Salvage transorbital approach for the endovascular treatment of carotid cavernous fistulas.

PURPOSE: Carotid cavernous fistulas (CCFs) are abnormal connections between the cavernous sinus (CS) and carotid arteries. In direct CCFs, a transarterial route is often the preferred vascular access; in case of indirect CCFs, the complex anatomy of the feeder vessels and their extra-intracranial anastomosis makes the transarterial embolization challenging and often ineffective. The aim of this study was to review our experience with the transorbital approach to treat patients affected by CCF who have already experienced an endovascular failure procedure, in order to assess this salvage technique feasibility, by analyzing possible risks and complications. METHODS: We performed a retrospective study of all patients affected by CCFs who underwent transorbital embolization between February 2017 and February 2019 at our institution. RESULTS: All patients (3 cases) tolerated both the retrograde embolization and the direct surgical approach with clinical improvement; the closure of the fistula was complete and verified intraoperatively by angiography. Esthetic result was acceptable in all cases with reduction of the proptosis and the intraocular pressure, and increased visual acuity. There were no complications or clinical recurrence. CONCLUSION: Transorbital approach for the endovascular treatment of CCFs is a feasible and safe salvage procedure, which can find indication after other endovascular access failures.

Subclavicular flap: A valid reconstructive option among anterior chest flaps in oral cancer patients.

BACKGROUND: The subclavicular pedicled flap is based on the thoracic branch of the supraclavicular artery, and it represents a versatile reconstructive option for low-middle third face defects. Since its use in head and neck surgical oncology has not been popularized yet, we propose its application for oral cavity reconstruction after cancer resection by showing favorable results. METHODS: Eighteen subclavicular pedicled flaps were used to treat intraoral defects after oral squamous-cell cancer resection between June 2015 and December 2018. Tumor dissection type, complications, donor and reconstructed area results, and functional and aesthetic outcomes were assessed. RESULTS: No major complications were observed and all of the flaps survived. Adjuvant therapy was administered without delay when needed, and all of the patients had normal functional outcomes and good aesthetic results. CONCLUSIONS: The subclavicular flap is an excellent choice for the reconstruction of oral cavity defects. Selection of patients should exclude positive lower-third neck node and include appropriate informed consent for women due to the possibility of deformity of the breast. In our opinion, this flap has the potential for common application given its consistent anatomy and donor site advantages, including long pedicle, high pivot point, and relatively unlimited flap width.

Evolution of Full Facial Feminization Surgery: Creating the Gendered Face With an All-in-one Procedure.

Facial feminization surgery (FFS) has recently gained popularity to enhance the female facial profile and promote a real transformation of the male to female face in transgender patients. The term involves overlapping of the surgical procedures devoted to feminization and represents a dual and reversible procedure unique in plastic and reconstructive surgery. Indeed, FFS envisages modifications of the hard and soft tissues and is both reductive and augmentative. For these reasons, full FFS (F-FFS) is used by surgeons with special expertise in FFS. This study describes a novel approach to F-FFS performed in a single surgery and thus renamed, de facto, all-in-one and representing its most recent evolution. Forty-nine consecutive nonrandomized patients underwent FFS at a private clinical practice (Face Surgery Center, Parma, Italy) between January 2003 and December 2017. Following a retrospective review according to specific inclusion criteria, the authors identified 9 patients aged 19 to 33 years (mean age, 21 years) who underwent all-in-one F-FFS. Patients were discharged the day after surgery with written postoperative care instructions. No reports of wound infection/dehiscence or nerve/vessel damage were recorded. Patients typically returned to work within 30 days following surgery. The mean operative time was 281 minutes (range, 245-305 minutes). The evolved all-in-one F-FFS provides a further step technically (overlapping several procedures) in terms of surgical outcome (higher satisfaction rate) and reduced overall costs and low morbidity.

A New Hybrid Technique for Performing a Safer Bilateral Sagittal Split Osteotomy: Combining Reciprocating Saw and Piezoelectric Devices.

The sagittal split osteotomy (SSO) is an indispensable tool in the correction of dentofacial abnormalities. In elective orthognathic surgery, it is important that surgeons inform patients about the risk of complications related to inferior alveolar nerve damage and unfavorable split. The purpose of this article is to describe a novel, hybrid technique to SSO by combining a reciprocating saw and piezoelectric devices with several advantages over traditional "pure" methods (osteotomies performed by reciprocating saw or piezoelectric devices only) in terms of precision, rapidity, easier splitting, and decreased complications related to inferior alveolar nerve damage and bad split with reduced overall morbidity. The level of evidence was Level IV, therapeutic study.

Classification of tongue cancer resection and treatment algorithm.

BACKGROUND AND OBJECTIVES: Reconstruction of tongue cancer defects is challenging due to the complex anatomy and physiology of the tongue. Here, we classify patterns of tongue tissue loss and describe a treatment algorithm for achieving good functional and oncologic outcomes. METHODS: We retrospectively reviewed 50 tongue squamous-cell carcinomas surgically treated between January 2010-June 2015. Cancer resection and tongue reconstruction were stratified according to the missing anatomical subunits. RESULTS: A type 1 defect is a unilateral and marginal defect, not crossing the midline, and not extending to the posterior-third of the tongue. Type 2 involves the two-anterior-thirds of the mobile body, not crossing the midline, without posterior-third evolvement. Type 3 involves the two-anterior-thirds of the mobile body of the tongue with contralateral extension. Type 4 extends to the tongue base. Type 5 defect comprises any of the previous defects along with involvement of the floor of the mouth. Type 2 and 3 defects were the most common. Microvascular reconstruction was performed in 23 out of 50 patients. Complications included infection, partial necrosis, dehiscence, and microvascular thrombosis. CONCLUSIONS: Our classification system and treatment algorithm represent a reliable method of addressing management of tongue defects.

Metastatic Squamous Cell Carcinoma of the Lower Lip: Analysis of the 5-Year Survival Rate.

OBJECTIVES: The author analyse the impact of extracapsular lymph node spread and bone engagement in the ipsilateral neck of patients suffering squamous cell carcinoma (SCC) of the lower lip. METHODS: The data of 56 neck dissections performed in patients suffering SCC of the lower lip between January 2000 and December 2008 were retrospectively analysed. Statistical analysis was performed with the Kaplan-Meier life table method, and the survival rate was investigated with the log rank statistic and significance test. The values were considered statistically significant at p<0.05. RESULTS: Nine patients took advantage from simultaneous treatment of tumor and prophylactic neck dissection (level I-III), reaching 100% survival rate. Patients suffering metastasized disease, who received radical neck dissection at the time of tumor treatment, presented 83.3% survival rate. Patients who underwent previous surgery and radiotherapy presented worse prognosis although radical neck dissection in case of extra-capsular spread only (24.7%) and osseous engagement (22.2%). CONCLUSION: Prophylactic neck dissection (level I-III) is recommended in T3-T4 N0 SCC. Simultaneous treatment of tumor and cervical lymph nodes provides a better prognosis as respect to delayed nodal management. Extra-capsular spread with or without bone engagement represents independent risk factor responsible for high mortality rate of SCC of the lower lip.

The role of bone marrow aspirate cells in the management of atrophic mandibular fractures by mini-invasive surgical approach: Single-institution experience.

PURPOSE: The treatment of fractures involves addressing the biology of fracture repair and the mechanical stability of fracture fixation. Traditionally it has included the addition of bone graft to enhance healing. New advances in the understanding of the cellular and molecular mechanisms of fracture repair have led to the use of growth factors to accelerate bone healing. This study aimed to assess the advantages of autologous stem cell use for atrophic mandibular fracture treatment in comparison to standard technique. MATERIALS AND METHODS: A total of 35 patients (14 male and 21 female) were treated for fractures of atrophic mandibles between January 2011 and December 2014. Surgical technique provided mini-invasive open reduction with or without immediate homologous bone graft, while selected patients received autologous bone marrow aspirate cell grafts in addition to the standard treatment. Demographic data and details of treatment and outcomes were recorded. RESULTS: Patients were categorized according to the use of autologous stem cells, leaving 17 patients treated with standard technique and autologous stem cells (Group A) and 18 treated with standard osteosynthesis only (Group B). Of the 35 patients, 26 had bilateral fractures; most patients had significant medical co-morbidities. Immediate bone graft was used in 37.1% of patients (7 in group A and 6 in group B). Complications occurred in 5 patients (14.3%). Two patients in group B (11.1%) showed non-union of the fracture. One patient in group A (5.8%) and one patient in group B (5.5%) showed wound dehiscence and were treated conservatively; one patient in group B had a local infection (5.5%), one out of 35 (2.8%), that was managed by prolonged antibiotic treatment. CONCLUSIONS: Despite the advanced age and medical co-morbidities of the vast majority of patients, mini-invasive open approach with autologous bone graft ensures a fast and excellent recovery. Moreover, the management of atrophic mandibular fractures by bone marrow aspirate cells is a safe and useful procedure which has a lower complication rate when compared to standard technique.

Analysis of Lipoasiprated Following Centrifugation: Wet Versus Dry Harvesting Technique.

BACKGROUND: The success of lipotransfer strongly depends on the harvesting, processing, and placement of the lipoaspirated samples. This study was designed to assess the histomorphometric characteristics and viability of fat harvested using different techniques (wet and dry) following centrifugation, as described by Coleman. METHODS: The study enrolled 85 consecutive, nonrandomized, healthy patients from March 2010 to December 2014 (45 males and 40 females). The mean age was 40 years (range, 18-59 years), and the mean body mass index was 25.8 (range, 24-32). The authors performed a histological analysis (hematoxylin/eosin), morphometry (ImageJ 1.33 free-share image analysis software), and a viability assessment (Trypan Blue exclusion test; Sigma-Aldrich, Milan, Italy) of the lipoaspirated samples. RESULTS: The hematoxylin and eosin-stained sections exhibited similar features; in particular, clear-cut morphological signs of adipocyte disruption, apoptosis, or necrosis were not detected in the examined samples. Morphometry confirmed the visual findings, and the values of the mean surface area of the adipocyte vacuoles were not significantly different. Additionally, the adipocyte viability was not significantly different in the analyzed fat tissue samples. CONCLUSIONS: The results from this study showed, for the first time, that there is not a reduction in the viability of fat grafts harvested with the dry or wet technique following centrifugation according to Coleman technique. Both methods of fat harvesting collect viable cells, which are not influenced by standard centrifugation. The fat grafts harvested and processed by this technique could be used in clinical settings without increasing the reabsorption rate. LEVEL OF EVIDENCE: V.

Management of Mandibular Angle Fractures by Two Conventional 2.0-mm Miniplates: A Retrospective Study of 389 Patients.

Fractures of the mandibular angle account for 23 to 42% of all facial fractures with a high complication rate (0-32%). Although the ideal treatment remains debatable, two main procedures are commonly used to manage the majority of mandibular angle fractures that are open reduction and internal fixation by a noncompression miniplate placed on the external oblique ridge with or without a second miniplate on the outer cortex. The purpose of this study was to describe our management of mandibular angle fractures by two noncompression miniplates placed on the outer cortex via a transbuccal approach. Medical records and radiographic examination of 389 patients (258 males [66.3%] and 131 females [33.7%]) operated from January 2000 to December 2012 were retrospectively reviewed. Postoperative complications including malocclusion, infection, wound dehiscence, nonunion, and reoperative surgery were recorded and analyzed. Fifty-three patients developed postoperative complications (overall complication rate: 13.6%). No significant difference was found in the complication rate by age and gender variables and regarding the interval between the trauma and the operation and the presence of the teeth in the line of fracture. A higher rate of complications was found among patients with alcohol/drug addiction and in patients with multiple-site involvement. The findings of this study suggest that the use of two transbuccal miniplates placed on the outer cortex for the internal fixation of mandibular angle fracture provided a low rate of complications. The global incidence of screw loosening, wound dehiscence, plate exposure, infection, reoperation, and plate removal were similar with the data reported in the literature with improved health outcomes, lower postoperative morbidity, and a faster return to normal life.

Full Facial Feminization Surgery: Patient Satisfaction Assessment Based on 180 Procedures Involving 33 Consecutive Patients.

BACKGROUND: Gender dysphoria refers to the discomfort and distress that arise from a discrepancy between a person's gender identity and sex assigned at birth. The treatment plan for gender dysphoria varies and can include psychotherapy, hormone treatment, and gender reassignment surgery, which is, in part, an irreversible change of sexual identity. Procedures for transformation to the female sex include facial feminization surgery, vaginoplasty, clitoroplasty, and breast augmentation. Facial feminization surgery can include forehead remodeling, rhinoplasty, mentoplasty, thyroid chondroplasty, and voice alteration procedures. Described here is an assessment of patient satisfaction after facial feminization surgery, including outcome measurements after forehead slippage and chin remodeling. METHODS: Thirty-three patients between 19 and 40 years of age were referred for facial feminization surgery between January of 2003 and December of 2013, for a total of 180 procedures. Surgical outcome was analyzed both subjectively through questionnaires administered to patients and objectively by serial photographs. RESULTS: Most facial feminization surgery procedures can be safely completed in 6 months, barring complications. All patients showed excellent cosmetic results and were satisfied with their procedures. Both frontal and profile views achieved a loss of masculine features. CONCLUSIONS: Patient satisfaction after facial feminization surgery is high. The reduction of gender dysphoria has psychological and social benefits and significantly affects patient outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Siliconomas of the lower limb: Tumour-like excision and reconstruction.

BACKGROUND: Silicone oil injection can cause several complications including pain, cellulitis, abscesses, skin compromise, migration, embolism and multiorgan failure. Oil-infested tissue excision remains the solely treatment to prevent such complications. OBJECTIVES: The authors evaluate tumor-like excision of the oil-infested tissue as a treatment for patients experiencing silicone injections in the lower limbs, to both preserve aesthetic appearance and solve further risk of complication from silicone. METHODS: Between January 2004 and January 2011 a total of 12 consecutive, nonrandomized female patients underwent surgical management of siliconoma of the lower limb. The mean age was 41-years, range from 22 to 61 years and all patients didn't referred comorbidities. Eight siliconomas were located on the leg and 4 were on the thigh. The mean area of siliconoma was 35 cm2, range from 25 to 60 cm2. Each patient was evaluated by ultrasonography and EchocolorDoppler of the soft tissue and in order to achieve a "staging" of siliconoma. RESULTS: Healing was uneventful in all cases. Three patients (25%) suffering hypertrophic scarring underwent further injection of corticosteroids to improve hypertrophic scars quality. Two patients (16.6%) required a further session of structural fat grafting to improve thigh's profile. All patients were satisfied with the cosmetic results and indispositions requiring medical therapy disappeared. CONCLUSIONS: Tumor-like excision and immediate reconstruction appears to be a safe and consistent surgical option that preserves aesthetic appearance for patients victims of illegal oil silicone injection of the lower limbs.

Complex craniofacial advancement in paediatric patients: Piezoelectric and traditional technique evaluation.

PURPOSE: The piezoelectric device allows bone cutting without damaging the surrounding soft tissues. The purpose of this study was to assess the role of this surgical instrument in paediatric craniofacial surgery in terms of safety and surgical outcomes. METHODS: Thirteen consecutive paediatric patients underwent craniofacial Le Fort osteotomies type III and IV. The saw was used on the right side in seven patients and on the left side in six patients; the piezoelectric instrument was used on the right side in six patients and on the left side in seven patients. Intraoperative blood loss, surgical procedure length, incision precision, postoperative haematoma and swelling, and nerve impairment were evaluated to compare the outcomes of both procedures. RESULTS: A longer surgical procedure was observed in 28% of the patients when using the piezoelectric device (p = 0.032), with an intraoperative blood loss reduction of 18% (p = 0.156). Greater precision in bone cutting was reported, together with a reduction in the requirement to protect and incise adjacent soft tissues during piezoelectric osteotomies. There was a lower incidence of postoperative haematoma and swelling following piezo-osteotomy, and a significant reduction in postoperative nerve impairment (p = 0.002). CONCLUSIONS: The ultrasonic surgical device guaranteed a clean bone cut, preserving the integrity of the adjacent soft tissues beneath the bone. Although the time required for a piezoelectric osteotomy was longer, the total operation time remained approximately the same. In conclusion, the device's lack of power appears to be a minor problem compared with the advantages, and an ultrasonic device could be considered a valuable instrument for paediatric craniofacial advancement.

Lipomodeling: An Innovative Approach to Global Volumetric Rejuvenation of the Hand.

BACKGROUND: Rejuvenation of the hand, particularly the dorsum, has garnered increased attention because of its unique aesthetic importance. Various methods have been advocated for achieving optimal aesthetic results. OBJECTIVES: The authors describe their experience applying lipotransfer to total hand rejuvenation, including rejuvenation of the radial and ulnar aspects of the fingers. METHODS: The authors conducted a retrospective review of 22 women who underwent global hand rejuvenation by lipotransfer. Aesthetic outcomes were assessed objectively by serial photography and subjectively by patient self-assessments. RESULTS: No major postoperative complications were observed. Of 22 patients, 21 indicated that they were "satisfied" or "very satisfied" with the procedure. Plastic surgeons noted improvement in the aesthetic appearance of the hands after treatment. CONCLUSIONS: Global hand rejuvenation should aim to restore volume and reduce skin laxity to reverse the signs of extrinsic aging. The fingers represent almost 50% of the length of the hand and should be included in treatments to achieve optimal aesthetic outcomes. LEVEL OF EVIDENCE: 4 Therapeutic.

Three-dimensional airways reconstruction in syndromic pedriatric patients following mandibular distraction osteogenesis.

BACKGROUND: Airway obstruction, associated with mandibular hypoplasia, is a frequent complication in syndromic pediatric patients. The clinical signs of airway obstruction change from mild positional obstruction to severe respiratory distress with cyanosis. The young age of the patients makes medical management extremely complex. METHODS: The purpose was to evaluate the success of surgery, evaluating the expansion of the respiratory volumes measured by computer tomography analyzed through a software (SimPlant Pro 15). Twelve patients with mandibular hypoplasia and respiratory distress were treated between December 2010 and December 2013. Eleven of them had tracheostomy in the preoperative period. The goal of surgery was to prevent permanent tracheostomy or to remove it, if present. RESULTS: Volume and surface area increased by an average of 279.2% and 89.4%, respectively. Tracheostomy was avoided in 1 patient who underwent surgery precociously, and it was removed in 10 patients. Only 1 case failed in volume airway augmentation, and tracheostomy was not removed. CONCLUSIONS: Computer tomography can calculate the cross-sectional areas of the airway in 3 planes of space: coronal, sagittal, and axial. In most patients, changes in airways have been accompanied by improvements in sleep and breathing, allowing for the removal of tracheostomy with an improved quality of life. Three-dimensional reconstruction of airways revealed a useful tool to better understand the success of surgery. LEVEL OF EVIDENCE: IV.

Infraorbital nerve block for isolated orbital floor fractures repair: review of 135 consecutive cases.

BACKGROUND: Orbital blowout fractures can be managed by several surgical specialties including plastic and maxillofacial surgery, otolaryngology, and ophthalmology. Recommendations for surgical fracture repair depend on a combination of clinical and imaging studies to evaluate muscle/nerve entrapment and periorbital tissue herniation. METHODS: The aim of this study was to verify the applicability of regional anesthesia when repairing orbital floor fractures. A retrospective chart review was performed for isolated orbital floor fractures treated at the Department of Maxillofacial Surgery in Florence between May 2011 and July 2012. The study included 135 patients who met the inclusion criteria: 96 subjects were male (71%) and 39 were female (29%). The mean age was 45.3 years, ranging from 16 to 77 years. RESULTS: The results revealed that isolated anterior orbital floor fractures can be safely repaired under regional and local anesthesia. Regional and local anesthesia should be combined with intravenous sedation when the fracture involves the posterior floor. The surgical outcome was comparable to the outcome achieved under general anesthesia. There was a lower rate of surgical revisions due to concealed malposition or entrapment of the inferior rectus muscle (19% vs 22%). However, this result was not statistically significant (P > 0.05). CONCLUSIONS: THERE ARE SEVERAL ADVANTAGES TO SURGICALLY REPAIRING ISOLATED ORBITAL FLOOR FRACTURES UNDER REGIONAL AND LOCAL ANESTHESIA THAT INCLUDE THE FOLLOWING: surgeons can check the surgical outcome (enophthalmos and extrinsic ocular muscles function) intraoperatively, thereby reducing the reoperation rate; patient discomfort due to general anesthesia is eliminated; and the hospital stay is reduced, thus decreasing overall healthcare costs.