Novel technique to prevent or correct open-mouth deformity after bilateral mandibular resection: Use of tensor fascia lata slings

Open-mouth deformity after mandibular resection presents a challenge for surgeons and patients, contributing to significant functional and cosmetic morbidity. We present an innovative surgical technique to prevent or correct open-mouth deformity. Tensor fascia lata slings were utilized in combination with maxillomandibular fixation to surgically correct or prevent open-mouth deformity in four patients who had previously undergone mandibulectomy or at the time of a contralateral mandibulectomy following prior hemimandibulectomy and reconstruction. Two patients achieved favorable outcomes, including oral competence and improved resting jaw position, while open-mouth deformity could not be corrected for one patient. Another patient remains in the early postoperative period following a secondary procedure to correct open-mouth deformity. Open-mouth deformity is a functional/aesthetic problem that has not been addressed in the literature. Use of tensor fascia lata slings to suspend the mandible is a novel approach to the surgical management of open-mouth deformity.

Diagnosis and management of pharyngoesophageal stenosis: A comprehensive approach to prophylactic, endoscopic, and reconstructive treatment options

BACKGROUND

Pharyngoesophageal stenosis (PES) is a serious complication that substantially impacts functional outcomes and quality of life (QOL) for up to a third of head and neck cancer patients who undergo radiotherapy. Dysphagia is often multifactorial in nature and is a devastating complication of treatment that impacts patients' QOL, general health and overall wellbeing. The authors detail the clinical presentation, risk factors, imaging characteristics, preventive measures, and multimodality treatment options for PES.

METHODS

The authors present a comprehensive management algorithm for PES, including treatment by dilation, stenting, spray cryotherapy and dilation, and reconstructive treatment options utilizing different pedicled and free flaps.

RESULTS

The authors advocate for a thorough assessment of the extent and degree of pharyngoesophageal involvement of PES to determine the optimal management strategy.

CONCLUSIONS

The development of post treatment dysphagia requires appropriate imaging and biopsy, when indicated, to rule out the presence of persistent/recurrent cancer. Multidisciplinary management by a team of physicians well-versed in the range of diagnostic and therapeutic interventions available for PES is critical to its successful management.

Radiation necrosis of the pharyngeal soft tissue: Unique clinical entity reconstructed with a previously unreported composite brachioradialis and flexor digitorum superficialis radial forearm flap

BACKGROUND

The radial forearm free flap (RFFF) is a versatile flap commonly used in head and neck reconstructive surgery. We describe the use of a composite RFFF that includes muscle for reconstruction of a hostile wound of the posterior pharyngeal wall.

METHODS

A 54-year-old male with a history of recurrent right palatine tonsil HPV+ squamous cell carcinoma developed severe soft tissue necrosis of the posterior pharyngeal wall secondary to reirradiation. The defect was reconstructed with a composite RFFF that included the brachioradialis (BR) muscle and the flexor digitorum superficialis (FDS) muscle.

RESULTS

Restoration of this complex defect was successfully accomplished with minimal donor site functional deficits and satisfactory functional outcomes including decannulation and resumption of oral intake.

CONCLUSION

This composite RFFF can be effectively used to reconstruct a hostile wound of the posterior pharyngeal wall. Incorporation of muscle in the reconstruction of complex wounds with soft tissue necrosis is beneficial.

The use of negative pressure wound therapy in the primary setting for high-risk head and neck surgery

BACKGROUND

In head and neck surgery, dead space is typically managed by transferring a secondary pedicled flap or harvesting a larger composite flap with a muscular component. We demonstrate the novel use of prophylactic negative pressure wound therapy (NPWT) to obliterate dead space and reduce possible communication between the upper aerodigestive tract and the contents of the neck.

METHODS

We present a single-institutional case series of five patients with high-risk head and neck cancer treated with NPWT after ablative and reconstructive surgery to eliminate dead space following surgical resection.

RESULTS

All patients achieved successful wound closure following NPWT, which was applied in the secondary setting to combat infection in one patient and the primary setting to prophylactically eliminate dead space in four patients.

CONCLUSION

NPWT can be used to treat unfilled dead space in the primary setting of head and neck ablative and reconstructive surgery and help to avoid wound healing problems as well as the need for secondary flap transfers.

Stair-step tracheal repair: Surgical technique

Typical surgical treatment for invasive thyroid carcinoma at the level of the cricoid substantially reduces surrounding cartilaginous support and risks damage to the recurrent laryngeal nerve (RLN). We present a novel tracheal reconstructive technique that minimizes this injury risk. A 72-year-old man with recurrent invasive thyroid carcinoma underwent cricotracheal resection and reconstruction using a stair-step approach. Diseased cartilage was removed by a left hemitracheal and hemicricoid resection. A portion of normal trachea was also resected on the contralateral right side, removing the third and fourth hemitracheal rings, to close the defect with a sliding tracheoplasty and avoid dissection near the right cricothyroid joint on the side of the functioning RLN. The trachea was elevated superiorly and reanastomosed to the cut margin of the cricoid. This novel stair-step approach to tracheal reconstruction offers reduced risk of injury to the contralateral RLN while still establishing a patent airway.

A novel radial forearm free flap design to treat pharyngoesophageal stenosis in combination with the posterior wall of the trachea

Pharyngoesophageal stenosis (PES) is a common and serious complication of head and neck cancer treatments such as radiation therapy, chemotherapy, tracheoesophageal puncture placement, and total laryngectomy surgery. Dilation-resistant stenosis requires surgical reconstruction, often with a radial forearm free flap (RFFF). With the present technique, the authors refine their previous bipaddled free flap design used to reconstruct a persistent tracheoesophageal fistulae (TEF) in combination with PES. Accordingly, we present a novel bipaddled triangular RFFF design ideally suited to address the shape of the defect in the posterior tracheal wall that results when the TEF is opened and the esophageal and tracheal components are restored.