Jon D. Holmes

Proposal for A Rational Classification of Neck Dissections

Alfio Ferlito, MD, DLO, DPath, FRCSEd ad hominem, FRCS (Eng, Glasg, Ir) ad eundem, FDSRCS ad eundem, FHKCORL, FRCPath, FASCP, IFCAP, K. Thomas Robbins, MD, FRCSC, Jatin P. Shah, MD, PhD (Hon), MS, FRCSEd (Hon), FRACS (Hon), FDSRCS, Jesus E. Medina, MD, Carl E. Silver, MD, Shawkat Al-Tamimi, MD, Johannes J. Fagan, MBChB, FCS (SA) MMed, Vinidh Paleri, MS, FRCS (ORL-HNS), Robert P. Takes, MD, PhD, Carol R. Bradford, MD, Kenneth O. Devaney, MD, JD, FCAP, Sandro J. Stoeckli, MD, Randal S. Weber, MD, Patrick J. Bradley, MB, BCh, BAO, DCH, MBA, FRCS (Ed, Eng, Ir), FHKCORL, FRCSLT (Hon), FRACS (Hon), Carlos Suarez, MD, PhD, C. Rene Leemans, MD, PhD, H. Hakan Coskun, MD, Karen T. Pitman, MD, Ashok R. Shaha, MD, Remco de Bree, MD, PhD, Dana M. Hartl, MD, PhD, Missak Haigentz, Jr, MD, Juan P. Rodrigo, MD, PhD, Marc Hamoir, MD, Avi Khafif, MD, Johannes A. Langendijk, MD, PhD, Randall P. Owen, MD, MS, Alvaro Sanabria, MD, MSc, PhD, Primož Strojan, MD, PhD, Vincent Vander Poorten, MD, PhD, Jochen A. Werner, MD, Stanislaw Bien, MD, PhD, Julia A. Woolgar, FRCPath, PhD, Peter Zbaren, MD, Jan Betka, MD, PhD, FCMA, Benedikt J. Folz, MD, Eric M. Genden, MD, Yoav P. Talmi, MD, Marshall Strome, MD, MS, Jesus Herranz Gonzalez Botas, MD, Jan Olofsson, MD, Luiz P. Kowalski, MD, PhD, Jon D. Holmes, DMD, MD, Yasuo Hisa, MD, PhD, Alessandra Rinaldo, MD, FRCSEd ad hominem, FRCS (Eng, Ir) ad eundem, FRCSGlasg

Fixation of Le Fort I Osteotomies With Poly-dl-Lactic Acid Mesh and Ultrasonic Welding—A New Technique

PURPOSE This report describes a technique for use of resorbable mesh (Resorb-X) and an ultrasonic sonotrode unit (SonicWeld Rx) to bond a pin (SonicPin Rx) to the mesh and underlying bone for Le Fort I osteotomy fixation, precluding the need to tap, shortening the time needed for fixation, and eliminating many disadvantages of titanium. In total, 659 cases have been performed from October 2005 through December 2010. This study examined the first 103 consecutive Le Fort osteotomies performed with this resorbable system and thus those with the longest follow-up. MATERIALS AND METHODS One hundred three consecutive patients who had completed growth and presurgical orthodontics were operated on using the Resorb-X plating system and SonicWeld Rx. Intraoperative adverse events were monitored and a minimum 12-month postoperative follow-up for complications was completed. RESULTS One patient (0.9%) had maxillary mobility at initial postoperative evaluation that resolved without malocclusion. Two patients (1.9%) exhibited signs of residual soreness and swelling in the maxilla, attributed to sterile abscess formation. At last follow-up, all patients demonstrated a clinically stable maxilla with correction of their malocclusion. CONCLUSION Use of ultrasonic-aided pins in fixation of resorbable mesh plates, in Le Fort I osteotomies, is a viable technique and superior resorbable plating system because it is easy to use, results in adequate fixation strength, and shortens time of application by eliminating the need for tapping. In addition, this resorbable system eliminates many disadvantages associated with using all-titanium fixation.

Neck Dissection: Nomenclature, Classification, and Technique

Lymph node status is the single most important prognostic factor in head and neck cancer because lymph node involvement decreases overall survival by 50%. Appropriate management of the regional lymphatics, therefore, plays a central role in the treatment of the head and neck cancer patients. Performing an appropriate neck dissection results in minimal morbidity to the patient, provides invaluable data to accurately stage the patient, and guides the need for further therapy. The purposes of this article are to present the history and evolution of neck dissections, including an update on the current state of nomenclature and current neck dissection classification, describe the technique of the most common neck dissection applicable to oral cavity cancers, and discuss some of the complications associated with neck dissection. Finally, a brief review of sentinel lymph node biopsy will be presented.

Full-thickness skin graft from the neck for coverage of the radial forearm free flap donor site.

PURPOSE This study describes the use of a full-thickness skin graft (FTSG) from the neck to cover the radial forearm free flap (RFFF) donor site in patients undergoing neck dissection and microvascular reconstruction for ablative head and neck oncologic surgery. The authors propose that an FTSG from the neck provides sufficient tissue quantity and quality, fewer surgical sites, and decreased surgical time and cost compared with other FTSG harvest sites and split-thickness skin grafts (STSGs). MATERIALS AND METHODS This was a retrospective study of 50 patients from 2007 to 2012 who underwent ablative surgery for oral and head and neck cancer with concomitant cervical lymphadenectomy and RFFF reconstruction with repair of the donor site using an FTSG harvested along the neck dissection incision. Patients who underwent donor site repair using other techniques, such as ulnar transposition flaps, were excluded. Medical records and perioperative photographs were reviewed. RESULTS Primary closure of the neck without dehiscence was achieved in all cases. There were no recipient site infections. Minor skin graft loss occurred in a minority of patients and was managed with local wound care until healing by secondary intention. No patients required surgical revision of the forearm. CONCLUSIONS An FTSG from the neck provides adequate coverage for most RFFF harvests and offers favorable functional and esthetic outcomes. The primary advantage is avoiding a third surgical site. Complications were comparable to those using FTSGs from other harvest sites. Importantly, cross-contamination from the head and neck with the forearm was shown not to be an issue.

Dental implants after reconstruction with free tissue transfer

The transfer of composite tissue flaps by microvascular techniques has become the standard for reconstructing complex defects of the oral and maxillofacial regions. Despite advances in these techniques, sites reconstructed by free tissue transfer (free flaps) are often compromised by scarring, bulky tissue, and altered architecture. Dental rehabilitation is often impossible without endosseous implants to aid in stabilization and retention of prostheses. The most commonly used free flaps, however, have significant shortcomings with regard to implant placement, prosthetics, and maintenance. This article describes some site development and prosthetic techniques that can be applied to improve outcomes when dental implants are used in conjunction with free flap reconstruction.

A Clinical Study of AlloDerm in Lip Augmentation

Introduction: Lip augmentation is a frequently requested facial cosmetic procedure. The use of AlloDerm cosmetically has been documented since 1994, with clinical observations of some degree of resorption. The purpose of this prospective study was to objectively and subjectively assess the degree of labial change with AlloDerm implantation and its long-term clinical stability. Materials and Methods: Nineteen patients were treated with AlloDerm lip augmentation between January 1999 and October 1999. These patients were then followed up at 3, 6, and 12 months after surgery with a combination of physical evaluation, patient questionnaires, photographs, and lateral cephalometric radiographs. The data obtained were then evaluated objectively and subjectively. Objective analysis included computer analysis of photographs and lateral cephalometric radiographs. Subjective analysis included patient questionnaires and visual photographic assessment by professional independent evaluators. Results: Of the 19 patients initially enrolled in the AlloDerm lip study, 74% were seen on 3-month follow-up, 79% on 6-month follow-up, and 58% at 12-month follow-up. At 3 months, the compiled National Institutes of Health computer-analyzed photographic data showed an overall mean increase in the collective vermilion surface area of 16% on frontal and 39% on profile from the preoperative status. By 1 year, the overall mean increase in vermilion surface area was 8% on frontal and 36% on profile. The compiled lateral cephalometric radiographic data showed an overall mean increase in lip projection of 16% in the upper lip and 7% in the lower lip at 3 months. However, by 1 year, the overall mean increase in lip projection from preoperative status had dropped to 6% in the upper lip and 2% in the lower lip. Preoperatively, only 16% of the patients perceived their lips as looking about right or younger; this improved to 91% at 1 year. Independent evaluators viewed 54.5% of the patients lips as looking about right or younger before surgery, as compared to 82% at 1 year. Conclusions: The objective results clearly indicate that there is substantial mean labial volumetric loss from 3 to 6 months after lip augmentation with AlloDerm. From 6 to 12 months, further volumetric loss is less substantial, with more stable clinical results. Despite documented resorption, there is an overall improvement in the subjective perception at all assessed points by both the patients and independent evaluators.