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Matsui C, Escandón JM, Mohammad A, Tanaka T, Wynn ET, Mizuno H, Roche N. Clinical applications of the chimeric anterolateral thigh (ALT) flap in head and neck reconstruction. Acta Chir Belg 2023; 123:473-480. [PMID: 35499297 DOI: 10.1080/00015458.2022.2073016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/28/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Surgical site infection (SSI) is a common complication following head and neck surgery. Dead space at the excision site can increase the risk of infection, abscess formation, and mortality. Herein, we evaluated the performance of the chimeric anterolateral thigh (ALT) flap in addressing these concerns. METHODS Patients who underwent oncologic head and neck reconstruction between October 2016 and November 2021 were divided in two groups: a normal ALT flap and a chimeric dead space filling (DSF) ALT-vastus lateralis flap group. We evaluated the postoperative outcomes. RESULTS Twenty-five patients treated with normal ALT flaps (34.7%) and 47 with DSF ALT flap group (65.2%) were included. Only one ALT per case was necessary. Most of the cases involved tongue (31.9%) and lower gingival reconstruction (27.8%). The time to harvest the DSF ALT flap was 134.3 min when compared to the normal ALT flap (116.2 min, p < .001). Vascular occlusion, flap loss, partial necrosis, and fat necrosis were not observed among the different groups. CONCLUSION The DSF process can be used as a preventive measure for SSI or vessel exposure due to radiation-induced skin damage. This flap allows same-site reconstruction if the primary tumor recurs by using the pedicle of the chimeric flap for reattachment of another free flap.
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Affiliation(s)
- Chihiro Matsui
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, New York, NY, USA
| | - Arbab Mohammad
- Aarupadai Veedu Medical College and Hospital, Puducherry, India
| | | | - Ei Thinzar Wynn
- Department of Plastic and Reconstructive Surgery, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Hiroshi Mizuno
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Nathalie Roche
- Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium
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Amendola F, Spadoni D, Lundy JB, Cottone G, Velazquez-Mujica J, Platsas L, Chen HC. Reducing complications in reconstruction of the cervical esophagus with anterolateral thigh flap: The five points protocol. J Plast Reconstr Aesthet Surg 2022; 75:3340-3345. [PMID: 35614011 DOI: 10.1016/j.bjps.2022.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/12/2022] [Indexed: 11/29/2022]
Abstract
Patients suffering from hypopharyngeal cancer commonly present in the advanced stage and undergo a circumferential pharyngolaryngectomy. The possibility to reconstruct the esophagus and achieve an oral alimentation can significantly reduce the additional burden of a jejunostomy. The cervical esophagus is usually reconstructed with jejunal free flap (JFF) or fasciocutaneous free flap such as the anterolateral thigh (ALT) free flap. The latter has proved its donor-site safety and fast recovery. However, it is burdened by a high fistula rate. We present our five points protocol for reducing fistula rate and improving outcome. Twenty-eight patients underwent total pharyngolaryngectomy and required esophageal reconstruction with ALT flap from 2015 to 2020. In each patient, we performed five adjustments: a thicker dermal layer, a two-layer closure, a barrier from the tracheostomy, a nonabsorbable monofilament suture, and two NG tubes to enhance neoesophageal drainage. Twenty-five (89%) patients returned to solid or soft food diet after the reconstruction. Three patients had liquid diet. Contrast media leakage was observed in only 2 (7%) patients during esophagography at three weeks, with only one needing surgical revision. Our five points protocol for ALT reconstruction of cervical esophagus proved to be effective in achieving an incredibly low rate of complications, without the burden of significant donor-site complications.
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Affiliation(s)
- Francesco Amendola
- Department of Plastic and Reconstructive Surgery, I.R.C.C.S. Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi, 4, Milan 20161, Italy
| | - Davide Spadoni
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, No. 91, Xueshi Road, North District, Taichung City 404, Taiwan
| | - Jonathan B Lundy
- US Army Institute of Surgical Research, 3698 Chambers Road, Fort Sam Houston 78234, TX, USA
| | - Giuseppe Cottone
- Department of Plastic and Reconstructive Surgery, I.R.C.C.S. Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi, 4, Milan 20161, Italy
| | - Jonathan Velazquez-Mujica
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, No. 91, Xueshi Road, North District, Taichung City 404, Taiwan
| | - Loukas Platsas
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, No. 91, Xueshi Road, North District, Taichung City 404, Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, No. 91, Xueshi Road, North District, Taichung City 404, Taiwan.
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Mascarella MA, Patel T, Vendra V, Gardiner L, Kergoat MJ, Kubik MW, Solari MG, Snyderman CH, Traylor KS, Ferris RL, Kim S, Duvvuri U, Sridharan SS. Poor treatment tolerance in head and neck cancer patients with low muscle mass. Head Neck 2022; 44:844-850. [PMID: 35020252 PMCID: PMC11412609 DOI: 10.1002/hed.26978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/05/2021] [Accepted: 01/03/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND We ascertain the role of a low cervical paraspinal skeletal muscle index (CPSMI) as a biomarker for poor treatment tolerance in patients with operable mucosal head and neck squamous cell carcinoma (HNSCC). METHODS A prospective cohort of patients with operable HNSCC requiring microvascular reconstruction was evaluated. Low CPSMI was calculated using preoperative CT neck imaging. Poor treatment tolerance, a composite measure of incomplete therapy or severe morbidity/mortality during treatment, was the primary outcome. RESULTS One hundred and twenty-seven patients underwent extirpative surgery with a mean age was 60.5. Poor treatment tolerance occurred in 71 (56%) patients with 21 not completing recommended adjuvant therapy and 66 having severe treatment-related morbidity. A low CPSMI was independently associated with poor treatment tolerance (OR 2.49, 95%CI 1.10-5.93) and delay to adjuvant therapy (OR 4.48, 95%CI 1.07-27.6) after adjusting for multiple confounders. CONCLUSION Low CPSMI was independently associated with poor treatment tolerance in patients with operable HNSCC.
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Affiliation(s)
- Marco A Mascarella
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Biomedical Sciences, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Lady Davis Institute of the Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Terral Patel
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Varun Vendra
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Lauren Gardiner
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Marie-Jeanne Kergoat
- Department of Biomedical Sciences, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Division of Geriatrics, Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Mark W Kubik
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mario G Solari
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Katie S Traylor
- Department of Diagnostic Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Robert L Ferris
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Seungwon Kim
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Umamaheswar Duvvuri
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shaum S Sridharan
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Bolletta A, Losco L, Lin J, Oh C, Di Taranto G, Trignano E, Cigna E, Chen HC. Partition of Pectoralis Major Musculocutaneous Flap as a Salvage Procedure for Simultaneous Coverage of the Exposed Carotid Artery and Reconstruction of Cervical Esophagus. Ann Plast Surg 2021; 87:435-439. [PMID: 34270475 DOI: 10.1097/sap.0000000000002895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In advanced pharyngoesophageal cancer patients, a critical event is represented by the failure of primary reconstruction with exposure of the carotid artery and partial or total defect of the cervical esophagus. For these high-risk patients, a partitioned pectoralis major musculocutaneous (PMMC) flap can prevent carotid blowout and provide skin for simultaneous esophageal reconstruction. METHODS Twenty-six patients needing pharyngoesophageal reconstruction together with coverage of carotid artery exposure were included in this retrospective case series. The patients were treated with a partitioned PMMC flap, based on the branching pattern of the pectoral branch of the thoracoacromial artery and the perforators of the pectoralis major muscle, to simultaneously reconstruct the defect and provide coverage for the carotid artery. RESULTS In 25 patients, the partitioned PMMC flap reconstructions resulted in complete wound healing without occurrence of carotid blowout syndrome or fistula formation. Minor complications as partial flap necrosis (7.7%) and strictures formation (7.7%) were recorded but did not compromise reconstruction. Twenty-two patients were able to adopt a semisolid diet, and 4 had recurrence of cancer. CONCLUSIONS The partitioned PMMC flap reconstruction represents a useful salvage solution to simultaneously restore the continuity of the alimentary tract and provide reliable coverage for the exposed carotid artery.
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Affiliation(s)
- Alberto Bolletta
- From the Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Luigi Losco
- Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Jason Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Christine Oh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Giuseppe Di Taranto
- Department of Plastic and Reconstructive Surgery, Sapienza University of Rome, Umberto I University Hospital, Rome, Italy
| | - Emilio Trignano
- Plastic Surgery Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Emanuele Cigna
- Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Hung-Chi Chen
- From the Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
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Tassone P, Galloway T, Dooley L, Zitsch R. Orocutaneous Fistula After Oral Cavity Resection and Reconstruction: Systematic Review and Meta-Analysis. Ann Otol Rhinol Laryngol 2021; 131:880-891. [PMID: 34553635 DOI: 10.1177/00034894211047463] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Orocutaneous fistula (OCF) after reconstruction for oral cavity resection can lead to prolonged hospitalization and adjuvant treatment delay. Few studies have examined factors leading to OCF after oral cavity resection. Primary objective: evaluate overall incidence and factors associated with OCF after oral cavity reconstruction. DATA SOURCES Scopus 1960-database was searched for terms: "orocutaneous fistula," "oro cutaneous fistula," "oral cutaneous fistula," "orocervical fistula," "oral cavity salivary fistula." REVIEW METHODS English language studies with >5 patients undergoing reconstruction after oral cavity cancer resection were included. About 1057 records initially screened; 214 full texts assessed; 78 full-texts included. PRISMA guidelines were followed, and MINORS criteria used to assess risk of bias. Data were pooled using random-effects model. Primary outcome was OCF incidence. Meta-analysis to determine the effect of preoperative radiation on OCF conducted on 12 eligible studies. Pre-collection hypothesis was that prior radiation therapy is associated with increased OCF incidence. Post-collection analyses: free versus pedicled flaps; mandible-sparing versus segmental mandibulectomy. RESULTS Seventy-eight studies were included in meta-analysis of overall OCF incidence. Pooled effect size showed overall incidence of OCF to be 7.71% (95% CI, 6.28%-9.13%) among 5400 patients. Meta-analysis of preoperative radiation therapy on OCF showed a pooled odds ratio of 1.68 (95% CI, 0.93-3.06). OCF incidence was similar between patients undergoing free versus pedicled reconstruction, or segmental mandibulectomy versus mandible-sparing resection. CONCLUSION Orocutaneous fistula after oral cavity resection has significant incidence and clinical impact. Risk of OCF persists despite advances in reconstructive options; there is a trend toward higher risk after prior radiation.
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Affiliation(s)
- Patrick Tassone
- Department of Otolaryngology-Head & Neck Surgery, University of Missouri, Columbia, MO, USA
| | - Tabitha Galloway
- Department of Otolaryngology-Head & Neck Surgery, University of Missouri, Columbia, MO, USA
| | - Laura Dooley
- Department of Otolaryngology-Head & Neck Surgery, University of Missouri, Columbia, MO, USA
| | - Robert Zitsch
- Department of Otolaryngology-Head & Neck Surgery, University of Missouri, Columbia, MO, USA
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Chimeric Anterolateral Thigh and Rectus Femoris Flaps for Reconstruction of Complex Oral and Maxillofacial Defects. J Craniofac Surg 2020; 32:1841-1844. [DOI: 10.1097/scs.0000000000007228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Gan W, Xiang Y, Lv D, Liu J, Wang H, Deng D, Wang J, Li L, Ma T, Liu S, Chen F. Complex reconstruction technique applied in advanced head and neck cancer. Medicine (Baltimore) 2020; 99:e18810. [PMID: 32000381 PMCID: PMC7004775 DOI: 10.1097/md.0000000000018810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Complex reconstruction skills in advanced head and neck cancer (HNC) could resolve the key problem of large defects after tumor resection. We combined the anterolateral thigh free flap, fascia lata flap, and greater saphenous vein graft in the reconstruction process of salvage surgery. Seven patients suffering from advanced HNC who experienced the failure of multiple therapeutic methods were enrolled in our study between June 2017 and January 2018. They all agreed to voluntarily undergo the tumor excision and complex reconstruction procedure we developed. The total flap size ranged from 20 × 13 cm to 30 × 15 cm. The length of the greater saphenous vein graft ranged from 4 to 11 cm. The hospitalization period ranged from 7 to 33 days. All of the flaps were viable, but in 1 patient, oral flap edge infection and necrosis necessitated partial debridement on day 7 postoperatively. All donor sites were closed primarily. We report our experience with this surgical method for complex reconstruction in advanced HNC patients.
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Affiliation(s)
- Weigang Gan
- Department of Otorhinolaryngology–Head and Neck Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu
| | - Yu Xiang
- Morphometric Research Laboratory, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Dan Lv
- Department of Otorhinolaryngology–Head and Neck Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu
| | - Jun Liu
- Department of Otorhinolaryngology–Head and Neck Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu
| | - Haiyang Wang
- Department of Otorhinolaryngology–Head and Neck Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu
| | - Di Deng
- Department of Otorhinolaryngology–Head and Neck Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu
| | - Ji Wang
- Department of Otorhinolaryngology–Head and Neck Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu
| | - Linke Li
- Department of Otorhinolaryngology–Head and Neck Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu
| | - Tengfei Ma
- Department of Otorhinolaryngology–Head and Neck Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu
| | - Shixi Liu
- Department of Otorhinolaryngology–Head and Neck Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu
| | - Fei Chen
- Department of Otorhinolaryngology–Head and Neck Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu
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8
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Ettyreddy AR, Chen CL, Zenga J, Simon LE, Pipkorn P. Complications and Outcomes of Chimeric Free Flaps: A Systematic Review. Otolaryngol Head Neck Surg 2019; 161:568-575. [PMID: 31109239 DOI: 10.1177/0194599819844997] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Ablations of locally advanced or recurrent head and neck cancer commonly result in large composite orofacial defects. Chimeric flaps represent a unique surgical option for these defects, as they provide diverse tissue types from a single donor site. The purpose of the study was to consolidate the literature on chimeric flaps with regard to postoperative complication rates to help inform surgical decision making. DATA SOURCES The librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946), Embase (1947), Scopus (1823), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrails.gov (1997). REVIEW METHODS Candidate articles were independently reviewed by 2 authors familiar with the subject material, and inclusion/exclusion criteria were uniformly applied for article selection. Articles were considered eligible if they included patients who received a single chimeric flap for reconstruction of head and neck defects and if they provided data on complication rates. RESULTS A total of 521 chimeric flaps were included in the study. The major complication rate was 22.6%, while the minor complication rate was 14.0%. There were 7 flap deaths noted in the series. Median operative time and harvest time were 15.0 and 2.5 hours, respectively. CONCLUSION Chimeric flaps represent a viable option for reconstruction of complex head and neck defects and have complication rates similar to those of double free flaps and single free flaps with locoregional flap while only modestly increasing total operative time.
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Affiliation(s)
- Abhinav R Ettyreddy
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Collin L Chen
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Joseph Zenga
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura E Simon
- Bernard Becker Medical Library, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
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Suárez C, Fernández-Alvarez V, Hamoir M, Mendenhall WM, Strojan P, Quer M, Silver CE, Rodrigo JP, Rinaldo A, Ferlito A. Carotid blowout syndrome: modern trends in management. Cancer Manag Res 2018; 10:5617-5628. [PMID: 30519108 PMCID: PMC6239123 DOI: 10.2147/cmar.s180164] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Carotid blowout syndrome (CBS) refers to rupture of the carotid artery and is an uncommon complication of head and neck cancer that can be rapidly fatal without prompt diagnosis and intervention. CBS develops when a damaged arterial wall cannot sustain its integrity against the patient’s blood pressure, mainly in patients who have undergone surgical procedures and radiotherapy due to cancer of the head and neck, or have been reirradiated for a recurrent or second primary tumor in the neck. Among patients irradiated prior to surgery, CBS is usually a result of wound breakdown, pharyngocutaneous fistula and infection. This complication has often been fatal in the past, but at the present time, early diagnosis and modern technology applied to its management have decreased morbidity and mortality rates. In addition to analysis of the causes and consequences of CBS, the purpose of this paper is to critically review methods for early diagnosis of this complication and establish individualized treatment based on endovascular procedures for each patient.
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Affiliation(s)
- Carlos Suárez
- Head & Neck Cancer Laboratory, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain, .,Head & Neck Cancer Laboratory, Instituto Universitario de Oncología del Principado de Asturias, CIBERONC, University of Oviedo, Oviedo, Spain,
| | | | - Marc Hamoir
- Department of Head and Neck Surgery, Head and Neck Oncology Program, King Albert II Cancer Institute, St Luc University Hospital, Brussels, Belgium
| | | | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Miquel Quer
- Department of Otolaryngology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Carl E Silver
- Department of Surgery, University of Arizona, Phoenix, AZ, USA
| | - Juan P Rodrigo
- Head & Neck Cancer Laboratory, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain, .,Head & Neck Cancer Laboratory, Instituto Universitario de Oncología del Principado de Asturias, CIBERONC, University of Oviedo, Oviedo, Spain, .,Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Alfio Ferlito
- International Head and Neck Scientific Group Padua, Italy
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Deng D, Liu J, Chen F, Lv D, Gan W, Li L, Wang J. Double-island anterolateral thigh free flap used in reconstruction for salvage surgery for locally recurrent head and neck carcinoma. Medicine (Baltimore) 2018; 97:e12839. [PMID: 30313121 PMCID: PMC6203530 DOI: 10.1097/md.0000000000012839] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Salvage surgery is usually the only treatment for recurrent head and neck tumors but often poses a challenge to surgeons due to post-resected defects at 2 or more sites. Here we present the outcomes and rationale for reconstruction by a double-island anterolateral thigh (ALT) free flap following the salvage surgery.Patients treated with double-island ALT free flaps in salvage surgery between September 2012 and January 2017 at West China Hospital, Sichuan University were retrospectively viewed.A total of 18 patients (15 males) underwent reconstruction with double-island ALT free flaps (range from 40 to 77 years old). All patients had recurrent tumors after surgery and/or chemoradiotherapy and were selected for salvage surgery by a multidisciplinary team. The flaps were initially harvested as 7 cm × 7 cm to 16 cm × 10 cm single blocks and then divided into double-island flaps with each individual paddle ranging from5 cm × 3 cm to 10 cm × 8 cm. The average flap thickness was 3.5 cm (range from 2 to 6 cm), and the average pedicle length was 8 cm (range from 6 to 10 cm). A total of 18 arteries and 32 veins were anastomosed. Three patients developed fistula, 1 developed flap failure due to thrombosis and was re-operated with a pedicle flap. One patient died of pulmonary infection 6 months after the operation.Flap reconstruction for complex head and neck defects after salvage surgery remains challenging, but double-island ALT free flap reconstruction conducted by a multidisciplinary team and experienced surgeons would have a role in this setting.
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11
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The "Flap Suture Anchoring" Technique for Safe Oral Floor Reconstruction With Preservation of Alveolar Process. J Craniofac Surg 2018; 29:1300-1304. [PMID: 29570530 DOI: 10.1097/scs.0000000000004533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Flaps-based microsurgery is routinely applied to reconstruct oral floor defects caused by oncologic resection. To prevent orocutaneous fistulae, flaps are frequently sutured with buccal vestibule mucosa after sacrificing the alveolar process. The patients suffered denture loss and irreversible structural damage. For reliable oral floor reconstruction with preservation of alveolar process, the authors introduced the flap "suture anchoring" technique. Oral floor, hemiglossal-oral floor, and tongue base-parapharyngeal wall-oral floor defects were included in this study. The flap anchoring technique involves structural oral floor reconstruction with a chimeric anterolateral thigh-free flap or radial forearm flap with adipofascial tissue extension. The dead space in oral floor is filled with vastus lateralis muscle or adipofascial tissue, then holes are drilled on the alveolar bone among tooth root, beneath the attached gingiva. Skin paddle is sutured with 4-0 sutures through the alveolar holes thus anchored to the mandible. By applying this technique, there was no wound infection or orocutaneous fistulae in all patients postoperatively, even experienced postoperative radiotherapy. In addition, a soft and natural jaw-tongue furrow could be formed to allow the free movement of tongue. Taken together, the flap anchoring technique offers a safe and reliable approach to recover oral function and preservation of occlusion.
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12
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Muscle versus Fasciocutaneous Free Flaps in Lower Extremity Traumatic Reconstruction: A Multicenter Outcomes Analysis. Plast Reconstr Surg 2018; 141:191-199. [PMID: 28938362 DOI: 10.1097/prs.0000000000003927] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clinical indications are expanding for the use of fasciocutaneous free flaps in lower extremity traumatic reconstruction. The authors assessed the impact of muscle versus fasciocutaneous free flap coverage on reconstructive and functional outcomes. METHODS A multicenter retrospective review was conducted on all lower extremity traumatic free flaps performed at Duke University (1997 to 2013) and the University of Pennsylvania (2002 to 2013). Muscle and fasciocutaneous flaps were compared in two subgroups (acute trauma and chronic traumatic sequelae), according to limb salvage, ambulation time, and flap outcomes. RESULTS A total of 518 lower extremity free flaps were performed for acute traumatic injuries (n = 238) or chronic traumatic sequelae (n = 280). Muscle (n = 307) and fasciocutaneous (n = 211) flaps achieved similar cumulative limb salvage rates in acute trauma (90 percent versus 94 percent; p = 0.56) and chronic trauma subgroups (90 percent versus 88 percent; p = 0.51). Additionally, flap choice did not impact functional recovery (p = 0.83 for acute trauma; p = 0.49 for chronic trauma). Flap groups did not differ in the rates of flap thrombosis, flap salvage, flap loss, or tibial nonunion requiring bone grafting. Fasciocutaneous flaps were more commonly reelevated for subsequent orthopedic procedures (p < 0.01) and required fewer secondary skin-grafting procedures (p = 0.01). Reconstructive and functional outcomes remained heavily influenced by injury severity. CONCLUSIONS Muscle and fasciocutaneous free flaps achieved comparable rates of limb salvage and functional recovery. Flap selection should be guided by defect characteristics and reconstructive needs. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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13
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Samra F, Bibbo C, Levin LS, Kovach SJ. A Practical Guide to the Use of the Anterolateral Thigh Flap. JBJS Essent Surg Tech 2017; 7:e22. [PMID: 30233957 DOI: 10.2106/jbjs.st.16.00092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction The anterolateral thigh (ALT) flap allows for healthy, reliable, vascularized, soft-tissue coverage of extremity or axial defects of traumatic or acquired deformities. Indications & Contraindications Step 1 Positioning and Markings Place the patient in the supine position, which allows for flap harvest and typically does not require any position changes (Fig. 1), and then mark the septum between the vastus lateralis and rectus femoris, which facilitates harvest of this flap (Video 1). Step 2 Perforator Dissection Dissect this flap, which is relatively straightforward and rapid after identifying the perforating vessels (Video 2, Fig. 4). Step 3 Pedicle Dissection Trace the course of the descending branch of the lateral femoral circumflex proximally and determine the maximum pedicle length and vessel diameter for microvascular anastomoses (Figs. 5 and 6). Step 4 Flap Harvest and Recipient Vessels Confirm the dimensions of the flap prior to final harvest of the flap, and pay special attention to the recipient arterial inflow and venous outflow to ensure success. Step 5 Microvascular Anastomoses When performing this flap as a microvascular free flap, identify and prepare suitable vessels for tissue transfer (Fig. 13). Step 6 Flap Inset Pay special attention to the flap inset to ensure that there is no mechanical obstruction to the pedicle and that the inset allows for the anticipated postoperative edema (Figs. 14 and 15). Step 7 Donor Site Closure Close the donor site for this flap, which is well tolerated and easily concealed (Fig. 16). Step 8 Flap Monitoring and Postoperative Care Postoperative monitoring is critical to identify any potential vascular compromise early and maximize successful outcomes4. Results The ALT is a highly successful and reliable flap that has become a workhorse of reconstructive microsurgery5. Pitfalls & Challenges
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Affiliation(s)
- Fares Samra
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher Bibbo
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - L Scott Levin
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Reconstruction of Extensive Orbital Exenteration Defects Using an Anterolateral Thigh/Vastus Lateralis Chimeric Flap. J Craniofac Surg 2017; 28:638-642. [DOI: 10.1097/scs.0000000000003430] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Ooi ASH, Teven CM, Inbal A, Chang DW. The utility of the musculocutaneous anterolateral thigh flap in pharyngolaryngeal reconstruction in the high-risk patient. J Surg Oncol 2017; 115:842-847. [PMID: 28194796 DOI: 10.1002/jso.24577] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/02/2017] [Accepted: 01/15/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Prior radiotherapy leads to increased wound complication rates for microsurgical reconstruction of pharyngolaryngeal (PL) defects. Incorporating vastus lateralis muscle together with anterolateral thigh flap (ALT) skin in defect reconstruction is useful in protecting vital structures and reinforcing irradiated neck skin and suture lines. This study shows the utility of the musculocutaneous ALT (MC ALT) in PL reconstruction in previously irradiated patients. METHODS A single-surgeon, retrospective chart review of all patients with defects of the PL region where an MC ALT was used for reconstruction from February 2014 to May 2016. The harvest of the MC ALT is described. RESULTS Thirteen consecutive patients underwent reconstruction with a MC ALT flap. All 13 patients had received previous radiotherapy. PL defects included five partial, five subtotal, and three total. There was a 100% flap survival rate with five early recipient site complications including three fistulas, one neck abscess, and one partial muscle necrosis. Three patients (23%) developed strictures requiring dilatation, two of whom had received post-reconstruction radiotherapy. CONCLUSIONS The use of the MC ALT for reconstruction of PL defects should be considered to mitigate the negative effects of prior irradiation and provide a back-up plan in instances where complications occur.
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Affiliation(s)
- Adrian S H Ooi
- Section of Plastic and Reconstructive Surgery, University of Chicago Medical Center, Chicago, Illinois.,Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore
| | - Chad M Teven
- Section of Plastic and Reconstructive Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Amir Inbal
- Section of Plastic and Reconstructive Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - David W Chang
- Section of Plastic and Reconstructive Surgery, University of Chicago Medical Center, Chicago, Illinois
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AL Deek NF, Wei FC, Tsao CK. Fistulae After Successful Free Tissue Transfer to Head and Neck. Clin Plast Surg 2016; 43:739-45. [DOI: 10.1016/j.cps.2016.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Color Doppler Ultrasound Assessment of Anterolateral Thigh Flap Perforators in Locally Advanced Head and Neck Cancer. Int Surg 2016. [DOI: 10.9738/intsurg-d-16-00103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
To overcome anatomic variations and make the anterolateral thigh flap (ALT) harvesting simpler and safer, we used color Doppler ultrasound to locate the cutaneous perforators preoperatively and evaluated the reliability for perforator vessels. Twenty-six patients with advanced head and neck cancer who underwent curative surgery between 2012 and 2013 were recorded. The characteristics of cutaneous perforators of the ALT were evaluated preoperatively by color Doppler ultrasound. Fifty-seven perforators detected by preoperative color Doppler ultrasound were found intraoperative. The 4 false-positive perforators were found to be a branch of suprafascial plexus in the subcutaneous fat. The average number of perforators per flap was 2.4 (range, 1–4). The color Doppler ultrasound, therefore, has an 88.3% true-positive rate. The false-positive rate was 6.7%, and the false-negative rate was 5.0%. The diameters detected by preoperative color Doppler ultrasound and by surgeons during the operations were significant differences. Preoperative color Doppler ultrasound assessment for perforators of the ALT can decrease the operative risk for locally advanced head and neck cancer.
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D’Arpa S, Toia F, Brenner E, Melloni C, Moschella F, Cordova A. Variability and reliability of the vastus lateralis muscle anatomy. Acta Chir Belg 2016; 116:203-212. [PMID: 27537671 DOI: 10.1080/00015458.2016.1145998] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE The aims of this study are to investigate the variability of the morphological and neurovascular anatomy of the vastus lateralis (VL) muscle and to describe the relationships among its intramuscular partitions and with the other muscles of the quadriceps femoris. Clinical implications in its reliability as a flap donor are also discussed. METHODS In 2012, the extra- and intramuscular neurovascular anatomy of the VL was investigated in 10 cadaveric lower limbs. In three specimens, the segmental arterial pedicles were injected with latex of different colors to point out their anastomotic connections. The morphological anatomy was investigated with regard to the mutual relationship of the three muscular partitions and the relation of the VL with the other muscles of the quadriceps femoris. RESULTS The VL has a segmental morphological anatomy. However, the fibers of its three partitions interconnect individually and with the other bellies of the quadriceps femoris, particularly, in several variable portions with the vastus intermedius and mainly in the posterior part of the VL. The lateral circumflex femoral artery and its branches have variable origin, but demonstrate constant segmental distribution. Intramuscular dissection and colored latex injections show a rich anastomotic vascular network among the three partitions. CONCLUSIONS Moderate variability exists in both the myological and the neurovascular anatomy of the VL. Despite this variability, the anatomy of the VL always has a constant segmental pattern, which makes the VL a reliable flap donor. Detailed knowledge of the VL anatomy could have useful applications in a broad clinical field.
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Naunheim M, Seth R, Knott PD. Sternocleidomastoid contour restoration: an added benefit of the anterolateral thigh free flap during facial reconstruction. Am J Otolaryngol 2016; 37:139-43. [PMID: 26954870 DOI: 10.1016/j.amjoto.2015.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 09/24/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To demonstrate the potential of the anterolateral thigh free flap for neck contour restoration. STUDY DESIGN Retrospective chart review at a tertiary care medical center of patients who underwent radical parotidectomy with sternocleidomastoid sacrifice, with or without temporal bone resection, and reconstruction of both facial and cervical contour with the anterolateral thigh free flap between November 2011 and March 2015. Seven patients were included and demographics, flap viability, pathology and tumor staging, surgical intervention, adjunctive reanimation procedures, ischemia time, and pre-operative and post-operative photos were recorded and analyzed. RESULTS There were no flap failures and the mean ischemia time was 82 minutes. There were 2 recipient site complications. Post-operative neck symmetry was improved for all 7 patients. CONCLUSIONS The adipofascial anterolateral thigh flap is useful for improving the aesthetic contour of the neck among patients undergoing sternocleidomastoid muscle resection/disinsertion following total parotidectomy with/without temporal bone resection. Contour restoration may be performed with minimal added morbidity and with relatively little additional operative time. This technique may be adapted for other complex facial and neck defects caused by ablative surgery. LEVEL OF EVIDENCE 4.
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Abstract
OBJECTIVES To compare the outcomes and complications of the anterolateral thigh free flap (ALT FF) versus other free muscle flaps for reconstruction of traumatic defects of the lower extremity. DESIGN Retrospective review from a single plastic and reconstructive surgical unit comparing outcomes between 2 free flap groups-ALT FF and other commonly used muscle free flaps. SETTING Tertiary referral University Hospital Level I Trauma Center. PATIENTS Hundred patients who underwent lower extremity salvage for traumatic injuries. INTERVENTION Free flap coverage of traumatic lower extremity injuries. MAIN OUTCOMES MEASUREMENTS Successful for limb salvage, intraoperative and postoperative complications. DATA SYNTHESIS Categorical variables were analyzed using χ and Fisher exact tests; continuous variables were examined using Wilcoxon rank-sum test. CONCLUSIONS The ALT FF is equivalent in success to other traditional nonfasciocutaneous free flaps but may provide a more durable supple coverage with all components of the native soft-tissue envelop that can be tailored to the reconstructive needs of the traumatized lower extremity. Limb salvage outcomes may still be heavily influenced by the original severity of injury. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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FLiGS Score: A New Method of Outcome Assessment for Lip Carcinoma-Treated Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e345. [PMID: 26034652 PMCID: PMC4448720 DOI: 10.1097/gox.0000000000000306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: Lip cancer and its treatment have considerable functional and cosmetic effects with resultant nutritional and physical detriments. As we continue to investigate new treatment regimens, we are simultaneously required to assess postoperative outcomes to design interventions that lessen the adverse impact of this disease process. We wish to introduce Functional Lip Glasgow Scale (FLiGS) score as a new method of outcome assessment to measure the effect of lip cancer and its treatment on patients’ daily functioning. Methods: Fifty patients affected by lip squamous cell carcinoma were recruited between 2009 and 2013. Patients were asked to fill the FLiGS questionnaire before surgery, 1 month, 6 months, and 1 year after surgery. The subscores were used to calculate a total FLiGS score of global oral disability. Statistical analysis was performed to test validity and reliability. Results: FLiGS scores improved significantly from preoperative to 12 months postoperative values (P = 0.000). Statistical evidence of validity was provided through rs (Spearman correlation coefficient) that resulted >0.30 for all surveys and for which P < 0.001. FLiGS score reliability was shown through examination of internal consistency and test-retest reliability. Conclusions: FLiGS score is a simple way of assessing functional impairment related to lip cancer before and after surgery; it is sensitive, valid, reliable, and clinically relevant: it provides useful information to orient the physician in the postoperative management and in the rehabilitation program.
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Bui TG, Dierks EJ. Reconstruction of cervical defects. Atlas Oral Maxillofac Surg Clin North Am 2015; 23:105-115. [PMID: 25707569 DOI: 10.1016/j.cxom.2014.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Tuan G Bui
- Oral and Maxillofacial Surgery, Oregon Health and Sciences University, Portland, OR, USA; Head and Neck Surgical Institute, 1849 Northwest Kearney Street, #300, Portland, OR 97209, USA.
| | - Eric J Dierks
- Oral and Maxillofacial Surgery, Oregon Health and Sciences University, Portland, OR, USA; Head and Neck Surgical Institute, 1849 Northwest Kearney Street, #300, Portland, OR 97209, USA
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