Epithelioid hemangioendothelioma of the mandibular gingiva: A rare case of metastasis 4 years after radical excision and literature review.

Malignant epithelioid hemangioendothelioma (MEH), or high-risk epithelioid hemangioendothelioma, is a low- to intermediate-grade vascular malignancy. A few cases of MEH have been documented in the head and neck region, including the neck, thyroid gland, larynx and scalp. MEHs are extremely rare in the oral cavity. Only 31 cases of MEH in the oral cavity were described in English literature between 1975 and 2014. Further, only eleven cases were referred to MEH of the maxillary or mandibular gingiva. No gingival MEH metastases have been described in literature. We report a literature review and a case of MEH with a metastatic occurrence 4 years after surgical excision.

Crescentic flap for the reconstruction of the nose after skin cancer resection.

PURPOSE: Non-melanoma skin cancers are the most frequent skin tumours; in 25.5% of cases, they are reported to affect the nasal area. For an excellent surgical outcome, first of all the radical excision of the lesion is important, with appropriate margins of healthy skin in order to avoid recurrences. Moreover is important to achieve a good aesthetical result, avoiding distortion of the aesthetic units and preserving their functions. MATERIAL AND METHODS: We have applied the modified crescentic flap, described by Smadja in 2007, to 24 nasal skin defects left by oncologic surgery. It consists of the crescent-shaped resection of Burow's triangle all around the alar groove that allows the advancement of the flap to the tip of the nose, hiding the scar in the alar groove. RESULTS: The outcome and the long-term follow-up were completely satisfactory both for patients and for surgeons. CONCLUSION: For skin defects localized in the midline or paramedian line of the dorsum of the nose, the crescentic flap seems to be a good solution to obtain the better aesthetic result with respect to both anatomy and function of the nasal area, sparing the patient a second intervention or an overly invasive procedure.

Guidance flap choice for lip cancer: Principles, timing and esthetic-functional results / Guía para la elección del colgajo en el cáncer de labio: principios, tiempos, resultados estéticos y funcionales

The purpose of this study is to help in the choice of an appropriate reconstructive technique by reference to the dimensions of the defect, the required functional and esthetic outcomes, and retention of adequate surgical safety margins to prevent primary tumor recurrence. Material and methods. A total of 158 patients were treated. We indicate how the most appropriate reconstructive method may be chosen, with reference to the size and position of the cancer and depth of tissue infiltration. Result. Of all patients, 89 (56.3%) had T1 (lesions up to 2 cm long, less than 1/3). The remaining patients had T2 lesions >2 cm, from 1/3 to 2/3 of lip involvement (50 patients), T3 lesions >4 cm, more than 2/3 of lip involvement (18), and a T4 lesion > 5.5 cm with commissure involvement (1). Conclusion. We share the widespread view that a surgeon who performs a reconstruction using the minimal tissue components required to close the lesion will achieve the best results. Reconstruction does not influence prognosis and overall should be oriented to the defect. Careful, clean, and safe resection of lip carcinoma, with creation of healthy margins, can be followed by functional and esthetic lip reconstruction (AU)

El objetivo de este estudio es orientar al cirujano en la correcta elección de una técnica reconstructiva según la dimensión del defecto, de los resultados estéticos-funcionales necesarios y tendente a conservar los margenes quirúrgicos de seguridad indispensables para prevenir la recidiva del tumor primitivo. Materiales y métodos. Analizaremos los casos de cáncer de labio tratados en 158 pacientes, indicaremos el método apropiado para la reconstrucción con referencia a la dimensión y localización del cáncer, y a la profundidad del tejido infiltrado. Resultados. De todos los pacientes que hemos analizado, 89 (56,3%) pertenecían al grupo clasificado como T1 (lesiones hasta 2 cm de largo, menos de 1/3 del labio implicado), 50 pacientes pertenecían al grupo T2 (lesiones > 2 cm, desde 1/3 hasta 2/3 del labio involucrado), 18 pacientes pertenecían al grupo T3 (lesiones > 4 cm, más de 2/3 de labio implicado) y un paciente pertenecía al grupo T4 (lesiones > 5,5 cm, con la comisura incluida). Conclusión. Coincidimos con la idea de que el cirujano reconstruye utilizando la cantidad mínima de tejido para corregir la deformidad y obtener los mejores resultados, pero la reconstrucción no puede influir en el pronóstico, solo debe orientar el tipo de defecto. Una extirpación segura de el tumor del labio, meticulosa, con el mantenimiento de los márgenes sanos, debe ser complementada con una cirugía reconstructiva del labio en su totalidad, es decir, en toda su estética y su funcionalidad (AU)

Intraoral approach for aesthetic restoration of posttraumatic zygomatic arch deformities.

Minimally invasive oral and maxillofacial surgery is now being developed for virtually all minor and major oral and maxillofacial surgeries, and developments are now focused on facial trauma surgery. This article assesses the feasibility of reducing isolated zygomatic arch fractures using the intraoral lateral coronoid approach. The procedure is cost-effective and timesaving, as it can be performed under local anesthesia in an emergency department or similar clinical setting and does not need postoperative hospitalization if no other comorbidities are present.

Technical tips for a cosmetic approach to parotid surgery.

PURPOSE: Recently, skin incisions have tended to be smaller if surgical exposure is not greatly compromised, especially for benign lesions of the head and neck. An incision in a visible area of the neck needs to be moved to hidden or less prominent sites or away from the head and neck. For aesthetic considerations, the preauricular broken/postauricular trichophytic skin incision was developed for parotid surgery. PATIENTS AND METHODS: This retrospective clinical study enrolled 36 patients (20 women and 16 men) with benign preneural parotid tumors. Six months after surgery, patients were specifically asked to rate their satisfaction with their postoperative appearance on a scale of 1 to 10, with higher scores meaning better patient satisfaction, and whether they would consent to the operation again. RESULTS: All patients were satisfied with the cosmetic outcome: 24, 9, and 3 patients rated the procedure 8, 9, and 10, respectively. CONCLUSIONS: The preauricular broken/postauricular trichophytic skin incision provides generous access to the parotid gland, which is at least as good as the access provided by a Blair incision. It is an aesthetically superior incision that allows good surgical access and improved contour reconstruction.

Wave technique for treatment of lower lip cancer.

PURPOSE: This article reports the authors' experience with treatment of lower lip cancer using the wave technique. PATIENTS AND METHODS: Twenty-one patients (16 males, 5 females) were treated using the wave technique between September 2009 and October 2010. Patients undergoing the procedure had tumors that were classified as either T1N0M0 or T2N0M0. Lateral defects less than 2 cm in size are generally treated with unilateral flaps, and median defects are closed with bilateral symmetric flaps. If the defect is paramedian and greater than 2 cm in width, two asymmetric flaps are used. RESULTS: No recurrence was observed during a 6- to 32 months follow-up (mean 19 months). All patients showed excellent esthetic results with no microstomia. CONCLUSIONS: We modified the straight lines of the staircase technique into round lines of the wave technique, resulting in an esthetic improvement. The goal of the broken lines and round lines is to create less visible scars. The wave technique can be used to close defects of up to two-thirds of the lower lip.

Cicatricial iatrogenic lower eyelid malposition in skin cancer surgery: results of a combined approach.

PURPOSE: Malposition of the lower lid, including rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, and ectropion, is a relatively frequent complication in the surgical treatment of skin cancer of the cheek and zygomatic areas. The tarsal strip technique, in association with a vertical vector cheek lift, is a reliable method for correcting lower lid malposition. MATERIALS AND PATIENTS: From January 2008 to January 2010, we treated 19 patients with lower eyelid malposition after skin cancer surgery of the cheek and zygomatic areas. To correct lower eyelid malposition, we used the tarsal strip technique and a vertical vector cheek lift in all patients. RESULTS: Eleven patients had scleral show and eight patients had ectropion. Sixteen patients obtained satisfactory correction of the eyelid malposition in a single surgical procedure, while three patients required a second surgical step to correct the remaining scleral show. Good esthetic and functional results were achieved in all cases. CONCLUSIONS: The surgical treatment of skin cancer of the cheek and zygomatic areas has the potential for postoperative sequelae. The tarsal strip technique, in association with a vertical vector cheek lift, is a relatively simple technique for correcting scleral show and ectropion.

Piezosurgery to perform hyoid bone osteotomies in thyroglossal duct cyst surgery.

Ultrasonic bone-cutting surgery has been introduced as a feasible alternative to the conventional sharp instruments used in craniomaxillofacial surgery because of its precision and safety. The device used is unique in that the cutting action occurs when the tool is used on mineralized tissues and stops on soft tissues. This work describes the use of piezosurgery for hyoid bone resection in thyroglossal duct cyst surgery, briefly reviews the literature on the surgical technique, and reports our experience with 12 cases.

Tracheostomy in maxillofacial surgery: a simple and safe technique for residents in training.

BACKGROUND: Tracheostomy is a frequently performed surgical procedure and may be required under emergency, semiurgent, or elective conditions. In maxillofacial surgery, it is indicated in congenital, inflammatory, oncologic, or traumatic respiratory obstruction and prolonged intubation. This article presents a simplified tracheostomy procedure based on anatomic markers that gives the best compromise between minimum invasiveness and safety. PATIENTS AND METHODS: A retrospective study analyzed the clinical aspects, treatment methods, and clinical course of 198 patients who underwent tracheostomies performed by residents in training under the supervision of surgeons between October 2002 and December 2007 at the Maxillofacial Surgery Department of Carlo Poma Hospital, Mantova, and the Maxillofacial Unit, Head and Neck Department, University of Modena and Reggio Emilia, Italy. Tracheostomies were performed in 127 patients (64.14%) with neoplastic diseases (tumors of the tongue base, tonsils, and oral and pharyngeal regions) and in 71 patients with trauma (35.86%). The patients were followed up for 3 to 65 months. RESULTS: Acceptable clinical healing and outcomes were obtained in all patients. Intraoperative complications occurred in 35 patients (17.7%): bleeding in 32 patients (16.2%) and pretracheal or paratracheal tube placement in 3 patients (1.51%). Postoperative complications after tracheostomy closure included tracheostomy dehiscence in 5 patients (2.52%) and subcutaneous emphysema in 26 patients (13.12%). Tracheostomy dehiscence occurred in 3 patients with neoplasia (1.51%) and in 2 patients with trauma (1.01%). No symptomatic tracheal stenosis developed. CONCLUSIONS: The standardized surgical technique presented here reduces the associated surgical risk when the correct anatomic markers are used and important structures are recognized and handled correctly.

The bilobed flap in skin cancer of the face: our experience on 285 cases.

BACKGROUND: This article describes how many of the defects caused by oncological surgery can be closed with an easily estended flap. PATIENT AND METHOD: The Zitelli bilobed flap was used to treat 285 consecutive patients with basal cell carcinomas (BCCs) or squamous cell carcinomas (SCCs); 167 men (58.60%) and 118 women (41.40%) between 45 and 98 years of age. Histologically, 247 BCCs (86.6%) and 38 SCCs (13.4%) were documented. Regarding the site, 148 (51.9%) involved the nose, 51 (17.9%) the cheeks, 36 (12.6%) the preauricular region, 27 (9.5%) the perilabial region and chin and 23 (8.1%) the periorbital region. To measure long-term satisfaction patients responded to a telephone survey consisting of a single global question. RESULTS: The size of the defect following tumour removal was between 1 and 4cm. Carcinomas up to 1cm were treated using a one step procedure with a cryostat test of the surgical margins; all others cases were treated using two step procedure after excision and histological in sano resection. Completely acceptable aesthetic and functional deficits were obtained in 275 (96.4%) patients over a 6-72-month follow-up. Ten (3.6%) patients suffered postoperative complications. Two cases of local infection; one case of completely flap necrosis and seven cases of partial revision due to flap necrosis occurred. The level of satisfaction with the surgical long-term result reported by the patients was high. CONCLUSION: In our experience the bilobed Zitelli flap for covering defects in the area of the face showed very few complications and good aesthetic results.

A comparative study of different approaches in the treatment of orbital trauma: an experience based on 274 cases.

PURPOSE: The aim of the study was to compare the aesthetic results, complications and surgical indications in patients treated for orbital trauma by one of three different approaches: subciliary, transconjunctival or transconjunctival with lateral canthotomy. MATERIALS AND METHODS: In this retrospective study, 274 patients (169 men and 105 women aged 16-78 years) who had been treated for orbital trauma without soft tissue lacerations of orbital region and then returned for long-term follow-up (6-48 months) between 2000 and 2007 were evaluated in terms of aesthetics and function for the presence of a visible scar and lower-eyelid malposition (scleral show or ectropion). RESULTS: Of the 274 patients, 50 (18.2%) experienced complications. In the group of 219 patients treated with the subciliary approach, 41 experienced complications, whereas amongst the 32 patients treated with the transconjunctival approach, there was one complication (0.3%) and amongst the 23 patients treated with the transconjunctival approach and canthotomy, there were eight complications (34.8%). CONCLUSIONS: Patients treated for orbital trauma with the transconjunctival approach with canthotomy had a higher rate of lower eyelid malposition. Transconjunctival incision without canthotomy was the most successful surgical approach for the treatment of isolated fracture of the orbital floor; however, when major surgical exposure is necessary, subciliary incision is recommended.

Usefulness of fine-needle aspiration in parotid diagnostics.

PURPOSE: Fine needle aspiration (FNA) is a safe diagnostic technique that is widely employed for lesions of the head and neck. Among head and neck sites, the parotid gland is unique in the number, diversity, and peculiarity of its pathological processes. This complexity has prompted a great deal of discussion regarding the application of FNA to parotid masses, primarily focusing on the reliability of FNA as a diagnostic tool in guiding patient management. METHODS: This review presents an analysis of the usefulness of FNA in differential diagnosis of parotid pathologies. RESULTS: Recent studies have confirmed a wide range of accuracy rates for FNA evaluation of parotid masses, varying from 79% to 97%. These data cannot be uniformly anticipated across all diagnostic scenarios. FNA is notoriously unreliable in recognising the malignant nature of parotid carcinoma providing its precise classification and establishing its grade. A few malignant neoplasms are particularly prone to diagnostic error: acinic cell carcinoma is frequently interpreted as benign, and low-grade lymphomas are often discounted as inflammatory processes. CONCLUSIONS: FNA cytology is useful in avoiding surgery (inflammatory lesions) or limiting surgical procedures (benign tumours). For planning the extent of surgery of malignant parotid tumours, the histological subtype and/or grade should be determined; therefore, a histological diagnosis by frozen section analysis is required. Moreover, reliance on FNA findings at the expense of clinical, radiographic, and intraoperative findings is unwarranted. Regardless of whether FNA is used routinely or selectively in patients with parotid masses, the findings should contribute to, and not replace, the overall diagnostic impression.

Combined technique for the correction of prominent ears: results in 140 patients.

We present our assessment of a combined technique for the correction of prominent ears in 140 patients between 1991 and 2007. We had no major complications, and minor complications including extrusion of a stitch, granuloma around a suture, hypertrophic scarring, and superficial ulceration on the anterior side of the helix developed in nine patients. Two also developed residual asymmetry. A good aesthetic result was achieved in all cases.

Surgical treatment of lip cancer: our experience with 106 cases.

PURPOSE: To report our experience with 106 cases of lip cancer. PATIENTS AND METHODS: We treated 106 patients with stages T1, T2, or T3 lip cancer (76, 22, and 8 cases, respectively). For the 34 T1 lesions up to 1 cm in diameter, we used a V or W excision. In the 42 T1 lesions greater than 1 cm and the 20 T2 lesions, we used the staircase technique. In 2 T2 cases, the carcinoma was located on the labial commissure and was treated with the Fries technique. For the 8 T3 cases, we used the Bernard-Freeman-Fries technique. In 28 patients, a lip shave was performed and tumor was removed. The 7 patients who were N+ at diagnosis underwent modified radical neck dissection and radiotherapy. RESULTS: Ten patients died during the follow-up period of 11 to 65 months: 8 of unrelated causes and 2 of new upper aerodigestive tract carcinoma. None of the patients died of their lip cancer. CONCLUSIONS: Lip cancer is a frequent disease of the oral cavity. Although general agreement has been reached concerning stage T and N+ surgical treatment, unresolved questions remain with regard to N0 treatment. We present our experience and suggestions.

A simple method of identifying the spinal accessory nerve in modified radical neck dissection: anatomic study and clinical implications for resident training.

PURPOSE: The major complication of neck dissection and surgery at the posterior triangle of the neck is the shoulder syndrome, which results from spinal accessory nerve injury. Erb's point (the great auricular nerve) and the point where the spinal accessory nerve enters the trapezius muscle are used to identify the spinal accessory nerve in the posterior nerve triangle. MATERIALS AND METHODS: Measurements were made during unilateral neck dissections in 30 patients to identify the relationship between the spinal accessory nerve and great auricular nerve and the distance between the entrance of the accessory nerve in the trapezious and clavicle. RESULTS: The distance between the spinal accessory nerve and Erb's point was ranging from 0 to 3.8 cm (mean 1.53 cm). The distance between the spinal accessory nerve entering the trapezious muscle and the clavicle was between 2.5 and 7.3 cm (mean 4.8 cm). CONCLUSIONS: Since the great auricular nerve (Erb's point) represents a constantly identifiable landmark, it allows simple and reliable identification of the course of the spinal accessory nerve. Also useful, but of secondary importance in our opinion, is identifying the nerve at the point where it enters the trapezius muscle.