Search

The authors sought correlations between harvesting of the scapular bone tip free flap used for head-and-neck reconstruction and any shoulder function deficit, particularly at the level of the rotator cuff. The flap permits reconstruction of large and diverse regions of the head and neck, but long-term harvest morbidity has not been investigated extensively. The authors analyzed the clinical records of all patients who underwent head-and-neck reconstructions using free scapular tip flaps in our department over the past 5 years. The inclusion criteria were complete clinical and radiological documentation and follow-up for at least 12 months. Two populations, a surgical and control population, were analyzed. All patients in both populations underwent the simple shoulder test, an internationally validated self-administered test that highlights functional shoulder deficits, and 3 additional tests at orthopedic visits: the external rotation test, Patte test, and external rotation lag sign test. A head-and-neck cancer-specific questionnaire (University of Washington Quality of Life, version 4) was completed by the surgical patients. All statistical analyses were performed using Software IBM SPSS Statistics (IBM Corp., Armonk, NY).A total of 19 patients met the inclusion criteria: 11 males (57.8%) and 8 females (42.2%) of mean age 60.9 years (range 23-75 years). In addition, 20 age-and sex-matched volunteers with no history of shoulder pathology were evaluated in terms of shoulder functionality. The average score on the simple shoulder test was 10.55 in the healthy population versus 8.31 in the study population ( P0.001); in particular, shoulder strength differed between the groups. Similarly, the orthopedic examinations revealed clinically significant differences between the controls and patients on the Patte test and external rotation lag sign test (both P0.001), but not the external rotation test ( P0.001). The mean University of Washington Quality of Life was 73.39; most patients reported good quality of life (52.6%), followed by very good (15.7%).The free scapular bone tip flap is valuable for reconstruction of head-and-neck defects; the long and reliable vascularpedicle allows rapid patient mobilization. Morbidity was confined to small reductions in shoulder strength and external rotation, which do not affect quality of life.

Introduction: Cavernous malformations of the ventral brainstem are a challenging disease to treat. From an anatomical perspective, the best surgical options are endoscopic endonasal approaches. The first reports of their usage for this purpose date back to 2012. In this study, we gathered data on the subject, share our experience, and outline technical notes and tips for this surgery. Case Presentation: We report a 14-year-old female with a ventral pons cavernoma, treated using an endoscopic endonasal transclival approach and followed-up for 5.9 years. This is the longest reported follow-up for this condition to date. Written informed consent was obtained from the patient for publication of this case report and the accompanying images. Discussion: An endoscopic endonasal transclival approach was used. The skull base was reconstructed using the multilayer grafting technique and a nasoseptal flap. There was no postoperative cerebrospinal fluid leakage. In a literature review, we identified 8 patients who were treated endoscopically: 1 transplanum-transtuberculum, 1 transtuberculum-transclival, and 6 transclival approaches were employed. Skull base closure was achieved using multilayer grafting and a nasoseptal flap in 4 cases, a gasket seal technique combined with nasoseptal flap in 3 cases and a periumbilical fat graft, fibrin sealant patch, and fibrin glue in 1 case. There were 2 cases of leakage, which resolved completely with revision surgery. Conclusion: Endoscopic surgery is a reliable alternative to traditional open surgery. It may be the preferred choice for intra-axial ventral brain cavernomas.

Study Design Description and validation of a surgical technique. Objective En-bloc maxillectomy with removal of the nasal septum is a rare procedure; preservation of the nasal bones and integrity of the alveolar ridge is even rarer. These procedures traditionally required a combined transfacial-transoral approach based on lateral rhinotomy. We describe a combined endoscopic transnasal-transoral approach for treatment of nasal septal malignancies that involve the hard palate. Methods Excision of malignant tumours arising from the nasal septum was achieved in 4 patients using a transnasal-transoral endoscopic approach. Using 4-mm optics angled at 0° and 30°, the septum was freed from the ethmoid and removed en-bloc with the hard palate, by pulling the septum down through the hard palate. Results Of the 4 patients, 2 underwent complete removal of septal chondrosarcomas, one removal of a sinonasal undifferentiated carcinoma and one removal of a mucoepidermoid carcinoma. In two cases, the palatal mucosa was spared and repositioned to restore separation between the nose and oral cavity. The remaining two cases underwent complete resection of the hard palate; one palate was reconstructed using a pedicled temporalis muscle flap and the other by employing an obturator. No infection was encountered. Partial ethmoidectomy was performed in all four cases. The mean hospital stay was 5 days. All patients are free of disease after a mean follow-up of 4 years (range: 2–7 years). Conclusions Our new approach allows for minimally invasive resection of nasal septal malignancies that extend to the palate. Our maxillary pull-through technique is a valuable new surgical procedure for malignant pathologies of the nasal septum; the only drawback is that endoscopic surgery has a steep learning curve.

The aim of this study was to understand the impact of the COVID-19 pandemic on the epidemiology of maxillofacial trauma in a regional trauma center in L'Aquila, Abruzzo, Italy, during the first wave of the pandemic and comparted it to an equivalent period from 2015 to 2018. The authorshave retrospectively analyzed personal data, site of trauma, etiology, and mechanism of injury. Statistical analysis has been carried out utilizing IBM SPSS Statistics software (IBM Corp., Armonk, NY) and significance was accepted for P values of0.05. From January 2015 to December 2020, a total of 296 were analyzed. In Pre-COVID era, 195 patients were evaluated, 130 males (66.6%) and 65 females (33.4%). Zygomatic-malar complex fractures were the most common site of trauma in both genders (53%), followed by mandibular fractures (23%) and orbital ones (15%). The highest incidences of injuries were recorded between 15 and 34 years (21%) with the most common etiology attributed to road accidents traumas (49%). In COVID19 era, the authors recorded 101 traumas, 58 males (57.4%), 43 females (42.6%). Zygomatic-malar complex fractures were confirmed as the most common ones in both genders (41%). The most common etiology was related to casual domestic accident and assaults (37% and 30%, respectively). There was no statistically significant difference in terms of incidence in the comparison of Pre-COVID19 and COVID19 periods (P 0.05) as opposed to the etiology in which the road traffic accidents decreased in favor of domestic accidents and interpersonal assaults (P 0.05). Our scientific study represents the first epidemiologic study related to the impact of COVID-19 on maxillo-facial trauma in the Province of L'Aquila, Abruzzo, Italy. A decrease in the number of Maxillofacial injuries related to road traffic accidents can be demonstrated as the benefit of lockdown, however, a significant increase in the number of physical assaults shows how isolation and restrictions have had a highly negative psychological impact on society.

Pharyngocutaneous fistula is one of the most common and serious complications associated with total laryngectomy. Numerous studies tried to evaluate causative and predisposing factors associated with this complication, but data are considerably variable and there is still no international consensus. Incidence rate varies considerably between studies, with reported rates from 3% to 65%. This 4K video presents our T-shaped four-step technique (FST) for closing the pharyngeal mucosa after total laryngectomy in a step-by-step manner. All sutures were performed by braided absorbable 3/0 26 mm 1/2c (Vicryl plus 3.0; Ethicon, Somerville, NJ, USA). Recordings were performed using a Karl Storz 4K 3D VITOM® exoscope (Karl Storz SECo. KG, Tuttlingen, Germany). We have been described this technique through a high-definition video, showing each step, and tips from the authors. Our T-shaped pharyngoplasty closure technique can be divided into four steps: 1. "Key Stitches"; 2. "Area Refinement Stitches"; 3. "Modified Connell Suture"; 4. "Modified Purse String Suture." Our T-shaped FST closure technique proved to be an effective and reproducible method, which we feel could be the preferred choice for primary pharyngoplasty closure.

Orbital fractures are among the most frequent facial traumas. This study retrospectively analysed patients treated in Umberto I Hospital Trauma-Centre, Sapienza University of Rome from 1 January 2010 to 31 December 2020. The inclusion criteria were as follows: diagnosis of pure/impure orbital bone fracture, complete clinical and radiological records, and a minimum 12-month follow up. Gender, age, aetiology, fracture type, treatment, and associated complications were analysed using IBM SPSS Statistics, and p values of0.05 were considered significant. In total, 1393 patients presented with orbital trauma, 543 of whom met the inclusion criteria and underwent surgery (394 males (72.6%) and 149 females (27.4%); mean (range) age 39.2 (7-90) years). Assault (n = 165, 30.4%) was the most common cause of trauma, followed by road traffic accidents and sports-related incidents. Diplopia was the major symptom at diagnosis (n = 183, 33.6%). Open reduction and internal fixation via a sub-eyelid approach was the preferred treatment, achieving a significant reduction in the functional changes induced by fracture (p 0.05). Our data will aid future studies of maxillofacial traumatology and suggest that education and prevention measures could reduce the incidence of this type of trauma.

Introduction Sentinel node biopsy (SNB) is the standard of care in women with breast cancer (BC) and clinically non suspicious axillary lymph nodes (LNs), due to its high negative predictive value (NPV) in the assessment of nodal status. SNB has significantly reduced complications related to the axillary lymph node dissection, such as lymphedema and upper limb dysfunction. Evidence acquisition The gold standard technique for SNB is the blue dye (BD) and technetium labelled nanocolloid (Tc-99m) double technique. However, nuclear medicine is not available in all Institutions and several new tracers and devices have been proposed, such as indocyanine green (ICG) and superparamagnetic iron oxides (SPIO). All these techniques show an accuracy and detection rate not inferior to that of the standard technique, with different specific pros and cons. The choice of how to perform a SNB primarily depends on the surgeon's confidence with the procedure, the availability of nuclear medicine and the economic resources of the Institutions. In this setting, new tracers, hybrid tracers and imaging techniques are being evaluated in order to improve the detection rate of sentinel lymph nodes (SNs) and minimize the number of unnecessary axillary surgeries through an accurate preoperative assessment of nodal status and to guide new minimally invasive diagnostic procedures of SNs. In particular, the contrast-enhanced ultrasound (CEUS) is an active field of research but cannot be recommended for clinical use at this time. Evidence synthesis The ICG fluorescence technique was superior in terms of DR, as well as having the lowest FNR. The DR descending order was SPIO, Tc, dual modality (Tc/BD), CEUS and BD. Conclusions This paper is a narrative review of the most common SNB techniques in BC with a focus on recent innovations.

The diagnosis of breast cancer (BC) during pregnancy is uncommon. It has varied among different studies from 1:10,000 to 1:3000 of all pregnancies, with a median age of 33 years. Pregnancy-associated BC represents a challenge in terms of clinical management to guarantee both maternal and fetal security in choosing the right treatment. This situation is complex and requires a multidisciplinary approach, including the surgeon, anesthesiologist, oncologist, radiotherapist, psychologist, and maternal-fetal medicine specialist. In the present review, we examined the management of pregnancy-associated BC, focusing on pathophysiologic background, risk factors, diagnosis, staging procedures, anesthesia, surgical management, and systemic treatment.

Oncoplastic surgery (OPS) has demonstrated its superiority above traditional breast conserving surgery, but is still struggling to consolidate its role in breast cancer therapeutic protocols mainly because of contrasting scientific evidences and reduced follow-up results available. The objective of our contribution is to analyze results obtained with 381 patients consecutively treated in our Multidisciplinary Breast Center by means of level II OPS between January 1998 and January 2018 for unilateral, primary breast cancer. Surgical endpoints were mean specimen weight and volume, mean diameter of main lesion (MLD), rates of positive margins (PMR), re-excision (RR), conversion to mastectomy (CMR), complications (CR) and oncological endpoints as overall survival (OS), disease-free survival (DFS), and local recurrence rate (LR). About 29.1% were treated for multifocal/multicentric disease, and 29.1% previously underwent neo-adjuvant chemotherapy (NACT). Regarding surgical techniques, 53.0% of patients received "inverted T" and 30.1% "J" mammoplasties, whereas 13.6% underwent "round block," 2.3% "Grisotti," and 1% "batwing" techniques. Regarding surgical outcomes, mean specimen weight was 215 g (50-2157) and volume 345 mm3 (21-7980). MLD 23 mm, PMR 7.6%, RR 3.6%, CMR 1.6%, and CR 5.8%. With a mean follow-up of 118 months, oncological outcomes were: OS 93.7%, DFS 82.3%, LR 4.4%. In conclusion, our analysis confirmed level II OPS reliability even for longer follow-up timing and in difficult situations as multifocal disease or after NACT.

The aim of the present study was to analyse the consequences of masseter muscle denervation. In facial palsy surgical treatment, the masseteric nerve constitutes an important nerve source for facial reanimation due to its anatomical position and large amount of available axons. Computed tomography and/or magnetic resonance imaging were performed in 30 control subjects, and three radiologists separately measured the longitudinal diameter (LD), anteroposterior diameter (APD), transverse diameter (TD), and skeletal muscle area (SMA) of the masseter muscles as reference values. Regarding the facial palsy group, from 2009 to 2018, 11 patients (4 men and 7 women) were selected on the following inclusion criteria: diagnosis of unilateral facial paralysis, minimum follow-up of 14 months, absence of temporomandibular dysfunction, presence of complete dentition (to minimise bias of stomatognathic evaluation), complete clinical and radiological records. The mean LD, APD, TD, and SMA values of the healthy and denervated masseter muscles were obtained and compared. Stomatognathic function was clinically examined through mean mouth opening (MMO) and Maximum Bite Force (MBF). Furthermore, facial symmetry analysis (FSA) was carried out using EMOTRICS Software. Reference values obtained were as follows: mean LD = 69 ± 5.9 mm (range: 59–85 mm); mean APD = 40.2 ± 3.3 mm (range: 34–48 mm); mean TD = 15.5 ± 3.1 mm (range: 11–26 mm); and mean SMA = 43.8 ± 13.5 mm3 (range: 26–85.8 mm3). No statistically significant difference was observed between the healthy facial palsy groups's masseter muscles and reference values. As the latter, in denervated masseter muscles, no statistically significant difference was observed for APD value in contrast to LD, TD and SMA that showed statistically significant difference in comparison with control population (p None of the latter showed a statistically significant difference with respect to the control population and the parameters present in the literature, indicating that masseter-facial neurorrhaphy is a safe and effective procedure for facial reanimation with good functional and aesthetic outcomes.

Nowadays, the overall attention is focused on de-escalating treatments for breast cancer (BC) including surgery, radiotherapy and chemotherapy. The introduction of sentinel lymph node biopsy (SLNB) has led to less invasive surgical approaches for accurately staging the axilla, with axillary lymph node dissection (ALND) progressively confined to a limited group of patients. One of the goal of surgery in de-escalating approaches is to reduce surgical morbidity by restricting or avoiding axillary surgery with no effect on survival. In this context the importance of imaging study for preoperative identification of axillary metastasis, in order to reduce axillary surgery, is gradually improving while the role of intraoperative assessment of sentinel nodes is progressively becoming limited to restricted groups of patients. According to the results of the ACOSOG Z0011 and following the most important guidelines, ALND can be safely omitted in selected patients treated with breast conserving surgery (BCS) with one or two positive SLNB while the adoption of SLNB positive alone in patients undergoing mastectomy is not yet defined. The increased employment of neoadjuvant chemotherapy (NAC) and the use of SLNB in patients after NAC plays an important role in de-escalation of axillary surgery in this group of patients. However current studies on this topic are still controversial, mainly about clinically positive lymph nodes (cN+) pre NAC patients or how to manage positive SLNB in post NAC patients. Some authors have collected predictive factors of positive non sentinel lymph nodes (NSLNs) in nomograms, considered an useful tool to avoid unnecessary further surgery. Elderly women represent specific group of patients where the axillary approach needs to be properly resized. The management of axilla in BC is in continuous evolution and ongoing studies could make even SLNB useless in the next future.

Ductal carcinoma in situ (DCIS) represents a disease that includes different risk categories and does not necessarily turn into invasive cancer. The 20% of all newly diagnosed breast cancers consist in DCIS, with an incidence increased due to the widespread diffusion of screening programs. Once upon a time, mastectomy was considered the gold standard in treatment of DCIS, but over the years, breast-conserving surgery (BCS) has been included as the treatment of choice for patients with small lesions. Several randomized trials demonstrated that adjuvant treatment as radiation and ET reduce the risk of local recurrence, including invasive recurrences. Therefore, in patients with DCIS susceptible to conservative surgery, the key decision for management is represented by the addition of radiotherapy (RT) or ET. With the variety of surgical and adjuvant treatment options available, there has been great interest in tailoring therapies to the individual, with the goal of optimizing the balance of risks and benefits. From the observation of the first data showing how such treatments are not clearly associated with an improvement in disease specific mortality, the upcoming hypothesis is to consider omitting some of such treatments or to plan close surveillance for low risk lesions. Prospective studies on women treated with BCS alone have identified low risk lesions. Actually, the main challenge is how to recognize cases that will not progress to invasive lesions. Despite all the studies carried out and the many available data, there are no unique and universally accepted treatment criteria, so some issues of controversy are still open.

Pathogenic mutations in two autosomal dominant genes, BRCA1 and BRCA2 , with high penetrance are supposed to be the cause for an approximated 5–7% risk of all breast cancer (BC) and ovarian cancer (OC). Compared to sporadic BC, BRCA mutated ( BRCAmut ) BC differs for lifetime risk of onset and sensitivity to systemic therapies. A hereditary BC syndrome should be taken into account when there are numerous relatives with BC early-onset (typically before menopause). Moreover, BRCAmut carriers showed a lifetime possibility of manifesting OC. When a BC diagnosis is made in young patients or in suspicious personal relatives’ anamnesis, be aware of being carriers of a BRCA mutation may influence the decision making-process about surgical procedure and prevention strategies. In this review, we examined surgical treatment choice for BRCAmut BC, risk of ipsilateral breast recurrence (IBR) and contralateral breast cancer (CBC). We examined the role of breast-conserving therapy (BCT), risk-reducing mastectomy (RRM) and preventive risk-reducing salpingo-oophorectomy (RRSO) with a special consideration about advantage in terms of mortality reduction for both conservative and prophylactic measures. We also reviewed the sensitivity of mutated BC to platinum-based antineoplastic drugs and poly (ADP-ribose) polymerase inhibitors (PARPi) by emphasizing the results of clinical trials recently published.

Phyllodes tumours (PTs) are rare fibroepithelial neoplasms representing about 0,2% to 2% of all breast tumors with an incidence of about 2.1 per million. The classification proposed by the World Health Organization for PTs into benign, borderline, and malignant is based on a combination of several histologic features. High-grade malignant phyllodes tumors may spread by hematogenous route. While smaller and moderate size malignant phyllodes may typically be seen, gigantic ones with larger than 10 cm in diameter are very rare. We report an unusual case of a giant malignant phyllodes tumor with metastases that grew over a 6 years period causing significant ulceration, body disfigurement and physical transformation. Our experience indicated that surgical treatment of malignant phyllodes tumor might be an option for improving patients' quality of life, regardless of the extremely poor prognosis.Breast, Malignant phyllodes tumor, Surgical treatment.I tumori filloidi sono rare neoplasie fibroepiteliali che rappresentano circa lo 0,2-2% di tutti i tumori al seno. La classificazione proposta dalla Organizzazione Mondiale della Sanità divide i tumori filloidi in benigni, borderline e maligni in base ad una combinazione di varie caratteristiche istopatologiche. I tumori filloidi maligni giganti, con un diametro maggiore di 10 cm, sono molto rari. Noi presentiamo un caso insolito di tumore filloide maligno gigante con metastasi, che nell’arco di 6 anni è cresciuto così tanto da determinare una significativa deformazione del corpo con trasformazione del fisico della paziente. Abbiamo pertanto eseguito un intervento chirurgico di mastectomia con asportazione della neoplasia con l’obiettivo di migliorare la qualità di vita della paziente, indipendentemente dalla prognosi estremamente sfavorevole. Ci auguriamo che la descrizione di questo particolare ed insolito caso possa essere l’occasione per rimarcare ancora una volta l’importanza di una corretta educazione alla salute del seno e sottolineare le conseguenze negative di trattamenti alternativi o ritardati.