Artery Grafting for Arterial Anastomoses in Head and Neck Free Tissue Transfer Reconstruction.

BACKGROUND: Vessel grafting is an important technique in head and neck free tissue transfer (FTT) reconstruction when a tension-free anastomosis is not otherwise feasible. To our knowledge, there are limited data regarding interposition artery grafts for arterial anastomoses in head and neck reconstruction. Here, we present a multi-institutional cohort of arterial interposition grafts for FTT reconstruction for head and neck defects. METHODS: A retrospective review was conducted at four tertiary care institutions for patients who underwent FTT reconstruction for head and neck defects which utilized an interposition artery graft for the arterial anastomosis. Charts were reviewed for type and length of artery grafts harvested, surgical indication, indication for artery graft, types of flaps harvested, and various preoperative characteristics (including history of radiation or previous FTT reconstruction surgery). Postoperative complications within postoperative day 30 were measured and reported. RESULTS: Nine patients met inclusion criteria. The lateral circumflex femoral artery (either transverse or descending branches) (n = 3) and facial artery (n = 3) were the most commonly harvested arteries. The scalp (n = 5) was the most common primary defect site. Seven grafts were harvested initially and in a planned fashion, while two were harvested as salvage techniques (either for flap salvage or vein graft failure). In planned grafts, arteries were the preferred interposition grafting method due to either size match preferences (n = 4) or similarities in wall thickness (n = 3) between graft and recipient artery. There were no reported cases of unplanned readmission, postoperative hematoma, fistula formation, wound infection, or donor site morbidities. Two patients required unplanned return to the operating room for flap compromise, both of which ultimately resulted in flap failure secondary to clot formation at both arterial and venous anastomoses. CONCLUSIONS: When arterial pedicle length is insufficient, interposition artery grafting is both a feasible and viable technique to achieve tension-free arterial anastomoses for select cases of highly complex head and neck free tissue reconstruction.

Impact of Obesity on Postoperative Complications after Lateral Skull Base Surgery: A Systematic Review.

INTRODUCTION: The relationship between obesity and complications after lateral skull base tumor resection is not clear. There is conflicting evidence regarding the incidence of postoperative complications in this patient population. The purpose of this study is to examine the relationship between obesity and outcomes following lateral skull base tumor resection. DATA SOURCES: Data were extracted from PubMed, Embase, CINAHL, and Cochrane CENTRAL. METHODS: Included studies assessed the relationship between obesity and outcomes following lateral skull base tumor removal. Studies with ≤5 patients, pediatric patients, duplicate patient populations, or insufficient data were excluded. Two independent investigators reviewed each study for inclusion. A third reviewer served as a tie-breaker for any conflicts. Extracted data includes patient demographics, tumor pathology, surgical approach, and postoperative outcomes including incidence of cerebrospinal fluid (CSF) leak and other postoperative complications, length of stay (LOS), and readmission and reoperation rates. Descriptive statistics were used to compare postoperative outcomes for obese and nonobese controls. RESULTS: 14 studies met final inclusion criteria. Nine studies evaluated the relationship between obesity and CSF leaks. Four studies found a significant increase in postoperative CSF leak in obese patients compared to nonobese controls. The remaining studies trended toward an increased incidence of CSF leak in the obese population but did not reach statistical significance. One out of seven studies found that obesity increased postoperative LOS, and one out of five studies found that obesity increased reoperation rates following tumor resection. CONCLUSIONS: Based on the results, obesity does not appear to increase LOS, readmission, or reoperation rates after lateral skull base tumor resection. The relationship between obesity and postoperative CSF leak, however, warrants further analysis.

Selective Neurectomy for Treatment of Post-Facial Paralysis Synkinesis: A Systematic Review.

BACKGROUND: Synkinesis is commonly encountered after flaccid facial paralysis and can have a detrimental impact on a patient's life. First-line treatment of synkinesis is chemodenervation with botulinum toxin (Botox) and neuromuscular retraining. Surgical options include selective myectomy, selective neurectomy (SN), cross-facial nerve grafting, nerve substitution, and free gracilis muscle transfer. Data on surgical management of synkinesis using SN is limited. EVIDENCE REVIEW: PubMed, Embase, Cochrane CENTRAL, Cochrane Neuromuscular Register, Clinicaltrials.gov, and World Health Organization International Clinical Trials Registry Platform were searched using a comprehensive keyword strategy in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All English-only texts published in the past 20 years were included. Two independent investigators reviewed 906 abstracts and 7 studies met inclusion criteria. Demographics, etiology of paralysis, time to surgery, and primary outcomes studied were collected. FINDINGS: A total of 250 patients were included across 7 studies. In 6 out of 7 studies, Botox was used prior to surgical intervention. Two studies showed significant reduction in Botox dosage postoperatively, while one study showed no difference. Other primary outcomes included the House-Brackmann Score, palpebral fissure width, electronic clinician-graded facial function scale (eFACE) score, Facial Clinimetric Evaluation (FaCE) scale, and Synkinesis Assessment Questionnaire (SAQ). Three studies showed significant improvement in the eFACE score, two studies showed significant improvement in the FaCE scale, while one study showed improvement in quality of life measured by the SAQ. CONCLUSION: SN can be considered as an adjunct to other management options including neuromuscular retraining, Botox, selective myectomy, and reanimation procedures. While there is great heterogeneity of study design in the studies included, many cohorts showed improvement in facial symmetry, facial function, and quality of life. There remains a great gap in knowledge in this subject matter and a need for large well-designed prospective studies comparing this technique to other management options.

Surgical versus Nonsurgical Management of Postmastectomy Lymphedema: A Prospective Quality of Life Investigation.

BACKGROUND: Postmastectomy secondary lymphedema can cause substantial morbidity. However, few studies have investigated longitudinal quality of life (QoL) outcomes in patients with postmastectomy lymphedema, especially with regard to surgical versus nonoperative management. This study prospectively investigated QoL in surgically versus nonsurgically managed patients with postmastectomy upper extremity lymphedema. METHODS: This was a longitudinal cohort study of breast cancer-related lymphedema patients at a single institution, between February 2017 and January 2020. Lymphedema Quality of Life Instrument (LyQLI) and RAND-36 QoL instrument were used. Mann-Whitney U and Fisher's exact tests were used for descriptive statistics. Wilcoxon's signed-rank testing and linear modeling were used to analyze longitudinal changes in QoL. RESULTS: Thirty-two lymphedema patients were recruited to the study (20 surgical and 12 nonsurgical). Surgical and nonsurgical cohorts did not significantly differ in clinical/demographic characteristics or baseline QoL scores, but at the 12-month time point surgical patients had significantly greater LyQLI overall health scores than nonsurgical patients (79.3 vs. 58.3, p = 0.02), as well as higher composite RAND-36 physical (68.5 vs. 38.3, p = 0.04), and mental (77.0 vs. 52.7, p = 0.02) scores. Furthermore, LyQLI overall health scores significantly improved over time in surgical patients (60.0 at baseline vs. 79.3 at 12 months, p = 0.04). Besides surgical treatment, race, and age were also found to significantly impact QoL on multivariable analysis. CONCLUSION: Our results suggest that when compared with nonoperative management, surgery improved QoL for chronic, secondary upper extremity lymphedema patients within 12-month postoperatively. Our results also suggested that insurance status may have influenced decisions to undergo lymphedema surgery. Further study is needed to investigate the various sociodemographic factors that were also found to impact QoL outcomes in these lymphedema patients.

Comparison of keystone flaps and skin grafts for oncologic reconstruction: A retrospective review.

BACKGROUND AND OBJECTIVES: Two common options for the closure of complex defects are local flaps and skin grafting. The keystone flap, a fasciocutaneous flap based on perforators, has demonstrated compelling ease of use, reproducibility, and low complication rates without requiring a distant donor site. Our objective for this study was to compare postoperative outcomes for keystone flaps and skin grafts in cancer resection. METHODS: A retrospective review was conducted of patients undergoing keystone flap closure or skin grafting for soft tissue defects resulting from cancer resection at a single institution from June 2017 to June 2018. Patient demographics, operative indications, length of stay, time to heal, and complications were reviewed. RESULTS: A total of 34 patients were identified having undergone either keystone reconstruction (n = 16) or skin graft (n = 18) after oncologic resection. Patients undergoing keystone flap reconstruction had significantly shorter mobility restriction and healing times. Length of hospital stay and overall complication rates were not significantly different. CONCLUSION: The keystone flap is an adaptable tool that can safely be used for the coverage of complex defects with faster healing, shorter mobility restriction, and comparable complication rates to skin grafting without the need for a distant donor site.

Reconstructive limb-salvage surgery after lower extremity soft tissue sarcoma resection: A 20-year experience.

BACKGROUND: Reconstructive surgery is often required following lower extremity soft tissue sarcoma resection. The relationship between the method of plastic surgery reconstruction and postoperative wound healing or functional oncologic outcomes in this patient population is poorly understood. METHODS: We performed a retrospective review on all adult patients that underwent soft tissue reconstruction following resection of lower extremity soft tissue sarcomas between 1996 and 2016 at our institution. RESULTS: One hundred and thirty-six patients were identified. Wound complications occurred within 6-months postoperatively in 72 patients (52.9%). Average time to heal was 13.0 weeks. Limb survival was 94.9%. 16.9% and 36.8% of patients had evidence of local recurrence or metastatic disease, respectively. There was no significant difference in the incidence of overall wound complications, time to heal, limb survival, local recurrence, or metastatic disease between the different reconstructive methods. CONCLUSIONS: In our cohort, the utilization of different reconstructive techniques did not correlate with a difference in postoperative wound complications or oncologic outcomes. Local flaps can effectively reconstruct the majority of lower extremity sarcoma defects that cannot be closed primarily. However, alternative reconstructive techniques may be utilized when indicated without a significant increase in postoperative morbidity in this patient population.

Utility of Prophylactic Antibiotics in Nonoperative Facial Fractures.

Facial fractures are commonly managed nonoperatively. Patients with facial fractures involving sinus cavities commonly receive 7 to 10 days of prophylactic antibiotics, yet no literature exists to support or refute this practice. The aim of this study was to compare the administration and duration of antibiotic prophylaxis on the incidence of soft tissue infection in nonoperative facial fractures. A total number of 289 patients who were admitted to our level I trauma center with nonoperative facial fractures from the beginning of 2012 to the end of 2014 were studied. Patients were categorized into 3 groups: no antibiotic prophylaxis, short-term antibiotic prophylaxis (1-5 days), and long-term antibiotic prophylaxis (>5 days). The primary outcome was the incidence of facial soft tissue infection and Clostridium difficile colitis. Fifty patients received no antibiotic prophylaxis. Sixty-three patients completed a short course of antibiotic prophylaxis and 176 patients received long-term antibiotics. Ampicillin/sulbactam, amoxicillin/clavulanic acid, or a combination of both were used in 216 patients. Twenty-three patients received clindamycin due to penicillin allergy. Short and long courses of antibiotic prophylaxis were administered more commonly in patients with concomitant maxillary and orbital fractures (P <0.0001). No mortality was found in any group. Soft tissue infection was not identified in any patient. C. difficile colitis was identified in 1 patient who had received a long course of antibiotic prophylaxis (P = 0.7246). There was no difference in the outcome of patients receiving short-term, long-term, and no antibiotic prophylaxis. Prospective randomized studies are needed to provide further clinical recommendations.

Management of Frontal Sinus Fractures at a Level 1 Trauma Center: Retrospective Study and Review of the Literature.

Study Design: Case series. Objective: This retrospective review of frontal sinus fractures aims to describe our current experience managing these fractures at an urban level I trauma center. Methods: An institutional database of 2081 patients who presented with maxillofacial fractures on computed tomography face/sinus in 2019 was queried for all patients with traumatic frontal sinus fractures. Demographics, trauma-related history, management approach, and follow-up data were collected and analyzed. Results: Sixty-three (7.3%) patients had at least one fracture involving the frontal sinus. The most common etiologies were assaults, falls, and motor vehicle accidents. Surgical repair was performed in 26.8% of patients with frontal sinus fractures, and the other 73.2% were observed. Fractures that were displaced, comminuted, obstructive of the frontal sinus outflow tract, or associated with a dural tear or cerebrospinal fluid leak were more likely to be operative. Conclusions: The majority of frontal sinus fractures in this study were treated with observation. Despite advances in transnasal endoscopic approaches, many surgeons still rely on open approaches to repair frontal sinus fractures.

Obesity and Survival After Immune Checkpoint Inhibition for Head and Neck Squamous Cell Carcinoma.

Importance: For patients treated with immune checkpoint inhibitors (ICIs), recent data suggest that obesity has a beneficial effect on survival outcomes in various cancer types. Reports on this association in head and neck cancer are limited. Objectives: To compare overall survival (OS) to 5 years and functional outcomes in patients with head and neck squamous cell carcinoma (HNSCC) treated with ICIs based on pretreatment body mass index (BMI). Design, Setting, and Participants: This retrospective population-based cohort study used data obtained from the TriNetX Global Collaborative Network database to identify patients with HNSCC who received ICI treatment between January 1, 2012, and December 31, 2023, resulting in a total of 166 patients (83 with BMI of 20.0-24.9 [normal BMI] and 83 with BMI of ≥30.0 [obesity BMI]) after propensity score matching (PSM) for pretreatment medical comorbidities and oncologic staging. Exposure: Normal BMI vs obesity BMI. Main Outcomes and Measures: Overall survival and functional outcomes (dysphagia, tracheostomy dependence, and gastrostomy tube dependence) were measured to 5 years after ICI treatment and compared between patients with obesity BMI and normal BMI. Additional analyses compared OS and functional outcomes in the cohort with normal BMI and cohorts with overweight BMI (25.0-29.9) and underweight BMI (<20.0). Results: Among the 166 patients included in the PSM analysis (112 men [67.1%]; mean [SD] age, 62.9 [15.4] years), obesity BMI was associated with significantly improved OS at 6 months (hazard ratio [HR], 0.54 [95% CI, 0.31-0.96]), 3 years (HR, 0.56 [95% CI, 0.38-0.83]), and 5 years (HR, 0.62 [95% CI, 0.44-0.86]) after ICI treatment, compared with patients with normal BMI. Obesity BMI was also associated with decreased risk of gastrostomy tube dependence at 6 months (odds ratio [OR], 0.41 [95% CI, 0.21-0.80]), 1 year (OR, 0.41 [95% CI, 0.21-0.78]), 3 years (OR, 0.35 [95% CI, 0.18-0.65]), and 5 years (OR, 0.34 [95% CI, 0.18-0.65]). Obesity was also associated with decreased risk for tracheostomy dependence at 1 year (OR, 0.52 [95% CI, 0.28-0.90]), 3 years (OR, 0.45 [95% CI, 0.45-0.90]), and 5 years (OR, 0.45 [95% CI, 0.45-0.90]). There were no differences in rates of dysphagia or immune-related adverse events between cohorts at any points. Conclusions and Relevance: Using population-level data for patients with HNSCC treated with ICIs, these results suggest that having obesity was associated with improved 6-month, 3-year, and 5-year OS compared with having normal BMI. Additionally, obesity was associated with decreased gastrostomy and tracheostomy tube dependence compared with normal BMI. Further investigation is required to understand the mechanism of these findings.

Current Management of Subcondylar Fractures: A Systematic Review.

OBJECTIVE: The aim of this study is to review the current literature on treatment of subcondylar fractures using traditional open reduction internal fixation (ORIF), closed reduction with maxillomandibular fixation (MMF), and endoscopic open approaches. DATA SOURCES: PubMed, Embase, Cochrane CENTRAL, Clinicaltrials.gov, and WHO ICTRP. REVIEW METHODS: A comprehensive database search was performed in accordance with PRISMA guidelines. All English-only texts published in the last 20 years with ≥10 patients were included. Studies that included patients <16 years old were excluded. RESULTS: Thirty-two studies met the final inclusion criteria. Nine studies compared ORIF with closed reduction using MMF, 12 studies evaluated ORIF via different approaches, and 10 studies evaluated outcomes after endoscopic approaches. Five studies reported significant improvement in mouth opening with ORIF compared to closed reduction. In 1 study that recorded patient-reported outcomes measure (FACE-Q scale), quality of life scores and patient satisfaction were significantly higher in the ORIF group. Among the 10 studies that used the endoscopic approach, transient facial nerve injury ranged from 0% to 10%. CONCLUSION: Several studies report better mouth opening, dental occlusion, and functional outcomes after ORIF compared to closed reduction, while some found no significant difference. Endoscopic approaches provide ease of access to the condyle with a low incidence of facial nerve injury. However, limitations include special equipment, longer operative times, and a steep learning curve using an endoscope. This review provides surgeons with an overview of the current literature on subcondylar fractures to allow for an individualized management approach for each patient.

Regionalization of Head and Neck Oncology Tumor Boards: Perspectives of Collaborating Physicians.

Objectives: To survey academic and community physician preferences regarding the virtual multidisciplinary tumor board (MTB) for further improvement and expansion. Study Design: This anonymous 14-question survey was sent to individuals that participated in the head and neck virtual MTBs. The survey was sent via email beginning August 3, 2021, through October 5, 2021. Setting: The University of Maryland Medical Center and regional practices in the state of Maryland. Methods: Survey responses were recorded and presented as percentages. Subset analysis was performed to obtain frequency distributions by facility and provider type. Results: There were 50 survey responses obtained with a response rate of 56%. Survey participants included 11 surgeons (22%), 19 radiation oncologists (38%), and 8 medical oncologists (16%), amongst others. More than 96% of participants found the virtual MTB to be useful when discussing complex cases and impactful to future patient care. A majority of respondents perceived a reduction in time to adjuvant care (64%). Community and academic physician responses strongly agreed that the virtual MTB improved communication (82% vs 73%), provided patient-specific information for cancer care (82% vs 73%), and improved access to other specialties (66% vs 64%). Academic physicians, more so than community physicians, strongly agreed that the virtual MTB improves access to clinical trial enrollment (64% vs 29%) and can be useful in obtaining CME (64% vs 55%). Conclusion: Academic and community physicians view the virtual MTB favorably. This platform can be adapted regionally and further expanded to improve communication between physicians and improve multidisciplinary care for patients.

Incident adverse events following therapy for acute promyelocytic leukemia.

The use of all-trans retinoic acid (ATRA) combined with arsenic trioxide (ATO) with or without cytotoxic chemotherapy is highly effective in acute promyelocytic leukemia (APL) but incident chronic adverse events (AEs) after initiation of therapy are not well understood. We retrospectively analyzed adult patients with newly diagnosed APL from 2004 through 2014 to identify incident AEs following treatment and contributing risk factors. Cardiac and neurologic AEs were more common and characterized in detail. Cardiac AEs such as the development of coronary artery disease (CAD), arrhythmias, and heart failure had a cumulative incidence of 6.4% (CI95 1.8-11.1%), 2.9% (CI95 0.0-6.4%), 5.8% (CI95 1.2-10.3%) at 4 years from diagnosis, respectively. In multivariate analyses of factors influencing heart failure, the presence of clinical or radiographic CAD (HR 4.25; P = 0.011) or troponin elevation prior to completion of therapy (HR 8.86; P = 0.0018) were associated with increased heart failure incidence, but not anthracycline use or dose. Neurological AEs were common following therapy; at 4 years, the cumulative incidence of vision changes was 12.4% (CI95 6.0-18.7%), peripheral neuropathy 10.3% (CI95 4.5-16.1%), and memory or cognitive change 7.6% (CI95 2.5-12.7%). We did not identify any association between specific therapies and the development of cardiac and neurologic AEs. APL is a highly curable leukemia; further efforts are needed to address incident chronic AEs, with particular focus on cardiac and neurological care.

The Effect of Sarcopenia on Outcomes in Geriatric Blunt Trauma.

Elderly patients are at a higher risk of morbidity and mortality after trauma, which is reflected through higher frailty indices. Data collection using existing frailty indices is often not possible because of brain injury, dementia, or inability to communicate with the patient. Sarcopenia is a reliable objective measure for frailty that can be readily assessed in CT imaging. In this study, we aimed to evaluate the effect of sarcopenia on the outcomes of geriatric blunt trauma patients. Left psoas area (LPA) was measured at the level of the third lumbar vertebra on the axial CT images. LPA was normalized for height (LPA mm2/m2) and after stratification by gender, sarcopenia was defined as LPA measurements in the lowest quartile. A total of 1175 patients consisting of 597 males and 578 females were studied. LPAs below 242.6 mm2/m2 in males and below 187.8 mm2/m2 in females were considered to be sarcopenic. We found sarcopenia in 149 males and 145 females. In multivariate analysis, sarcopenia was associated with a higher risk of in-hospital mortality (odds ratio [OR]: 1.61, 95% confidence interval [CI]: 1.01-2.56) and a higher risk of discharge to less favorable destinations (OR: 1.42, 95% CI: 1.05-1.97). Lastly, sarcopenic patients had an increased risk of prolonged hospitalization (hazard ratio: 1.21, 95% CI: 1.04-1.40).