The evolution of a Department of Internal Medicine under an integrated clinical enterprise model: the University of Kentucky experience

The impact on the Department of Internal Medicine of the emergence of the University of Kentucky Healthcare Enterprise as an integrated clinical model has been enormous. In fiscal year 2004, the department was financially insolvent and on the verge of implementing plans to decrease faculty from 127 to 65. Since that time, the department has changed dramatically with a corresponding improvement in its clinical, academic, and financial activity. The department has grown to 175 faculty, with a healthy financial outlook and a shared vision with the clinical enterprise. Departmental clinical growth has been accompanied by growth in extramural research funding. The clinical growth of the department, in turn, supported the growth of the integrated clinical enterprise overall.The purpose of this article is to present a case history of the impact of transition to an integrated clinical enterprise financial model on the clinical, research, and educational functions of a department of internal medicine, and the opportunities and lessons learned from this transition. The implementation of an enterprise model allowed revival and expansion of the clinical programs of the department. This expansion did not occur at the expense of the research and educational missions of the department but, rather, was associated with improved performance in these areas. The processes which were established during the conversion to the enterprise model, which involve strategic planning, monitoring of plan implementation, recalibration of objectives, financial transparency, and accountability of leadership and faculty, may better prepare the institution to face the challenges of the rapidly changing economic environment.

Functional hemitongue reconstruction with the microvascular ulnar forearm flap

Thirteen patients with squamous cell carcinoma of the tongue underwent full-thickness longitudinal resection of the hemitongue and immediate microvascular reconstruction using a large, contoured ulnar forearm flap. Six of the 13 patients had a composite resection for which an additional vascularized iliac crest graft was used to reconstruct the mandible and to provide support to the overlying contoured flap. To increase tongue mobility, the skin flap was designed for independent reconstruction of the hemitongue and the floor of mouth. Twelve patients were evaluated for swallowing and speech, including dietary assessment, cineradiography, and voice spectrographic analysis. Contrast cineradiography was performed to determine oral tongue mobility during the first phase of swallow. Nine patients with a narrow reconstructed tongue root and a large surface area in the floor of the mouth had good tongue mobility, allowing them to transfer food dynamically from the mouth into the pharynx for swallowing. The remaining three patients, who had a wide tongue root and an ill-defined floor of the mouth, had decreased tongue mobility and poor oral transport. The functional outcome of swallowing and speech strongly correlated with the shape of the root of the tongue, the proximity of the reconstructed tongue to the palate, and the surface area of the floor of the mouth.

Management of buccal space tumors by rhytidectomy approach with superficial musculoaponeurotic system reconstruction

PURPOSE

To show that the rhytidectomy approach without a submandibular limb can be successfully used for excision of buccal space tumors and how this technique allows reconstruction of the contour defect associated with tumor extirpation by utilization of the superficial musculoaponeurotic system (SMAS) interposition.

PATIENTS AND METHODS

Five cases of buccal space tumors are presented: two accessory lobe of parotid tumors, one parotid duct cyst, one nodular fasciitis of anterior masseter, and one lymphoma.

RESULTS

Rhytidectomy approach without a submandibular limb incision afforded adequate exposure to the tumors with excellent cosmetic results. Furthermore, SMAS interposition, which was allowed through this technique, ameliorated the contour defect created.

CONCLUSION

Rhytidectomy approach with SMAS interposition is effective for management of buccal space tumors.

Pharyngoesophageal reconstruction with the ulnar forearm flap

OBJECTIVE

To evaluate the use of a generous fasciocutaneous ulnar forearm free flap in pharyngoesophageal reconstruction.

DESIGN

Tertiary referral center.

SETTING

Private practice.

PATIENTS

From September 1, 1991, to October 30, 1996, 20 ulnar forearm free flaps were used to reconstruct the pharyngoesophagus in 19 patients after surgery for squamous cell carcinoma. There were 13 circumferential defects and 7 near-circumferential defects (<2 cm of mucosa remaining). The reconstructions were performed primarily (at the time of tumor resection) in 16 cases and secondarily in 4 cases.

INTERVENTION

A generous fasciocutaneous ulnar forearm flap with a minimum dimension of 9 x 22 cm was harvested to reconstruct the pharyngoesophagus. A 2-layer closure was performed in flap tailoring and proximal (pharynx to flap) and distal (flap to esophagus) anastomoses to minimize the risk of leakage. Also, portions of the flap were used to monitor flap viability, to cover cervical vessels, to obliterate dead space, and as skin coverage when the skin flaps were deficient.

RESULTS

Nineteen of the 20 flaps transferred were successful. Swallow function was restored in 18 cases, and voice was rehabilitated in all the patients using either tracheoesophageal puncture and a voice device or an electrolarynx device. There was 1 perioperative mortality. Three fistulas occurred, all of which healed with nonsurgical treatment. One stricture developed that required intermittent dilatation. The donor site morbidity was minor.

CONCLUSIONS

This versatile technique achieves excellent results with a decreased complication rate compared with other methods currently available in pharyngoesophageal reconstruction.

Reconstruction of the base of the tongue with the microvascular ulnar forearm flap: a functional assessment

Ten patients with infiltrating carcinomas of the base of the tongue/tonsillar region underwent 30 to 100 percent resection of the base of the tongue and lateral pharyngeal wall. The surgical defect was reconstructed (9 primary, 1 secondary) with a large microvascular ulnar forearm flap that was selectively contoured to provide bulk for the base of the tongue and a thin lining for the pharyngeal wall. Seven patients were evaluated for swallowing and speech 6 weeks to 2 years following the reconstruction. Cineradiographic studies showed excellent base of the tongue and flap mobility allowing glossopharyngeal closure in all patients and complete pharyngeal evacuation in four patients. Four patients who were in good health preoperatively were able to eat a regular diet postoperatively, and the remaining three patients were able to handle soft food. Functional recovery after major tongue base surgery is contingent upon a three-dimensional microvascular reconstruction using a thin forearm flap.

Prevention of Frey's syndrome with superficial musculoaponeurotic system interposition

Frey's syndrome after parotidectomy has an incidence generally reported to be 50% to 60% and is thought to be due to aberrant reinnervation of sweat glands by postganglionic parasympathetic fibers normally supplying the parotid gland. One hundred twelve patients had interposition of a flap of the superficial musculoaponeurotic system between the parotid bed and the overlying skin. Only one patient developed symptomatic Frey's syndrome, and one other patient had positive results on starch iodine testing. In patients not having the interposition, the incidence of symptomatic Frey's syndrome and positive starch iodine testing was 83% and 87%, respectively.

Secondary microvascular tongue reconstruction: functional results

Between 1978 and 1991, 56 microvascular composite flaps were used for oromandibular reconstructions: 15 for primary total and subtotal tongue reconstruction and five for secondary major tongue reconstruction. The delayed reconstructions were performed to improve the oral and pharyngeal phases of swallowing. Using a floor of the mouth composite bone grafting technique to reposition the tongue and obliterate the oral dead space intraoral food transport was improved (three of five patients), but aspiration persisted (three of four patients). When compared with 10 patients evaluated for primary total and subtotal tongue reconstruction the primary reconstruction group showed superior swallowing (eight dynamic oral transport, no aspiration) and speech results. The poor results of secondary reconstruction are attributed to scarring and irreversible damage to remaining functional muscles involved in protecting the laryngeal aditus.

Total and subtotal glossectomy: function after microvascular reconstruction

Twelve patients with advanced carcinoma of the floor of the mouth and tongue were treated with total (five patients) or subtotal (seven patients) glossectomy, partial mandibulectomy, and immediate reconstruction with the microvascular composite groin flap. The osteomusculocutaneous groin flap was used in eleven patients, and the osteomuscular flap was used in one patient. The groin musculocutaneous or muscle flap was designed to resemble the shape of the tongue for dynamic food transport, improved swallowing, and acceptable speech. Eight of the 12 patients who survived more than 1 year were evaluated for speech and swallowing. Eight patients were able to speak intelligibly, six patients could tolerate a soft/pureed diet, and two patients were limited to fluids. Cinefluorographic swallow studies using semisolid contrast material showed voluntary active intraoral transport and propulsive pharyngeal emptying without aspiration in six patients with complete flap to palate contact; the remaining two patients were unable to move the intraoral contrast material effectively for swallowing because of poor palatal contact.

Anatomy of the auricle

A fundamental knowledge of anatomy of the ear aids in the performance of periauricular surgery. Details of vascular anatomy may help in replantation and reconstruction of the auricle, and in the use of the retroauricular free flap.

Horizontal versus vertical block resection for early floor of mouth carcinoma

Although the literature affirms the superiority of block resection over local excision for the surgical treatment of early squamous cell carcinoma of the anterior floor of the mouth, the best method of block resection is not certain. Two methods are in widespread use; a horizontal procedure (HB) and a vertical procedure (VB). This retrospective study compares these two procedures according to outcome in separate series of patients treated between 1970 and 1984. Patients were followed for a minimum of 3 years with an average follow-up of 6 years. Twenty-five patients underwent HB while 27 underwent VB. Control at the primary site was 100% for HB and 74% for VB. Neck metastasis and distant metastasis occurred with equal frequency. Determinate survivals at 3 and 5 years were 96% and 91% for the HB group and 93% and 65% for the VB group. Local recurrence correlated with tumor growth posteriorally toward the ventrum of the tongue, suggesting an explanation for the difference in outcome between the two procedures. We conclude that the HB procedure is the preferable surgical procedure for stage I and II disease.

Persistent oral antral fistulas

Oral antral fistulas that have been already subjected to previous attempts at closure have been difficult to treat. Gold foil, bony plugs, and other materials have been used for many years to close these fistulas. Because of all of the various techniques and materials used in this procedure, it has been vexing to evaluate their efficacy. Although the persistent fistula is a rare entity, the surgeons faced with treating this condition must understand the principles of flap closure. In six cases in which multiple attempts at oral antral fistula closure had failed, we used either bilateral or unilateral palatal flaps based on the posterior palatine artery. The patients have been followed up for ten years after surgery and can wear dentures if indicated. There has not been any recurrent fistulization in any of these cases.

Adaptive mechanisms of speech and swallowing after combined jaw and tongue reconstruction in long-term survivors

Twelve patients have been studied for speech and swallowing function after major combined jaw and tongue reconstruction with the microvascular iliac bone and groin skin composite flap. Cinegraphic barium swallows demonstrated that for bolus propulsion, it is important to be able to occlude the palate with the flap. Glottic competence prevents aspiration. Speech studies show that although there is loss of certain speech sounds, approximate sounds are substituted. Speech is intelligible when soft-tissue contact to the palate can be accomplished. The adaptive mechanisms in these patients have been compared with the mechanisms used by a patient with uncorrected congenital aglossia and hypomandibulosis who developed excellent speech and swallowing. The mobility of this patient's mouth and pharynx was similar to that in the reconstructed cancer patients who were able to swallow and speak. This procedure has become our reconstruction method of choice for these major defects.

Superficial musculoaponeurotic system amelioration of parotidectomy defects

Resection of the parotid area for tumor results in several deformities. In addition to the neck scar, there is a retromandibular and cheek depression. By using a rhytidectomy incision and advancement of the superficial musculoaponeurotic fascia, we have obtained excellent exposure for all parotid operations, including those for accessory parotid lobe lesions, and have corrected the resultant deformities initially or secondarily. This procedure has been used for superficial and deep lobe tumors, partial masseter muscle resection, and recurrent tumors without compromising any of the principles of parotid tumor resection. The approach has resulted in greater acceptance of the tumor surgery by patients and less dissatisfaction postoperatively.

Circummandibular or nasomaxillary suture with pullout loop for secure placement of endotracheal tube

An oral endotracheal tube is secured with a double-armed black nylon circummandibular suture. A green pullout suture is incorporated to aid in removal. A nasal endotracheal tube is placed similarly except that the posterior strand is passed from the oral surface of the palate to the nasal floor with an eyed awl.

"Lethal midline granuloma"

We have recently had two cases of midfacial granulomas in which laboratory examinations and multiple biopsies did not reveal a more specific diagnosis. Both responded to treatment. We feel that in such cases therapy should be given and based on the extent of local destruction and the history of the disease in the patient.

Growth of homotransplanted ear cartilage in baby rabbits

Our study verifies that homografted ear cartilage in baby rabbits does, indeed, grow in size. It showed an average increase of 75 percent in length and 211 percent in area.