Free Flap Donor Sites in Head and Neck Reconstruction.

Microvascular free tissue transfer, also referred to as free flaps surgery, is a reconstructive technique that has become a foundational component of complex head and neck reconstruction. There have been considerable advancements in the field over the last 30 years including the number and variety of free flaps. Each of these free flaps has unique characteristics that must be considered for the defect when selecting a donor site. Here, the authors focus on the most common free flaps used in head and neck reconstruction.

Managing Oromandibular Hardware Failure after Free Flap Surgery.

Hardware failure after oromandibular reconstruction using free tissue transfer can delay additional therapies directed at cancer treatment and prevent patients from returning to normal oral function. Understanding and strict adherence to principles of rigid fixation is critical in preventing complications. Early surgical intervention for hardware exposure as well as utilization of locoregional flaps may prevent the need for more extensive revision surgery.

Association of Neoadjuvant Pembrolizumab for Oral Cavity Squamous Cell Carcinoma With Adverse Events After Surgery in Treatment-Naive Patients.

Importance: Pembrolizumab, a monoclonal antibody targeting programmed cell death 1, is currently approved by the US Food and Drug Administration for recurrent or metastatic head and neck squamous cell carcinoma (HNSCC). The potential neoadjuvant role of programmed cell death 1 inhibitors in primary surgical management of HNSCC and effects on surgical outcomes are poorly understood. Objective: To evaluate the incidence of postoperative adverse events in treatment-naive patients with advanced oral cavity cancer receiving neoadjuvant pembrolizumab when compared with matched controls, as part of a window-of-opportunity multi-institutional clinical trial assessing neoadjuvant pembrolizumab for locally advanced HNSCC. Design, Setting, and Participants: This retrospective cohort study at a single tertiary academic institution included treatment-naive patients with local regionally advanced oral cavity squamous cell carcinoma (OCSCC) who were undergoing surgical resection. Exposures: Patients with local regionally advanced resectable OCSCC who received neoadjuvant pembrolizumab were retrospectively reviewed for postoperative adverse events. Controls were matched by age, race, smoking status, and overall cancer stage based on historical data at the same institution. Matched-cohort analysis was performed using a McNemar test to assess differences between the groups. Main Outcomes and Measures: Incidence of adverse events following surgical resection of advanced OCSCC within 30 days of surgery and on continued follow-up. Results: A total of 64 patients (32 as part of the prospective clinical trial and 32 as controls; mean [SD] age, 59.6 [10.3] years; 28 [44%] women) were included in the analysis. Postoperative adverse events in the 32 patients receiving pembrolizumab included lymphedema (n = 20 [63%]), trismus (n = 7 [22%]), return to operating room (n = 7 [22%]), wound infection (n = 7 [22%]), fistula (n = 6 [19%]), wound dehiscence (n = 4 [13%]), flap failure (n = 3 [9%]), and hematoma (n = 2 [6%]). The matched control group demonstrated similar complication rates without considerable differences, except for trismus (n = 16 [50%]), which was greater by a difference of 28.1% (95% CI, 5.6%-50.6%) in the control group. Conclusions and Relevance: This cohort study examined surgical complications among patients with local regionally advanced OCSCC treated with neoadjuvant pembrolizumab and found that serious adverse events were similar to those in patients who underwent standard-of-care treatment. This suggests that there is no increased perioperative morbidity in the use of preoperative treatment with immunotherapy. Further prospective studies are needed to validate these findings for oral cavity cancer and other subsites of the head and neck.

Trends in Number of Women Speakers at the American Head and Neck Society Meetings, 2007-2019.

Importance: The number of female speakers at American Head and Neck Society (AHNS) conferences should ideally be consistent with the number of women entering head and neck surgery fellowships to ensure gender equity in the field. Yet the presence of women speakers at the annual AHNS meetings, which is specific to the field of head and neck cancer, endocrine and microvascular reconstructive surgery, has yet to be studied. Objective: To determine whether the proportion of female speakers at the AHNS has increased in a manner consistent with the numbers of women entering fellowships since 2007. Design, Setting, and Participants: This qualitative study assessed 13 final meeting programs from AHNS national/international conferences from 2007 to 2019. The number of male and female participants in different roles throughout the meeting were retrospectively tracked. Participants were male and female speakers at AHNS national/international conferences who took part in the roles of scientific session presenter, scientific session moderator, expert panelist, miscellaneous moderator, and named lecturers/keynote speaker. Gender of the speaker was determined by searching names on the internet and using available published pronouns. Main Outcomes and Measures: Number of speaking opportunities for men and women in different roles from 2007 to 2019 as well as number of men and women entering AHNS fellowships since 2007 and new active AHNS members since 2012. Results: In this qualitative study, from 2007 to 2019, 4059 speakers were identified. Of these speakers, 902 (22%) were women and 3157 (78%) were men. Overall, there was a strong correlation between increasing years and number of women speakers from 2007 to 2019 (ρ = 0.75; 95% CI, 0.72-0.78). There were 2096 invited speaking roles that excluded research presentations, of which 400 were offered to female participants (19.1%) across the study period. There were 131 different women that made up all 400 of the opportunities that were offered to women in the years surveyed. There was a strong correlation in the proportion of women as presenters for oral abstracts, expert panelists, and miscellaneous moderators between the years but no correlation in scientific session moderators and named lecturers/keynote speakers. Of the 45 named lecturers/keynote speakers in the programs tracked, only 2 were women. Conclusions and Relevance: In this study, from 2007 to 2019, the presence of women at ANHS has increased overall, reflecting the changing demographic characteristics of those entering in head and neck oncology and microvascular surgery fellowships. However, a strong disparity continues to exist for preeminent speaking opportunities.

Heparin-mediated antibiotic delivery from an electrochemically-aligned collagen sheet.

BACKGROUND: Implantable medical devices and hardware are prolific in medicine, but hardware associated infections remain a major issue. OBJECTIVE: To develop and evaluate a novel, biologic antimicrobial coating for medical implants. METHODS: Electrochemically compacted collagen sheets with and without crosslinked heparin were synthesized per a protocol developed by our group. Sheets were incubated in antibiotic solution (gentamicin or moxifloxacin) overnight, and in vitro activity was assessed with five-day diffusion assays against Pseudomonas aeruginosa. Antibiotic release over time from gentamicin-infused sheets was determined using in vitro elution and high performance liquid chromatography (HPLC). RESULTS: Collagen-heparin-antibiotic sheets demonstrated larger growth inhibition zones against P. aeruginosa compared to collagen-antibiotic alone sheets. This activity persisted for five days and was not impacted by rinsing sheets prior to evaluation. Rinsed collagen-antibiotic sheets did not produce any inhibition zones. Elution of gentamicin from collagen-heparin-gentamicin sheets was gradual and remained above the minimal inhibitory concentration for gentamicin-sensitive organisms for 29 days. Conversely, collagen-gentamicin sheets eluted their antibiotic load within 24 hours. Overall, heparin-associated sheets demonstrated larger inhibition zones against P. aeruginosa and prolonged elution profile via HPLC. CONCLUSION: We developed a novel, local antibiotic delivery system that could be used to coat medical implants/hardware in the future and reduce post-operative infections.

Cancellous Tibial Bone Graft for Malunion after Mandibular Reconstruction in Head and Neck Cancer.

OBJECTIVES/HYPOTHESIS: While nonunion after mandibular reconstruction for head and neck surgery is rare, literature exploring management is scarce. Our primary objective was to determine success rates of tibial bone graft (TBG) in achieving mandibular union. Secondary objectives include determining factors that contribute to failure of TBG. STUDY DESIGN: Retrospective Chart Review. METHODS: Retrospective chart review between January 1, 2008 and December 31, 2018. Patients who underwent a mandibulotomy or mandibulectomy with osteocutaneous free flap reconstruction were identified. Patients who were pursuing dental rehabilitation, subsequently diagnosed with mandibular nonunion and received a cancellous TBG were assessed. RESULTS: The 15 patients meeting inclusion criteria were mostly male (67%), white (87%), and nonsmokers (67%) with a median age of 64 (IQR = 60-73). Successful union occurred in 13 of 18 (72%) TBGs and the majority (63%) had a partial union documented at the time of surgery. Five patients (83%) who initially had a mandibulotomy achieved union compared to 78% of those with osteocutaneous reconstruction (P = 1.0). Postoperative radiation did not affect rates of union: 80% for both (P = 1.0). Patients with osteoradionecrosis (ORN) achieved union in 67% of cases compared to 75% of cases who did not have ORN (P = .86). There were similar rates of union for those who required perioperative antibiotics for infection and those without infection (67% vs. 75%, P = .86). Dental rehabilitation was achieved in 55% of patients, most commonly dentures. CONCLUSIONS: This study shows that TBG can be used to achieve union for patients with malunion after head and neck cancer reconstruction. We show its successful use within the reconstructive algorithm for patients regardless of postoperative radiation for very small defects. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1291-1296, 2021.

The prefabricated supraclavicular artery flap in high-risk tracheal stenosis patients.

OBJECTIVES/HYPOTHESIS: Primary tracheal resection in appropriately selected patients with tracheal stenosis achieves >90% success rate. Risk factors for complications have been identified, making some patients high risk for this procedure. Herein is a review and discussion of a novel treatment method for tracheal stenosis utilizing a prefabricated composite auricular cartilage graft embedded in a supraclavicular artery island flap (pSCAIF) for tracheal reconstruction in high-risk patients. STUDY DESIGN: Retrospective case series. METHODS: After institutional review board approval, cases were analyzed after data collection. Between 2014 and 2016, eight patients underwent airway reconstruction using an auricular cartilage graft prefabricated within a supraclavicular artery island flap reconstruction; all of these were included in the study. Each case was reviewed, and relevant details of patient and disease characteristics, operative course, postoperative course, decannulation, and status at last follow-up were isolated and reported. RESULTS: Seven of eight patients were female. The most common cause of stenosis was iatrogenically induced multilevel stenosis (7/8 patients). All patients had undergone prior airway procedures, were high risk based on comorbid conditions, and underwent grafting and reconstruction with a composite supraclavicular island flap. All patients continue to follow up in a multidisciplinary clinic, and at last follow-up, eight of eight patients were successfully decannulated. CONCLUSIONS: The pSCAIF is a novel method for tracheal reconstruction. The analysis of the prefabricated locoregional approach cohort supports its utility for tracheal reconstruction in patients with complicated multilevel stenosis and adverse comorbidities and characteristics. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:641-648, 2020.

Sentinel Node Biopsy in Young Patients with Atypical Melanocytic Tumors of the Head and Neck.

OBJECTIVE: To examine the diagnostic value of the sentinel lymph node biopsy in pediatric through young adult head and neck melanocytic tumors of unknown malignant potential. STUDY DESIGN: Retrospective case series. SETTING: Single academic institution. SUBJECTS AND METHODS: Demographics, histology, and outcomes were examined in 14 patients aged 4 to 24 years with head and neck melanocytic tumors of unknown malignant potential. Information on age at diagnosis, primary lesion characteristics, and sentinel lymph node biopsy were compared. RESULTS: Of 14 patients meeting criteria for head and neck melanocytic tumors of unknown malignant potential, 8 patients underwent sentinel lymph node biopsy (57%). Of those, 4 biopsies (50%) had positive sentinel nodes. All patients undergoing sentinel lymph node biopsy had primary lesions greater than 1 mm depth or mitotic rate of at least 1 mitosis per mm2. No patients had recurrence of their primary lesion at time of follow-up. CONCLUSION: Our data show a high rate of node-positive sentinel lymph node biopsy for pediatric and young adult head and neck patients with melanocytic tumors of unknown malignant potential, supporting the value of sentinel lymph node biopsy in this population.

Clinical Significance of Sarcopenia among Patients with Advanced Oropharyngeal Cancer.

OBJECTIVES: We investigated the prevalence and impact of sarcopenia on disease-free survival (DFS) and overall survival (OS) in advanced oropharyngeal cancer. STUDY DESIGN: Retrospective study. SETTING: Single-institution tertiary cancer care center. SUBJECTS AND METHODS: We identified patients with advanced oropharyngeal cancer with pretreatment positron emission tomography-computed tomography scans for image analysis. Data were collected on the following variables: age, sex, smoking and alcohol status, stage (TNM and American Joint Committee on Cancer), human papillomavirus (HPV) status, body mass index (BMI), and treatment modality. RESULTS: Of 113 patients identified with oropharyngeal cancer, 32 had sarcopenia: these patients were older (63.5 vs 57.6 years, P = .01), were less likely to be male (53.1% vs 76.5%, P = .03), and had a lower mean BMI (24.5 vs 28.4 kg/m2, P = .009). Eighty-five subjects had HPV-positive disease, and they had a higher BMI (28.2 vs 24.2 kg/m2, P = .01) than that of patients without HPV. Twenty-one subjects who were HPV positive had less cancer recurrence (24.7% vs 48.1%, P = .04) than that of their HPV-negative counterparts. Log-rank testing showed no difference in DFS ( P = .06) associated with sarcopenia but a significant difference in OS ( P = .049). There were differences in DFS ( P = .009) and OS ( P = .023) based on HPV status. According to univariable and multivariable models, HPV positivity exhibited improved DFS and OS. Sarcopenia was not statistically significant in survival models; however, it was associated with increased mortality and recurrence. CONCLUSION: Sarcopenia is a prognostic factor affecting OS independent of HPV status in advanced oropharyngeal cancer.

Surgical outreach and microvascular surgery in developing countries.

Due to the discrepancy between surgical demand and resources in Low-Middle Income Countries (LMIC), surgical outreach programs (SOP) have increased in popularity. In these resource-constrained healthcare environments, the resources necessary to perform basic head and neck procedures are often lacking, and offering microvascular reconstruction adds yet another level of complexity. Here we discuss the difficulties and challenges in establishing a SOP abroad and more specifically some of the challenges specific to microvascular reconstruction - including patient selection, burden of cost, lack of infrastructure and equipment, and patient follow up and outcomes. Although challenges certainly exist, we present the feasibility and the benefit for patient care as well as the role it can play in the foundation development of a low-resource region. The goals of the SOP must be well-defined, and incorporating microvascular surgery can be used as an adjunct to enhance the development of many aspects of the LMIC healthcare system. We present a model of care in which the initial focus is centered on providing safe care to these patients undergoing complex procedures, but after the development of a strong foundation, the focus can begin to include program sustainability and education.

Clinical significance of tumor mitotic rate and lack of epidermal attachment in melanoma of the head and neck.

BACKGROUND: The primary purpose of this study was to identify the prognostic role of primary dermal melanoma and tumor mitotic rate in melanomas of the head and neck. METHODS: A retrospective review of the histopathologic, clinical, and demographic data of 256 patients was performed to investigate the impact of primary dermal melanoma and tumor mitotic rate on sentinel lymph node positivity, recurrence, and 5-year overall and disease-free survival. RESULTS: Increased tumor mitotic rate, but not primary dermal melanoma, is a significant predictor of sentinel lymph node positivity and higher likelihood of recurrence. Survival analysis demonstrated that both increased tumor mitotic rate and primary dermal melanoma decreased the 5-year overall and disease-free survival rates of patients with head and neck melanoma lesions. CONCLUSION: Tumor mitotic rate and primary dermal melanoma may have prognostic significance for both overall and disease-free survival in patients with head and neck melanoma. A larger prospective study is warranted to further elucidate prognostic factors for melanoma in the head and neck region.

Submental artery island flap versus free flap reconstruction of lateral facial soft tissue and parotidectomy defects: Comparison of outcomes and patient factors.

OBJECTIVES: The submental artery island flap (SIF) has recently been described in temporal bone defects. At our institution we have broadened the application of the SIF and modified the harvest technique for complex lateral facial and skull base defects. Our primary aim is to evaluate the outcomes of patients undergoing complex lateral facial soft tissue, parotidectomy, and temporal bone defects who are reconstructed with the SIF to a similar cohort undergoing free tissue transfer reconstruction. MATERIALS AND METHODS: Nineteen patients undergoing SIF and 54 patients undergoing free tissue flaps for oncologic lateral facial, parotidectomy and temporal bone defects were retrospectively identified. Comparative statistics were used to analyze variables between the two cohorts, specifically operative time, flap size, length of stay, regional recurrence, disease free survival, and overall survival. RESULTS: No significant difference in demographic and disease related variables was observed. Operative time was significantly lower in SIF group with mean of 412.9 (SD 93.4) minutes compared to 544.1 (SD 139.9) minutes in free flap group. Flap size was significantly larger in free tissue transfer, 32.4 (SD 17.5) cm2 (SIF) compared to mean area of 105.2 (SD 53.2) cm2 (Free tissue transfer). A significant difference in length of stay was also noted between groups. There was no regional recurrence of disease in level I-III in SIF group. There was no significant difference in DFS or OS between the two groups. CONCLUSION: SIF is an oncologically sound option for reconstruction of lateral facial soft tissue, parotidectomy, and temporal bone defects.

The impact of a head and neck microvascular fellowship program on otolaryngology resident training.

OBJECTIVE: To assess the impact of a microvascular head and neck (H&N) fellowship on senior residents' surgical experience. STUDY DESIGN: Retrospective review of Accreditation Council for Graduate Medical Education-generated operative case log reports, retrospective chart review, and electronic survey. METHODS: A retrospective review of one institution's residents' H&N operative case logs and free flap operative reports was performed to determine changes in key indicator cases (KICs) after the addition of a H&N fellowship. An electronic survey was distributed to senior residents at all U.S. otolaryngology residency programs to determine residents' perceptions of a H&N fellow's impact on their surgical experience. An electronic survey was distributed to senior medical students applying to surgical residencies to explore the perceived impact that a fellowship has on the desirability of a residency program. RESULTS: The average number of each postgraduate year (PGY)5's H&N KIC before and after the addition of the fellowship were: parotidectomy, 19 versus 17.8; neck dissection, 33.2 versus 40.6; oral cavity resection, 15.3 versus 12.6; thyroid/parathyroid, 45.5 versus 45.6; and flaps/grafts, 56.7 versus 42. PGY5 participation as first assistant in free flaps dropped from 78% to 17%; however, residents still participated in some aspect of 45% of the cases. Seventy percent of senior residents reported a positive perception of the H&N fellow on their H&N operative experience. Eighty-nine percent of senior medical student respondents reported a nonnegative perception of a fellowship in their applied field. CONCLUSION: The addition of a H&N fellowship did not decrease senior residents' H&N KIC, and most senior residents at programs with fellowships report that the fellow has a positive impact on their H&N operative experience. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:52-56, 2018.

AHNS Series: Do you know your guidelines? Review of current knowledge on laryngeal cancer.

The following article is part of a series in an initiative by the American Head and Neck Society's Education Committee and will review clinical practice guidelines for head and neck oncology. The primary goal is to increase awareness of current best practices pertaining to head and neck surgery and oncology. This manuscript is a review of current knowledge in laryngeal cancer with a focus on anatomy, epidemiology, diagnosis, evaluation, and treatment.

Post-operative MRSA infections in head and neck surgery.

PURPOSE: Surgical site infection (SSI) with methicillin-resistant Staphylococcus aureus (MRSA) is a serious post-operative complication, with head and neck cancer patients at greater risk due to the nature of their disease. Infection with MRSA has been shown to be costly and impart worse outcomes on patients who are affected. This study investigates incidence and risks for MRSA SSIs at a tertiary medical institution. MATERIALS AND METHODS: This study reviewed 577 head and neck procedures from 2008 to 2013. Twenty-one variables (i.e. tumor characteristics, patient demographics, operative course, cultures) were analyzed with SPSS to identify trends. A multivariate analysis controlled for confounders (age, BMI, ASA class, length of stay) was completed. RESULTS: We identified 113 SSIs of 577 procedures, 24 (21.23%) of which were MRSA. Of all analyzed variables, hospital exposure within the preceding year was a significant risk factor for MRSA SSI development (OR 2.665, 95% CI: 1.06-6.69, z statistic 2.086, p=0.0369). Immunosuppressed patients were more prone to MRSA infections (OR 14.1250, 95%CI: 3.8133-52.3217, p<0.001), and patients with a history of chemotherapy (OR 3.0268, 95% CI: 1.1750-7.7968, p=0.0218). Furthermore, MRSA SSI resulted in extended post-operative hospital stays (20.8±4.72days, p=0.031). CONCLUSIONS: Patients who have a history of chemotherapy, immunosuppression, or recent hospital exposure prior to their surgery are at higher risk of developing MRSA-specific SSI and may benefit from prophylactic antibiotic therapy with appropriate coverage. Additionally, patients who develop MRSA SSIs are likely to have an extended postoperative inpatient stay.

Outcomes of microvascular free tissue transfer in twice-irradiated patients.

BACKGROUND: Patients may require microvascular free tissue transfer (MFTT) following re-irradiation for recurrent cancer or radiation complications. The objective of this study was to describe the indications for and outcomes of free flaps performed in twice-radiated patients. METHODS: A retrospective chart review identified the indications for and outcomes of 36 free flaps performed on 29 twice-irradiated patients. RESULTS: The free flap success rate was 92%. The most common indications requiring MFTT were cancer recurrence and osteoradionecrosis. Sixty-one percent experienced postoperative complications, most commonly wound infection (33%). Twenty-five percent of the procedures required return to the operating room due to postoperative complication. CONCLUSIONS: MFTT can be successfully performed in the twice-irradiated patient population with a success rate comparable to singly-radiated patients. Despite a high success rate, there is also a high rate of surgical site complications, especially infection.

Use of concurrent chemoradiation in advanced staged (T4) laryngeal cancer.

HYPOTHESIS: Patients with advanced laryngeal cancer sometimes desire organ preservation protocols even if it portends a worse outcome. BACKGROUND: To assess outcomes of patients with T4 laryngeal cancer treated with chemoradiation therapy. METHODS: Case series with chart review at a tertiary university hospital. Twenty-four patients with T4 laryngeal cancer all declined total laryngectomy with adjuvant radiation as the primary treatment modality and alternatively received concurrent chemoradiation therapy. The primary outcome was overall survival. Secondary outcomes were rates of tracheotomy dependence, gastric tube dependence, and need for salvage laryngectomy. RESULTS: All patients had T4 laryngeal disease, 71% had cartilage invasion and 59% had regional metastasis to the neck. Kaplan-Meier analysis determined 2-year and 5-year overall survival to be 64% and 59% respectively. The locoregional recurrence rate was 25%. The distant metastasis rate was 21%. The rate of salvage laryngectomy was 17%, which occurred at a mean of 56.5months after the original diagnosis. The rate of tracheotomy dependence was 33% while gastric tube dependence was 25%. CONCLUSION: Advanced T4 laryngeal cancer, particularly with cartilage invasion, remains a surgical disease best treated with total laryngectomy and adjuvant radiation. This data may help guide patients and practitioners considering concurrent chemoradiation therapy for definitive treatment of advanced laryngeal cancer.

Contemporary management of carotid blowout syndrome utilizing endovascular techniques.

OBJECTIVES/HYPOTHESIS: To illustrate complex interdisciplinary decision making and the utility of modern endovascular techniques in the management of patients with carotid blowout syndrome (CBS). STUDY DESIGNS: Retrospective chart review. METHODS: Patients treated with endovascular strategies and/or surgical modalities were included. Control of hemorrhage, neurological, and survival outcomes were studied. RESULTS: Between 2004 and 2014, 33 patients had 38 hemorrhagic events related to head and neck cancer that were managed with endovascular means. Of these, 23 were localized to the external carotid artery (ECA) branches and five localized to the ECA main trunk; nine were related to the common carotid artery (CCA) or internal carotid artery (ICA), and one event was related to the innominate artery. Seven events related to the CCA/ICA or innominate artery were managed with endovascular sacrifice, whereas three cases were managed with a flow-preserving approach (covered stent). Only one patient developed permanent hemiparesis. In two of the three cases where the flow-preserving approach was used, the covered stent eventually became exposed via the overlying soft tissue defect, and definitive management using carotid revascularization or resection was employed to prevent further hemorrhage. In cases of soft tissue necrosis, vascularized tissues were used to cover the great vessels as applicable. CONCLUSIONS: The use of modern endovascular approaches for management of acute CBS yields optimal results and should be employed in a coordinated manner by the head and neck surgeon and the neurointerventionalist. LEVEL OF EVIDENCE: 4. Laryngoscope, 2016 127:383-390, 2017.

The use of the submental island flap in reconstructing palatal and facial defects in a surgical camp in East Africa.

BACKGROUND: The goals of successful reconstructive surgery are to restore function and cosmesis; however, limitation of resources can become an important consideration in low-middle income countries. METHODS: We describe our experience using the submental island flap in two cases during a short-term surgical camp in East Africa. RESULTS: The submental island flap was utilized as an excellent alternative to a free flap to reconstruct a subtotal maxillectomy and a parotidectomy defect in two patients. CONCLUSIONS: We demonstrate the successful use of this flap and describe some necessary modifications to achieve optimal results in a resource limited setting.

Cardiovascular risk and prevention in patients with head and neck cancer treated with radiotherapy.

BACKGROUND: The underlying contributors to cardiovascular disease (CVD) in patients with head and neck squamous cell carcinoma (HNSCC) are poorly characterized. METHODS: Patients with HNSCC who underwent definitive or adjuvant (chemo)radiation between 2011 and 2013 were retrospectively reviewed. The 10-year risk estimates for a CVD event were calculated according to the Framingham Risk Score (FRS). RESULTS: One hundred fifteen patients with predominantly stage III/IV HNSCC had a median follow-up of 2 years. At diagnosis, 23% of patients had CVD. The FRS was higher among patients with laryngeal cancer versus other sites (20.5% vs 14.4%). Twenty-four percent of all patients had uncontrolled blood pressure at diagnosis. Among the patients with CVD, 41% were not taking antiplatelet therapy and 30% were not taking statin therapy. Thirty-four percent of patients without CVD had indications for initiating statin therapy. CONCLUSION: Patients with HNSCC have a high baseline CVD risk and many do not receive optimal preventive care. © 2016 Wiley Periodicals, Inc. Head Neck 39: 527-532, 2017.