Valerio Arietti

Background/Objectives: Mandibular reconstruction following ablative oral surgery is particularly challenging in elderly patients due to comorbidities and reduced physiological healing potential. While vascularized bone flaps represent the gold standard, the combination of an anterolateral thigh (ALT) flap and a bone reconstruction metallic plate may be considered as a less invasive alternative. This systematic review aimed to evaluate the effectiveness of such reconstructive techniques, in terms of success rate and complication rate, in patients aged over 55. Methods: Studies were included if the sample size consisted of at least 20 patients undergoing mandibular reconstruction with an ALT flap and plate following oral cavity resection for benign or malignant conditions. Studies were excluded if relevant outcomes were not reported and the mean age was 55 years were included. Mean hospital stay ranged from 10 to 24 days. The overall clinical success rate of the ALT flap procedure was 97% (95% confidence intervals (CIs): 92%, 99%). Flap-related complications were rare, with flap loss reported in only one patient and partial necrosis or failure affecting up to 6.6% of cases. Conversely, the overall plate-related complications rate was 28% (95% CI: 15%, 41%), with plate exposure rates ranging from 10% to 38.7% in the included studies. Wound complications, including infection and fistula formation, ranged from 20% to 38.7% of patients. Conclusions: In patients over 55, despite the not negligible rate of complications, the use of ALT flaps and reconstruction plate represents a viable alternative to vascularized bone flaps for mandibular reconstruction, particularly when comorbidities or frailty preclude more complex procedures. Further studies with a large sample size are needed to validate these findings and guide clinical decision-making.

Objective: This article evaluates the reconstructive potential and functional outcomes, as well as the risks and potential perioperative complications of using free flaps in patients with advanced-stage malignant laryngeal neoplasms who require salvage surgery and reconstruction. Additionally, it assesses the effectiveness of various flap harvesting and in-setting techniques, including the performance of microvascular anastomoses. Materials and Methods: This retrospective study included 13 male patients (age range 47–76 years) diagnosed with laryngeal neoplasms, who were referred to the Department of Otolaryngology at the University of Verona between 2017 and 2022. All patients underwent salvage total laryngectomy followed by concurrent reconstructive surgery utilizing microvascular flaps. Recovery of function (phonation) and incidence of complications were evaluated in a follow-up of at least three years. Results: Only one patient experienced necrotic failure of the microvascular free flap, probably due to post-op complications. The patient required revision on the 10th day after surgery and was reconstructed using a pedicled pectoralis major muscle flap. Two patients developed a pharyngocutaneous fistula. Other three patients had pharyngoesophageal stenosis, two experienced recurrence, and one patient passed away due to septic shock. All patients achieved satisfactory functional outcomes regarding vocalization, while complete oral intake was restored in eight patients. Conclusions: Considering the limited sample size, the findings suggest that microvascular flaps represent a feasible option for reconstructing advanced laryngeal tumors, though complication rate may still be considerable. Tailoring reconstructive approaches to individual patients may enhance surgical outcomes.

Introduction: Tumors of the lateral skull base, particularly those arising from the external auditory canal and peri-retroauricular regions, present considerable surgical and reconstructive difficulties due to their intricate anatomy and aggressive nature. The anterolateral thigh (ALT) free flap offers a viable reconstruction option, enhancing oncological radicality while minimizing morbidity. Materials and Methods: A retrospective analysis was conducted on five cases of malignant tumors involving the external auditory canal and adjacent soft tissues, treated at a tertiary center from March 2023 to March 2025. All patients underwent radical resection, which included lateral or subtotal temporal bone resection, along with parotidectomy and neck dissection when necessary. Reconstruction was performed using myocutaneous anterolateral thigh free flaps. The study evaluated clinical outcomes, complications, and esthetic results. Results: The ALT flap was used in all cases without major postoperative complications. Two patients received adjuvant radiotherapy; one did not start treatment due to early recurrence. At follow-up, three patients were disease-free, while two had died from unrelated causes. Esthetic and functional outcomes were satisfactory in all patients. Conclusions: The ALT free flap is a universal and reliable option for the reconstruction of complex lateral skull base defects, especially in patients following the radical removal of tumors of the external auditory canal and peri-retroauricular areas. It offers excellent tissue coverage, facilitates adjuvant treatment, and has a low complication rate. While our experience supports its use in aggressive oncological resection, larger studies are needed to confirm these findings. Level of evidence: 4.

Objectives: The application of fasciocutaneous free flaps for reconstruction of head and neck defects following oncological surgery has increased since the 1970s, coinciding with developments in microvascular techniques. Although reported success rates are between 90% and 99%, flap failure continues to occur, most frequently due to venous congestion. This study examines the rates of re-exploration and flap failure according to the number of venous anastomoses in patients receiving free flap reconstruction after head and neck cancer surgery. Materials and Methods: This retrospective analysis included 163 patients who underwent head and neck reconstruction with free flaps (radial forearm free flap [RFFF] and anterolateral thigh flap [ALTF]) at the University Hospital of Verona between January 2019 and June 2024. Variables examined comprised the type of flap performed, donor and recipient vessels utilized, and number of venous anastomoses, as well as the type (end-to-end [ETE] versus end-to-side [ETS]) and site (internal jugular vein versus external jugular vein) of venous anastomosis. Results: The overall success rate was 93.3%, with no significant difference between single and dual venous anastomosis groups. Prompt re-exploration upon detecting signs of flap failure is critical, as approximately one-third of such failures may be prevented through timely intervention. Conclusions: Single venous end-to-end anastomosis utilizing the internal jugular vein system is typically effective. Further research is warranted to clarify the indications for dual anastomosis involving the external jugular vein system.

Endoscopic dacryocystorhinostomy (DCR) is a widely recognized and highly effective procedure. This surgical procedure is performed globally, with minimal modifications across different regions. Background/Objectives: The fundamental goal of DCR is to marsupialize the lacrimal sac into the nasal cavity, which helps eliminate epiphora (excessive tearing) and recurrent dacryocystitis (inflammation of the tear sac). With advancements in technology, new instruments are being developed to minimize risks and maximize efficacy, ultimately improving surgeon convenience, patient safety, and quality of life. One such innovation is piezosurgery, a method of bone cutting that utilizes ultrasound vibrations. Originally prevalent in oral and maxillofacial surgery, piezosurgery is now being applied in many clinical applications. Its primary advantages include the preservation of soft tissues, precise bone cutting, and the ability to work effectively in narrow spaces. Methods: This article outlines the standard technique used at our facility for performing endoscopic dacryocystorhinostomy (DCR) with a piezoelectric system. We describe the preoperative evaluation, intraoperative techniques, and postoperative care to present what we consider the standard procedure in our clinic. Results and Conclusions: Piezosurgery’s selective cutting prevents damage to surrounding soft tissues, making it theoretically advantageous in DCR by preserving tissue integrity. Additional case–control and multicenter studies are necessary to compare its outcomes with those of traditional osteotomy, particularly in relation to the potential increase in operative time.

Background/Objectives: The endoscopic repair of the tympanic membrane is an established method for addressing perforations in the tympanic membrane. However, there are limited studies in the literature examining the success rate of this procedure in the pediatric population. Methods: This study retrospectively analyzed data from the tertiary referral center at the University Hospital of Verona, Italy. This medical record contains data from 84 type 1 transcanal endoscopic tympanoplasties performed in pediatric patients between November 2014 and February 2022. Seventy-seven pediatric patients aged 4 to 16 years who underwent type 1 transcanal endoscopic tympanoplasty (seven of whom underwent bilateral surgery at different time points) were included in the study. Our study did not include more extensive procedures than type 1 endoscopic tympanoplasty. Only patients with tympanic membrane perforation due to simple chronic otitis media, trauma or when no apparent cause was found were included. Chronic otitis with cholesteatoma and other pathologies of the external or middle ear were exclusion criteria. Patients with a follow-up of less than 12 months were excluded from this study. The technique was based on the endoscopic placement of an underlay graft of temporal fascia or tragal cartilage to repair a tympanic membrane perforation. Demographic, clinical, audiologic, and surgical data were collected from each patient. In the study, we considered the reduction of the air-bone gap (ABG) as a functional outcome and the integrity of the reconstruction as an anatomic outcome of success. Results: The primary surgery had a closure rate of 92.9% (78 of 84). All patients underwent audiological evaluation 4–6 months post-surgery, with 84 ears tested. The mean preoperative ABG was 17.13 dB HL, reduced to 9.16 dB HL postoperatively, showing a mean reduction of 7.97 dB HL. No significant complications occurred. Conclusions: Transcanal endoscopic type 1 tympanoplasty should be considered a safe procedure with a high success rate for the repair of tympanic membrane perforations, even in pediatric patients.

Introduction: Schwannomas are a common condition encountered in clinical ENT practice, but they are rarely found in the pharyngeal or laryngeal regions. Materials and Methods: In this report, we share our experience using the transoral robotic approach to treat a schwannoma located on the lateral pharyngeal wall, with the surgery being performed exclusively using transoral robotic surgery (TORS). It is important to be aware of any pseudocystic lesions in this area, as they can lead to unpredictable anatomopathological outcomes. Results and Conclusions: Our technique allows us to achieve complete resection of the tumor, facilitating rapid recovery for the patient without the need for additional treatment.

Objective: Transoral robotic surgery (TORS) is becoming increasingly popular in head and neck surgery. Its applications have expanded beyond oncologic indications to obstructive sleep apnea syndrome (OSAS) and, more recently, to benign pathologies. Data Sources: A systematic search for articles published in the PubMed and Google Scholar databases between January 2003 and December 2023 was performed using the following combined search query (robot OR sleep OR apnea OR syndrome) AND (robot OR tongue OR base). Review methods: Given the limited literature, we conducted a systematic review focusing on the outcomes of TORS for benign pathologies of the base of the tongue. Our search methodology followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: We found 16 articles that met our inclusion criteria. These were mainly case reports and a few case series. Conclusions: Compared to other transoral techniques, TORS offers better exposure, visualization, and access to the oropharynx, especially the base of the tongue, even in benign pathology. TORS should be considered a feasible, safe, and effective technique. Several more studies are needed to effectively evaluate the role of TORS in benign pathology that does not correlate with OSAS.