple-sparing mastectomy (NSM) with a deep inferior epigastric perforator (DIEP) flap using delayed primary retention suture (DPRS) to achieve superior breast esthetics. METHODS: Between December 2010 and March 2021, patients who underwent NSM with DIEP flap were inset with or without a skin paddle (using DPRS) as Group A or B, respectively. Demographics, operative findings, complications, BREAST-Q questionnaire, and Manchester scar scale were compared between two groups. RESULTS: Twelve patients underwent 12 unilateral reconstructions in Group A, while 12 patients underwent 13 DIEP flaps in Group B. There was no significant difference in demographics, ischemia time, flap-used weight and percentage, complications of hematoma, infection, re-exploration, partial flap loss, and total flap loss (All p > 0.05, respectively). At a mean 9 months of follow-up, the Breast-Q "Satisfaction with surgeon" domain was significant in Group B (p = 0.04). At a mean 12 months of follow-up, the overall Manchester scar scale of 10.3 in Group B was statistically superior to 12.6 in Group A (p = 0.04). CONCLUSIONS: The NSM with a DIEP flap using DPRS is a reliable and straightforward technique. It can provide greater cosmesis of the reconstructed breast mound in a single-stage procedure.

Outcomes and quality of life in immediate one-stage versus two-stage breast reconstructions without an acellular dermal matrix: 17- years of experience.

BACKGROUND: Advantages of one-stage implant-based reconstructions include expedited surgery and recovery. This study aimed to investigate clinical and patient-reported outcomes in one-stage implant-based breast reconstructions without acellular dermal matrix (ADM). METHODS: A prospectively collected database from 2002 to 2018 was retrospectively reviewed. One-stage and two-stage groups were compared for demographics, implant properties, early complications (hematoma, seroma, poor wound healing, implant removal), late complications (skin necrosis, capsular contracture, implant exposure, implant rupture), revision procedures, and Breast-Q questionnaire outcomes. RESULTS: A total of 223 patients, 187 one-stage (84%) and 36 two-stage (16%) patients were recruited. At a mean follow-up of 124.9 and 92.5 months, respectively (p < .01), there were no differences in early (p = .85) or late (p = .23) complications or revision procedures (p = .12). Eighty patients (36%) returned the Breast-Q questionnaire (60 one-stage, 20 two-stage patients). There were no statistical differences in patient reported outcomes in breast well-being (p = .07), psychosocial well-being (p = .84), or sexual well-being (p = .78). CONCLUSIONS: One-stage implant-based breast reconstruction without an ADM is a viable reconstruction providing comparable outcomes to two-stage procedures, with the benefit of minimal complications, a shorter reconstructive journey, and satisfactory quality of life.

Four Lessons Learned from Complications in Head and Neck Microvascular Reconstructions and Prevention Strategies.

Free flap reconstruction in the head and neck region is a complex field in which patient comorbidities, radiation therapy, tumor recurrence, and variability of clinical scenarios make some cases particularly challenging and prone to devastating complications. Despite low free flap failure rates, the impact of flap failure has enormous consequences for the patients. METHODS: Acknowledging and predicting high risk intra- and postoperative situations and having planned strategies on how to deal with them can decrease their rate and improve the patient's reconstructive journey. RESULTS: Herein, the authors present 4 examples of significant complications in complex microvascular head and neck cancer reconstruction, encountered for the last 10 years: compression and kinking of the vascular pedicle, lack of planning of external skin coverage in osteoradionecrosis, management of the vessel-depleted neck, and vascular donor site morbidity after fibula harvest. CONCLUSION: The authors reflect on the causes and propose preventative strategies in each peri-operative stage.

A National Survey of Undergraduate Suture and Local Anesthetic Training in the United Kingdom.

BACKGROUND: Suturing is a skill expected to be attained by all medical students on graduation, according to the General Medical Council's (GMC) Tomorrow's Doctors. There are no GMC recommendations for the amount of suture training required at medical school nor the level of competence to be achieved. This study examines the state of undergraduate suture training by surveying a sample of medical students across the United Kingdom. METHODS: We distributed a survey to 17 medical schools to be completed by undergraduates who have undergone curricular suture training. The survey included questions relating to career intention, hours of curricular suture training, hours of additional paid training, confidence in performing various suture techniques and knowledge of their indications. We also asked about the students' perceived proficiency at injecting local anesthetic and their overall opinion of medical school suture training. RESULTS: We received responses from 705 medical students at 16 UK medical schools. A total of 607 (86.1%) medical students had completed their scheduled curricular suture training. Among them, 526 (86.5%) students reported inadequate suture training in medical school and 133 (21.9%) students had paid for additional training. Results for all competence markers were significantly lower than the required GMC standards (p < 0.001). Students who had paid for additional training were significantly more confident across all areas examined (p < 0.001). CONCLUSIONS: Our study identified a deficiency in the curricular suture training provided to the medical students surveyed. These findings suggest that medical schools should provide more opportunities for students to develop their suturing skills to achieve the GMC standard.