Alberto Paderno

Free Flaps in Head and Neck Reconstruction after Oncologic Surgery Expected Outcomes in the Elderly

Objective To provide surgeons and clinicians with a critical review of microvascular reconstructive options and their expected outcomes after head and neck cancer resection in the elderly. Data Sources Medline, Isiweb, and Cochrane databases. Review Methods A literature search was performed in May 2014 and included studies published between 2000 and 2014. Keywords were used for articles identification, and inclusion criteria were defined for consideration in the present review. Conclusions Evaluation of the pertinent literature is hampered by a number of biases, such as a lack of general consensus of a definition of “elderly,” differences among scales used to quantify comorbidities, and subjective evaluation of flap-related and systemic complications. However, our findings showed no differences in terms of free flap success, surgical complications, or mortality rate between older and younger patients. Moreover, recipient site complications do not seem to be affected by age. Implication for Practice Microvascular reconstruction in the elderly can be performed with high success rates, even though medical complications can occur more frequently compared to younger patients. Minor and major surgical complications in the elderly appear to be comparable to those in the younger population and do not affect final outcome or the perioperative mortality rate. Flap outcome does not seem to be significantly affected by age. Careful preoperative assessment and postoperative monitoring are mandatory to prevent adverse events, and prompt management is warranted whenever present.

Preoperative clinical predictors of difficult laryngeal exposure for microlaryngoscopy: the Laryngoscore.

To identify a clinical predictor score for difficult laryngeal exposure (DLE) during operative microlaryngoscopy.

Evolution of complex palatomaxillary reconstructions: the scapular angle osteomuscular free flap.

Purpose of reviewThis review summarizes the worldwide experience (105 patients) in primary and secondary reconstruction of palatomaxillary oncologic defects with the angular branch-based subscapular system of free flaps, comparing the advantages and disadvantages of the technique with those of other well known osseous donor sites such as the fibula and iliac crest. Recent findingsThe most recognized indications for angular branch-based osteomuscular free flaps are class II (especially in association with zygomaticomaxillary buttress and/or floor of the orbit removal) and class III defects according to the Okay classification. Defects involving clearance of the orbital content have also been reconstructed in this manner. One of the most important drawbacks of this technique (i.e., need for intraoperative patient repositioning) is no longer considered an issue, and evidence has been provided that harvesting of angular branch-based scapular flaps may be routinely performed in a supine position. Three-dimensional morphologic similarity of the tip of the scapula with the native hard palate and other maxillary structures makes flap fabrication easy and practical, with at least two (horizontal and vertical) most commonly used flap orientations applied to reconstruct different defects. SummaryAngular branch-based osteomuscular scapular free flaps represent a major advance in palatomaxillary reconstruction: their versatility, long pedicle with large caliber donor vessels, morphologic similarity with maxillary bony structures, and limited donor-site morbidity compare favorably with those of other osteomuscular and osteomusculocutaneous free flaps described for such challenging reconstructive purposes.

Is it time to incorporate 'depth of infiltration' in the T staging of oral tongue and floor of mouth cancer?

Purpose of reviewTo summarize recent acquisitions in three-dimensional tongue and floor of mouth anatomy that can help in better evaluation of the pathways of cancer progression within these oral subsites, thus giving some hints for refining of the current TNM staging system. Recent findingsThe Visual Human Project is an initiative aimed at establishing a three-dimensional dataset of anatomy of two cadavers made available free to the scientific community. Visual human data have been analyzed by specific software thus improving our three-dimensional understanding of the tongue myostructure. It is already known that there is limited prognostic utility in using the two-dimensional surface diameter alone as criterion for T1–T3 definition. Recently, also the T4a categorization for the infiltration of ‘deep’ or extrinsic tongue muscles has been criticized. This is largely because the descriptor ‘deep’ does not take into account the fact that considerable portions of these muscles lie in a very superficial plane. Different prognosticators have been proposed for inclusion into the TNM staging system of oral cancer but ‘depth of tumor infiltration’ seems to be the most robust, universally recognized, and reproducible in the preoperative, intraoperative, and postoperative settings. SummaryOral tongue and floor of mouth cancer needs to be classified according to a revised TNM staging system in which ‘depth of infiltration’ should be taken into account. An ‘ideal cut off’ for distinguishing ‘low’ (T1–T2) from ‘high-risk’ (T3–T4) categories has been proposed based on the literature review, but needs retrospective as well as large prospective trials before its validation.

Transoral laser microsurgery as primary treatment for selected T3 glottic and supraglottic cancers

T3 laryngeal cancer encompasses heterogeneous lesions whose treatment is still debated. The purpose of this study was to evaluate transoral laser microsurgery (TLM) in management of selected T3 glottic and supraglottic cancers.

Recent advances in surgical management of parapharyngeal space tumors.

Purpose of reviewTo summarize nuances in the surgical management of parapharyngeal space (PPS) tumors aimed to reduce postoperative sequelae without affecting oncologic outcomes. Recent findingsThe contemporary trend in surgery of PPS tumors is to develop minimally invasive approaches that allow tumor resection without the need for mandibulotomy or lateral skull base approaches. This can be obtained by refining well established surgical routes like the transcervical, improving those with limited applications like the transoral, and developing novel corridors like the transnasal (or the transoral/transvestibular). Therefore, careful surgical planning is mandatory in order to tailor treatment according to the patient and characteristics of the tumor, in view of a wide and heterogeneous choice of techniques (to be employed alone or in combination). SummaryTechnical refinements of transcervical and transoral approaches may lead to reduction in the rate of mandibulotomy performed for benign PPS tumors. This is also true when considering the possibility of combined approaches that provide excellent exposure and management of the upper PPS up to the skull base.

Microvascular head and neck reconstruction after (chemo)radiation: facts and prejudices.

Purpose of reviewThis article critically analyzes the recent literature on microvascular head and neck reconstruction after (chemo)radiation [(C)RT], taking into consideration both the underlying pathogenetic mechanisms and their clinical consequences. Recent findingsMicrovascular reconstruction has gradually become a mainstay in the management of head and neck cancer both in primary and salvage scenarios. However, limited data are available concerning the influence of previous radiotherapy/chemoradiation therapy (CRT) on free flap survival and surgical complications. Molecular studies show that the effects of radiotherapy/CRT may be essentially reduced to three components: inflammation, a prothrombotic state and fibrosis. From a clinical point of view, this is reflected in a moderate increase in free flaps failure and surgical complications. Nevertheless, free flaps continue to offer clear advantages even in such an unfavorable condition. SummaryRadiotherapy/CRT induce a less favorable tissue environment, potentially leading to a higher risk of complications. In this scenario, however, free tissue transfer still plays the role of favoring wound healing bringing well vascularized tissue to less vascularized microenvironments.

Complications After Tracheal and Cricotracheal Resection and Anastomosis for Inflammatory and Neoplastic Stenoses

Objective: This study aimed to evaluate complications and success rates of tracheal resection and anastomosis (TRA) and cricotracheal resection and anastomosis (CTRA) in patients treated in 2 academic institutions. Methods: Retrospective charts review of 137 patients submitted to TRA/CTRA. Fifty (36.5%) had neoplastic (group A) and 87 (63.5%) benign (group B) stenoses. Using univariate analysis, age, medical comorbidities, previous radiotherapy, type of TRA/CTRA, association with neck dissection and thyroidectomy, length of resected airway, and preoperative tracheotomy were evaluated to identify factors predictive of complications and outcomes. Results: The mean length of resected airway was 2.7 and 3 cm in groups A and B, respectively. Overall decannulation and complication rates for group A were 96% and 36%, and 99% and 46% for group B, respectively. Length of airway resected and presence of preoperative tracheotomy had a statistically significant effect on major surgical complications. Age older than 70 and cardiovascular and pulmonary comorbidities were significantly associated with the incidence of major medical complications. No statistically significant difference was found considering the complication rates of group A versus group B. Conclusion: Even though the overall success rate of TRA/CTRA is high, it should always be regarded as a major surgical procedure with a non-negligible incidence of complications.

Functional outcomes after different types of transoral supraglottic laryngectomy

To seek a correlation between the four types of transoral supraglottic laryngectomies (TSLs) according to the European Laryngological Society (ELS) and postoperative morbidity.

Microvascular head and neck reconstruction in the elderly: The University of Brescia experience

Microvascular reconstruction in head and neck surgery is increasing in the elderly because of prolonged life expectancy. The purpose of this study was to evaluate the impact of age on outcomes after microvascular reconstruction.