Guido Gabriele

Scarless lymphatic venous anastomosis for latent and early-stage lymphoedema using indocyanine green lymphography and non-invasive instruments for visualising subcutaneous vein

BACKGROUNDnLymphoedema can be treated conservatively or surgically. Early treatment is important, but the surgical indication and the effect of surgery on pain in lymphoedema-affected limbs have not been described. The objective of this study was to examine the effect of low-invasive scarless lymphatic venous anastomosis (LVA) for early or latent lymphoedema.nnnMETHODSnLVA was performed in six patients (eight legs) with leg lymphoedema between April 2010 and March 2011. Lymphoedema was stage 0 (defined as subclinical) in three patients (five legs) and stage 1 in three patients (three legs). Subjective symptoms, circumference of the affected leg and a lymphoscintigram were evaluated before and 6 months after surgery. Preoperatively, subcutaneous lymph vessels and veins were identified non-invasively using ICG lymphoscintigraphy and non-invasive instruments for visualising subcutaneous vein, AccuVein system, through the skin. These vessels and veins were secured with vessel loops passed underneath and side-to-side anastomosed under a surgical microscope.nnnRESULTSnSubjective symptoms improved after surgery in all patients. The leg circumference improved in stage 1 cases, which all had an increased circumference before surgery. Lymph retention was observed on preoperative lymphoscintigraphy in all six patients and was improved after surgery in all cases.nnnCONCLUSIONSnScarless LVA performed through a small incision improves abnormal lymph circulation and subjective symptoms in cases of early lymphoedema, in which the limb circumference has just started to increase, and latent lymphoedema, in which the circumference has not increased, but abnormal findings on lymphoscintigraphy or subjective symptoms are present.

A dental implant in the anterior cranial fossae

Foreign bodies in the anterior cranial fossa are unusual. This is a case of a 50-year-old man who presented with a dental implant displaced into the anterior cranial fossae, which was removed endoscopically with dural reconstruction.

Functional outcomes in bilateral temporomandibular joint ankylosis treated with stock prosthesis

AbstractThe purpose of this study was to evaluate the functional outcomes in patients affected by bilateral temporomandibular joint (TMJ) ankylosis treated with TMJ total alloplastic reconstruction with stock prosthesis. As a matter of fact, ankylosis of the TMJ may produce the narrowing of the oropharyngeal airway space resulting in the obstructive sleep apnea syndrome, a pathological condition characterized by repetitive upper airway obstructions during sleep, resulting in arousal from sleep, sleep fragmentation, arterial oxygen desaturation. and daytime hypersomnolence.Clinical results demonstrate that total TMJ reconstruction with prosthesis is the surgical modality of choice to obtain the counterclockwise rotation and the advancement of the maxillomandibular complex, which significantly increase the volume of the oropharyngeal airway space in this kind of patients.

Magnetic resonance lymphangiography: How to prove it?

We found interest in the article by Mitsumori et al that reported their experience of magnetic resonance lymphangiography (MRL). We congratulate Mitsumori et al on their article on the four consecutive patients studied; however, some critical aspects in the text should be pointed out. For example, Mitsumori et al report a literature review of lymphaticovenular anastomosis (LVA) treatments, but do not report if the four patients affected by lymphedema referred to in that article were operated on with LVA, and the data regarding the postoperative outcomes are not present. MRL has been previously studied for lymphedema diagnosis and staging: Recently at the Lymphoedema Mondial Congress in Rome, 2013, and the International Lymphoedema Congress in Genova, 2014, many criticisms were raised against the use of MRL and the possible discrimination between lymphatic and venous vessels. Lohrmann et al reported the visualization of venous vessels, as contrast may be captured by both lymphatic and venous capillaries: venous vessels resulted in contrast enhancement faster than lymphatic vessels, which were slower. In a lymphedematous limb the diffusion of the contrast in the venous system may be modified due to the previous surgery. Further resonance imaging of lymphatic vessels may be even more doubtful on nonedematous limbs. Another aspect that evoked our attention in the Mitsumori et al article is their criticism of indocyanine green (ICG) lymphography: this minimally invasive imaging technique is more accepted by patients than a 2-hour MRL, it is easy to repeat, and the costs are reduced compared to MRL: further, no pain is usually referred by the patients, while Mitsumori et al report mild to moderate pain in the four patients who received the gadobenate (Gd) contrast injections. Mitsumori et al refer only to the Chang et al and Ogata et al studies regarding ICG lymphography, while recent articles reported even more advantages from the use of this technique. The main doubtful aspect of this article is their difficulty in proving that the identified vessels are really lymphatic vessels: the absence of an MRL performed on healthy limbs reduces the proof of the results of this article. In comparing ICG lymphography to MRL in a limb of healthy patients, we may observe numerous lymphatic vessels in the ICG lymphography that are not reported in the MRL (Fig. 1). To prove this theory, our multidisciplinary study group is performing a study of MRL performed on lymphedema patients enrolled for LVA and histological examination of biopsy specimens of the vessels identified at the MRL. We will soon submit this article.

Temporomandibular synovial chondromatosis with numerous nodules.

Synovial chondromatosis of the temporomandibular joint is an uncommon disorder with an indolent clinical course and a slow progression. We report a rare case of unilateral early synovial chondromatosis of the temporomandibular joint with numerous nodules and discuss possible etiologies for the entity of loose bodies and the evolution of this disease.

Mandibular nerve fascicular cross-face for sensitive recovery after mandibulectomy: A new technique

Abstract Trigeminal nerve damage after mandibulectomy is a condition that may occur not infrequently when oncologic resections of the maxillo-facial district are performed. In the last decades microsurgery has made possible effective osteomuscular reconstructions using vascularised free flaps. Nevertheless, this procedure, if assuring satisfactory results, involved the sacrifice of the mandibular nerve. Nowadays, supramicrosurgical innovation has shifted the gold-standard to a higher level, allowing the complete sensitive recovery after mandibulectomy. The cross-face nerve transfer technique is an innovative procedure that provides excellent nerve regeneration in mini-invasive operations, avoiding visible scars and any deficiency in donor sites. We suggest that the cross-face nerve transfer is the surgical modality of choice to restore lower lip and chin sensibility after mandibulectomy.

Side-to-end trigeminal to trigeminal fascicular neurorrhaphy to restore lingual sensibility: a new technique.

Injuries to the lingual nerve can result from a variety of oral and maxillofacial surgical procedures. The anatomical proximity of lingual nerve puts it at risk during procedures on adjacent structures. The most common surgical procedure associated with iatrogenic lingual nerve lesions is extraction of third molars. However, lingual nerve injury has also been reported after mandibular sagittal split osteotomies, mandibular fractures, submandibular salivary gland excision, sialolith, dental implant placement, laryngoscopy, and general dental therapy, such as local anesthesia injection.1,2 Lingual nerve can also be involved in oncologic resection in the head and neck district. The tongue is an important and sensitive anatomical structure that serves a range of vital functions such as mastication, phonation, and deglutition.3 Patients with loss of lingual nerve function are affected by serious discomfort complaining recurrent tongue bite lesions, unilateral numbness, neurogenic paresthesia, or dysesthesia, difficulty with pronunciation and chewing, loss of gustatory function in the lesion side. Some patients may even suffer from episodic or constant neuralgic pain, known as allodynia. Depending on the nature and extent of the injury, some lingual nerve lesions have the potential for functional regeneration.4,5 In the majority of cases, direct neurorraphy still remains the surgical option of choice. Nevertheless, oncologic resections for treating oral or lingual cancers often require the sacrifice of lingual nerve making direct neurorraphy impossible. Nowadays, the advancement in microsurgery and, moreover, the introduction of supramicrosurgery, have made surgical restoration of lingual nerve lesions effective.6,7 Gennaro et al8 describe a new supramicrosurgical procedure to restore lingual sensibility.

LEOPARD syndrome: maxillofacial care.

This article reports a case of a boy with LEOPARD syndrome with unusual mandibular osteolytic osteoclastic-like lesions and eruption disorder. The patient was referred to our department for bilateral facial swelling: systemic examinations, diagnosis, and dental and maxillofacial care are reported.

Giant palatal schwannoma.

Schwannoma is a benign tumor that arises from nerves that contain Schwann cells. We report a case of giant schwannoma of the hard palate, which originated from the greater palatine nerve and is interesting for its large dimensions.

Comparative study in orthognathic surgery between Dolphin Imaging software and manual prediction.

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