1
|
Urken ML, O’Malley Q, Sandler M, Xing MH, Ansari E, Mundi N, Buchbinder D, Alon E, Okay D. Staged Head and Neck Reconstruction: Heresy or a Reasoned Approach in a Select Group of Patients? Craniomaxillofac Trauma Reconstr 2022; 15:253-263. [PMID: 36081675 PMCID: PMC9446279 DOI: 10.1177/19433875211031361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023] Open
Abstract
Study Design case series. Objective The restoration of defects in a single procedure with microvascular free flap reconstruction has become a mainstay of head and neck surgery. Yet in patients with complex defects and pre-existing comorbid medical conditions, a staged-reconstructive approach can enhance the safety of the procedure and improve the patient's outcome. Methods We present 3 representative case examples of a larger series of patients who underwent reconstruction of major defects and discuss the usefulness of a staged-reconstructive approach in the management of complex patients. Results All 3 patients, with an existing composite defect in the setting of prior radiation therapy, underwent successful staged-reconstructive surgery using a variety of free tissue and regional flap transfers. Conclusions A staged approach facilitates the reconstruction of complex composite defects, increases vessel availability, and mitigates the risk of flap failure. Although this approach commits the patient to multiple procedures and a more prolonged plan of care, it is preferable to 1 operation in specific complex situations with adverse, high-risk clinical features.
Collapse
Affiliation(s)
- Mark. L. Urken
- THANC (Thyroid, Head and Neck Cancer)
Foundation, New York, NY, USA
- Department of Otolaryngology-Head and Neck
Surgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Beth Israel, New
York, NY, USA
| | - Quinn O’Malley
- THANC (Thyroid, Head and Neck Cancer)
Foundation, New York, NY, USA
| | - Mykayla Sandler
- THANC (Thyroid, Head and Neck Cancer)
Foundation, New York, NY, USA
| | - Monica H. Xing
- THANC (Thyroid, Head and Neck Cancer)
Foundation, New York, NY, USA
| | - Edward Ansari
- Department of Otolaryngology-Head and Neck
Surgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Beth Israel, New
York, NY, USA
| | - Neil Mundi
- Department of Otolaryngology-Head and Neck
Surgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Beth Israel, New
York, NY, USA
| | - Daniel Buchbinder
- Department of Otolaryngology-Head and Neck
Surgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Beth Israel, New
York, NY, USA
| | - Eran Alon
- Department of Otolaryngology Head and Neck
Surgery, The Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Devin Okay
- Department of Otolaryngology-Head and Neck
Surgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Beth Israel, New
York, NY, USA
| |
Collapse
|
2
|
Smith DK, Freundlich RE, Shinn JR, Wood CB, Rohde SL, McEvoy MD. An improved predictive model for postoperative pulmonary complications after free flap reconstructions in the head and neck. Head Neck 2021; 43:2178-2184. [PMID: 33783905 DOI: 10.1002/hed.26689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 02/11/2021] [Accepted: 03/16/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Commonly used predictive models for postoperative pulmonary complications (PPCs) do not perform when applied to head and neck cases. A head and neck-specific risk prediction tool is needed. METHODS Data on 794 free flap head and neck surgery cases at a single center were abstracted from the electronic medical record. Each case was reviewed for the development of PPCs. A predictive model was developed and was then compared to existing predictive models for PPCs. RESULTS The least absolute shrinkage and selection operator procedure identified age, alcohol use, history of congestive heart failure, preoperative packed cell volume, preoperative oxygen saturation, and preoperative metabolic equivalents as predictors of PPCs in the head and neck population. The model demonstrated an area under the receiving operating characteristic curve of 0.75 (0.69-0.80) with moderately good calibration. Comparisons to the performance of existing models demonstrate superior performance. CONCLUSIONS The model for the development of PPCs developed in this article displays superior performance to existing models.
Collapse
Affiliation(s)
- Derek K Smith
- Department of Oral and Maxillofacial Surgery and Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert E Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C Burton Wood
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L Rohde
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
3
|
Schultz JJ, Viviano SL, Ayyala HS, Lee BB, Keith JD. Superficial temporal artery perforator flaps for reconstruction of intraoral defects. Microsurgery 2020; 41:119-123. [PMID: 33230926 DOI: 10.1002/micr.30687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 07/28/2020] [Accepted: 11/10/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND Intraoral defects after tumor resection are often reconstructed with free tissue transfer. However, in patients who are not good candidates for free tissue transfer, regional flaps based on the superficial temporal artery can be utilized. The authors present our technique to reconstruct intraoral defects with the superficial temporal artery perforator (STAP) flap and early outcomes. METHODS Five patients underwent STAP flaps for defects including the hard palate, buccal sulcus, floor of mouth, and retromolar trigone between 2017 and 2019. The mean defect size was 5.6 × 3.4 cm2 (3 × 3 cm2 - 7 × 4 cm2 ). The mean age was 74 (57-88) and all patients had recurrent cancer. External Doppler, indocyanine green laser angiography, and FLIR thermal imaging were used intra-operatively to identify the best perforators and plan for flap design. RESULTS The mean flap size was 7.6 × 3.5 cm2 (6 × 3 cm2 - 10 × 5 cm2 ). Four flaps were based off of the posterior branch of the STA, while the fifth was based off of the anterior branch. Two donor sites were closed primarily, and three required skin grafts. One patient experienced partial flap necrosis. There were no complete flap losses and no donor site complications. Average follow up was 14.6 months (9-20 months). All patients maintained preoperative level of speech, mastication, and oral continence. CONCLUSIONS The STAP flap can be based on the anterior or posterior branch of the superficial temporal artery and is a useful regional flap for intraoral defects after tumor resection.
Collapse
Affiliation(s)
- Jerette J Schultz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Stephen L Viviano
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Haripriya S Ayyala
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Bryant B Lee
- Department of Otolaryngology, St. Barnabas Medical Center, Livingston, New Jersey, USA
| | - Jonathan D Keith
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| |
Collapse
|
4
|
Existing Predictive Models for Postoperative Pulmonary Complications Perform Poorly in a Head and Neck Surgery Population. J Med Syst 2019; 43:312. [PMID: 31451999 DOI: 10.1007/s10916-019-1435-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 08/20/2019] [Indexed: 12/11/2022]
Abstract
Postoperative pulmonary complications (PPCs) are common following major surgical procedures. Risk stratification tools have been developed to identify patients at risk for PPCs. While otolaryngology cases were included in the development of common predictive tools, they comprised small percentages in each tool. It is unclear how these tools perform in patients undergoing major head and neck surgery with free flap reconstruction. This retrospective review studied all free flap reconstructions in head and neck surgery over a 12-year period at a single institution in the southeastern US. Baseline demographic and medical information were included for each case. All cases were reviewed for development of major PPCs, including pneumonia and respiratory failure. The cohort underwent risk stratification using the ARISCAT and Gupta pulmonary risk indices. Performance of these predictive models for head and neck surgery was determined through receiver-operator curve comparison. 794 patients were identified with a median age of 62 years (IQR 41-83). Sixty-five percent were male. Forty-three (5.4%) developed pneumonia, 23 patients developed respiratory failure (2.9%), and 38 patients developed both (4.8%), resulting in a total PPC proportion of 13.1% (n = 104). Both ARISCAT and Gupta pulmonary risk indices demonstrated low discrimination to predict PPCs in head and neck free flap reconstruction, with areas under the curve of 0.60 and 0.65, respectively. Two major indices for prediction of postoperative pulmonary complications do not accurately identify risk in patients undergoing major head and neck surgery. Further studies are needed to develop predictive tools for PPCs in this high-risk population.
Collapse
|
5
|
Benanti E, Starnoni M, Spaggiari A, Pinelli M, De Santis G. Objective Selection Criteria between ALT and Radial Forearm Flap in Oral Soft Tissues Reconstruction. Indian J Plast Surg 2019; 52:166-170. [PMID: 31602131 PMCID: PMC6785316 DOI: 10.1055/s-0039-1693504] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Different locoregional and free flaps were described for oral soft tissues reconstruction after oncological resections; however, free flaps remain the first choice. Among free flaps, the radial forearm flap (RFF) and the anterolateral thigh perforator flap (ALT) are preferred the most. The lack of standardization of the flap choice leaves the selection to the surgeon's experience. The purpose of our observational study is to provide an algorithm to support the flap choice for the reconstruction of oral soft tissues. Sixty patients with squamous cell carcinoma of oral soft tissues were enrolled in our study. All the patients underwent preoperative magnetic resonance imaging (MRI) to measure the three-dimensional size of the tumor. During the follow-up, the patients were evaluated by using the University of Washington-Quality of Life Questionnaire. The questionnaire score was better for small tumors and worse for large tumors in both functional and relational fields. We observed that most of the overlapping results were obtained for small defects and the choice of RFF, as well as for large defects and the use of ALT. We observed that in the preoperative time, it is possible to select which flap between radial forearm and ALT is more appropriate for oral soft tissues defects reconstruction, according to the size of the tumor evaluated by MRI. We propose a decisional algorithm that suggests the type of flap to use between ALT and RFF.
Collapse
Affiliation(s)
- Elisa Benanti
- Department of Plastic and Reconstructive Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italia
| | - Marta Starnoni
- Department of Plastic and Reconstructive Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italia
| | - Antonio Spaggiari
- Department of Plastic and Reconstructive Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italia
| | - Massimo Pinelli
- Department of Plastic and Reconstructive Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italia
| | - Giorgio De Santis
- Department of Plastic and Reconstructive Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italia
| |
Collapse
|
6
|
Weinand C, Dittes C. Soft Tissue Mandibula and Tongue Reconstruction Using A Suprafascial, Folded, Deepithelialized Antero-Lateral Thigh Perforator Free Flap. World J Plast Surg 2019; 8:103-107. [PMID: 30873370 PMCID: PMC6409148 DOI: 10.29252/wjps.8.1.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Head and neck squamous cell carcinoma (HNSCC) is the most frequent carcinoma of the head and neck region. For coverage of an entire resected mandible with floor of the mouth, 3/4 of the tongue and soft tissue of cheeks and neck bony reconstruction of the mandible and soft tissue reconstruction of tongue, cheeks and a neck large flap are needed. A patient with a superinfected T4 HNSCC was presented to our outpatient clinic. Complete resection of the mandible, bilateral neck dissection and 3/4 resection of the tongue were performed. A complex reconstruction using two free flaps was not feasable, so a large, folded, suprafascial Antero Lateral Thigh Perforator (ALTP) flap for immediate soft tissue reconstruction was used. Because of the anatomy, no reconstruction plate was inserted. On postop day 11, an understandable speaking was possible using a speach canula. Swallowing was possible without regurgitation. Eight months postoperatively, the patients mimic and closure of the mouth were satisfactory. The flap was viable throughout the entire time. It was shown that the suprafascial ALTP flap was a versatile part in the armamentarium for complex mandible soft tissue reconstruction.
Collapse
Affiliation(s)
- Christian Weinand
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Dietrich-Bonhoeffer-Klinikum Neubrandenburg, Germany
| | - Carsten Dittes
- Department of Oral- Maxillo-Facial Surgery, Plastic Operations, Dietrich-Bonhoeffer-Klinikum Neubrandenburg, Germany
| |
Collapse
|
7
|
Moreno MA, Bonilla‐Velez J. Clinical pathway for abbreviated postoperative hospital stay in free tissue transfer to the head and neck: Impact in resource utilization and surgical outcomes. Head Neck 2019; 41:982-992. [DOI: 10.1002/hed.25525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 09/12/2018] [Accepted: 10/01/2018] [Indexed: 11/05/2022] Open
Affiliation(s)
- Mauricio A. Moreno
- Department of Otolaryngology – Head and Neck SurgeryUniversity of Arkansas for Medical Sciences Little Rock Arkansas
| | - Juliana Bonilla‐Velez
- Department of Otolaryngology – Head and Neck SurgeryUniversity of Arkansas for Medical Sciences Little Rock Arkansas
| |
Collapse
|
8
|
Huang AT, Day TA. Double paddle ulnar perforator free flap in reconstruction of through-and-through and fistulous defects of the head and neck. Laryngoscope 2016; 127:1302-1305. [PMID: 28000215 DOI: 10.1002/lary.26440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 10/28/2016] [Accepted: 11/02/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Andrew T Huang
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Terry A Day
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| |
Collapse
|
9
|
Abstract
Whatever is excisable, is reconstructable! “You excise, we will reconstruct” are the confident words of reconstructive surgeons today. Reconstruction with multiple flaps has become routine. Radial artery (FRAF), Antero lateral thigh (ALT) and Fibula osteo cutaneous flap (FFOCF) are three most popular free flaps which can reconstruct any defect with excellent asthetics and performance. Radial Artery provides thin, pliable innervated skin; ALT large amount of skin & bulk; and FFOCF strong 22 to 25 centimetres of bone and reliable skin paddle. Free flap survival has gone to 98% in most of the renouned institutes and is an established escalator in management of defects.
Collapse
Affiliation(s)
- Prabha Yadav
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India
| |
Collapse
|
10
|
Chinn SB, Spector ME, Bellile EL, Rozek LS, Lin T, Teknos TN, Prince ME, Bradford CR, Urba SG, Carey TE, Eisbruch A, Wolf GT, Worden FP, Chepeha DB. Efficacy of induction selection chemotherapy vs primary surgery for patients with advanced oral cavity carcinoma. JAMA Otolaryngol Head Neck Surg 2014; 140:134-42. [PMID: 24370563 DOI: 10.1001/jamaoto.2013.5892] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE The University of Michigan has investigated the use of induction selection (IS) with chemoradiotherapy (CRT) for patients who respond to CRT and found this approach effective in the management of advanced laryngeal cancer. The IS approach was extended to oral cavity squamous cell carcinoma (OCSCC) to help understand whether organ preservation or survival benefit resulted. OBJECTIVE To evaluate the efficacy of an IS protocol vs primary surgical extirpation and selective postoperative radiotherapy for advanced OCSCC. DESIGN AND SETTING Retrospective matched cohort study at a tertiary care hospital. PARTICIPANTS Nineteen patients with resectable stages III and IV OCSCC were enrolled into a phase 2 IS trial. Patients with a response of at least 50% underwent concurrent CRT; those with a response of less than 50% underwent surgical treatment and radiotherapy. A comparison cohort of patients treated with primary surgical extirpation during a similar time period was frequency matched for inclusion criteria and patient characteristics to those patients included from the phase 2 IS trial. No difference was noted in age, sex, pretreatment American Joint Committee on Cancer stage, T and N classifications, smoking status, alcohol consumption, or tumor subsite between the IS and surgical cohorts. Median follow-up was 9.4 years in the IS cohort and 7.1 years in the surgical cohort. INTERVENTIONS Induction selection and CRT vs primary surgical extirpation with or without postoperative radiotherapy. MAIN OUTCOMES AND MEASURES Overall and disease-specific survival and locoregional control. RESULTS The Kaplan-Meier estimate for overall survival at 5 years was 32% in the IS cohort and 65% in the surgical cohort. The Kaplan-Meier estimate for disease-specific survival at 5 years was 46% in the IS cohort and 75% in the surgical cohort. The Kaplan-Meier estimate for locoregional control at 5 years was 26% in the IS cohort and 72% in the surgical cohort. Multivariable analysis demonstrated significantly better overall and disease-specific survival and locoregional control outcomes (P = .03, P = .001, and P < .001, respectively) in the surgical cohort. CONCLUSIONS AND RELEVANCE Primary surgical treatment showed significantly better survival and locoregional control compared with IS in this matched patient cohort. Despite success of organ preservation IS protocols in the larynx, comparative survival analysis of an IS protocol vs primary surgical extirpation for OCSCC demonstrates significantly better outcomes in the surgical cohort. These findings support surgery as the principal treatment for OCSCC.
Collapse
Affiliation(s)
- Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor
| | - Emily L Bellile
- Comprehensive Cancer Center Biostatistics Unit, University of Michigan, Ann Arbor
| | - Laura S Rozek
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor
| | - Tasha Lin
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor
| | - Theodoros N Teknos
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor4now with Department of Otolaryngology-Head and Neck Surgery, Ohio State University Medical Center, Columbus
| | - Mark E Prince
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor5Comprehensive Cancer Center, University of Michigan, Ann Arbor
| | - Carol R Bradford
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor5Comprehensive Cancer Center, University of Michigan, Ann Arbor
| | - Susan G Urba
- Comprehensive Cancer Center, University of Michigan, Ann Arbor6Division of Hematology Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Thomas E Carey
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor5Comprehensive Cancer Center, University of Michigan, Ann Arbor
| | - Avraham Eisbruch
- Comprehensive Cancer Center, University of Michigan, Ann Arbor7Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Gregory T Wolf
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor5Comprehensive Cancer Center, University of Michigan, Ann Arbor
| | - Francis P Worden
- Comprehensive Cancer Center, University of Michigan, Ann Arbor6Division of Hematology Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Douglas B Chepeha
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor5Comprehensive Cancer Center, University of Michigan, Ann Arbor
| |
Collapse
|
11
|
Speech and swallowing following tongue cancer surgery and free flap reconstruction – A systematic review. Oral Oncol 2013; 49:507-24. [DOI: 10.1016/j.oraloncology.2013.03.001] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 02/04/2013] [Accepted: 03/04/2013] [Indexed: 11/20/2022]
|
12
|
Russi EG, Corvò R, Merlotti A, Alterio D, Franco P, Pergolizzi S, De Sanctis V, Ruo Redda MG, Ricardi U, Paiar F, Bonomo P, Merlano MC, Zurlo V, Chiesa F, Sanguineti G, Bernier J. Swallowing dysfunction in head and neck cancer patients treated by radiotherapy: review and recommendations of the supportive task group of the Italian Association of Radiation Oncology. Cancer Treat Rev 2012; 38:1033-49. [PMID: 22542950 DOI: 10.1016/j.ctrv.2012.04.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Revised: 03/24/2012] [Accepted: 04/03/2012] [Indexed: 12/18/2022]
Abstract
PURPOSE Dysphagia is a debilitating complication in head and neck cancer patients (HNCPs) that may cause a high mortality rate for aspiration pneumonia. The aims of this paper were to summarize the normal swallowing mechanism focusing on its anatomo-physiology, to review the relevant literature in order to identify the main causes of dysphagia in HNCPs and to develop recommendations to be adopted for radiation oncology patients. The chemotherapy and surgery considerations on this topic were reported in recommendations only when they were supposed to increase the adverse effects of radiotherapy on dysphagia. MATERIALS AND METHODS The review of literature was focused on studies reporting dysphagia as a pre-treatment evaluation and as cancer and cancer therapy related side-effects, respectively. Relevant literature through the primary literature search and by articles identified in references was considered. The members of the group discussed the results and elaborated recommendations according to the Oxford CRBM levels of evidence and recommendations. The recommendations were revised by external Radiation Oncology, Ear Nose and Throat (ENT), Medical Oncology and Speech Language Pathology (SLP) experts. RESULTS Recommendations on pre-treatment assessment and on patients submitted to radiotherapy were given. The effects of concurrent therapies (i.e. surgery or chemotherapy) were taken into account. CONCLUSIONS In HNCPs treatment, disease control has to be considered in tandem with functional impact on swallowing function. SLPs should be included in a multidisciplinary approach to head and neck cancer.
Collapse
Affiliation(s)
- Elvio G Russi
- Radiation Oncology Department, A.O. S. Croce e Carle, Cuneo, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Abstract
Microsurgical free flaps are today considered state of the art in head and neck reconstruction after composite tumor resections. Free flaps provide superior functional and aesthetic restoration with less donor-site morbidity. This article details our approach to this challenging and complex procedure. Free tissue transfer can be viewed as consisting of 4 essential stages: (1) defect assessment, (2) preparation of recipient vessels, (3) flap selection and harvest, and (4) flap inset and microsurgical anastomoses. The essential details of each step are highlighted. Meticulous attention to each step is important because each plays a crucial role in the overall success of the procedure. Workhorse flaps in our practice are the anterolateral thigh, radial forearm, fibula, and jejunum flaps. Unique issues related to postoperative care and monitoring of head and neck free flaps are discussed. The management of complications, in particular those threatening flap survival, are reviewed in detail.
Collapse
Affiliation(s)
- Chin-Ho Wong
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Chang Gung University, Taoyuan, Taiwan
| | | |
Collapse
|
14
|
|
15
|
Smith RB, Sniezek JC, Weed DT, Wax MK. Utilization of free tissue transfer in head and neck surgery. Otolaryngol Head Neck Surg 2007; 137:182-91. [PMID: 17666238 DOI: 10.1016/j.otohns.2007.04.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Revised: 03/19/2007] [Accepted: 04/18/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Free tissue transfer is frequently incorporated into the reconstructive algorithm for a multitude of defects in the head and neck. With the increasing usage of free tissue transfer we undertook to review the most current advances in the field. DATA SOURCES PubMed search of all pertinent articles as they related to oropharyngeal reconstruction, flap choice, new technologies and techniques, and outcomes. Articles were chosen based on reviewer selection. METHODS The microvascular committee met and discussed the current important topics in free tissue transfer. A priority list was created and ranked. Topics were assigned to the authors who conducted a narrative review of the literature. RESULTS Free tissue transfer has evolved to the point where a limited number of specific flaps are now utilized for most defects. Composite tissue is used to reconstruct composite defects. The coupling device and implantable Doppler are demonstrating a positive impact on flap survival and efficiency. Finally, outcomes in terms of quality of life, swallowing, and return to function have been shown to improve with the use of free tissue transfer. CONCLUSION Free tissue transfer continues to be the reconstructive modality of choice for head and neck defects.
Collapse
Affiliation(s)
- Russell B Smith
- Department of Otolaryngology--Head and Neck Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | | | | | | |
Collapse
|
16
|
de Bree R, Rinaldo A, Genden EM, Suárez C, Rodrigo JP, Fagan JJ, Kowalski LP, Ferlito A, Leemans CR. Modern reconstruction techniques for oral and pharyngeal defects after tumor resection. Eur Arch Otorhinolaryngol 2007; 265:1-9. [PMID: 17684754 DOI: 10.1007/s00405-007-0413-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Accepted: 07/19/2007] [Indexed: 11/28/2022]
Abstract
Several techniques have been developed to reconstruct oral and pharyngeal defects following surgery, in order to restore function and cosmesis. These are primary closure, skin grafts, local transposition of skin, mucosa and/or muscle, regional flaps and free vascularized flaps. Because of the 'bulky', pedicled nature and problems with the donor area of locoregional flaps, and consequently frequently unsatisfactory functional results, free vascularized flaps have gained popularity during the last decade. The authors review the current options available to give physicians, who are not experienced in the field of reconstruction in the head and neck, an impression of the range of techniques available for reconstruction of oral and pharyngeal defects following tumor resection. For reconstruction of oral cavity and pharyngeal defects, fasciocutaneous (e.g. radial forearm and anterolateral thigh flaps) and myocutaneous free flaps (e.g. rectus abdominis and latissimus dorsi) have proven to be very reliable. Free vascularized osteocutaneous flaps (e.g. fibula and iliac crest) permit reconstructive options for bony defects of the mandible or maxilla that can be adapted to a variety of defects. Depending on the site, size and involved tissues of the surgical defect and patient factors, a variety of reconstructive options are available. For both soft tissue and bony defects of the upper aerodigestive tract, microvascular free flaps provide good functional outcomes.
Collapse
Affiliation(s)
- Remco de Bree
- Department of Otolaryngology, Head and Neck Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand current trends in the treatment of head and neck cancer. 2. Discuss the challenges of reconstructing head and neck defects 3. Understand the different reconstructive options available for specific anatomical regions of the head and neck. BACKGROUND Reconstructive surgery of the head and neck is both technically challenging and rewarding. In the past 20 years, significant advances in this field have improved surgical outcomes and patient function. The development and subsequent refinement of microvascular techniques, in particular, have been a major reason for this progression. METHODS In this article, the authors review the current options available in head and neck reconstruction. Because a large number of major craniocervicofacial defects result from oncologic resection, the authors have focused their review on this particular subject. By dividing their discussion into different anatomical sites, the authors hope to cover all major aspects of this broad topic. RESULTS Free tissue transfer has revolutionized head and neck reconstruction. The most widely used free flaps include the fibula, radial forearm, anterolateral thigh, and rectus abdominis. Restoration of both form and function is the ultimate goal. CONCLUSIONS Although defects of the head and neck region present a challenge, successful cosmetic and functional results have been achieved with both local and free tissue flaps. The flexibility of free tissue transfer, however, has dominated this area and continues to be the method of choice for reconstruction of sizable defects.
Collapse
Affiliation(s)
- Keith A Hurvitz
- Orange, Calif. From the Aesthetic and Plastic Surgery Institute, University of California Irvine Medical Center
| | | | | |
Collapse
|
18
|
Rickert D, Scheithauer MO, Coskun S, Lendlein A, Kelch S, Franke RP. Erste Ergebnisse zur Untersuchung der Stabilität und Gewebeintegration eines abbaubaren, elastischen Copolymers im Tiermodell / First results of the investigation of the stability and tissue integration of a degradable, elastomeric copolymer in an animal model. BIOMED ENG-BIOMED TE 2006; 51:116-24. [PMID: 16961454 DOI: 10.1515/bmt.2006.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The stability and tight integration into adjacent tissue of a novel, degradable, elastic copolymer were examined in an animal model. The biomaterial was used for the reconstruction of a gastric wall defect in Sprague-Dawley rats (n=42) to test the polymeric material under the extreme chemical, enzymatical and mechanical conditions of the stomach. In the control group (n=21) the same defect of the gastric wall was primarily closed without biomaterial implantation. In the baseline group (n=21) the animals were kept under standard conditions without any surgical procedure. The implantation periods were 1 week, 4 weeks and 6 months. The animals' weight was determined preoperatively and before explantation. After explantation, air was pumped into the stomach and the pressure was measured by using a pressure-gauge in order to test whether the surgically produced union of the stomach wall and the polymer patch was gas-tight. After 1 week of implantation time a statistically significant increase of the body weight of the animals was found only in the baseline group. Four weeks and 6 months after the abdominal surgical procedure, a statistically significant increase of the animals' weight was found in the implantation group, the control and the baseline group. Gastrointestinal complications like fistula, perforation or peritonitis did not occur in any of the animals. The measurement of the stomach pressure after maximal gas insufflation did not show significant differences between the implantation group, the control and the baseline group in any of the time periods investigated. Despite very high strains of the gastric wall, no gas leakage was detected. There was a tight connection between the polymer and the adjacent stomach wall in all animals investigated. An adequate mechanical stability of the biomaterial was detectable under the extreme pathophysiological conditions of the stomach milieu. A fast and unfavourable degradation of the degradable polymer was not found in any of the animals. Further investigations are needed to analyse the mechanisms of the tissue integration of the biomaterial as well as the degradation kinetic of the polymer and the process of the tissue remodeling. The knowledge of these processes is necessary to adapt the novel biomaterial and thus prepare it for the use and implantation in different body locations and to develop novel therapeutical options in medicine.
Collapse
Affiliation(s)
- Dorothee Rickert
- Universitätsklinik für Hals-Nasen-Ohrenheilkunde, Universität Ulm, Deutschland.
| | | | | | | | | | | |
Collapse
|
19
|
Abstract
The length and quality of head and neck cancer survivorship continues to improve. Radiotherapy has been central to this process through advances in treatment technology, fractionation schemas, radiosensitizing chemotherapy, and surgical technique. The future of head and neck radiotherapy looks brighter still with progress in radiosensitizing biologic therapy, molecular characterization, functional imaging, and rehabilitative strategies fast approaching. Head and neck cancer, a disease once fraught with nihilism and failure, is evolving into a major success story of multidisciplinary solid tumor management. Continued dedication and work on the part of provider and patient alike will be required to make this promise a reality.
Collapse
Affiliation(s)
- D L Schwartz
- Department of Radiation Oncology, M.D. Anderson Cancer Center, Unit 97, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | | |
Collapse
|
20
|
Roostaeian J, Suh JD, Sercarz JA, Abemayor E, Lee JT, Blackwell KE. Factors affecting cancer recurrence after microvascular flap reconstruction of the head and neck. Laryngoscope 2005; 115:1391-4. [PMID: 16094111 DOI: 10.1097/01.mlg.0000166706.61652.15] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Our objective was to determine which factors are associated with cancer recurrence after microvascular reconstruction of the head and neck for squamous cell carcinoma (SCC). STUDY DESIGN A cohort of patients who fit the inclusion/exclusion criteria were identified retrospectively. METHODS A group of 184 patients who underwent successful surgical resection and simultaneous microvascular reconstruction of the head and neck for treatment of SCC were identified. The mean age was 60 (range 23-90) years, there were 115 males and 69 females, and mean follow-up was 26.2 (range 1-99) months. Various factors were analyzed to determine whether they were associated with cancer recurrence, including those pertaining to 1) recipient vessel choice, 2) prior cancer treatment, and 3) cancer staging criteria. Statistical analysis was performed using SPSS statistical software. RESULTS Overall cancer stage (P = .005), T stage (P = .0001), history of previous cancer treatment (P = .004), and history of previous chemotherapy (P = .044) were found to be statistically significant predictors of cancer recurrence on univariate analysis. However, on multivariate analysis, only T stage (P = .005) and history of previous cancer treatment (P = .008) remained as statistically significant predictors of cancer recurrence. Recipient vessel selection was not statistically associated with cancer recurrence. CONCLUSIONS In our study, only T stage and a history of previous cancer treatment were associated with increased cancer recurrence. Neither the recipient vessel chosen nor its location impacted cancer recurrence. This suggests that recipient vessel selection and preparation for microvascular reconstruction do not jeopardize the adequacy of oncologic resection and are therefore oncologically sound.
Collapse
Affiliation(s)
- Jason Roostaeian
- Division of Head and Neck Surgery, the Department of Surgery, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA 90095-1624, U.S.A
| | | | | | | | | | | |
Collapse
|