Transdermal Nitroglycerine Patch: An Optional Device to Reduce Flap Venous Congestion? A Case Report

ABSTRACT Sometimes in free flap there is a venous congestion without an obstruction of the venous anastomosis or other organic causes of reduction venous drainage (haematoma, seroma compressing the pedicle). In these cases the authors suggest the application of nitroglycerine patch in the congested area of the flap few hours before the surgical exploration of the anastomosis. If there is a fast improvement of the clinical feature of the flap, the surgical exploration could be avoided. The authors underline that applying the nitroglycerin patch should not be regarded in any way as a therapy of a free flap venous thrombosis but only as an useful device, an option to be taken only when the surgeon is undecided whether to revisit the anastomosis or not

Histology of the Oral Mucosa in Patients With BRONJ at III Stage: A Microscopic Study Proves the Unsuitability of Local Mucosal Flaps.

BACKGROUND: Bisphosphonate Osteonecrosis of the Jaw (BRONJ) is a newly recognized condition reported in patients treated with aminobisphosphonates (BF). BRONJ is defined as the presence of exposed necrotic alveolar bone that does not resolve over a period of 8 weeks in a patient taking bisphosphonates who has not had radiotherapy to the jaw. Treatment protocols have been outlined, but trials and outcomes of treatment and long-term follow-up data are not yet available. In 2004 an expert panel outlined recommendations for the management of bisphosphonate-associated osteonecrosis of the jaws. Through the histological study of the oral mucosa over the bone necrosis and around the osteonecrosis area in 8 patients affected by BRONJ at III stage, the authors highlight the inappropriateness of the local mucosal flaps to cover the losses of substance of the jaw, BF-related. METHODS: Mucosa tissue was taken from 8 patients, affected by BRONJ, III stage. The samples taken from the mucosa around and over the osteonecrosis area were fixed with formalin and an ematossilina-eosin dichromatic coloring was carried out. RESULTS: The samples of mucosa showed pathognomonic signs of cell suffering that prove that in these patients using local mucosa flaps is inappropriate. CONCLUSIONS: The authors suggest that only a well vascularized flap as free flap must be used to cover the osteonecrosis area in patients with BRONJ stage III. Because of the structural instability of the mucosa in patients suffering of osteonecrosis Bf related the local flaps are prone to ulceration and to relapse

ANTITHROMBOTIC PROPHYLAXIS IN MICROSURGERY

Background. The most common complication of microsurgical reconstruction is graft failure secondary to thrombosis. It is clear that thromboprophylaxis is helpful for a successful microsurgery. However, it's also obvious that thrombosis can't be avoided in cases of poor microsurgical technique. There is no consensus regarding the use of anticoagulation therapy during and after microsurgery. The authors compared two different antithrombotic prophylaxis protocols used in the past ten years, and analyzed the effectiveness and risks of different pharmacological protocols. Materials and methods. The authors performed a retrospective review of microsurgical patients operated between 2005-2014 by the same surgical team. 37 patients (Group A) operated between 2005-2010 and 45 patients (Group B) operated between 2011-2014 were selected. The majority of patients had generic and specific risk factors. Different thromboprophylaxis therapies were used in the two groups. While reviewing medical records, the authors compared Hb values before and after surgery, the free flap success rate, the need for blood transfusions intra and post-op in order to assess the efficacy (failure rate), and safety of the administered antithrombotic therapies (bleeding complications). Results. The pharmacological protocol used for the patients from Group B was more effective and less risky compared to results obtained from Group A. The therapy used in Group B did not increase the risk of bleeding and postoperative blood loss, and the flap success rate in Group B was significantly higher than that of Group A (p<0.000). Discussion and Conclusion. This study suggests that even in a perfect microanastomosis, prothrombotic mechanisms are activated, which lead to flap failure. A reasoned and balanced drug therapy can counteract the natural tendency of pedicle thrombosis, without exposing the patient to bleeding complications. Vasoactive drugs, although still experimental in microsurgery, may be used in the near future in order to further improve the success rates of free flap

The chimeric ALT-vastus lateralis free flap in reconstruction of advanced BRONJ of the maxilla.

Introduction Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a dangerous complication of bisphosphonates, a class of pharmaceutical agents used in numerous bone disor- ders. No gold standard therapy exists, but recent literature suggests that, in advanced stages, the best results are achieved with aggressive debridement. In this paper, we report our experience of treatment of stage 3 BRONJ of the maxilla with extensive surgical debridement and reconstruction with a chimeric ALT-Vastus lateralis flap. Methods Five selected patients with stage 3 BRONJ underwent partial maxillectomy with dis- ease-free margins followed by immediate reconstruction with a chimeric ALT-Vastus lateralis free flap. Results Only two patients experienced minor complications. All other patients healed unevent- fully within two weeks and donor site morbidity was minimal. Conclusions Our data suggest that aggressive debridement and reconstruction with a chimeric ALT -Vastus lateralis flap is an effective option for the treatment of stage III BRONJ of the maxilla

A difficult case of necrotizing fasciitis caused by Acinetobacter baumannii

This study reports the case of a 55-year-old woman with diabetes with a necrotizing fasciitis of the right lower limb and the perineum, first admitted at the emergency department for septic shock with cardiac arrest, and later transferred to the department of surgery. Microbiological and histopathological examination confirmed the diagnosis of necrotizing fasciitis caused by Acinetobacter baumannii. A broad-spectrum antibiotic therapy was administered and later readjusted according to the results of microbiological culture. Intensive hemodynamic support was required. Wounds were dressed daily with a 3 percent boric acid solution and a silver sulfadiazine-impregnated dressing. An extensive surgical debridement was promptly performed and repeated until complete control of the infection. Wounds were finally covered with split-thickness skin grafts. The infection was overcome 35 days after admission. The graft take was 100%. Postoperative rehabilitation was required because of the functional limitation of lower limb movements. Follow-up at 6 months showed no functional deficit and an acceptable aesthetic result. Necrotizing fasciitis is a life-threatening disorder, especially in patients with diabetes, whose clinical diagnosis may sometimes be challenging. Early recognition and treatment represent the most important factors influencing surviva

Prophylactic chimera anterolateral thigh/vastus lateralis flap: preventing complications in high-risk head and neck reconstruction

PURPOSE: In high-risk head and neck cases treated with tumor resection and associated radical neck dissection, orocutaneous fistulas and wound breakdowns in the neck are relatively frequent and can have serious consequences, such as carotid blowout syndrome (CBS), the need for salvage reoperations, and prolonged recovery time. The authors present the application of a prophylactic chimeric anterolateral thigh (ALT) and vastus lateralis (VL) flap to prevent complications. MATERIALS AND METHODS: A retrospective review was performed of a historical group (96 patients) of patients with head and neck cancer treated with tumor resection, radical neck dissection, and microsurgical reconstruction of the tumor site only and a prospective cohort (21 patients) in which a chimeric ALT-VL flap was used to simultaneously reconstruct the tumor site and sternocleidomastoid muscle to fill dead space and protect the carotid artery. RESULTS: The rate of complications was higher in the historical group: CBS occurred in 4.1% and orocutaneous fistulas in 11.5% of patients; 5.2% of patients required major salvage surgery for a wound complication. In the cohort group, no CBS or orocutaneous fistula occurred and no major salvage surgical procedure was needed. CONCLUSIONS: Prophylactic ALT-VL flaps in high-risk head and neck cancers provide adequate and long-lasting soft tissue coverage for the carotid artery, with minimal additional morbidity, and could be beneficial in preventing serious and life-threatening wound complications and the need for reoperatio

Systematic review on spheroids from adipose‐derived stem cells: Spontaneous or artefact state?

Three‐dimensional (3D) cell cultures represent the spontaneous state of stem cells with specific gene and protein molecular expression that are more alike the in vivo condition. In vitro two‐dimensional (2D) cell adhesion cultures are still commonly employed for various cellular studies such as movement, proliferation and differentiation phenomena; this procedure is standardized and amply used in laboratories, however their representing the original tissue has recently been subject to questioning. Cell cultures in 2D require a support/substrate (flasks, multiwells, etc.) and use of fetal bovine serum as an adjuvant that stimulates adhesion that most likely leads to cellular aging. A 3D environment stimulates cells to grow in suspended aggregates that are defined as “spheroids.” In particular, adipose stem cells (ASCs) are traditionally observed in adhesion conditions, but a recent and vast literature offers many strategies that obtain 3D cell spheroids. These cells seem to possess a greater ability in maintaining their stemness and differentiate towards all mesenchymal lineages, as demonstrated in in vitro and in vivo studies compared to adhesion cultures. To date, standardized procedures that form ASC spheroids have not yet been established. This systematic review carries out an in‐depth analysis of the 76 articles produced over the past 10 years and discusses the similarities and differences in materials, techniques, and purposes to standardize the methods aimed at obtaining ASC spheroids as already described for 2D cultures