New Nasopharyngeal Flap for Posterior Skull-Base Reconstruction: The Upper-Tongue Flap

Introduction Reconstructions of clival resection are still challenging, and additional reconstructive methods may be necessary to achieve full coverage of the skull-base defect in patients with middle- and lower-clivus disease. Objective To describe a new nasopharyngeal flap for the middle and lower clivus. Methods Using nasal endoscopy in a cadaver dissection, we demonstrated a new nasopharygeal flap to cover the lower and middle clival resection. Results We described a new nasopharyngeal flap capable of covering the lower and middle portion of the clivus. Discussion The new nasopharyngeal flap, called the upper-tongue flap, is particularly adequate as an alternative for the reconstruction of middle and lower clivus defects, and it is better used in association with a nasalseptal flap in cases in which the nasalseptal flap alone does not provide enough mucosal coverage. Conclusion The new nasopharyngeal flap can be used in the reconstruction of clival resection.

METHODS OF THE COMPLEX PROCESS OF THE RESTORATION-RECONSTRUCTIVE TRANSFORMATIONS

The article deals with the systematization of existing restoration and reconstructive methods in a hierarchical order, depending on the possibility of introducing a new one into the historically established – from, the gentlest, restoration to the most active reconstructive. Their classification is proposed: according to the activity of the intervention – into preserving, restoring, renewing, transforming; to carry out qualitative changes at different system levels – urban planning, volumetric and functional. Preserving and restoring methods are classified as restoration, and renewing and transforming methods are classified as reconstructive. Their correspondence is shown depending on their activity in bringing new into the historical formed and their use for various system levels in the implementation of the complex process of restoration-reconstructive transformations. A brief explanation of each method is provided. It has been determined that the use of the restoration or reconstructive methods depends on the qualitative indicator of the existing state of the selected site, namely, its degree of value (historical-architectural value) and the degree of destruction (integrity). It is recommended to use restoration methods (preserving and restoring) for sites of the I and II degrees of value and integrity, and reconstructive methods (renewing and transforming) for sites of the III and IV degrees of value and integrity. It was indicated that the restoration methods correspond to the I and II degrees of restoration-reconstructive transformations, and the reconstructive methods correspond to the III and IV degrees of the RRT. For the effectiveness of the complex process of restoration-reconstruction transformations in any historical urban environment, it is recommended to use not individual methods, but their combinations.

Analysis of epidemiological characteristics and surgical treatment of patients with pressure ulcer

Introduction/Objective. A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence. It appears as a result of pressure or combination of pressure and shear. Pressure ulcers can be identified within a wide variety of patient subpopulations and a major role in their treatment plays epidemiological and etiological aspects. Methods. A retrospective study of data analysis included 72 patients with pressure ulcers that were hospitalized and surgically treated during a five-year period at the Clinic for Burns, Plastic and Reconstructive Surgery of the University Clinical Center of Serbia in Belgrade. Main data features used in the analysis were: gender, age, principal diseases, comorbidities and biochemical indicators of malnutrition. The patients' data was obtained from the existing patients? records. Additionally, the study analyzed the method of treating pressure ulcers, types of reconstructive methods in surgical treatment, as well as the incidence rate of partial osteotomy. Results. A total of 72 patients with pressure ulcers were included into this study with 54.7 ? 16.1 mean age. Three times more patients injured in traffic accidents were male (75% vs. 25%), while the most of the patients with multiple sclerosis were female (85.7%). More than 95% of patients who had pressure ulcers of III or IV stage were treated surgically with a reconstructive method of transposition or rotation myocutaneous flap. The patient with pressure ulcer of stage IV was usually treated with partial osteotomy. Conclusion. A surgical reconstructive treatment with fasciocutaneous and myocutanaeous flaps represents a gold standard for treating patients with pressure ulcers. These procedures provide reconstruction with adequate flap coverage and obliteration of dead space with well-vascularized tissue but with necessity of further implementation of antidecubitus measures.

Retrospective Comparative Analysis of POPF Using Fistula Risk Score According to Pancreaticoenterostomy Method

Background The aim of this study is to examine whether pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ) is the better reconstructive method to reduce postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) according to the fistula risk. Methods An institutional database was reviewed for patients undergoing PD between January 2008 and August 2019. A total of 159 patients were stratified into 4 groups according to the Clinical Risk Score-Pancreatic Fistula. POPF according to 4 risk groups was compared between PJ and PG. Results Of the 159 patients, 82 underwent PG (51.6%) and 77 underwent PJ (48.4%) reconstruction. POPF rate was 17.1% (n = 14) in the PG group and 12.9% (n = 10) in the PJ group (P = 0.51). POPF rates were not different in intermediate, low, and negligible risks between 2 reconstructive methods. In the high-risk group (n = 47), there were 4 POPFs (22.2%) in PJ group and 9 (31.0%) in the PG group, respectively (P = 0.74). Conclusion In PD, there was no superior method of reconstruction with regard to POPF, even in high-risk glands.

Matched Analysis of Postoperative Pancreatic Fistula Using Fistula Risk Score According to Pancreaticoenterostomy Methods

Background To examine whether pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ) is the better reconstructive method to reduce Postoperative Pancreatic Fistula (POPF), after pancreaticoduodenectomy (PD) according to the fistula risk. Methods An institutional database was reviewed for patients undergoing PD between January 2008 and August 2019. 159 patients were stratified into four groups according to the Clinical Risk Score-Pancreatic Fistula (CRS-PF). POPF according to 4 risk groups was compared between PJ and PG. Results Of the 159 patients, 82 underwent PG (51.6%) and 77 underwent PJ (48.4%) reconstruction. POPF rate was 15.1% and 17.1% (n=14) in the PG group and 12.9% (n=10) in the PJ group (P =0.51). POPF rates were not different in intermediate, low and negligible risks between two reconstructive methods. In High risk group (n=47), there was 4 (22.2%) POPF in PJ group and 9 (31.0%) in PG group, respectively (p=0.74). Conclusions In PD, there was no superior method of reconstruction with regards of POPF, even in high risk glands.

Biomechanical Analysis of Various Reconstructive Methods for the Mandibular Body and Ramus Defect Using a Free Vascularized Fibula Flap

Several different methods exist for reconstructing the mandibular body and ramus defect with the use of a free vascularized fibula flap, but none have adequately addressed the long-term mechanical stability and osseointegration. The aim of this study is to compare the biomechanics of different surgical methods and to investigate the best approach for reconstructing the mandibular body and ramus defect. Five finite element models based on different reconstructive methods were simulated. Stress, strain, and displacement of connective bone sections were calculated for five models and compared. The models were printed using a 3D printer, and stiffness was measured using an electromechanical universal testing machine. The postoperative follow-up cone beam computed tomography (CBCT) was taken at different time points to analyze bone mineral density of connective bone sections. The results showed that the “double up” (DU) model was the most efficient for reconstructing a mandibular body and ramus defect by comparing the mechanical distribution of three sections under vertical and inclined loading conditions of 100 N. The stiffness detection showed that stiffness in the DU and “double down” (DD) models was higher compared with the “single up” (SU), “single down” (SD), and “distraction osteogenesis” (DO) models. We used the DU model for the surgery, and postoperative follow-up CBCT showed that bone mineral density of each fibular connective section increased gradually with time, plateauing at 12 weeks. We conclude that a free vascularized fibula flap of the DU type was the best approach for the reconstruction of the mandibular body and ramus defect. Preoperative finite element analysis and stiffness testing were shown to be very useful for maxillofacial reconstruction.

Effect of Eyelid Involvement in the Reconstruction of Medial Canthal Defects

The purpose of this study was to present surgical techniques for the reconstruction of medial canthal defects with and without the involvement of the eyelid. This study included 31 patients who underwent medial canthal reconstruction after tumor excision during a 6-year period. Data regarding patient demographics, defect size, tumor pathology, surgery techniques, functional and cosmetic outcomes, and complications were recorded. The reconstructive methods used in the study were divided into groups as per the site of the defect (medial canthal, medial canthal with upper eyelid, medial canthal with lower eyelid, and medial canthal with both eyelids). The most common histopathological diagnosis of the lesions was basal cell carcinoma (74.2%). Postoperative complications (6.4%) included flap necrosis in one patient and lid margin notching in another. Among patients who underwent reconstruction, 8 (25.8%) had only medial canthal defect, 6 (19.3%) had medial canthal defect extending to the upper eyelid, 7 (22.6%) had medial canthal defect extending to the lower eyelid, and 10 (32.3%) had medial canthal defect extending to both the eyelids. The functional outcome was regarded as normal in 30 (96.8%) patients and limited in 1 (3.2%) patient. Cosmetic outcomes were satisfactory in all the patients. The use of alternative reconstructive approaches for different subunits of the medial canthus is an efficient method to achieve superior functional and cosmetic outcomes.