746 EXPERIENCE IN RECONSTRUCTION OF LARYNGOPHARYNGOESOPHAGECTOMIES IN A THIRD LEVEL CENTER

Pharyngoesophageal reconstruction after laryngo-pharyngo-esophagectomy, due to malignant or benign causes, is challenging due to its high morbidity and mortality. There are different reconstructive flaps: visceral flaps (pedicle stomach and colon flaps and free jejunum or colon grafts) and myocutaneous flaps (pedicle local flaps, such as the pectoralis major flap, or free grafts, such as the anterolateral thigh-ALT). The objective is to evaluate the morbidity and mortality and functional results of the reconstruction after laryngo-pharyngo-esophagectomy. Methods This is a retrospective study of patients who underwent laryngo-pharyngo-esophagectomy in our center, due to a benign cause (ingestion of caustic) or malignant (cancer of the larynx, pharynx, parathyroid and cervical esophagus) with circumferential pharyngeal reconstruction with flap, from 2008 to November 2020. Demographic variables, neoadjuvant treatment, procedure performed and flap used for reconstruction, complications related to reconstruction (fistula, stenosis, necrosis), postoperative complications, days until adequate swallowing, functional result of the flap, hospital stay, recurrence and mortality were collected. Results Twelve patients, with a median age of 59 years (45–78), underwent surgery, 1 case due to benign cause and 11 cases with an oncological diagnosis. There were complications related to the reconstruction in 42% of the patients (see table 1). Postoperative morbidity was 67% (75% Clavien-Dindo ≥ III). The median hospital stay was 21 days (16–94). The median time to swallowing was 13 days (3–73). An optimal functional result (oral intake) was achieved in 75% (only 3 patients with poor results). The median follow-up was 18 months (4–56), with a survival rate of 50%. 30-days mortality was 8% (1 case). Conclusion Our study shows a high morbidity and mortality after circumferential pharyngeal reconstruction, similar to literature published. We have observed a higher rate of reconstruction related complications (fistulas and stenosis) and worse functional results in reconstructions performed with gastroplasty and coloplasty after total laryngo-pharyngo-esophagectomy, compared to less aggressive local resections (laryngopharyngeal) with ALT free flap reconstruction.

Geometrical Model of Free Skin Graft for the Optimization of Glans Reconstruction after Partial Penectomy

Introduction and Objective The management of penile carcinoma is very disabling and mutilating, bur early treatment can be curative. Our group systematically performs oncological management with immediate penile reconstruction and preservation of the organ (partial penectomy, resurfacing, or glansectomy) when feasible. Due to the low incidence of penile carcinoma, it is difficult to achieve experience in penile reconstruction using free grafts in a standardized and reproducible way. Therefore, we herein present the results of the use of an inanimate model to identify the most efficient geometric way to procure and apply a free skin graft to reconstruct the penis. Methods A preclinical inanimate model of the penis was developed to simulate the surgical reconstruction using a free skin graft. Six different geometric skin-graft models were created and tested. For each of them, we measured graft's surface area as well as the discarded surface after placing the graft on the penis for reconstruction. We also measured the amount of suture lines required for reconstruction. All of these measurements in the six different models were compared. Results Based on the six models, we identified that the longitude of the graft must measure the same as the maximum perimeter of the glans in order to have a square that enables the complete coverage of the penile defect. The total graft area for the first 4 models was of 40 cm2; for models 5 and 6, it was of 60 cm2. The average discarded area of the graft was of 18.135 cm2 (range: 12 cm2 to 30 cm2). Models 4 years 6 were the ones with the least discarded tissue: 12 cm2. The average amount of suture lines to secure the different model grafts was 7.3 (range: 5 to 12). The models that required the least amount of suture lines were number 1 and 4, with a total of 5 suture lines. Conclusions The double trapezoid is the most efficient model to reconstruct the glans after organ-sparing oncological management. Our results contribute to establish a more standardized and predictable technique to reconstruct the penis.

A Comparative Analysis of Outcomes of Free Nipple Areolar Grafting in Autologous Breast Reconstruction

Background Preserving the nipple areolar complex (NAC) increases satisfaction in breast reconstruction. This study aims to describe outcomes using free NAC grafts in microvascular breast reconstruction. Methods A case–control study evaluated prospective outcomes of microvascular breast reconstruction with free NAC grafts compared with matched controls with tattoo or local flap nipple reconstruction. Eligible patients for NAC grafting required correction of ptosis or nipple malposition. Postoperative photographs were rated for complications and aesthetics by the four study authors and two additional unbiased board-certified plastic surgeons. Satisfaction was measured with the BREAST-Q. Results Twenty patients who underwent 35 autologous breast reconstructions were analyzed. Nipple areolar reconstruction with grafts was completed with 13 NACs in 7 patients. The majority of free NAC grafts (11/13, 85%) were completed in immediate reconstruction, and 15% (2/13) were completed in delayed reconstruction. Partial graft hypopigmentation (mean 18.0%, standard deviation [SD] 7.5) was noted in all grafts. Less than half of grafts had areas of depigmentation (6/13, mean 6.1%, SD 7.5). Minor areas of partial loss occurred in 6/13 grafts (mean 2.9%, SD 4.6). Nipple projection was maintained in 54% of nipples (7/13). Depigmentation, hypopigmentation, graft loss, and projection were not statistically correlated with NAC aesthetic or overall aesthetic rating. However, NAC size (p = 0.003), position (p = 0.022), and symmetry (p = 0.028) were all correlated with aesthetic outcomes. Outcomes and satisfaction were similar to those seen with local flap reconstruction, although partial loss was less common in NAC grafts. Conclusion Nipple reconstruction can successfully be performed in microvascular breast reconstruction using free grafts. Although partial graft hypopigmentation is common, smaller areas of graft loss or depigmentation are anticipated and do not affect aesthetic outcomes. The use of free NAC grafts may allow additional patients to use their own nipples as part of their microvascular reconstruction and avoid secondary NAC reconstruction procedures.

Facial human bites. Vision on STMMs in Africa

ABSTRACT Objectives: Human bites of the face are a frequent and serious health issue as they often compromise patients function and aesthetics as well as lead to further complications. The aim of the study is to review human bites of the face referred to our team during 112 short-term medical missions (STMMs) in Sub-Saharan Africa over the past 20 years and to discuss the epidemiology, appearance, management and outcome, including the most common complications. Methods: A retrospective medical documentation review was carried out examining all human bites of the face operated by our team during 112 STMMs from 2000 to 2019 in different countries of Sub-Saharan Africa. Results: Out of about 5500 patients medical charts 51 patients were selected due to history of human bite. Patients’ age range was 15-65 years, female to male ratio was 1, 55:1, the most often involved parts were: lips, ear and nose. Various surgical procedures were carried out including local flaps and free grafts. Infection and graft necrosis were the most common reported complication (n=4, 9,3 %). Conclusion: Human bites injuries are a serious health problem in some African populations because of their frequency and possible severity. The treatment is particularly challenging due to their potential to cause local infections, the risk they pose for transmission of systemic diseases as well as their demanding surgical management.

Surgical Reconstruction of the Metatarsal Pad Using Nonweight-Bearing Surfaces of the Footpads in a Dog

ABSTRACT A 9 yr old mixed-breed dog weighing 6.3 kg was presented with degloving injuries and multiple lacerations on the footpads of both hindlimbs. After amputation of the left hindlimb and debridement of the necrotic footpads on the right hindlimb, the remaining pads were insufficient for ambulation. The complete carpal pads and the peripheral, nonweight-bearing portions of the second and fifth digital pads of both forelimbs were harvested for pad grafting. All segments were sutured on the cutaneous trunci muscle in the predetermined location of the right abdominal wall for the pouch flap. After detaching the flap, the grafted segments were gradually strengthened, and the dog was able to regain ambulation. When considering pad grafting, the entire carpal pad and crescent-shaped segments from the nonweight-bearing surfaces of digital pads are excellent candidates for free grafts without compromising the ambulation of other limbs.

Perichondrium - An Autologous Substitute for Temporalis Fascia in Type I Tympanoplasty: A Comparative Study

Introduction Temporalis fascia is the commonly used graft material for tympanic membrane reconstruction. Tragal perichondrium share with the fascia the quality of being mesenchymal tissue. In our study we compared perichondrium and temporalis fascia in terms of graft uptake and hearing improvement. Materials and Methods All patients presenting with discharge from ear and decreased hearing were subjected to clinical examination and investigation. Patients satisfying inclusion criteria were included in study with total of 40 patients. Twenty underwent type1 tympanoplasty with temporalis fascia (TF) and another 20 patients with tragal perichondrium (TP). To evaluate success patients are evaluated at end of 6 months for graft uptake and 3 months for hearing results in audiological gain of 10 dB in two consecutive frequencies. Results Mean Pre-op AC Threshold in TF group was 30.75 dB±5.16 and Post-op AC Threshold was 14.15 dB±8.05. Mean Pre-op AC Threshold in TP group was 32.2 dB±4.81 and Post-op AC Threshold was 20.95 dB±7.14. Mean post-op AC Threshold, Mean Post-Op AB Gap and Mean Audiological Gain was statistically significant among 2 groups p=0.0075, p=0.0013, p=0.0294 respectively. Temporalis fascia was better than Tragal Perichondrium. Graft uptake in 2 groups was not significant (p=0.6325). Conclusion From the present study we may conclude that temporalis fascia, tragal perichondrium free grafts provide viable autograft material for tympanoplasty. Both achieve good hearing restoration but the improvement in hearing or audiological gain is better in temporalis fascia graft than in tragal perichondrium graft.

MANDIBULAR AMELOBLASTOMA RECONSTRUCTION: A CASE REPORT WITH 10-YEAR FOLLOW-UP

Ameloblastoma is a benign dental tumor mostly found in the mandible, with several variations. The treatment of this pathology ranges from simple enucleation to resection of large sections of the affected bone. There are several options for correcting the sequelae of ameloblastoma treatment, including the use of grafts and currently microvascular free flaps, which have become the standard treatment. This report describes a clinical case of a large mandibular ameloblastoma, which was resected with safety margins about 10 years ago, reconstructed by free grafts in successive surgical times and rehabilitated using removable prostheses. The question is then what the best option is today in the reconstruction of patients affected by this type of pathologies, taking into account emerging options, the clinicians’ learning curve and the patients’ resources.

A Primary Clival Defect: Endoscopic Binostril Approach With Nasal Septal Flap Closure and Preservation of Septal Integrity

Primary spontaneous cerebrospinal fluid (CSF) rhinorrhea is an unusual phenomenon that may occur anywhere along the skull base. However, CSF leaks originating from clival defects are rarely reported in the literature. The majority of reported cases were managed with microscopic techniques, using free grafts. The present study discusses a case of spontaneous CSF rhinorrhea from a clival defect closed with our transnasal operative approach using endoscopic techniques. The skull base defect was successfully managed with an endoscopic binostril approach to create a nasal septal flap pedicled at the sphenopalatine artery, while also preserving the integrity of the nasal septum.