Dale H. Brown

Flap Selection in Cranial Base Reconstruction

&NA; We have compared our local, pedicled, and free‐flap reconstructions for 90 skull base defects performed over the past 10 years. The pericranial flap was found to provide a reliable dural seal. Free‐flap reconstructions exhibited a significantly higher incidence of uncomplicated primary wound healing (95 versus 62.5 percent) and a much lower incidence of flap loss (0 percent), cerebrospinal fluid leak (5 percent), meningitis, and abscess (0 percent) when compared with defects reconstructed with pedicled myocutaneous flaps. We conclude that microvascular freetissue transfer is the safest, most economical procedure when faced with moderate to large composite defects of the cranial base.

The free flap and plate in oromandibular reconstruction: long-term review and indications.

The purpose of this study was to define the role of reconstruction plates as bone replacement in oromandibular reconstruction. From 1987 through 1991, 71 consecutive oral cancer patients underwent composite resection and reconstruction and were entered into one of two studies. In the first study of 31 patients, 15 underwent oromandibular reconstruction using a radial forearm osteocutaneous flap, while the remainder (16) received a radial forearm fasciocutaneous flap together with a mandibular reconstruction plate. The second study involved 40 subsequent patients, all receiving the latter form of reconstruction. Twenty-one of the plates were stainless steel, and the remaining 19 were of the titanium hollow screw (THORP) type. We followed the patients prospectively. We defined success as a reconstruction that we did not have to remove. Additionally, since the patients had limited life expectancy, we developed the idea of days of life lost and incorporated it into our definition of a successful outcome. Vascularized autogenous bone proved to be more successful than metallic plates used alone in terms both of reconstruction survival and of minimizing days of life lost. The overall success rate of mandibular plate reconstruction was 78.9 percent, but analysis by defect type revealed a failure rate of 35 percent when the defects were anterior and only 5 percent when they were lateral. THORP plates demonstrated a trend towards more durability. We would now recommend plate reconstruction only in lateral defects in patients with a poor prognosis. (Plast. Reconstr. Surg. 95: 1018, 1995.)

PREDICTORS OF MORBIDITY FOLLOWING FREE FLAP RECONSTRUCTION FOR CANCER OF THE HEAD AND NECK

Free flap reconstruction of head and neck cancer defects is complex with many factors that influence perioperative complications. The aim was to determine if there was an association between perioperative variables and postoperative outcome.

Atypical clinical behavior of p16-confirmed HPV-related oropharyngeal squamous cell carcinoma treated with radical radiotherapy.

PURPOSE To report atypical clinical behavior observed in human papillomavirus (HPV)-related oropharyngeal carcinoma (OPC) treated with radiotherapy. METHODS AND MATERIALS A retrospective cohort study was conducted for all newly diagnosed OPC cases treated with radiotherapy on July 1, 2003 to April 30, 2009. HPV positivity was determined by p16 immunostaining in tumors. The incidence of additional malignancies and the pattern of distant metastases (DMs) were compared between the HPV-positive (HPV+) and HPV-negative (HPV-) cohorts. RESULTS HPV status was evaluated in 318 of 613 consecutive OPC cases (52%), showing 236 HPV+ and 82 HPV- patients. Compared with HPV-, HPV+ cases were less likely to have additional malignancies (prior: 11% vs. 20%, p = 0.038; synchronous: 1% vs. 9%, p = 0.001; metachronous: 6% vs. 16%, p = 0.003). Whereas the majority (10 of 12) of HPV- additional head-and-neck (HN) mucosal malignancies were in the oral cavity, there was none (0 of 7) in the HPV+ cohort (p < 0.001). HPV+ synchronous HN second primaries (SPs) were in the supraglottis, post-cricoid, and nasopharynx; metachronous HN SPs were in the glottis, supraglottis, and ethmoid plus glottis/post-cricoid region. All SPs that could be tested were HPV+. There was no difference in DM rate (10% vs. 15%, p = 0.272), but HPV+ DMs were more likely to involve multiple organs (46% vs. 0%, p = 0.005) and unusual sites. CONCLUSIONS This study reports atypical clinical behavior seen in HPV+ OPC, including multicentric lesions in HN mucosa and DM to multiple organs and unusual sites. The frequency of these events is low, but they may have clinical implications. The routine assessment of HPV status for all OPC is warranted.

Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: are we making sense?

Eight patients who underwent a partial glossectomy and associated floor of the mouth resection for squamous cell carcinoma were reconstructed with a sensate radial forearm flap in which the lateral antebrachial cutaneous nerve was anastomosed to the (divided) lingual nerve. The patients were compared prospectively with matched controls who received noninnervated forearm flaps for the same defect. A “blinded” therapist performed detailed sensory testing at least 6 months following surgery. In all modalities examined, the sensate proved superior to the nonsensate flap and not statistically different from the opposite side of the tongue. Two-point discrimination and pressure sensitivity were much greater in the innervated forearm flaps than in the forearms from which they came. The results are discussed with reference to the density of sensory receptors, the degree of cortical representation, and the subcortical anatomy of the neuro-sensory tracts. It appears that the density of sensory receptors is not directly related to the sensory potential in a given tissue transfer and that this potential is more related to the cortical fidelity of the recipient nerve. A historical matched cohort of 10 patients receiving pectoralis flaps for similar defects also was examined. Although the follow-up was longer, reinnervation was of a very low order—even worse than with noninnervated forearm flaps. This work supports the concept that sensory reinnervation should be attempted whenever possible following ablative oral surgery. This would include suture or grafting of major sensory nerves as well as the reinnervation of flaps. (Plast. Reconstr. Surg. 93: 1350, 1994.)

Recipient vessels in head and neck microsurgery: radiation effect and vessel access.

Historical cohort analysis compared free-flap survival rates in 226 irradiated and 108 nonirradiated head and neck reconstructions. The failure rate for the irradiated flaps (3.5 percent) did not differ significantly from that for the nonirradiated group (2.9 percent). A case-control study of the failed irradiated flaps revealed infection and lag time between radiotherapy and surgery as the only factors significantly associated with free flap failure. Salvage techniques (vein grafting, cephalic transposition, and Corlett looping) for recruiting recipient vessels into radically ablated head and neck beds are reviewed. (Plast. Reconstr. Surg. 92: 628, 1993.)

The free iliac crest and fibula flaps in vascularized oromandibular reconstruction: comparison and long-term evaluation.

A variety of free flaps have been successfully used for mandible reconstruction. This study compared the short‐ and long‐term results of using the free iliac crest and fibula flaps.

Postlaryngectomy Voice Rehabilitation: State of the Art at the Millennium

Total laryngectomy or laryngopharyngectomy remains the procedure of choice for advanced laryngeal/hypopharyngeal carcinoma, either as a primary procedure or as salvage following irradiation alone or concurrent chemoradiation therapy. Over the past 25 years there has been significant improvement in the rehabilitation of these patients, with speech restoration that has dramatically altered and improved their quality of life. This article reviews postlaryngectomy voice rehabilitation with a historical background as well as the present state-of-the-art tracheoesophageal shunt voice with an artificial valve. Finally, this article reviews and compares artificial valve prostheses as to their voice characteristics, patient satisfaction, complications associated with the procedure, and devices used at a center in Europe (The Netherlands Cancer Institute, Amsterdam) and a North American center (The Wharton Head and Neck Center, Princess Margaret Hospital, University of Toronto, Canada).

Molecular cytogenetic analysis of head and neck squamous cell carcinoma: By comparative genomic hybridization, spectral karyotyping, and expression array analysis†

A combination of molecular cytogenetic and expression array analysis has been performed on head and neck squamous cell carcinoma (HNSCC) of the oral cavity and supraglottis. These studies were performed to identify consensus regions of chromosomal imbalance and structural rearrangement to determine whether genes located in these genomic regions are subject to alterations in gene expression. Such combinatorial studies may help to identify recurrent patterns of altered gene expression in the context of specific chromosomal changes.

Clinicopathologic and therapeutic risk factors for perioperative complications and prolonged hospital stay in free flap reconstruction of the head and neck

We aimed to determine predictors of morbidity in patients undergoing microvascular free flap reconstruction of the head and neck.