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Tropiano et al. Mini-invasive Surg 2024;8:17 https://dx.doi.org/10.20517/2574-1225.2024.41 Page 7 of 15

Figure 7. Freiburg flap silicon spheres can be used to protect the skin from mechanical damage (courtesy of Luca Tagliaferri, Policlinico
Agostino Gemelli Hospital, Rome).

Figure 8. Merocel® fragments are perforated using a metal guide needle for plastic tubes.

Pre-plan evaluation of MRI and/or CT imaging is performed to define the extent of target volume. After the
surgical procedure, a planning CT is acquired to perform implant reconstruction and target delineation. A
new CT scan is acquired to check implant stability and to proceed to replanning if necessary.

Delivery
High dose rate (HDR) IRT was applied using an I-192 source, delivered by a Bravos (Varian Medical
Systems) afterloader with a standardized fractionation: 44-Gy total dose, 3 Gy per fraction, except for first
and last fractions of 4 Gy, two fractions per day, 6-hour interval between the fractions, and maximum
overall treatment time of ten days.

Removal of the implant was done immediately after the treatment was finished. The removal was done in
the outpatient ENT office of Mater Olbia Hospital.