Ultrasonic Shears Decrease Postoperative Hematomas in Head and Neck Microvascular Reconstruction.

OBJECTIVE: To evaluate postoperative hematoma and takeback rates in a large series of microvascular reconstructions. We sought to determine whether the use of ultrasonic shears reduced these rates. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral hospital. METHODS: A total of 2288 patients undergoing free flap reconstruction for head and neck defects between 1995 and 2022 were reviewed. Patients undergoing dissection with and without ultrasonic shears were compared to determine postoperative hematoma and takeback rates. RESULTS: The overall hematoma rate was 1.3% (29/2288) for the entire cohort. The postoperative hematoma rates with and without ultrasonic shears were 0.63% (9/1418) and 2.3% (20/870), relative risk = 0.28, P = .0015. Of 870 patients undergoing surgery without ultrasonic shears, 14 (1.61%) were taken back to the operating room for control of bleeding compared to 8 of 1418 (0.56%) in the ultrasonic shears cohort. CONCLUSION: Our large series of patients undergoing microvascular reconstruction shows a decrease in postoperative hematoma rate and takeback for bleeding with the adoption of ultrasonic shears. Ultrasonic shears are an effective tool that can help decrease perioperative morbidity secondary to hematoma after head and neck tumor resection and microvascular reconstruction.

The Deep Fascia of the Infraorbital Region, Deep Plane, and Suprafibromuscular Facelift: New Anatomy for Safer Facelifting.

Deep-plane rhytidectomy, first described by Skoog, has had a resurgence in popularity and is in high demand today. We describe anatomical findings that establish the presence of a true deep fascia in the midface, we named as Chiara's fascia, like the first author's first name, which helps to form the facial ligaments and is contiguous with the superficial layer of the deep temporal fascia. This fascia inserts on the periosteum of the inferior orbital rim at the arcus marginalis and separates the suborbicularis oculi fat (SOOF) from the preperiosteal fat. This distinct fascial layer lies under the superficial fascia or superficial musculoaponeurotic system (SMAS) and represents the floor of what is commonly termed the "deep plane." When this fascial highway is identified intraoperatively, blunt dissection immediately superficial to this layer will protect facial nerve branches overlying the muscles lifting the upper lip such as the zygomaticus. Subsequent dissection over the middle and lower face can usually be performed bluntly. Over a 10-year period, a total of 100 hemifaces were dissected with a 100% success rate of identifying this fascia in all specimens. This work was further validated by examining histologic specimens that clearly demonstrate this unique fibrofatty fascial layer. These dissections and new anatomical findings were then correlated to over 300 intraoperative deep-plane facelift cases by the primary and senior authors. We term this operative technique as the suprafibromuscular facelift. Dissection in this plane allows for safe release of facial retaining ligaments with protection of facial nerve branches.

End-to-Trunk Masseteric to Facial Nerve Transfer With Selective Neurectomy for Facial Reanimation.

OBJECTIVE: To examine functional outcomes following end-to-trunk masseteric to facial nerve transfer in patients with chronic flaccid facial paralysis. DESIGN: Retrospective chart review. SETTING: Tertiary-care private practice setting. PARTICIPANTS: Patients with complete unilateral facial paralysis of less than 24 months duration. INTERVENTIONS: Direct end-to-trunk masseteric to facial nerve anastomosis. OUTCOME MEASURES: Outcome measures included time to first movement, development of synkinesis, and an objective assessment of the resting tone and dynamic movement that was achieved. RESULTS: Patient age at the time of transfer ranged from 6 to 61. Follow-up ranged from 12 to 24 months. No patients had any perioperative complications. No patient experienced significant mass movement or synkinetic facial movement with chewing. No patient had worsened chewing or swallowing. Patients have not yet recovered significant resting tone. All patients achieved smile activity when biting down with a median (interquartile range) oral commissure excursion of 7.57 mm (5.19-9.94 mm), starting 3 to 5 months after transfer. CONCLUSIONS: End-to-trunk masseteric to facial nerve transfer is a safe and effective procedure. Patients had rapid reinnervation with good excursion and achieved a natural appearing smile. The rehabilitated smile appears better than that achieved with hypoglossal-facial nerve transfer. The procedure can be performed coincident with cross-facial nerve grafting, and in some cases may produce dynamic facial movement that obviates the need for free muscle transfer.

Deep Plane Facelift: An Evaluation of the High-SMAS versus Standard Incision Points.

In surgery of the aging face, operative adjustments of the superficial musculoaponeurotic system (SMAS) enhance facial contours. The senior author has observed that the standard deep plane face lift entry points on the SMAS do not provide as much tissue movement in a vertical direction as high-SMAS deep plane face lift entry points. In this study, tissue movement was measured comparing the conventional SMAS entry point with a high-SMAS entry point for deep plane face lifts. Institutional review board approval was obtained. Fourteen facelift patients were enrolled, 10 female and 4 male. Average age was 63.4 (50-81) years. Tissue movement at three points along the jaw line was measured intraoperatively. Standard SMAS entry point suspension resulted in average vertical movements of 6.4, 10.3, and 13.8 mm and average horizontal movements of 3.5, 5.7, and 6.5 mm. High-SMAS entry point resulted in average vertical movements of 11.8, 17.9, and 24.1 mm and average horizontal movements of 5.8, 9.8, and 9.9 mm. This resulted in a 77.3% increase (p = 0.03) in vertical movement and a 61.4% increase (p = 0.02) in horizontal movement with a high-SMAS entry compared with standard SMAS entry. The high-SMAS entry point for a deep plane facelift resulted in a significant increase in lift for both the horizontal and vertical vector on the facial skin flap when compared with the conventional entry.

Lasers, Microneedling, and Platelet-Rich Plasma for Skin Rejuvenation and Repair.

Skin resurfacing for the purpose of rejuvenation and repair continues to evolve with the development of noninvasive or minimally invasive surgical substitutes. Advances in laser therapy, microneedling, and platelet-rich plasma have reinvigorated research in wound repair and regenerative science. An overall positive clinical response toward the use of platelet-rich plasma as an adjuvant to fractional photothermolysis and percutaneous collagen induction is observed. Its effect on post-treatment adverse symptoms, erythema, edema, crusting, and clinical outcomes in rejuvenation are summarized in this article. The lack of identifiable complications and convenience of treatment provides a positive outlook for future use and investigations.

The Prevalence of Cosmetic Facial Plastic Procedures among Facial Plastic Surgeons.

This is the first study to report on the prevalence of cosmetic facial plastic surgery use among facial plastic surgeons. The aim of this study is to determine the frequency with which facial plastic surgeons have cosmetic procedures themselves. A secondary aim is to determine whether trends in usage of cosmetic facial procedures among facial plastic surgeons are similar to that of nonsurgeons. The study design was an anonymous, five-question, Internet survey distributed via email set in a single academic institution. Board-certified members of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) were included in this study. Self-reported history of cosmetic facial plastic surgery or minimally invasive procedures were recorded. The survey also queried participants for demographic data. A total of 216 members of the AAFPRS responded to the questionnaire. Ninety percent of respondents were male (n = 192) and 10.3% were female (n = 22). Thirty-three percent of respondents were aged 31 to 40 years (n = 70), 25% were aged 41 to 50 years (n = 53), 21.4% were aged 51 to 60 years (n = 46), and 20.5% were older than 60 years (n = 44). Thirty-six percent of respondents had a surgical cosmetic facial procedure and 75% has at least one minimally invasive cosmetic facial procedure. Facial plastic surgeons are frequent users of cosmetic facial plastic surgery. This finding may be due to access, knowledge base, values, or attitudes. By better understanding surgeon attitudes toward facial plastic surgery, we can improve communication with patients and delivery of care. This study is a first step in understanding use of facial plastic procedures among facial plastic surgeons.

Predictors of prolongation in radiation treatment time in a veteran population treated with chemoradiation for oropharyngeal cancer.

BACKGROUND: Prolonged radiation treatment time (RTT) is associated with worse tumor control. Here we identify and determine the implications of factors that predict treatment prolongation in Veterans Affairs (VA) patients undergoing chemoradiation. METHODS: Chart review from July 2000 to October 2013. 81 patients with advanced stage oropharyngeal cancer treated with chemoradiation. RESULTS: Twenty-nine patients (35.8%) had RTT prolonged by ≥10 days. Prolongation mainly resulted from acute treatment toxicity (n = 22, 76%). There was no significant difference in RTT for patients treated with concurrent cisplatin versus cetuximab, or in patients treated with or without induction chemotherapy. One-/three-year locoregional control and overall survival rates of 83.4%/76.3% and 83.5%/63.6% for patients without prolonged RTT versus 61.8%/61.8% and 82.8%/73.8% for those with prolongation (p >.05). CONCLUSIONS: Prolonged RTT is a significant predictor of worse locoregional control and predominantly resulted from treatment side effects. More aggressive regimens with induction and concurrent chemotherapy did not predispose to prolonged RTT.

It Takes Two: One Resects, One Reconstructs.

Care of patients with advanced head and neck cancer is a multidisciplinary effort through all phases of care. Head and neck cancer surgery involves balancing oncologic control, functional preservation, and aesthetics. Given the advances in free tissue reconstruction, the majority of defects can be reconstructed using free tissue transfer flaps. A 2-team approach allows for early, continual communication and meticulous operative planning. Operations can be combined into a single effort. This approach maximizes efficiency and enables multidisciplinary collaboration for comprehensive surgical treatment. We present our experience and an outline of how responsibilities between the ablative and reconstructive teams are shared.

Voriconazole increases the risk for cutaneous squamous cell carcinoma after lung transplantation.

Lung transplant recipients (LTR) are at high risk of cutaneous squamous cell carcinoma (SCC). Voriconazole exposure after lung transplant has recently been reported as a risk factor for SCC. We sought to study the relationship between fungal prophylaxis with voriconazole and the risk of SCC in sequential cohorts from a single center. We evaluated 400 adult LTR at UCLA between 7/1/2005 and 12/22/2012. On 7/1/2009, our center instituted a protocol switch from targeted to universal antifungal prophylaxis for at least 6 months post-transplant. Using Cox proportional hazards models, time to SCC was compared between targeted (N = 199) and universal (N = 201) prophylaxis cohorts. Cox models were also used to assess SCC risk as a function of time-dependent cumulative exposure to voriconazole and other antifungal agents. The risk of SCC was greater in the universal prophylaxis cohort (HR 2.02, P < 0.01). Voriconazole exposure was greater in the universal prophylaxis cohort, and the cumulative exposure to voriconazole was associated with SCC (HR 1.75, P < 0.01), even after adjustment for other important SCC risk factors. Voriconazole did not increase the risk of advanced tumors. Exposure to other antifungal agents was not associated with SCC. Voriconazole should be used cautiously in this population.

Physician as a Conscious Leader.

Surgical practice requires the mastery of modern leadership principles and skills in addition to the acquisition of medical knowledge and technical skills. Previously, there was no formal leadership training in graduate medical education at the David Geffen School of Medicine, Los Angeles, California, and resident physicians identified a lack of leadership skills training as an area of weakness. Leadership education for surgeons can improve the perioperative atmosphere and positively affect interpersonal collaboration with perioperative nurse colleagues. Physicians are leaders in daily patient care, and they need leadership training with an emphasis on consciousness to be successful leaders. This article reviews a leadership program that I instituted at the David Geffen School of Medicine, which teaches leadership skills and techniques that emphasize consciousness as a physician leader. This patient-based leadership program demonstrates the tools, methods, and techniques that physicians need to be successful as conscious leaders.

The Downside of Fat: Avoiding and Treating Complications.

Three-dimensional facial volume restoration using fat has become widely accepted as an essential component of facial rejuvenation. Transplanted fat has benefits due to its inherently nonallergenic nature. The versatility of fat grafts allows for their use in all types of facial enhancement-improving the appearance of nasolabial folds, mesolabial grooves, flattened cheeks and upper lips, glabellar furrows, lipoatrophy, acne scars, and temporal hollowing. Yet despite its virtues as the ideal filler, autologous fat has its shortcomings with risks of complications. Our objective in this article is to present a systematic approach demonstrating the complications that can occur with each step of autologous fat grafting in facial rejuvenation and offering pearls to avoid and treat these complications.

Assessment of Fibula Flap Skin Perfusion in Patients Undergoing Oromandibular Reconstruction: Comparison of Clinical Findings, Fluorescein, and Indocyanine Green Angiography.

IMPORTANCE: Complications of partial flap necrosis contribute substantially to morbidity in patients who undergo head and neck reconstructive surgery. OBJECTIVE: To assess the usefulness of clinical findings, intraoperative fluorescein angiography, and intraoperative indocyanine green angiography (ICGA) for evaluation of flap skin paddle perfusion in patients undergoing oromandibular reconstruction who are at high risk of partial skin paddle necrosis. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review from May 21, 1996, to May 27, 2015, at a tertiary care academic medical center. Participants were 73 patients who underwent reconstruction of through-and-through defects of the mucosa, mandible, and skin using fibula free flaps that contained large bilobed skin paddles. MAIN OUTCOMES AND MEASURES: The rates of partial skin paddle necrosis and revision reconstructive surgery. RESULTS: The rates of partial flap necrosis were 8% (n = 2) among 25 patients in whom the skin paddle was trimmed based on ICGA and 33% (n = 16) among 48 patients in whom the skin paddle was trimmed according to clinical findings (P = .02). The rates of revision reconstructive surgery were 20% (5 of 25) when flap skin paddles were trimmed using ICGA and 42% (20 of 48) when trimmed per clinical findings (P = .06). CONCLUSIONS AND RELEVANCE: The use of ICGA may reduce the risk of partial skin flap necrosis in free flaps used in patients undergoing head and neck reconstruction who are at high risk of developing flap necrosis. Indocyanine green angiography imaging should be considered in any flap in which skin paddle viability is uncertain based on clinical findings and in patients in whom the skin paddle extends beyond the primary and adjacent angiosomes. LEVEL OF EVIDENCE: 3.

Carcinoma ex-pleomorphic adenoma of the parotid gland consisting of high-grade salivary duct carcinoma and keratinizing squamous cell carcinoma.

Carcinoma ex-pleomorphic adenoma (CXPA) is a rare salivary gland malignancy that presents diagnostic difficulties partly because of its wide range of histologic presentations. We report a case of a 77-year-old man, who presented with a 6-year history of a parotid mass that had undergone rapid growth within weeks. Magnetic resonance imaging revealed an infiltrative mass in the parotid gland, and the fine-needle aspiration (FNA) biopsy result was highly suspicious for carcinoma. Subsequent excision of the tumor demonstrated a poorly differentiated epithelial neoplasm consisting of keratinizing squamous cell carcinoma (SCC) and adenocarcinoma with regions of both ductal carcinoma in situ and invasive salivary duct carcinoma (SDC). Only focal areas exhibited a benign pleomorphic adenoma component. To our knowledge, this is the first case of a CXPA that consists of both a high-grade SDC and a keratinizing SCC in the parotid gland.

Microvascular reconstruction of segmental mandibular defects without tracheostomy.

OBJECTIVE: To report our experience with mandibular resection and reconstruction using vascularized bone-containing free flaps without an elective tracheostomy. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral hospital center. SUBJECTS AND METHODS: Sixty-six patients undergoing mandibular reconstruction with vascularized bone-containing free flaps without an elective tracheostomy were identified between 1995 and 2013. We describe patient, tumor, and surgical factors and report perioperative outcomes in this population. RESULTS: Most patients underwent fibula free flap reconstruction (n = 61, 92.44%). The 4 most frequent indications for resection were osteoradionecrosis, parotid carcinoma, oral squamous cell carcinoma, and osteomyelitis. Bone defects ranging from 4.0 to 13.0 cm were reconstructed, and associated soft-tissue defects were reconstructed with skin paddle sizes ranging from 24.0 to 450.0 cm(2). There was only 1 patient with a bilateral central mandibular defect, and there were no tongue/pharyngeal soft-tissue defects or bilateral neck dissections. One case required emergent tracheostomy on postoperative day 1, and 2 more patients developed respiratory complications. There were no cases of perioperative death or flap failure. CONCLUSION: Mandibular free flap reconstruction is feasible without an elective tracheostomy in a subset of carefully selected patients without bilateral central mandibular defects, tongue/pharynx defects, or bilateral neck dissection.

Oncologic validity of recipient vessel preservation in microvascular free-flap reconstruction.

OBJECTIVES: The use of free-flap reconstruction requires a more limited neck dissection to allow for microvascular anastomosis. This study seeks to determine the oncologic validity of cervical vessel preservation. MATERIALS AND METHODS: The current study is a prospective review of cervical vessel biopsies from patients undergoing resection of squamous cell carcinoma (SCCA) tumors of the head and neck with free tissue reconstruction. RESULTS: From June 2010 to March 2012, 227 recipient vessel biopsies were performed on 100 patients. Three of these patients had grossly abnormal vessels, with malignancy confirmed by frozen section analysis. One patient had a vessel positive for malignancy that was grossly normal but found to have SCCA on the final pathology. CONCLUSIONS: When the recipient vessel appears grossly suspicious, a frozen section biopsy and re-resection should be considered. Recipient vessel trimmings should routinely be sent for permanent pathology since in rare cases, they can be involved by tumor, affecting the margin status, prognosis, and indications for adjuvant therapy.

Changing indications for maxillomandibular reconstruction with osseous free flaps: a 17-year experience with 620 consecutive cases at UCLA and the impact of osteoradionecrosis.

OBJECTIVES/HYPOTHESIS: To characterize the changing indications for osseous free flaps in maxillomandibular reconstruction at our institution. STUDY DESIGN: Retrospective chart review. METHODS: Database review of patients who underwent free-flap reconstruction of the jaws using vascularized bone-containing free tissue transfer from 1995 to 2012 at the University of California Los Angeles (UCLA). RESULTS: A total of 620 osseous free flaps were performed. The most common indications for surgery were squamous cell carcinoma (n = 442) and osteoradionecrosis (ORN)) of the mandible (n = 73). There were no significant differences in 90-day perioperative complication, flap viability, or mortality rates between any of the indications for surgery. Patients older than 60 years had a higher rate of major perioperative complication (P = 0.0028). ORN cases represented 1.3% ± 1.2% of surgical volume from 1995 to 2000, 8.7% ± 1.8% from 2001 to 2006, and 17.5% ± 2.2% from 2007 to 2012 (P <0.0001). Among cases of ORN, 95.8% of patients had radiation therapy completed at centers outside of our hospital system. For patients with ORN, there was an average interval of 8.7 ± 8.0 years from initiation of radiotherapy to the date of mandibulectomy (range 1-37 years). CONCLUSION: The incidence of ORN as an indication for free-flap reconstruction has increased at our institution in recent years. This may reflect an increasing need for the surgical management of medically refractory ORN, a rising awareness or prevalence of ORN overall, and/or increasing comfort with free flaps as a treatment for ORN. Patients who undergo free-flap surgery for ORN do not have greater risks of 90-day perioperative complications or differences in free-flap viability as compared to patients who undergo free-flap reconstruction for other indications. LEVEL OF EVIDENCE: 2b.

Comparison of dental health of patients with head and neck cancer receiving IMRT vs conventional radiation.

OBJECTIVE: To analyze the dental health of patients with head and neck cancer who received comprehensive dental care after intensity-modulated radiation therapy (IMRT) compared with radiation therapy (RT). STUDY DESIGN: Historical cohort study. SETTING: Veteran Affairs (VA) hospital. SUBJECTS AND METHODS: In total, 158 patients at a single VA hospital who were treated with RT or IMRT between 2003 and 2011 were identified. A complete dental evaluation was performed prior to radiation treatment, including periodontal probing, tooth profile, cavity check, and mobility. The dental treatment plan was formulated to eliminate current and potential dental disease. The rates of dental extractions, infections, caries, mucositis, xerostomia, and osteoradionecrosis (ORN) were analyzed, and a comparison was made between patients treated with IMRT and those treated with RT. RESULTS: Of the 158 patients, 99 were treated with RT and 59 were treated with IMRT. Compared with those treated with IMRT, significantly more patients treated with RT exhibited xerostomia (46.5% vs 16.9%; P < .001; odds ratio [OR], 0.24; 95% confidence interval [CI], 0.11-0.52), mucositis (46.5% vs 16.9%; P < .001; OR, 0.24; 95% CI, 0.11-0.52), and ORN (10.1% vs 0%; P = .014; OR, 0.07; 95% CI, 0.00-1.21). However, significantly more patients treated with IMRT were edentulous by the conclusion of radiation treatment (32.2% vs 11.1%; P = .002; OR, 3.8; 95% CI, 1.65-8.73). CONCLUSION: Patients who were treated with IMRT had fewer instances of dental disease, more salivary flow, and fewer requisite posttreatment extractions compared with those treated with RT. The number of posttreatment extractions has been reduced with the advent of IMRT and more so with a complete dental evaluation prior to treatment.