Vascularized lymph node transfer with submental free flap

Limb lymphoedema is common in patients who have undergone inguinal or axillary lymph node dissection. Lymphoedema seriously impacts the patient's quality of life by inducing adipogenesis, fibrosis and repeated episodes of lymphangitis and cellulitis. Following failure of compression therapies, several curative or symptomatic surgical options have been proposed over recent decades, such as liposuction or lymphovenous anastomosis. Vascularized lymph node transfer techniques have recently been described, with promising results. Vascularized lymph node transfer with submental free flap appears to be the most reliable of these technique, associated with the lowest morbidity. The flap harvesting technique presents several specific differences compared to conventional submental free flap. A good knowledge of neck anatomy is essential and multimodal and multidisciplinary management is often required. In the light of a case report, we describe the basic submental free flap technique for vascularized lymph node transfer for the treatment of lower limb lymphoedema. This technique may be used by head and neck surgeons performing flap harvest, as well as plastic surgeon surgeons or gynaecologists ensuring long-term management of these patients

The impact of patients’ and physicians’ characteristics on surgery decision for head and neck cancer: Results of a national survey

Background: Population’s aging leads to an increased diagnosis of head and neckcancer (HNC) in older patients (pts). Treatment can involve surgery, radiation, sys-temic therapy or multimodal therapy. Due to heterogeneity of older pts, thecomprehensive geriatric assessment (CGA) is considered the gold standard tool toclassify pts according to frailty profile. Multidisciplinary approach including a geria-trician is essential. CGA may be helpful to personalize treatment plan and to detectgeriatric conditions that can be reversible through geriatric interventions. We aim toevaluate the impact of CGA on therapeutic decision

Closure of radial forearm free flap donor site: A comparative study between keystone flap and skin graft

Background The aim was to investigate the feasibility of radial forearm free flap (RFFF) donor site closure by keystone flap (KF) and compare its outcomes to those of skin graft (SG) closure. Methods One hundred and one patients who underwent RFFF for head and neck reconstruction were included (35 KF closure and 65 SG closure). Duration of wound healing and donor site complications was collected. After a minimal follow‐up of 1 year, patients were questioned about functional and esthetic impairment. Results Coverage of donor site by KF was successful in all cases. The duration of wound healing was longer after SG than after KF (32 days vs 18 days, P < .001). Healing complications, esthetic and functional results were not statistically different. Conclusion Forearm donor site closure by KF is a feasible alternative to the traditional SG. Its main advantages are the reduced wound healing time and the avoidance of a second donor site

Management of the irradiated N0-neck during salvage pharyngo-laryngeal surgery

Background: Salvage surgeries are challenging procedures, with an associated poor prognosis. Management of the N0 neck in those situations remains controversial. We aim to compare oncologic outcomes regarding neck management after surgery for N0 pharyngo-laryngeal carcinoma occurring after loco-regional radiotherapy. Methods: We conducted a multicentric retrospective study, including all patients undergoing surgery for persistent, recurrent or new primary N0 carcinoma of the oropharynx, hypopharynx or larynx between 2005 and 2015, following loco-regional radiotherapy. Results: A total of 239 patients were included, concerning respectively 44%, 34% and 22% oropharyngeal, laryngeal and hypopharyngeal tumors operated. A neck dissection was performed in 143 patients (60%), with an occult nodal metastasis rate of 9%. This rate was higher for hypopharyngeal carcinomas (18%, p = 0.16) and tumors with initial nodal involvement (16%, p = 0.05). With a median follow-up of 60 months, the median overall survival (OS) and progression-free survival rates (PFS) were 34 months and 25 months. We identified negative margin excision status, age at the time of surgery (under 60) and delay between RT and surgery over 2 years as the only variables associated with better OS (p < 0.0001 and p = 0.004) and PFS (p < 0.0001 and p = 0.010) in multivariable analysis, with no difference regarding neck management. Regional progression (alone or with distant metastasis) was noted in 10 cases: 4 in the neck observation group (4%) versus 6 in the neck dissection group (4%). Conclusion: Elective lymph node dissection of irradiated neck should not be routinely performed in patients undergoing surgery for persistent, recurrent or new primary pharyngo-laryngeal carcinoma

Polyanionic Hydrogels as Reservoirs for Polycationic Antibiotic Substitutes Providing Prolonged Antibacterial Activity

Implantation of biomedical devices is often followed by bacterial infections that may seriously affect implant functionalities and lead to their failure. In the context of bacterial resistance to antibiotics, which is a growing problem worldwide, new strategies that are able to overcome these problems are needed. In this work, we introduce a new formulation of hyaluronic acid (HA)-based antimicrobial material: HA hydrogels loaded with polyarginine (PAR), a polycationic antibiotic substitute. The loading is possible through electrostatic interactions between negatively charged HA and positively charged PAR. Such hydrogels absorb high quantities of PAR, which are then gradually released from the hydrogel. This original system provides a long-lasting antibacterial effect on an in vitro model of repetitive infection, thus demonstrating a strong potential to fight multiple rounds of infections that are resistant to antibiotic treatment. In addition, HA-PAR hydrogels could be deposited onto/into medical devices such as wound dressings and mesh prostheses used in clinical applications. Finally, we performed first in vivo tests of hydrogel-coated mesh materials to verify their biocompatibility in a rat model, which show no difference between control HA hydrogel and PAR-loaded hydrogel in terms of inflammation

The super thin external pudendal artery (STEPA) free flap for oropharyngeal reconstruction – A case report

The radial forearm flap is one of the most used micro‐anastomotic flaps in cervicofacial reconstruction in a carcinological context. This flap is an ideal in terms of reliability and fineness; it has, however, some disadvantages in terms of the functional and aesthetic complications of its donor site. In alternative to a radial forearm free flap, we report the use of the free super thin external pudendal artery flap (STEPA flap) for an oropharyngeal reconstruction. The aim was to decrease the donor site morbidity. A 71‐years‐old man with a T2N0M0 oropharyngeal squamous cell carcinoma has undergone surgical treatment. A left STEPA free flap was performed to reconstruct a defect about 8 × 6 cm2. This flap was designed as a half‐scrotal free flap sized 9 × 7 cm2 and was inset after tunneling of the pedicle at the floor of the mouth. A surgical revision was needed on the 15th day postoperative for disunion. There was no skin flap failure. After 12 month of follow‐up, no complication was observed at the donor site and no erectile dysfunction was recorded. Its characteristics in terms of fineness, flexibility, ease of conformation, and pedicle length are similar to those of the radial forearm flap with less aesthetic and functional sequelae of the donor site. The STEPA flap may be a promising free flap in oropharyngeal or oral cavity reconstruction

Foam-Based Bionanocomposite Scaffold for Bone Tissue Engineering

The repair of large bone defects is a major clinical problem for which tissue engineering (association of a biomaterial and cells) constitutes a valuable alternative. In this domain, the architecture and the mechanical properties of the 3D scaffold aimed to support cells is of key importance to succeed in bone reconstruction. In this study, we aim to design and evaluate a bionanocomposite foam-based scaffold, exhibiting all the desired biofunctional attributes of biocompatibility, bioactivity, osteoconduction/induction, combined with potential release properties. To perform this, 2 components have been associated: (i) a biopolymer, pectin, incorporating (ii) calcium phosphate nanoparticules to provide bone apatite nucleation sites, mechanical reinforcement, and to play the role of potential drug reservoir. The goal of this study was to determine the feasibility of obtention of such bionanocomposite by foam-templating, and to study the influence of mineral particules ratio on pectin foam and final scaffold 3D architecture and properties

Risk Factors for Pharyngocutaneous Fistula After Total Pharyngolaryngectomy

Purpose:To evaluate the risk factors of pharyngocutaneous fistula after total pharyngolaryngectomy (TPL) in orderto reduce theirincidence and propose a perioperative rehabilitation protocol.Materials and Methods:This was a multicenter retrospectivestudy based on 456 patients operated for squamous cell carcinoma by total laryngectomy or TPL. Sociodemographic, medical,surgical, carcinologic, and biological risk factors were studied. Reactive C protein was evaluated on post-op day 5. Patients weredivided into a learning population and a validation population with patients who underwent surgery between 2006 and 2013 andbetween 2014 and 2016, respectively. A risk score of occurrence of salivary fistula was developed from the learning population dataand then applied on the validation population (temporal validation).Objective:To use a preoperative risk score in order tomodify practices and reduce the incidence of pharyngocutaneous fistula.Results:Four hundred fifty-six patients were included,328 in the learning population and 128 in the validation population. The combination of active smoking over 20 pack-years, ahistory of cervical radiotherapy, mucosal closure in separate stitches instead of running sutures, and the placement of a pedicleflap instead of a free flap led to a maximum risk of post-op pharyngocutaneous fistula after TPL. The risk score was discriminantwith an area under the receiver operating characteristic curve of 0.66 (95% confidence interval [CI]¼0.59-0.73) and 0.70 (95% CI¼0.60-0.81) for the learning population and the validation population, respectively.Conclusion:A preoperative risk score couldbe used to reduce the rate of pharyngocutaneous fistula after TPL by removing 1 or more of the 4 identified risk factors

Interaction of Folic Acid with Nanocrystalline Apatites and Extension to Methotrexate (Antifolate) in View of Anticancer Applications

Nanocrystalline apatites mimicking bone mineral represent a versatile platform for biomedical applications thanks to their similarity to bone apatite and the possibility to (multi)functionalize them so as to provide “à la carte” properties. One relevant domain is in particular oncology, where drug-loaded biomaterials and engineered nanosystems may be used for diagnosis, therapy, or both. In a previous contribution, we investigated the adsorption of doxorubicin onto two nanocrystalline apatite substrates, denoted HA and FeHA (superparamagnetic apatite doped with iron ions), and explored these drug-loaded systems against tumor cells. To widen their applicability in the oncology field, here we examine the interaction between the same two substrates and two other molecules: folic acid (FA), often used as cell targeting agent, and the anticancer drug methotrexate (MTX), an antifolate analogue. In a first stage, we investigated the adsorptive behavior of FA (or MTX) on both substrates, evidencing their specificities. At low concentration, typically under 100 mmol/L, adsorption onto HA was best described using the Sips isotherm model, while the formation of a calcium folate secondary salt was evidenced at high concentration by Raman spectroscopy. Adsorption onto FeHA was instead fitted to the Langmuir model. A larger adsorptive affinity was found for the FeHA substrate compared to HA; accordingly, a faster release was noticed from HA. In vitro tests carried out on human osteosarcoma cell line (SAOS-2) allowed us to evaluate the potential of these compounds in oncology. Finally, in vivo (subcutaneous) implantations in the mouse were run to ascertain the biocompatibility of the two substrates. These results should allow a better understanding of the interactions between FA/MTX and bioinspired nanocrystalline apatites in view of applications in the field of cancer

Hybrid Titanium/Biodegradable Polymer Implants with an Hierarchical Pore Structure as a Means to Control Selective Cell Movement

UNLABELLED: In order to improve implant success rate, it is important to enhance their responsiveness to the prevailing conditions following implantation. Uncontrolled movement of inflammatory cells and fibroblasts is one of these in vivo problems and the porosity properties of the implant have a strong effect on these. Here, we describe a hybrid system composed of a macroporous titanium structure filled with a microporous biodegradable polymer. This polymer matrix has a distinct porosity gradient to accommodate different cell types (fibroblasts and epithelial cells). The main clinical application of this system will be the prevention of restenosis due to excessive fibroblast migration and proliferation in the case of tracheal implants. METHODOLOGY/PRINCIPAL FINDINGS: A microbead-based titanium template was filled with a porous Poly (L-lactic acid) (PLLA) body by freeze-extraction method. A distinct porosity difference was obtained between the inner and outer surfaces of the implant as characterized by image analysis and Mercury porosimetry (9.8±2.2 µm vs. 36.7±11.4 µm, p≤0.05). On top, a thin PLLA film was added to optimize the growth of epithelial cells, which was confirmed by using human respiratory epithelial cells. To check the control of fibroblast movement, PKH26 labeled fibroblasts were seeded onto Titanium and Titanium/PLLA implants. The cell movement was quantified by confocal microscopy: in one week cells moved deeper in Ti samples compared to Ti/PLLA. CONCLUSIONS: In vitro experiments showed that this new implant is effective for guiding different kind of cells it will contact upon implantation. Overall, this system would enable spatial and temporal control over cell migration by a gradient ranging from macroporosity to nanoporosity within a tracheal implant. Moreover, mechanical properties will be dependent mainly on the titanium frame. This will make it possible to create a polymeric environment which is suitable for cells without the need to meet mechanical requirements with the polymeric structure