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The purpose of this pictorial essay is to clarify and propose a novel positioning technique for raising the free flaps on the peroneal system with the aim of obtaining optimal exposure of the operating field, good stabilization of the inferior limb with high comfort for the surgical teams without the need of a third assistant during the harvest or closure. A review of the literature, focusing on the exact position of the patient during the harvest of the peroneal system flaps, was made and no key publications were found. In February 2007, the Maxillofacial group at the Bufalini Hospital of Cesena and the University of Sassari Hospital switched from putting the patient in a standard Gilbert's technique with the use of a second assistant to a novel positioning technique in the supine position with the use of the orthopedic-derived supports in order to hold the leg during the harvest. A broad literature review was also performed, revealing very little literature on this topic. A shared guideline for standardized positioning of the patient in FFF harvesting can decrease the potential risk for gravitational-related injuries on the operating table and thus the legal complaints as well. We think that our novel positioning technique can be useful for all residents in maxillofacial, plastic and ENT Departments, improving the time spent in the operating room and for all the more skilled senior colleagues who carry out this type of intervention to facilitate their task and make it more comfortable. Level of evidence: level V, therapeutic study [ABSTRACT FROM AUTHOR]

Soft tissue sarcomas represent an heterogeneous group of rare mesenchymal tumors comprising 1% of all solid malignancies. Among them, liposarcoma is one of the most common histotypes with atypical lipomatous tumor/well differentiated liposarcoma and dedifferentiated liposarcoma (ALT/WDLPS and DDLPS) as the major sub-entities. The unavailability of predictive, prognostic and druggable biomarkers makes the management of these lesions challenging. In recent years CDK4 and its inhibitors have emerged as potential agents for these lesions especially for ALT/WDLPS and DDLPS but the results are not conclusive and need to be elucidated. This study involved 21 ALT/WDLPS and DDLPS patients. Histological analyses of MDM2 and CDK4 were carried out. Moreover, a DDLPS patient-derived cancer model was established in vitro and in vivo assessing the efficacy of palbociclib in combination and sequential treatment. Finally, in silico analyses on CDK4 expression were carried out. The results showed a higher expression of CDK4 and MDM2 in DDLPS compared to ALT/WDLPS. Moreover, no correlation between MDM2 expression and CDK4 was observed. Next, in vitro analysis of CDK4 inhibitor palbociclib showed an antagonistic effect when combined to other chemotherapeutics, while it exhibited a significant synergy when administered in sequential schedule with lenvatinib. Next, in vivo analysis on DDLPS xenotransplanted embryos assessing the efficacy and safety profile of the in vitro tested schedules confirmed the observed data. This proof-of-concept study sheds light on the natural history of ALT/WDLPS and DDLPS and provides the rationale for the clinical applicability of sequential treatment with palbociclib in the management of DDLPS. [ABSTRACT FROM AUTHOR]

The principles of nasal reconstruction include the need to reconstruct three tissue layers, the need to restore entire skin aesthetical units, and, possibly, the replacement with like tissues. Computer-aided design (CAD) and computer-aided manufacturing (CAM) technologies were applied to two total nasal reconstructions in male patients who underwent rhinectomy for cancer. Three-dimensional (3D) data were obtained from computerized tomography (CT) scan-derived DICOM files (Digital Imaging and Communications in Medicine), this allowed us to design the shape of the reconstructive nose in order to mimic the native nose and to plan dimensions and angles. A custom-made titanium plate was manufactured for the structure and a bi-dimensional template for the forehead flap was printed. The patients underwent a total nasal reconstruction in three layers: local flaps for the lining, custom-made titanium plate for the structure, and expanded forehead flap for the skin. Forehead flap pedicle was divided 3 weeks postoperatively under local anesthesia in an outpatient clinic, as well as further minor refinements. The patients underwent a 6-month post-operative CT scan in order to compare the result to the planned nose. No complications were reported. The superimposition demonstrated a 92% match in case 1 and 95% match in case 2 between the reconstructed nose and the planned one. Forehead flap is still the most favorable option for nasal reconstruction, CAD technology allows to implement the planning and makes the procedure easier; moreover, the use of a CAM plate for the structure allows to reconstruct a nose with the desired naso-frontal angle. Level of evidence: level V, therapeutic study. [ABSTRACT FROM AUTHOR]

Trans Oral Robotic Surgery (TORS) is a modality in the management of oropharyngeal squamous cell carcinoma(OPSCC). This study was conducted to show the rates of peri-operative complications after TORS for OPSCC in our experience. Single centre retrospective analysis of consecutive OPSCC treated with TORS. The surgical complication severity was recorded according to Clavien-Dindo criteria (CDC). Eighty-seven OPSCC were operated with TORS. According to CDC, grade I, grade II and IIIb were registered in 8%, 4.6% and 11.5% of cases, respectively. The postoperative pain, registered with visual-analogue scale (VAS) score, was 8 ± 1.2 for the secondary healing wounds and 6.2 ± 1.5 for the flap reconstructions (p < 0.01). The impact on swallowing function was not significant between secondary healing and flap reconstructions(p = 0.96). Any major or life-threatening intraoperative complications have not been recorded. Only one patient had postoperative bleeding into the neck whilst 13.3% of patients had postoperative bleeding from the primary tumor. No total local or free flap failure were registered. The mean duration of tracheostomy use was 7.4 ± 2.6 days, and nasogastric tube 14.3 ± 6.9 days. Only one patient, who had also reconstruction with flap, experienced a postoperative severe dysphagia with severe aspiration, needing a permanent tracheostomy tube and percutaneous endoscopic gastrostomy feeding. TORS for OPSCC showed less morbidity, lower risk of severe complication and mortality. Thus, this treatment modality could be offered as first line treatment in selected cases. [ABSTRACT FROM AUTHOR]

Background: The goal of any oncological therapy should be to achieve long-term disease-free survival while minimising acute and late toxicities. One of the goals of transoral robotic surgery (TORS) resection is to obtain negative margins around the primary tumour with minimal functional morbidity. The aim of this study was to assess the functional morbidity of TORS and evaluate the post-operative pain and functional outcomes 6 months after TORS for head and neck squamous cell carcinoma (SCC) in reconstructed and non-reconstructed patients. Methods: We retrospectively reviewed 64 patients with head and neck SCCs resected by TORS from 2008 to December 2017 in our institution. The tumour localisation, pathologic T classification, defect size, reconstructive method, wound healing time, complications, post-operative pain and functional outcomes at 6 months were statistically evaluated (Table 1). Results: Fifty-four resections healed by secondary intention, and 4 patients were reconstructed with a local flap and 6 with a free flap. No flap loss was encountered, while two cases of flap dehiscence that needed surgical revision and one case of partial necrosis were recorded. Eight patients had post-operative oral bleeding from the primary tumour resection field with an average bleeding time of 6.2 days. All bleeding occurred in patients with secondary healing of the defect after tumour excision, while no oral bleeding was recorded in patients with flap reconstructions. The pain scores in the first 3 post-operative days were 8 ± 1.2 for the secondary healing wounds and 6.2 ± 1.5 for the flap reconstructions. From day 4 to day 10, the mean VAS score was 5.7 ± 1.2 for the secondary healing wounds and 5.5 ± 1.2 for the flap reconstructions. The average wound healing time was 21.3 days in the secondary healing wound patients and 14.5 days in the reconstructed patients. At the 6-month follow-up, 63 out of the 64 patients recovered oral feeding and comprehensive locution, and only one patient experienced severe post-operative dysphagia and needed a permanent tracheostomy tube and percutaneous endoscopic gastrostomy (PEG) feeding. Conclusion: In this retrospective study, the functional morbidity and complications of TORS for head and neck squamous cell carcinoma resection were favourable in reconstructed and non-reconstructed patients. Level of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Purpose: To determine the utility of intraoperative nerve monitoring (IONM) during tracheal resection or slide tracheoplasty to prevent recurrent laryngeal nerve injury.Methods: 110 patients underwent tracheal resection or tracheoplasty between 1997 and 2016. During the first 10-year period, IONM was not used while during the second 10-year period, IONM was used. 49 patients had surgery without IONM while 61 had surgery with IONM. During the post-operative period, patients with nerve injury were compared to determine if significant difference existed between the two modalities.Results: In patients who had surgery without IONM, 7 (14.2%) patients were found to have compromised nerve function whereas 8 (13.1%) patients in the group with IONM had nerve injury. 3 patients regained function in the first group while four regained function in the second. A Fisher's exact test was run on the entire cohort and the difference in vocal fold injury was not found to be statistically significant (p > 0.05).Conclusion: Based on this single surgeon experience, there may be no protective benefit with the use of IONM during tracheal surgery. [ABSTRACT FROM AUTHOR]

Adult rhabdomyosarcoma (RMS) represents an uncommon entity with an incidence of less than 3% of all soft tissue sarcomas (STS). Consequently, the natural history and the clinical management of this disease are infrequently reported. In order to fill this gap, we investigated the molecular biology of an adult RMS case series. The expression of epithelial mesenchymal transition-related gene and chemoresistance-related gene panels were evaluated. Moreover, taking advantage of our STS translational model combining patient-derived primary culture and 3D-scaffold, the pharmacological profile of an adult head and neck sclerosing RMS was assessed. Furthermore, NGS, microsatellite instability, and in silico analyses were carried out. RT-PCR identified the upregulation of CDH1, SLUG, MMP9, RAB22a, S100P, and LAPTM4b, representing promising biomarkers for this disease. Pharmacological profiling showed the highest sensitivity with anthracycline-based regimen in both 2D and 3D culture systems. NGS analysis detected RAB3IP-HMGA2 in frame gene rearrangement and FGFR4 mutation; microsatellite instability analysis did not detect any alteration. In silico analysis confirmed the mutation of FGFR4 as a promising marker for poor prognosis and a potential therapeutic target. We report for the first time the molecular and pharmacological characterization of rare entities of adult head and neck and posterior trunk RMS. These preliminary data could shed light on this poorly understood disease. [ABSTRACT FROM AUTHOR]