Paolo Gennaro

Lymphaticovenular anastomosis to prevent cellulitis associated with lymphoedema

One of the complications of lymphoedema is recurrent cellulitis. The aim was to determine whether lymphaticovenous anastomosis (LVA) was effective at reducing cellulitis in patients with lymphoedema.

MR lymphangiography: a practical guide to perform it and a brief review of the literature from a technical point of view

We propose a practical approach for performing high-resolution MR lymphangiography (MRL). We shall discuss and illustrate the technical approach for the visualization of lymphatic vessels in patients suffering from lymphedema, how to distinguish lymphatic vessels from veins, and MRL role in supermicrosurgery treatment planning. A brief review of literature, from a technical point of view, is also reported.

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.

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.

Inferior alveolar nerve lateralization: A dual technique

Dear Editor We read the article ‘Rehabilitation of edentulous posterior atrophic mandible: inferior alveolar nerve lateralization by piezotome and immediate implant placement’ by Fernández Dı́az & Naval Gı́as with great interest, and we congratulate the authors for their review of inferior alveolar nerve lateralization (IANL) and for describing the challenges in re-using an updated technique. The use of piezosurgery is an appealing concept in maxillofacial surgery due to the frequent proximity of the bone surgical site to the nerve and/or vascular tissues; many studies have suggested this application in implant surgery, and have reported satisfactory in vivo and in vitro results compared with the bur technique. In the discussion section, Fernández Dı́az and Naval Gı́as refer to the common habit of the surgeon to choose techniques based on their own experience. We partially agree with this concept, as young surgeons and researchers often introduce new techniques or use validated theories from other medical disciplines to find better postoperative outcomes; hence this appears to be a related condition, more due to the specific personal characteristics of some surgeons than to a common habit. Fernández Dı́az and Naval Gı́as discuss mandibular atrophy, a common case in prosthetic dentistry, and refer to the occurrence of vertical bone resorption and postoperative infections due to wound dehiscence as complications in mandibular bone grafts that could suggest the use of IANL to obtain the needed vertical bone instead. They also relate the use of a sandwich technique as a key factor in decreasing the occurrence

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

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Conservative surgical and microsurgical techniques for the management of dental implants that impinge on the inferior alveolar nerve

Loss of sensation in the lip after insertion of an implant is annoying. The aim of this paper was to describe two techniques for management of osseointegrated dental implants that impinge on the mandibular nerve, the purpose of which is to improve sensation without unscrewing the dental implant.

Implant surgery triggered bisphosphonate-related osteonecrosis of the jaws (BRONJ).

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Management of a bulky capillary hemangioma in the parapharyngeal space with minimally invasive surgery.

In this article, the authors report their management with minimally invasive surgery of a bulky capillary hemangioma in the parapharyngeal space. Parapharyngeal space capillary hemangioma is a rare tumor in adults. Because of its rarity and difficulty to treat, we suggest a multidisciplinary approach in choosing the best treatment, with an accurate follow-up.