Krishnakumar Thankappan

Reconstructive indications of simultaneous double free flaps in the head and neck: A case series and literature review

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior history of radiotherapy or chemo‐radiotherapy. Forty‐two free flaps were used in these patients. The predominant combination was that of free fibula osteo‐cutaneous flap with free anterolateral thigh (ALT) fascio‐cutaneous flap. The indications of the simultaneous use of double free flaps can be broadly classified as: (a) large oro‐mandibular bone and soft tissue defects (n = 13), (b) large oro‐mandibular soft tissue defects (n = 4), (c) complex skull‐base defects (n = 2), and (d) dynamic total tongue reconstruction (n = 2). Flap survival rate was 95%. Median follow‐up period was 11 months. Twelve patients were alive and free of disease at the end of the follow‐up. Eighteen of 19 patients with oro‐mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an extensive oro‐mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed.

Lateral arm free flap for oral tongue reconstruction: An analysis of surgical details, morbidity, and functional and aesthetic outcome

The purpose of this study was to report the effectiveness of the lateral arm free flap (LAFF) in the reconstruction of oral tongue defects, the subsite in which it may have advantage over the other donor sites. This is a retrospective analysis of 48 consecutive cases of LAFF used for the reconstruction of partial glossectomy defects for squamous cell carcinoma of the oral tongue. Primary defect and donor-site morbidity and the functional and aesthetic outcomes were assessed in 37 evaluable patients, with a minimum of 6 months follow-up. Patient-reported Visual Analog Scale score from 0 (minimum satisfaction) to 10 (maximum satisfaction) was used to evaluate the aesthetic outcome. The follow-up was for 6 to 52 months (mean, 24 months). The flap was successful in 45 (93.8%) patients. The commonest observed donor-site morbidity was a broad scar, but it did not cause much patient dissatisfaction because it could be covered with appropriate dressing. Speech was normal or near-normal in all patients. Poor functional outcome was associated with adjuvant postoperative radiotherapy. The visual analog scale score for the aesthetic satisfaction (mean [standard deviation]) was 6.58 (1.82) for primary site and 7.13 (1.99) for the donor site. LAFF is an excellent option for the reconstruction of partial glossectomy defects of oral tongue without significant involvement of the floor of mouth and base of tongue.

Safety and efficacy of low molecular weight dextran (Dextran 40) in head and neck free flap reconstruction

BACKGROUND Antithrombotic agents have been used in microvascular surgeries. Low molecular weight dextran (dextran 40), though used, is not without complications. METHODS Retrospective analysis of 172 consecutive flaps. A comparison was made between two groups of patients (86 flaps each) with and without the use of dextran 40, in terms of safety and efficacy. RESULTS The free flap survival rate was 95.9%. The flap survival rates were comparable between the groups. Total flap loss in Group A (patients who received dextran 40) was 3.5% compared with 2.3% in Group B (patients who did not receive dextran 40) (p = 1.00). There was no statistically significant difference in the incidence of thrombotic flap complications between the groups. None of the patients developed acute respiratory distress syndrome or required prolonged ventilator support. No patient had dextran-related anaphylactoid reactions. Thirty-eight patients (43.7%) in Group A had postoperative atelectasis and 21 (25.6%) patients in Group B had this complication (p = 0.01). Six patients in Group A developed postoperative pneumonia, and five patients in Group B developed this complication (p = 0.93). CONCLUSIONS Though dextran 40 did not result in any significant adverse local or systemic complications, it is not useful as a postoperative antithrombotic agent in head and neck oncologic reconstruction with free tissue transfer.

Rapid detection of oral cancer using Ag–TiO2 nanostructured surface-enhanced Raman spectroscopic substrates

The unique vibrational signatures of the biochemical changes in tissue samples may enable the Raman spectroscopic detection of diseases, like cancer. However, the Raman scattering cross-section of tissues is relatively low and hence the clinical translation of such methods faces serious challenges. In this study, we report a simple and efficient surface-enhanced Raman scattering (SERS) substrate, for the rapid and label-free detection of oral cancer. Raman active silver (Ag) surfaces were created on three distinct titania (TiO2) hierarchical nanostructures (needular, bipyramidal and leaf-like) by a process involving a hydrothermal reaction, followed by the sputter deposition of Ag nanoparticles (average size: 30 nm). The resulting SERS substrate efficiencies, measured using crystal violet (CV) as an analyte molecule, showed a highest analytical enhancement factor of ∼106, a detection limit ∼1 nM and a relative standard deviation of the Raman peak maximum of ∼13% for the nano-leafy structure. This substrate was used to analyze tissue sections of 8 oral cancer patients (squamous cell carcinoma of tongue) comprising a total of 24 normal and 32 tumor tissue sections and the recorded spectra were analyzed by principal component analysis and discriminant analysis. The tissue spectra were correctly classified into tumor and normal groups, with a diagnostic sensitivity of 100%, a specificity of 95.83% and the average processing time per patient of 15-20 min. This indicates the potential translation of the SERS method for the rapid and accurate detection of cancer.

Oncologic and functional outcome of the preserved eye in malignant sinonasal tumors

The purpose of this study was to analyze the oncologic and functional outcomes of the preserved eye in malignant sinonasal tumors with orbital involvement.

Microvascular free tissue transfer after prior radiotherapy in head and neck reconstruction – A review

Microvascular free tissue transfer has become an integral part of head and neck reconstruction. The role for it has widened in this era of organ preservation and surgical salvage. There are many reports on the influence of radiotherapy on the success of microvascular head and neck reconstruction, though there is a paucity of reports studying its effect after chemoradiotherapy. This article reviews the existing evidence regarding the influence of prior radiotherapy on microvascular free tissue transfer and sets a platform for further studies in the current setting of organ preservation with chemoradiotherapy and surgical salvage. Laboratory studies on animals, though demonstrating considerable tissue damage, could not find any influence of radiotherapy on the patency of the anastomosed vessels. Flap failure is reported to be more common after preoperative radiotherapy, but majority of the studies could not demonstrate a significant difference due to the lack of statistical power owing to the very high success rate of microvascular free flap surgery. Operative complications increased as the time between radiotherapy and surgery increased. There are very few reports on the outcome of free flap reconstruction after the organ preservation regimens of chemoradiotherapy. Such outcome studies would be coming forth in the near future.

Isolated skip nodal metastasis is rare in T1 and T2 oral tongue squamous cell carcinoma.

Objective Nodal metastasis from oral tongue squamous cell carcinoma follows a predictable pattern. Isolated level IV involvement, termed skip metastases, is described. This study attempts to identify the incidence of skip metastasis. Study Design Case series with chart review. Setting Tertiary academic hospital. Subjects Fifty-two consecutive patients with T1 to T4 N0 stage who underwent excision of the primary tumor with neck dissection (levels I-IV). Methods Retrospective study. The incidence of isolated level III or IV involvement pathologically and isolated nodal recurrence in levels III and IV was analyzed. Results Pathologically, isolated level III involvement occurred in 2 (3.8%) patients. Isolated level IV occurred in 1 (1.9%) patient. Mean follow-up was 24 months. Two patients had recurrence in the primary site; 1 had recurrence in neck level II. None had recurrence in level III or IV. Conclusion Skip metastasis is rare in T1 and T2 oral tongue squamous cell carcinoma. Inclusion of level IV is not mandatory in selective neck dissection for clinically and radiologically negative neck disease in early tumors (T1 and T2).

Basaloid squamous cell carcinoma of the larynx--A systematic review.

OBJECTIVES This study pools all the cases of Basaloid squamous cell carcinoma of the larynx in the English literature to investigate the clinical course of this rare clinico-pathological disease entity. METHODS We found and analyzed 100 cases with individual patient data from 36 publications spanning 20 years. RESULTS It is a rare disease of the elderly with strong male predominance and more common in the supraglottis. Patients typically present with locoregionally advanced stage. Surgery alone or combined with radiotherapy is commonly reported. It has a worse survival outcome when compared to laryngeal cancers in general. Twenty-two percent eventually develop distant metastases with the lung being the predominant site. CONCLUSIONS Given the rarity of this clinical condition and the lack of data from studies with adequate number of cases, this systematic literature analysis provides the best possible relevant evidence.

Maxillary reconstruction: Current concepts and controversies

Maxillary reconstruction is still an evolving art when compared to the reconstruction of the mandible. The defects of maxilla apart from affecting the functions of the speech, swallowing and mastication also cause cosmetic disfigurement. Rehabilitation of the form and function in patients with maxillary defects is either by using an obturator prosthesis or by a surgical reconstruction. Literature is abundant with a variety of reconstructive methods. The classification systems are also varied, with no universal acceptance of any one of them. The oncologic safety of these procedures is still debated, and conclusive evidence in this regard has not emerged yet. Management of the orbit is also not yet addressed properly. Tissue engineering, that has been hyped to be one of the possible solutions for this vexing reconstructive problem, has not come out with reliable and reproducible results so far. This review article discusses the rationale and oncological safety of the reconstructing the maxillary defects, critically analyzes the classification systems, offers the different reconstructive methods and touches upon the controversies in this subject. The management of the retained and exenterated orbit associated with maxillectomy is reviewed. The surgical morbidity, complications and the recent advances in this field are also looked into. An algorithm, based on our experience, is presented.

Selective Neck Dissection Is Effective in N1/N2 Nodal Stage Oral Cavity Squamous Cell Carcinoma

PURPOSE Although the efficacy of selective neck dissection (SND) in the management of a node-negative neck is established, its utility in the management of node-positive disease remains controversial. The objective of this study was to evaluate the oncologic safety of SND in the management of N1/N2 oral cavity squamous cell carcinoma. MATERIALS AND METHODS From a prospectively collected electronic database of patients with oral cavity cancer, a retrospective analysis was conducted of patients with nonrecurrent, clinical, and/or pathologic N1/N2 oral cavity squamous cell carcinoma who underwent SND of levels I to III/IV. The patients were stratified into 2 groups: clinical N0 but pathologic N1/N2 (cN0-pN1/N2) and clinical N1/N2 (cN1/N2). The primary outcome variable of the study was the ipsilateral regional recurrence rate. Categorical data were analyzed by the 2-sided Fisher exact test, and 3-year Kaplan-Meier ipsilateral regional control rate, regional recurrence-free survival, disease-free survival, and overall survival were estimated. RESULTS Forty-nine patients constituted the study sample, with 37 patients in the cN1/N2 group and 12 patients in the cN0-pN1/N2 group. During the follow-up period of 3 years, 2 patients (∼4%) developed ipsilateral neck recurrence, and these patients were in the cN1/N2 group. The 3-year Kaplan-Meier ipsilateral regional control rate was 95%. CONCLUSIONS SND may produce a satisfactory ipsilateral regional control rate in patients with early-stage node-positive oral squamous cell carcinoma. A prospective, randomized clinical trial comparing SND with modified radical neck dissection may be required for a categorical conclusion of these findings.