Is Head and Neck Free Flap Reconstruction Feasible in Jehovah's Witness Patients?

BACKGROUND: Jehovah's Witnesses (JW) population are members of a religious group that refuses blood transfusion. This presents a dilemma for surgical teams when performing major surgical procedures on these patients. PURPOSE: This study aimed to assess the safety and feasibility of undergoing microvascular free flaps for maxillofacial reconstruction in JW patients and whether the type of underlying pathology impacts outcomes. STUDY DESIGN, SETTING, AND SAMPLE: This was a multi-institutional retrospective cohort study. The sample consisted of all JW patients who have undergone microvascular free tissue transfer for maxillofacial pathology between January 2016 and January 2021. PREDICTOR VARIABLE: The primary predictor variable was the underlying pathology for which patients underwent head and neck free flap reconstruction; this was benign versus malignant disease. MAIN OUTCOME VARIABLES: The primary outcome variables were safety, defined as discharge from the hospital with no mortality, and feasibility defined as successful free flap reconstruction. COVARIATES: Other variables included age, race, sex, length of surgery, length of hospital stay, and intraoperative use of vasopressors. ANALYSIS: Data analysis was performed utilizing t-tests for means and χ2 for proportions. Alpha was set at < 0.05. RESULTS: A total of 12 participants from 7 participating sites met the inclusion criteria. There were 9 males and 3 females with a mean age of 58.3 ± 8.3 years. There were no deaths in this cohort and all patients were discharged from the hospital. All 12 free flap reconstructions were successful with no incidents of free flap loss; none of the patients received any blood transfusions or any other blood products. Subgroup analysis showed that patients treated for malignant disease versus benign disease had longer operations (11.2 ± 2.9 vs 6.3 ± 0.2 hours, P < .01) and a longer hospital length of stay (11.8 ± 4.9 vs 5.3 ± 0.5 days, P = .04). CONCLUSION AND RELEVANCE: Our series supports the safety and feasibility of maxillofacial free flap reconstruction in this challenging subset of patients. Microvascular reconstructive surgeries for malignant diseases often result in longer operative times and hospital stays.

Minimally Invasive Cervical Access in Head and Neck Microvascular Surgery.

Free flap reconstruction often involves extensive cervical access for microvascular anastomosis where management of pathology would otherwise not require cervical approach. This study reports a minimally invasive alternative technique. Investigators designed a prospective case series with subjects who underwent microvascular reconstruction between 2015 and 2020, using a small 2 cm incision for vessel access, just below the mandible where facial artery/vein cross. Study variables were subject demographic characteristics, type and location of pathology/defect, and free flap types. Outcomes examined were flap success, postoperative facial weakness using House-Brackmann scale, and esthetic result with Visual Analog Scale. Descriptive statistics computed for study variables. Study sample was 43 subjects, mean age of 48 years with 20 males and 23 females. There were a total of 43 flaps with 100% success using our technique. One subject had House-Brackmann level 2 postoperative facial weakness that resolved within 1 week. Mean Visual Analog Scale score for scar satisfaction was 9.23/10, standard deviation 0.83. This minimally invasive approach represents an alternative to extensive open cervical access for microvascular anastomosis, offering minimal morbidity and excellent esthetic results.

Comprehensive Oromandibular Reconstruction Utilizing an Anterolateral Thigh Free Tissue Transfer Flap and Tissue Engineering: Technical and Timing Considerations.

The present report describes the technical nuances involved in oromandibular reconstruction utilizing a soft tissue free flap and tissue engineering in a step wise fashion for complete oral rehabilitation.

Use of soleus musculocutaneous perforator-based propeller flap for lower extremity wound coverage after osteocutaneous fibula free flap harvest.

BACKGROUND: Osteocutaneous fibula free flap (OCFFF) donor sites are often covered with skin grafts, with an additional donor site, more postoperative care, and increased cost. The authors examine posterior tibial artery (PTA) based pedicled propeller flaps (PPF) as an alternative for OCFFF donor site coverage. PATIENTS AND METHODS: Retrospective review of 16 consecutive patients from 30 to 79 years old, who underwent OCFFF reconstruction of head and neck defects (11 mandibular, 5 maxillary), with the closure of donor site with PPF based on a perforator from PTA. Mean donor site defect measured 12.9 × 5.1 cm, PPF was an elliptical design, and rotated 180 degrees in a propeller fashion, to cover donor site defect. Visual analog scale (VAS) was used to assess esthetic results, functional outcomes assessed using mobility and range of motion (ROM), and secondary complications including infections, hematomas, and seromas were recorded. Follow-up period was noted in months postoperatively. Other information collected included underlying head and neck pathology. RESULTS: Average dimension of PPF measured 13.9 × 4.1 cm. Successful closure of donor site defects in 14 of 16 patients, with two flaps having partial necrosis, one requiring a secondary skin graft. Follow-up was 6 to 10 months, esthetic results with mean VAS 8.8 of 10, full ROM, and mobility noted. No secondary complications were observed. The most common pathology noted was squamous cell carcinoma (6 of 16 patients). CONCLUSION: PPFs based on the soleus branch of the PTA represent an excellent alternative to skin grafts for the closure of OCFFF donor site defects.

Palatal Basal Cell Adenocarcinoma From Misdiagnosis to Cure: A Unique Case Report and Review.

We describe a 66-year-old woman who received a misdiagnosis of benign neoplasms twice before receiving the appropriate diagnosis of basal cell adenocarcinoma. At the time of recurrence, her care was assumed by the senior author, who made the appropriate diagnosis and administered treatment including transoral microvascular reconstruction, as well as adjuvant radiation therapy, which achieved a cure. A review of the current literature on this disease entity also is included.

Synchronous Reconstruction of a Total Mandibulectomy Defect With a Single Fibula Osteocutaneous Free Flap.

Osteoradionecrosis (ORN) is a well-known and usually late complication of radiation therapy in the treatment of head and neck cancer. Although the therapy can be life extending, it also produces tissue toxicity in ipsilateral and contralateral tissues in an acute and chronic fashion. In the most severe cases of ORN, such as the one presented in this report, bilateral disease results in the need for total mandibulectomy and creates a tremendous reconstructive challenge. The advent of microvascular surgery and free tissue transfer has caused an evolution of the management protocol for severe ORN cases. This report describes a unique case of total mandibulectomy with synchronous reconstruction using a single vascularized fibula osteocutaneous flap with subsequent dental implant reconstruction and prosthetic rehabilitation.

Immediate Microsurgical Bone and Nerve Reconstruction in the Irradiated Patient: A Case Report.

Microsurgical reconstructive techniques have revolutionized the treatment of large head and neck defects. These defects were once forever life altering because of the considerable morbidity to both the form and function of the patient. As time has progressed, microsurgical technique has improved dramatically and has become institutionalized in our training programs. Free flap outcomes in head and neck reconstruction have improved dramatically, and optimization of these outcomes is now key. One overlooked area has been neurosensory reconstruction. In our practice we have focused on this detail, which has proved to be quite important to the patient. This case report details one such case in which a mandibular resection was performed to treat osteoradionecrosis. We, as the reconstructive team, elected to perform a double-barrel fibular free flap procedure with simultaneous inferior alveolar nerve reconstruction using a 70-cm processed nerve allograft. Normal neurosensory function returned in this patient. As the state of the art advances with continued successful osseous and soft tissue reconstruction in the head and neck, we propose concomitant neurosensory functional reconstruction always be considered.

Combined Anterolateral Thigh and Tensor Fasciae Latae Flaps: An Option for Reconstruction of Large Head and Neck Defects.

PURPOSE: The advent of microvascular free tissue transfer has provided the reconstructive surgeon with an enormous array of treatment options for reconstruction of large head and neck defects. However, when indicated by defect size, the need for more than 1 flap not only increases surgical complexity but also patient morbidity. The combination of the anterolateral thigh (ALT) flap and the tensor fascia latae (TFL) flap can be used to reconstruct such complex head and neck defects, thereby minimizing any additional morbidity that would be imposed by an additional flap harvest site. The present study reports on the use of the combined ALT-TFL flap to reconstruct large and complex head and neck defects. MATERIALS AND METHODS: A retrospective chart review was conducted of all microvascular head and neck reconstructions performed by the Maxillofacial Tumor and Reconstructive Surgery Service at the University of Miami/Jackson Health System (Miami, FL) from 2013 through 2016. Inclusion criteria for the study were head and neck defects at least 20 m × 10 cm and reconstruction with soft tissue flaps using perforating vasculature to the TFL and ALT vascular territories. Other study data included disease history, location of defect, flap size, recipient vessels, harvest time, ischemia time, surgical complications, and overall flap survival. RESULTS: Seven patients met the inclusion criteria. Five patients were treated for the diagnosis of stage III osteoradionecrosis and 2 patients underwent reconstruction in conjunction with ablative surgery for head and neck carcinoma. All 7 patients underwent successful head and neck reconstructions using the ALT-TFL flap. There was no partial or total flap failure. One patient had a wound healing complication at the donor site that did not require surgical intervention. CONCLUSION: Reconstruction of a large head and neck soft tissue defect with a combined ALT-TFL flap is a reliable method with minimal donor site morbidity and no major postoperative complications. This combined flap should be considered when the defect size extends beyond the bounds allowed by the ALT flap alone.

Reconstruction of a Post-Traumatic Maxillary Ridge Using a Radial Forearm Free Flap and Immediate Tissue Engineering (Bone Morphogenetic Protein, Bone Marrow Aspirate Concentrate, and Cortical-Cancellous Bone): Case Report.

The purpose of this article is to describe reconstruction of the maxillary alveolar ridge by use of a microvascular free flap combined with an immediate tissue-engineered bone graft. This novel surgical technique involved the use of a radial forearm free flap and immediate allogeneic avascular bone graft augmented with bone morphogenetic protein and bone marrow aspirate concentrate. A poly-d,l-lactic acid mesh was used as a containment unit for the bone graft. The patient was successfully treated with a viable radial forearm free flap for soft tissue and regeneration of bone with adequate height and width, which allowed the placement of 3 dental implants with excellent arch coordination. We believe this is the first published case describing such a technique to reconstruct the maxillary alveolus.

Recurrent Malignancy in Osteoradionecrosis Specimen.

PURPOSE: Osteoradionecrosis (ORN) is a well-known complication of head and neck radiation therapy. Statistically, the mandible is the most commonly affected site. The incidental finding of malignancy in the resection specimen has been documented but is somewhat rare. The aim of this review is to investigate the presence of recurrent carcinoma and sarcoma or new primary malignancies in resection specimens previously diagnosed and treated as ORN. PATIENTS AND METHODS: This study is a retrospective case series. We conducted a chart review of all cases managed at the University of Miami Miller School of Medicine/Jackson Memorial Hospital. The inclusion criteria included a history of head and neck carcinoma treated with radiation of at least 6,000 cGy; clinical diagnosis of ORN; and surgical intervention with osseous resection for treatment of ORN. The study endpoint measured included microscopic evidence of malignancy in the resected ORN specimen. Additional data collected included gender, age, and type of primary pathology. RESULTS: A total of 564 patients met the inclusion criteria. Of these patients, 14 had microscopic evidence of cancer in the specimen (2.48%) and 5 had a proven second primary malignancy in the foregut (1 in the lung, 0.18%, and 4 in the oropharynx, 0.70%). In 1 of the 14 patients, a high-grade sarcoma was diagnosed and the patient died within 1 year of diagnosis. In the treatment of our ORN patient population, a total of 19 malignancies were found collectively (3.37%). Of the 564 patients, 352 were men and 212 were women. The median age was 46 years (range, 33 to 97 years). Head and neck squamous cell carcinoma represented 531 cases in our sample, followed by 28 cases of salivary gland carcinoma and only 5 cases of sarcoma. CONCLUSIONS: Although the finding of malignancy in ORN patients is relatively rare (3.37% in this study), oral and maxillofacial surgeons should be cognizant of its potential presence. The treatment of malignant disease is different than that of ORN, and a multidisciplinary treatment approach is recommended if a malignancy is diagnosed in an ORN patient.

Comparison of propeller flaps versus skin grafts for coverage of osteocutaneous fibula free flap donor site defects.

BACKGROUND: Authors compare use of propeller flaps versus skin grafts in defect coverage after fibula flap harvest. MATERIALS AND METHODS: Retrospective review of patients who received either PFPF or STSG. Primary predictor variable was technique, and secondary predictor variables were comorbidities. Primary outcome variable was flap/graft healing, and secondary outcome variables were cosmesis, adverse events, effect on activities of daily living (ADLs), pain, additional procedures, and cost. Statistical analysis performed via independent sample t tests, ANOVA, and χ2 tests. Logistic regression analysis was performed. RESULTS: Study sample was 50 patients. PFPFs showed higher rates of success, while STSG showed increased complications and adverse events. Pain and ADLs significantly affected in STSG group. Cosmesis was better in the PFPF group, and overall cost was significantly higher in STSG group. CONCLUSION: PFPFs show greater success rates, fewer complications, improved cosmesis, less pain, reduced cost compared to STSG for wound coverage after fibula flap harvest.

Nonunion of mandibular midline osteotomy after tumor surgery and radiation repaired by endosseous implants.

Nonunion of the mandible after microvascular flap reconstruction of defects resulting from tumor surgery is a known but rare complication, occurring in 5% of cases. When nonunion results with the use of microvascular flaps, rigid internal fixation, and radiotherapy, other options to treat the nonunion carry a greater risk of osteomyelitis, osteoradionecrosis, and/or persistent nonunion. Although endosseous implants have been reported to cause mandibular fracture in some cases, our case proposes and supports the use of implants for immobilization and/or prevention of nonunion of the mandible in patients who have a high probability of this complication developing, thereby avoiding plating across the nonunion site with the risk of plate exposure and osteoradionecrosis. This technique permitted a good quality of life in our patient during the healing period. He was able to masticate and phonate properly when compared with other treatment options that would have required external and/or intermaxillary fixation devices.

The Trigeminal Nerve Injury.

Trigeminal nerve branches are never far from the operating field of the oral and maxillofacial surgeon. Increasingly the surgeon is required to provide accurate diagnosis and grading of trigeminal nerve injury, and surgical management by oral and maxillofacial surgeons will become common. Although trauma and ablative procedures for head and neck pathology can cause injuries, dentoalveolar surgical procedures remain an important cause of injury to the fifth cranial nerve, with the third division being the main branch affected. Oral and maxillofacial surgeons should be aware of strategies of avoiding iatrogenic injury, and know when referral and surgical management are appropriate.

Concurrent presence of secretory carcinoma and Warthin's tumor in ipsilateral parotid gland.

BACKGROUND: The presence of synchronous benign and malignant salivary gland neoplasms is very rare. The authors present a previously unreported combination of Secretory Carcinoma (SC) and Warthin's Tumor (WT) within the same parotid gland. METHODS: The patient presented with increasingly painful enlargement of the left parotid gland. CT scan with contrast revealed a heterogeneous solid/cystic mass in the superficial lobe. Fine needle aspiration cytology favored pleomorphic adenoma (PA) and patient underwent superficial parotidectomy without complication. RESULTS: Final pathology revealed concomitant presence of SC and WT. Stains were positive for S100 and mammaglobin, and FISH revealed the presence of t(12;15) (p13;q25) translocation, resulting in the ETV6-NTRK3 fusion gene. CONCLUSION: It is important for surgeons and pathologists to note the potential for co-existing benign and malignant pathology within the same salivary gland, as this can have an impact on management and prognosis for patients.

Clinical behavior of T1-T2 squamous cell carcinoma of the oral cavity.

OBJECTIVES: The main aim of the present study is to analyze the differences in the clinical behavior of pT1 and pT2 oral squamous cell carcinoma of the oral cavity and the importance of tumor thickness in these groups of patients. METHODS: A retrospective analysis was conducted using the records of patients diagnosed with pT1 and pT2 oral squamous cell carcinoma between 2006 and 2015 to identify significant differences between these two groups of patients. Several pathological features such as T-stage, N-stage, tumor thickness, surgical margins, and locoregional failure were analyzed. RESULTS: 194 patients were included in this study. Tumor thickness >0.4 cm was significantly related with nodal involvement and overall survival (p < 0.001). T and N stage, tumor thickness, extracapsular spread and surgical margins were associated with poorer outcomes in terms of overall survival (p < 0.001). CONCLUSION: Tumor thickness represents an extremely important prognostic factor and to include depth of invasion (DOI) in the staging of oral squamous cell carcinoma will help in the choice of better treatment strategies and to improve overall survival.

A technique for the treatment of oral-antral fistulas resulting from medication-related osteonecrosis of the maxilla: the combined buccal fat pad flap and radical sinusotomy.

OBJECTIVE: Bisphosphonates and monoclonal antibodies directed at osteoclastic function are frequently used to treat postmenopausal and corticosteroid-induced osteoporosis. They are also used in the treatment of certain metastatic malignancies. However, osteonecrosis of the jaw has been reported after intravenous, subcutaneous, or oral use of these agents. More than 12 million Americans and another 20 million worldwide are thought to be taking a bisphosphonate. Exposed bone with oral-antral fistulas has been known to occur increasingly as a specific presentation of what is now termed medication-related osteonecrosis of the jaws (MRONJ) with a specific International Classification of Diseases, 10th revision (ICD-10) code. Oral-antral communications caused by bisphosphonate concomitant with secondary sinusitis represent a unique treatment challenge for the oral and maxillofacial surgeon. The purpose of this article is to demonstrate a simple but effective technique to treat oral-antral communications caused by MRONJ. STUDY DESIGN: With the review and approval of the University of Miami Internal Review Board, we identified 23 patients who had undergone this surgical procedure. RESULTS: We report a 100% resolution of osteonecrosis of the jaw (ONJ) and sinusitis with repneumatization. CONCLUSIONS: The buccal fat pad and radical sinustomy can be used as an effective and predictable technique for the resolution of oral-antral fistulas caused by MRONJ.

A qualitative and quantitative analysis of autologous human multipotent adult stem cells derived from three anatomic areas by marrow aspiration: tibia, anterior ilium, and posterior ilium.

PURPOSE: The purpose of this article was to compare the yields of stromal multipotent stem cells (CD34+ and CD105+) and hematopoetic multipotent stem cells (CD44+) obtained from different areas via bone marrow aspiration (BMA). MATERIALS AND METHODS: Sixty 60-mL bone marrow aspirates were taken from the tibial plateau, the anterior ilium, and the posterior ilium using a single point-of-care BMA technique and a single BMA concentration (BMAC) device. A 1-mL portion of each sample was used to determine CD stem cell concentrations and the nucleated cell count. The remaining BMA was centrifuged to separate the more mature red blood cell precursors from the stem cells and then concentrate the latter into a BMAC. The BMAC yield of 10 mL was analyzed with flow cytometry and nucleated cell counts to derive a concentration factor for the BMAC. RESULTS: The yield of total nucleated cells was equal between the anterior and posterior ilium and more than twice that obtained from the tibial plateau. The CD44+ and CD105+ cell yields were also nearly equal between the anterior and posterior ilium but more than twice that of the tibial plateau; however, the ratios between the three different stem cell types in BMAC obtained from the different areas suggest varying potentials for tissue development. CONCLUSIONS: The ilium is the preferred donor site for obtaining autologous stem cells at the point of care. The tibial plateau yielded only half as much bone marrow multipotent/progenitor stem cells as did the anterior and posterior ilium. The composition of the BMAC from each site suggests that the potential for differentiation into various cell types changes depending on the source of bone marrow, but that BMAC represents 6.5 ± 1.0 concentration factor from BMA.