Bryce E. Potter

Analysis of Microvascular Free Flaps for Reconstruction of Advanced Mandibular Osteoradionecrosis: A Retrospective Cohort Study

PURPOSE Previous studies have suggested that radiation therapy does not impact local complication rates after microvascular free flap (MVFF) reconstruction for head and neck cancer. There is little data, however, indicating whether or not the presence of osteoradionecrosis (ORN) affects treatment outcome. The purpose of this retrospective cohort study is to review the outcome of patients undergoing MVFF reconstruction for ORN and to determine if there is a difference in outcome and/or complications when compared to similarly reconstructed patients who received radiation therapy but did not develop ORN, as well as un-radiated controls. PATIENTS AND METHODS The records of 305 consecutive patients who underwent MVFF reconstruction for a variety of cancer-related therapies or post-traumatic craniofacial defects from 1994 to 2004 were reviewed. Of these, all patients who underwent surgery for Marx stage III ORN involving the mandible were identified (n = 21). For purposes of comparison, patients who received preoperative radiation therapy (XRT) and underwent similar reconstruction but did not have ORN were identified and included in the study group. Similarly matched patients who never received XRT served as controls. Patients were reconstructed with a variety of MVFFs harvested from the fibula (n = 48), radial forearm (n = 11), rectus abdominus (n = 3), latissimus dorsi (n = 3), serratus anterior (n = 1) and iliac crest (n = 1). The study cohort was divided according to XRT status: group 1 (ORN), patients that received XRT and developed ORN (n = 21); group 2 (no ORN), patients that received XRT but did not develop ORN (n = 21); and group 3 (control), patients that never received XRT (n = 25). The following data were collected: age, gender, diagnosis, recipient site, donor site, hyperbaric oxygen therapy (HBO), flap complications, flap survival, patient survival. Outcome measures were defined as flap survival, complications and resolution of ORN. Descriptive statistics were recorded and an analysis of variance was calculated to evaluate differences between the 3 groups. The Fishers exact test was used to evaluate whether a complication occurred more frequently in any one particular group. RESULTS The mean age of the 67 patients included in the study was 57 years (SD = 15.4) years (M = 32, F = 35) and there were no significant demographic differences between the 3 groups (P = .8528). All patients were successfully reconstructed although 21% required reoperation for various reasons. Overall flap survival was 88% (ORN = 86%, no ORN = 87%, control = 90%) and there was no difference between the 3 groups studied (P = 1.0). Complications were evenly distributed among the 3 groups (50% overall) and included skin necrosis (P = .824), wound infection (P = .6374), salivary fistula (P = .1178), and partial flap loss (P = 1.0). Carotid blowout occurred in 2 patients in the ORN group, however, this was not statistically significant (P = .1844). Fourteen of the 21 patients in the ORN group had received preoperative HBO. CONCLUSION Overall MVFF survival and complication rates among patients with ORN versus control groups are the same in this study cohort. Free tissue transfer is a viable option for advanced mandibular ORN.

Survival analysis and risk factors for recurrence in oral squamous cell carcinoma: does surgical salvage affect outcome?

PURPOSE The purpose of this retrospective study was to review the outcomes and recurrence rates of subjects with oral cavity squamous cell carcinoma treated at a single institution by primary surgical resection, with or without adjuvant radiation or chemotherapy, to identify factors that affect locoregional control and determine whether surgical salvage affects survival. MATERIALS AND METHODS The records of 157 subjects diagnosed with oral cavity squamous cell carcinoma treated at a single institution from 1997 to 2007 were identified. Data on demographics, site, clinical stage, pathologic stage, treatment, recurrence, and survival were collected. Defined outcome measures were overall survival, disease-free survival, and length of survival after recurrence. Analysis of the data was performed by use of the Cox proportional hazards model. Kaplan-Meier survival curves were created for disease-free survival, as well as survival by histologic grade, nodal status, recurrence, and tumor stage. RESULTS We identified 157 subjects, with 155 meeting the inclusion criteria. The overall 5-year survival rate was 48%, with a disease-free survival rate of 42% (95% confidence interval, 36%-53%). Survival was found to be influenced by stage (P = .0001), nodal status (P = .0025), and histologic grade (P = .04). There were 24 subjects with recurrence (15%). Of these, 11 had local recurrence (46%), 9 had regional recurrence (37%), 2 had distant recurrence (8%), 1 had both local and regional recurrence (4%), and 1 had both local and distant metastasis (4%). Recurrence was not found to be significantly affected by pathologic stage (P = .71), clinical stage (P = .6), histologic grade (P = .178), postoperative radiation therapy (P = .54), postoperative chemotherapy (P = .66), N-positive status (P = .71), or whether the subject underwent a neck dissection (P = .984). Surgery significantly increased both overall survival time (P = .009) and survival time after recurrence (P = .006). Radiation therapy (P = .4) and chemotherapy (P = .82) did not have a survival benefit as therapy for recurrence. CONCLUSIONS Survival is influenced by stage at presentation, nodal status, and histologic grade. No variables were found to influence recurrence rates. Surgery significantly increased overall survival time, and salvage surgery increased survival after recurrence.

Reliability of Intraoperative Navigation in Restoring Normal Orbital Dimensions

PURPOSE To assess the reliability and effectiveness of intraoperative navigation in restoring normal orbital and globe dimensions in traumatic and postablative orbital defects. MATERIALS AND METHODS To address the research purpose, the investigators initiated a retrospective cohort study and enrolled a sample of subjects that underwent primary or secondary reconstruction for unilateral orbital deformities secondary to traumatic injury or tumor surgery during the study enrollment period. Using computed tomographic datasets, pre- and postoperative orbital volume and globe projection were measured using Analyze software (Mayo Clinic Biomedical Imaging Resource, Rochester, MN). Intraclass correlation coefficient (ICC) was used to evaluate the reliability between preoperative unaffected orbit and the postoperative affected orbital and globe dimensions. A matched pairs t test was used to assess the difference in pre- and postoperative orbital volume and globe projection. RESULTS The sample was composed of 23 subjects that underwent orbital reconstruction secondary to traumatic of postablative defects. There was a linear and reliable relationship between preoperative unaffected and postoperative affected orbital volumes (ICC, 0.67; 95% CI, 0.37 to 0.86), and preoperative unaffected and postoperative affected globe projections was high (ICC, 0.87; 95% CI, 0.69 to 0.94). There was a significant difference in pre- and postoperative mean orbital volume (30.6 vs 25.5 cm(3), P ≤ 0.001), and pre- and postoperative globe projection (51.2 vs 53.6 mm, P ≤ 0.001). CONCLUSIONS The results of this study suggest that intraoperative navigation-assisted orbital reconstruction is reliable in restoring orbital volume and globe projection to pretraumatic and preablative conditions.

Treatment of an infected mandibular graft using tobramycin-impregnated methylmethacrylate beads: Report of a case

Abstract Immediate osseous reconstruction following segmental mandibulectomy for benign neoplasms is reasonable if an adequate soft-tissue bed and oral mucosal seal can be maintained or reestablished at the time of ablative surgery. Should postoperative infection develop, debridement of the graft is usually followed by collapse and contracture of the soft-tissue bed, and subsequent attempts at reconstruction are generally delayed and must deal with deficits of both bone and soft tissue. A case is presented in which tobramycin-impregnated beads were used to salvage part of a grafted mandible and to maintain a sterile dead space in anticipation of prompt regrafting.

Gun orientation in self-inflicted craniomaxillofacial gunshot wounds: risk factors associated with fatality

The purpose of this study was to evaluate whether orientation of a firearm predicts survival, and to identify risk factors associated with fatality in subjects with self-inflicted craniomaxillofacial gunshot wounds. A retrospective cohort study design was used. The primary predictor variable was orientation of the weapon, defined as in the coronal (lateral) or sagittal (anterior-posterior) trajectory pattern. The primary outcome variable was death for subjects on arrival or during their hospital stay. Other covariates measured include demographic, firearm-related, and psychosocial variables. Risk factors for fatality were identified using multivariate logistic regression. Of the 92 subjects that met study inclusion criteria, 47 (67.2) held the firearm in the coronal position. In the full multivariate model, coronal gun orientation (OR=7.7, 95% CI: 2.0, 30.1, p=0.003) and the absence of a psychiatric diagnosis were associated with an increased risk of fatality (OR=0.1, 95% CI: 0.04, 0.5, p=0.002). Coronal firearm orientation was associated with an increased risk of fatality following self-inflicted craniomaxillofacial gunshot injuries. A patient with a documented psychiatric disorder was not found to be more likely to succumb to this type of injury.

Post-therapeutic surveillance schedule for oral cancer: is there agreement?

IntroductionPatients with oral cavity squamous cell carcinoma represent a diverse group, and the treatment these patients undergo also varies widely. Some patients undergo local excision alone while others require extensive surgery, often with adjuvant chemoradiotherapy. The post-therapeutic surveillance schedule for these patients tends to be a “one size fits all” formula for all head and neck squamous cell carcinoma patients, which has often been dictated by institutional doctrine or a senior surgeon’s dogma. The post-therapeutic needs and risks of a T1 oral cancer patient treated with surgery alone differ from those of a patient with advanced laryngeal carcinoma, and the follow-up regimen should be tailored to the specific patient’s risk of loco-regional recurrence, distant metastasis, and other related medical issues.Resources and materialsA total of 65 papers were identified, 18 of which either focused on follow-up strategy for oral cavity squamous cell carcinoma or their tabular data allowed these cases to be extracted. Internationally recognized cancer entities were also queried.ConclusionsNo international consensus was achieved about the follow-up strategies. The value of post-therapeutic surveillance schedule following oral cancer treatment is generally not in dispute, although patient-initiated symptom-driven visits can be effective in identifying tumor recurrence for oral cancer patients. The range of appointment interval schemes tends to identify a progressive escalation of visit intervals such that there are more visits in the first year than in the second, and fewer yet during the third. Patients may fail to comply with their clinic visit structure. Most references agree that follow-up beyond the third year is unnecessary and may waste medical resources as well as the time of both patient and surgeon. There is no agreement as to the need for or interval of imaging studies.

Tracheotomy in the unprotected airway.

PURPOSE Although rare, there are many circumstances in which a secure airway is needed urgently. A newly developed technique is presented for quick and efficient performance of this procedure. PATIENTS AND METHODS All patients who had tracheotomies performed at a tertiary referral center from January 1, 2004, through December 31, 2008, were found by querying the admission database. Three hundred twenty-seven separate procedures performed in 325 patients were identified. Urgent tracheotomies were distinguished from elective and emergent tracheotomies by reading operative reports and excluding elective and emergent procedures. Elective procedures were defined as performed in patients with a secure airway (with an endotracheal tube or laryngeal mask airway). Urgent tracheotomies were defined as having an intact, unprotected airway. Emergent procedures were performed in a patient with complete airway obstruction. RESULTS Twenty instances of urgent, awake tracheotomies were found in 19 patients, resulting in an incidence of 20 of 327 tracheotomies (6.1%) in 19 of 325 patients (5.8%). CONCLUSIONS Tracheotomy is an alternative to cricothyroidotomy as a surgical airway in patients with deteriorating respiratory status who cannot be safely intubated by nonsurgical means.

Facial Soft Tissue Injuries as an Aid to Ordering a Combination Head/Facial CT in Trauma Patients

ever, no occlusal changes occurred either objectively or subjectively during this year or during the subsequent follow-up period. The mean interincisal opening was 47 mm (range, 40 to 56). With the exception of one patient who had a nonpainful reciprocal click of the treated TMJ, no patients demonstrated either objective or subjective signs of TMJ pathology. No patients reported dietary limitations, and all reported satisfaction with treatment to date. Conclusion: Based on objective and subjective evaluation, free-grafting of the condylar segment during ORIF of subcondylar fractures in this patient population has had a 67 percent success rate. All failures occurred within 9 months and required secondary reconstruction.