Jennings R. Boyette

Bisphosphonates and jaw osteonecrosis: The UAMS experience

Background Over the past year at least 10 case series and several case reports on osteonecrosis of the jaw (ONJ) have been published with most found in the oral surgery literature. This clinical entity is largely unknown to head and neck surgeons. Methods Retrospective chart review. Results A total of 479 charts were reviewed, identifying 25 individuals meeting inclusion criteria. Mean age was 63.4 (standard deviation, 9.9) years; 40% were female. Multiple myeloma was the most common comorbidity. Twenty-five patients were treated with bisphosphonates for 4.4 years (range, 1 to 8 years); most commonly pamidronate before ONJ diagnosis. Forty-two percent (10) took steroids within the month before diagnosis. Fifty-two percent (11) underwent dental work before developing ONJ. Conclusion These data reflect the importance of awareness of the possibility of ONJ with bisphosphonate therapy.

Management of orbital fractures: challenges and solutions

Many specialists encounter and treat orbital fractures. The management of these fractures is often challenging due to the impact that they can have on vision. Acute treatment involves a thorough clinical examination and management of concomitant ocular injuries. The clinical and radiographic findings for each individual patient must then be analyzed for the need for surgical intervention. Deformity and vision impairment can occur from these injuries, and while surgery is intended to prevent these problems, it can also create them. Therefore, surgical approach and implant selection should be carefully considered. Accurate anatomic reconstruction requires complete assessment of fracture margins and proper implant contouring and positioning. The implementation of new technologies for implant shaping and intraoperative assessment of reconstruction will hopefully lead to improved patient outcomes.

Facial fractures in children.

Facial trauma in children differs from adults. The growing facial skeleton presents several challenges to the reconstructive surgeon. A thorough understanding of the patterns of facial growth and development is needed to form an individualized treatment strategy. A proper diagnosis must be made and treatment options weighed against the risk of causing further harm to facial development. This article focuses on the management of facial fractures in children. Discussed are common fracture patterns based on the development of the facial structure, initial management, diagnostic strategies, new concepts and old controversies regarding radiologic examinations, conservative versus operative intervention, risks of growth impairment, and resorbable fixation.

Prospective quality of life assessment in congenital laryngomalacia

PURPOSE OF STUDY Disturbances in breathing or feeding may profoundly affect parental perceptions of a newborns health. Previous research into quality of life for patients with laryngomalacia is limited to retrospective analysis. The purpose of this study is to prospectively evaluate the quality of life of families of infants with laryngomalacia and the impact of surgical and non-surgical treatments. DESIGN AND METHOD Pilot prospective analysis using the laryngomalacia quality of life (QOL) survey in families of infants with newly diagnosed laryngomalacia under age one year. A 29-question survey regarding severity of symptoms related to overall health, airway, and swallowing is completed at initial and post-treatment visits. Responses are quantified over a range from 1 to 5 (1 never to 5 always). RESULTS Twenty-six families were enrolled in the study. Eleven patients were managed medically and fifteen underwent supraglottoplasty. The overall mean QOL score for patients treated medically was 2.57 (standard error, SE 0.16) on initial visit and 1.67 (SE 0.16) post-treatment (mean 3.9 months). Patients undergoing supraglottoplasty had an overall mean QOL score of 3.59 (SE 0.14) on initial visit and 2.22 (SE 0.22) post-treatment (mean 3.5 months). Analysis of variance (ANOVA) and post hoc testing revealed significant improvement between initial and follow-up visits in both treatment groups (p < 0.01). Patients who underwent supraglottoplasty had significantly higher scores at initial visit (p < 0.01). No statistically significant difference was noted between patient groups post-treatment (p > 0.05). CONCLUSIONS Prospective QOL assessment of children with laryngomalacia and their families reveals a significant burden of disease. Quality of life improves in all patients but may improve more significantly in patients managed surgically.

Cervicofacial Advancement-Rotation Flap in Midface Reconstruction: Forward or Reverse?

Objective. To present the authors’ experience and outcomes in the reconstruction of midfacial defects using cervicofacial advancement-rotation flaps (CARFs) based on a method of determining forward or reverse design in relation to the proportions of the defect. Study Design. Case series with retrospective chart review. Setting. Tertiary care academic medical center. Subjects and Methods. Patients who underwent CARF reconstruction and the subset of patients with midfacial defects medial to the lateral canthus were included. CARF was designed in a forward fashion with an anteromedial movement for the defects with a larger vertical dimension and in a reverse fashion with a posterosuperior movement for the defects with a larger horizontal dimension. Results. Thirteen of 45 patients who underwent CARF reconstruction qualified for the analysis as a subset based on defect location. CARF was used in a forward fashion in 7 patients and in a reverse fashion in 6 patients. The largest defect in this subset was measured as 9 × 6 cm, while the smallest defect was 3 × 2 cm. Average follow-up was 11.5 months. None of the patients developed partial or total flap loss. Six patients had mild ectropion, which was managed with conservative measures only. The outcome of the reconstruction was satisfactory in all cases. Conclusion. Designing the CARF based on the proportion of the vertical and horizontal diameters of the selected midfacial defects as described allows for closure of the defects with minimal tension and minimizes the amount of discarded healthy skin overlapping at the suture lines.

Flaps and Grafts

A variety of techniques can be implemented for facial reconstruction. Each defect is unique and a unique solution is often necessary. The reconstructive ladder may serve as a guide for repair, but often the ideal method is site specific. Adjacent tissue transfer with local flaps may provide skin that more closely matches the surrounding skin color, texture, and thickness; however, more complex defects will often require regional or free flap reconstruction. The skin is not the only concern, as the three-dimensional structure of the face, ears, and nose also requires attention in order to restore premorbid appearance and function. This chapter outlines the various common techniques utilized in facial reconstruction and provides site-specific guidelines for repair.

Role of Vastus Lateralis Myofascial Free Flap in Reconstruction of Head and Neck Defects

Objectives: There is a paucity of data regarding the role of the vastus lateralis free flap (VLFF) in head and neck reconstruction. Our objectives were to (1) describe the flap outcomes in this setting and (2) identify ideal clinical scenarios for its use. Methods: Retrospective review of 7 patients undergoing reconstruction with a VLFF at an academic tertiary institution between 2009 and 2013. Demographics, indications, complications, and outcomes were retrieved. Results: There were 4 males and 3 females with a mean age of 54.7 years. Indications included skull base reconstruction (n = 3/43%), scalp/calvarial defect (n = 2/28%), maxillary (n = 1), and exposed pharyngeal cervical spine hardware (n = 1). The myofascial component length ranged from 7 to 20 cm, and width ranged from 6 to 11 cm, with a mean area of 102 cm2 (range, 35-240). The mean pedicle length was 11.3 cm. Handheld (n = 3) or implantable (n = 4) Doppler was used for monitoring, and there were no flap losses. The flap was skin grafted in 3 cases with no reported graft loss. The mean intensive care unit stay was 1.1 days (0-3) and length of stay was 7.8 days (5-13). Complications included wound infection (n = 1) and myocardial infarction (n = 1) in a patient with significant comorbidities. The donor site was closed primarily in all cases, with no significant donor site morbidity reported. Conclusions: The VLFF is an underutilized option in head and neck reconstruction. This flap provides a large amount of soft tissue that can be harvested in supine position and with minimal donor site morbidity. Given its long pedicle and variable myofascial component that can be tailored to a wide range of defects, the VLFF appears ideal for skull base reconstruction.

Prospective Quality-of-Life Assessment in Congenital Laryngomalacia and Its Treatment

Objectives: Disturbances in breathing or feeding may profoundly affect parental perceptions of an infant’s health. Previous research into quality of life (QOL) for patients with laryngomalacia is limited to retrospective analysis. The purpose of this study is to prospectively evaluate the QOL of children with laryngomalacia and their parents and the impact of surgical and non-surgical treatments. Methods: Pilot prospective analysis using the Laryngomalacia QOL Survey in patients with newly diagnosed laryngomalacia under age one year. A 29-question survey regarding severity of symptoms related to overall health, airway, and swallowing is completed at initial and post-treatment visits. Responses are quantified over a range from 1 to 5 (5 always or severe). Results: Twenty-seven patients were enrolled in the study. Twelve were managed medically, and 15 underwent supraglottoplasty. The overall mean QOL score for patients treated medically was 2.57 (standard error SE 0.16) on initial visit and 1.67 (SE 0.16) post-treatment (mean 3.9 months). Patients undergoing supraglottoplasty had an overall mean QOL score of 3.59 (SE 0.14) on initial visit and 2.22 (SE 0.22) post-treatment (mean 3.5 months). Analysis of variance and post-hoc testing revealed significant improvement between initial and follow-up visits in both treatment groups (P < 0.01). Patients who underwent supraglottoplasty had significantly higher scores at initial visit (P < 0.01). No statistically significant difference was noted between patient groups post-treatment (P > 0.05). Conclusions: Prospective QOL assessment of children with laryngomalacia and their families reveals a significant burden of disease. Quality of life improves in all patients but may improve more significantly in patients managed surgically.

Selectin blockade decreases postischemic recruitment of bone marrow stromal cells

Investigate the localization mechanisms of bone marrow stromal cells following transient ischemia‐reperfusion injury in a murine flap model.