Judith M. Skoner

Massive flap donor sites and the role of negative pressure wound therapy.

Objective Report our experience with negative pressure wound therapy (NPWT) applied to massive scapular and latissimus free flap donor sites, in the setting of microvascular reconstruction for extensive head and neck defects. Study Design Retrospective case series with chart review. Setting Tertiary academic referral center. Subjects and Methods Retrospective review was conducted of all patients who underwent scapular or latissimus free tissue transfer by the senior author for head and neck reconstruction, over a 5-year period (2006-2011). In addition to NPWT details, comprehensive patient data were abstracted and compiled, including demographics, operative details, hospital stay, postoperative follow-up, and donor site complications. Results Ninety-four patients underwent reconstruction of extensive postablative head and neck defects using either a scapular or latissimus free flap. Mean harvested flap skin paddle size was 140 cm2. All donor sites were closed primarily. Fifty-two patients (55%) had NPWT applied over closed donor site incisions postoperatively. The other 42 patients (45%) received only conventional incision care. Major donor site complications occurred in 12% (n = 5) of the patients who did not undergo NPWT, as compared with a 6% (n = 3) complication rate among patients in the NPWT-treated group. Conclusion This is the first study to examine NPWT in the postoperative treatment of closed high-tension wounds following scapular or latissimus dorsi harvest for reconstruction of extensive head and neck defects. Our results suggest that NPWT is a safe technique in the management of massive scapular and latissimus free flap harvest sites that may decrease associated major donor wound complications.

Intraoperative goal-directed hemodynamic management in free tissue transfer for head and neck cancer

The purpose of this study was to determine the effect of algorithmic physiologic management on patients undergoing head and neck free tissue transfer and reconstruction.

Management of Salivary Bypass Tube and Stent Migration in Pharyngoesophageal Microvascular Reconstruction

Objective: Post-chemoradiation salvage surgery with pharyngoesophageal reconstruction may be associated with postop fistula, even with free tissue transfer. Salivary bypass tubes and stents have thus been used to minimize this complication, but migration is a real risk. We present our series of bypass tube and esophageal stent distal migrations and management. Method: A retrospective chart review at a tertiary academic medical center identified those patients undergoing pharyngoesophageal salvage resection, simultaneous complex pharyngoesophageal reconstruction, and salivary bypass tube or esophageal stent placement. Demographics, surgical details and postop management of tube or stent migration distally into the GI tract were investigated. Results: Distal migration of the salivary bypass tube was identified in 2 patients, and migration of the esophageal stent was identified in 1 patient. All cases were in the setting of complex pharyngoesophageal flap reconstruction after salvage surgical resection. Dates of migration discovery ranged from weeks to months postop. All patients were asymptomatic and without fistula formation, but with the tubes/stent radiographically confirmed in the GI tract. Management was via a team approach with our GI colleagues, and all salivary-channeling devices were successfully retrieved endoscopically, without complication. Conclusion: Pharyngoesophageal reconstruction after salvage surgery carries the risk of fistula even in the setting of micro-vascular tissue transfer. To minimize this dreaded complication, salivary bypass tubes/stents may be used, but migration is a well-recognized risk. Our series presents successful management of such via a team approach.

S113 – Facial Suspension & Free Flaps in Composite Parotid Defects

Objectives 1) Study efficacy of 2 methods of immediate static facial suspension after total composite parotidectomy, facial nerve sacrifice & free flap reconstruction. 2) Compare these regarding outcomes & patient satisfaction. Methods Retrospective review 2005–08 of all patients at academic tertiary referral center with advanced H&N malignancy necessitating extirpation, including parotidectomy, CN-VII sacrifice, and microvascular reconstruction. Ipsilateral face addressed simultaneously with either acellular human dermal allograft (AHDA) ‘sling’ or suture suspension (SS). Follow-up 2–18 months. Outcomes assessed: suspension status (commissure symmetry 1–4 complete ptosis), overall aesthetics (excellent 1–4 unsatisfactory), oral competence (no drooling 1–3 constant drooling) and patient/family satisfaction scores (very satisfied 1–4 very dissatisfied). Results 9 patients underwent extirpation, CNVII sacrifice, fasciocutaneous microvascular reconstruction (forearm, ALT or parascapula) and facial suspension. 8 received postoperative radiation; 1 expired. 2 underwent AHDA facial ‘slings.’ 7 underwent SS using polybutilate-coated braided polyester (Ethibond Excel). Both techniques used 3 distal suspension sites (nasolabial crease, upper/lower commissure) and proximal zygomatic stablization. Suspension grades were 1–3 for AHDA, 1–2 for SS; aesthetic 2–3 for AHDA, 1–3 for SS; competence 2 for AHDA, 1–2 for SS; satisfaction 1–2 for AHDA, 1–2 for SS. Conclusions Facial nerve rehabilitation in post-extirpative oncologic setting remains challenging for optimizing function/aesthetics. In our series of patients undergoing extensive resection with facial nerve sacrifice and free flap reconstruction, suture suspension provided slightly better oral symmetry and overall aesthetics compared to AHDA ‘sling’ suspension. Patient satisfaction was high in both groups. Long-term follow-up and greater sample size are needed to determine if any observed advantage is real and sustained.

Utility of bone scanning in the postoperative assessment of fibula-free tissue transfers

Abstract Objectives: The fibula osteocutaneous free flap has proven one of the most versatile and reliable flaps available for reconstruction of mandibular defects. Survival rates are exceedingly good with most centers reporting survival in >95% of cases. Viability of the bone is indirectly inferred by examination and visibility of the skin paddle. Occasionally, the skin paddle dies and the status of the bone is unknown. In these instances, one must ascertain the status of the bone in order to plan appropriately. We report on our experience with bone scanning in differentiating bone survival from bone death when the skin paddle has necrosed. Setting: Tertiary referral academic center Oregon Health & Science University. Methods: From 1998 to 2004, 130 fibula osteocutaneous free tissue transfers were undertaken. Results: In 7 of these, viability of the bone was questioned (5 skin paddle necrosis, 2 buried flap with no external monitor and a severe neck infection. Bone scanning was undertaken to help in operative planning. In 4 flaps, the bone paddle was felt to be alive on scan and confirmed intraoperatively. The skin paddle was debrided and replaced with a radial forearm free flap. Bone viability was confirmed at most recent follow-up. In 3 cases, the bone was confirmed to be nonviable by bone scan and confirmed by inspection intraoperatively. These cases were repaired with a second fibula free flap. Conclusion: Bone scanning is a useful investigation in cases where viability of the bone is in question. In flaps where the bone is buried or those in which the skin paddle has died, a positive bone scan will allow for planning of only soft tissue coverage, whereas a negative bone scan will imply a second bone flap.

Dysphagia in diffuse idiopathic skeletal hyperostosis (DISH): a surgical disease?

Objectives: Diffuse idiopathic skeletal hyperostosis (DISH), or Forestier’s disease, is a chronic condition that may present with dysphagia. When the hyperostosis occurs in the cervical area, dysphagia, hoarseness, food impaction, and stridor can all be manifest. The dysphagia may be severe enough to preclude oral intake. Conservative care often fails. Methods: Surgical removal of the offending osteophytes through an anterolateral transcervical approach is the procedure of choice. Results: Palliation of the dysphagia is possible. It will also enable the patient to have a higher quality of life. Conclusion: We will use four patients recently treated at our institution to demonstrate the underlying pathology, physiologic effects, and surgical approach of this unusual disease entity. Removal of the osteophytes can result in the patient resuming an oral diet. Morbidity of the procedure is low.