Phillip Pirgousis

Versatility of supraclavicular artery island flap in head and neck reconstruction of vessel-depleted and difficult necks.

PURPOSE The advent of microvascular free tissue transfer has given reconstructive surgeons a vast repertoire of treatment options for reconstruction of head and neck defects. However, the success of free flaps in head and neck reconstruction depends on the presence and quality of the recipient vessels in the neck for microvascular anastomosis. The supraclavicular artery island flap can be used to reconstruct a variety of head and neck defects, allowing the reconstructive surgeons to circumvent some of the problems inherent in vessel-depleted necks. The present study reports the use of the supraclavicular artery flap (SCAF) in the reconstruction of vessel-depleted neck and in difficult necks. MATERIALS AND METHODS The present study was a retrospective study of patients who had undergone reconstruction with an SCAF and who also had a difficult neck or vessel-depleted neck in the head and neck surgery section from 2011 to 2012. Our inclusion criteria were patients treated at our institution with an SCAF who also had undergone multiple previous neck surgeries or patients with severely restricted donor options for soft tissue reconstruction. We excluded any patient for whom we did not have adequate follow-up or if the flap procedure was not performed by the faculty of the head and neck section. RESULTS We identified 8 patients with a total of 9 SCAFs. One patient received bilateral SCAFs. Of the 8 patients, 6 were men and 2 were women. With the exception of 1 patient, all had received previous radiotherapy to the head and neck region. All the patients had undergone multiple surgical procedures. The flap survival was 100%. However, 2 patients had partial loss of the flap, and 2 had partial donor site wound dehiscence. Our overall complication rate was 38%, including dehiscence of the flap and partial loss of the flap. CONCLUSIONS The SCAF is a sound option for reconstructing defects in the head and neck region in patients with previous radiotherapy and in multiple neck surgeries. The surgeon and patient should be aware of the high incidence of complications associated with this reconstructive option.

Survival of microvascular free flaps in mandibular reconstruction: A systematic review and meta-analysis

Free tissue transfer is commonly used in the reconstruction of post‐ablative defects of the mandible. Due to lack of statistical power, comparing the survival of various free flaps, even in large studies, is challenging. The purpose of this study was to perform a meta‐analysis comparing the survival of the most commonly used free flaps for mandibular reconstruction.

Microvascular Free Tissue Transfer for Head and Neck Reconstruction in Children: Part I.

Background:Limited outcome data exist regarding the survival of microvascular free flaps for head and neck reconstruction in children. The objectives of this study were to perform a systematic review of the literature and meta-analysis comparing the survival of the most commonly used free flaps used for head and neck reconstruction in children. Methods:A systematic search of PubMed, Embase, and Scopus was conducted using various keywords up to January 1, 2015. Meta-analysis was used to compare the survival of the most commonly used free flaps. The primary predictor variable was free flap type. The primary outcome variable was flap failure. The pooled relative risk (RR) with 95% confidence intervals (CIs) was estimated using a Mantel-Haenszel, fixed-effects model. Results:The authors reviewed 25,303 abstracts. Five studies met inclusion criteria. A total of 646 children received a total of 694 free flaps. The pooled survival rate among all free flaps was 96.4%. The fibula free flap (fibula) and subscapular system free flaps (scapula) were the most commonly used flaps. There was no difference in survival when comparing the scapula (RR = 0.59, 95% CI: 0.26, 1.56, P = 0.29), or fibula (RR = 1.91, 95% CI: 0.55, 6.65, P = 0.31) to other free flaps, or when comparing the scapula to the fibula (RR = 2.29; 95% CI: 0.40, 13.08, P = 0.35). Conclusions:Free tissue transfer is highly successful in children. Although data are limited, there appears to be no difference in survival among various free flaps used for head and neck reconstruction in children.

Digital Measurements of 120 Mandibular Angles to Determine the Ideal Fibula Wedge Osteotomy to Re-Create the Mandibular Angle for Microvascular Reconstruction

PURPOSE Mandibular reconstruction continues to be a challenge, even for the seasoned reconstructive surgeon. The present study sought to determine the normal anatomic mandibular angle and to establish a predictable angle of resection for the fibula bone cut to re-create the neomandibular body-ascending ramus angle. MATERIALS AND METHODS A total of 30 random male and female panoramic radiographs were selected from our database. The selection criteria included age older than 21 years and a full or near total complement of teeth. The exclusion criteria were an edentulous mandible or maxilla, a history of trauma or maxillary or mandibular pathologic features, and age younger than 21 years. A total of 120 total measurements were performed. The angle measured was determined from a line coinciding with the posterior border of the ramus and the lower mandibular border. The measurements were taken from each side and from each gender group. The institutional review board of our institution approved the present study. RESULTS The mean female mandibular right angle was 122.62°, and the left was 124.59° (average, 123.61°). The mean male mandibular right angle was 122.66°, and the left was 124.2° (average, 123.43°). The mean and median values were very similar. A statistically significant difference was identified between the left and right sides but not between the genders. Given this information, one can calculate a wedge cut in the fibula of about 56° to re-create the mean mandibular angle. CONCLUSIONS This information can be used to make predictable fibula wedge closing osteotomies to re-create the normal mandibular ascending ramus body angle in a low-cost manner with the aid of an autoclavable metal wedge of 56°. This method would obviate the need for costly prefabricated guides.

Preoperative Protective Endovascular Covered Stent Placement Followed by Surgery for Management of the Cervical Common and Internal Carotid Arteries with Tumor Encasement

Objective The objective of this study was to report the outcomes on a preliminary cohort of patients with tumor encasement of either, or both, the cervical internal carotid artery (ICA) and common carotid artery (CCA) following preoperative covered stent placement and surgical resection. Setting This study was set at the University of Florida College of Medicine, Jacksonville, FL. Participants Subjects who received preoperative stenting of the cervical ICA/CCA before surgical resection of head and neck tumors between April 1, 2015, and July 31, 2015 were participated. Main Outcome Measures The outcomes assessed were resectability of tumors after stenting, histopathological assessment of specimen margins, complications associated with stenting. Results Five subjects received preoperative covered stent placement of the ICA/CCA before surgical resection. The mean age was 65.2 years. Median follow‐up was 3.5 months. Excision of the adventitia from the stent was performed in all subjects. No intraoperative complications occurred. One vascular‐related complication occurred in one subject who suffered occlusion of the stent, sustaining a ministroke. No involvement of tumor at the deep margin (inner surface of adventitia) of the resection was seen in any subjects. Conclusions Preoperative covered stent placement of the cervical ICA/CCA in the management of subjects with head and neck tumors who display encasement on preoperative imaging may represent a safe and effective treatment.

Metastatic Squamous Cell Carcinoma of an Unknown Primary Site With Cardiac Involvement: Case Report

Head and neck squamous cell carcinomas frequently metastasize to cervical lymph nodes. Distant metastasis by hematogenous dissemination pathways is less common. Cardiac involvement is a particularly rare occurrence. The first case of cardiac metastasis was reported in the early 18th century as a postmortem discovery. Since then, there have been sporadic reports of oropharyngeal cancer with cardiac metastasis. This report describes a case of metastatic squamous cell carcinoma of an unknown primary site involving the lungs, heart, and soft tissue of the bilateral paraspinal regions and lower extremity.

Local/Regional Flaps in Oral/Head and Neck Reconstruction

The contemporary dictum in head and neck reconstruction is to utilize microvascular transfer techniques. More and more, the use of local or regional flaps has been relegated to the use in the salvage setting of failed microvascular flaps or in patients deemed too sick to undergo long anesthetics as is required for free flap transfers.