Although direct exposure to procedures in the operating theater environment, together with practice on laboratory animals, is still seen as the gold standard of teaching in microsurgery, practice on nonliving simulators is currently being validated as an important educational tool. We reviewed the widely used nonliving training models, together with currently accepted innovations, which are parts of curricula of training courses in microsurgery. Using the experience accumulated in training programs at the Centre for Simulation and Training in Surgery, we identified which particular skills can be reliably targeted by each nonliving tissue exercise. We were able to find five groups of nonliving training models: basic manipulation, knot-tying principles, completing the anastomosis, the real tissue experience, and training in virtual reality. The more abstract models might seem quite far from the real life experience, but they each closely address specific skills. It thus becomes convenient for the instructor to train these skills separately. This generates series of consistently favorable results once the skills are integrated into a more complex procedure. Focused exercises, once assembled in continuity, reconstruct the real life scenario. The training program can comprise a series of increasingly difficult exercises, which mirror the real life situations. Performance on nonliving models in each progressively more challenging exercise can be assessed via direct observation, assisted by clear and objective criteria. Finally, focused training will help both the transition to human surgery and replication of the favorable results to large series of subjects.

No abstract

Squamous cell carcinoma (SCC) is a frequent cancer of the oral cavity, more aggressive in young patients and mostly affecting males with a history of smoking and alcohol consumption. After oncological excision, reconstruction is possible using an array of flaps, such as the radial forearm flap, anterolateral thigh flap, rectus abdominis flap, each with various indications, advantages and disadvantages. Functional reconstruction is difficult, as the multiple and highly specialized muscles of the tongue cannot be replaced by any of the abovementioned options. A 23 year-old male presented with squamous cell carcinoma of the anterior ⅔ of the tongue and left submandibular enlarged lymph nodes (T3N2bM0, stage IVA). A preoperative nutritional and metabolic optimization was established using a percutaneous endoscopic gastrostomy, tracheostomy, then we performed a total glossectomy with modified radical bilateral neck dissection and VRAM flap reconstruction. Postoperatively the patient developed an orocervical salivary fistula and partial skin necrosis of the upper left cutaneous laterocervical flap. The postoperative pathology confirmed extended SCC of the tongue. The patient received adjuvant radiotherapy postoperatively. There were no major complications, and the one-year followup concluded on normal feeding, satisfactory speech recovery, and no recurrence.

Primary squamous cell carcinoma of the parotid gland accounts for 0.35% up to 9.8% of all parotid malignancies. In advanced stages, the gold standard is wide excision, lymphadenectomy and postoperative radiotherapy. Furthermore, head and neck cancers have an increased risk of secondary primary tumors development. Case report: A 82-year-old male underwent subtotal parotidectomy with facial nerve preservation for right parotid squamous cell carcinoma, in another department. Due to incomplete resection, 4 months later he presented with locoregional recurrence and cutaneous invasion. The patient underwent total parotidectomy en bloc with facial nerve, part of the external auditory meatus, posterior belly of digastric and part of sternocleidomastoid muscle with modified radical neck dissection, levels I-V. The defect was closed with ipsilateral pectoralis major myocutaneous flap, followed by a temporary lateral tarsorrhaphy after two months. The patient underwent adjuvant radiotherapy. One year after surgery, functional and aesthetic impairment of the facial nerve palsy were corrected: the lower face deficit by an orthodromic temporalis tendon transfer; lagophthalmos by lid loading with gold-weight. Postoperative outcome was satisfactory for the patient, with 3 years of postoperative evolution with no recurrence or metastasis. Concomitantly, the patient developed pT1a secondary primary melanoma on the skin island of the flap, which was excised. Conclusion: Patients with locoregional advanced parotid squamous cell carcinoma can benefit from wide excision with neck dissection and postoperative radiotherapy. When the facial nerve cannot be preserved, facial asymmetry can be improved through reanimation procedures. Secondary primary malignancies require proper treatment concomitantly with index tumor follow-up.

Background: Basosquamous carcinoma (BSC) is a variant of basal cell carcinoma subtype that is locally aggressive with high tendency for recurrence and metastasis and a poor prognosis. Up to 95% are located in head and neck area. Treatment for invasive BSC with aggressive growth pattern is wide excision and reconstruction. Complex defects require free tissue transfer to protect underlying structures and to sustain the adjuvant radiotherapy.Case report: A 57 year-old male presented with ulcerated, bleeding tumors in frontal and periauricular area, identified as BSC on biopsy. CT-scan revealed contact to dura mater. Wide excision included frontal bone and dura mater, frontal sinus, lateral orbital wall and exenteration, ear en-bloc with parotid gland. Dura mater was replaced with fascia lata graft, frontal sinus was filled with pedicled temporalis muscle and 20/25 cm soft tissue defect was covered with free Latissimus dorsi muscle anastomosed to superior thyroid artery and internal jugular vein branch, respectively. The muscle was skin grafted 14 days later.Results: Postoperative recovery was complicated: cerebrospinal fluid leak, extradural hematoma, posthemorrhagic anemia, pneumonia, and withdrawal syndrome, remitted under specific treatment. Muscle flap survived entirely with skin graft fully integrated. Positive margins on dura mater and mastoid bone required radiotherapy.Conclusions: Wide excision of head invasive BSC resulted in complex defect reconstructed with fascia lata graft, temporalis muscle and Latissimus dorsi free flap grafted secondarily. Short-term evaluation showed no recurrence and good life-quality; follow-up is needed to evaluate long-term results. Interdisciplinary approach is the key for patient's successful treatment.