The sternocleidomastoid flap--its indications and limitations

Radial Forearm Flap for Esophageal Perforation After Anterior Cervical Hardware Removal: Surgical Technique and Case Report

CASE

A 51-year-old woman, who had previously undergone C5-C7 anterior cervical discectomy and fusion, presented with symptomatic hardware failure and subsequently underwent instrumentation removal. Her postoperative course was complicated by an esophageal perforation. Despite initial repair using a rotational flap, the leak persisted, prompting esophageal reconstruction with a radial forearm free flap (RFFF).

CONCLUSION

Persistent esophageal perforation is exceedingly rare and difficult to treat. This report discusses the surgical technique for RFFF, an excellent option for revising failed sternocleidomastoid rotational flaps. The decision between rotational repair and free flap reconstruction depends on factors such as defect size, vascularization, wound condition, and donor site morbidity.

First standardized assessment of perforators and perforasomes of the occipital artery - An anatomical study

BACKGROUND

Flaps have become an integral part of plastic and reconstructive surgery. The robust blood supply of such flaps is a prerequisite to reduce flap failure. Despite the reported versatility of the occipital flap, comprehensive anatomical studies on its perforators and perforasomes are lacking. Hence, we examined the perforators originating from the occipital artery and their associated perforasomes, aiming to fill this knowledge gap for reconstructive surgery techniques.

METHODS

39 of 40 occipital arteries of 20 fresh anatomical head specimens were dissected. Perforators with a least an outer diameter of 0.50 mm were identified and injected with dye to color their respective perforasomes. Location and size of the colored skin areas were determined as well as the location of their perforators were documented and analyzed.

RESULTS

In total, 183 perforators were found and described. The mean diameter of these vessels was 0.88 ± 0.27 mm (0.5-2.1 mm). The mean area of the perforasomes was 1288.26 ± 662.51 mm2 (144.60-3890.60 mm2). They were localized over the whole nuchal and occipital area. Lastly, perforator diameters were significantly associated with the size of their resulting perforasomes.

CONCLUSION

This study is the first comprehensive overview of perforators and associated perforasomes of the occipital artery on a respectable amount of specimen. The arterial supply of big portions of the occipital and nuchal area is provided solely by the perforators of the occipital artery. For flap surgery, perforator diameter is a crucial detail to be considered in the decision-making process.

Features of the use of ladder myoplasty of a gunshot wound to the laryngopharynx: Case report

INTRODUCTION AND IMPORTANCE

The laryngopharynx wound is considered to be one of the most severe wounds of neck both in war and in peace, as it may cause life threatening changes in the whole body (asphyxia, bleeding, shock). Important aspects of surgical treatment are to ensure full breathing, acceptable ways of feeding, and the use of reliable wound closure techniques aimed to prevent digestive tract failure and to maintain the framework and aerostasis of the laryngotracheal region.

CASE PRESENTATION

A case of unilateral multiple wounds of the laryngopharynx was described in the article. The features of diagnostics, surgical treatment and conservative therapy in the postoperative period with this injury were presented. The wounded man was urgently operated. During surgery the pharynx was mobilized. The metal fragment was removed. The wound of the pharynx was sutured with a two-row suture. The next stage of the surgical treatment was myoplasty. In the case of the patient, the purpose of myoplasty was additional sealing of the pharyngeal suture and myoplasty of the thyroid cartilage injury zone for the purpose of aerostasis. Because of the size of the wounds and their anatomical localization, we used the mobilized lower edge of the Musculus sternocleidomastoideus for myoplasty and proposed the method of ladder myoplasty developed by us.

CLINICAL DISCUSSION

In myoplasty method the following criteria must be followed: the muscle flap must be of sufficient length and width, so as not to cause excessive tension in the myoplasty area; the flap must be thick enough to avoid necrosis that may cause subsequent infectious complications; when taking the flap, the most sparing operative access should be used to avoid functional and anatomical disorders; the volume of the taken muscle flap must not lead to functional and anatomical disorders.

CONCLUSION

The proposed method of ladder myoplasty using Musculus sternocleidomastoideus is unique, and proves its high efficiency in unilateral multiple laryngopharyngeal injuries, and can be recommended for wide clinical implementation in such clinical situations.

Clinical comparison of superior thyroid artery perforator flap and sternocleidomastoid myocutaneous flap for intraoral reconstruction

The aim was to evaluate the techniques and outcomes of superior thyroid artery perforator flaps (STAPF) for intraoral reconstruction and to compare them with those of the sternocleidomastoid myocutaneous flap (SCMMF). The cases of 43 patients who underwent reconstruction with either a SCMMF or STAPF for the repair of a medium-sized intraoral defect, between January 2013 and December 2020, were reviewed retrospectively. Although both flaps are based on the superior thyroid artery, their specific harvesting techniques largely differ. All SCMMF (n = 23) were superiorly-based rotational flaps with myocutaneous designs. The STAPF cases (n = 20) included 18 septocutaneous flaps and two chimeric flaps. The flap size was larger in the STAPF group (P = 0.008), while incomplete level IIB dissection (oncological safety) was more frequent in the SCMMF group (P = 0.002). The flap necrosis rate was lower in the STAPF group (STAPF 15% vs SCMMF 34.8%, though this was not statistically significant). Cox multivariate analysis showed that the postoperative flap outcome (total flap necrosis vs flap survival; hazard ratio 27, 95% confidence interval 2.149-336.05; P = 0.001) and complications (excluding fistula) (hazard ratio 14, 95% confidence interval 1.314-142.767; P = 0.029) were associated with overall patient survival. Both speech (P < 0.001) and neck mobility (P < 0.001) functions were superior with STAPF reconstruction. Compared with the traditional SCMMF, the STAPF was found to have a lower necrosis rate with uncompromised oncological safety during harvesting. The STAPF is a good alternative for the repair of medium-sized head and neck defects.

Facial Reconstruction Using Sternocleidomastoid (SCM) Flap: A Review of the Literature

The sternocleidomastoid (SCM) flap has been used for a long time in protective coverage of major vessels, reconstruction of intraoral pharyngeal, closure of pharyngo-cutaneous fistulas, and augmentation of soft tissue defects in the oral and maxillofacial region. However, this flap is not yet commonly used due to doubtful blood supply to the flap. This flap offers favorable esthetic results, combined flap, rich vascularization, and the possibility of shifting the two heads of the muscle. Thus, this flap has been used broadly in the maxillofacial region to reconstruct the defects of the post-parotidectomy, mandible, pharynx, and floor of the mouth defects. Previous studies discussed the use of a SCM flap following parotidectomy. However, few studies explained the use of SCMs in facial reconstruction. This study aims to review published articles discussing the use of SCMs for facial reconstruction.

A comparative study on using superior thyroid artery perforator flaps versus traditional sternocleidomastoid myocutaneous flaps for reconstructions after oral cancer ablation: "New tricks for old dogs"?

OBJECTIVES

To introduce new superior thyroid artery perforator flaps (STAPF), and to compare the clinical outcomes with sternocleidomastoid myocutaneous flaps (SCMMF) for their intraoral applications.

MATERIALS AND METHODS

Between January 2013 and December 2020, forty-three oral cancer patients who received post-oncologic reconstructions with one of these two regional flaps were retrospectively collected. Their techniques and outcomes were compared. All the STAPFs were preprepared with radiologic evaluations.

RESULTS

Despite the common arterial origins, the compositions and harvesting procedures of STAPF and SCMMF were different. Though SCMMFs (n = 23) were designed in rotational styles, most STAPFs (n = 20) were septocutaneous perforator flaps, with 2 chimeric ones. In addition, the sizes of STAPFs were generally larger than those of SCMMFs (p = 0.006). Success rate for STAPFs was much higher, with only three partial cutaneous necroses. Radiotherapy delay was more frequently found in those reconstructed with SCMMFs (P = 0.046), mostly due to fistula formations. Besides, incomplete level IIB dissections were also reported in 9 (20.9%) patients in SCMMF group. In our study, the overall survival was affected by both flap conditions (p = 0.014, 1.333-12.881) and postoperative surgical complications (except fistula) (P = 0.005, 2.240-84.134). Functionally speaking, post-reconstructive speech and neck mobility (p < 0.001) were better in the STAPF group.

CONCLUSIONS

With accumulated experiences on the use of locoregional flaps in the neck, STAPF, when well-prepared, can provide superior reconstructive outcomes for various intraoral defects. As a comparison with SCMMF in the same middle region, STAPF is a viable option with higher success rates and oncological safety for oral cancer patients.

Island sternocleidomastoid myocutaneous flap for posterior pharyngeal wall defect repair after anterior cervical spine surgery

Injuries and tumours of the cervical spine represent therapeutic challenges to the treating surgeon due to the complex anatomical relationships and biomechanical features. The anterior cervical midline (ACM) and anterior cervical retropharyngeal (ACR) approaches are effective and safe surgical approaches for certain cervical spine lesions, such as cervical spine neoplasms, atlantoaxial subluxation, and certain odontoid fractures. Posterior pharyngeal wall defects (PPWDs) is one of the most frequently encountered surgical morbidities after anterior cervical spine surgery (ACSS). However, limited information has been published concerning effective approaches for PPWD reconstruction after ACSS. The manuscript aimed to describe a novel application of the island sternocleidomastoid myocutaneous flap (ISMF) in the management of PPWDs after ACSS, including surgery with the ACM approach and ACR approach. From April 2015 to November 2019, the clinical data of three patients with PPWDs repaired using the ISMF in Peking university third hospital were retrospectively analysed. The observational indexes are as follows: postoperative survival of the flap, wound healing 2 weeks after surgery, eating and pronunciation function 2 months after surgery. The above indexes of these three cases recovered well. Three patients did not have any persistent PPWD after repair with the ISMF and did not require any further surgical procedures related to the cervical spine.

The effect of external jugular vein's preservation on the prognosis of sternocleidomastoid myocutaneous flap

OBJECTIVE

As a supplementary and significant pedicle flap,the sternocleidomastoid (SCM) myocutaneous flap has been be flexiblely used in the reconstruction of oral soft tissue defect. The problem of venous stagnation after its transposition limited its clinical application.To improve its application, we raised a modified SCM flap for oral softtissue defect reconstruction.

METHOD

We carried out a continuous retrospective study of 43 patients who had tissue defects because of oral carcinomas resection and underwent reconstruction with modified SCM flap from April 2014 to January 2017.

RESULTS

3 of 43 cases had partial flap necrosis and there were primary healing in the rest 40 cases. During the follow-up,4 patients were lost, 2 patients recurred in situ and 2 patients had neck recurrence. The remaining patients were satisfied with their appearance, and had normal oral function.

CONCLUSION

Modified SCM flap is simple to harvest. It can improve the venous return and has a high survival rate. It has active effect in the recovery of the function of oral and maxillofacial region and elevates quality of life of patients.

A novel application of superior thyroid artery perforator flaps for medium-sized intraoral reconstructions: Retrospective analysis of 12 cases

BACKGROUND

To describe the indications, technique, and preliminary experience in the application of the superior thyroid artery perforator flap (STAPF) for the reconstruction of various medium-sized intraoral defects.

METHODS

From September 2018 to September 2019, 12 consecutive cases of oral squamous cell carcinoma underwent reconstruction with a STAPF. Clinical details were collected, and postoperative function was analyzed.

RESULTS

The venous drainage of the STAPF is variable with drainage into the internal jugular vein in six cases, into both the internal and external jugular veins in four cases, and into the external jugular vein in two cases. Ten cases were harvested as pedicled flaps, while two cases required a venous anastomosis due to inadequate length of the venous pedicle. Ten flaps survived completely, whereas two flaps had partial necrosis that ultimately resolved with secondary healing.

CONCLUSIONS

STAPF is a reliable method for the reconstruction of medium-sized intraoral defects.

Reconstruction of Oromandibular Defect After Tumor Resection by Sternomastoid-clavicular Flap

ABSTRACT

The study aims to evaluate sternocleidomastoid-clavicular osteo-myocutaneous flap (SCM-OMCF) for reconstruction of mandibular defects after tumor resection. In the period between 2010 and 2018, thirteen patients with primary mandibular tumors underwent mandibular resection and reconstruction with SCM-OMCF. Patients were followed up for 10 to 66 months. Hospital was 13 ± 4 days. All patients started fluid in the 2nd day. The mean time to start oral fluid was 7.5 ± 0.8 day. Four (30.8%) patients suffered from complications (infection and salivary leak in 1 case due to partial flap loss, donor wound dehiscence in 1 case, deep venous thrombosis in 1 case and chest infection in 1 case). None of our cases experienced motor disability. Two cases (15.9%) underwent reoperations. The overall aesthetic outcome was found excellent in 5 cases, satisfactory in 5 cases and fair in 3 cases. The functional outcomes were satisfactory. Tumor recurrences were detected in 2 (15.9%) patients. Two patients died during follow up within 2 years after 1st surgery due to local and distant recurrences. SCM-OMCF is a versatile, safe and simple technique for reconstructing mandibular defects less than 11 cm.

Clinical management of squamous cell carcinoma of the tongue: patients not eligible for free flaps, a systematic review of the literature

INTRODUCTION

The management of squamous cell carcinoma (SCC) of the tongue represents the most demanding treatment planning in head and neck surgery. Ablation followed by free flap reconstruction is considered the gold standard, but not all patients are suitable for this strategy. The aim of this review is to provide a comprehensive view of surgical reconstruction possibilities in patients not eligible for free flaps.

METHODS

Following PRISMA recommendations, a systematic literature review was conducted searching for original papers that investigated outcomes of patients treated by surgical ablation for tongue SCC followed by reconstruction with local or pedicled flaps. Selected papers were read and data extracted for qualitative analysis.

RESULTS

Twenty articles met the inclusion/exclusion criteria. The study design was case series in sixteen papers, cohort study in the remaining four. Four different local flaps (BMM, FAMM, NLIF, SMIF) and four regional flaps have been discussed in included studies (IHF, SFIF, SCM, PMMC).

CONCLUSION

The improved anatomical knowledge makes local flaps a reliable alternative to free tissue transfer in cases requiring small-/medium-sized defects. Regional flaps still represent cornerstones in reconstruction of the tongue. Ease of execution, costs-to-benefit ratio, low-rate complications, minimal donor site morbidity represent the best advantages choosing local/regional flaps.

Smart flap of sternocleidomastoid muscle in anterior cervical spine surgery: Surgical anatomical dissection technique

The use of sternocleidomastoid muscle flap has firstly been described in 1909. In spine surgery, it is usually reserved in the cases of revision after anterior cervical spine procedures. The aim of this article is to introduce its usage as prophylactic measure in cases at high risk of iatrogenic fistula formation. The procedure consists of three main steps: sternocleidomastoid isolation, flap design and harvesting, and flap fixation. The use of a surgical anchor allows a better adherence to the plate preventing hematoma formation. The use of SCM smart flap in primary anterior cervical spine surgery as a prophylactic method could be considered a safe and feasible procedure in patients with a high risk of iatrogenic fistulas.

Revisiting the sternocleidomastoid flap as a reconstructive option in head and neck surgery

Background

The sternocleidomastoid can be used as a pedicled flap in head and neck reconstruction. It has previously been associated with high complication rates, likely due in part to the variable nature of its blood supply.

Objective

To provide clinicians with an up-to-date review of clinical outcomes of sternocleidomastoid flap surgery in head and neck reconstruction, integrated with a review of vascular anatomical studies of the sternocleidomastoid.

Methods

A literature search of the Medline and Web of Science databases was conducted. Complications were analysed for each study. The trend in success rates was analysed by date of the study.

Results

Reported complication rates have improved over time. The preservation of two vascular pedicles rather than one may have contributed to improved outcomes.

Conclusion

The sternocleidomastoid flap is a versatile option for patients where prolonged free flap surgery is inappropriate. Modern vascular imaging techniques could optimise pre-operative planning.

The Sternocleidomastoid Myocutaneous Flap: A Laryngeal Preservation Option for Total Hypopharyngoesophageal Stenosis

Complete hypopharyngoesophageal (HPE) stenosis is rare and a challenging condition to treat. When endoscopic therapy fails, total laryngectomy with or without pharyngeal reconstruction is usually performed. We present a retrospective case series involving 3 patients with complete HPE stenosis who failed endoscopic repair and were gastrostomy dependent. All were managed successfully with the sternocleidomastoid myocutaneous (SCM) flap. A temporary fistula occurred in 1 patient. Hospitalization ranged from 5 to 15 days, patients resumed oral intake from 21 to 82 days postoperatively, and their gastrostomy tubes were removed from 28 to 165 days postoperatively. We suggest that the SCM flap is a laryngeal preservation option for reconstruction of complete HPE stenosis when endoscopic techniques fail. This flap allows HPE repair and reconstruction within the same surgical field, imposes no significant donor site morbidity, and affords good functional and cosmetic outcomes.

Use of the sternocleidomastoid flap in association with a dermal regeneration template and a skin graft in the temporal region reconstruction

Since its first description in 1908, the sternocleidomastoid flap (SCM) has gained popularity in head-and-neck reconstruction as a regional flap. We reported a 69-year-old Caucasian male who was evaluated in our clinic for a large, bloody, esophitic, and ulcerated lesion of the right temporoparotideal region associated with several actinic keratoses of the head skin. After resection of the tumor, taking into consideration the patient's comorbidities and surgical defect characteristics, we decided to use the SCM flap for the reconstruction. The SCM flap was harvested as a muscular flap to avoid as possible skin paddle necrosis due to the poor conditions of the patient's vessels. Moreover, considering the surgical site depth and to prevent a postsurgical excessive scar retraction, the muscle was covered with Integra^® Dermal Regeneration Template single layer and a skin graft was harvested from the left thigh. The follow-up at 1 year confirmed that both oncological and reconstructive goals were successfully achieved. In our experience, the SCM flap in association with a dermal regeneration template and a skin graft can be considered as a reliable and possible option in temporal region reconstruction when local or systemic conditions of the patient do not permit other reconstructive options.

The Effects of Superficial Musculoaponeurotic System Flap on the Development of Frey's Syndrome and Cosmetic Outcomes After Superficial Parotidectomy

Objective

To investigate the outcomes of superficial musculoaponeurotic system (SMAS) flap and classic techniques in superficial parotidectomy in terms of Frey's syndrome (FS) and cosmetic satisfaction.

Methods

In this study, a retrospective chart review of patients that underwent superficial parotidectomy was performed. These patients were divided into two subgroups: group 1 included patients in which the SMAS flap was harvested and group 2 comprised the remaining patients on whom classic superficial parotidectomy was performed. All the patients were evaluated clinically and with Minor's starch-iodine test for FS. For the evaluation of the cosmetic results, the patient's satisfaction was queried according to the incision scar and surgical field skin retraction/facial symmetry. Both groups were compared in terms of complications and numbness of surgical area.

Results

Fifty-five patients (31 male and 24 female) with a mean age of 50.19 years were included in the study. Thirty-two patients were in group 1 and 23 in group 2. Thirteen patients (23.7%) described as having FS and six of them were in group 1, while seven were in group 2. Minor's starch-iodine test was positive in nine patients in group 1 (28.1%) and six patients in group 2 (26.1%) (p=1.000). With regard to cosmetic satisfaction, eight patients (25%) stated mild discomfort from the incision scar and two patients (6.3%) stated cosmetic dissatisfaction for facial asymmetry in group 1. In group 2 for the same factors the number of patients were 11 (47.8%) and 2 two (8.7%), respectively (p=0.027). There were no statistically significant differences in means of complication and numbness (p>0.05).

Conclusion

According to our study results, there was no superiority between both the groups in terms of FS and incision scar satisfaction. We determined that there was a significant benefit of SMAS flap application in the prevention of volume loss and surgical area retraction.

Surgical Management of Recurrent Tracheocarotid Fistula following Endovascular Stent Placement

We report the case of a 25-year-old woman who developed a tracheocarotid fistula secondary to an infected endovascular stent placed in the right carotid artery after the patient experienced hemorrhage on her first tracheostomy change. The patient originally had the tracheostomy placed at an outside hospital in September 2014, due to prolonged intubation after a motor vehicle accident. The patient presented to the otolaryngology service with an acute tracheal hemorrhage. This necessitated a neck exploration, median sternotomy, right carotid stent removal with subclavian to carotid bypass, and sternocleidomastoid flap reconstruction. This paper addresses the epidemiology and anatomy of a tracheocarotid fistula and discusses methods to treat such a complication.

Flap Reconstruction for Esophageal Perforation Complicating Anterior Cervical Spinal Fusion: An 18-year Experience

Background:

Esophageal injury following anterior cervical discectomy and fusion (ACDF) poses a significant reconstructive challenge. Buttressing flap repairs have proven beneficial; however, there remains a paucity of evidence to guide optimal flap selection.

Methods:

A retrospective chart review was performed for patients who presented to the senior author with esophageal perforations after ACDF from 1995 until present. Demographic, clinical, and postoperative details were collected. Outcomes of omental flap reconstructions were compared against other flap reconstructions.

Results:

A total of 13 flap reconstructions were performed in 11 patients with the following distribution: 7 free omental, 1 anterolateral thigh, 1 osteomuscular fibula, 2 radial forearm, and 2 pedicled pectoralis flaps. Patients receiving omental flap reconstructions demonstrated a significantly faster resolution of leak on contrast swallow imaging and earlier return to oral feeding compared with all other flap reconstructions (22.5 versus 268 days, respectively; P < 0.05). This relationship remained evident even when calculations excluded an outlying patient from the nonomental cohort (22.5 versus 111 days, respectively; P < 0.05). Length of hospital stay, complications, and success rates were also more favorable in the omental cohort but failed to reach statistical significance.

Conclusions:

Esophageal perforation after ACDF is an uncommon but devastating complication. The use of free omentum flap reconstruction is associated with a more rapid functional recovery and may prove beneficial in the management of these challenging cases.

Reconstruction of periparotid defects using temporoparietal fascia flap with layered acellular human dermal allograft

Excision of lesions in the periparotid area can leave a sizable concavity of the preauricular area with skeletonization of the mandible. To achieve the bulk necessary to fill this defect, we propose using a composite graft. Acellular human dermal allograft provides the thickness of the graft, and the temporoparietal fascia flap provides blood supply to the dermal graft. Our hypothesis is that vascularization of the graft will promote greater ingrowth of native tissue and prevent breakdown and absorption of the graft. Four representative patients are described.

Surgical repair of long-segment cervical esophageal injury with a sternocleidomastoid myocutaneous flap

We present a useful technique for the surgical management of long-segment cervical esophageal tears using a sternocleidomastoid flap with overlying skin patch. The flap is easily accessible, customizable, and offers the ability to repair long segments of cervical and upper thoracic esophageal injuries.

The sternocleidomastoid myocutaneous "patch esophagoplasty" for cervical esophageal stricture

Esophageal strictures may be caused by many etiologies. Patients suffer from dysphagia and many are tube-feed dependent. Cervical esophageal reconstruction is challenging for the plastic surgeon, and although there are reports utilizing chest wall flaps or even free flaps, the use of a sternocleidomastoid (SCM) myocutaneous flap provides an ideal reconstruction in select patients who require noncircumferential "patch" cervical esophagoplasty. We present two cases of esophageal reconstruction in which we demonstrate our technique for harvesting and insetting the SCM flap, with particular emphasis on design of the skin paddle and elucidation of the vascular anatomy. We believe that the SCM flap is simple, reliable, convenient, and technically easy to perform. There is minimal donor site morbidity with no functional loss. The SCM myocutaneous flap is a viable option for reconstructing partial esophageal defects and obviates the need to perform staged procedures or more extensive operations such as free tissue transfer.

Lucja Frey--historical relevance and syndrome review

BACKGROUND

This article documents an objective review ofthe neuro-anatomical, diagnostic and clinical implications of the auriculotemporal syndrome (Frey's syndrome). The incidence of Frey's syndrome after parotidectomy as cited in the literature varies. It may also be a sequela to a variety of inflammatory, infective and traumatic aetiologies.

METHOD

An electronic search using the search engine Google, Medline and Pubmed was performed under 'Lucja Frey', 'Gustatory sweating', 'The auriculotemporal syndrome', 'Botulinum toxin'. Relevant papers were systematically reviewed from 1965 to present.

CONCLUSIONS

This disorder is important for ENT surgeons and allied specialties. We present the main surgical and cosmetic therapeutic strategies in the literature. We also discuss the fascinating life of Lucja Frey. As one of the first female academic neurologists in Europe, her career and life were tragically altered by the events of World War II.

Evaluation of meta-analyses in the otolaryngological literature

OBJECTIVE: To evaluate the quality of meta-analyses written on otolaryngological topics and define areas that can be improved upon in future studies.

DATA SOURCES: MEDLINE (PubMed) and EMBASE databases were searched. The Cochrane database of systematic reviews was excluded, because these meta-analyses have already been critically evaluated and found to be of high quality.

REVIEW METHODS: A systematic review of otolaryngological meta-analyses published between 1997 and 2006 (10 years) was performed in duplicate and independently by two authors. The search included 16 common otolaryngological terms. Inclusion criteria were meta-analytic methodology, otolaryngological topic, and at least one author from a department of otolaryngology. Fifty-one articles fulfilled eligibility criteria. In duplicate and independently, two reviewers assessed the quality of eligible metaanalyses using a validated 10-item index called the Overview Quality Assessment Questionnaire. Using the methods of Spearman, correlation coefficients are reported for associations examined between covariates and the Overall Score Quality.

RESULTS: The majority of studies had methodologic flaws (mean score 3.9, scale of 1-7). Variables predicting higher-quality meta-analyses were publication in journals with higher impact factors ( P = 0.0007) and authors who previously published metaanalyses ( P = 0.0001). Using and reporting about a validity assessment tool needs to be improved upon in future studies.

CONCLUSION: The quality of meta-analyses on otolaryngological topics is moderate. Future meta-analyses can be improved upon by following evidence-based guidelines for the reporting of metaanalyses, which include the use of a validity assessment tool, and consulting with an author familiar with meta-analysis methodology.

Sternocleidomastoid Myofascial Flap for Reconstruction After Composite Resection of Invasive Squamous Cell Carcinoma of the Tonsillar Region: Technique and Outcome

OBJECTIVE

To present the surgical technique and determine the efficacy of sternocleidomastoid myofascial (SCMF) flap reconstruction after composite resection with intent to cure.

STUDY DESIGN

Retrospective review of 73 consecutive patients with a previously isolated and untreated moderately to well-differentiated invasive squamous cell carcinoma of the tonsillar region and a minimum of 3 years follow-up, managed at a tertiary referral care center during the years 1970 to 2002, with an ipsilateral superiorly based SCMF flap after composite resection.

METHODS

The surgical procedure is presented in detail. Potential technical pitfalls are highlighted. Survival, mortality, and morbidity are documented. Univariate analysis for potential correlation between the incidence for postoperative flap complications and various variables is also performed.

RESULTS

The 1, 3, and 5 year Kaplan-Meier actuarial survival estimates were 82.2%, 64.4%, and 49.3%, respectively. Death never appeared to be related to the completion of the SCMF flap. Thirty-three (45.2%) patients had some kind of significant postoperative surgical complication, and nine (12.3%) patients had some kind of significant postoperative medical complication. The most common significant postoperative complication was partial SCMF flap necrosis and pharyngocutaneous fistula noted in 30.1% and 10.9% of patients, respectively. Complete SCMF flap necrosis was never encountered. No patient developed carotid artery rupture or died as a result of the SCMF flap, and none required additional surgery. In univariate analysis, no significant statistical relation was noted between the significant postoperative surgical complications related to the use of the SCMF flap and the variables under analysis.

CONCLUSIONS

The superiorly based SCMF flap appears to be simple to perform and useful for reconstruction of defects after composite resection.

Critical oropharyngocutaneous fistulas after microsurgical head and neck reconstruction: indications for management using the "tissue-plug" technique

Despite advances in head and neck reconstruction with free-tissue transfer techniques, oropharyngocutaneous fistulas continue to present challenging and potentially lethal complications. The authors present a system for prioritizing these fistulas and the surgical management of nine patients in whom critical fistulas developed after microsurgical head and neck reconstruction. The indications for aggressive management of these fistulas were primarily dependent on their location. Three peristomal and six midneck fistulas were considered critical because of the risk of aspiration pneumonia and carotid artery blowout, respectively. Fistulas located in the submental and/or submandibular region were considered noncritical and were managed conservatively. Using the concept of a "tissue plug" for fistula repair, a dermal component (i.e., a deltopectoral or pectoralis major pedicled flap) is guided through the fistula, and with external traction the tissue "plugs" the tract. No sutures are placed directly in the surrounding friable tissue. There were no partial or total flap losses. There were two fistula recurrences in patients who had received postoperative radiation therapy. One of these recurrences was due to tumor recurrence within the previous fistula and was managed with palliative measures. The other fistula recurrence was closed with a local-flap procedure on an outpatient basis. All patients resumed oral feeding, except for the patient in whom tumor recurrence was suspected. This tissue-plug technique can be used in the management of critical peristomal and/or midneck oropharyngocutaneous fistulas not only to obliterate the tract but also to augment volume and vascularity in already damaged, ischemic, and deficient tissue.