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Background: Macro, and microcirculatory effects of crystalloids and colloids are difficult to compare, because interventions to achieve haemodynamic stability seldom follow similar criteria., Objectives: Our aim was to compare the effects of crystalloids and colloids on the microcirculation during free flap surgery when management was guided by detailed haemodynamic assessment., Design: A randomised, controlled clinical trial., Settings: The investigation was performed at the University of Szeged, Hungary., Patients: Patients undergoing maxillofacial tumour resection and free flap reconstruction were randomised into groups treated with either intra-operative crystalloid (Ringerfundin, n = 15) or colloid (6% hydroxyethyl starch, HES, n = 15) solutions., Interventions: Macrohaemodynamics were monitored by a noncalibrated device (PulsioFlex-PULSION). Central venous oxygen saturation, venous-to-arterial PCO2-gap, lactate levels and urine output were measured hourly. Maintenance fluid was Ringerfundin (1 ml kg h), and a multimodal, individualised, approach-based algorithm was applied to guide haemodynamic support. Hypovolaemia was treated with Ringerfundin or HES fluid boluses, respectively. The microcirculatory effects were assessed by laser-Doppler flowmetry (PeriFlux 5000 LDPM), with the probe placed on the flap and on a control area. Measurements were performed after the flap was prepared, then 1 and 12 h later., Main Outcome Measures: The primary end-point was microcirculatory perfusion as determined by laser-Doppler flowmetry., Results: There was no difference between the groups regarding patient characteristics. Both groups remained haemodynamically stable throughout due to the use of approximately a 1.5 times higher total fluid volume in the Ringerfundin group than in the HES group: mean ± SD: 2581 ± 986 and 1803 ± 497) ml, respectively, (P = 0.011). There was no significant difference in the microcirculatory blood flow between the groups., Conclusion: Our results showed that when fluid management was guided by detailed haemodynamic assessment, more crystalloid than colloid was needed to maintain haemodynamic stability, but there was no difference between the effects of crystalloids and colloids on the microcirculation., Trial Registration: ClinicalTrials.gov NCT03288051.

Background: The surgical management of malignant tumors in the head and neck region often leads to functional and esthetic defects that impair the quality of life of the patients. Reconstruction can be solved with prostheses in these cases, but various types of microsurgical free flaps can provide a better clinical outcome., Case Presentation: In this case report, the tumor and parts of the involved facial muscles and nerve were excised surgically from a 42-year-old patient after a third relapse of basal cell carcinoma in the left midface. The tissue defect was reconstructed with an anterolateral thigh chimeric type I fascio-myocutaneous flap, where the facial palsy was restored with a segmental branch of the femoral nerve and the involved mouth corner elevator muscles for the segmented vastus lateralis muscle. The 6-month follow-up revealed a good esthetic outcome, the soft tissue defect reconstruction with good functional activity of the reconstructed facial nerve and with acceptable mimic movements. There has been no subsequent recurrence., Conclusions: It is concluded that the chimeric type I anterolateral fascio-myocutaneous free flap can offer a good option for the esthetic and functional reconstruction of an extensive tissue defect in the maxillofacial region.

Progressive hemifacial atrophy (PHA) is a rare disorder characterized by slow, unilateral atrophy of the soft tissues and bones of the craniofacial region. The defect becomes more pronounced with age, leading to esthetic and functional deficits. However, the proper timing and method of surgical reconstruction are still debated. The correction of this defect markedly influencing the quality of life of the patient can be achieved with less invasive to more invasive surgical approaches. A 21-year-old female patient with hemifacial atrophy and extensive alopecia presented to our clinic. Considering the body type and the expectations of the patient, a profunda artery perforator flap was applied for the reconstruction and esthetic improvement of the facial region. The facial asymmetry attenuated after the reconvalescence period. This case shows that in the up-to-date surgical treatment of severe PHA, the use of microvascular free flaps may provide a better approach when trying to achieve an acceptable esthetic result. This is the first time that a profunda artery perforator flap was used to restore facial asymmetry caused by PHA., (Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

A new method of stapled ileo and coloanal anastomosis with PPH gun (Johnson and Johnson USA) is presented. On 47 totalcolectomised FAP and UC patients and 9 low rectal benign or clinically T1 or T2N0 rectal tumor resection there was only 5 radiologically proven anastomotic leakadge without serious septic complications. The anal sphincter function after 6 month of the ileoanal anastomosis remained good in 33/39 and acceptable in 6 cases, if the sphincter function was intact praeoperatively. There was no worthening of the moderate praeoperatively observed insufficiency. After the ultra low rectal resections all patients kept the normal anal shpincter function. The procedure seems to be as good as the double stapler method, but there remained no remnant mucosal ring between the anastomsois and the dentate line. An additional advantige of the method, that only one stapler was consumed per patient compared to the two one at the double stapler technic.

Fluoro-Gold (FG) injected into the cerebello-medullary cistern (CMC) is accumulated in several nuclei and neurons of the brain. These structures include: taenia tecta, some fusiform perikarya in the diagonal band of Broca, pyramidal cells in the fifth layer of the cerebral cortex, paraventricular nuclei, zona incerta, medial habenular nuclei, red nuclei, dorsal tegmental nuclei, median raphe nucleus, nuclei pontis, cochlear and vestibular nuclei and some Purkinje cells in the most lateral segment of the cerebellar cortex. The supraoptic nucleus and the median eminence are free of FG. Many nuclei in the myelencephalon and large groups of neurons in the dorsal, intermediate and anterior horns of the spinal cord are also labeled with FG, but exact identification of these cell groups needs further experimentation. Our findings indicate that FG can be picked up from the subarachnoid space into many cell groups of the brain and spinal cord. It is concluded that possible leaking of FG into the subarachnoid space following its injection into the central nervous system has to be taken into account whenever FG is used in tract tracing experiments.