Michael J. Nuara

Analysis of outcomes of vascularized flap reconstruction in patients with advanced mandibular osteoradionecrosis.

OBJECTIVE: To examine outcomes of vascularized bone flap reconstruction of end-stage osteoradionecrosis of the mandible. STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary care academic hospital. SUBJECTS: Patients with end-stage radiation-induced osteoradionecrosis (ORN) refractory to conservative therapy with wound complications including chronic infections, fistula formation, and pathologic fracture were included. RESULTS: Outcomes of 33 patients were prospectively collected and analyzed, making this the largest series on this subject in the literature and the only one with planned data collection. Data on preoperative variables including radiation dose, sub-site location, treatment date, and prior therapy, along with intraoperative issues and postoperative outcomes, were tracked and are presented. ORN was seen to develop in a bimodal distribution based on the timing of interval surgical intervention. The extent of local soft tissue injury often required the use of contralateral recipient vessels. Local wound complication rates were higher than that seen in primary reconstructions. CONCLUSIONS: Successful reconstruction was achieved in all of the patients in this series. Long-term resolution of infectious complication and disease resolution was seen in 91 percent of the patients in this series.

Prospective Analysis of Outcomes and Complications of 300 Consecutive Microvascular Reconstructions

OBJECTIVE To prospectively follow up patients requiring microvascular reconstruction of head and neck defects to determine preoperative factors predictive of surgical complications. METHODS A prospectively collected database comprising 300 consecutive microvascular head and neck reconstructions performed by a single surgeon (D.S.A.) in a tertiary care hospital over a 6-year period was reviewed in a retrospective manner. Data collected included preoperative medical and surgical history (presence of documented cardiac disease, diabetes mellitus, and hypertension) and previous cancer treatment (surgery or radiation therapy). Postoperative data, including early or late complications, hematocrit during hospitalization, and functional status, were also collected. A multiple linear regression was used to identify predictors of surgical complications and secondarily crossed to determine the strength of the prediction. Statistical significance was set at P = .05. RESULTS Patients were stratified into 4 groups based on (1) previous radiation therapy, (2) previous surgery, (3) no previous radiation therapy or surgery, and (4) both previous radiation therapy and previous surgery, with an increased predictability of complications with both. Diabetes also added to the predictability of complications, with a smaller effect. Cardiac disease and hypertension were not predictive. CONCLUSIONS Previous radiation therapy and surgery are positive predictors for wound complications after microvascular reconstruction. Diabetes may add further risk in this setting.

Comprehensive Analysis of the Anterolateral Thigh Flap Vascular Anatomy

OBJECTIVE The anterolateral thigh (ALT) flap has become a frequently used free flap for head and neck reconstruction. Widespread use has been based on literature of ALT flap thickness performed primarily in Asian populations. To our knowledge, to date there has not been a comprehensive analysis of the anthropomorphic parameters of this flap in the Western population, in which it is often much thicker, thereby potentially limiting its utility. METHODS Computed tomographic angiograms of 106 patients were assessed, yielding 196 lower-extremity scans examined for volumetric characteristics and vascular anatomical variations. RESULTS Perforator vessels were located in 88.8% of scans, and most commonly located were a hybrid musculoseptocutaneous vessel (52.3%) followed by septocutaneous (33.9%) and musculocutaneous (13.8%) vessels. The midpoint perforator was located within ±2% of the midpoint of the total thigh length in only 47% of legs. The proximal and distal perforators were located 52.7 and 58.6 mm from the midpoint, respectively. Subcutaneous fat thickness differed significantly by sex, with mean male and female thicknesses of 9.9 mm and 19.9 mm (P < .001), respectively. Thickness increased with increasing body mass index, especially in women. CONCLUSION This study used computed tomographic angiography to characterize the ALT flap vasculature and thickness, providing a degree of predictability to these 2 highly variable flap characteristics.

Nasal Valve Suspension Revisited

Objectives: Nasal valve suspension (NVS) is a simple technique to correct nasal valve obstruction or collapse by providing a lateral vector of pull on the nasal sidewall. The purpose of this research was to review our experience with NVS in a cohort of patients with nasal valve collapse, including a subset of patients with facial paralysis. The objectives were to determine patient satisfaction and complication rates after NVS.

Perioral Burns After Adenotonsillectomy: A Potentially Serious Complication

OBJECTIVES To evaluate an institutional experience with perioral burns after adenotonsillectomy and to survey the national experience of other pediatric otolaryngologists regarding this complication. DESIGN A retrospective review of adenotonsillectomy cases from January 1, 1997, to December 31, 2005, was performed to determine the incidence, etiology, severity, and treatment of perioral burns. An online national survey of pediatric otolaryngologists was conducted in May 2006 to identify their experience with perioral burns. SETTING A tertiary pediatric medical center. PARTICIPANTS We evaluated cases with patients younger than 18 years who developed a perioral burn during an adenotonsillectomy or tonsillectomy at Primary Childrens Medical Center, Salt Lake City, Utah. MAIN OUTCOME MEASURES Institutional and national incidence, number of injuries per physician, technique used, severity of injury, and outcomes. Comparisons were made with respect to respondent experience and techniques used. RESULTS Seven cases of perioral burn from a single institution were identified from 4327 procedures, with 1 injury requiring reconstructive surgery. The survey response rate was 101 of 298 invitations (33.9%). Sixty-one respondents reported a total of 124 perioral burns after adenotonsillectomy. Monopolar cautery was the most common technique associated with this injury (n = 84). Coblation was the second most common technique associated with perioral burns and represented 15 (12.1%) of the reported complications. A defective electrocautery device tip was the most commonly identified cause of burn (n = 25), followed by operator error (n = 13), conduction through a metal instrument (n = 8), and lack of insulation in a cautery device (n = 7). Coblation injury was attributed to direct heat transfer from the device shaft. No significant association with operator experience was noted. A total of 14 (11.3%) of the reported injuries were severe, resulting in the need for additional treatment. CONCLUSION Perioral burns are an underreported complication of adenotonsillectomy that can result in severe long-term morbidity.

Reconstructive Rhinoplasty Using Multiplanar Carved Costal Cartilage

IMPORTANCE Reconstructive rhinoplasty often requires the use of cartilage grafts. Full-thickness autologous costal cartilage grafts provide a large amount of cartilage in a single uncarved block and are often used for major reconstructions. Warping is frequently described as a complication of rib cartilage use in rhinoplasty. OBJECTIVE To describe an approach to cartilage carving whereby a single block of cartilage is carved in a multiplanar manner to mimic or redefine the anatomic relationships and resist warping. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of reconstructive rhinoplasty cases using multiplanar costal cartilage grafting technique was performed. A consecutive sample of 11 patients with complex nasal deformity underwent reconstruction with an autologous costal cartilage block carved in 3 dimensions to address complex deformities at the University of New Mexico Hospital between January 2010 and December 2014. The follow-up period ranged from 3 to 36 months. INTERVENTIONS Autologous rib cartilage harvest was performed to obtain a full-thickness segment of rib cartilage. The deficient or malformed nasal cartilage is defined and soft tissue prepared using an open rhinoplasty approach. Rib cartilage graft curvature is removed to create a uniform, symmetric, solid block of cartilage. A cartilage graft is carved in a multiplanar fashion to simulate normal nasal anatomy. MAIN OUTCOMES AND MEASURES Postoperative evaluation of nasal airway function, cartilage graft warping, and aesthetic outcomes were reported in the follow-up period. Nasal Obstructive Symptom Evaluation (NOSE) scores are documented in the majority of cases and were obtained at least 3 months postoperatively. RESULTS Overall, 11 patients with complex nasal deformity underwent reconstruction with an autologous costal cartilage block carved in 3 dimensions. The most common use was for reconstruction of the septum with the upper lateral cartilage. There were no major complications. No patients experienced graft warping in the follow-up period. Several patients required minor revision procedures. All patients reported improved nasal airway and improved aesthetic appearance of the nose. CONCLUSIONS AND RELEVANCE Multiplanar costal cartilage grafting is a useful surgical technique for complex reconstructive rhinoplasty that yields optimal and predictable results. LEVEL OF EVIDENCE 4.

Longitudinal voice outcomes following laryngeal reinnervation via vagus-to-recurrent laryngeal nerve anastomosis after vagal nerve sacrifice: a case series.

Objective: This study aimed to describe longitudinal voice outcomes of vagus-to-recurrent laryngeal nerve anastomosis following operative vagal nerve sacrifice. Methods: Two patients who underwent anastomosis were assessed by a multidisciplinary voice team at 1, 4, 9, 12, and 18 months after vagal sacrifice. Results: Long-term changes in voice function based on auditory perceptual measures of voice quality and visual perceptual changes in glottal closure were observed and maintained for 18 months after vagus-to-recurrent laryngeal nerve anastomosis in 2 patients with proximal vagal nerve sacrifice. Patients achieved acceptable voice outcomes and elected not to undergo further treatment, which was supported by Voice Handicap Index scores. Conclusion: Gradual restoration of voice following operative vagal sacrifice can be achieved over an 18-month period using vagus-to-recurrent laryngeal nerve anastomosis and warrants further investigation in appropriately selected patients.