Marc W. Herr

Incidence and survival patterns of cranial chordoma in the United States

To determine trends in survival patterns for cranial chordoma in the United States.

Supraclavicular Artery Island Flap for Reconstruction of Complex Parotidectomy, Lateral Skull Base, and Total Auriculectomy Defects

IMPORTANCE There are limited data on the use of the supraclavicular artery island flap (SCAIF) for parotid and lateral skull base (LSB) surgery. This flap can be an important reconstructive tool for these procedures. OBJECTIVE To describe the use of the SCAIF for parotid and LSB surgery and its success, as well as important technique modifications for successful use of the flap in this setting. DESIGN, SETTING, AND PARTICIPANTS Retrospective single-institution review from July 1, 2011, to September 30, 2013, of patients in a tertiary care referral center. A prospectively collected institutional database was reviewed to identify patients who received SCAIF reconstruction for parotid and/or LSB surgery. Forty-six SCAIF reconstructions were identified; 16 were performed for the indication of parotidectomy or LSB surgery. INTERVENTIONS The SCAIF reconstruction for parotid and/or LSB surgery. MAIN OUTCOMES AND MEASURES Indication for reconstruction, flap viability, flap size, reconstruction site complication, and donor site complication. RESULTS Resection was performed for advanced cutaneous malignant tumor in 10 patients, primary salivary gland malignant tumor in 4 patients, and chronic infection and mastoid cutaneous fistula in 2 patients. All defects were complex, involving multiple subsites; 5 patients underwent facial nerve resection and 4 had previous radiation therapy. No complete flap loss occurred. One partial flap loss occurred. The average flap island size was 7 × 10 cm. No major complications occurred. Two minor reconstruction site complications and 3 donor site seromas occurred. CONCLUSIONS AND RELEVANCE The SCAIF can be successfully and reliably used for complex defects following parotid and LSB surgery. There are 3 important technique modifications to help facilitate rotation and coverage of this region.

Treatment outcomes and prognostic factors, including human papillomavirus, for sinonasal undifferentiated carcinoma: A retrospective review

Sinonasal undifferentiated carcinoma (SNUC) is a high‐grade, aggressive neoplasm. Low incidence and poor outcomes make identification of prognostic factors and treatment standardization difficult. Similarly, little is known regarding the association of human papillomavirus (HPV) with SNUC.

The Supraclavicular Artery Flap for Head and Neck Reconstruction

IMPORTANCE This study demonstrates the versatility of the supraclavicular artery (SCA) flap in head and neck reconstruction and offers technical highlights to improve the efficiency of flap harvest. OBJECTIVES To report our series of diverse reconstructions utilizing the SCA flap and to highlight several technical aspects of flap harvest that make the procedure more safe, reliable, and efficient. DESIGN, SETTING, AND PARTICIPANTS A retrospective review was conducted from July 2011 to December 2012 on all patients who had undergone SCA flap reconstruction of a head and neck defect at a tertiary referral center. The average follow-up time was 8 months. INTERVENTION OR EXPOSURE Supraclavicular artery flap reconstruction of defects at various head and neck subsites. MAIN OUTCOME AND MEASURE Reconstructive outcomes and complications were assessed and cases were reviewed to identify key aspects of flap harvest. RESULTS Twenty-four SCA flaps were performed on defects at multiple head and neck subsites. Several technical modifications were developed to increase the safety and efficiency of flap harvest. Complications were typically self-limited and were successfully managed nonsurgically. CONCLUSIONS AND RELEVANCE The SCA flap is a versatile and reliable reconstructive option for head and neck defects. There are 4 key steps to making the harvest of this flap safe, reliable, and efficient. LEVEL OF EVIDENCE 4.

Shoulder function following reconstruction with the supraclavicular artery island flap

The supraclavicular artery island flap (SCAIF) is a pedicled fasciocutaneous flap used for head and neck reconstruction. In recent years, its use has significantly increased as a result of several advantageous characteristics, including pliability, an excellent color and texture match, ability to reconstruct a variety of skin and aerodigestive tract defects, and short harvest times. Clinical experience suggests that donor site complications are relatively infrequent and typically self‐limiting, and there have been no documented cases of prolonged or permanent shoulder dysfunction. However, formal studies have not been performed to assess this outcome. The goal of this study was to evaluate the effects of SCAIF flap harvest on postoperative shoulder strength and flexibility.

Comparison of Perioperative Outcomes between the Supraclavicular Artery Island Flap and Fasciocutaneous Free Flap.

Objective Outcomes of the supraclavicular artery island flap (SCAIF) have not been extensively studied in comparison with free tissue transfer (FTT) flaps for head and neck reconstruction. We hypothesize that the pedicled SCAIF has decreased operating room time, length of stay, time to wound healing of recipient site, complications, and hospital charges as compared with FTT. Study Design Case series with chart review. Setting Tertiary care teaching hospital. Subjects and Methods Medical records were reviewed for patients who underwent SCAIF (n = 45) or FTT (n = 28) reconstruction between 2011 and 2013. Results Total operating room time was significantly lower for the SCAIF group vs the FTT group (6.7 vs 8.1 hours, P = .002). Procedural time was 5.7 hours for the SCAIF group, as compared with 7.2 hours for FTT group (P = .0015). Mean area for SCAIF donor site was 63.89 cm2 vs 81.8 cm2 for the radial forearm free flap group (P = .015). There was no significant difference in mean length of stay between SCAIF (8.8 days) and FTT (11 days, P = .12). Mean length of time to wound healing of the recipient site was similar in the SCAIF group vs the FTT group (17.3 vs 22.1 days, P = .071). Ratio of total hospital charges for SCAIF were 32% lower than that of FTT (P = .0001). Conclusion This is among the first studies to compare SCAIF with FTT in a large cohort analysis. We find decreased operating room times for SCAIF vs FTT, with similar length of stay and wound healing. Other outcomes between SCAIF and FTT were also comparable.

Malignant head and neck paragangliomas: Treatment efficacy and prognostic indicators ☆,☆☆,★

PURPOSE Malignant head and neck paragangliomas (MHNPs) are rare and occur in 6%-19% of all HNPs. We sought to identify predictors of survival and compare efficacy of treatment modalities to inform management of this rare disease. MATERIALS AND METHODS We performed a retrospective cohort study of MHNP cases in the National Cancer Institute Surveillance Epidemiology and End Results database (SEER) from 1973 to 2009. We identified 86 patients with MHNP who had documented regional or distant tumor spread with a median follow-up of 74 months. We used Cox proportional hazard models to assess the significance of demographic factors and treatment on five-year overall survival. RESULTS The most common treatment was surgery alone (36.0 %), followed by surgery with adjuvant radiation (33.7%). Five-year overall survival was 88.1% for surgery alone and 66.5% for adjuvant radiation (p = 0.2251). In univariate analysis, regional (vs. distant) spread (HR 0.23, p < 0.0001), surgery alone (HR 0.29, p < 0.0001) and primary site in the carotid body (HR 0.32, p = 0.006) conferred significant survival advantage whereas age > 50 (HR 4.04, p < 0.0001) worsened survival. Regional (vs. distant) spread (HR 0.42, p = 0.046) and age > 50 (HR 2.98, p = 0.005) remained significant in multivariate analysis. In patients with regional-only disease, five-year overall survival was 95.4% for surgery alone compared to 75.6% for surgery with radiation (p = 0.1055). CONCLUSIONS This is the largest and most contemporary series of MHNP patients. Age and tumor stage are significant factors in predicting survival. Surgical resection significantly improves survival outcomes. From this analysis, the value of adjuvant radiation is not clear.

Tracheoesophageal voice after total laryngopharyngectomy reconstruction: Jejunum versus radial forearm free flap

Tracheoesophageal (TE) voice restoration after laryngopharyngectomy with jejunal (Jej) flap and radial forearm flap (RFF) reconstruction has been successfully completed and studied for both techniques, but no direct comparisons exist. We undertook this study to directly compare TE voice in patients with total laryngopharyngectomy (TLP) reconstruction using the Jej and the RFF in a comprehensive and rigorous manner.

Orbital preservation in patients with esthesioneuroblastoma.

Objectives Surgical resection in addition to adjuvant radiation with or without chemotherapy is the mainstay of treatment for esthesioneuroblastoma (ENB). However, management of patients with orbital involvement remains controversial. Historically, orbital exenteration has been advocated when there is evidence of periorbital invasion. Recently, the indications for orbital exenteration have become more selective and orbital preservation has been advocated. We report our experience with anterior craniofacial resection and orbital preservation in patients with ENB. Design Retrospective review of all patients diagnosed with esthesioneuroblastoma who underwent traditional open anterior craniofacial resection at the Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center from 1997 to 2008. Results Sixteen patients were identified with a mean follow-up of 76 months. All patients underwent anterior craniofacial resection via an open approach and adjuvant proton beam radiation. Six of the 16 patients had evidence of either periorbital or lacrimal sac involvement at the time of surgery. All of these patients underwent periorbital resection to negative histologic margins with preservation of the orbit. Conclusion In our study, patients with ENB and periorbital invasion-who were treated with anterior craniofacial resection and periorbital resection with orbital preservation-had no evidence of decreased survival. In all patients, negative histologic margins of the periorbital resection were achieved.

Microvascular Free Flaps in Skull Base Reconstruction

The anatomical challenges of skull base surgery are well known. Furthermore, ablative and traumatic defects in this region produce complex reconstructive problems with a high risk of significant postoperative morbidity and mortality. Over the past two decades, microvascular free tissue reconstruction following open resection has been shown to improve outcomes and reduce complication rates when compared to the traditional use of pedicled flaps. The increasing use of free tissue transfer has been further strengthened by improved technical expertise and high flap success rates. Since the size and type of free tissue to be utilized must be individualized to each defect, the accomplished reconstructive surgeon should be extremely versatile and, by extension, facile with a several types of free flaps. Thus, four of the most commonly used flaps--the rectus abdominis, radial forearm, latissimus dorsi and anterolateral thigh flaps--are discussed.