Vittorio Ramella

How we fix free flaps to the bone in oral and oropharyngeal reconstructions.

PURPOSE The use of suture anchors has been described in orthopedic, hand, oculoplastic, temporomandibular joint and in aesthetic surgery, but no study reports the use of the Mitek® anchors (Depuy Mitek Surgical Products, Inc. Raynham, Massachusetts) for fixing the free flaps used in oncologic oral and oropharyngeal reconstruction. MATERIALS AND METHODS In this prospective non-randomized study, 9 patients underwent surgical resection of oral or oropharyngeal cancer followed by a free flap reconstruction; mini anchors were used to fix the flap directly to the bone. We collected data regarding the patients, the tumor stage, the surgical procedure, the radiotherapy and the number of anchors used. RESULTS The average follow-up was 28months (range 24-38).We observed no complications with trans-oral, sub-mandibular and trans-mandibular approach in both oral and oropharyngeal reconstructions. All anchors became osteo-integrated and no complications occurred after radiotherapy. CONCLUSIONS In our opinion this device favors free flap adhesion to the bone. We registered no postoperative complications related to the use of the device which looks suitable for use in irradiated tissues. The radiotherapy did not cause any long-term complications related to the use of Mitek® mini bone anchors.

Five Years of Experience Using a Dermal Substitute: Indications, Histologic Studies, and First Results Using a New Single‐Layer Tool

Background Dermal substitutes have been used in Europe since 1996 as a mean of reconstructing the dermal layer. Objectives To introduce the dermal substitute as a dual‐stage reconstructing procedure using the dual‐layer version and as a single‐stage procedure, combining the single layer with a skin graft to achieve immediate closure. Our further objective was to evaluate the persistence of a commercial dermal substitute in the hosts dermal layer using serial histologic studies. Materials and Methods The dermal substitute used was a membrane made using a porous coprecipitate of type I bovine collagen and glycosaminoglycan organized in a three‐dimensional structure that allows the hosts cell to migrate into it. It is available in a double‐layer structure, covered by a silicone sheet, and in a single‐layer structure without silicon. Results and Conclusion We describe the dermal substitute indications in dermatologic surgery and our first results with the single layer as a single‐stage procedure with an 80% to 100% take rate. Our histological studies of both products show their perfect integration and the persistence of the peculiar three‐dimensional structure (neodermis) 5 years from implantation of the dual‐layer dermal substitute. The authors have indicated no significant interest with commercial supporters.

Suture anchors to fix free flaps in oral and oropharyngeal reconstruction

F he use of suture anchors has been widely described in rthopaedic, oculoplastic, temporomandibular, and aesthetic urgery,1,2 and they have also been used to fix pedicle flaps in ases of ulcers or post-traumatic deficiency.3 Other authors ave described their use in oncological head and neck surgery, ut only when a free flap was not needed.4 We have recently ested the use of the anchors for fixing free flaps to reconstruct oth the oral cavity and the oropharynx after resections for ancer.5 The Mitek® suture anchors (Depuy Mitek Surgical Prodcts, Inc. Raynham, Massachusetts) are produced in a number f different sizes (micro, mini, GII, and Super) but we use the ini. It is composed of a body and two wings, the body being ade of titanium alloy, and the wings of nickel-titanium alloy, hich benefits from superelasticity and its memory of shape. he packaging includes both the anchor and the insertion evice, in which the anchor is already preloaded. The bottom f the anchor has a loop that contains the suture, which is harged on to the insertion device (Fig. 1). The first step is the exposure of the bone. A calibrated ole is then drilled with the drill bit supplied in the package hat corresponds to the size of the anchor. The drilling is one slowly, perpendicular to the bone, and under abundant rrigation (Fig. 2). It is important to realise that the drill is not equired to pierce the entire thickness of the bone, because he anchor has to be positioned within the cortical bone to inimise the risk of overpenetration. Once the pilot hole has

Surgical Therapy: Forearm Free Flap Phalloplasty

Since its first description more than 20 years ago, phalloplasty using a free sensate flap is commonly considered as the gold standard for phallic reconstruction in female-to-male (FTM) transsexuals. Surgeons performing this procedure have to face different patient’s needs, including a good cosmetic result, a good rigidity, a tactile sensitivity and voiding while standing. The procedure may include the reconstruction of the urethra. Different techniques have been adopted during decades. Free flaps from nearly all parts of the body were described for penile reconstruction, but after an initial and euphoric phase, more recent publications of larger series of patients revealed a restriction to only two favourite donor sites: forearm flaps and fibula flaps.

Treatment of Subacute Traumatic Lower Limb Wounds by Assisted Healing and Delayed Selective Reconstruction

From 2007 to 2017, 34 patients with subacute wounds to lower limbs were treated by the assisted healing and delayed selective reconstruction method (AH-GSR). Sixteen patients (47%) presented with a concomitant fracture; 18 patients (53%) sustained degloving with a soft tissue injury only. Negative pressure wound therapy was used in 28 patients (82.3%). Antibiotics were given to all patients, in 12 (35.3%) as prophylaxis and in 22 (64.7%) as therapy. The reconstruction was performed by split-thickness skin grafts (SG) in 16 patients (47%), by dermal substitutes (DS) in 8 patients (23.5%), by local fascio-cutaneous flaps in 2 patients (5.9%), and by free flaps in 8 patients (23.5%). In this case series, three (8.8%) complications were recorded. Adhering to the AH-GSR method of treatment of lower extremities subacute wounds guarantees results comparable to the ones obtained with the treatment of acute wounds during the first week after injury.

Limb and Flap Salvage in Gustilo IIIC Injuries Treated by Vascular Repair and Emergency Free Flap Transfer

Background Gustilo classification system defines IIIC fractures as open fractures associated with an arterial injury that requires repair. The aim of our study was to analyze the early outcome in terms of limb and flap salvage, early amputation, and early complication rate in patients with Gustilo IIIC open fractures treated in an emergency setup. Methods We retrospectively reviewed 20 patients with Gustilo IIIC injuries treated by the “fix and flap” principle during the first surgical procedure in the first 24 hours after injury (emergency free flap transfer). All patients underwent surgery with radical debridement, wound irrigation, skeletal stabilization, vascular repair, and immediate free flap coverage. Results In this study, 18 patients were men (90%) and 2 were women (10%). In all patients, a vascular repair was performed and in 17 cases (85%), the lower limb/foot was avascular and limb salvage was performed. Three patients had one vessels injured (15%) and 17 had two or three vessels injured (85%). In 9 out of 20 (45%), a revision surgery was needed for arterial (10%, 2 patients), arterial‐venous (15%, 3 patients), and venous thrombosis (20%, 4 patients), while 4 patients required an early amputation (20%) and 1, a late one (5%). In three patients (15%), a flap loss occurred. Superficial infection occurred in seven cases (35%) and deep infection (osteomyelitis) in one (5%). Conclusion A single‐stage procedure performed in an emergency operating room could lead to an effective outcome with a high rate of limb salvage and satisfying long‐term results.

Is it possible to calculate surface areas of intraoral structures from preoperative CT scan

Microsurgical reconstruction of intraoral structures requires accurate planning of flap shape and dimensions. The goal of this study is to describe a method that allows to calculate surfaces of oral structures from preoperative CT-scan in order to determine a precise flap design before the surgery. We created casts of the human mouth from cadavers with a head and neck CT-scan available using an impression material. We digitalized the mouth casts and unwrapped the surfaces of the different structures of the mouth in a bi-dimensional plane in order to measure the area. Furthermore, we measured distances from pre-determined bony landmarks using the CT-scan 3D reconstruction model and we correlated the two type of measurements. We performed a simple regression analysis and afterwards a multivariate analysis using the more statistically correlated measurements. We found a statistical correlation between the surface of the tongue and the surface floor of the mouth with three bone distances that let us to create three mathematical formulas. With those formulas, we can calculate the surfaces of the tongue and the floor of the mouth using simple bony distances that can be easily measured from the head and neck preoperative CT scan. Using standard templates layouts, we can create a precise preoperative flap design in the reconstruction of the tongue and of the floor of the mouth.

Assisted Healing–Selective Delayed Reconstruction for Subacute Traumatic Wounds of the Lower Limb

1 BACKGROUND Patients often are being referred to plastic surgery for reconstruction of complex wounds in the subacute phase of healing. According to Godina,1 the time interval for the acute reconstruction (early free flaps) is less than 72 hours.2 Byrd et al,3 however, believe that the acute period of the wound lasts 1 week. Only after that, the wound enters in the subacute phase in which treatment of complex wounds becomes more prone to complications (bone and soft-tissue infection, free flap failure).

Arterial Pressure Management in a Reconstructive Microsurgery Patients by Dopamine Infusion in a Nonintensive Care Ward

1 BACKGROUND Free flap perfusion and arterial pressure management have always had a crucial role in free flap reconstruction. Blood pressure values requested can be reached either by using vasoactive agents or fluid replacement or the combination of both.1,2 In contrast to the most frequently tested phenylephrine, norepinephrine, and dobutamine,3,4 this work evaluates dopamine efficacy in perioperative blood pressure management. In our institution, dopamine infusion is the only vasoactive agent authorized in a non-intensive care unit department. This drug stimulates αand β-adrenergic receptors with positive chronotropic and inotropic effects and reduces peripheral vascular resistance helping in this way to achieve an increase of blood pressure and free flap perfusion.5

The Importance of Internal Mammary Vein in Breast Reconstruction

Since the 70s when the first autologous breast reconstruction by a free flap has been performed by Fujino, the interest for finding the optimal recipient vessels is ever present. Being centrally located on the chest, the internal mammary vessels have been a logical solution. However, the use of these vessels has serious limits: the internal mammary artery (IMA) should be spared, if possible, to serve as a by-pass conduit for revascularization of ischemic heart and the vein usually divides in the 4th ICS and may be inappropriate for a matching diameter anastomosis with the free flap pedicle. The unknown anatomy of the IMV has been a limiting factor for selection of IM vessels as recipient until detailed studies of anatomy in cadavers and clinical set-up have been performed in the 90s. From then on, there has been a constant progress in understanding the IMV, its course, ramifications, branches, interconnections and perforators. The classic approach to the IM vessels has been replaced by a less invasive rib-sparing and IMA preserving approach and anastomosis to perforators from IMA and IMV. Algorithms for selection of appropriate recipient vessels have been proposed.