Protein C deficiency in microvascular head and neck reconstruction.

OBJECTIVE: To determine the incidence of perioperative protein C deficiency in patients undergoing free flap reconstruction of cancer-related defects in the head and neck. STUDY DESIGN: Prospective case series. INTERVENTION: Ten patients underwent microvascular reconstruction after surgical therapy of carcinomas of the oral cavity or oropharynx. Coagulation studies were determined in all patients 72 hours after surgery. SETTING: Academic tertiary care medical center RESULTS: Protein C deficiency was detected in 70% of patients. One free flap failure was attributed to protein C deficiency. CONCLUSIONS: Vitamin K-dependent clotting factors are frequently deficient during the postoperative period after major head and neck surgery, which may result in a state of hypercoagulability. Protein C deficiency should be considered as a possible cause of free flap thrombosis in patients who undergo microvascular head and neck reconstruction.

Recovery of laryngeal sensation after superior laryngeal nerve anastomosis.

OBJECTIVES/HYPOTHESIS: Reliable motor reinnervation has been show in multiple laryngeal transplant studies; however, sensory reinnervation of the larynx after nerve anastomosis has yet to be demonstrated. The role of sensory nerve anastomosis in the transplanted larynx in unknown, but is thought to be necessary to provide airway protection. A canine model was developed to examine the possibility of reformation of sensory pathways in the larynx after nerve section and anastomosis. STUDY DESIGN: Randomized controlled experiment. METHODS: Ten canines were randomly assigned to two groups. Hydrochloric acid-induced laryngospasm was demonstrated in every dog. All dogs then had their necks explored, and the internal branch of the superior laryngeal nerve was identified and transected bilaterally. Following nerve section all dogs were retested for an acid-induced laryngospasm reflex. The control group had their wounds closed and were then awakened from anesthesia. The study group underwent microscopic anastomosis of their sensory nerves. Following a 6-month period the two groups of dogs were compared for the presence of the laryngospasm reflex. RESULTS: No dog in the control group had a response to the acid. All dogs in the study group had some response to the acid, although none of them had return of true laryngospasm. CONCLUSION: We concluded that sensory reinnervation does occur after nerve anastomosis, but the recovery of sensation may be incomplete or altered.

Tracheal transplantation: superior and inferior thyroid artery perfusion territory.

OBJECTIVE: To determine the perfusion territories of the superior and inferior thyroid arteries in humans. Tracheal transplantation is a potential option for management of long-segment tracheal stenosis. However, the maximum length of vascularized trachea that can be reliably transplanted has not been established. STUDY DESIGN: The tracheal vascular territory of individual superior and inferior thyroid arteries was determined separately in 10 humans postmortem. METHODS: India ink was infused unilaterally under controlled pressure into the superior (n = 5) and inferior (n = 5) thyroid arteries of cadaveric tracheas. Tracheas were sectioned longitudinally and the caudalmost extent of mucosal dye staining was determined via microscopic assessment. RESULTS: The tracheal perfusion territory of the superior thyroid artery was two to five rings (1.7 +/- 0.5 cm) and the inferior thyroid artery, nine to 13 rings (6.5 +/- 1.1 cm). In both cases, the tracheal mucosa on the contralateral side was stained to the same caudal level. CONCLUSIONS: The inferior thyroid artery was shown to perfuse the trachea maximally to the 13th ring (8.1 cm). As such, the unilateral inferior thyroid artery would serve as a suitable vascular component for long-segment tracheal transplantation in humans.

Open bedside tracheotomy in the intensive care unit.

OBJECTIVE: To demonstrate that open bedside tracheotomy is an efficient, safe, and cost-effective procedure. STUDY DESIGN: Retrospective review of more than 200 open bedside tracheotomies performed at UCLA Medical Center, Harbor-UCLA Medical Center, and West Los Angeles VA Medical Center from 1995 to 1998. METHODS: The only personnel required for the procedure were an attending or senior resident and a junior resident or intern, as well as the respiratory therapist to withdraw the endotracheal tube. No anesthetist or scrub nurse was present for any of the procedures. The procedure took an average of 15 to 25 minutes. Patients were followed for 30 days after surgery to determine the incidence of complications. RESULTS: The incidence of major complications related to the procedure, including hemorrhage and myocardial infarction, was less than 1%. The incidence of minor complications, including moderate bleeding at the tracheotomy site, was 4%. Overall mortality within 30 days was 8%, but was not related to the tracheotomy for any patients in this series. The charge for the procedure was $233 for the tracheotomy tube supplies and instruments. This cost compares favorably with an average charge of more than $3000 for the procedure in the operating room and about $1000 for a percutaneous tracheotomy kit. CONCLUSION: Review of our experience demonstrates that open bedside tracheotomies can be performed more efficiently and economically than operating room tracheotomies. The safety of this procedure is comparable to percutaneous tracheotomy but at a decreased cost.

Nitric oxide improves cisplatin cytotoxicity in head and neck squamous cell carcinoma.

OBJECTIVE: To test whether nitric oxide (NO) enhances the cytotoxicity of cisplatin in a head and neck squamous cell carcinoma (HNSCC) cell line. BACKGROUND: Cisplatin is one of the most frequently used chemotherapeutic agents in the treatment of HNSCC. NO has been shown to play an important role in regulating tumor growth. Previous studies demonstrate that NO can enhance the cytotoxicity of cisplatin in Chinese hamster lung fibroblasts. In this report, we examined the in vitro interaction of NO and cisplatin in a HNSCC cell line. MATERIALS AND METHODS: CCL23 cells were pretreated with three different NO donors: PAPA/NO (t 1/2 = 15 min), DPTA/NO (t 1/2 = 3 h), and DETA/NO (t 1/2 = 20 h). The cells were rinsed and exposed for 6 hours to a culture medium containing cisplatin. Cell survival and LD50 of cisplatin were calculated with and without NO pretreatment. RESULTS: PAPA/NO and DPTA/NO did not show any cytotoxic activity and did not change the LD50 of cisplatin. DETA/NO when used alone resulted in 25.6% cell death at its peak dose (100 microM). Pretreatment with DETA/NO resulted in almost a threefold reduction of the LD50 of cisplatin (6.8 vs. 2.4 microg/mL). Pretreatment with DETA/NO sensitized the HNSCC cells to subsequent cisplatin activity (two-sided P =.00016). CONCLUSION: Pretreatment of HNSCC cells with long-acting NO donors enhances cisplatin activity. Short- and medium-acting NO donors do not exert a toxic effect and do not augment the activity of cisplatin. NO agonists should be considered in the future as a possible adjunct to cisplatin in the treatment of HNSCC. Further studies with animal models are necessary to further clarify this relationship.

Palliative laser therapy for recurrent head and neck cancer: a Phase II clinical study.

OBJECTIVES: Laser therapy is becoming a more precise, minimally invasive alternative for tumor ablation. Recent reports confirm successful palliation of pain and functional disabilities in patients with advanced deep carcinoma of the head and neck using interstitial laser phototherapy (ILT). STUDY DESIGN, PATIENTS, AND METHODS: The current study describes an ongoing Phase II trial of neodymium/yttrium-aluminum-garnet (Nd:YAG) laser therapy for palliation of advanced head and neck cancer. A total of 40 advanced cancer patients have been entered into this protocol (25 men and 15 women). RESULTS: Nineteen of these patients had no evidence of recurrence after ILT with an average follow-up of 11 months (range, 2 to 24 mo). Currently, 19 of these patients are alive, 14 with tumor remission and six with persistent disease. A total of 79 tumor sites received ILT with 43 (54.5%) completely ablated. Stratified by tumor site, ILT led to a complete response in 21 of 24 in the oral cavity, eight of 28 neck tumors, four of 10 in skin, and 10 of 17 in other sites. The procedure was well tolerated in most cases and was repeated at intervals in patients with residual disease or recurrences for a total of 118 laser treatments (average, 2.95 treatments per patient). CONCLUSIONS: The results suggest that ILT can be performed safely and repeated as needed, and may be less costly than conventional surgery for head and neck cancer. However, additional follow-up is needed to obtain convincing evidence of long-term therapeutic benefits.

Radial forearm free flap pharyngoesophageal reconstruction.

OBJECTIVES: This study evaluates the outcome of pharyngoesophageal reconstruction using radial forearm free flaps with regard to primary wound healing, speech, and swallowing in patients requiring laryngopharyngectomy. STUDY DESIGN: Retrospective review in the setting of a tertiary, referral, and academic center. PATIENTS AND METHODS: Twenty patients underwent reconstruction of the pharyngoesophageal segment using fasciocutaneous radial forearm free flaps. RESULTS: All free flap transfers were successful. An oral diet was resumed in 85% of the patients after surgery. Postoperative pharyngocutaneous fistulas occurred in 4 patients (20%) with 3 resolving spontaneously. Distal strictures also occurred in 20% of the patients. Five patients who underwent tracheoesophageal puncture achieved useful speech. CONCLUSIONS: Advantages of radial forearm free flaps for microvascular pharyngoesophageal function include high flap reliability, limited donor site morbidity, larger vascular pedicle caliber, and the ability to achieve good quality tracheoesophageal speech. The swallowing outcome is similar to that achieved after jejunal flap pharyngoesophageal reconstruction. The main disadvantage of this technique relates to a moderately high incidence of pharyngocutaneous fistulas, which contributes to delayed oral intake in affected patients.

Papillary squamous neoplasms of the head and neck.

Papillary squamous neoplasms of the upper respiratory tract are rare variants of squamous cell carcinoma and are related temporally to proliferative verrucous leukoplakia. Fifty-two cases of papillary squamous neoplasms were selected from 2366 cases of squamous cell carcinoma. This is the first study to characterize the biological behavior of papillary squamous neoplasms. Papillary squamous neoplasms exhibit two distinct, yet sometimes overlapping, histologic patterns including an exophytic papillary and an inverting verrucous morphologic appearance. A high rate of synchronous or metachronous lesions were found, especially with the inverting-type of papillary squamous neoplasm. Stage T3 and T4 lesions had a high rate of neck metastasis. Early surgical intervention and close long-term follow-up is mandatory.

Unsurpassed reliability of free flaps for head and neck reconstruction.

OBJECTIVE: To review the outcome and incidence of perioperative complications in patients undergoing microvascular free flaps for reconstruction of the head and neck region. DESIGN: A prospective case series. SETTING: An academic tertiary care otolaryngology-head and neck surgery program. PATIENTS: One hundred fifteen patients who underwent 119 consecutive free flaps performed by 1 surgeon during a 32-month period. INTERVENTIONS: Reconstruction primarily by means of radial forearm, fibula, and rectus abdominis flaps (95% of the flaps selected for reconstruction). MAIN OUTCOME MEASURE: The incidence of perioperative reconstructive and medical complications. RESULTS: There was 1 perioperative death (0.8%). Among the surviving patients, there was 1 case of complete flap failure, resulting in an overall flap survival of 99.2%. There were 2 additional cases (1.8%) of partial flap necrosis. Perioperative reconstructive complications occurred during 10.1% of the hospitalizations, half of which required additional surgical intervention. Notable perioperative medical complications occurred in 17.1% of the patients. CONCLUSIONS: Despite their reliance on small-vessel anastomoses for survival, free flaps are extremely reliable with regard to the incidence of flap necrosis, which contributes to a low incidence of perioperative complications. Selection of flaps that have proven dependability contributes to a successful outcome. While this technique frequently requires lengthy surgery in an elderly patient population, the perioperative mortality) and morbidity are acceptable. Because of their unsurpassed reliability, free flaps have become the preferred method of reconstruction for most patients with major defects in the head and neck region.

Functional neck dissection for treatment of recurrent branchial remnants.

OBJECTIVE: To evaluate the role of functional neck dissection for treatment of cervical branchial remnants that are recurrent after previous surgical intervention. DESIGN: A retrospective review was undertaken of six patients undergoing functional neck dissection for excision of recurrent branchial anomalies treated over an 18-year period. SETTING: Academic tertiary referral medical center. PARTICIPANTS: Six patients with recurrent branchial cysts, sinuses, or fistulas. Each participant previously had undergone between one and 14 ineffective surgical procedures. INTERVENTION: Each patient was treated by functional neck dissection. OUTCOME MEASURES: Clinically noted complications and recurrences. RESULTS: There were no major complications. Minor complications included one postoperative wound infection and one transient spinal accessory nerve paresis. There were no recurrences. CONCLUSIONS: Functional neck dissection is a safe and effective procedure for surgical management of recurrent cervical branchial remnants.

The bridging lateral mandibular reconstruction plate revisited.

BACKGROUND: Lateral oromandibular reconstruction using a soft tissue free flap with a first-generation locking mandibular reconstruction plate (MRP) was rejected in a previous series by the senior author (K.E.B.) owing to a high incidence of delayed plate extrusion through the cheek skin. OBJECTIVE: To reexamine this method of reconstruction using a second-generation, low-profile MRP. PATIENTS AND DESIGN: A prospective case series of 27 patients with segmental defects of the lateral mandible after treatment of head and neck cancer. SETTING: An academic tertiary care referral center. INTERVENTION: All patients had mandibular continuity restored using the Leibinger Locking System (Stryker Leibinger Inc, Kalamazoo, Mich) MRP. Associated soft tissue defects were repaired using radial forearm (n = 22) or rectus abdominis (n= 5) free flaps. MAIN OUTCOME MEASURE: Incidence of hardware-related complications. RESULTS: All microvascular flap transfers were successful. One patient experienced a plate fracture 9 months after reconstruction. Only 1 patient experienced external plate exposure, 6 months after undergoing reconstruction of a through-and-through defect. Reconstruction was successful in 25 (93%) of the cases after a median follow-up period of 19.5 months. CONCLUSIONS: The high incidence of external plate exposure in patients undergoing lateral oromandibular reconstruction using soft tissue free flaps and first-generation locking MRPs may have resulted from a plate geometry that was prone to result in extrusion. After a similar length of follow-up, the incidence of reconstructive failure was reduced by using a low-profile, rounded-contour MRP. Final assessment of the durability of this technique will require long-term follow-up.

Overcoming the learning curve in microvascular head and neck reconstruction.

BACKGROUND: It is widely accepted that most microvascular reconstructive surgeons experience a learning curve. A compilation of 6 series of microvascular surgery reported in the literature revealed that the average rate of successful free flap transfer rose from 79% to 96% as the surgeons gained clinical experience. OBJECTIVE: To review the collective experience of 3 otolaryngologist-head and neck surgeons performing free flaps during their first year of clinical practice after completion of postgraduate training. DESIGN: A multi-institutional retrospective case series. SETTING: Three academic tertiary care otolaryngology-head and neck surgery programs. PATIENTS: Eighty-one microvascular free flaps were performed in patients undergoing surgical reconstruction of head and neck defects during a 1-year period. INTERVENTIONS: Free flap selection was based on specific defect characteristics. Radial forearm, fibula, and rectus abdominis flaps together accounted for 90% of the donor sites selected. MAIN OUTCOME MEASURE: Reported incidence of partial or complete free flap necrosis. RESULTS: There were 2 perioperative deaths. Among the surviving patients, there were 2 cases of complete flap failure, for an overall success rate of 97.5%. There were 2 additional cases of partial flap necrosis (2.5%) that were related to errors in flap insetting. CONCLUSION: The availability of high-quality postgraduate training combined with the judicious selection of free flaps that offer long vascular pedicles and large diameter vessels can allow junior microvascular head and neck surgeons to achieve free flap survival rates that are comparable with those reported by experienced microvascular surgeons.

Lateral mandibular reconstruction using soft-tissue free flaps and plates.

OBJECTIVE: To assess the outcome of patients who are undergoing reconstruction of segmental lateral mandibular defects by using soft-tissue free flaps combined with mandibular reconstruction plates. DESIGN: Retrospective case series of 15 patients who were undergoing primary reconstruction of mandibular segments posterior to the mental foramen, resulting from treatment of head and neck cancer. All patients received either preoperative or postoperative radiation therapy. SETTING: Academic tertiary care referral center. INTERVENTIONS: Fourteen patients had mandibular continuity restored by using the titanium hollow screw reconstruction plate system, and 1 patient received a stainless steel mandibular reconstruction plate. Associated soft-tissue defects were repaired by using radial forearm (n = 11), rectus abdominis (n = 2), scapular and parascapular (n = 1), or lateral arm (n = 1) free flaps. MAIN OUTCOME MEASURES: Early and delayed complications. RESULTS: All 15 microvascular free tissue transfers were successful. Early complications were minor and occurred in 5 (33%) of 15 patients. One patient in whom the titanium hollow screw reconstruction plate system had been used experienced a fracture at 15 months after reconstruction. Three patients experienced delayed external plate exposure between 7 and 15 months after primary oromandibular reconstruction. Patients who experienced delayed external plate exposure required secondary reconstruction with a vascularized bone-containing free flap. The overall rate of delayed reconstructive failure was 40% in patients who were followed up for a minimum of 1 year. CONCLUSIONS: For patients who are undergoing free flap reconstruction of lateral mandibulectomy defects, the technique that used soft-tissue free flaps combined with mandibular reconstruction plates has been abandoned in favor of using vascularized bone-containing free flaps or a combination of free flaps to achieve optimal long-term results.

Continuous tissue oxygen tension measurement as a monitor of free-flap viability.

Early recognition of vascular compromise within microvascular free-tissue transfers is essential if reexploration is to prove successful. Tissue oxygen tension is increasingly recognized to be a sensitive and reliable index of tissue perfusion, and preliminary studies suggest that it may be of value in the assessment of free-flap viability. We describe our investigation into the application of an implantable microcatheter oxygen sensor in the monitoring of free flaps used in head and neck and extremity reconstruction. In a preliminary study using the rabbit model, we sought to evaluate the response of oxygen tension as an index of tissue perfusion in myocutaneous (n = 20) and osteomyocutaneous flaps (n = 5) under conditions of arterial and venous occlusion. A clinical study was then undertaken to evaluate the role of this method in the monitoring of surface and buried free flaps. In 30 heterogeneous free-tissue transfers, sensors placed intraoperatively were used to provide continuous information about flap oxygen tension (mean monitoring period 3.2 +/- 0.8 days). The data generated were correlated with changes in clinical parameters and routine flap observations. Results for experimental and clinical data have confirmed the efficacy of continuous tissue oxygen measurements using this device as a method that provides an objective, recordable index of free-tissue transfer viability in a variety of circumstances and vascular events. Tissue oxygen tension is a suitable index by which to evaluate flap viability with the probe placed in muscle or bone but is unreliable when used for the monitoring of revascularized cutaneous flaps.

Glandular carcinoma of the larynx: the UCLA experience.

Glandular carcinomas of the larynx are rare tumors that constitute less than 1% of all laryngeal malignancies. A retrospective case review of 12 patients with glandular carcinomas of the larynx is presented to identify patient and tumor characteristics, therapeutic modalities, and treatment outcomes. Ten patients underwent surgical excision of the primary tumor, by either supraglottic laryngectomy, vertical partial laryngectomy, or total laryngectomy. Seven of these patients also received postoperative radiotherapy. After a median follow-up period of 23 months, 7 of the 12 patients (58.3%) died as a result of uncontrolled locoregional disease or distant metastases. The 5-year survival rate was 57% in patients who underwent combination therapy versus 50% for those patients who received surgery alone. Surgical resection is the primary treatment modality used in the majority of cases. Neck dissection is reserved for patients with clinically apparent adenopathy, adenocarcinoma, or high-grade mucoepidermoid carcinoma. Combination therapy with surgical resection and radiotherapy may be more effective in achieving tumor remission than is surgical resection alone.

Laryngeal dysplasia: epidemiology and treatment outcome.

A retrospective analysis was undertaken of 65 patients with long-term follow-up for laryngeal squamous dysplasia. Based on the degree of dysplasia demonstrated on initial biopsy, 0 of 6 patients showing hyperkeratosis without dysplasia, 3 of 26 patients (12%) showing mild dysplasia, 5 of 15 patients (33%) showing moderate dysplasia, 4 of 9 patients (44%) showing severe dysplasia, and 1 of 9 patients (11%) showing carcinoma in situ eventually progressed to invasive carcinoma. An analysis was made of the impact of various treatment modalities in 33 patients demonstrating moderate dysplasia, severe dysplasia, or carcinoma in situ. Invasive carcinoma developed in 10 of 21 patients (48%) treated endoscopically and 0 of 12 patients treated by more aggressive therapy, including external beam radiotherapy, partial laryngectomy, or total laryngectomy. Of the patients in the endoscopic therapy group who developed invasive carcinoma, all were salvaged successfully. The overall rate of laryngeal preservation was 15 of 21 patients (71%) in the endoscopic treatment group and 11 of 12 patients (92%) in the aggressive treatment group. This difference is not statistically significant. We conclude that there is a moderately high rate of progression to invasive carcinoma in patients undergoing repeated endoscopic therapy for intraepithelial neoplasms of the larynx. However, with close, long-term follow-up, patients undergoing endoscopic therapy have an overall outcome similar to that in patients treated with partial laryngectomy or radiotherapy prior to developing invasive disease.

Atelectasis of the maxillary sinus with enophthalmos and midface depression.

Enophthalmos previously has been reported to be a rare complication of maxillary sinus mucoceles. We report three patients treated by the senior author (T.C.C.) over a 2-month period for enophthalmos or obvious deformity of the midface associated with complete opacification of the maxillary antrum. Most previous authors have stressed the role of chronic pressure necrosis or osteitis leading to bone destruction, with primary involvement of the orbital floor. No patients in this series had symptoms typical of maxillary sinus mucoceles. Two of our three patients presented with minimal symptoms of chronic infection. There was inward collapse of the anterior, superior, lateral, and medial walls of the maxillary sinus, with no radiographic or intraoperative confirmation of bone destruction. We speculate that this process may be the result of chronic maxillary hypoventilation with subsequent atelectasis of the antrum secondary to chronic negative pressure. All patients had obstruction at the osteomeatal complex and were treated by endoscopic enlargement of the natural maxillary ostium.

Adenoid cystic carcinoma of the base of the tongue.

A retrospective review of 14 patients with adenoid cystic carcinoma of the tongue treated between 1955 and 1997 was performed. Treatment consisted of surgery (n = 2), radiotherapy (n = 2), chemotherapy (n = 1), or combination therapy (n = 9). The 2-, 5-, and 10-year absolute survival rates were 92%, 79%, and 63%, respectively. Seventy-five percent of the patients who died of cancer succumbed to distant metastases. However, long-term survival was common despite a high incidence of local and distant recurrence. The presence of positive surgical margins, the incidence of regional metastases, the incidence of perineural invasion, the initial stage of disease, and the eventual development of locoregional recurrence and distant metastases did not significantly alter the survival rate. Surgical extirpation combined with postoperative radiotherapy is advocated for the treatment of adenoid cystic carcinoma of the tongue. Given the indolent nature of this disease process, surgery should be directed toward conservation of speech and swallowing function.

Distant lymphatic metastasis from head and neck cancer.

A predictable pattern of metastasis based on tumor histology and site of origin has been well documented for most cancers that arise in the head and neck region. The current study demonstrates that this predictable pattern of metastasis can be significantly impacted by previous therapy, resulting in unusual patterns of metastasis in patients with recurrent tumors. A retrospective case series of 5 patients with head and neck carcinomas who developed metastases to distant lymph nodes is presented. All patients underwent surgery and radiotherapy to the primary tumor and regional lymphatics at the time of their initial treatment. All of the patients developed a local recurrence less than a year before the detection of distant lymphatic metastases. Cytology or excision confirmed metastases to the axillary, inguinal, or anterior intercostal lymph nodes. All of the patients underwent aggressive surgery for attempted cure of the local recurrence shortly before the presence of distant lymphatic metastases was clinically recognized. The metastatic workup of patients with carcinomas of the head and neck frequently includes examination of the regional lymph nodes as well as chest radiography, liver function tests, and serum calcium determination. This evaluation may fail to detect metastases to distant lymph nodes in patients who present with recurrent or second primary cancers. Such patients should undergo careful examination of all major lymph node-bearing regions of the body when being evaluated for the presence of distant metastases.

Comparison of nerve banking techniques in delayed laryngeal reinnervation.

Successful laryngeal transplantation will require adequate reinnervation of the larynx to allow phonation, coordinated swallowing, and respiration. A delay between laryngectomy and transplantation would be necessary in oncology patients because of the need for immunosuppression. In these patients, reinnervation of the donor organ would require "banking" and recovery of dormant recipient recurrent laryngeal nerves (RLNs). This pilot study was undertaken to compare the effectiveness of RLN storage using 1 of 2 techniques: 1) inserting the nerve into a muscle pocket or 2) anastomosing the proximal RLN stump to the ansa cervicalis. Six months following nerve transection and "banking," the proximal anterior branch of the RLN was reanastomosed to the distal anterior segment and the posterior branch was anastomosed directly to the posterior cricoarytenoid muscle. Tensionometry, image analysis, and electromyographic data were collected 1 year later. Results show reinnervation of adductors and abductors with both techniques. Banking of the RLN branches during total laryngectomy is effective and should permit delayed physiological reinnervation following laryngeal transplantation.