Mark E. Krugman

Total and subtotal glossectomy : function after microvascular reconstruction

Twelve patients with advanced carcinoma of the floor of the mouth and tongue were treated with total (five patients) or subtotal (seven patients) glossectomy, partial mandibulectomy, and immediate reconstruction with the microvascular composite groin flap. The osteomusculocutaneous groin flap was used in eleven patients, and the osteomuscular flap was used in one patient. The groin musculocutancous or muscle flap was designed to resemble the shape of the tongue for dynamic food transport, improved swallowing, and acceptable speech. Eight of the 12 patients who survived more than 1 year were evaluated for speech and swallowing. Eight patients were able to speak intelligibly, six patients could tolerate a soft/pureed diet, and two patients were limited to fluids. Cinefluorographic swallow studies using semisolid contrast material showed voluntary active intraoral transport and propulsive pharyngeal emptying without aspiration in six patients with complete flap to palate contact; the remaining two patients were unable to move the intraoral contrast material effectively for swallowing because of poor palatal contact.

Functional hemitongue reconstruction with the microvascular ulnar forearm flap.

Thirteen patients with squamous cell carcinoma of the tongue underwent full-thickness longitudinal resection of the hemitongue and immediate microvascular reconstruction using a large, contoured ulnar forearm flap. Six of the 13 patients had a composite resection for which an additional vascularized iliac crest graft was used to reconstruct the mandible and to provide support to the overlying contoured flap. To increase tongue mobility, the skin flap was designed for independent reconstruction of the hemitongue and the floor of mouth. Twelve patients were evaluated for swallowing and speech, including dietary assessment, cineradiography, and voice spectrographic analysis. Contrast cineradiography was performed to determine oral tongue mobility during the first phase of swallow. Nine patients with a narrow reconstructed tongue root and a large surface area in the floor of the mouth had good tongue mobility, allowing them to transfer food dynamically from the mouth into the pharynx for swallowing. The remaining three patients, who had a wide tongue root and an ill-defined floor of the mouth, had decreased tongue mobility and poor oral transport. The functional outcome of swallowing and speech strongly correlated with the shape of the root of the tongue, the proximity of the reconstructed tongue to the palate, and the surface area of the floor of the mouth.

Adaptive mechanisms of speech and swallowing after combined jaw and tongue reconstruction in long-term survivors☆

Twelve patients have been studied for speech and swallowing function after major combined jaw and tongue reconstruction with the microvascular iliac bone and groin skin composite flap. Cinegraphic barium swallows demonstrated that for bolus propulsion, it is important to be able to occlude the palate with the flap. Glottic competence prevents aspiration. Speech studies show that although there is loss of certain speech sounds, approximate sounds are substituted. Speech is intelligible when soft-tissue contact to the palate can be accomplished. The adaptive mechanisms in these patients have been compared with the mechanisms used by a patient with uncorrected congenital aglossia and hypomandibulosis who developed excellent speech and swallowing. The mobility of this patients mouth and pharynx was similar to that in the reconstructed cancer patients who were able to swallow and speak. This procedure has become our reconstruction method of choice for these major defects.

Reconstruction of the base of the tongue with the microvascular ulnar forearm flap : A functional assessment

Ten patients with infiltrating carcinomas of the base of the tongue/tonsillar region underwent 30 to 100 percent resection of the base of the tongue and lateral pharyngeal wall. The surgical defect was reconstructed (9 primary, 1 secondary) with a large microvascular ulnar forearm flap that was selectively contoured to provide bulk for the base of the tongue and a thin lining for the pharyngeal wall. Seven patients were evaluated for swallowing and speech 6 weeks to 2 years following the reconstruction. Cineradiographic studies showed excellent base of the tongue and flap mobility allowing glossopharyngeal closure in all patients and complete pharyngeal evacuation in four patients. Four patients who were in good health preoperatively were able to eat a regular diet postoperatively, and the remaining three patients were able to handle soft food. Functional recovery after major tongue base surgery is contingent upon a three-dimensional microvascular reconstruction using a thin forearm flap.

Laser-assisted hair transplantation: histologic comparison between holmium:YAG and CO2 lasers

The histological effects of flash-scanned CO2 (λ=10.6μm) and pulsed Holmium:YAG (Ho:YAG, λ=2.12μm) lasers were evaluated in human scalp following the creation of hair transplant recipient channels. Ho:YAG laser irradiation created larger zones of thermal injury adjacent to the laser channels than irradiation with the CO2 laser device. When the two lasers created recipient sites of nearly equal depth, the Holmium:YAG laser caused a larger region of lateral thermal damage (589.30μm) than the CO2 laser (118.07μm). In addition, Holmium:YAG irradiated specimens exhibited fractures or discontinuities beyond the region of clear thermal injury. This shearing effect is consistent with the photoacoustic mechanism of ablation associated with pulsed mid-IR laser irradiation. In contrast, channels created with the CO2 exhibited minimal epithelial disruption and significantly less lateral thermal damage. While the Holmium:YAG laser is a useful tool for ablation soft tissue with minimal char in select applications (sinus surgery, arthroscopic surgery), this study suggests that the use of the CO2 laser for the creation of transplantation recipient channels result in significantly less lateral thermal injury for the laser parameters employed.

Small incision blepharolipectomy

Our experience with the small incision blepharolipectomy is presented. The procedure is indicated for the correction of baggy eyelids without excess skin. The operation is simple, almost free of complications and can be combined with other surgical procedures. The results in our series have been consistently good.

A new triaxial fiberoptic soft tissue retractor

The triaxial configuration of this fiberoptic instrument allows for operation through a small incision site and expansion within the wound. It also has a self-retaining aspect.