Requiring Complex Reconstruction Research Articles

815. FREE JEJUNAL GRAFT (FJG) FOR COMPLEX RECONSTRUCTION AFTER PHARINGO-LARINGO-ESOPHAGECTOMY

Abstract Background Pharyngo-esophageal reconstruction using free jejunal grafts has been widely used for the treatment of locally advanced carcinomas of the hypopharynx and cervical esophagus. However, the procedure is technically demanding and requires complex recontractions. The aim of this study was to evaluate our institutional outcomes of reconstruction using a free jejunal graft with vascular reconstruction in patients undergoing pharyngo laryngo esophagectomy with a multidisciplinary surgical team. Material and methods Unicentric retrospective case series between 2014-2023 with 6 patients that require complex reconstruction with free jejunal graft. Information was obtained from institutional database. Quantitative variables are expressed with median and interquartile range (IQR), and qualitative variables with percentage and absolute number. Results In our sample, all patients were male with median age of 62 (7) years old and had previous history of squamous cell carcinoma (SCC) treated with radical Qt/Rt with maximum radiotherapy dose who developed local recurrence at hypopharynx involving the cervical esophagus. Patients demographics and characteristics are shown in table 1. FJG was the primary procedure in five cases after PLPE, of which three were done as curative procedure and the rest as a palliative procedure. In one patients FJG was considered after gastric tube reconstruction with transhiatal esophagectomy. JFG vessels were commonly anastomosed to the common superior thyroid artery (42,9%) and the external jugular vein (21%) and thyroid vein (21,2%). Operative time was 440 (359) minutes. After FJG procedure time to oral intake reintroduction was 7 (6-20) days and hospital stay length was 20,5 (16) days. Pneumonia was the most frequent complication in four patients (57,2%). Leakage rate after FJG was 33% (2). Three patients required reintervention, (1) mesenteric graft bleeding, (1) graft anastomoses dehiscence and (1) graft necrosis. FJG failure rate was 33%, one due complete graft ischemia secondary to arterial thrombosis at 2nd POD and other due to failed conversative management of dehiscence of both anastomoses with partial ischemia. After failed FJG only one patient underwent reconstruction by transhiatal esophagectomy and gastric tube replacement. Two patients were readmitted before 30 days and two patients before 12 months after discharge. BMI after JFG was 22.7 (13,1) kg/m2. According to late complication, dysphagia was the most common complication (42,7%) also one patient cannot feed orally due to severe stenosis after chronic fistula. In-patient mortality was 0%. Overall survival was 19 (37) months. One patient with FJG failure died due to septic complications after pharingostoma, and one patient due to disease progression. Conclusion Free jejunal graft with vessel reconstruction for patients undergoing pharyngo-laryngo-esophagectomy is a safe procedure but with high complications rate which enhance the priority of centralize this pathology in high volume centers.

Extra-articular hip resection with maintenance of pelvic continuity in malignant tumours of the proximal femur with articular invasion.

Extra-articular hip resection may be necessary in cases of malignant tumour of the pelvic bone or of the proximal femur invading the hip joint. When the tumour is in the proximal femur, it is possible to resect the acetabulum en bloc by performing a periacetabular osteotomy, but this creates a discontinuity in the pelvic ring with difficult reconstruction and diminished function. Several techniques described recently seek to be as sparing as possible on the pelvic bone by preserving the posterior column or both columns in order to facilitate reconstruction and improve function. However, these still require complex reconstructions and can necessitate intra-pelvic dissection. We describe here an extra-articular hip resection technique for tumours of the proximal femur invading the joint, with maintenance of pelvic continuity by preserving both columns and the quadrilateral plate of the acetabulum, without intra-pelvic dissection, that can be performed on patients in whom the medial wall of the acetabulum is thick enough. Our preliminary assessments have included studies on dry bone and imaging analyses. The technique was first tested on a single cadaver pelvis (encompassing 2 hips) and subsequently performed on a patient with a pathological fracture of the femoral neck due to osteosarcoma secondary to Paget's disease. Further clinical applications are essential to evaluate the overall effectiveness, safety and impact on patient functionality of this experimental technique.

From Augmented to Virtual Reality in Plastic Surgery: Blazing the Trail to a New Frontier.

Augmented reality (AR) and virtual reality (VR)-termed mixed reality-have shown promise in the care of operative patients. Currently, AR and VR have well-known applications for craniofacial surgery, specifically in preoperative planning. However, the application of AR/VR technology to other reconstructive challenges has not been widely adopted. Thus, the purpose of this investigation is to outline the current applications of AR and VR in the operative setting. The literature pertaining to the use of AR/VR technology in the operative setting was examined. Emphasis was placed on the use of mixed reality technology in surgical subspecialities, including plastic surgery, oral and maxillofacial surgery, colorectal surgery, neurosurgery, otolaryngology, neurosurgery, and orthopaedic surgery. Presently, mixed reality is widely used in the care of patients requiring complex reconstruction of the craniomaxillofacial skeleton for pre- and intraoperative planning. For upper extremity amputees, there is evidence that VR may be efficacious in the treatment of phantom limb pain. Furthermore, VR has untapped potential as a cost-effective tool for microsurgical education and for training residents on techniques in surgical and nonsurgical aesthetic treatment. There is utility for mixed reality in breast reconstruction for preoperative planning, mapping perforators, and decreasing operative time. VR has well- documented applications in the planning of deep inferior epigastric perforator flaps by creating three-dimensional immersive simulations based on a patient's preoperative computed tomography angiogram. The benefits of AR and VR are numerous for both patients and surgeons. VR has been shown to increase surgical precision and decrease operative time. Furthermore, it is effective for patient-specific rehearsal which uses the patient's exact anatomical data to rehearse the procedure before performing it on the actual patient. Taken together, AR/VR technology can improve patient outcomes, decrease operative times, and lower the burden of care on both patients and health care institutions.

Management of periocular keratinocyte carcinomas with Mohs micrographic surgery and predictors of complex reconstruction: a retrospective study

BackgroundSkin cancer is the most frequent cancer worldwide and the most frequent periocular tumor. Keratinocyte Carcinomas (KC) located in periorificial areas, such as periocular tumors, are considered high-risk tumors. Mohs Micrographic Surgery (MMS) is considered the first line for the treatment of high-risk KC, providing a lower recurrence rate than conventional wide excision. ObjectiveTo describe the clinical-pathological features of periocular KC treated with MMS in a tertiary university center in Chile. MethodsA single-center, retrospective study of patients with KC located on the periocular area, that underwent MMS between 2017‒2022. MMS details were recorded. ResultsOne hundred thirteen patients with periocular carcinomas were included. The mean age was 59 ± 13 years; 52% were women. The most frequent location was the medial canthus (53%), followed by the lower eyelid (30.1%). The most frequent BCC histology was the nodular variant (59.3%). Regarding MMS, the average number of stages was 1.5 ± 0.7, and 54% of the cases required only 1 stage to achieve clear margins. To date, no recurrence has been reported. Tumors larger than 8.5 mm in largest diameter or 43.5 mm2 were more likely to require complex reconstruction. Study limitationsRetrospective design and a relatively low number of patients in the SCC group. Possible selection bias, as larger or more complex cases, may have been referred to oculoplastic surgeons directly. ConclusionThe present study confirms the role of MMS for the treatment of periocular KCs. Periocular KCs larger than 8.5 mm might require complex reconstruction. These results can be used to counsel patients during pre-surgical visits.

D107. Head and Neck Cancer Reconstruction and Relative Disincentives to Surgical Reconstruction

PURPOSE: The incidence of head and neck cancers (HNC) is rising as HPV becomes the dominant disease etiologic factor. Financial support for HNC care is critical for ensuring equitable access to care. Examining non-profit support, reimbursement rates and hospital-associated costs for HNC patients relative to other patients requiring complex reconstruction may reveal possible care disparities. METHODS: Reimbursement data from HNC and breast cancer (BC) reconstructive procedures was abstracted from the Centers for Medicare and Medicaid Services Physician Fee Schedule Look-Up Tool. Patient-level data for 2015 to 2017 was acquired from the New York State Department of Health. Inflation-adjusted reimbursement values from 2012 to 2021 were compared using Student’s t-test. Wilcoxon-Mann-Whitney tests were used for inter-group analyses. Analysis was completed in R Studio (v1. 3.1). RESULTS: Procedure reimbursements for free and pedicled flaps indicate that HNC reconstruction procedures are reimbursed significantly lower than both breast and extremity reconstruction (p < 0.01). New York State inpatient data indicates that HNC procedure recipients are more likely to have public insurance, generate higher hospital costs and require longer lengths of stay than patients hospitalized for BC procedures (p < 0.01). CONCLUSION: Reimbursements for HNC reconstructive procedures are significantly lower than BC and extremity reconstructive procedures of comparable work effort. HNC patients are more likely to be publicly insured and have longer lengths of stay than patients undergoing breast reconstruction. The large discrepancy in reimbursement may financially disincentivize investment in care for HNC patients and limit future access to care in this vulnerable and growing patient population.

Management of Hematometra and Hematocolpos in Obstructive Mullerian Anomalies by Image-Guided Drainage with Interventional Radiology: A Multi-Institutional Case Series

Study ObjectiveTo describe cases of image-guided drainage of symptomatic hematometrocolpos from obstructive Müllerian anomalies as a temporizing measure to manage acute pain symptoms and delay definitive management of the obstructive Müllerian anomalies that require complex reconstruction MethodsInstitutional Review Board exemption from all included institutions was obtained. A retrospective case series from 3 academic children's hospitals of 8 females under the age of 21 with symptomatic hematometrocolpos due to obstructive Müllerian anomalies drained by image-guided percutaneous transabdominal vaginal or uterine drainage with interventional radiology was reviewed and described. ResultsEight pubertal patients with obstructive Müllerian anomalies (6 patients with distal vaginal agenesis, 1 patient with an obstructed uterine horn, and 1 patient with a high obstructed hemi-vagina) and symptomatic hematometrocolpos are reported. All patients with distal vaginal agenesis had greater than 3 cm lower vaginal agenesis, which would usually require complex vaginoplasty and use of postoperative stents. Given their immaturity and inability to use stents or dilators postoperatively or medical complexity, they subsequently underwent ultrasound-guided drainage of hematometrocolpos with interventional radiology to relieve pain symptoms, followed by menstrual suppression. The patients with obstructed uterine horns had complex medical and surgical histories requiring perioperative planning; they also underwent ultrasound-guided drainage of hematometra as a temporizing measure to manage acute symptoms. ConclusionPatients presenting with symptomatic hematometrocolpos due to obstructive Müllerian anomalies might not be psychologically mature enough to undergo definitive complex reconstruction, which requires vaginal stent or dilator use postoperatively to prevent stenosis and other complications. Image-guided percutaneous drainage of symptomatic hematometrocolpos serves as a temporizing measure by offering pain relief until patients are ready to undergo surgical management and/or to allow time for complex surgical planning.

Revision after prior failed pectus excavatum repair: higher risks and greater complications than primary surgery.

Revision of a prior failed pectus excavatum (PE) repair is occasionally required. These procedures may be technically more complex and have a greater risk of complications. This study was performed to evaluate the outcomes of adult patients undergoing revision procedures. A retrospective review of adult patients who underwent revision of a prior PE repair from 2010 to 2023 at Mayo Clinic Arizona was performed. Patients were classified by prior procedure [minimally invasive repair of pectus excavatum (MIRPE), Open/Ravitch, and both] and the type of revision procedure performed [MIRPE, hybrid MIRPE, complex hybrid reconstruction, or complex reconstruction of acquired thoracic dystrophy (ATD)]. Outcomes and complications of these groups were analyzed and compared. In total, 190 revision cases were included (mean age was 33±10 years; 72.6% males, mean Haller Index: 4.4±1.8). For the initial repair procedure, 90 (47.4%) patients had a previous MIRPE, 87 (45.8%) patients a prior open repair, and thirteen (6.8%) patients had both. Furthermore, 30 (15.8%) patients had two or more prior interventions. Patients having had a prior MIRPE were able to be repaired with a revision MIRPE in 82.2% of the cases. Conversely, patients with a prior open repair (including those who had both prior MIRPE and open repairs) were much more likely to require complex reconstructions (85%) as none of the ATD patients in this group had an attempted MIRPE. Operative times were shortest in the MIRPE redo approach and longest in the complex reconstruction of the ATD patients (MIRPE 3.5±1.3 hours, ATD 6.9±1.8 hours; P<0.001). The median length of hospital stay was 5 days [interquartile range (IQR), 3.0 days] with the shortest being the MIRPE approach and the longest occurring in the complex reconstruction of the ATD patients [MIRPE 4 days (IQR, 3.0 days); ATD 7 days (IQR, 4.0 days); P<0.001]. Major and minor complications were more frequent in the ATD complex reconstruction group. Preoperative chronic pain was present in over half of the patients (52.6%). Although resolution was seen in a significant number of patients, significant pain issues persisted in 8.8% of the patients postoperatively. Overall, persistent, long term chronic pain was greatest in the post open/Ravitch patient group (open 13.6% vs. MIRPE 3.6%, P=0.02). Revision of a prior failed PE repair can be technically complex with a high risk of complications, prolonged duration of surgery, and lengthy hospitalization. Chronic pain is prevalent and its failure to completely resolve after surgery is not uncommon. The initial failed repair will influence the type of procedure that can be performed and potentially subsequent complications. Even when some recurrences after previous PE surgeries can be repaired with acceptable results, this study demonstrates the importance of proper primary repair due to these increased risks.

Management of Total Frontal Bone Loss After Surgery for Craniosynostosis: The Modified Visor Bone Flap With Brain Cage.

Complications after craniosynostosis surgery occur in 11% to 36% of cases and may be precipitated by poor soft tissue coverage and concomitant exposure of non-sterile regions; sequelae may result in infection, osteomyelitis, and bone loss requiring complex reconstruction. In the pediatric population, autologous cranioplasty remains the gold standard due to growth potential and a more favorable complication profile than synthetic cranioplasty. Virtual surgery planning (VSP) and computer-assisted design (CAD)/computer-assisted manufacturing (CAM) technology can be utilized to create innovative, patient-specific autologous solutions, similar to the approach with synthetic cranioplasty. A novel surgical approach using VSP was used for an 18-month-old female with near total bifrontal bone loss. Surface area measurements were used to determine the amount of bone available to replace the infected frontal bone. VSP was utilized to determine the most efficient construct configuration possible to achieve maximal coverage via calculation of cranial bone surface area measurements. Surgical reconstruction of the defect was planned as a Modified Visor Bone Flap with Posterior Brain Cage. A construct was fashioned from available cranial bone struts to obtain widespread coverage. 3D Recon images from before and after surgery demonstrate almost complete re-ossification of the cranial vault with significant resulting clinical improvement. Reconstruction of total frontal bone loss is possible by utilizing this technique. VSP can improve the safety and efficiency of complex autologous cranial bone reconstructions. We propose a treatment algorithm to address the problem of near total frontal bone loss in young children for whom alloplastic implants are not suitable.

Reconstruction Using Perforator Propeller Flaps After Malignant Melanoma Resection of the Lower Extremity.

Introduction: Surgical excision with margin of 2 cm is the treatment of choice in malignant cutaneous melanoma when Breslow index is >1 mm. When located on the lower limb, these resections can lead to large defects that require complex reconstruction in order to salvage the limb. The use of propeller-perforator flaps has multiple advantages such as the preservation of adjacent muscles, decrease in morbidity in the donor site, and good aesthetic and functional results. Our objective is to expose our experience and results with the use of propeller-perforator flaps for coverage of this kind of defects. Materials and Methods: Patients with malignant cutaneous melanoma of the lower limb who required reconstruction with a propeller-perforator flap between the years 2015 and 2021 in our plastic surgery department were included in this retrospective research. Demographic, reconstructive, oncologic, and functional data were collected and analyzed. Results: The cohort of 22 patients showed 100% of successful reconstructive outcomes. Only 2 patients experienced distal necrosis of the flap that was resolved with local dressings. Fast recovery and early capacity to walk were achieved in the majority of the patients with an average of 10.1 days until weight-baring walking. The 2-year overall and progression-free survival rates were 86.37% and 81.82%, respectively. Conclusion: The use of propeller perforator flaps for oncological defects coverage in the lower limb location has to be considered as a reliable choice as it takes less surgical time and a faster recovery. It allows limb salvage with an adequate length and functionality, with minimal donor site morbidity and a lower index of complications, contributing to improve patient's quality of life and not delaying other oncological treatments.

Oral Cavity Reconstruction over a 30-Year Period at a Dedicated Tertiary Head and Neck Cancer Centre

There are around 2,500 new cases of oral cavity squamous cell carcinoma (OSCC) reported yearly within Australia. Resection often leads to substantial defects, requiring complex reconstruction. The aim of this study was to examine how reconstruction at a dedicated head and neck cancer unit has evolved over a 30-year period. A retrospective review was conducted of all OSCC carcinoma cases performed from 1988 to 2017. Data was analysed in six-time periods; pre-1995, 1995–1999, 2000–2004, 2005–2009, 2010–2014, and 2015 and above. A total of 903 patients were identified, of which 56.1% (n = 507) underwent free flap reconstruction including 426 (84.0%) soft tissue free flaps (STFF) and 81 (16.0%) bony free flaps (BFF). STFF usage remained stable over time. The radial forearm was the most common free flap but declined over time with increasing use of the anterolateral thigh flap. The number of BFF increased from 5.0% before 1995 to 20.4% in 1995–2015. The tongue was the most common subsite, followed by the floor of mouth. Free flaps were utilised in more than 50% of OSCC reconstructions at each time period. Over time, the proportion of different STFF evolved towards increased use of the ALT flap and BFF within our institution. Level of evidence: Level four.

Anatomic variants of the subscapular-thoracodorsal arterial system: A radiologic analysis of 200 arterial systems

BackgroundComposite flaps based on the subscapular arterial system are excellent choices for complex defects, including those of the head and neck, though rates of anatomic variants are not well described. ObjectiveCharacterize subscapular-thoracodorsal arterial system in a large cohort of patients using CT chest angiography. MethodsCTA chest studies from 100 adult patients were analyzed to characterize the bilateral subscapular-thoracodorsal arterial systems. ResultsOut of 200 arterial systems, 25 (12.5%) were lacking a subscapular artery, with the thoracodoral and circumflex scapular arteries arising independently off of the axillary (or other nearby vessels). Strikingly, the subscapular artery was absent bilaterally in 5 patients and absent unilaterally in 15 patients, meaning that one in five patients harbored abnormal anatomy on at least one side. There was no radiographic evidence of atherosclerosis in the studied vessels in any patient, including smokers and patients with atherosclerosis in other vessels. ConclusionVariations in the subscapular-thoracodorsal arterial system appear more frequent than previously described. For select patients requiring complex reconstruction using the scapular system, CTA chest may aide surgical planning.

Use of Intraoperative Frozen Section in the Surgical Management of Patients with Nonmelanoma Skin Cancer.

Background Intraoperative frozen section (IFS) is often utilised in the surgical treatment of nonmelanocytic skin cancer (NMSC) in sensitive facial regions when Mohs micrographic surgery (MMS) is not available. Objective To compare the outcome of NMSC patients with excision performed with and without IFS. Materials and Methods A retrospective, single-centre study was performed on all patients who had undergone resection of NMSC with and without IFS control at the National University Hospital (NUH) from 2010 to 2015. Results 116 patients were recruited, of which 86 had IFS and 30 did not. The complete excision rate of patients with IFS was higher at 87.2% (p=0.0194), need for secondary operation was lower at 1.2% (p=0.005), and need for postsurgery radiotherapy or chemotherapy was lower at 1.2% (p=0.001). The average duration of surgery in patients who underwent IFS was 95.4 minutes compared to 70.1 minutes in cases which did not undergo IFS. Conclusion Our study showed an increased complete excision rate and reduced need for secondary surgeries and adjuvant therapy in patients with IFS. However, a longer operative duration was required. Use of IFS may be useful in patients with NMSC lesions in sensitive regions requiring complex reconstruction after tumour excision.

Overcoming Nuclear Winter: The Cutting-edge Science of Bone Healing and Regeneration in Irradiated Fields.

Background:The incidence of cancer worldwide is expected to be more than 22 million annually by 2030. Approximately half of these patients will likely require radiation therapy. Although radiotherapy has been shown to improve disease control and increase survivorship, it also results in damage to adjacent healthy tissues, including the bone, which can lead to devastating skeletal complications, such as nonunion, pathologic fractures, and osteoradionecrosis. Pathologic fractures and osteoradionecrosis are ominous complications that can result in large bone and soft tissue defects requiring complex reconstruction. Current clinical management strategies for these conditions are suboptimal and dubious at best. The gold standard in treatment of severe radiation injury is free tissue transfer; however, this requires a large operation that is limited to select candidates.Methods:With the goal to expand current treatment options and to assuage the devastating sequelae of radiation injury on surrounding normal tissue, our laboratory has performed years of translational studies aimed at remediating bone healing and regeneration in irradiated fields. Three therapeutics (amifostine, deferoxamine, and adipose-derived stem cells) have demonstrated great promise in promoting healing and regeneration of irradiated bone.Results:Amifostine confers prophylactic protection, whereas deferoxamine and adipose-derived stem cells function to remediate postradiation associated injury.Conclusions:These prospective therapeutics exploit a mechanism attributed to increasing angiogenesis and ultimately function to protect or restore cellularity, normal cellular function, osteogenesis, and bone healing to nonirradiated metrics. These discoveries may offer innovative treatment alternatives to free tissue transfer with the added benefit of potentially preventing and treating osteoradionecrosis and pathologic fractures

Head and neck cancer surgery during the COVID-19 pandemic: An international, multicenter, observational cohort study.

The aims of this study were to provide data on the safety of head and neck cancer surgery currently being undertaken during the coronavirus disease 2019 (COVID-19) pandemic. This international, observational cohort study comprised 1137 consecutive patients with head and neck cancer undergoing primary surgery with curative intent in 26 countries. Factors associated with severe pulmonary complications in COVID-19-positive patients and infections in the surgical team were determined by univariate analysis. Among the 1137 patients, the commonest sites were the oral cavity (38%) and the thyroid (21%). For oropharynx and larynx tumors, nonsurgical therapy was favored in most cases. There was evidence of surgical de-escalation of neck management and reconstruction. Overall 30-day mortality was 1.2%. Twenty-nine patients (3%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within 30 days of surgery; 13 of these patients (44.8%) developed severe respiratory complications, and 3.51 (10.3%) died. There were significant correlations with an advanced tumor stage and admission to critical care. Members of the surgical team tested positive within 30 days of surgery in 40 cases (3%). There were significant associations with operations in which the patients also tested positive for SARS-CoV-2 within 30 days, with a high community incidence of SARS-CoV-2, with screened patients, with oral tumor sites, and with tracheostomy. Head and neck cancer surgery in the COVID-19 era appears safe even when surgery is prolonged and complex. The overlap in COVID-19 between patients and members of the surgical team raises the suspicion of failures in cross-infection measures or the use of personal protective equipment. Head and neck surgery is safe for patients during the coronavirus disease 2019 pandemic even when it is lengthy and complex. This is significant because concerns over patient safety raised in many guidelines appear not to be reflected by outcomes, even for those who have other serious illnesses or require complex reconstructions. Patients subjected to suboptimal or nonstandard treatments should be carefully followed up to optimize their cancer outcomes. The overlap between patients and surgeons testing positive for severe acute respiratory syndrome coronavirus 2 is notable and emphasizes the need for fastidious cross-infection controls and effective personal protective equipment.

The feasibility of urethral plate preservation in proximal and mid-penile hypospadias: sequential and anatomical approach to the repair

BackgroundThe assessment of a child having hypospadias with chordee/ventral curvature (VC) and meatal position that appears to be proximal/mid-penile can be challenging with regard to the choice of chordee correction and type of urethroplasty. The feasibility of preservation of native urethral plate is dependent on these choices. Classically, urethral plate resection of the corpora is performed to correct severe VC, whenever VC is presumed to be due to short urethral plate. But VC is seen to persist in many such cases, in spite of this maneuver that commits the patient to a more complex reconstruction. The aim of the study was to analyze the variation in preoperative and intraoperative assessment of proximal and mid-penile hypospadias, with respect to severity and possible surgical options, in patients treated by a standard protocol of sequential and anatomical approach to repair. The other objective was to ascertain if “extensive ventral urethral detethering” (in all cases) and “urethral plate augmentation” (in select cases) could facilitate more anatomical repair in these cases, with urethral plate preservation and utilization for repair wherever feasible.ResultsFifty-two children who underwent the specific protocol of repair during the 5-year period from January 2014 to December 2018 at a tertiary teaching institution were included in the study. The essential principles adopted for the surgery were as follows: (i) urethral plate preservation in all possible situations; (ii) “extensive ventral urethral detethering” up to the bulb, as a preliminary step, (iii) sequential correction of VC with urethral plate augmentation (in select cases); and (iv) selecting the optimal repair based on the following principles: (a) urethral plate tubularization, (b) urethral plate augmentation, and (c) urethral plate substitution. There was considerable difference in the preoperative and intraoperative assessment of meatal position, with 12 of the apparently mid-penile hypospadias being reclassified as distal penile after preliminary dissection. Three of the penoscrotal variants were regrouped as proximal penile and 6 of the proximal penile were regrouped as mid-penile type. Majority of cases which were deemed to require complex reconstruction on preoperative assessment could be treated by a single-stage procedure.ConclusionThe meatal position is seen to shift distally in select cases of proximal or mid-penile hypospadias after thorough degloving, dartos release, and detethering of Buck’s fascia over ventral urethra. Urethral plate can be preserved for utilization in repair in many of these cases by augmenting the urethral plate, enabling a more anatomical neourethral reconstruction. Resection of urethral plate can be thus restricted to the most severe cases of VC.

Lateral Forehead Flap in Neglected Giant Basal Cell Carcinoma of the Nose: A Case Report

Introduction: Neglected basal cell carcinoma (BCC) of the nose can grow into giant BCCs, rare cases with extensive nasal defects. Such large defects would require complex reconstruction such as free flaps or multiple local flaps. Lateral forehead flap may provide a simpler alternative with good functional and cosmetic results.Case Presentation: We present a case of a 76-year-old man with neglected giant BCC of nose extending to right lower eyelid and upper lip. Wide excision of the tumor leaves a 12cm x 10cm defect. Reconstruction was performed using lateral forehead flap and donor site was covered with split-thickness skin graft from thigh. The second surgery was done after four months to create nostrils and wider eye-opening. Six months later, flap was viable and there was no sign of recurrence. Nasal reconstruction is planned to further improve cosmetics. In this case, neglect is due to low social-economic status and adaptation to painless tumors. The use of lateral forehead flap allows for simpler and faster surgery suitable for elderly. Delayed reconstruction was needed to ensure optimal tissue healing. Conclusions: Neglected BCC causes disfigurement with remarkable morbidity, requiring complex reconstruction. The lateral forehead flap is a simple and reliable reconstruction method for extensive nasal defects with good functional and cosmetic outcomes.

Impact of internal mammary artery perforator propeller flap in neck resurfacing and fistula closure after salvage larynx cancer surgery: Our experience.

Salvage total laryngectomy (TL) and laryngopharyngectomy (LP) after chemoradiotherapy may produce disfiguring defects with severe complications that require complex reconstructions. Between January 2012 and December 2018, we enrolled 25 patients who underwent internal mammary artery perforator (IMAP) flap reconstruction after salvage TL or LP. We performed retrospective review of clinical charts to collect information such as history, timing of reconstruction, type of defect, follow-up, donor and recipient site complications, and overall flap survival (OFS) rate. Three years overall survival (OS), relapse-free survival (RFS), and disease-specific survival (DSS) were calculated. The OFS rate was 95%. One partial flap necrosis was recorded. No donor-site complications were found. The mean follow-up was 18 months. Three years OS was 44%, RFS was 47%, and DSS was 54%. IMAP flap appears to be safe, versatile, and easy to harvest, with minimal donor site morbidity. It is a reliable option in Head&Neck reconstruction, in salvage surgery as well.

Great vessel anomalies and their impact on the surgical treatment of tracheobronchomalacia

BackgroundTracheobronchial compression (TBC) from great vessel anomalies (GVA) can contribute to tracheobronchomalacia (TBM) symptoms. The frequency, impact on symptoms and optimal management of GVA in these patients, with or without a history of esophageal atresia (EA), are still unclear. Study designPatients who underwent surgery for TBM/ TBC between 2001 and 2017 were reviewed. Demographics, type of GVA, and operative interventions were collected. The frequency and treatment modalities of GVA between EA and non-EA patients were compared. ResultsOverall, 209 patients met criteria; 120 (57.4%) patients had at least one GVA, including double aortic arches (n = 4, 1.9%), right aortic arches (n = 14, 6.7%), aberrant right subclavian arteries (n = 15, 7.2%), and innominate artery compression (n = 71, 34.0%). Non-EA patients were more likely to have surgery later in life (29.5 months versus 16 months, p = 0.0002), double aortic arch (p = 0.0174), right aortic arch (p < 0.0001), and undergo vascular reconstruction concurrently with their airway procedure (25% vs 8.4%, p = 0.002). Vessel reconstruction was performed in 25 patients; six required cardiac bypass. ConclusionThe frequency of GVA in patients with symptomatic airway collapse is substantial. Multidisciplinary evaluation is imperative for operative planning as many require complex reconstruction and collaboration with cardiac surgery, particularly patients without a history of EA. Level of evidenceLevel III.

Minimally invasive dual iliac screw, dual rod fixation in a rare case of pathological sacral fracture from a paraganglionoma: a technique description.

The management of lumbosacral neoplastic disease can be demanding, often requiring complex reconstruction. In the context of extensive sacral involvement, the risk of iliac screw breakage is greater. Few studies advocate the use of dual iliac screw techniques to reduce implant failure. In this report, the authors have described the first case of percutaneous dual iliac screw, dual rod insertion as part of a minimally invasive spinopelvic stabilization in a patient with a sacral fracture from a paraganglionoma. The patient underwent percutaneous L-2 to ilium fixation. A dual iliac screw, dual rod construct was used for stabilizing the left lumbopelvic junction. At the 1-year follow-up, the patient remained asymptomatic, with radiographs showing no signs of instrumentation failure. Minimally invasive dual iliac screw, dual rod fixation is a viable option in cases in which additional stability is required due to extensive neoplastic disease or active individuals have increased functional demands. Short-term results in this report are encouraging; however, more research is warranted to establish the procedure's long-term safety.

Outcomes of multimodal management for sinonasal squamous cell carcinoma

BackgroundPoor prognosis of sinonasal cancers (SNC) is usually due to the non-specific symptoms leading to late diagnosis with locally advanced disease. However, previous prognostic studies were often based on heterogeneous cohorts because of the scarcity of SNC. With squamous cell carcinoma being the main histological subgroup, the study aimed to perform a prognostic analysis on sinonasal squamous cell carcinoma (SNSCC) particularly, and to evaluate the oncological results of a multimodal therapy. MethodsA retrospective review of 68 cases involving SNSCC treatment between 1998 and 2012 at Gustave Roussy Cancer Campus was performed. Clinical, pathological, and treatment characteristics were evaluated as prognostic markers for oncological outcomes. ResultsThe 5-year overall survival (OS) and progression-free survival (PFS) rates were 58.1% and 52.6% respectively. Tumor downsizing under neoadjuvant chemotherapy (NACT) was observed in 82.5% of cases. The main pattern of recurrence was local with a 2- and 5-year rate of 37.3%. Decreased OS, PFS and local control were associated with involvement of the orbit, the soft tissue, and the suprastructure (p < 0.005). ConclusionPrognosis of surgically treated SNSCC remains poor. Multimodal treatment combining NACT followed by wide resection requiring complex reconstruction and adjuvant radiation therapy seems to provide promising results.