Jung-Ju Huang

Refining the role of preoperative C‐reactive protein by neutrophil/lymphocyte ratio in oral cavity squamous cell carcinoma

Elevated inflammatory biomarkers such as C‐reactive protein (CRP) and the recently identified neutrophil/lymphocyte ratio (NLR) were demonstrated to be associated with prognosis in human cancers. The aim of our present study is to analyze the relationship of preoperative levels of CRP and NLR with clinicopathological factors and prognosis in oral squamous cell carcinoma (OSCC) patients.

Two small flaps from one anterolateral thigh donor site for bilateral buccal mucosa reconstruction after release of submucous fibrosis and/or contracture

Oral submucous fibrosis causes health-related and social problems for affected patients. Free flap reconstruction has proved effective for maintaining mouth opening after release of fibrosis. Two independent free flaps from separate donor sites, such as bilateral forearm flaps or bilateral anterolateral thigh (ALT) flaps, were traditionally required for reconstruction. The former option sacrifices one of the two major arteries in the forearm. Both options are time consuming and required two donor sites. To eliminate these disadvantages, we developed a technical modification that allows harvesting of two independent flaps from one ALT thigh based on one descending branch of the lateral circumflex femoral artery (d-LCFA). Eighteen flaps from nine donor sites were harvested for post-release reconstruction of oral submucous fibrosis. Mean flap size was 4.1 x 7.5 cm, mean pedicle length was 7.6 cm, mean ischaemia time was 104 min and mean total operation time was 13 h and 19 min. All donor sites were closed primarily, with one exception. One flap failed and was replaced with a contralateral ALT flap. One patient developed a wound infection and another developed a seroma at the recipient site. Four flaps required secondary de-bulking in three patients. The improvement in mouth opening was evaluated by inter-incisor distance (IID): mean preoperative IID was 9.6mm (range: 0-20mm), mean follow-up time was 16.2 months (range: 10-33 months); mean postoperative IID was 23.8mm and mean improvement in IID was 15.3mm (range: 10-27 mm). In conclusion, two independent flaps can be harvested from d-LCFA of the same thigh, instead of from both thighs, to reconstruct bilateral buccal defects after release of submucous fibrosis and/or contracture.

Does Ischemia Time Affect the Outcome of Free Fibula Flaps for Head and Neck Reconstruction? A Review of 116 Cases

Background: The fibula osteoseptocutaneous flap is an excellent option for the reconstruction of segmental mandibular defects. This study was conducted to investigate the relationship between ischemia time and outcome of the fibula flap, thus establishing the critical ischemia time for this procedure. Methods: Between February of 2003 and March of 2005, 114 patients who underwent 116 fibular osteoseptocutaneous flaps for head and neck reconstruction were reviewed retrospectively. Complications were classified as acute, subacute, or chronic based on the time at which they were detected postoperatively. Outcomes among different ischemia time groups were evaluated: group A, less than 3 hours; group B, 3 to 4 hours; group C, 4 to 5 hours; and group D, 5 to 7 hours. Results: The mean success rate of the fibula osteoseptocutaneous flap was 98.3 percent. Mean flap ischemia time was 3.6 ± 0.97 hours. Sixty-six patients (56.9 percent) experienced one or more complications at different stages (86 complications total). There were no statistically significant differences in acute, subacute, and chronic complications among the four groups (p = 0.6, p = 0.6, and p = 0.2, chi-square test). The overall complication rate was significantly higher in group D (81.8 percent) (p = 0.03, chi-square test). The partial flap loss rate was also statistically higher in group D (45.5 percent) compared with the other three groups (12.1, 12.2, and 8.7 percent) (p = 0.02, chi-square test). Conclusions: Using the fibula osteoseptocutaneous flap for head and neck reconstruction, ischemia times less than 5 hours do not increase complication rates in different postoperative stages. However, the critical ischemia time of the fibula osteoseptocutaneous flap should be limited to 5 hours to reduce partial skin paddle loss and overall complications.

Risk Stratification in Oral Cavity Squamous Cell Carcinoma by Preoperative CRP and SCC Antigen Levels

BackgroundSquamous cell carcinoma antigen (SCC-Ag) level and C-reactive protein (CRP) have been shown to be associated with tumor invasion, lymph node metastasis, staging and survival in patients with oral squamous cell carcinoma (OSCC). The purpose of the present study was to analyze the relationship between preoperative levels of both SCC-Ag and CRP, with clinicopathologic factors and prognosis in OSCC patients.MethodsA retrospective study was performed on 142 OSCC patients between March 2008 and March 2011. Their serum SCC-Ag and CRP levels were measured preoperatively.ResultsSCC-Ag level of ≥2.0xa0ng/ml and CRP level ≥5.0xa0mg/L were significantly associated with pathologic tumor status (Pxa0<xa00.001), pathologic nodal metastasis (Pxa0=xa00.001), tumor depth (≥10xa0mm vs. <10xa0mm, Pxa0<xa00.001), disease-free survival (Pxa0≤xa00.001) and overall survival (Pxa0≤xa00.001). The influence of SCC-Ag and CRP level on disease-free survival (hazard ratio 4.046, 95xa0% confidence interval 1.698–9.692) and overall survival (hazard ratio 3.655, 95xa0% confidence interval 1.464–9.130) still existed after adjusting for tumor status, lymph node metastasis and tumor cell differentiation.ConclusionsConcurrent high levels of both preoperative SCC-Ag and CRP levels act as a predictor for lymph node metastasis, advanced tumor stage and tumor recurrence. It therefore has significant potential as a biomarker for risk stratification in OSCC.

Clinical significance of preoperative squamous cell carcinoma antigen in oral‐cavity squamous cell carcinoma

Previous studies have demonstrated a relationship between elevated serum squamous cell carcinoma (SCC) antigen (SCC‐Ag) levels and shorter survival in cancer patients. Few studies, however, have investigated the role of serum SCC‐Ag levels in oral SCC (OSCC). This study was conducted to analyze the relationship between preoperative SCC‐Ag levels, clinicopathologic factors, and prognosis in OSCC patients.

Simultaneous Contralateral Breast Reduction/mastopexy With Unilateral Breast Reconstruction Using Free Abdominal Flaps

Background:Successful breast reconstruction includes the creation of a natural breast mound in addition to achieving maximal symmetry of both breasts. This study investigated the patients outcome and satisfaction of simultaneous contralateral balancing reduction/mastopexy with unilateral breast reconstruction using free abdominal flaps. Methods:Between March 2000 and September 2009, 22 of 288 patients underwent unilateral breast reconstructions using a free abdominal flap with simultaneous contralateral breast reduction/mastopexy (group A). The remaining 266 cases were used as the control group (group B). The ultimate cosmesis with the complete pre- and postoperative pictures was assessed. The survey for the quality of life using the Heden questionnaire was obtained from 16 patients in group A. Results:All 22 flaps survived. Two deep inferior epigastric artery perforator flaps developed venous congestion and subsequent partial flap loss. The mean flap-used weight was 568 ± 128.6 g and 486 ± 158 g in group A and B, respectively (P < 0.01). There were no complications resulted from the reduction/mastopexy. The mean reduced breast tissue was 173.6 ± 101 g (range, 85–355 g). The overall cosmetic scores in group A were higher than in the group B. Of 16 patients, 7 (43.8%) graded this technique as very advantageous and the remaining 9 patients (56.2%) as advantageous. Conclusions:Simultaneous contralateral balancing procedures including reduction/mastopexy in selected patients can be performed with unilateral breast reconstruction using free abdominal flaps with greater patient satisfaction, minimal increase in operative time, and no increase in complication rates.

Preplanning vascularized lymph node transfer with duplex ultrasonography: an evaluation of 3 donor sites.

Background: As experience with vascularized lymph node (VLN) transfer has grown, new VLN sources have become apparent. Descriptive studies have elucidated variable lymph node presence in these donor basins. Yet, no study has evaluated preoperative imaging evaluation between donor sites in patients undergoing VLN transfer. This study was to compare the findings on duplex ultrasonography of the submental, groin, and supraclavicular lymph node basins in patients undergoing VLN transfer. Methods: A review of a prospective database was performed for patients who had undergone preoperative planning for VLN transfer with duplex ultrasonography to provide objective donor-site characteristics. Multiple regression analysis was used to identify factors that correlated with specific flap characteristics. A P value less than 0.05 was considered statistically significant. Results: Sixty-eight patients (28 upper extremities and 40 lower extremities) were identified as undergoing preoperative duplex ultrasonography for VLN transfer. Little variation was seen when evaluating donor sites for laterality in patients. Groin and submental VLN sites had 3.1 and 3.3 lymph nodes, respectively, compared with 0.9 lymph nodes in the supraclavicular donor site (p < 0.01). Increasing age had an inverse relationship with estimated flap volume, whereas higher body mass index correlated with increasing flap thickness. Conclusions: Preoperative imaging with duplex ultrasonography before VLN transfer may allow for accurate identification of specific VLN donor-site characteristics. When considering lymph node–specific characteristics, higher quantity of lymph nodes were found on the groin and submental flap axis compared with the transverse cervical artery axis.

Simultaneous scarless contralateral breast augmentation during unilateral breast reconstruction using bilateral differentially split DIEP flaps.

Background: Simultaneous contralateral augmentation is performed with unilateral breast reconstruction to achieve pleasing and symmetric breast mounds. This prospective study investigated the outcome of simultaneous scarless contralateral augmentation with unilateral breast reconstruction using bilateral differentially split deep inferior epigastric perforator (DIEP) flaps. Methods: Between August of 2009 and May of 2010, six patients with a mean age of 46.2 ± 7 years underwent unilateral breast reconstruction and simultaneous contralateral augmentation using bilateral differentially split DIEP flaps. The ipsilateral internal mammary vessels served as the recipient vessels for the reconstruction split flap. The pedicle of the augmentation split flap was anastomosed to that of the reconstruction split flap in a flow-through manner. The augmentation split flap was inset through the midline with endoscopic assistance. The Modified BREAST-Q questionnaire was administered preoperatively and at the 1- and 3-month follow-up visits. Results: All flaps survived, giving a success rate of 100 percent. One reconstruction split flap required reexploration and was salvaged successfully. Mean flap weights used for reconstruction and augmentation were 410 ± 145 and 192 ± 58 g, respectively. At a mean follow-up of 12.7 ± 3.6 months, all patients were satisfied with the outcome of both reconstructed and augmented breast mounds. There were statistical improvements in breast satisfaction (p = 0.004), psychosocial function (p = 0.000), and sexual well-being (p = 0.004) postoperatively, as assessed by the Modified BREAST-Q. Conclusion: Simultaneous scarless contralateral breast augmentation can be performed safely during unilateral breast reconstruction using bilateral differentially split DIEP flaps with satisfactory outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Anatomical basis and clinical application of the ulnar forearm free flap for head and neck reconstruction

This study was designed to investigate the anatomical features and applications of the ulnar forearm flap in head and neck reconstructive surgery.

Postoperative alcohol withdrawal syndrome and neuropsychological disorder in patients after head and neck cancer ablation followed by microsurgical free tissue transfer.

PURPOSEnThe use of microsurgical free flap reconstruction has resulted in improved patient outcomes and survival after head and neck cancer resection. Although postoperative care in an intensive care unit (ICU) for airway management and flap surveillance can increase the success rate, any accompanying neuropsychological problems can potentially affect the outcome.nnnMATERIALS AND METHODSnFrom January 2006 to December 2008, we retrospectively reviewed 1,506 ICU patients who underwent head and neck cancer ablative surgery followed by microsurgical free tissue transfer. Twelve patients (Group A) had alcohol withdrawal syndrome (AWS), whereas 29 patients (Group B) had other neuropsychological problems. The clinical manifestations and outcomes of each group were investigated and statically analyzed.nnnRESULTSnAll the flaps survived. There was no significant difference in onset time, duration, ICU stay, hospital stay interval, overall complications, and flap circulation-related complications. However, the non-flap-related complication rates (10/12, 83.3%; 14/29, 48.3%; p = 0.038), including failure of extubation or ventilator weaning (7/12, 58.3%; 7/29, 24.1%; p = 0.036), were significantly higher in Group A.nnnCONCLUSIONnPatients with postoperative AWS have a higher chance of developing non-flap-related complications, especially respiratory problems. The identification of a multidisciplinary approach to identify and manage these patients preoperatively and postoperatively is required.