[Show abstract][Hide abstract] ABSTRACT: Purpose: Vascular compromise after microvascular head and neck reconstruction is rare. When it does occur venous problems are most likely to blame. The benefit of utilizing one versus two veins for outflow is debatable in the literature1-4. We hypothesize that performing dual vein outflow improves flap viability and reduces peri-operative complications in head and neck microvascular reconstruction.
Methods: A retrospective chart review was performed. All subjects who underwent head and neck microvascular reconstruction at the University of Kansas Medical Center between January 2004 and December 2012 were included. Outcomes of flaps utilizing one and two vein outflow were compared. First peri-operative vascular compromise was compared between the two groups. Secondly, flap complications including hematoma, wound healing problems/dehiscence/fistula, and partial or complete flap failure were compared. A Chi-square test was used to compare both groups.
Results: In this study, 309 subjects underwent a total of 317 microvascular free flap reconstructions of the head and neck. 213 of the 317 (67.2%) flaps utilized one vein outflow and 104 (32.8%) employed dual vein outflow. 57 of 317 (18%) flaps required urgent exploration for peri-operative vascular compromise. Of these 57 flaps, 41 (71.9%) had only one venous anastomosis while 16 (28.1%) had two venous anastomoses. Venous congestion was the reason for urgent exploration in 37 of the 57 (64.9%) subjects. 30 of the 37 (81.1%) flaps with venous congestion had one vein anastomosis and 7 of the 37 (18.9%) had dual vein outflow (p = 0.03). The incidence of flap complications included 38 of 213 (17.8%) in the single vein group and 15 of 104 (14.4%) in the group utilizing dual venous outflow (p = 0.44). The overall flap success rate was 303 out of 317 (95.6%) flaps. Interestingly, 12 of 14 (85.7%) flap failures had a single vein anastomosis while 2 of 14 (14.3%) flap failures utilized a dual vein outflow (p = 0.15).
Conclusion: Our experience demonstrates a statistically significant decrease in re-exploration for venous congestion when dual vein outflow is utilized compared with single vein anastomosis. The incidence of overall flap complications and flap failure was lower although not significant when dual vein outflow was utilized. Based on these findings, when feasible, coapting two veins should be considered in any head and neck microvascular reconstruction.
[Show abstract][Hide abstract] ABSTRACT: We performed a retrospective study of cases from 2005 to 2010 at an academic tertiary care center to analyze the factors that influence morbidity in surgical management of thyroid malignancy.
The rates of recurrent laryngeal nerve (RLN) injury and hypoparathyroidism (HPT) were analyzed in the entire cohort. The comparison groups were 1) primary surgery versus revision; 2) total thyroidectomy versus total thyroidectomy combined with neck node dissection; and 3) two groups defined by surgical technique according to the RLN approach: group 1, in which the RLN was identified inferiorly in the tracheoesophageal groove, and group 2, in which the RLN was identified near the cricothyroid joint point of entry.
We reviewed 308 patients who underwent surgery for thyroid cancer. Thirty-six (11.7%) had temporary HPT, and 8 (2.6%) had permanent HPT. Of a total of 586 RLNs at risk, 16 (2.7%) had temporary damage and 2 (0.3%) had permanent damage. The incidences of temporary RLN injury significantly differed between the primary-surgery and revision-surgery groups (2.5% versus 15.6%; p = 0.001), and also between the groups with total thyroidectomy and thyroidectomy with neck dissection (1.2% versus 7.8%; p = 0.027). The incidences of temporary HPT were significantly different between the groups with primary surgery and revision surgery (6.6% versus 31.3%; p = 0.001), between the groups with total thyroidectomy and total thyroidectomy with neck dissection (4.7% versus 15.6%; p = 0.009), and between group 1 and group 2 (surgical technique in terms of RLN approach; 8.2% versus 17.9%; p = 0.011). Permanent HPT and permanent RLN injury both occurred rarely in this cohort, with no significant differences among comparison groups.
Our study shows a higher incidence of temporary RLN injury and teniporary HPT in revision surgery cases and in total thyroidectomy with neck dissection. Temporary HPT was significantly more common when the RLN was identified near the cricothyroid joint.
The Annals of otology, rhinology, and laryngology 06/2013; 122(6):398-403. DOI:10.1177/000348941312200609 · 1.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose:
To evaluate the prognosis of head and neck (HN) squamous cell carcinoma (SCC) diagnosed in young people (≤40 years), and to compare it with the typical older patients.
The study population comprised 69 HN cancer patients below the age of 40 years. An equal-sized control group of older patients was pair-matched with the young cases. Cases and controls were compared for type and frequency of recurrence, in addition to survival. Tongue tumor specimens from 12 women of the study group (6 young and 6 old) were included in a pilot immunohistochemical analysis of estrogen receptors (ER) expression.
Young patients with early (T1,T2) tongue cancer had shorter overall survival (OS) than their matched controls, but the finding was marginally non-significant (p=0.056). In the young population, late neck metastasis was a particularly aggravating factor for survival (p=0.004). In the case of tongue SCCs, young women were at the greatest risk of recurrence than any other gender-age combination (p=0.006). However, only 8.3% of tumors expressed ER.
Early-stage tongue cancer, regional recurrence, and tongue SCCs in women are negative prognostic factors for young HN cancer patients. Treatment modifications targeting these subgroups might be beneficial.
Journal of B.U.ON.: official journal of the Balkan Union of Oncology 04/2013; 18(2):459-464. · 0.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: IMPORTANCE Limited donor and recipient site complications support the osteocutaneous radial forearm free flap (OCRFFF) for mandibular reconstruction as a useful option for single-stage mandibular reconstruction. OBJECTIVE To examine and report long-term outcomes and complications at the donor and recipient sites for patients undergoing the OCRFFF for mandibular reconstruction. DESIGN Retrospective review. SETTING Academic, tertiary care medical center. PATIENTS The study population comprised 167 consecutive patients who underwent single-staged mandibular reconstruction with an OCRFFF. MEAN OUTCOME MEASURES Rates of complications at the donor and recipient sites. RESULTS The mean patient age was 61 years (range, 20-93 years). Men compromised 68% of the population. Follow-up interval ranged from 2 to 99 months (mean, 25.9 months). The median length of bone harvested was 7 cm (range, 2.5-12.0 cm). Prophylactic plating was completed for each of the radii at the time of harvest. Donor site complications included radial fracture (1 patient [0.5%]), tendon exposure (47 patients [28%]), and donor hand weakness or numbness (13 patients [9%]). Recipient site complications included mandible hardware exposure (29 patients [17%]), mandible nonunion or malunion (4 patients [2%]), and mandible bone or hardware fracture (4 patients [2%]). Using regression analysis, we found that patients were 1.3 times more likely to have plate exposure for every increase of 1 cm of bone harvest length; this was statistically significant (P = .04). CONCLUSIONS AND RELEVANCE This is the largest single study reporting outcomes and complications for patients undergoing OCRFFF for mandibular reconstruction. Prophylactic plating of the donor radius has nearly eliminated the risk of pathologic radial bone fractures. Limited long-term donor and recipient site complications support the use of this flap for single-stage mandibular reconstruction.
JAMA Otolaryngology - Head and Neck Surgery 02/2013; 139(2):168-72. DOI:10.1001/jamaoto.2013.1615 · 1.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES To evaluate functional swallowing outcomes in patients undergoing transoral robotic surgery vs primary chemoradiotherapy for the management of advanced-stage oropharynx and supraglottis cancers. DESIGN Prospective nonrandomized clinical trial. SETTING Academic research. PATIENTS We studied 40 patients with stage III or stage IVA oropharynx and supraglottis squamous cell carcinoma. Group 1 comprised 20 patients who received transoral robotic surgery with adjuvant therapy, while group 2 comprised 20 patients whose disease was managed by primary chemoradiotherapy. MAIN OUTCOME MEASURES Patients completed the M. D. Anderson Dysphagia Inventory (MDADI) before treatment and then at follow-up visits at 3, 6, and 12 months. The MDADI scores were analyzed and compared. RESULTS The median follow-up period for both groups was 14 months (range, 12-16 months). When comparing the median MDADI scores between group 1 and group 2, we found no statistically significant differences before treatment or at the 3-month follow-up visit. However, this difference was significant at the posttreatment visits at 6 months (P = .004) and 12 months (P = .006), where group 1 had better swallowing MDADI scores. We also found significant differences in swallowing MDADI scores between the groups at the 6-month posttreatment visit for patients with T1, T2, and T3 disease and at the 12-month follow-up visit for patients with T2 and T3 disease, where group 1 had significantly better MDADI scores. Comparing tumor subsites, group 1 fared significantly better at the follow-up visits at 6 months (P = .02) and 12 months (P = .04) for patients with primary tumor at the tonsil. Compared with group 2, group 1 patients having base of tongue cancers exhibited significantly better swallowing MDADI scores at the 6-month follow-up visit (P = .02), and group 1 patients having lateral oropharynx disease had significantly better swallowing MDADI scores at the 12-month follow-up visit (P = .04). CONCLUSION Advanced-stage oropharynx and supraglottis cancers managed by transoral robotic surgery with adjuvant therapy resulted in significantly better swallowing MDADI outcomes at the follow-up visits at 6 and 12 months compared with tumors treated by primary chemoradiotherapy.
Archives of otolaryngology--head & neck surgery 12/2012; 139(1):1-6. DOI:10.1001/jamaoto.2013.1074 · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to meet and demonstrate outcomes across 6 competencies. Measuring residents' competency in practice-based learning and improvement (PBLI) is particularly challenging.
We developed an educational tool to meet ACGME requirements for PBLI. The PBLI template helped programs document quality improvement (QI) projects and supported increased scholarly activity surrounding PBLI learning.
We reviewed program requirements for 43 residency and fellowship programs and identified specific PBLI requirements for QI activities. We also examined ACGME Program Information Form responses on PBLI core competency questions surrounding QI projects for program sites visited in 2008-2009. Data were integrated by a multidisciplinary committee to develop a peer-protected PBLI template guiding programs through process, documentation, and evaluation of QI projects. All steps were reviewed and approved through our GME Committee structure.
An electronic template, companion checklist, and evaluation form were developed using identified project characteristics to guide programs through the PBLI process and facilitate documentation and evaluation of the process. During a 24 month period, 27 programs have completed PBLI projects, and 15 have reviewed the template with their education committees, but have not initiated projects using the template.
The development of the tool generated program leaders' support because the tool enhanced the ability to meet program-specific objectives. The peer-protected status of this document for confidentiality and from discovery has been beneficial for program usage. The document aggregates data on PBLI and QI initiatives, offers opportunities to increase scholarship in QI, and meets the ACGME goal of linking measures to outcomes important to meeting accreditation requirements at the program and institutional level.
[Show abstract][Hide abstract] ABSTRACT: We studied the efficacy of prophylactic plate fixation technique and a modified harvest of the osteocutaneous radial forearm free flap (OCRFFF) to minimize the incidence of postoperative donor radius pathological fracture. We retrospectively studied of the first 70 consecutive patients undergoing OCRFFF harvest by the University of Kansas Head and Neck Microvascular Reconstruction Team. Mean follow-up was 13 months. One of two patients undergoing OCRFFF harvest without prophylactic fixation developed a pathological radius fracture. The 68 subsequent OCRFFF patients underwent prophylactic fixation of the donor radius, and none developed a symptomatic radius fracture. Five of 68 patients did have a radiographically visible fracture requiring no intervention. The plate fixation technique was further modified to exclude monocortical screws in the radius bone donor defect (subsequent 39 patients), without any further fractures detected. One patient required forearm hardware removal for an attritional extensor tendon tear. The described modified OCRFFF harvest and prophylactic plate fixation technique may eliminate postoperative pathological fracture of the donor radius. Donor morbidity is similar to that of the fasciocutaneous radial forearm free flap , affording safe use of OCRFFF in head and neck reconstruction.
Craniomaxillofacial Trauma and Reconstruction 09/2011; 4(3):129-36. DOI:10.1055/s-0031-1279675
[Show abstract][Hide abstract] ABSTRACT: To compare the efficacy of acellular dermal matrix (ADM) and split thickness skin grafts (STSG) in oral cavity reconstruction.
Prospective cohort study.
Thirty-four patients were included in this study (ADM, n = 22; STSG, n = 12). Evaluation for patient demographics, graft site, graft contracture, and functional status as defined by the EORTC QLQ-C30 and the H&N35 questionnaires. A subgroup of patients underwent graft site biopsy for histological analysis. A cost estimate of both procedures was also performed.
Patient groups were similar in age, sex, race, smoking exposure, and site grafted. More patients were treated with radiation therapy (pre- or postoperative) in the ADM group (45%) compared to the STSG group (17%). Graft failure rate was higher in the ADM group (14% vs. 0%), and both groups had similar estimated graft contraction. The quality of life survey results favored the ADM group, but only the category of trouble with social eating was statistically significant (P = .03). Radiation therapy had a significantly negative impact for both ADM and STSG. Histology demonstrated increased inflammation, fibrosis, and elastic fibers in the STSG group. The cost of the STSG was 3.5 times higher than the ADM group.
Acellular dermis grafting for reconstruction of the oral cavity offers several advantages over STSG, including the lack of donor site morbidity, lower cost, a natural appearing mucosal surface, and comparable if not superior functional status. Lower graft survival rates for ADM in the setting of prior radiation and with thicker graft material was encountered.
The Laryngoscope 11/2009; 119(11):2141-9. DOI:10.1002/lary.20548 · 2.14 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Technical skill is only one component of overall surgical competency, but it has been one of the most difficult to measure. Assessment methods are currently subjective and unreliable, and include techniques such as operative logs, end-of-rotation global assessments, and direct observation without criteria. Newer objective methods of technical skill assessment are being developed and undergoing rigorous validation, including methods such as direct observation with criteria, final product analysis, and hand-motion analysis. Following the example set in other fields in which high-stakes assessment is paramount, such as in aviation, virtual reality simulators have been introduced to surgical competency assessment and training. Significant work remains to integrate these assessments into both training programs and practice and to demonstrate a resultant improvement in surgical outcome.
Otolaryngologic Clinics of North America 01/2008; 40(6):1237-59, vii. DOI:10.1016/j.otc.2007.07.005 · 1.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The osteocutaneous radial forearm free flap (ORFFF) is an ideal source of vascularized bone and soft tissue for repair of defects in reconstructions of the head and neck. However, studies have revealed significant donor site morbidity, decreasing the popularity of this procedure. We have previously reported our technique of prophylactic internal fixation of the radius at the time of graft harvest, developed to decrease donor radius fractures. This is a retrospective radiographic review of our long-term radius donor site morbidity. Forearm radiographs more than 3 years after ORFFF with prophylactic plating were evaluated and compared with prior postoperative films. No donor radius fractures were identified. All radiographs exhibited remodeling and/or reconstitution of donor radii. There was no evidence of implant failure, loosening, or surrounding osteopenia. This study lends further credibility to the ORFFF, when prophylactically plated, as a safe and reliable source of vascularized bone and soft tissue for reconstructive procedures.
[Show abstract][Hide abstract] ABSTRACT: We sought to evaluate the functional and aesthetic outcomes of immediate facial reconstruction with a Gore-Tex (expanded polytetrofluoroethylene) sling in irradiated patients undergoing large head and neck tumor extirpation with facial nerve resection.
We conducted a retrospective study of 17 patients at two academic institutions who underwent extirpative surgery with immediate Gore-Tex sling reconstruction and completed radiotherapy. Functional and aesthetic results were evaluated at three intervals.
All patients had excellent immediate results and good or excellent intermediate-term results. At long-term follow-up, results were good to excellent in 47% and unacceptable in 35% of patients.
In irradiated patients undergoing total parotidectomy with immediate facial reconstruction using Gore-Tex slings, early results are excellent, but there is a high incidence of major wound complications and unacceptable results in long-term follow-up.
There is a high rate of late complications associated with immediate facial reconstruction with Gore-Tex slings in irradiated patients.
Otolaryngology Head and Neck Surgery 09/2007; 137(2):228-32. DOI:10.1016/j.otohns.2007.03.013 · 2.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Static facial suspension (SFS) continues to play a role for rehabilitation in patients with facial paralysis. We perform SFS almost exclusively with a suture technique in our practice. Monofilament polypropylene suture (Prolene) is commonly used for SFS, but we have witnessed occasional failure and some stretching with this material. The purpose of this study was to establish and compare the biomechanical properties of 3 suture types-polypropylene, polybutilate-coated braided polyester (PBCP) (Ethibond Excel), and braided polyester impregnated with polytetrafluoroethylene (PIP) (Tevdek)-to assess their suitability for SFS.
Six samples of 0, 2-0, and 3-0 polypropylene, PBCP, and PIP were tested. The mean load to failure was calculated for each suture type. Stiffness and elongation at specific loads were calculated to compare stretch between materials.
The load to failure of PBCP and PIP was significantly greater than that for polypropylene for all suture sizes. In addition, PBCP and PIP had significantly less elongation than did polypropylene at clinically relevant loads.
Both PBCP and PIP had superior load-bearing properties and decreased stretch when compared with polypropylene. These properties suggest that, for SFS with suture, use of PBCP or PIP may reduce the incidence of breakage and elongation, improving outcomes.
Archives of Facial Plastic Surgery 05/2007; 9(3):188-93. DOI:10.1001/archfaci.9.3.188 · 1.71 Impact Factor