Jordan P. Sand

Scalp Reconstruction An Algorithmic Approach and Systematic Review

IMPORTANCE Reconstruction of the scalp after acquired defects remains a common challenge for the reconstructive surgeon, especially in a patient with a history of radiation to the area. OBJECTIVE To review the current literature and describe a novel algorithm to help guide the reconstructive surgeon in determining the optimal reconstruction from a cosmetic and functional standpoint. Pertinent surgical anatomy, considerations for patient and technique selection, reconstructive goals, as well as the reconstructive ladder, are also discussed. EVIDENCE REVIEW A PubMed and Medline search was performed of the entire English literature with respect to scalp reconstruction. Priority of review was given to those studies with higher-quality levels of evidence. FINDINGS Size, location, radiation history, and potential for hairline distortion are important factors in determining the ideal reconstruction. The tighter and looser areas of the scalp play a major role in the potential for primary or local flap closure. Patients with medium to large defects and a history of radiation will likely benefit from free tissue transfer. CONCLUSIONS AND RELEVANCE Ideal reconstruction of scalp defects relies on a comprehensive understanding of scalp anatomy, a full consideration of the armamentarium of surgical techniques, and a detailed appraisal of patient factors and expectations. The simplest reconstruction should be used whenever possible to provide the most functional and aesthetic scalp reconstruction, with the least amount of complexity. LEVEL OF EVIDENCE NA.

BMP-2 expression correlates with local failure in head and neck squamous cell carcinoma.

Objective Preclinical data show that exogenous administration of recombinant human bone morphogenetic protein-2 (rhBMP-2) to human oral carcinoma cell lines increases pathogenicity using a nude mouse model. The objectives of this study are to (1) describe the characteristics of baseline protein expression of BMP-2 in head and neck squamous cell carcinomas (HNSCC) and (2) determine if BMP-2 expression level correlates with worse oncologic outcomes. Study Design Retrospective analysis of previously harvested patient samples. Setting Academic medical center. Subjects In total, 149 patients with oral cavity, oropharynx, larynx, and hypopharynx HNSCC treated between January 1, 1997, and December 31, 2004. Methods A tissue microarray of HNSCC was assembled and immunohistochemistry for BMP-2 performed. Staining was quantified using a standardized scoring system. Specimens were dichotomized into high or low expression level. Statistical analyses using log-rank, Wilcoxon, and Fisher exact test were performed for associations between BMP-2 protein level and clinicopathologic features and patient survival. Results BMP-2 expression at any level was noted in 146 of 149 (98%) of samples. Tumors with high BMP-2 expression had higher rates of local failure compared with low-expressing tumors (17.3% vs 6.3%; P = .04). There was no significant association for BMP-2 expression level with tumor location, T stage, N stage, overall survival, regional failure, or distant failure. Conclusion Head and neck squamous cell carcinomas with high baseline BMP-2 protein level are associated with higher rates of local recurrence. These data have important implications for using rhBMP-2 in tissue engineering reconstructive approaches in the setting of cancer-related defects.

Reconstruction of the Lateral Mandibular Defect: A Review and Treatment Algorithm

Reconstruction of the lateral mandibular defect presents a complex challenge to the reconstructive surgeon, often involving interconnected soft-tissue and bone requirements. This review examines the current literature on functional outcomes of lateral mandibular reconstruction and presents an algorithm on selecting an optimal reconstructive choice for patients with lateral mandibular defects resulting from oncologic ablative surgery or trauma. PubMed and Medline searches on reconstructing lateral mandibular defect were performed of the English literature. Search terms included lateral mandibular defect, outcomes of mandibular reconstruction, and free flap reconstruction of mandible. Although most of the articles presented are retrospective reviews, priority was given to the articles with high-quality level of evidence. Restoration of function, including speech and swallow, and acceptable cosmetic result are the primary objectives of lateral mandibular reconstruction. When reconstructing the mandible in a patient following tumor extirpation, the patients overall prognosis, medical comorbidities, and need for adjuvant therapy should be considered. In the patient with aggressive malignant disease and a poor prognosis, a less complex reconstruction, such as soft-tissue flap with or without a reconstruction plate, may be adequate. In a dentate patient with favorable prognosis, a durable reconstruction, such as osseocutaneous microvascular free flap, is often preferred. Various reconstructive options are available for patients with lateral mandibular defects. Depending on the predominance of the soft-tissue or bony components of the defect, with consideration of the patients characteristics and functional and aesthetic goals, the surgeon can wisely select from these reconstructive possibilities.

Surgical Anatomy of the Eyelids.

Slight alterations in the intricate anatomy of the upper and lower eyelid or their underlying structures can have pronounced consequences for ocular esthetics and function. The understanding of periorbital structures and their interrelationships continues to evolve and requires consideration when performing complex eyelid interventions. Maintaining a detailed appreciation of this region is critical to successful cosmetic or reconstructive surgery. This article presents a current review of the anatomy of the upper and lower eyelid with a focus on surgical implications.

Septal Perforation Repair Using Polydioxanone Plates: A 10-Year Comparative Study.

Summary: Medium to large septal perforations are a challenging problem to the rhinoplasty surgeon. In this study, records and outcomes are reviewed for 25 patients who underwent septal perforation repair over a 10-year period. All patients underwent an open septorhinoplasty approach with use of bilateral opposing mucoperichondrial flaps and a unique intervening graft that included acellular dermis, temporalis fascia alone, or a novel closure technique using temporalis fascia and a polydioxanone plate. The authors identify that for medium to large septal perforations, the use of the polydioxanone plate with temporalis fascia provided the highest rate of closure as a method of scaffolding a fascial graft, and also provided ease of placement between opposing mucoperichondrial flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Full-Thickness Scalp Defects Reconstructed With Outer Table Calvarial Decortication and Surface Grafting.

Full-Thickness Scalp Defects Reconstructed With Outer Table Calvarial Decortication and Surface Grafting Reconstruction of full-thickness scalp defects is critical to avoid calvarial desiccation, sequestration, and sepsis.1 When a surgeon is faced with a scalp defect caused by a malignant tumor, several factors must be considered during a planned reconstruction, including the location of the defect, pathologic features of the tumor, margin status, and the patient’s comorbidities. However, these factors may preclude use of a large local flap or free tissue transfer, and an alternative method of reconstruction should be considered.2 Surface grafting is a quick, easy, and reliable form of reconstruction for scalp defects. However, grafts require a vascular bed to provide a nutrient blood supply. Previous authors have described the use of a single-stage approach for repair of these wounds by removing the outer table with immediate application of a split-thickness skin graft, an acellular dermis, an artificial dermis, or a wound vacuum-assisted closure.3-6 For select patients (ie, anticipated high surgical morbidity, tight scalp location, significant comorbidities, uncertain margin status, or aggressive pathologic features), reconstruction of fullthickness scalp defects can be successfully performed with outer table calvarial decortication and surface grafting.

Comparison of Conventional, Revascularized, and Bioengineered Methods of Recurrent Laryngeal Nerve Reconstruction

IMPORTANCE Damage to the recurrent laryngeal nerve (RLN) is highly detrimental to voice, swallow, and cough. The optimal method for reconstitution of a nerve gap after injury is unknown. OBJECTIVE To evaluate multiple methods of RLN reconstruction. DESIGN, SETTING, AND PARTICIPANTS This study used an established canine model of RLN injury to examine purpose-bred, conditioned, female, 20-kg mongrel hounds at Washington University. A total of 32 dogs were examined, with 63 experiments performed. INTERVENTIONS Surgical transection or excision of the RLN with reconstruction by multiple methods. MAIN OUTCOMES AND MEASURES Six months after injury repair, laryngeal adductor pressures (LAPs), spontaneous and stimulable movement, and graft axon counts by histologic analysis were assessed. RESULTS Simple RLN transection with direct neurorrhaphy provided a mean (SD) recovery of 55.5% (12.5%) of baseline LAPs (P = .18 for comparison of LAP recovery among cases from the conventional nerve graft [39.4% (22.2%)]; P = .63 for comparison of LAP recovery among cases from the reverse autograft [60.8% (27.5%)]). Revascularized grafts provided a recovery of 54.5% (46.4%) while short and long acellular grafts provided recoveries of 60.4% (NA) and 39.5% (17.0%). Two of 11 polyglycolic acid reconstructions provided a measurable LAP with a mean (SD) recovery of 37.1% (8.9%) of baseline. Reconstruction with a neural conduit in any condition provided no measurable LAP recovery. CONCLUSIONS AND RELEVANCE Conventional nerve grafting resulted in no significant difference in recovery of LAP function compared with simple neurorrhaphy or reverse autograft. Conventional and revascularized nerve grafts provided similar recovery. The use of bioengineered acellular nerve grafts or nerve conduits for reconstruction resulted in poor recovery of function.

Asymptomatic p16-Positive Oropharyngeal Squamous Cell Carcinoma: An Emerging Trend

IMPORTANCE The rapid increase of human papillomavirus-associated oropharyngeal cancer has demonstrated a need for new strategies in prevention, diagnosis, evaluation, and treatment. Because there are currently no available screening technologies to detect early disease, a trend of purely incidentally identified asymptomatic p16-positive squamous cell carcinoma has been observed. We identify and describe a case series of these patients. OBSERVATIONS A total of 134 patients with p16-positive oropharyngeal cancer were identified. Of these patients, 5 (3.7%) were identified as having completely asymptomatic primary site p16-positive tumors found during workup for other nonrelated medical problems. Four patients were found with early T-stage disease without nodal metastasis, and underwent surgical treatment as a single modality. One patient had advanced-stage disease and underwent chemoradiation. At a mean follow-up of 12.6 months, all patients remained disease free. CONCLUSIONS AND RELEVANCE With the rise of p16-positive oropharyngeal squamous cell carcinoma and lack of screening technologies for early-stage disease, purely incidentally diagnosed disease might increase in incidence. These findings underscore the importance of a comprehensive physical examination on all patients. Although follow-up is too limited for definitive conclusions, early experience suggests that these patients can be treated with unimodality therapy when presenting with stage I or II disease.

Platelet-Rich Plasma for Hair Loss: Review of Methods and Results.

Given substantial advances in hair regrowth research and platelet-rich plasma (PRP) science, a review of currently used systems and results is informative for physicians using a biologics approach to hair restoration. Overall positive clinical response to the use of PRP in androgenetic and alopecia areata patients is observed. The effects on hair density, count, and thickness were demonstrated through multiple clinical trials. Use as an adjunct to hair transplantation and with other technologies is also described. When compared with traditional oral/topical treatments, the lack of identifiable complications and convenience of treatment provide a positive outlook for future use and investigation.

BMP-2 Expression Correlates with Local Failure in Surgically Treated Head and Neck Squamous Cell Carcinoma:

Objectives: Preclinical data show that exogenous administration of recombinant human bone morphogenetic protein-2 (rhBMP-2) to human oral carcinoma cell lines increases pathogenicity using a nude mouse model. The objectives of this study are to 1) describe the characteristics of baseline protein expression of BMP-2 in head and neck squamous cell carcinomas (HNSCCs), and 2) determine if BMP-2 expression level correlates with worse oncologic outcomes. Methods: Tissue samples from 149 patients with oral, oropharyngeal, and laryngeal/hypopharyngeal squamous cell carcinomas treated at an academic medical center between 1999 and 2010 were assembled into a tissue microarray. Immunohistochemistry for BMP-2 was performed, and staining was quantified using a standardized scoring system. Specimens were categorized by high or low expression level. Statistical analyses using log-rank, Wilcoxon, and Fisher’s exact test were performed for associations between clinical and pathologic features and patient survival. Results: BMP-2 expression at any level was present in 146 of 149 (97.9%) tissue samples. Tumors with high BMP-2 expression had higher rates of local failure compared with low-expressing tumors (17.3% vs 6.3% P = 0.04). However, there was no significant association for BMP-2 expression level and tumor location, T stage, N stage, regional failure, distant failure, or overall survival. Conclusions: HNSCCs with high levels of BMP-2 protein expression are associated with higher rates of local recurrence. These data may have important implications for using rhBMP-2 in tissue engineering reconstructive approaches in the setting of cancer-related defects. Further, the consistent expression of BMP-2 suggests this pathway may be a novel therapeutic target.