Use of Buccinator Myomucosal Flap in Tongue Reconstruction.

The myomucosal buccinator flap, first described by Bozola in 1989, has become an important tool for intraoral defects reconstruction. In the literature, there is a variety of proposed myomucosal cheek flaps, both pedicled and island, based on the buccal or the facial arteries. From January 2007 to December 2011, the authors used a pedicled buccinator flap based posteriorly on the buccal artery to reconstruct partial lingual defects following tumor resection in 27 patients. The buccal fat pad was translated to cover the donor site defect. After 3 to 4 weeks from the original surgery, a second procedure under local anesthesia was performed to detach the pedicle and remodel the flap. The morphological and functional outcomes of the procedures were evaluated by the surgeons and a speech and language therapist. All patients presented satisfactory results. The authors consider the use of the described technique as the gold standard in the reconstruction of partial tongue defects after tumor resection.

The reconstruction of the spheno-orbital region using latissimus dorsi flap and costal graft.

To minimize complications in skull base surgery, it is necessary to separate intracranial structures from the upper aerodigestive tract with well-vascularized tissue. The majority of defects can be reconstructed using local flaps using pericranium, galea, or temporalis muscle. However, there are conditions that affect the suitability of the previously mentioned flaps, for example, previous surgical procedures or radiotherapy. Local flaps may also be inadequate to reconstruct particularly large defects. Extensive bony demolitions produce aesthetic deformities that need accurate reconstructions. Orbital wall defects have to be reconstructed to avoid complications such as the transmission of cerebral pulsation, bulbar dystopias, diplopia, and ophthalmoplegia. The microvascular latissimus dorsi flap is ideal in all these cases, and the use of a costal graft allows simultaneous reconstruction of bony defects. From January 2000 to January 2008, 17 patients have undergone surgical ablation of the spheno-orbital region and reconstruction with latissimus dorsi flap and costal grafts. The flap survival rate was 100%. One patient required revision of the venous anastomosis. No cerebrospinal fluid leak or intracranial infections have been detected. The only complications registered were dystopias in 6 patients and diplopia in 4; all of these spontaneously resolved within 2 months. The microvascular latissimus dorsi flap with costal graft is an effective method for the reconstruction of the spheno-orbital region when local flaps are not indicated. It has a negligible donor-site morbidity, an ideal vascular pedicle, and an easy harvesting technique. The costal graft allows the simultaneous reconstruction of the orbital walls, giving good results.

The Impact of Upcoming Treatments in Huntington's Disease: Resource Capacity Limitations and Access to Care Implications.

BACKGROUND: The most advanced disease-modifying therapies (DMTs) in development for Huntington's disease (HD) require intrathecal (IT) administration, which may create or exacerbate bottlenecks in resource capacity. OBJECTIVE: To understand the readiness of healthcare systems for intrathecally administered HD DMTs in terms of resource capacity dynamics and implications for patients' access to treatment. METHODS: Forty HD centres across 12 countries were included. Qualitative and quantitative data on current capacity in HD centres and anticipated capacity needs following availability of a DMT were gathered via interviews with healthcare professionals (HCPs). Data modelling was used to estimate the current capacity gap in HD centres. RESULTS: From interviews with 218 HCPs, 25% of HD centres are estimated to have the three components required for IT administration (proceduralists, nurses and facilities). On average, 114 patients per centre per year are anticipated to receive intrathecally administered DMTs in the future. At current capacity, six of the sampled centres are estimated to be able to deliver DMTs to all the anticipated patients based on current resources. The estimated waiting time for IT administration at current capacity will average 60 months (5 years) by the second year after DMT availability. CONCLUSION: Additional resources are needed in HD centres for future DMTs to be accessible to all anticipated patients. Timely collaboration by the HD community will be needed to address capacity gaps. Healthcare policymakers and payers will need to address costs and navigate challenges arising from country- or region-specific healthcare delivery schemes.

Management of Migraine and the Accessibility of Specialist Care: Findings from an Extended Multinational Survey (My Migraine Center Survey).

INTRODUCTION: The parent study was a survey in 28 headache centers (6 countries) which identified five potential root causes for long waiting lists that limit patient access to specialist care. Here we performed an extension of the parent study to increase the panel of centers contacted, the representativeness of the analysis, and the statistical validity of the results, and to explore the role of dedicated headache clinics, triage, and specialized nurses. METHODS: We conducted a 19-question survey using a sample of 239 headache centers (16 countries). The five-area framework identified in the parent study was confirmed and further developed by describing treatment center archetypes according to their setting (general neurology versus dedicated clinic) and resources available within the center (number of healthcare professional [HCPs] full-time-equivalent positions). RESULTS: In total, 474 HCPs were interviewed across 16 countries. The proportion of patients with chronic migraine and episodic migraine varied across centers and countries. There was limited access to specialized centers in this enlarged sample; with global average waiting list of 3.7 months for the first visit and 2.5 months for the follow-up visit. Long waiting lists for headache patient care is a major issue in several countries, with the waiting lists for new patient visits extending up to 14 months. The presence of a dedicated nurse was correlated positively with the use of triage for prioritization of patient access (correlation coefficient: 0.85) and completing migraine diary (0.71). CONCLUSION: This study confirmed differences across treatment center archetypes in terms of patients, waiting lists, level of delegation to nurse, and patient education and compliance, and provides support for the potential benefit of dedicated clinical settings for headache patients. The survey highlighted the potential role of nurses in patient education and waiting list prioritization, consequently benefiting headache centers.

Thoracodorsal nerve graft for reconstruction of facial nerve branching.

OBJECT: Surgical treatment of parotid malignancies may frequently involve facial nerve amputation to achieve oncological radical resection. The entire facial nerve branching from its exit from the stylomastoid foramen to the periphery of the gland is often sacrificed. The first reconstructive strategy is the immediate reconstruction of the facial nerve by directly anastomosing the trunk of the facial nerve to its distal branches by interpositional nerve grafting. The present study was performed to determine the adequacy of thoracodorsal nerve grafting for immediate repair of the facial nerve. The anatomical features of the thoracodorsal nerve make it particularly appropriate to match its trunk to the stump of the facial nerve at its exit from the stylomastoid foramen. Up to seven branches of the thoracodorsal nerve may be distally anastomosed to the severed distal branches of the facial nerve. More complex reconstruction may be addressed simultaneously by contemporary harvesting a de-epithelialized free flap from the same site based on thoracodorsal vessel perforators and preparing a rib graft from the same donor site. METHODS: Between October 2003 and August 2010, seven patients affected by parotid tumors (6 with parotid malignancies and 1 with multiple recurrences of pleomorphic adenoma) underwent radical parotidectomy with intentional sacrifice of the facial nerve to obtain oncological radical resection. In all patients, the facial nerve was reconstructed with an interpositional thoracodorsal nerve graft. In four patients, a de-epithelialized free flap based on the latissimus dorsi was transposed to cover soft tissue defects. Moreover, two of these patients also required a rib graft to reconstruct both the condyle and ramus of the mandible. With the exception of one patient affected by recurrent pleomorphic adenoma, all patients underwent radiotherapy after surgical treatment. RESULTS: All patients in our study recovered mimetic facial function. Facial muscles showed clinical signs of recovery within 5-14 (mean: 7.8) months, with varying degrees of mimetic restoration, and almost complete facial symmetry at rest in all patients. The House-Brackmann final score was I in two patients, II in two patients, and III in three patients. CONCLUSIONS: A thoracodorsal nerve graft to replace extratemporal facial nerve branching is a valid alternative technique to multiple classical nerve grafts, with good matching at both the proximal and distal anastomoses.

Reconstruction of complex defects of the parotid region using a lateral thoracic wall donor site.

Radical treatment of parotid neoplasms may lead to complex parotid defects that present functional and aesthetic reconstructive challenges. We report our experience using the lateral thoracic wall as a single donor site. Between 2003 and 2009, four patients with malignant tumours in the parotid gland underwent radical parotidectomy and simultaneous reconstruction using a perforator latissimus dorsi cutaneous free flap (de-epithelialized and entire skin paddle in two cases each). A thoracodorsal nerve graft was used in all cases to replace the intraglandular branches of the facial nerve. Costal grafts were used for mandibular reconstruction in two patients. All patients underwent postoperative physiotherapy. No donor-site complication occurred and all treatments achieved good aesthetic results. All patients recovered nearly complete symmetry at rest and partial facial mimetic function. The lateral thoracic wall is a good donor site for the reconstruction of complex parotid defects.

Functional results after condylectomy in active laterognathia.

INTRODUCTION: Mandibular asymmetry due to overgrowth has two main forms, hemimandibular hyperplasia and hemimandibular elongation. It is necessary to distinguish between inactive and active forms, since surgical treatment of the latter, with a solely morphological aim, could lead to recurrence of further condylar growth. In these cases orthognathic surgery is performed in association with high condylectomy to interrupt the hyperactivity of the condyle. Condylectomy alone in growing patients stops the progression of deformities and sometimes achieves facial symmetry at the end of growth. Some authors have viewed condylectomy as a dangerous procedure, with the possibility of compromising articular function. We aimed to verify immediate and long-term results of condylar function after high condylectomy. MATERIALS AND METHODS: Between 1998 and 2007, 15 patients underwent high condylectomy for active laterognathia. All but one patient underwent postoperative Delaire functional rehabilitation. Long-term articular function was evaluated using subjective and objective criteria. RESULTS: In 14 patients, articular function was subjectively satisfactory. In one case, this did not occur because the patient refused postoperative functional rehabilitation. DISCUSSION AND CONCLUSIONS: Some authors have advised against condylectomy because of the possibility of temporomandibular joint dysfunction. High condylectomy in active laterognathia seems to be the procedure of choice in both adults and growing patients. In our experience, functional alterations of practical relevance are rare if the operation is followed by successful functional rehabilitation.