Eugene L. Alford

Quality of Life and disease-specific functional Status following microvascular reconstruction for advanced (T3 and T4) oropharyngeal cancers

&NA; In an effort to evaluate quality‐of‐life benefits of ablative head and neck cancer surgery and microvascular reconstruction, a longitudinal study was undertaken in which patients with T3 or T4 oropharyngeal cancers without systemic metastases at presentation were administered both general and disease‐specific quality‐of‐life instruments preoperatively and postoperatively. In an initial prospective pilot study, 17 cancer patients were evaluated both preoperatively and postoperatively using the Medical Outcomes Short‐Form Health Survey questionnaire (SF‐36) and the Performance Status Scale for Head and Neck Cancer Patients. In the second part of the study, the need was recognized for a different diseasespecific measure, for more frequent intervals of longitudinal follow‐up (rather than be limited by a single data collection point), and for a noncancer control group. Since then, 17 more cancer patients were evaluated in the second part of the study and were compared with patients who had similar reconstructions after suffering head and neck trauma and also with age‐matched controls. Instead of the performance status scale, the University of Washington Head and Neck Quality of Life questionnaire was substituted. Interval assessments were done at 1, 3, 6, and 12 months and preoperatively. Whereas many of the general and disease‐specific quality of life subclasses initially worsened following extensive surgery and radiation therapy, most returned to the preoperative baseline by 6 months following conclusion of treatment and surpassed pretreatment values at 1 year. It can be concluded, based on this study, that large resections and reconstructions for head and neck cancer patients are justified in terms of outcome; the resection controls the local disease, and the microvascular reconstruction restores quality of life and functional status. (Plast. Reconstr. Surg. 105: 1628, 2000.)

Orbital Involvement in Allergic Fungal Sinusitis

BACKGROUNDnAlthough allergic fungal sinusitis is a relatively common, noninvasive form of paranasal sinus mycosis, and despite frequent orbital involvement, there have been few reports of this condition in the ophthalmic literature.nnnMETHODSnTwo cases of allergic fungal sinusitis having orbital symptoms are described. The current classification, typical presentation, and ideal management of fungal sinusitis are reviewed.nnnRESULTSnDistinguishing radiologic and pathologic features were present in both patients. Aspergillus flavus was cultured in one case, and Bipolaris spicifera was cultured in the other.nnnCONCLUSIONSnAllergic fungal sinusitis is a unique subset of sino-orbital disease with highly characteristic clinical, radiologic, and pathologic features. Unlike invasive forms of mycotic disease, allergic fungal sinusitis may be managed adequately with surgical debridement, aeration of the involved sinuses, and systemic and topical corticosteroids.

Combined transconjunctival/intranasal endoscopic approach to the optic canal in traumatic optic neuropathy.

Surgical decompression of the optic canal is indicated in patients with traumatic optic neuropathy who fail to respond to corticosteroids. Traditional surgical approaches to the orbital apex have been effective in achieving optic nerve decompression but require either a craniotomy, provide limited exposure with late identification and protection of the optic nerve, or require external incisions. The combined transconjunctival/intranasal endoscopic approach to the optic canal offers sufficient exposure, allows early identification and protection of the optic nerve, provides space for the use of multiple surgical instruments, obviates a craniotomy and external incisions, and can be performed quickly with minimal morbidity. The technique of combined transconjunctival/intranasal endoscopic optic nerve decompression will be described and the experience with nine cases will be presented.

Baseline and post-treatment assessment of the general health status of head and neck cancer patients compared with United States population norms.

It is a common perception that the overall health of patients with head and neck cancer (HNC) is likely to be poor compared with the general population. This project was undertaken to investigate the pre‐ and post‐treatment, global health status of HNC patients in comparison with age‐matched, U.S. population norms using a self‐administered general health status survey.

Free composite myo-osseous flap with serratus anterior and rib: indications in head and neck reconstruction.

Although the microvascular transfer of the serratus/rib myo‐osseous composite flap has been previously described, the indications for its use in head and neck reconstruction have not been fully explored. Slender and easily contoured, rib bone offers reconstructive advantages over other bone sources under certain circumstances. The serratus/rib myo‐osseous flap can provide vascularized muscle, bone, and cartilage; in combination with the latissimus dorsi muscle, the serratus/rib flap provides additional soft‐tissue bulk on a single thoracodorsal vascular pedicle unrestricted by orientation requirements of the bone. Many orientations of bone and soft tissue are possible.

Superficial versus deep: options in venous drainage of the radial forearm free flap.

We performed a fresh cadaver dissection study of the superficial venous system (cephalic vein and its branches) and the deep venous system (venae comitantes) of the radial forearm to assess the suitability of each system for venous anastomosis during free tissue transfer. We used methyl methacrylate to evaluate vessel diameters and anatomic variability of both venous systems. Colored radiopaque injectate allowed us to combine anatomic dissection with tissue radiographs. We discovered the cephalic vein to invariably be of larger caliber than the venae comitantes. Ensuring capture of the cephalic vein in the flap necessitated additional dorsoradial subcutaneous dissection beyond the boundaries of the skin flap in four of ten specimens. The vessel diameters of the venae comitantes in four cadavers were less than 2 mm. Proximal confluence of the two venae comitantes, and communication between the deep and superficial venous systems were encountered in only-four cases. In these cases, had an anastomotic site been chosen proximal to such a communication to ensure greater vessel caliber, pedicle length probably would have made free tissue transfer unwieldy. We recommend mapping the course of the cephalic vein before flap elevation and maintaining a wide proximal subcutaneous pedicle to capture the best possible superficial drainage system. If the superficial venous system has been damaged (as by previous intravenous catheterization), one may not necessarily be able to rely on the vessel caliber of the deep venae comitantes for microvenous anastomosis.

Basal cell carcinoma of the scalp resulting in spine metastasis in a black patient

Basal cell carcinoma (BCC), the most common skin cancer in the United States, is locally invasive but has a low risk of metastasis. BCC is rare in black patients but, regardless of racial origin, most BCC occurs on sun-exposed areas. We describe a 67-year-old black man with a large BCC on the hairy scalp, a relatively sun-protected area, that metastasized to the spine. To our knowledge, this is the first description of a black patient with development of metastatic BCC on an otherwise normal scalp.

Neural anatomy of the radial forearm flap.

&NA; Typically the lateral antebrachial cutaneous nerve alone is used to innervate the radial forearm free flap when a sensate flap is required. The authors desired, by means of fresh cadaveric microdissections and by means of local anesthetic injections in living subjects, to map the sensory nerve territories of this flap. Eight radial forearm flaps were elevated and the medial antebrachial cutaneous nerve (MABC), lateral antebrachial cutaneous nerve (LABC), and superficial radial sensory nerve (SRSN) were dissected with the aid of an operating microscope (2.5‐10×) and traced to their dermal insertions. In the injection study, the MABC, LABC, and SRSN in eight forearms of 4 subjects were blocked sequentially with 2% lidocaine injections. The resulting sensory deficit from each injection was mapped on the skin and superimposed on the marked radial forearm flap territory. Distribution of the three dissected nerve regions and the sensory deficit after injection were determined by digital images and computer analysis. During flap dissections, mean nerve distributions of total flap area were as follows: LABC, 61.8% (range, 48.3‐71.6%); MABC, 33.8% (range, 30.5‐38.9%); and SRSN, 34.6% (range, 26.8‐44.1%). After nerve block the mapped sensory areas were as follows: LABC, 62.3% (range, 44.5‐88.5%); MABC, 19.6% (range, 8.0‐35.8%); and SRSN, 19.5% (range, 9.9‐26.3%). At least 40% of the total flap area was not innervated by the LABC as identified both by nerve dissection and sensory local anesthetic blockade. By including the LABC, MABC, and SRSN in the radial forearm flap, both the theoretical and the clinically determined useful sensory innervation of the radial forearm flap potentially would be increased. Boutros S. Yuksel E, Weinfeld AB, Alford EL, Netscher DT. Neural anatomy of the radial forearm flap. Ann Plast Surg 2000;44:375‐380

Basal Cell Carcinoma on the Scalp of an Indian Patient

BACKGROUND Basal cell carcinoma (BCC) is the most common malignancy in whites, but it rarely occurs in dark persons. OBJECTIVE To report a BCC on the hairy scalp of an Asian Indian female with no obvious risk factors except previous scalp trauma. METHODS We review the English literature concerning BCC in Indians, and compare this with data for North American blacks and whites; and reports of BCC arising in areas of prior trauma. RESULTS/CONCLUSION Skin cancer accounts for 1–2% of malignancies in blacks and Indians, compared with one‐third of neoplasms in whites. BCC comprises 75% of skin cancers in whites, but squamous cell carcinoma represents 60–65% of skin cancers in blacks and Indians. Although most BCCs occur in sun‐exposed areas in whites, blacks, and Indians, a significant percentage also develop in photoprotected areas. Trauma may be a significant risk factor for BCC, either with actinic damage or alone, as in our case.

Intracranial complications of sinusitis

In addition to the surgical excision of metastatic melanomas, other treatment modalities now include radiation, chemotherapy, and most recently the use of recombinant interferons. When the trachea and bronchi become affected with tumor metastasis, relieving airway obstruction with laser excision allows the patient to have hope for survival while on chemotherapy or some other form of therapy. Combined laser excision is very effective in keeping the airway safe while the patient continues to undergo treatment of the other tumor sites.