Riccardo Cipriani

Oromandibular reconstruction using a fibula osteocutaneous free flap: four different "preplating" techniques.

Background: The aim of oromandibular reconstruction following a partially or fully extended resection is to recreate the normal morphology with a mandibular profile as similar as possible to the original and to restore oral function. Oromandibular reconstruction can be performed with fibula osteocutaneous free flaps combined with the preplating technique. The authors report their experience using the preplating technique for oromandibular reconstruction. Methods: Four different methods can be used to mold the titanium plate that will be used in reconstruction against the existing mandible before resection. The preplating technique was used in 18 patients between 1998 and 2003. In eight patients, the external cortical bone of the mandible was spared by the tumor and the vestibular preplating technique was used. In one patient, the internal cortical bone was unaffected and the lingual preplating technique was used. When the tumor affected both the internal and external cortical bones, the double preplating technique was adopted in eight cases and Luhr’s approach was used in one case. Results: A good cosmetic appearance was obtained through the accurate reconstruction of the inferior mandibular border. Mandible continuity was restored, and the masticatory and oral muscles were anchored to the titanium plate, resulting in good occlusal and functional rehabilitation. Conclusion: The preplating technique combined with a fibula microvascular free flap is a useful, predictable method for oromandibular reconstruction.

Hand reconstruction using the thin anterolateral thigh flap.

Background: Perforator flaps have been introduced for various kinds of reconstruction and resurfacing; in particular, the free thin anterolateral thigh flap is becoming one of the most preferred options for reconstruction of soft-tissue defects. Methods: Between 1999 and 2002, the authors used this flap as a free flap for nine cases for covering hand defects after burn, crushing injuries, or severe scar contracture release. There were eight men and one woman, the mean age of the patients was 31 years, and the size of the flaps ranged from 7 × 3.5 cm to 15 × 9 cm; thinning was performed in all flaps. Results: All flaps survived completely, and the donor site was closed directly in seven cases; in two cases, the exposed muscle was covered with split-thickness skin graft. Conclusions: The anterolateral thigh flap was thin enough for defects on the dorsum and/or palm of the hand and for first web reconstruction after scar contracture release. It has many advantages in free flap surgery including a long pedicle with a suitable vessel diameter, and the donor-site morbidity is acceptable. The thin anterolateral thigh flap is a versatile soft-tissue flap that achieves good hand contour with low donor-site morbidity.

Abdominal Wall Transplantation with Microsurgical Technique

Many patients undergoing intestinal or multivisceral transplantation have a past history of complete midgut removal with the loss of the domain of the abdominal compartment or have severely damaged abdominal walls from repeated laparotomies, tumours or enterocutaneous fistulae. These patients may encounter severe abdominal wall closure problems at the end of transplantation, resulting in increased morbidity and mortality. It is, therefore, of paramount importance to properly cover transplanted organs in order to reduce postoperative complications.

Prosthetically guided maxillofacial surgery: evaluation of the accuracy of a surgical guide and custom-made bone plate in oncology patients after mandibular reconstruction.

Background: The aim of the present study was to evaluate the accuracy of prosthetically guided maxillofacial surgery in reconstructing the mandible with a free vascularized flap using custom-made bone plates and a surgical guide to cut the mandible and fibula. Methods: The surgical protocol was applied in a study group of seven consecutive mandibular-reconstructed patients who were compared with a control group treated using the standard preplating technique on stereolithographic models (indirect computer-aided design/computer-aided manufacturing method). The precision of both surgical techniques (prosthetically guided maxillofacial surgery and indirect computer-aided design/computer-aided manufacturing procedure) was evaluated by comparing preoperative and postoperative computed tomographic data and assessment of specific landmarks. Results: With regard to midline deviation, no significant difference was documented between the test and control groups. With regard to mandibular angle shift, only one left angle shift on the lateral plane showed a statistically significant difference between the groups. With regard to angular deviation of the body axis, the data showed a significant difference in the arch deviation. All patients in the control group registered greater than 8 degrees of deviation, determining a facial contracture of the external profile at the lower margin of the mandible. With regard to condylar position, the postoperative condylar position was better in the test group than in the control group, although no significant difference was detected. Conclusions: The new protocol for mandibular reconstruction using computer-aided design/computer-aided manufacturing prosthetically guided maxillofacial surgery to construct custom-made guides and plates may represent a viable method of reproducing the patient’s anatomical contour, giving the surgeon better procedural control and reducing procedure time. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Accuracy of fibular sectioning and insertion into a rapid-prototyped bone plate, for mandibular reconstruction using CAD-CAM technology.

Modern techniques of mandibular reconstruction, such as CAD-CAM technology and rapid prototyping, offer new means by which reconstructive surgery can be planned to optimise aesthetic outcomes and prosthetic rehabilitation. The high degree of accuracy afforded by these approaches is principally attributable to high-precision fibular sectioning and insertion of the bone into a customised bone plate. CAD-CAM mandibular reconstruction procedures using vascularised bone free-flap transfers were performed on 10 patients with benign or malignant neoplasms. Five were not treated with the aid of CAD-CAM technology, and served as the control group. Five were scheduled for maxillofacial surgery using surgical cutting guides and customised bone plates. A generalised linear model for linear measures was used to compare the accuracy of reconstruction between the two groups. A difference, even though not significant, in the lateral shift of the mesial and distal positions of the fibular units was evident between groups. CAD-CAM-generated fibular surgical guides afford improved accuracy when used to restore native anatomy, especially in the context of mandibular arch restoration, and both operating room time and related costs are reduced during fibular sectioning.

The CAD–CAM technique for mandibular reconstruction: An 18 patients oncological case-series

BACKGROUND Modern techniques for mandibular reconstruction, such as CAD-CAM, offer new solutions for planning of reconstructive surgery in relation to the aesthetic outcome and the prosthetic rehabilitation. METHODS CAD-CAM reconstruction procedures using vascularised bone free-flap transfers and surgical guides to cut the mandible and fibula were performed in 18 cases of neoplasms. The planned surgery was used to design and manufacture customised surgical devices. RESULTS The mean follow-up was 12 months. All patients, except one, are alive without disease at the time of writing. Reconstructive microvascular flap survival was 100%. No major or minor microvascular complication occurred. No donor site complication was observed. CONCLUSIONS CAD-CAM technology is a very useful way to obtain the native morphology of the mandible, especially when both bi-dimensional and tri-dimensional defects occur. The reconstruction protocol presented offers several benefits and few disadvantages, which are discussed in the article.

Leg perforators and leg length: an anatomic study focusing on topography and angiogenesis.

The highly variable anatomic distribution of lower leg perforators is explored, with a standardization based on leg length. The possibility of a correlation between leg length and number of perforators is investigated. Twenty‐two lower limbs of cadavers were utilized for an anatomic study on the leg perforators branching from the three major vascular axes, anterior tibial, posterior tibial, and fibular. The parameters considered were the number of vascular pedicles per each major axis, the caliber, the distance of the fascial hole from the bony landmark (knee joint line), and the route of the vessels (muscular, septal). Arteries taken into account had a caliber of 0.5 mm or greater, with a maximum of 1.7 and a mean of 0.78. The perforators of the anterior tibial artery distribute along the entire length of the leg, but the peak of concentration is between second and third tenth and around the middle tenth. The fibular system provides perforators between the fourth and seventh tenth. The posterior tibial perforators concentrate to the middle third and to the supramalleolar region. A correlation exists between leg length and number of perforating vessels for the tibial vascular systems, possibly due to neoangiogenesis during growth, at the level of the metaphyseal plates. On the contrary no relationship was noticed for the fibular artery, whose perforators concentrate far from the growth cartilages. Some tenths where perforators concentrate are identifiable. Tibial systems have a perforator incidence depending on leg length, which, on the contrary, does not influence the number of fibular perforators. Clin. Anat. 23:593–605, 2010.

Adapting a Vacuum Assisted Closure dressing to challenging wounds: negative pressure treatment for perineal necrotizing fasciitis with rectal prolapse in a newborn affected by acute myeloid leukaemia.

We report the case of a newborn with acute myeloid leukaemia, who developed perineal necrotizing fasciitis due to Pseudomonas Aeruginosa, after twenty days of life. Following surgical debridement, she was effectively treated with topical negative pressure therapy (V.A.C.(R) device) with silver foam dressings, this achieved complete closure in thirteen days. Negative pressure therapy should be considered when conventional wound care fails to achieve complete wound closure, even in neonates.

ANTEROLATERAL THIGH FREE FLAP FOR TRACHEAL RECONSTRUCTION AFTER PARASTOMAL RECURRENCE

Stomal recurrence after total laryngectomy is 1 of the most serious issues in head and neck surgery, both because of the complexity of its management and because of its morbidity. Prior to the introduction of free‐tissue transfer, mediastinal tracheostomy has been the standard reconstructive procedure with high rate of complications. The ideal reconstructive solution to these problems must provide well‐vascularized soft tissues that can cover the defect after resection and also allow suturing of the tracheal remnant to skin edges without tension.

Does microvascular free flap reconstruction in oral squamous cell carcinoma improve patient survival

Objective We analyzed our experiences with microvascular reconstruction after oncologic resections for oral squamous cell carcinoma. Has microvascular surgery changed the survival rate of these patients? Design Retrospective study. Subjects and Methods Forty-two consecutive patients enrolled from March 1999 to December 2004. Follow-up time ranged from 1 to 94 months. Survival rates were evaluated by the Kaplan-Meier method and compared among different groups with the use of Cox regression. Results The actuarial 5-year survival rate was 41.9% (SD = 9.6%). Survival rates were also analyzed according to T, N, and stage. The survival was significantly related only to N, which showed a 72.4% increase in the risk related to the increase of one N stage. Conclusions A comparison between our study group and those of 3 previous similar studies would not provide definitive statistical evidence, but it could certainly suggest a trend. The comparison seems to support that microvascular free tissue transfer does not change the survival of these patients.