Virtual surgical planning for mandibular reconstruction in an abbreviated admission pathway

OBJECTIVES

Virtual Surgical Planning (VSP) creates individualized surgical plans for free flap reconstruction of mandibular defects. Prior studies indicate that VSP can offer cost benefits due to reduced operative time and length of stay (LOS). We assessed the impact of VSP in the context of a validated postoperative abbreviated LOS clinical pathway.

METHODS

This study assessed patients undergoing VSP vs conventional fibular free flap reconstruction for mandibular defects (12/2015-10/2020) and their operative time, ischemia time, and LOS were evaluated.

RESULTS

Forty-four patients underwent VSP reconstruction, while 52 patients underwent conventional reconstruction for mandibular defects. VSP was associated with significantly lower total operative time (6 h and 57 mins vs 7 h and 54 mins, p = 0.011), but not length of stay or ischemia time. Total OR time was significantly increased with increasing number of segments needed in both the VSP group (p = 0.002) and the conventional group (p = 0.015).

CONCLUSION

Shorter operative times and LOS have been attributed to the use of VSP in free tissue transfers. It is argued that these reductions offset the added cost of VSP. Our study indicates that there is no cost benefit for VSP utilization due to a significantly reduced operative time with no impact on length of admission in an abbreviated admission clinical pathway following free tissue transfer.

Utility of video fluoroscopic swallow study in advancing oral diet post TORS for oropharyngeal malignancies

OBJECTIVE

TORS is a minimally invasive surgical alternative to chemoradiotherapy for oropharyngeal malignancies. While early postoperative oropharyngeal dysphagia is linked to TORS, this study explores both subjective and objective swallowing outcomes.

STUDY DESIGN

Retrospective and prospective review of the patients who underwent TORS for oropharyngeal malignancy from 2018 to 2023.

SETTING

Single tertiary referral center.

METHODS

Postoperative transnasal feeding tubes were administered to 142 patients undergoing TORS. Data on oncological, clinical, surgical, and pathological parameters, including VFSS records, pain with swallow, and feeding tube removal timing, were collected. Clinical swallow exam (CSE) was conducted on POD-1, with a formal swallow study pursued if inconclusive. Once a safe swallow was confirmed, oral diets were initiated, and the feeding tube removed, with most patients discharged on POD-2.

RESULTS

At an average age of 59.3 years on the day of operation, the palatine tonsil (N = 101) was the predominant subsite. A dobhoff feeding tube was intraoperatively placed in 98 % of patients (N = 139). On POD-1, CSE was conducted in 119 patients, with 26 % (37/119) cleared for total oral diet (NOMS ≥ 4). Additionally, 30 out of 73 VFSS patients were cleared for total oral diet. A total of 54.9 % (78/142) had the feeding tube removed before discharge on POD-2, with a mean time of 6.5 ± 6.6 days. Overall, 71.1 % (101/142) achieved a total oral diet within one week after TORS.

CONCLUSION

Early post-TORS swallowing is vital for oropharyngeal malignancies. VFSS assesses post-operative swallowing safety, allowing most patients to resume total oral nutrition shortly after TORS.

Correlating area deprivation index with initial stage at presentation and with follow up and recurrence within an advanced practice provider-led survivorship clinic

INTRODUCTION

Living in disadvantaged neighborhoods has been shown to result in worse healthcare outcomes. The Area Deprivation Index (ADI) is a metric that ranks neighborhoods by socioeconomic disadvantage utilizing numerous factors including income, education, employment, and housing quality.

METHODS

A retrospective review of all patients who underwent surveillance in an APP-led head and neck cancer survivorship clinic from Dec 2016 to Oct 2020 at an academic tertiary care center were included. Tumor characteristics, visit frequency, recurrence, number of missed appointments, loss of follow up, and ADI scores were collected.

RESULTS

543 patients were included in the study. A majority were male (69.9 %) and white race (84.9 %) with an average age of 64.6 years old. Average ADI national percentile score was 71.6(range: 17 to 100). ADI national percentile score was not predictive of tumor characteristics at initial presentation: lymphovascular invasion (p = 0.940; OR 1.0 [95 % CI: 0.9 to 1.1]), extranodal extension (p = 0.576; OR 1.0 [95 % CI: 0.9 to 1.2]), positive margins (p = 0.069; OR 0.9 [95 % CI: 0.9 to 1.0]). ADI national percentile score was not significantly correlated with loss to follow up (p = 0.153; OR 1.2 [95 % CI: 0.9 to 1.7] or cancer recurrence (p = 0.594; OR 1.0 [95 % CI: 0.9 to 1.1]). Missing one or more clinic visits was correlated with loss to follow up (p = 0.029; OR 13.1 [95 % CI: 1.3 to 131.7].

CONCLUSION

Living in a disadvantaged neighborhood did not correlate with negative tumor characteristics, loss to follow up, or recurrence within an APP-led survivorship head and neck cancer clinic.

Subjective Voice Outcomes in Surgeon Versus Technician-Monitored Recurrent Laryngeal Nerves in Thyroidectomy

OBJECTIVES

To compare subjective voice outcomes and postoperative laryngoscopic examination findings of patients with subjective voice complaints between surgeon-monitored and certified technician-monitored thyroidectomies.

METHODS

Patients who underwent hemithyroidectomy, total thyroidectomy, and completion thyroidectomy using a nerve monitoring system between November 2015 and June 2018 were included in the study. Retrospective chart review was carried out to assess how often patients reported voice changes and to record postoperative flexible laryngoscopic findings of patients when that examination was performed. Data were analyzed using the χ2 test to identify significant differences in outcomes for the 2 groups.

RESULTS

A total of 293 procedures was performed among 3 surgeons. Surgeons monitored the nerves in 147 cases and a certified technician monitored the nerves in 146 cases. Subjective voice changes were identified in 11 (7.48%) cases in the surgeon-monitored group and in 20 (13.70%) cases in the technician-monitored group (P = .084). Among the patients who expressed subjective voice changes, 7 patients were identified with vocal cord hypomobility or immobility in the surgeon-monitored group and 13 patients had an abnormal examination in the technician-monitored group (P = .234).

CONCLUSIONS

Subjective voice changes or proven vocal cord mobility problems were not different between surgeon-monitored patients and technician-monitored patients in thyroidectomies.

Oncologic Safety of Close Margins in Patients With Low- to Intermediate-Grade Major Salivary Gland Carcinoma

Importance

Postoperative radiation therapy for close surgical margins in low- to intermediate-grade salivary carcinomas lacks multi-institutional supportive evidence.

Objective

To evaluate the oncologic outcomes for low- and intermediate-grade salivary carcinomas with close and positive margins.

Design, Setting, and Participants

The American Head and Neck Society Salivary Gland Section conducted a retrospective cohort study from 2010 to 2019 at 41 centers. Margins were classified as R0 (negative), R1 (microscopically positive), or R2 (macroscopically positive). R0 margins were subclassified into clear (>1 mm) or close (≤1 mm). Data analysis was performed from June to October 2023.

Main Outcomes and Measures

Main outcomes were risk factors for local recurrence.

Results

A total of 865 patients (median [IQR] age at surgery, 56 [43-66] years; 553 female individuals [64%] and 312 male individuals [36%]) were included. Of these, 801 (93%) had parotid carcinoma and 64 (7%) had submandibular gland carcinoma, and 748 (86%) had low-grade tumors and 117 (14%) had intermediate-grade tumors, with the following surgical margins: R0 in 673 (78%), R1 in 168 (19%), and R2 in 24 (3%). Close margins were found in 395 of 499 patients with R0 margins (79%), for whom margin distances were measured. A total of 305 patients (35%) underwent postoperative radiation therapy. Of all 865 patients, 35 (4%) had local recurrence with a median (IQR) follow-up of 35.3 (13.9-59.1) months. In patients with close margins as the sole risk factor for recurrence, the local recurrence rates were similar between those who underwent postoperative radiation therapy (0 of 46) or observation (4 of 165 [2%]). Patients with clear margins (n = 104) had no recurrences. The local recurrence rate in patients with R1 or R2 margins was better in those irradiated (2 of 128 [2%]) compared to observed (13 of 64 [20%]) (hazard ratio [HR], 0.05; 95% CI, 0.01-0.24). Multivariable analysis for local recurrence found the following independent factors: age at diagnosis (HR for a 10-year increase in age, 1.33; 95% CI, 1.06-1.67), R1 vs R0 (HR, 5.21; 95% CI, 2.58-10.54), lymphovascular invasion (HR, 4.47; 95% CI, 1.43-13.99), and postoperative radiation therapy (HR, 0.10; 95% CI, 0.04-0.29). The 3-year local recurrence-free survivals for the study population were 96% vs 97% in the close margin group.

Conclusions and Relevance

In this cohort study of patients with low- and intermediate-grade major salivary gland carcinoma, postoperative radiation therapy for positive margins was associated with decreased risk of local recurrence. In isolation from other risk factors for local recurrence, select patients with close surgical margins (≤1 mm) may safely be considered for observation.

Comparing donor site morbidity in osteocutaneous radial forearm versus fibula free flap for mandibular reconstruction

PURPOSE

The osteocutaneous radial forearm free flap has gained popularity as a less morbid option for oromandibular reconstruction compared to the fibular free flap. However, there is a paucity of data regarding direct outcome comparison between these techniques.

METHODS

Retrospective chart review of 94 patients who underwent maxillomandibular reconstruction intervened from July 2012-October 2020 at the University of Arkansas for Medical Sciences. All other bony free flaps were excluded. Endpoints retrieved encompassed demographics, surgical outcomes, perioperative data, and donor site morbidity. Continuous data points were analyzed using independent sample t-Tests. Qualitative data was analyzed using Chi-Square tests to determine significance. Ordinal variables were tested using the Mann-Whitney U test.

RESULTS

The cohort was equally male and female, with a mean age of 62.6 years. There were 21 and 73 patients in the osteocutaneous radial forearm free flap and fibular free flap cohorts, respectively. Excluding age, the groups were otherwise comparable, including tobacco use, and ASA classification. Bony defect (OC-RFFF = 7.9 cm, FFF = 9.4 cm, p = 0.021) and skin paddle (OC-RFFF = 54.6 cm2, FFF = 72.21 cm2, p = 0.045) size were larger in the fibular free flap group. However, no significant difference was found between cohorts with respect to skin graft. There was no statistically significant difference between cohorts regarding the rate of donor site infection, tourniquet time, ischemia time, total operative time, blood transfusion, or length of hospital stay.

CONCLUSIONS

No significant difference in perioperative donor site morbidity was found between patients undergoing fibular forearm free flap and osteocutaneous radial forearm flap for maxillomandibular reconstruction. Osteocutaneous radial forearm flap performance was associated with significantly older age, which may represent a selection bias.

A randomized study on the value of self-directed versus traditional mentor-led microsurgical training

Objective

Analyze efficacy of self-directed resident microvascular training versus a mentor-led course.

Study Design

Randomized, single-blinded cohort study.

Setting

Academic tertiary care center.

Methods

Sixteen resident and fellow participants were randomized into two groups stratified by training year. Group A completed a self-directed microvascular course with instructional videos and self-directed lab sessions. Group B completed a traditional mentor-led microvascular course. Both groups spent equal time in the lab. Video recorded pre and post-course microsurgical skill assessments were performed to assess the efficacy of the training. Two microsurgeons, blinded to participant identity, evaluated the recordings and inspected each microvascular anastomosis (MVA). Videos were scored using an objective-structured assessment of technical skills (OSATS), a global rating scale (GRS), and quality of anastomosis scoring (QoA).

Results

The pre-course assessment identified that the groups were well matched with only "Economy of Motion" on the GRS favoring the mentor led group (p = .02). This difference remained significant on the post assessment (p = .02) Both groups significantly improved in OSATS and GRS scoring (p < .05). There was no significant difference in OSATS improvement between the two groups (p = .36) or improvement in MVA quality between groups (p > .99). Time to completion of MVA significantly improved overall by a mean of 8 min and 9 s (p = .005) with no significant difference between post training times to complete (p = .63).

Conclusion

Different microsurgical training models have previously been validated as effective methods for improved MVA performance. Our findings indicate that a self-directed microsurgical training model is an effective alternative to a traditional mentor driven models.

Level of Evidence

Level 2.

Remote smart pill cap monitoring of post-surgical pain management in thyroid and parathyroid surgery

BACKGROUND

With recent efforts to decrease opioid use following surgery, this study aims to answer: what pain regimen do patients follow at home? Is it controlling pain?

METHODS

This is a prospective, pilot study of thyroid and parathyroid surgery patients. Patients were prescribed acetaminophen, ibuprofen, and tramadol dispensed in smart pill (Pillsy) bottles that record "events" corresponding to medication use. Patients received messages querying their current pain level. Patients were compared to historical controls.

RESULTS

26 patients were in the Pillsy group and 30 in the control group. In the Pillsy group, pain scores averaged 3.67 out of 10 in the first 24 h after surgery and decreased each day. Patients took an average of 6.45 doses of acetaminophen, 6.64 doses of ibuprofen, and 1.82 doses of tramadol in the first week.

CONCLUSIONS

Pain scores are highest in the first 24 h after surgery and decrease thereafter. This acceptable level of pain can be achieved with non-opioid medications.

Early postoperative complications following tracheotomy: Does suturing technique influence outcomes?

Introduction

Tracheotomy is one of the most commonly performed procedure by otolaryngologists, but no consensus exists on the effect of suturing techniques on postoperative complications. Stay sutures and Bjork flaps are utilized frequently for securing the tracheal incision to the neck skin in order to create a tract for recannulation.

Methods

Retrospective cohort study of tracheotomies performed by Otolaryngology-Head and Neck Surgery providers (May 2014 to August 2020) was conducted to determine the effect of suturing technique on postoperative complications and patient outcomes. Patient demographics, medical comorbidities, indication for tracheostomy, and postoperative complications were analyzed with a statistical alpha set of .05.

Results

Out of 1395 total tracheostomies performed at our institution during the study period, 518 met inclusion criteria for this study. Three hundred and seventeen tracheostomies were secured by utilizing a Bjork flap, while 201 were secured with up and down stay sutures. Neither technique was noted to be more commonly associated with tracheal bleeding, infection, mucus plugging, pneumothorax, or false passage of the tracheostomy tube. One mortality was noted following decannulation during the study period.

Conclusion

Though various techniques exist; adverse outcomes are not associated with the manner in which a new tracheostomy stoma is secured. Medical comorbidities and the indications for tracheostomy likely play a more significant role in postoperative outcomes and complications.

Level of evidence

Level 3.

Postoperative and 1-Year Functional Outcomes After Free Flap Surgery Among Patients 80 Years or Older

OBJECTIVE

To evaluate the postoperative and 1-year functional outcomes after free flap surgery among patients ≥80 years old.

STUDY DESIGN

Retrospective chart review.

SETTING

Single tertiary care center.

METHODS

We conducted a retrospective review of 596 patients who underwent head and neck ablation and reconstruction with free tissue over a 7-year period. Patients ≥80 years of age were included.

RESULTS

Fifty patients were ≥80 years old, with an average age of 83.7 years. Ninety-day mortality was 12.0%, and those who died were of older age (87.5 vs 83.1 years, P = .036). Prior radiation therapy (odds ratio, 6.8 [95% CI, 1.1-42.7]) and a Charlson Comorbidity Index ≥3 (odds ratio, 10.0 [95% CI, 1.5-67.0]) were associated with an increased risk of 90-day mortality. Overall 21 (42.0%) patients experienced a 30-day complication; 7 (14.0%) were readmitted within 30 days; and 5 (10.0%) underwent additional flap-related operations. Flap failure occurred in 2 (4.0%) patients. Before surgery, 45 (90%) patients were living independently or within assisted living; among these, 19.5% declined to dependent functional status at 90-day follow-up. At 90 days, 2 (8.3%) of 24 patients remained tracheostomy dependent, and 20 (66.7%) of 30 patients required feeding tube supplementation. Among 42 patients, 36 (85.7%) had unrestricted or modified oral diets at 90 days. Charlson Comorbidity Index ≥2 was associated with an increased risk of 1-year mortality (odds ratio, 5.1 [95% CI, 1.4-18.6]).

CONCLUSION

The potential for functional decline and risk of 90-day mortality should be discussed with patients aged ≥80 years.

Model of an Advanced Practice Provider-Led Head and Neck Cancer Survivorship Clinic: Evaluation of a 4-Year Experience

OBJECTIVE

To report the efficacy and safety of an advanced practice provider-led head and neck cancer survivorship clinic.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic medical center.

METHODS

Patients were enrolled into the survivorship clinic after undergoing 1-year follow-up with the primary head and neck surgeon. Those enrolled between December 2016 and October 2020 were retrospectively reviewed for diagnosis, staging, pattern of recurrence, visit frequency, and compliance. Surgical respectability of recurrent disease was used as a surrogate for timely diagnosis.

RESULTS

An overall 570 patients were followed within the survivorship clinic. The mean length of follow-up was 13.6 months. Mucosal primaries represented 72.6% of patients. A majority of the primary malignancies were squamous cell carcinoma (77.7%). The most common primary subsites were the oropharynx (26.7%), oral cavity (25.1%), cutaneous (17.0%), and larynx (15.3%). Recurrence was detected in 50 patients (8.8%): 26 local, 12 regional, and 14 distant. Two patients had multiple synchronous recurrences. Twelve (2.1%) second primary cancers were detected. Of the 36 cases of locoregional recurrence, 32 (88.9%) were deemed amenable to salvage surgical intervention, with or without adjuvant therapy. Negative margins were obtained in 21 of the 23 (91.3%) local recurrences that underwent salvage resection.

CONCLUSION

Advanced practice provider-based surveillance of head and neck cancer, without risk stratification, appears to be a sound model but needs further prospective evaluation. Consistent with literature, 88.9% of patients with locoregional recurrence were candidates for curative-intent salvage surgery, emphasizing that recurrences are identified in a timely fashion.

Association of Continuous Intraoperative Vasopressor Use With Reoperation Rates in Head and Neck Free-Flap Reconstruction

Importance

Continuous vasopressor use in free-flap reconstruction is a point of contention among microvascular surgeons despite data demonstrating safety.

Objective

To investigate the association between continuous vasopressor use and the incidence of reoperation in the early postoperative period.

Design, Setting, and Participants

In this cohort study, a retrospective medical record review was conducted of patients who underwent head and neck free-flap reconstructions between May 1, 2014, and October 31, 2019, in an academic tertiary care center. All patients undergoing free-flap reconstruction for head and neck defects were included.

Exposures

Continuous intraoperative vasopressors.

Main Outcomes and Measures

Patient medical records were queried for demographic variables; intraoperative use of vasopressors; vasopressor type, duration, and infusion rate; reoperation within the first 5 postoperative days; and reason for reoperation.

Results

Four hundred forty-nine consecutive free-flap reconstructions were performed on 426 patients. The mean age was 62 years (IQR, 55.7-71.1); 293 patients were men (65.3%), 380 were White (84.6%), 55 were Black (12.2%), and 14 were of other race or ethnicity (3.1%). A total of 174 patients received a continuous vasopressor during their reconstruction. Twenty-three reoperations occurred within 5 days postoperatively, 8 of which included vasopressors during initial intervention. Vasopressor type had no association with reoperation (4.5% vs 5.5% [8/174 vs 15/275, respectively] for patients who received vasopressors vs those who did not) (dobutamine odds ratio [OR], 1.02 [95% CI, 0.21-2.91]; dopamine OR, 1.48 [95% CI, 0.33-4.26]). No difference was seen in the duration (dobutamine OR, 1.50 [95% CI, 0.78-2.90]; dopamine OR, 0.87 [95% CI, 0.59-1.28]) or infusion rate (dobutamine OR, 1.50 [95% CI, 0.99-1.02]; dopamine OR, 1.00 [95% CI, 0.99-1.01]) of vasopressors between patients who underwent reoperation and those who did not. Analysis after the exclusion of reasons for reoperation that did not represent possible microvascular anastomosis failure (eg, Doppler malfunction, donor site complications) showed no increased propensity for reoperation (OR, 1.18; 95% CI, 0.27-3.9).

Conclusions and Relevance

In this cohort study, use of vasopressors for extensive periods intraoperatively during free-tissue transfer appeared to have no association with the rate of reoperation within 5 days of intervention, regardless of agent used, simultaneous use of agents, type of free-flap operation performed, or reason for reoperation. This study adds to the body of literature supporting the judicious use of vasopressors in patients requiring intraoperative pharmacological pressure support during free-flap reconstruction.

Preemptive Utilization of Anterior Belly of the Digastric Muscle Flaps in Transoral Robotic Radical Tonsillectomy

Objective

To demonstrate the use of an anterior belly of the digastric muscle flap (ABDMF) during transoral robotic radical tonsillectomy (TORRT) with concomitant neck dissection with the intent of preventing the formation of postoperative pharyngocutaneous fistulas.

Study Design

Retrospective study.

Setting

Single academic tertiary care center.

Methods

In this study, all patients were included who underwent TORRT plus limited pharyngectomy with concomitant neck dissection and ABDMF for the treatment of oropharyngeal squamous cell carcinoma between September 2012 and September 2020. The rate of fistula formation was assessed in patients with preemptive utilization of ABDMF.

Results

A total of 43 patients underwent TORRT with neck dissection and ABDMF. No patients developed a fistula in the postoperative period or associated morbidity with the use of this flap.

Conclusion

Preemptive use of ABDMF in TORRT with concomitant neck dissection represents a reconstructive option that may help prevent the formation of pharyngocutaneous fistula by reinforcing the posteroinferior boundary of the parapharyngeal space.

Free Tissue Transfer for Repair of Chronic Esophageal Perforations

Objective

Anterior cervical discectomy and fusion have become a common intervention for cervical spine stabilization. However, complications can cause life-threatening morbidity. Among them, esophageal perforation is associated with severe morbidity, including dysphagia, malnutrition, and infection with the potential development of mediastinitis. Presentation is variable but often results in chronic morbidity. Herein we examine our experiences in the management of esophageal perforation with microvascular free tissue transfer.

Study Design

Retrospective review from January 2013 to September 2020.

Setting

Single academic tertiary care center.

Methods

This study comprised all patients (age, 41-73 years) undergoing free tissue transfer for the repair of chronic esophageal perforation secondary to anterior cervical discectomy and fusion at an academic tertiary care center. Four patients underwent repair via vastus lateralis myofascial onlay grafting for defects ≤2 cm in greatest dimension, while 1 patient underwent a fasciocutaneous radial forearm free flap repair of an 11 × 5-cm defect.

Results

Defect location ranged from hypopharynx to cervical esophagus. Mean operative time was 6.2 hours; the average length of stay for all patients was 6.6 days. Of 5 patients, 1 required additional hardware placement for spine stabilization. All patients underwent gastrostomy tube placement to bypass the surgical site during healing, and all eventually resumed an oral diet postoperatively. Recurrent fistula occurred in 1 of 5 patients. No flap failures were encountered in the study population.

Conclusion

Vastus lateralis myofascial onlay grafting and fasciocutaneous radial forearm free flap are robust, relatively low-morbidity interventions with a high success rate for definitive repair of chronic esophageal perforation. Repair should be undertaken in concert with a spine surgeon for management of the cervical spine.

Vascularity Outcomes of Lingual Artery Ligation in Transoral Robotic Base of Tongue Resections

To explore the effect of lingual artery ligation on tongue vascularity, we performed an analysis of 25 patients who underwent transoral robotic surgery for base of tongue cancers (May 2011 to December 2019). Hounsfield units of the intrinsic muscles (IMs) and genioglossus muscles (GGs) were measured in postoperative imaging (mean 4 months) as a surrogate for vascularity. In ligated patients (n = 15), the values from the ligated/resected side of the tongue were compared with the contralateral side and the nonligated side of resection. Individually, IMs and GGs on the ligated side demonstrated no significant difference to the contralateral side (P = .662 and .618, respectively). Ligation produced a significant decrease in IM measurements but no difference between GG values vs nonligated patients (P = .050 and .818, respectively). No difference was appreciated in mean values for combined IMs and GGs between cohorts (P = .212). No gross tongue atrophy or complications were incurred. Future studies are warranted to delineate long-term effects.

Outcomes of Single Anastomoses for Superficial and Deep-System Venous Drainage of Radial Forearm Free Flaps

Objective

Venous insufficiency occurs in radial forearm free flaps (RFFFs) when either the deep venous system (DVS) or superficial venous system (SVS) is used as the venous outlet. We report our experience using the antecubital perforating vein (APV) in a single-vessel anastomosis to the median-cubital or cephalic vein to drain both systems.

Study Design

Retrospective review.

Setting

Single, academic, tertiary care center.

Methods

Data were collected from 72 patients who underwent RFFF from October 2009 to January 2017. In all cases, DVS and SVS were dissected, and an APV single-vessel anastomosis was attempted.

Results

Anatomical variations precluded single-vessel anastomosis in 11 (15.3%) cases. In 61 (84.7%) cases, single-vessel anastomosis produced unobstructed drainage for DVS and SVS without intrinsic venous insufficiency. Venous thrombosis and total loss occurred in 2 (3.3%) and 1 (1.6%) patients, respectively. Proximal dissection of the cephalic vein addressed a vessel-depleted neck in 3 cases.

Conclusion

The antecubital perforating vein is present and functional in most patients, allowing for single anastomosis techniques for RFFF. Antecubital perforators capture DVS and SVS outflow through a single, extended venous pedicle, eliminating the risk of venous insufficiency and need for vein grafts.

Comparative Morbidity Profile of Elective vs Therapeutic Neck Dissection

OBJECTIVE

Neck dissection (ND) is one of the most commonly performed procedures in head and neck surgery. We sought to compare the morbidity of elective ND (END) versus therapeutic ND (TND).

STUDY DESIGN

Retrospective chart review.

SETTING

Academic tertiary care center.

METHODS

Retrospective chart review of 373 NDs performed from January 2015 to December 2018. Patients with radical ND or inadequate chart documentation were excluded. Demographics, clinicopathologic data, complications, and sacrificed structures during ND were retrieved. Statistical analysis was performed with χ² and analysis of variance for comparison of categorical and continuous variables, respectively, with statistical alpha set a 0.05.

RESULTS

Patients examined consisted of 224 males (60%) with a mean age of 60 years. TND accounted for 79% (n = 296) as compared with 21% (n = 77) for END. Other than a significantly higher history of radiation (37% vs 7%, P < .001) and endocrine pathology (34% vs 2.6%, P < .001) in the TND group, no significant differences in demographics were found between the therapeutic and elective groups. A significantly higher rate of structure sacrifice and extranodal extension within the TND group was noted to hold in overall and subgroup comparisons. No significant difference in rate of surgical complications was appreciated between groups in overall or subgroup analysis.

CONCLUSION

While the significantly higher rate of structure sacrifice among the TND population represents an increased morbidity profile in these patients, no significant difference was found in the rate of surgical complications between groups. The significant difference seen between groups regarding history of radiation and endocrine pathology likely represents selection bias.

Predictors for Postoperative Chyle Leak Following Neck Dissection, a Technique-Based Comparison

OBJECTIVE

Assess the impact of surgical technique used to address level IV on the rate of postoperative chyle leak.

STUDY DESIGN

Retrospective chart review.

SETTING

Academic tertiary care center.

METHODS

An analysis of 436 consecutive neck dissections (NDs) in 368 patients was performed by 3 head and neck surgeons between 2014 and 2017. Variation in technique reflects individual approaches to the management of level IV and included suture ligation (SL), monopolar electrocautery (MC), and harmonic scalpel transection (HS). Data points included patient demographics, surgical technique, intraoperative findings, postoperative chyle leaks, and leak management. Correlation between variables was analyzed through χ² test and Student t test with statistical α set at .05.

RESULTS

Overall, 12 patients (3.2%) developed chyle leaks postoperatively. Nine of 12 and 3 of 12 presented with left- and right-sided leaks, respectively. Five of 12 leaks occurred following bilateral ND, 5 of 12 following left ND, and 2 of 12 following right ND. Univariate analysis showed a statistically significant difference (P = .001) favoring SL (1.0%) and MC (1.2%) techniques over the HS technique (8.6%). A statistically significant increase existed in the rate of leak with endocrine vs nonendocrine pathology (P = .003). Average duration of leak was 13.3 ± 13.5 days. Management included diet modification (n = 11, 91.6%), pressure-dressing placement (n = 7, 58.3%), and octreotide (n = 5, 41.7%). No cases required reoperation, and no mortality or severe malnutrition was observed in this series.

CONCLUSIONS

SL and MC techniques demonstrated superiority over the HS technique in preventative management of chyle leak in level IV, with a significantly higher rate of chyle leak observed in endocrine-related pathology.

Opioid reduction in ambulatory thyroid and parathyroid surgery after implementing enhanced recovery after surgery protocol

BACKGROUND

Opioid abuse is widespread in the United States and the risk for chronic use is increased in surgical patients, including patients with thyroid and parathyroid.

METHODS

Records for 171 patients prior to and 67 patients following implementation of an enhanced recovery after surgery (ERAS) protocol for ambulatory thyroid/parathyroid surgeries were reviewed. The ERAS included superficial cervical plexus block, multimodal premedication, and postoperative reliance on acetaminophen and ibuprofen with judicious prescribing of opioids.

RESULTS

Post-ERAS patients were prescribed a mean 72 morphine milligram equivalents (MME); pre-ERAS patients were prescribed a mean 163 MME (p < 0.001). 97.1% of pre-ERAS patients were prescribed opioids with 91.1% filled; 68.7% of post-ERAS study patients were prescribed opioids with 84.8% filled.

CONCLUSION

Implementation of ERAS and focus on prescribing practices decreased the MME prescribed and used for ambulatory thyroid and parathyroid surgery. Future steps include increased patient education and tracking pain scores and medication utilization out of hospital.

Functional outcome predictors following mandibular reconstruction with osteocutaneous fibula free flaps: correlating early postoperative videofluoroscopic swallow studies with long-term clinical results

Background

Advancements in the field of microvascular surgery and the widespread adoption of microvascular surgical techniques have made the use of osteocutaneous fibula free flaps the standard of care in the surgical management of segmental mandibular defects. Although the literature possesses abundant evidence to support the effectiveness of fibula free flaps as a reconstructive method, there are relatively few studies reporting on outcomes as objectively measured by videofluoroscopic swallowing studies (VFSS). The purpose of this study is to explore the potential correlation between early postoperative VFSS and the long-term swallowing outcomes in patients who underwent mandibular reconstruction with fibula free flaps.

Methods

We performed a retrospective chart review of 36 patients who underwent mandibular reconstruction with osteocutaneous fibular free flaps between 2009 and 2012. Demographics, clinical variables, VFSS data, and diet information were retrieved. Penetration and aspiration findings on VFSS, long-term oral feeding ability, and the need for gastrostomy tube were statistical endpoints correlated with postoperative clinical outcomes.

Results

Thirty-six patients were reviewed (15 females and 21 males) with a mean age of 54 years (7-81). Seventeen cases were treated for malignancy. The size of the bony defect ranged from 3 to 15 cm (mean = 9 cm). The cutaneous paddle, a surrogate for soft tissue defect, ranged from 10 to 125 cm² (mean = 52 cm²). A gastrostomy tube was present in patients preoperatively (n = 8), and postoperatively (n = 14). Seventeen patients had neoadjuvant exposure to radiation. Postoperative VFSS showed penetration in 13 cases (36%) and aspiration in seven (19%). Overall, 29 patients (80.6%) achieved unrestricted diet, and this was statistically correlated with age (p = 0.037), radiation therapy (p = 0.002), and preoperative gastrostomy tube (p = 0.03). The presence of penetration or aspiration on VFSS was a strong predictor for long-term unrestricted oral diet (p < 0.001).

Conclusion

Early postoperative VFSS is an excellent predictor for long-term swallowing outcomes in patients undergoing mandibular reconstruction with osteocutaneous fibula free flaps.

American Society of Anesthesiologists Class as Predictor for Perioperative Morbidity in Head and Neck Free Flaps

OBJECTIVE

To evaluate outcomes of free flaps in low- versus high-risk American Society of Anesthesiologists (ASA) classes utilizing a standardized perioperative clinical pathway.

STUDY DESIGN

Case series with chart review.

SETTING

Single tertiary care academic institution.

SUBJECTS AND METHODS

Data were collected from 301 patients who underwent 305 free flap reconstructions for head and neck defects from January 2012 to March 2016 by a single surgeon (M.M.). A standardized perioperative clinical pathway was utilized for all patients, aimed at abbreviating hospital stay and minimizing intensive care unit stay. Data included ASA classification, comorbidities, length of hospitalization, intensive care unit stay, 30-day mortality/readmission, discharge disposition, flap survival, and postoperative complications. Low-risk ASA classes were defined as 1 and 2 (n = 53) and high risk as 3 and 4 (n = 248).

RESULTS

Total medical complication rates (P = .012) were mildly increased in the high-risk group, as a result of increased minor-not major-medical complication rates (P = .007). Discharge to a nursing or rehabilitation facility was found to be more common in the high-risk group (P = .024). All other outcomes were not statistically different between the cohorts.

CONCLUSION

The ASA classification system is a validated tool in determining perioperative risk. We found that minor medical complications and discharge to a rehabilitation/nursing facility were increased in the high-risk ASA classes; otherwise, there were no statistical differences between the groups. These findings suggest that the ASA classification may be helpful for preoperative discharge planning and counseling but should not be used for patient selection or to assess candidacy for the procedure.

Histological Comparison of Implanted Cadaveric and Porcine Dermal Matrix Grafts

OBJECTIVES: Histological comparison of human-based (AlloDerm) and porcine-based (ENDURAGen) dermal matrices regarding tissue incorporation and neovascularization as potential soft tissue augmentation materials.

STUDY DESIGN: In vivo, rat model.

METHODS: Subcutaneous implantation of 1-mm thick, 1 cm X 1 cm pieces of AlloDerm, ENDURAGen, and meshed ENDURAGen was performed in 24 Sprague Dawley rats. Implant materials were harvested at 4 (n = 12) and 8 weeks (n = 12). Histological quantification of soft tissue ingrowth and microvascular density was performed following hematoxylin-eosin staining and CD34 immunohistochemistry, respectively.

RESULTS: AlloDerm showed significantly greater soft tissue in-growth and microvascular density compared with both ENDURAGen and meshed ENDURAGen at 4 and 8 weeks ( P < 0.001).

CONCLUSIONS: Although these results may differ in human host tissues, AlloDerm seems to be a more suitable dermal matrix implant than ENDURAGen for cases in which tissue incorporation and neovascularization are sought for the optimal outcome based on this animal model.

Correlation of neural cell adhesion molecules with perineural spread of squamous cell carcinoma of the head and neck

Perineural spread (PNS) is a poor prognostic factor associated with increased risk of local recurrence and nodal metastasis and reduced survival of patients with squamous cell carcinoma of the head and neck (SCCHN). There is some evidence to indicate that neural cell adhesion molecules (NCAMs) may play a role in PNS of a variety of tumor types. We performed this study to investigate whether NCAM expression can be used as a predictor of PNS in SCCHN. The surgical specimens of 66 patients with SCCHN were evaluated with monoclonal IgG antibody immunoperoxidase staining for NCAM. Of the 41 specimens with PNS, 38 (93%) showed evidence of NCAM expression. In contrast, only 9 specimens (36%) without PNS expressed NCAMs. The difference in NCAM expression between the study and control groups was statistically significant ( P < 0.01).

Evaluation of the inferior and superior laryngeal nerve stumps for perineural spread in laryngeal cancer

Objective

Perineural spread (PNS) is an important risk factor for locoregional failure and is correlated with reduced survival rates in squamous cell carcinoma of the larynx. PNS may extend proximally and/or distally in the nerve sheath by leaving unin-volved nerve segments. This method of extension may preclude obtaining tumor-free surgical margins, which may be responsible for recurrent disease. The purpose of this study is to investigate the presence or absence of PNS in extralaryngeal superior and inferior laryngeal nerves in patients who underwent total laryngectomy for squamous cell carcinoma of the larynx.

METHODS

Extralaryngeal segments of superior and inferior laryngeal nerves were resected bilaterally during 15 consecutive laryngectomies. Laryngectomy specimens and the harvested proximal nerve segments were histopathologically examined for the presence or absence of PNS.

RESULTS

Ten of 15 laryngectomy specimens showed PNS; however, none of the extralaryngeal superior or inferior laryngeal nerve segments revealed perineural involvement.

CONCLUSION

Extralaryngeal extension of PNS is highly unlikely in squamous cell carcinoma of the larynx.

Disruption of BRD4 at H3K27Ac-enriched enhancer region correlates with decreased c-Myc expression in Merkel cell carcinoma

Pathologic c-Myc expression is frequently detected in human cancers, including Merkel cell carcinoma (MCC), an aggressive skin cancer with no cure for metastatic disease. Bromodomain protein 4 (BRD4) regulates gene transcription by binding to acetylated histone H3 lysine 27 (H3K27Ac) on the chromatin. Super-enhancers of transcription are identified by enrichment of H3K27Ac. BET inhibitor JQ1 disrupts BRD4 association with super-enhancers, downregulates proto-oncogenes, such as c-Myc, and displays antitumor activity in preclinical animal models of human cancers. Here we show that an enhancer proximal to the c-Myc promoter is enriched in H3K27Ac and associated with high occupancy of BRD4, and coincides with a putative c-Myc super-enhancer in MCC cells. This observation is mirrored in tumors from MCC patients. Importantly, depleted BRD4 occupancy at the putative c-Myc super-enhancer region by JQ1 correlates with decreased c-Myc expression. Thus, our study provides initial evidence that super-enhancers regulate c-Myc expression in MCC.

The Role of Interventional Radiology in Head and Neck Cancer

Objectives:

Evaluate the indications for endovascular techniques in the management of patients with head and neck squamous cell carcinoma.

Methods:

Retrospective chart review of patients with head and neck cancer who underwent endovascular embolization. Patients’ demographics, type of cancer, type of cancer treatment, TNM staging, bleeding site, and medical outcomes were recorded from 2004-2012, at a university medical center.

Results:

A total of 14 patients out of 1000 undergoing endovascular procedures had an endovascular procedure due to a head and neck cancer. Their ages ranged from 33-67 years old (mean = 54 years old). 7 patients had oropharyngeal, 3 laryngeal, 1 hypopharyngeal, 2 oral cavity and 1 skin squamous cell cancer. 8 patients had hypertension. 7 patients underwent chemoradiation therapy as a primary treatment. 9 patients with oral hemorrhage underwent emergency embolization due to bleeding and 5 patients underwent elective embolization. Bleeding arose from the common carotid artery in 2 patients, and external carotid artery and its branches in 6 patients, internal carotid artery in 3 patients, internal maxillary artery in 3 patients. Hemorrhage was successfully controlled in all patients. 2 patients had carotid rupture one month post-embolization and one patient died. At last follow-up 6 patients were alive with disease, 4 patients had no evidence of disease and 4 patients were dead due to disease.

Conclusions:

Interventional radiologic techniques are safe and effective treatment techniques not only for treating life-threatening hemorrhage but also for pre-emptive management in the treatment of head and neck cancer.

Functional Outcomes of Chemoradiation in Patients with Head and Neck Cancer

Objective

Concurrent chemoradiotherapy (CCRT) has become the treatment of choice for oropharyngeal and hypopharyngolaryngeal cancers in many centers. Although it has increased the rates of organ preservation, there has also been an increase in treatment-related complications. We aimed to evaluate the functional outcomes of CCRT in head and neck cancer.

Study Design

Case series with chart review.

Setting

Tertiary cancer center.

Subjects and Methods

A retrospective study of patients treated with CCRT at the University of Arkansas for Medical Sciences was performed. Demographic data and treatment outcomes were extracted, specifically feeding tube and tracheotomy dependence and number of esophageal dilatations.

Results

Of the 243 patients treated with concurrent chemoradiotherapy (5-flourouracil + cysplatin and radiotherapy), 152 patients received a feeding tube. The median percutaneous gastrostomy tube (PEG) use was 9 months (range, 1-96 months). More than 70% of the patients who had a PEG more than 6 months had a T3 or T4 tumor. Thirty-seven patients underwent esophageal dilatations, (median, 1; range, 1-7). The median use of a tracheotomy was 7 months, and 77% of these patients were treated for hypopharyngolaryngeal cancer.

Conclusions

Despite major improvement in locoregional control rates, CCRT has a significant negative impact on the functional outcomes of head and neck cancer patients, with a high number of patients remaining PEG and tracheotomy dependent.

Predictors of Neck Failure in T1/T2 -N0 Oral Tongue Squamous Cell Carcinoma

Objective: The incidence of early squamous cell carcinoma of the oral tongue (SCCOT) is increasing, particularly among young patients. The development of loco-regional recurrence is associated with poor survival. We sought to identify the predictors for nodal recurrence in early (T1/T2) SCCOT presenting with a radiologically N0 neck.

Method: Retrospective chart review of 50 consecutive patients primarily treated for T1/T2-N0 SCCOT at an academic tertiary institution between 1998 and 2007. N0 status confirmed by preoperative contrasted neck CT in all cases.

Results: Twenty-six men and 24 women with a median age of 61 years (range, 24-90 years); 46% presented with a T1 and 54% with a T2. Depth of invasion >4 mm was present in 76%; positive margins in 8%; dysplasia at the margin 6%; perineural invasion 18%; and lymphovascular invasion 12%. Ipsilateral neck dissection was performed in 60% (20% microscopically positive) while adjuvant radiation was used in 32%. Twenty percent of the patients recurred in the neck, ipsilateral in all cases. It presented between 4 and 47 months and was associated with dysplasia at the margin ( P = .037) and local recurrence ( P = .002), while pathological T-stage (pT2/pT1) trended ( P = .087).

Conclusion: Pathological T-stage, field cancerization and development of local recurrence are predictors for regional failure in patients with early SCCOT. Neck recurrence appears to be primarily determined by biological behavior rather than treatment modality in this subset of patients.

Outcomes of paramedian forehead and nasolabial interpolation flaps in nasal reconstruction

OBJECTIVE

To determine the factors contributing to failure of interpolation flaps in nasal reconstruction.

DESIGN

Retrospective medical chart review.

SETTING

Tertiary care academic center.

PATIENTS

A total of 107 patients with nasal defects needing reconstruction, performed at the University of Arkansas for Medical Sciences, Little Rock.

INTERVENTION

Patients underwent nasal reconstruction with 2-stage paramedian forehead or nasolabial flaps (PMFF and NLF, respectively) from 2002 to 2011. Defect thickness, location, flap type, use of cartilage grafts, and comorbidities, including diabetes mellitus, peripheral vascular or coronary artery disease, and smoking habits, were recorded.

MAIN OUTCOME MEASURES

Full success, partial failure, or full failure of the respective flap.

RESULTS

Eighty-two of the patients (77%) underwent 2-stage PMFF repair and 25 (23%) underwent 2-stage NLF repair. Fifty-eight defects (54%) were full thickness, in which 46 repairs used PMFF and 12 used NLF for reconstruction. The overall failure rate was 6%. Five PMFF failed (6%); 3 of these were used for full-thickness repairs. There was only 1 NLF failure (4%), which was also performed for the repair of a full-thickness defect. Use of cartilage in the reconstruction did not affect failure rates of the different soft tissue flaps. No single comorbidity was noted to have a statistically significant effect on failure rates, although 83% of failures were observed in smokers.

CONCLUSIONS

The overall success rate of interpolation flaps in nasal reconstruction was 94.4%. Defect thickness, use of a cartilage graft, type of flap used, and presence of comorbidities did not affect outcome. Although the comparison was not statistically significant (P  = .21), flap failures were more commonly observed in smokers.

Comparison of the exposure obtained by endoscope and microscope in the extended trans-sphenoidal approach

OBJECTIVE

Trans-sphenoidal surgery is often combined with other approaches for the treatment of middle cranial base tumors. By combining a maxillotomy with trans-sphenoidal approach, significantly wider exposure to these regions is gained. However, endoscope-assisted techniques have also been used for sellar and parasellar and upper clival regions.

METHODS

An extended trans-sphenoidal approach was performed on 10 cadaver heads using the operating microscope and was repeated with a 0-degree endoscope. The mean horizontal and vertical distances were measured and pictured for each technique, and both distances were compared using a parametric paired Student's t-test.

RESULTS

The mean horizontal distances in the 10 specimens were 19.5 +/- 1.8 mm by microscope and 27.5 +/- 2.2 mm by endoscope, and the mean vertical distances were 25.8 +/- 1.9 mm by the microscope and 34.5 +/- 3.5 mm by the endoscope.

CONCLUSION

The aim of this study was to quantify the amount of exposure obtained with an extended trans-sphenoidal approach and to compare both endoscopic and microscopic techniques. Using the endoscope in conjunction with the operating microscope may provide additional exposure and better access in skull base surgery.

Cervicofacial advancement-rotation flap in midface reconstruction: forward or reverse?

OBJECTIVE

To present the authors' experience and outcomes in the reconstruction of midfacial defects using cervicofacial advancement-rotation flaps (CARFs) based on a method of determining forward or reverse design in relation to the proportions of the defect.

STUDY DESIGN

Case series with retrospective chart review.

SETTING

Tertiary care academic medical center.

SUBJECTS AND METHODS

Patients who underwent CARF reconstruction and the subset of patients with midfacial defects medial to the lateral canthus were included. CARF was designed in a forward fashion with an anteromedial movement for the defects with a larger vertical dimension and in a reverse fashion with a posterosuperior movement for the defects with a larger horizontal dimension.

RESULTS

Thirteen of 45 patients who underwent CARF reconstruction qualified for the analysis as a subset based on defect location. CARF was used in a forward fashion in 7 patients and in a reverse fashion in 6 patients. The largest defect in this subset was measured as 9 × 6 cm, while the smallest defect was 3 × 2 cm. Average follow-up was 11.5 months. None of the patients developed partial or total flap loss. Six patients had mild ectropion, which was managed with conservative measures only. The outcome of the reconstruction was satisfactory in all cases.

CONCLUSION

Designing the CARF based on the proportion of the vertical and horizontal diameters of the selected midfacial defects as described allows for closure of the defects with minimal tension and minimizes the amount of discarded healthy skin overlapping at the suture lines.

Distinct epigenetic profiling in head and neck squamous cell carcinoma stem cells

OBJECTIVE

To identify unique epigenetic signature in cancer stem cells (CSCs) in head and neck squamous cell carcinoma (HNSCC).

STUDY DESIGN

Molecular and microarray studies.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

Head and neck CSCs were isolated in HNSCC cells by CD44 staining and flow cytometry sorting. CSCs with highest CD44 expression (CD44(hi)) and non-stem cells (non-SCs) with lowest CD44 expression (CD44(low)) were then characterized for stemness gene expression and their responses to chemotherapeutic agents, followed by high-throughput epigenetic profiling using the Illumina BeadChip Array, targeting 28,544 CpG sites covering more than 14,956 genes.

RESULTS

CD44(hi) CSCs expressed higher levels of stem cell markers and were more resistant to chemotherapeutic agents as compared to CD44(low) non-SCs. By DNA methylation microarray analysis, 17 hypomethylated and 9 hypermethylated genes were identified in CD44(hi) CSCs as compared to non-SCs in most HNSCC cell lines. Cluster analysis using these 26 genes showed that CD44(hi) CSCs were epigenetically distinct from the CD44(low) non-SCs in all 5 HNSCC cell lines.

CONCLUSION

A unique epigenetic profile consisting of 17 hypomethylated and 9 hypermethylated genes was seen in HNSCC CSCs. These genes may be critically required in maintaining the stemness or pluripotency of CSCs and may represent novel molecular targets for anticancer therapies aimed at eradicating CSCs in HNSCC.

Skin graft take rates, granulation, and epithelialization: dependence on myeloid cell hypoxia-inducible factor 1alpha

OBJECTIVE

To compare the "take" rates of skin grafts between myeloid-selective hypoxia-inducible factor (HIF) 1alpha knockout (KO) and wild-type (WT) mice. Production of the alpha subunit of HIF-1alpha is increased in healing wounds, which stimulates expression of vascular endothelial growth factor (VEGF) to promote angiogenesis. Therefore, the take rate of skin grafts may be closely associated with the presence or absence of HIF-1alpha production in the recipient bed.

DESIGN

The percentage of healthy graft areas obtained by planimetry and scores for epithelialization and granulation tissue formation obtained by histopathologic analysis were compared in 12 KO and 12 WT mice following skin grafting.

RESULTS

The graft take rate was significantly impaired in the KO group (P = .009), whereas epithelialization (P = .46) or granulation (P = .41) tissue formation scores did not reveal any significant differences.

CONCLUSION

Hypoxia-inducible factor 1alpha in myeloid cells may be an important molecule for revascularization of avascular tissues such as skin grafts, probably owing to its stimulating effect on angiogenesis.

Increased microsatellite instability and epigenetic inactivation of the hMLH1 gene in head and neck squamous cell carcinoma

OBJECTIVE

The study is designed to elucidate the relationship between epigenetic silencing of the hMLH1 (human MutL homologue 1) gene and microsatellite instability (MSI) and the prognostic values of hMLH1 promoter methylation and MSI in head and neck squamous cell carcinoma (HNSCC).

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

A total of 120 cases of HNSCC were analyzed for hMLH1 promoter hypermethylation, protein expression, and MSI by using methylation-specific polymerase chain reaction, immunohistochemical staining, and polymerase chain reaction amplification with the use of 16 fluorescent-labeled microsatellite markers, followed by fragment analysis.

RESULTS

Of 120 HNSCCs, hMLH1 promoter hypermethylation and decreased hMLH1 protein expression were shown in 39 (32.5%) and 22 (18.3%), respectively. hMLH1 promoter hypermethylation was detected in 13 of 52 (25%) normal-appearing squamous mucosa adjacent to invasive carcinoma. MSI was detected in 21 (17.5%) tumors at two or more markers and in 99 (82.5%) tumors with no evidence of MSI or at only one marker. Hypermethylation of the hMLH1 gene is significantly associated with decreased hMLH1 protein expression (P < 0.001). High-frequency MSI was significantly associated with promoter hypermethylation (P = 0.01) but not with decreased protein expression (P = 0.069) of hMLH1 gene. hMLH1 promoter hypermethylation is significantly associated with decreased cause-specific survival for HNSCC patients (P = 0.03).

CONCLUSIONS

Promoter hypermethylation of the hMLH1 gene could be detected early in head and neck squamous carcinogenesis and may be associated with increased MSI and poor survival in HNSCC.

Selective deficiency of HIF-1alpha in myeloid cells influences secondary intention wound healing in mouse skin

BACKGROUND

Hypoxia-inducible factor-1 (HIF-1) influences myeloid cell function. In this study we examined the role of myeloid cell HIF-1alpha on wound healing in vivo using a cell-specific knockout (KO) mouse model.

MATERIALS AND METHODS

HIF-1alpha KO mice and wild-type (WT) controls received 8 mm full thickness dorsal dermal wounds. Wound dimensions were measured until full closure. Tissue was obtained from 3-day-old wounds for (immuno-)histochemical analysis. Production of interleukin-1beta (IL-1beta) and nitric oxide (NO) in response to lipopolysaccharide (LPS) and/or desferrioxamine (DFX) was examined in vitro.

RESULTS

Early wound closure occurred significantly faster in HIF-1alpha KO mice than in WT mice. Wounds of KO mice contained similar numbers of neutrophils and macrophages, but more activated keratinocytes, consistent with accelerated re-epithelialization. Interestingly, while LPS and LPS+DFX elicited a similar IL-1beta response in macrophages from the 2 mouse types, NO production was blunted in HIF-1alpha KO macrophages.

CONCLUSION

Absence of HIF-1alpha in myeloid cells accelerates the early phase of secondary intention wound healing in vivo. This may be associated with a deficient ability of myeloid cells to initiate an appropriate NO production response. Pharmacologic modulators of HIF-1alpha should be explored in situations with abnormal wound healing.

Sculpting resection of rhinophyma using the Shaw scalpel

BACKGROUND

Rhinophyma is a disfiguring disorder of the nasal skin characterized by hypervascularity, sebaceous gland hyperplasia, occluded sebaceous ducts, and dermal fibrosis. It has no known effective medical treatment; however, a myriad of surgical treatments have been reported. We report an effective, efficient, and safe approach to treat this disorder using the Shaw scalpel to surgically sculpt the nose.

OBJECTIVE

To evaluate the efficacy and safety of using the Shaw scalpel to treat rhinophyma.

METHODS

We performed a retrospective review of 7 male patients (age range, 58-81 years) who underwent primary surgical treatment of rhinophyma with the Shaw scalpel.

RESULTS

A good to excellent outcome was noted in all 7 patients. No perioperative complications occurred. Essentially no blood loss was noted during or after the procedures.

CONCLUSION

Use of the Shaw scalpel as the sole surgical instrument and method is a safe, efficient, and effective means to treat rhinophyma.

The effects of molar tooth involvement in mandibular angle fractures treated with rigid fixation

Objective: To determine whether the presence of a tooth in the line of mandibular angle fracture increases the incidence of complications and whether removing these teeth has an effect on complication rates.

Design: Case series with chart review.

Subjects and Methods: The analysis was performed on 83 patients who underwent open reduction and internal fixation for mandibular angle fractures. Lower molar teeth involved in the fracture line were extracted if they were loose, fractured, or grossly infected or prevented satisfactory reduction. Data regarding demographics, involvement of a molar tooth, management of the involved tooth, and postoperative outcome were analyzed. Statistical analysis was performed by using likelihood ratio χ2 and logistic regression.

Results: The revision surgery in fractures with molar tooth involvement was 28.9 percent, compared to 12.9 percent when no tooth was involved ( P = 0.084). When a tooth was involved in the fracture, the revision surgery rate was 25 percent when it was removed and 30% when it was preserved ( P = 0.734).

Conclusion: Postoperative complications, especially the revision surgery rates, may not increase by involvement of lower molar teeth in the fracture line and selective removal of these teeth by using commonly accepted guidelines may not decrease complication rates in angle fractures.

The expression of vascular endothelial growth factor and its receptors in port-wine stains

OBJECTIVE

To investigate the expression of vascular endothelial growth factor (VEGF) and its receptor (VEGF-R2) in port-wine stains (PWSs).

DESIGN

An immunohistochemistry (IHC) study on formalin-fixed, paraffin-embedded specimens.

METHODS

Representative sections from surgical resection specimens of 12 PWS patients and 12 control specimens stained with routine IHC by using polyclonal anti-VEGF and anti-VEGF-R2 antibodies. Slides were evaluated semiquantitatively for the intensity of staining for VEGF and VEGF-R2 by using a scoring system varying from 0 to 3+.

RESULTS

PWS specimens showed statistically significant overexpression of both VEGF and VEGF-R2 molecules when compared with control specimens (P < 0.005).

CONCLUSIONS

VEGF and its receptor may play an important role in the pathogenesis of PWS. It is possible that PWS may progress by hyperplasia in addition to hypertrophy. VEGF-R blockade may have a potential role as a targeted approach in the treatment of this disfiguring condition in the future.