The value of postoperative anticoagulants to improve flap survival in the free radial forearm flap: a systematic review and retrospective multicentre analysis.

BACKGROUND: Free radial forearm flap (FRFF) reconstruction is a valuable technique in head and neck surgery, which allows closure of large defects while striving to maintain functionality. Anticoagulative drugs are often administered to improve flap survival, although evidence regarding effectiveness is lacking. OBJECTIVE OF REVIEW: To investigate the effectiveness of postoperative anticoagulants to improve survival of the FRFF in head and neck reconstruction. TYPE OF REVIEW: Systematic review and multicentre, individual patient data meta-analysis. SEARCH STRATEGY: MEDLINE, EMBASE, Web of Science and CINAHL were searched for synonyms of 'anticoagulants' and 'free flap reconstruction'. EVALUATION METHOD: Studies were critically appraised for directness of evidence and risk of bias. Authors of the highest quality publications were invited to submit their original data for meta-analysis. RESULTS: Five studies were of adequate quality, and data from four studies (80%) were available for meta-analysis, describing 759 FRFF procedures. Anticoagulants used were as follows: aspirin (12%), low molecular weight dextran (18.3%), unfractioned heparin (28.1%), low molecular weight heparin (49%) and prostaglandin-E1 (2.1%). Thirty-one per cent did not receive anticoagulants. Flap failure occurred in 40 of 759 patients (5.3%) On univariate analysis, use of unfractioned heparin was associated with a higher rate of flap failure. However, these regimens were often administered to patients who had revision surgery of the anastomosis. In multivariate logistic regression analysis, anticoagulant use was not associated with improved flap survival or flap-related complications. CONCLUSIONS: The studied anticoagulative drugs did not improve FRFF survival or lower the rate of flap-related complications. In addition, some anticoagulants may cause systemic complications.

Radial forearm osteocutaneous free flap in maxillofacial and oromandibular reconstructions.

OBJECTIVES/HYPOTHESIS: The radial forearm osteocutaneous free flap is an excellent reconstructive modality for oromandibular and maxillofacial reconstruction in certain well-defined circumstances. The initial concern over donor site morbidity and the ability of the bone to reconstruct mandibular defects have led to only a few published series. STUDY DESIGN: Retrospective study of the experience of two tertiary medical centers with radial forearm osteocutaneous free flap. METHODS: Retrospectively, 52 patients were studied who underwent radial forearm osteocutaneous free flap reconstruction for cancer (49 cases) and trauma (3 cases). Bone length and skin paddle harvested, general morbidity (hematoma, wound infection, and dehiscence), recipient site morbidity (nonunion of neomandible, flap failure, and bone or plate exposure), and donor site morbidity (radius bone fracture, plate exposure, and skin graft failure) were reviewed. RESULTS: The average skin paddle size was 55.1 cm (range, 15-112 cm). The average radius bone harvest length was 6.3 cm (range, 2.5-11 cm). Donor site complications included tendon exposure (3 cases), radius bone fracture (1 case), and exposure of the plate (0). Recipient site complications included nonunion of the mandible (4), exposed mandible (1), exposed mandibular plates (2), exposed maxillary plates or bone (0), venous compromise (1), and flap failure (1). Two patients had perioperative deaths. CONCLUSION: Radial forearm osteocutaneous free flap is a valuable and viable option for oromandibular and maxillofacial reconstruction.

The mucosal invasion model: a novel in vitro model for evaluating the invasive behavior of mucocutaneous malignancies.

BACKGROUND: Prevention of regional and metastatic spread of cutaneous malignancies requires understanding the physiologic mechanism of tumor cell invasion. In vitro models are convenient for studying the in vitro invasive phenotype of normal cells, tumor cell lines, or genetically altered cells in a 3-dimensional matrix, but they should attempt to recapitulate the complex in vivo submucosal environment. A new acellular extracellular matrix, porcine submucosal matrix (PSM), is thought to accurately recapitulate the submucosal matrix. A novel in vitro model using PSM to assess mucocutaneous tumor cell invasion was studied. METHODS: The morphologic characteristics, growth, and invasive behavior of human head and neck squamous cell carcinoma (UM-SCC-1, UM-SCC-5, UM-SCC-17B, and OSC-19) cell lines were assessed on the PSM gel and compared with commonly used in vitro invasion models (type I collagen and Matrigel matrices). The invasive phenotype of canine kidney cells was also assessed on each matrix, because this cell line is known to demonstrate a characteristic in vitro invasive phenotype. RESULTS: The PSM-supported head and neck squamous cell carcinoma tumor cell line growth and single cell invasion were seen under stimulated conditions, similar to type I collagen gels. The invasive phenotype of canine kidney cells behaved similarly on PSM and collagen. Matrigel did not support growth well, and invasion occurred only superficially in isolated areas. CONCLUSION: The PSM is a good in vitro model for assessment of pharmacologic and genetic manipulations of head and neck squamous cell carcinoma tumor cell lines and has several advantages over other commonly used matrices.

Postoperative antibiotic use of septoplasty: a survey of practice habits of the membership of the American Rhinologic Society.

Prophylactic antibiotics are used routinely in otolaryngology. Little objective data exist concerning their use in sinonasal procedures. We wished to determine the practice patterns of otolaryngologists regarding prophylactic antibiotics for septoplasty patients. A survey of 743 (60.3% responded) members of the American Rhinologic Society was used to get information about their practice habits and rationale for using antibiotics after septoplasty. Sixty-six percent of respondents routinely used antibiotics. Postoperative infection and toxic shock syndrome (TSS) were the primary indications. Forty-four percent of respondents used some form of packing and 38% used a splint. There was no relationship between the annual number of procedures and the reasons for using antibiotics. Doctors who performed more than 50 cases a year were less likely to use packing or splints (p < 0.001). Older surgeons used less younger surgeons a packing/splints (p < 0.001). Respondents who used packing/ splints were more likely to use antibiotics (p = 0.008). Older respondents used packing whereas younger respondents used splints (p = 0.002). The rationale for antibiotics varied by age; re more concerned with TSS and older physicians were more concerned with infection (p = 0.005). This survey shows great variability in the usage and rationale for antibiotics after septoplasty.

Emerging perceptions of facial plastic surgery among medical students.

OBJECTIVE: The purpose of this study was to examine the perceptions of medical students regarding facial aesthetic surgery and those specialists most likely to perform aesthetic or reconstructive facial surgery. METHODS: A survey was designed based on a review of the literature to assess the desirable characteristics and the perceived role of the facial plastic and reconstructive surgeon (FPRS). The surveys were distributed to 2 populations: medical students from 4 medical schools and members of the general public. RESULTS: A total of 339 surveys were collected, 217 from medical students and 122 from the general public. Medical students and the public had similar responses. The results demonstrated that respondents preferred a male plastic surgeon from the ages of 41 to 50 years old and would look to their family doctor for a recommendation. Facial aesthetic and reconstructive surgery was considered the domain of maxillofacial and general plastic surgeons, not the FPRS. CONCLUSION: Integration of the FPRS into the medical school curriculum may help to improve the perceived role of the specialty within the medical community. It is important for the specialty to communicate to aspiring physicians the dedicated training of an otolaryngologist specializing in FPRS.

Tracheoesophageal puncture in the office setting with local anesthesia.

Tracheoesophageal puncture (TEP) with voice prosthesis placement is currently the method of choice for vocal rehabilitation of patients who have undergone total laryngectomy. Occasionally, secondary TEP needs to be performed. We have used a TEP technique that is performed in the clinic setting with local anesthesia and no sedation. The purpose of this study was to review our technique and experience and to evaluate results, complications, and patients' acceptance of the procedure. We performed a retrospective chart review of the records of 14 patients who had undergone total laryngectomy and secondary TEP placement in the clinic setting. The procedure was well tolerated. The voice results were fair to good in 11 of 12 patients. There was 1 complication, a false passage between the trachea and the esophagus. Voicing was immediate in 12 of the 14 cases. We conclude that TEP can be performed in the office setting with local anesthesia. The voice results are excellent, and the procedure is well tolerated by the patient. Proper patient selection and regular follow-up by a speech-language pathologist are important.

Use of the radial forearm free tissue flap to treat persistent stricture after esophagogastrectomy.

BACKGROUND: Persistent stricturing or anastomotic leakage at the cervical esophagogastric anastomosis can be a troublesome complication of gastric pull-up procedures. When the stricture is the result of ischemia of the stomach, the strictures are long and often not responsive to dilatation and require large operations such as jejunal interposition or replacement with colonic pull-up. In this report we describe the use of a radial forearm flap to patch strictures. METHODS: The radial forearm flap is a fascia cutaneous flap taken from the forearm and based on the radial artery and its venae comitantes. The advantages of this flap are that it is thin and pliable, conforms easily, has excellent reliability due to the size of the feeding vessels, and has a relatively long pedicle. The vascular anastomosis can be made to several arteries and veins within the neck. The epithelial component can be made in sizes up to 10 by 20 cm. RESULTS: We have used the radial forearm flap to patch strictures in 6 patients with persistent complex strictures in the cervical region after esophagectomy. Results were excellent in 4 patients (able to eat liquids and solids without problems) and good in 1 patient (liquids okay, some problem with solids), and 1 patient died postoperatively. Follow-up is 4 months to 7 years. CONCLUSIONS: The radial forearm flap is an excellent option for handling persistent stricture after esophagogastrectomy. In many instances, this flap can be used in lieu of a jejunal interposition flap and obviates a laparotomy to harvest jejunum. The flap fits easily into the neck and conforms to the space.

A prospective comparison of scalpel versus bipolar scissors in the elevation of radial forearm fasciocutaneous free flaps.

OBJECTIVES/HYPOTHESIS: The radial forearm fasciocutaneous free flap has become the workhorse for reconstruction of head and neck ablative defects. A location distal to the head and neck allows this flap to be elevated concurrent with the ablation. Most commonly, the flap is elevated under tourniquet control. This involves a primary ischemic insult with a certain amount of hemorrhage after the tourniquet is released. Bipolar scissors are a new method of dissection. They may allow for a speedier dissection with a concomitant decrease in ischemic time. Their hemostatic properties may control hemorrhage after use of the tourniquet. STUDY DESIGN: A prospective study of patients undergoing radial forearm free flaps over a 12-month period at a tertiary care referral center was undertaken. RESULTS: Forty patients were entered into the study, flaps were elevated with scalpel (20) and with bipolar scissors (20). Mean time under tourniquet was 39 minutes (range, 30-56 min) with scalpel compared with 27 minutes (range, 21-31 min) with bipolar scissors (P <.001). Total mean time of elevation (including control of hemostasis and pedicle dissection) for scalpel elevation was 50 minutes (range, 35-61 min) compared with 32 minutes (range, 20-41 min) for bipolar scissors elevation (P <.001). Mean blood loss was 46 mL (range, 15-110 mL) in the scalpel elevation group compared with 14 mL (range, 0-50 mL) in the bipolar scissors elevation group (P <.001). Complications at the donor site were equal between groups. CONCLUSIONS: Bipolar scissors are a safe, efficient method for elevating radial forearm free flaps.

Effect of anemia on the fasciocutaneous flap survival in a rat model.

OBJECTIVE/HYPOTHESIS: Ablative surgery for head and neck cancer that creates large composite defects often results in a significant decrease in the hematocrit level. These defects are best reconstructed with a microvascular free tissue transfer. Effect of the decreased hematocrit on microvascular flap survival is controversial. The purpose of this study was to assess the effect of isovolemic anemia on flap survival in a rat model. STUDY DESIGN: Prospective analysis. METHODS: Ninety rats were used (30 control and 60 experimental animals). Experimental animals were rendered anemic by blood draw and volume resuscitated with either a colloid (30 animals) or crystalloid (30 animals) solution. In all animals a ventral fasciocutaneous flap was raised. A vascular clamp was applied to the arteriovenous pedicle, and different ischemic times were allowed to elapse before clamp removal. Flap survival was assessed at 5 days. Probit analysis was performed for the three animal groups. RESULTS: A significantly increased probability of the flap survival was found in the anemic animals compared with the control group (P < or = .05). No difference was found between the colloid and crystalloid resuscitation groups. CONCLUSIONS: A decreased hematocrit level increases fasciocutaneous flap tolerance to ischemia and significantly increases the primary ischemic time in the ventral flap clamp model in rats. Fluid replacement with either crystalloid or colloid produces identical results.

Dysphonia and dysphagia following the anterior approach to the cervical spine.

BACKGROUND: Speech and swallowing dysfunctions are common following the anterior approach to the cervical spine. Despite functional morbidity and legal implications, the incidence and etiologic factors of these complications have not been adequately elucidated. OBJECTIVE: To better define speech and swallowing dysfunction both in the quantitative and qualitative sense. METHODS: A questionnaire was mailed to 497 patients who had undergone anterior cervical fusion or anterior cervical discectomy at a university hospital (study group). One hundred fifty questionnaires were sent to a control group. RESULTS: The study group response rate was 46%; the control group response was 51%. The incidence of hoarseness in the study group was 51%; the incidence in the control group was 19%. The difference was statistically significant (P<.01). Dysphagia was present in 60% of study group patients vs 23% of control group patients (P<.01). Qualitative questions revealed that constant hoarseness, pain with talking, difficulty eating solid foods, and odynophagia were significantly more common following the anterior approach to the cervical spine. CONCLUSIONS: Our findings show a much higher incidence than previously reported of both voice and swallowing impairment following the anterior approach to the cervical spine. Hoarseness and dysphagia may adversely affect recovery and the patient's sense of well-being. Preoperative counseling and postoperative evaluation are essential.

MRI detection of cervical metastasis from differentiated thyroid carcinoma.

BACKGROUND: With the advent of the use of serum thyroglobulin as a marker for the recurrence of well-differentiated thyroid cancer (WDTC) after total thyroidectomy, clinicians are increasingly faced with the diagnostic dilemma of detecting the site of recurrence in thyroglobulin-positive patients with normal clinical examinations. The high protein content of this thyroglobulin may make it specifically detectable by magnetic resonance (MR) imaging. OBJECTIVE: To determine the ability of MR imaging to detect the presence of metastatic WDTC in cervical lymph nodes. STUDY DESIGN: Retrospective cohort. METHODS: Blinded review by two independent head and neck radiologists of 34 head and neck MR scans obtained from 26 patients with thyroid cancer (12 with primary disease and 14 with recurrent disease) all of whom subsequently underwent surgical removal of the lymph nodes considered at risk by imaging. RESULTS: The average overall percent sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MR imaging were 95%, 51%, 84%, 78%, and 83%, respectively. The concordance between the two radiologists was 69%. There was no overall difference in the ability of the MR scan to detect the presence of disease in the upper jugular, lower jugular, or paratracheal nodal stations. However, it was more useful for papillary carcinoma (PPV 86%, accuracy 85%) than for follicular carcinoma or the follicular variant of papillary carcinoma (PPV 63%, accuracy 67%). CONCLUSION: MR imaging is a sensitive and accurate technique for the detection of WDTC, particularly papillary carcinoma, metastatic to cervical lymph nodes. However, the lower specificity of this modality precludes its use as a screening tool.

Accuracy of computed tomography in determining the presence or absence of metastatic retropharyngeal adenopathy.

OBJECTIVE: To decide the accuracy of computed tomography in determining the presence or absence of metastatic retropharygeal adenopathy in patients with squamous cell carcinoma of the head and neck. DESIGN: A comparison of the results of retrospective blinded review of preoperative computed tomographic scans with the histologic findings of retropharyngeal node dissection at the time of surgery. SETTING: Academic tertiary care center. PATIENTS: Twenty-six patients with advanced stage squamous cell carcinoma of the head and neck. MAIN OUTCOME MEASURES: Computed tomographic findings and histologic results of retropharyngeal node dissection. RESULTS: The retropharyngeal nodes were pathologically positive for metastasis in 6 (23%) of the 26 patients. The radiologist (J.M.T.) correctly read the scan in 3 of 6 patients with histologically proved metastasis, and in 14 of 20 patients with histologic features negative for metastasis. The sensitivity of the radiologist reading was 50%, and the specificity was 70%. The positive predictive value was 33%, and the negative predictive value was 82%. CONCLUSION: The presence of retropharyngeal node metastasis cannot be determined by computed tomographic imaging alone. Arch Otolaryngol Head Neck Surg. 2000;126:1478-1481

Unilocular cervical lymphatic cyst in an adult.

Unilocular cervical lymphatic lesions are rare clinical entities. These endothelial-lined, fluid-filled structures must be distinguished from true cysts (epithelial lining), and pseudocysts (no cellular lining). This article presents a case report of a unilocular cervical lymphatic cyst in an adult. The embryology and anatomy of the cervical lymphatic system is discussed.

Pursestring closure of radial forearm fasciocutaneous donor sites.

BACKGROUND: The radial forearm fasciocutaneous free flap has become one of the most common methods of reconstructing defects after head and neck ablative surgery. The fasciocutaneous flap is an excellent replacement for the tissue that has been removed. Unfortunately, donor site morbidity remains a problem. Donor site morbidity is primarily related to poor skin graft take, cosmesis, and neural dysfunction. Decreasing the size of the donor site defect may allow for improved cosmesis with decreased morbidity. MATERIAL AND METHODS: Prospective evaluation of a pursestring closure of radial forearm fasciocutaneous donor sites over a 16-month period. RESULTS: Seventy-one radial forearm free flaps were used. Sixty-seven had a pursestring closure of the donor site. After flap elevation the mean size of the defect was 61 cm2 (range, 28-140 cm2). Pursestring closure decreased the mean of the defect to 34 cm2 (range, 10-104 cm2) (P <.0001). Defect size was decreased by a mean of 44.5% (range, 24.5%-66.7%) (P <.0001). COMPLICATIONS: The rate of skin graft loss (>25%) (9% of patients) was less than that reported in the literature. No patient required a second surgical procedure. Neural morbidity was equal in both groups. Cosmesis was much improved. CONCLUSIONS: Pursestring closure allowed for a significantly decreased donor defect, associated with better cosmesis and less skin graft loss.

The relative value of fine-needle aspiration and imaging in the preoperative evaluation of parotid masses.

BACKGROUND: To establish the sensitivity, specificity, and accuracy of imaging and fine-needle aspiration (FNA), alone or in combination, in distinguishing benign from malignant histologic findings for parotid lesions. METHODS: Retrospective blinded review of preoperative imaging and FNA studies of parotid masses and comparison with histologic findings after excision. RESULTS: Forty-eight patients were identified (13 with CT, 35 with MRI); 23 (48%) of the lesions were malignant, 25 (52%) were benign. MRI, CT, and FNA misclassified 17%, 46%, and 21% of the lesions, respectively. The sensitivity/specificity/accuracy of these tests for detecting malignant lesions were as follows: MRI (88%,77%,83%), CT (100%,42%, 69%), and FNA (83%,86%,85%) and were not significantly different. Combinations of imaging and FNA were not significantly better in detecting malignancy. CONCLUSIONS: Imaging and FNA are comparable in their ability to correctly identify malignant parotid lesions preoperatively. Combining these two modalities yields no advantage in terms of specificity, sensitivity, or accuracy of a malignant diagnosis.

External beam radiation followed by planned neck dissection and brachytherapy for base of tongue squamous cell carcinoma.

BACKGROUND: Surgical resection of tongue base cancer can leave the patient with significant functional deficits. Other therapies, such as external beam radiation followed by neck dissection and radiation implants, have shown equal tumor control with good functional outcome. METHODS: Between March 1991 and July 1999, 12 patients at Oregon Health Sciences University, the Portland Veterans Administration Medical Center and West Virginia University School of Medicine Hospital were treated with external beam radiation followed by neck dissection and Ir192 implants. Two patients had T1 disease, two had T2, five patients had T3 tumors, and three had T4 tumors. Six had N2a necks, three had N2b necks, and three had N2c. Follow-up ranged from 13 months to 8 years. RESULTS: After external beam radiation, five patients had complete response and seven had partial response in the neck without complications. One patient underwent a unilateral radical neck dissection, eight had unilateral selective neck dissections involving levels I to IV, and three had dissections involving levels I to III. One of the five patients who had a complete clinical response in the neck had pathologically positive nodes. One patient had a pulmonary embolus that was treated and had no permanent sequelae. There were three complications from brachytherapy. Two patients had soft tissue necrosis at the primary site and one patient had radionecrosis of the mandible. All healed without further therapy. One patient had persistent disease and underwent a partial glossectomy but died of local disease. Distant metastasis developed in two patients. All others show no evidence of disease and are able to eat a normal diet by mouth. CONCLUSION: This combination of therapies should be considered when treating tongue base cancer.

Bipolar scissors in facial plastic surgery.

BACKGROUND: Many methods are available to the facial plastic surgeon for elevating and separating tissue, from cold steel to monopolar cautery to various laser-cutting technologies. Bipolar cautery has replaced monopolar cautery as the optimal hemostatic technique because of its decreased tissue damage and improved capabilities. Bipolar scissors concurrently offer a dissecting technique with hemostatic capability. Little exists in the otolaryngology literature on the use of bipolar scissors for soft tissue dissection. OBJECTIVE: To describe our experience using bipolar scissors in a variety of facial plastic and reconstructive procedures. SETTING: Tertiary care referral academic center. DESIGN: We retrospectively reviewed 78 procedures performed using bipolar scissors between June 1997 and August 1999. In facial plastic cosmetic surgery, bipolar scissors were used 31 times for deep plane face-lifts and 16 times for endoscopic browlifts. In facial plastic reconstructive surgery, bipolar scissors were used in 15 radial forearm free flaps, 10 fibula osteocutaneous flaps, 3 rectus abdominis free flaps, and 3 latissimus dorsi myocutaneous free flaps. RESULTS: In all procedures, bipolar scissors facilitated the dissection. By allowing for a drier field, less time was required to elevate the flap and obtain hemostasis. Complications were not increased compared with historical controls. In the harvesting of fibula osteocutaneous free flaps, use of bipolar scissors allowed harvesting without use of a tourniquet. CONCLUSION: Bipolar scissors, a new technology in facial plastic surgery, allow the same control as sharp dissection and provide simultaneous hemostasis.