Carrlene B. Donald

Oncologic safety of the submental flap for reconstruction in oral cavity malignancies

Objectives To evaluate the oncologic safety of the submental flap regarding potential transposition of involved nodes to the reconstruction site and recognize the submental flap as an excellent option for oral cavity reconstruction. Study Design Case series with chart review. Setting Tertiary academic referral center. Subjects and Methods All patients undergoing reconstruction with submental flaps following the resection of primary and recurrent malignancies of the oral cavity between 2002 and 2012 were reviewed. Analysis included tumor location, staging, reconstructive details, postoperative course, and outcomes. Results Fifty patients were identified having undergone submental flap reconstruction of defects following resection for oral cavity malignancies. No patient had identifiable clinical or radiographic level I nodal involvement preoperatively. Patients’ ages ranged from 35 to 88 years (mean, 70 years). American Joint Committee on Cancer staging of patients included stage II (n = 16, 32%), stage III (n = 10, 20%), and stage IVa disease (n = 28, 48%). All patients underwent a level 1A and 1B dissection with removal of the nodal basin and submandibular gland. The prevalence of occult lymph node metastasis involving level 1 was 10%. On follow-up, there were no local recurrences associated with submental flap transposition to the oral cavity. One patient with multifocal oral disease had a tongue recurrence geographically separate from the submental flap reconstruction. There was 100% flap survival. Conclusions The submental flap provides a rapid and reliable option for oral cavity defect reconstruction. With appropriate management of the level 1 nodal compartment, oncologic outcomes are not compromised.

Hybrid submental flaps for reconstruction in the head and neck: part pedicled, part free.

Evaluate feasibility and success of elongating only the venous pedicle of the submental flap to increase the superior arc of rotation for the “hybrid” flap allowing coverage of more distal defects.

Reconstruction of Lateral Skull Base Defects A Comparison of the Submental Flap to Free and Regional Flaps

Objectives To compare reconstructive techniques, operative times, duration of hospitalization, and need for subsequent flap revisions between reconstructive approaches to lateral skull base defects. Study Design Case series with chart review. Setting Tertiary academic referral center. Subjects Patients (n = 31) undergoing reconstruction of composite lateral skull base defects from 2002 to 2014. Methods Data were analyzed for demographics, tumor characteristics, reconstructive technique, operative time, duration of hospitalization, complications, and outcomes. Results Thirty-one patients were identified for inclusion. Lateral temporal bone defects resulted from resection of malignant lesions, including squamous cell carcinoma (n = 25), basal cell carcinoma (n = 2), and other carcinoma (n = 4). Defects were reconstructed with submental flaps (n = 16), pedicled latissimus dorsi flaps (n = 6), and free anterolateral thigh flaps (n = 9). All cases involved neurosurgery, neurotology, and head and neck surgery services. Although time of surgical resection was similar, time saving was noticed with submental reconstruction. Compared with free flaps, submental flap reconstruction was associated with significantly reduced total operative time (mean, 544 vs 683 min; P = .00817) and duration of hospitalization (4.9 vs 9.8 days; P = .02067). Submental flaps were significantly less likely to require revision debulking procedures (mean = 0.6) compared with latissimus dorsi flaps (mean, 1.3; P < .00001) and free flaps (mean, 1.6; P < .00001). There was 100% flap survival. Conclusion The musculocutaneous submental flap provides an excellent option for reconstruction of lateral skull base defects given its proximity, reliability, ease of harvest, and exceptional color match. Submental flap reconstruction was associated with reduced operative time, hospitalization duration, and flap revisions.

Interprofessional orientation for health professionals utilising simulated learning: Findings from a pilot study

ABSTRACT We describe a novel, interprofessional educational intervention pilot used to orient new health profession employees through the simulation laboratory. Health profession employees were recruited to engage in a simulation training session that focused on communication, collaboration, and healthcare roles and responsibilities. Learners (N = 11) were divided into two groups with representation from various health disciplines. Each group participated in a simulated patient scenario while the other group actively observed in another classroom. At the end of both sessions, the group reconvened for a debriefing session. Participants were given a survey before and after the training session, to evaluate the content, experience, and value to their practice. The pre- and post-evaluation survey analysis showed improvement in all objectives with a mean (SD) pre-evaluation score of 4.10 (0.40–1.01) and mean (SD) post-evaluation score of 4.73 (0.30–0.81). Results were favourable, and plans to expand this project are under way.

Managing acute invasive fungal sinusitis.

ABSTRACTAcute invasive fungal sinusitis is the most aggressive form of fungal sinusitis and can be fatal, especially in patients who are immunosuppressed. Early diagnosis and intervention are crucial and potentially lifesaving, so primary care providers must maintain a high index of suspicion for this disease. Patients may need to be admitted to the hospital for IV antifungal therapy and surgical debridement.

Hpv-associated oropharyngeal squamous cell carcinoma

ABSTRACT Human papillomavirus (HPV) can infect the tonsillar tissues of the oropharynx and is associated with oropharyngeal squamous cell carcinoma. This article provides an overview to guide primary care providers in screening patients for oropharyngeal cancer and making appropriate referrals. The article also reviews available HPV vaccines and immunization adherence rates.

Eye problems in a woman with Churg-Strauss syndrome.

ABSTRACT Churg-Strauss syndrome is a rare, systemic vasculitis of unknown cause. Ocular involvement is a rare but established complication and can lead to vision damage or blindness if not treated promptly. Treatment of ocular manifestations corresponds with systemic treatment of the disease and consists primarily of corticosteroids.

Surgical Management and Reconstruction of Hoffman's Disease (Dissecting Cellulitis of the Scalp)

Dissecting cellulitis of the scalp, or Hoffmans disease, is a rare dermatologic condition characterized by recurrent pustules and sinus tract formation leading to scarring and alopecia. Medical management includes the use of corticosteroids, antibiotics, isotretinoin, and adalimumab. In cases where the disease is severe, refractory, and intractable, surgery is an option. We report two cases of Hoffmans disease, where medical management failed to achieve remission. Surgical treatment was undertaken with complete resection of the affected scalp in staged procedures with subsequent split-thickness skin grafting for reconstruction. Surgery achieved both disease remission and excellent aesthetic outcomes in both patients.

Lateral Skull Base Reconstruction: A Comparison of the Submental Flap to Free and Regional Flaps

Objectives: (1) Recognize reconstructive options for lateral skull base defects. (2) Compare reconstructive techniques, operative times, duration of hospitalization, and need for subsequent flap revisions. Methods: Retrospective review of surgical techniques used at a tertiary academic referral center between 2002 and 2014 to reconstruct lateral skull base composite defects involving facial skin, ear, and temporal bone. Data were analyzed for demographics, tumor characteristics, reconstructive technique, operative time, duration of hospitalization, complications, and outcomes. Results: Thirty-one patients were identified for inclusion. Lateral temporal bone defects resulted from resection of malignant lesions including squamous cell carcinoma (n = 22), basal cell carcinoma (n = 2), melanoma (n = 4), and sarcoma (n = 3). Defects were reconstructed with musculocutaneous free flaps (n = 9), pedicled latissimus dorsi flaps (n = 6), and pedicled submental flaps (n = 16). All cases involved neurosurgery, neurotology, and head and neck surgery services. Although time required for surgical resection was similar, time savings was noticed with submental reconstruction. Compared with free flaps, submental flap reconstruction was associated with significantly reduced total operative time (mean 578 vs 455 minutes; P = .0170) and duration of hospitalization (9 vs 4.9 days; P = .0207). Submental flaps were significantly less likely to require revision debulking procedures (median = 0) compared to free flaps (median = 1.8; P = .00002) and latissimus dorsi flaps (median = 1; P = .0093). There was 100% flap survival. Conclusions: The musculocutaneous submental flap provides an excellent option for reconstruction of lateral skull base defects given its proximity, reliability, ease of harvest, and exceptional color match. Submental flap reconstruction was associated with reduced operative times, duration of hospitalization, and flap revisions.

Recipient Artery Rupture in Free Tissue Transfer in Heavily Radiated Beds

Objectives: Report a patient series of microvascular arterial rupture in fibula free flap tissue transfer for osteoradionecrosis of the mandible. 1) Evaluate the risk factors for arterial anastomotic rupture in free tissue transfer. 2) Evaluate management strategies and outcomes of these rare cases. Methods: Retrospective review of the senior surgeon’s experience at a tertiary referral center for reconstruction of mandibulectomy defects for osteoradionecrosis with free tissue transfer from 2004 through 2013. Data collection included oncologic history, surgical resection and reconstructive details, postoperative course, complications, and outcomes. Results: Over a 10-year period 38 patients underwent free fibula osseocutaneous flap reconstruction for a diagnosis of osteoradionecrosis of the mandible. There was a prevalence of 11% (4/38) that suffered delayed rupture of the recipient artery proximal to the microvascular anastomosis. Histopathology of the anastomotic segment demonstrated acute arteritis with acute inflammatory cells and pseudoaneurysm formation of the native vessel. The recipient artery of the anastomosis was the facial artery in 3 cases and the internal maxillary artery in 1 case. Timing to initial rupture ranged from 7 to 17 (median 8.5) days. In 2 of the 4 cases the anastomosis was revised, only to suffer repeat rupture. Ultimately all anastomoses required ligation, timing ranging from 10 to 20 (mean 15) days. There was 100% flap survival. Conclusions: Recipient arterial rupture is a rare occurrence, and in our experience heavily radiated tissue is the greatest risk factor. If salvage anastomosis with the same artery is undertaken, a high risk for repeat rupture exists.