Kevin Higgins

What treatment for early-stage glottic carcinoma among adult patients: CO2 endolaryngeal laser excision versus standard fractionated external beam radiation is superior in terms of cost utility?†

To determine which treatment for Tis/T1 glottic carcinoma among adult patients, transoral CO2 laser excision (TOL) versus external beam radiation (XRT), is superior in terms of cost utility.

Predictors of complications of free flap reconstruction in head and neck surgery: Analysis of 304 free flap reconstruction procedures†

The objectives of this study were to classify and analyze perioperative complications following free flap reconstruction in the head and neck and investigate potential predictors of these complications.

Internal mammary artery and vein: Recipient vessels for free tissue transfer to the head and neck in the vessel-depleted neck

Microvascular free tissue transfer is a standard reconstructive option for postablative defects of the head and neck. However, the success of this surgery requires suitable recipient vessels in the cervical region. This form of reconstruction can be particularly challenging in the vessel‐depleted neck. While the internal mammary artery and vein (IMA/V) have been used extensively in breast reconstruction, there are few reports describing their use in head and neck reconstruction. We report the first case series of the use of the internal mammary vessels for head and neck microvascular reconstruction.

The utility of the microvascular anastomotic coupler in free tissue transfer

BACKGROUND The microvascular anastomosis remains a technically sensitive and critical determinant of success in free tissue transfer. The microvascular anastomotic coupling device is an elegant, friction-fit ring pin device that is becoming more widely used. OBJECTIVE To systematically review the literature to examine the utility of the microvascular coupler in free tissue transfer. METHODS A comprehensive database search was performed to identify eligible publications. Inclusion criteria were anastomotic coupler utilization and free-tissue transfer. Recorded information from eligible studies included patient age, follow-up, radiation history, number of free-flaps and failure rates, reconstruction subsites, number of coupled venous and arterial anastomoses, coupling time, conversion to sutured anastomosis, coupler size and thrombosis rates. RESULTS Twenty-five studies reporting on 3207 patients were included in the analysis. A total of 3576 free-flaps were performed within the following subsites: 1103 head and neck, 2094 breast, 300 limb or body, and 79 nonspecified. There were only 26 reported flap failures (0.7%). A total of 3497 venous and 342 arterial coupled anastomoses were performed. The primary outcome measure was thrombosis rates, and there were 61 venous (1.7%) and 12 arterial (3.6%) thromboses reported. Mean coupling time was 5 min, and 30 anastomoses (0.8%) were converted to suture. CONCLUSION Flap survival and revision-free application of the microvascular coupler occurred in more than 99% of cases. There is a substantial time savings with coupler use. Venous and arterial thrombosis rates are comparable with the best results achieved by sutured anastomosis and, when used by experienced surgeons, the coupler achieves superior results.

Radial Forearm Free Flap Donor Site Morbidity: Ulnar-Based Transposition Flap vs Split-Thickness Skin Graft

OBJECTIVES To evaluate morbidity associated with the radial forearm free flap donor site and to compare functional and aesthetic outcomes of ulnar-based transposition flap (UBTF) vs split-thickness skin graft (STSG) closure of the donor site. DESIGN Case-control study. SETTING Tertiary care institution. PATIENTS The inclusion criteria were flap size not exceeding 30 cm(2), patient availability for a single follow-up visit, and performance of surgery at least 6 months previously. Forty-four patients were included in the study and were reviewed. Twenty-two patients had UBTF closure, and 22 had STSG closure. MAIN OUTCOME MEASURES Variables analyzed included wrist mobility, Michigan Hand Outcomes Questionnaire scores, pinch and grip strength (using a dynamometer), and hand sensitivity (using monofilament testing over the radial nerve distribution). In analyses of operated arms vs nonoperated arms, variables obtained only for the operated arms included Vancouver Scar Scale scores and visual analog scale scores for Aesthetics and Overall Arm Function. RESULTS The mean (SD) wrist extension was significantly better in the UBTF group (56.0° [10.4°] for nonoperated arms and 62.0° [9.7°] for operated arms) than in the STSG group (59.0° [7.1°] for nonoperated arms and 58.4° [12.1°] for operated arms) (P = .02). The improvement in wrist range of motion for the UBTF group approached statistical significance (P = .07). All other variables (Michigan Hand Outcomes Questionnaire scores, pinch and grip strength, hand sensitivity, and visual analog scale scores) were significantly better for nonoperated arms vs operated arms, but no significant differences were observed between the UBTF and STSG groups. CONCLUSIONS The radial forearm free flap donor site carries significant morbidity. Donor site UBTF closure was associated with improved wrist extension and represents an alternative method of closure for small donor site defects.

Microvascular reconstruction in the vessel-depleted neck.

Purpose of reviewMicrovascular reconstruction for head and neck cancers has improved both cosmesis and functionality of patients undergoing treatment. Many patients have had prior surgery (neck dissection), radiation and/or chemotherapy as part of their management. When microvascular reconstruction is required after previous treatment, finding appropriate vessels for anastomosis can be difficult. In this paper we explore the options for microvascular reconstruction in the vessel-depleted neck. Recent findingsArterial options that exist when the neck is depleted of vessels include the superficial temporal, transverse cervical, thoracoacromial, and the internal mammary artery. Venous options include the cephalic vein and vein grafts. SummaryThe external carotid artery and the internal jugular vein are the most commonly utilized vessels in microvascular reconstruction when available. However, prior chemotherapy and/or radiation can cause significant scarring and damage to these vessels. Also in patients who have had previous surgery, these vessels can be resected or altered in a way that they are deemed unusable. In these situations several vascular options exist outside the neck.

Salvage surgery for locally recurrent oropharyngeal cancer

There are limited data on whether recurrent human papillomavirus (HPV)‐associated oropharyngeal squamous cell carcinoma (SCC) is associated with higher surgical salvage rates. The purpose of this study was to determine the success rate of salvage surgery for locally recurrent oropharyngeal cancer and factors influencing the outcome, including p16 status.

The temporoparietal fascia flap: a versatile tool in head and neck reconstruction.

Purpose of reviewThe article reviews recent significant advances and current applications of the temporoparietal fascia flap (TPFF) in head and neck surgery. Recent findingsThe recent literature describes a wide span of new applications of the TPFF in many areas. Significant developments and refinements in the reconstruction of orbitomaxillary composite defects and orbital exenteration cavities are reported. The TPFF combined with alloplastic framework is gaining in importance in external ear reconstruction. Innovative prefabricated skin or soft-tissue grafts based on the TPFF are used to restore facial contour or in the reconstruction of complex facial defects. The free TPFF finds a role in laryngotracheal reconstruction as a vascular carrier to support cartilage grafts. SummaryOwing to its reliability and unequalled structural properties, the TPFF still plays a central role in facial reconstruction. Future investigation will likely incorporate the free TPFF as a vascular carrier of bioengineered tissues, such as cartilage and mucosa, for various head and neck indications.

Assessment of the Clavien-Dindo classification system for complications in head and neck surgery

The importance of reporting and grading surgical complications is central to quality improvement in head and neck surgery. The purpose of this study is to assess the interobserver reliability, content validity, and construct validity of the Clavien‐Dindo classification system for use in grading complications related to head and neck surgery.

Local flap reconstruction of acquired lip defects.

Purpose of reviewThe goal of this article is to review contemporary local flap reconstructive techniques for acquired lip defects. Lip reconstruction is a complex undertaking that necessitates an understanding of underlying principles. New techniques focus on local flap reconstruction which maintain oral competence, avoid microstomia, and achieve aesthetically satisfactory results. Recent findingsThe contemporary literature employs an aesthetic subunit approach to achieve reconstruction of vermillion, perioral cutaneous, and full-thickness defects. Several new techniques are variations of traditional techniques with modifications that preserve tissue and place incisions along the borders of aesthetic subunits. SummaryThis review presents techniques for vermillion, perioral cutaneous, and full-thickness lip reconstruction. Also presented is an algorithm for contemporary local flap reconstruction of the lip.