Joan E. Lipa

Head and neck reconstruction with anterolateral thigh flap.

OBJECTIVEnOur goal was to present our experience with the free anterolateral thigh flap for reconstruction of various cutaneous and mucosal defects of the head and neck.nnnSTUDY DESIGNnWe conducted a retrospective review of 37 patients who underwent reconstruction between 1994 and 2002. Outcome measures included ethnicity, flap harvest technique, vascular anatomy, flap success, general surgical complications, and donor site morbidity.nnnRESULTSnThe majority of our patients were white (n = 33). The size of the 39 free anterolateral thigh flaps varied from 24 to 252 cm(2). There was 1 arterial failure and flap loss (2.6%) and 2 venous occlusions that were both salvaged. The donor site was closed primarily in 37 cases and with a split-thickness skin graft in 2 cases.nnnCONCLUSIONSnThis is the first report on using the free anterolateral thigh flap in whites. This free transfer has proved to be a versatile and reliable flap for reconstruction of the head and neck.

TEN-YEAR EXPERIENCE OF FREE FLAPS IN HEAD AND NECK SURGERY. HOW NECESSARY IS A SECOND VENOUS ANASTOMOSIS?

Successful free flap surgery in the head and neck is dependent on the successful anastomosis of both artery and vein. The success of all free flaps was analyzed to determine the necessity for performing 2 venous anastomoses.

Expansion and characterization of human melanoma tumor-infiltrating lymphocytes (TILs).

Background Various immunotherapeutic strategies for cancer are aimed at augmenting the T cell response against tumor cells. Adoptive cell therapy (ACT), where T cells are manipulated ex vivo and subsequently re-infused in an autologous manner, has been performed using T cells from various sources. Some of the highest clinical response rates for metastatic melanoma have been reported in trials using tumor-infiltrating lymphocytes (TILs). These protocols still have room for improvement and furthermore are currently only performed at a limited number of institutions. The goal of this work was to develop TILs as a therapeutic product at our institution. Principal Findings TILs from 40 melanoma tissue specimens were expanded and characterized. Under optimized culture conditions, 72% of specimens yielded rapidly proliferating TILs as defined as at least one culture reaching ≥3×107 TILs within 4 weeks. Flow cytometric analyses showed that cultures were predominantly CD3+ T cells, with highly variable CD4+:CD8+ T cell ratios. In total, 148 independent bulk TIL cultures were assayed for tumor reactivity. Thirty-four percent (50/148) exhibited tumor reactivity based on IFN-γ production and/or cytotoxic activity. Thirteen percent (19/148) showed specific cytotoxic activity but not IFN-γ production and only 1% (2/148) showed specific IFN-γ production but not cytotoxic activity. Further expansion of TILs using a 14-day “rapid expansion protocol” (REP) is required to induce a 500- to 2000-fold expansion of TILs in order to generate sufficient numbers of cells for current ACT protocols. Thirty-eight consecutive test REPs were performed with an average 1865-fold expansion (+/− 1034-fold) after 14 days. Conclusions TILs generally expanded efficiently and tumor reactivity could be detected in vitro. These preclinical data from melanoma TILs lay the groundwork for clinical trials of ACT.

Recovery of erectile function after unilateral and bilateral cavernous nerve interposition grafting during radical pelvic surgery.

PURPOSEnThe use of cavernous nerve interposition grafting to preserve erectile function in men who require neurovascular bundle resection for cancer control is controversial. We report outcomes and predictors of cavernous nerve interposition grafting in men undergoing unilateral grafting during radical prostatectomy or bilateral grafting during radical cystectomy and prostatectomy with autologous nerve grafts.nnnMATERIALS AND METHODSnWe retrospectively reviewed the electronic records of 36 patients who underwent cavernous nerve interposition grafting between 2003 and 2006. Postoperatively erectile function was assessed with the International Index of Erectile Function 15-item questionnaire. Predictors of potency, including age at surgery, time since surgery and prostate specific antigen at surgery, were assessed by univariate analysis.nnnRESULTSnA total of 33 patients (92% response rate) were followed for a median of 32, 25 and 11 months after bilateral grafting during radical cystectomy (10), unilateral grafting during radical prostatectomy (20), and bilateral grafting during radical cystectomy and prostatectomy (3), respectively. The rate of potency, defined as the ability to attain and maintain erection sufficient for penetration at least 50% of the time with or without phosphodiesterase-5 inhibitors, was 31% (5 of 13 men) for unilateral grafts, 38% (5 of 16) for bilateral grafts and 30% (3 of 10) for bilateral grafts during radical cystectomy. Age at surgery was the only significant determinant of potency and it showed an inverse relationship in the bilateral nerve graft group (p = 0.02).nnnCONCLUSIONSnCavernous nerve interposition grafting appears to have a role in the recovery of erectile function. To our knowledge this study represents the largest series of cavernous nerve interposition grafting during cystectomy and it suggests that this should be considered during bilateral neurovascular bundle resection.

Patient satisfaction following nipple reconstruction incorporating autologous costal cartilage.

BACKGROUNDnNipple-areolar reconstruction completes post-mastectomy breast reconstruction. Many techniques for nipple reconstruction have been described, and each has their advocates and critics. One of the frequent failings of most designs is loss of nipple projection with time.nnnOBJECTIVESnTo determine the effect of including autologous costal cartilage on patient satisfaction with their nipple reconstruction.nnnMETHODSnSixty-eight patients were identified who had undergone fishtail flap nipple reconstruction following autologous free flap breast reconstruction between 1990 and 2004. Qualitative questionnaires, using Likert scales, were sent to each patient to specifically assess their satisfaction with their nipple reconstruction.nnnRESULTSnOf 26 respondents (mean +/- SEM follow-up period 3.7+/-3.6 years), 13 had undergone nipple reconstruction incorporating costal cartilage banked at the time of initial breast reconstruction, and the other 13 had no cartilage in their nipple reconstructions. While both groups would opt for nipple reconstruction again, patients with cartilage grafts incorporated into their reconstructions had overall satisfaction ratings 1.92 grades higher on average (not significant, P=0.12) than those without. This difference increased to 3.2 grades when the satisfaction of the patients partner was taken into account (P<0.05). Improved satisfaction corresponded to higher scores for volume, consistency, texture, and particularly for projection and contour of the nipple (P<0.05). Although nipple morphology changed over time, there was a trend toward improved stability in the cartilage group.nnnCONCLUSIONSnPatient satisfaction with nipple reconstruction can be improved by incorporating costal cartilage beneath the skin flaps. Superior contour and projection are sustained over time.