Computer-aided design and manufacturing technology applied to total nasal reconstruction

The principles of nasal reconstruction include the need to reconstruct three tissue layers, the need to restore entire skin aesthetical units, and, possibly, the replacement with like tissues. Computer-aided design (CAD) and computer-aided manu- facturing (CAM) technologies were applied to two total nasal reconstructions in male patients who underwent rhinectomy for cancer. Three-dimensional (3D) data were obtained from computerized tomography (CT) scan-derived DICOM files (Digital Imaging and Communications in Medicine), this allowed us to design the shape of the reconstructive nose in order to mimic the native nose and to plan dimensions and angles. A custom-made titanium plate was manufactured for the struc- ture and a bi-dimensional template for the forehead flap was printed. The patients underwent a total nasal reconstruction in three layers: local flaps for the lining, custom-made titanium plate for the structure, and expanded forehead flap for the skin. Forehead flap pedicle was divided 3 weeks postoperatively under local anesthesia in an outpatient clinic, as well as further minor refinements. The patients underwent a 6-month post-operative CT scan in order to compare the result to the planned nose. No complications were reported. The superimposition demonstrated a 92% match in case 1 and 95% match in case 2 between the reconstructed nose and the planned one. Forehead flap is still the most favorable option for nasal reconstruction, CAD technology allows to implement the planning and makes the procedure easier; moreover, the use of a CAM plate for the structure allows to reconstruct a nose with the desired naso-frontal angle

The sternum reconstruction: Present and future perspectives

Sternectomy is a procedure mainly used for removing tumor masses infiltrating the sternum or treating infections. Moreover, the removal of the sternum involves the additional challenge of performing a functional reconstruction. Fortunately, various approaches have been proposed for improving the operation and outcome of reconstruction, including allograft transplantation, using novel materials, and developing innovative surgical approaches, which promise to enhance the quality of life for the patient. This review will highlight the surgical approaches to sternum reconstruction and the new perspectives in the current literature

Prevention of Surgical Site Infections in Neonates and Children: Non-Pharmacological Measures of Prevention

A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery and have a significant economic impact on health systems. Preventive measures are essential to decrease the incidence of SSIs and antibiotic abuse, but data in the literature regarding risk factors for SSIs in the pediatric age group are scarce, and current guidelines for the prevention of the risk of developing SSIs are mainly focused on the adult population. This document describes the current knowledge on risk factors for SSIs in neonates and children undergoing surgery and has the purpose of providing guidance to health care professionals for the prevention of SSIs in this population. Our aim is to consider the possible non-pharmacological measures that can be adopted to prevent SSIs. To our knowledge, this is the first study to provide recommendations based on a careful review of the available scientific evidence for the non-pharmacological prevention of SSIs in neonates and children. The specific scenarios developed are intended to guide the healthcare professional in practice to ensure standardized management of the neonatal and pediatric patients, decrease the incidence of SSIs and reduce antibiotic abuse

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Allotrapianto di trachea: studio anatomico sull'utilizzo del lembo ALT

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Elaboration of an algorithm to plan oral cavity, oropharinx and mandibular reconstruction.

1.Ricostruzione mandibolare La ricostruzione mandibolare è comunemente eseguita utilizzando un lembo libero perone. Il metodo convenzionale (indiretto) di Computer Aided Design e Computer Aided Manifacturing prevede il modellamento manuale preoperatorio di una placca di osteosintesi standard su un modello stereolitografico della mandibola. Un metodo innovativo CAD CAM diretto comprende 3 fasi: 1) pianificazione virtuale 2) computer aided design della dima di taglio mandibolari, della dima di taglio del perone e della placca di osteosintesi e 3) Computer Aided Manufacturing dei 3 dispositivi chirurgici personalizzati. 7 ricostruzioni mandibolari sono state effettuate con il metodo diretto. I risultati raggiunti e le modalità di pianificazione sono descritte e discusse. La progettazione assistita da computer e la tecnica di fabbricazione assistita da computer facilita un'accurata ricostruzione mandibolare ed apporta un miglioramento statisticamente significativo rispetto al metodo convenzionale. 2. Cavità orale e orofaringe Un metodo ricostruttivo standard per la cavità orale e l'orofaringe viene descritto. 163 pazienti affetti da cancro della cavità orale e dell'orofaringe, sono stati trattati dal 1992 al 2012 eseguendo un totale di 175 lembi liberi. La strategia chirurgica è descritta in termini di scelta del lembo, modellamento ed insetting. I modelli bidimensionali sono utilizzati per pianificare una ricostruzione tridimensionale con il miglior risultato funzionale ed estetico. I modelli, la scelta del lembo e l' insetting sono descritti per ogni regione. Complicazioni e risultati funzionali sono stati valutati sistematicamente. I risultati hanno mostrato un buon recupero funzionale con le tecniche ricostruttive descritte. Viene proposto un algoritmo ricostruttivo basato su template standard.1.Mandibular reconstruction Mandibular reconstruction is commonly performed using a free fibula flap. The conventional (indirect) Computer Aided Design and Manufacturing method involves preoperative plating, in which a standard osteosynthesis plate is manually shaped on a stereolithographic model of the mandible. A new computer aided design and computer aided manufacturing (direct or CAD/CAM) technique includes: 1) a virtual surgical plan 2) computer aided design of the mandibular cuts, the fibular cuts and the osteosynthesis plate and 3) computer aided manufacturing of the customized surgical device. 7 mandibular reconstructions were performed with the direct method. The results achieved and the planning method are described and discussed. The computer aided design and computer aided manufacturing technique facilitates accurate mandibular reconstruction and is a statistically significant improvement on the conventional method. 2.Oral cavity and oropharinx reconstruction A standardized reconstructive approach to the oral cavity and oropharynx soft tissue defects is described. 163 patients affected by oral cavity and oropharynx cancer, were treated from 1992 to 2012 performing a total of 175 flaps. A systematic postoperative functional study prompted a surgical strategy, in terms of flap choice, shape, and insetting. A two-dimen- sional template was used to obtain a three-dimensional reconstruction for the best functional and aesthetic outcome. The templates, flap choice, and insetting are described for each region. Results Complications and functional results were systematically evaluated. Results showed a good functional recovery with the described reconstructive techniques. A standardized surgical strategy based on reproducible templates is proposed

Multiple Flaps for Trochanteric Pressure Sore Reconstruction: A Case Series

Trochanteric pressure sores can be quite difficult to treat, especially in cases of large bone involvement requiring a wide debridement. The residual wound is large and deep, and the reconstruction must ensure a complete fill of all dead spaces, then must be covered with adequate tissue to allow for healing, and reduce the risk of recurrence. We report a case series of spinal cord-injured patients affected by a trochanteric pressure sore. The reconstruction was achieved using a combination of muscle and a cutaneous muscle flap from the thigh. The result was complete healing of the wound with no recurrence at 18 months. In these cases, muscle or musculocutaneous flaps are the better choices because they permit the use of a good volume of viable tissue. In some cases, the flap can be combined to obtain a better result

Clinical evidences, personal experiences, recent applications

Management of difficult wounds can be a complex, challenging and expensive task, especially for wounds showing a slow healing process. Topical negative pressure (TNP) therapy has greatly improved difficult wounds treatment. It allows to treat patient on an outpatient management, to reduce the complication rate with shorter hospital stay, to avoid frequent dressings with expensive advanced materials and allow a lower commitment of health professionals. Vacuum Assisted Closure\uae (VAC\uae) system is a therapeutic device based on the administration of a controlled TNP introduced by Morykwas and Argenta in 1997. It is indicated in different kinds of wound, but clinical evidences are present only for few of them. In this work we summarize indications and recommendations for VAC\uae therapy and we analyze the actual better choice of treatment based on evidences and personal experience in order to stimulate further studies. Finally we introduce recent applications of VAC\uae system such as Prevena\uae, VAC Instill\uae and VAC Via\uae. Prevena\uae is a system based on TNP indicated in the management of closed wounds that present risk factors for dehiscence. VAC Instill\uae is a system that allows to associate TNP and topical administration of solutions, such as antibiotics or disinfectants, to treat specific type of wounds. VAC Via\uae is a device based on TNP, characterized by little dimension and a preset system that allow the treatment of little wounds for 7 d, with no impairment for the patient. The aim of our paper is to describe a report of VAC\uae therapy use in order to stimulate further studies and to define the level of evidence of VAC\uae therapy

Microvascular reconstruction of the columella using a small radial forearm free flap: a case report

Columellar defects can result from various causes, a number of methods have been described for the reconstruction using local, regional, or free flaps. When local tissues are not available due to the presence of scars, free flaps become the treatment of choice. We present the case of a columellar defect resulting from a distal necrosis of a forehead flap in total nasal reconstruction. The columella was reconstructed using a small radial forearm free flap and a conchal cartilage graft. The flap and the graft survived completely with a satisfactory cosmetic result and good respiratory function during the follow-up time of 2 years. The result was achieved in a single-stage operation: the patient did not need any further procedures to improve the nasal appearance. We propose that the radial forearm free flap may be an easy and reliable alternative among the surgical options for columellar defects when local tissues are not available