Breast Tissue Expanders with Magnetic Ports: Clinical Experience at 1.5 T.

BACKGROUND: The purpose of this study was to evaluate breast tissue expanders with magnetic ports for safety in patients undergoing abdominal/pelvic magnetic resonance angiography before autologous breast reconstruction. METHODS: Magnetic resonance angiography of the abdomen and pelvis at 1.5 T was performed in 71 patients in prone position with tissue expanders with magnetic ports labeled "MR Unsafe" from July of 2012 to May of 2014. Patients were monitored during magnetic resonance angiography for tissue expander-related symptoms, and the chest wall tissue adjacent to the tissue expander was examined for injury at the time of tissue expander removal for breast reconstruction. Retrospective review of these patients' clinical records was performed. T2-weighted fast spin echo, steady-state free precession and gadolinium-enhanced spoiled gradient echo sequences were assessed for image artifacts. RESULTS: No patient had tissue expander or magnetic port migration during the magnetic resonance examination and none reported pain during scanning. On tissue expander removal (71 patients, 112 implants), the surgeons reported no evidence of tissue damage, and there were no operative complications at those sites of breast reconstruction. CONCLUSION: Magnetic resonance angiography of the abdomen and pelvis in patients with certain breast tissue expanders containing magnetic ports can be performed safely at 1.5 T for pre-autologous flap breast reconstruction perforator vessel mapping. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Pectoralis major myocutaneous flap for reconstruction of circumferential pharyngeal defects.

BACKGROUND: A 270-degree partially tubed pectoralis major myocutaneous flap (PMMF) is an excellent option for total circumferential pharyngoesophageal defects in patients who are not candidates for more complex reconstructions. METHODS: Patients undergoing circumferential pharyngoesophageal reconstruction with partially tubed PMMF were reviewed. End points were stricture, fistula, resumption of oral intake, perioperative death, and recurrence. RESULTS: Eleven patients underwent 270-degree PMMF for reconstruction: 6 (55%) were men and 5 (45%) were women (mean, 62 years; range, 42-78 years). Three patients (27%) developed fistulas and 2 (18%) developed stenosis. Ten patients (91%) were able to resume adequate nutrition via oral intake. There were no perioperative deaths. CONCLUSIONS: Patients with severe comorbidities, metastatic disease, a lack of donor vessels, or a potentially hostile abdomen may not be ideal candidates for free tissue transfer. For these patients, partially tubed PMMF using the prevertebral fascia provides a reliable alternative for reconstruction with excellent functional results.

Breast reconstruction with SGAP and IGAP flaps.

BACKGROUND: Perforator flaps represent the latest in the evolution of soft-tissue flaps. They allow the transfer of the patient's own skin and fat in a reliable manner with minimal donor-site morbidity. The powerful perforator flap concept allows transfer of tissue from numerous, well-described donor sites to almost any distant site with suitable recipient vessels. Large-volume flaps can be reliably supported with perforators from areas such as the buttock and transferred microsurgically for breast reconstruction. INDICATIONS: The ideal tissue for breast reconstruction is fat with or without skin, not implants or muscle. Absolute contraindications specific to perforator flaps in our practice include history of previous liposuction of the donor site, some previous donor-site surgery, or active smoking (within 1 month before surgery). METHODS: Perforator flaps are supplied by blood vessels that arise from named, axial vessels and perforate through or around overlying muscles and septa to vascularize the overlying skin and fat. During flap harvest, these perforators are meticulously dissected free from the surrounding muscle, which is spread in the direction of the muscle fibers and preserved intact. The pedicle is anastomosed to recipient vessels in the chest, and the donor site is closed without the use of synthetic mesh. CONCLUSION: Perforator flaps allow for safe, reliable tissue transfer from a variety of sites and provide ideal tissue for breast reconstruction, with minimal donor-site morbidity.

Transplantation in identical twins: another option for breast reconstruction.

BACKGROUND: Deriving their name from the Greek word plastikos, meaning related to molding, plastic surgeons have made their reputation by transplanting tissues from one area of the body to another to "remold" defects caused by trauma, congenital anomaly, or disease. Dr. Joseph Murray, a plastic surgeon, performed the first successful kidney transplant between identical twins in 1954. The authors present three cases involving the transplantation of perforator flaps from one identical twin to another for breast reconstruction, including cases using both deep inferior epigastric perforator and superficial inferior epigastric artery flaps. METHODS: Three sets of recipient monozygotic twins that had breasts treated with mastectomies underwent reconstruction using transplanted tissue from their donor monozygotic twins. All sets of twins underwent DNA testing to determine that they were monozygotic; therefore, no immunosuppressive therapy was indicated. RESULTS: The three sets of recipient monozygotic twins underwent successful breast reconstruction using perforator flap transplants from their donor monozygotic twins. The operations included two unilateral reconstructions (one using a deep inferior epigastric perforator flap and the other using a superficial inferior epigastric artery flap) and one bilateral deep inferior epigastric perforator reconstruction. Their hospital courses were unremarkable. CONCLUSIONS: Transplant surgery continues to evolve in the twenty-first century. The authors present three cases of breast reconstruction using skin flap transplantation as a new option for breast reconstruction.

Breast reconstruction with perforator flaps.

BACKGROUND: Perforator flaps represent the latest in the evolution of soft-tissue flaps. They allow the transfer of the patient's own skin and fat in a reliable manner, with minimal donor-site morbidity. The powerful perforator flap concept allows transfer of tissue from numerous, well-described donor sites to almost any distant site with suitable recipient vessels. Large-volume flaps can be supported reliably with perforators from areas such as the abdomen, buttock, or flank and transferred microsurgically for breast reconstruction. INDICATIONS: The ideal tissue for breast reconstruction is fat with or without skin, not implants or muscle. Absolute contraindications specific to perforator flaps in the authors' practice include history of previous liposuction of the donor site, some previous donor-site surgery, or active smoking (within 1 month before surgery). TECHNIQUE: Perforator flaps are supplied by blood vessels that arise from named, axial vessels and perforate through or around overlying muscles and septa to vascularize the overlying skin and fat. During flap harvest, these perforators are meticulously dissected free from the surrounding muscle, which is spread in the direction of the muscle fibers and preserved intact. The pedicle is anastomosed to recipient vessels in the chest, and the donor site is closed without the use of mesh. CONCLUSION: Perforator flaps allow for safe, reliable tissue transfer from a variety of sites and provide ideal tissue for breast reconstruction, with minimal donor-site morbidity.

Congenital breast deformity reconstruction using perforator flaps.

BACKGROUND: Congenital breast deformities such as Poland syndrome, unilateral congenital hypoplasia, tuberous breast anomaly, and amastia pose a challenging plastic surgical dilemma. The majority of patients are young, healthy individuals who seek esthetic restoration of their breast deformities. Currently, both implant and autologous reconstructive techniques are used. This study focuses on our experience with congenital breast deformity patients who underwent reconstruction using a perforator flap. METHODS: From 1994 to 2005, a retrospective chart review was performed on women who underwent breast reconstruction using perforator flaps to correct congenital breast deformities and asymmetry. Patient age, breast deformity type, perforator flap type, flap volume, recipient vessels, postoperative complications, revisions, and esthetic results were determined. RESULTS: Over an 11-year period, 12 perforator flaps were performed. All cases were for unilateral breast deformities. The patients ranged from 16 to 43 years of age. Six patients had undergone previous correctional surgeries. Eight (n = 8) flaps were used for correction of Poland syndrome and its associated chest wall deformities. Four (n = 4) flaps were used for correction of unilateral breast hypoplasia. In all cases, the internal mammary vessels were the recipient vessels of choice. No flaps were lost. No vein grafts were used. All patients were discharged on the fourth postoperative day. Complications encountered included seroma, hematoma, and nipple malposition. Revisional surgery was performed in 30% of the cases. Esthetic results varied from poor to excellent. CONCLUSIONS: Perforator flaps are an acceptable choice for patients with congenital breast deformities seeking autologous breast reconstruction. Deep inferior epigastric artery (DIEP) or superficial inferior epigastric artery (SIEA) flaps are performed when adequate abdominal tissue is available; however, many young patients have inadequate abdominal tissue, thus a GAP flap can be used. Perforator flaps are a safe, reliable surgical technique. In the properly selected patient, donor-site morbidity and functional compromise are minimized, improved self-esteem is noted, postoperative pain is decreased, and excellent long-term esthetic results can be achieved.

Quality of life outcomes in laryngeal and oropharyngeal cancer patients after chemoradiation.

OBJECTIVE: The purpose of this study was to compare quality of life issues in patients with advanced laryngeal versus oropharyngeal cancer after treatment with chemoradiation. DESIGN: A cohort study of 31 patients with laryngeal or oropharyngeal squamous cell carcinoma treated with chemoradiation completed the University of Washington quality of life instrument version 4 (UW-QOL v4). Statistical analysis was performed with Wilcoxon rank sum and chi-square tests. SETTING: Academic tertiary care center. RESULTS: Both groups reported similar impairment in the domains of swallowing, chewing, and taste. Oropharyngeal cancer patients reported significantly worse quality of life in the domain of saliva (P < 0.007). CONCLUSION: Swallowing, chewing, and taste were adversely affected by chemoradiation for both groups. Oropharyngeal patients experienced significantly worse problems with saliva than laryngeal patients. These patients reported high levels of satisfaction with health-related quality of life issues. SIGNIFICANCE: Specific head and neck subsites have different morbidities when treated with primary chemoradiation for advanced tumors.

Quality of life in advanced oropharyngeal carcinoma after chemoradiation versus surgery and radiation.

OBJECTIVE: The objective of this cohort study from a tertiary academic university practice was to identify differences in patients' perceived quality of life after either chemoradiation or surgery and radiation for advanced-stage oropharyngeal carcinoma. METHODS: From institutional databases, thirty-five patients were identified who had undergone either primary chemoradiation or primary surgery and postoperative radiation for advanced oropharyngeal cancer (stage II-IV). Patients voluntarily responded by mail using the University of Washington quality-of-life instrument version 4 (UW-QOL). Data were analyzed using chi and Wilcoxon tests. RESULTS: There were 17 patients who underwent chemoradiation and 18 patients who underwent surgery and postoperative radiation. All surgical patients had undergone free-flap reconstruction. Patients completed the UW-QOL an average of 25 months after treatment. There was no statistically significant difference between the two groups with regard to any specific domain, including pain, appearance, swallowing, chewing, speech, saliva, or mood. There was a trend toward significance for taste (P = .07) with chemoradiation patients reporting poorer taste function. The lack of difference in the patients' perception of appearance and swallowing was rather surprising given the vastly different treatment modalities. Respondents reported equivalent overall quality of life in response to global quality-of-life questions. CONCLUSION: Most patients with advanced oropharyngeal carcinoma report good quality of life after treatment, regardless of treatment modality. Although the short-term side effects of treatment may be different between the groups, long-term quality of life is remarkably similar whether the patients choose primary chemoradiation or surgery with postoperative radiation.

Pharyngeal diverticulum as a sequela of anterior cervical fusion.

A rarely diagnosed etiology of dysphagia is a pharyngeal diverticula occurring after anterior cervical fusion. Here we review 2 cases where patients developed pharyngeal diverticula following anterior cervical fusion. The first patient was a 28-year-old female who presented with regurgitation following C5 through C6 cervical fusion. She was diagnosed with a pharyngeal diverticulum and underwent open repair, but began to experience symptoms again a few months later. A barium swallow showed a recurrent pharyngeal diverticulum. Endoscopic repair was attempted; however, because of the thick scar band between the diverticulum and the esophagus, the operation had to be converted to an open repair with cricopharyngeal myotomy. The second case involved a 63-year-old male who presented with dysphagia and regurgitation 6 months after anterior cervical fusion. Esophagram demonstrated a small diverticulum at the right lateral border of the upper esophagus. Open repair of the diverticulum with cricopharyngeal myotomy was successfully performed. Pharyngeal diverticula after anterior cevical fusion have only been reported in 2 prior cases in the literature. Here we describe 2 additional cases at our institution, both requiring open repair. Radiographic studies demonstrate the diverticulum at the site of scarring from the cervical fusion. Because of the thick scar band and the atypical location of these diverticula, endoscopic repair with stapping (as done for Zenker's diverticula) may not be feasible. These cases highlight the importance of considering a diverticulum in the differential of posoperative patients presenting to the otolaryngologists with complaints of dysphagia following cevical spine surgery.

Curcumin suppresses growth of head and neck squamous cell carcinoma.

PURPOSE: The purpose of this study was to determine whether curcumin would trigger cell death in the head and neck squamous cell carcinoma (HNSCC) cell lines CCL 23, CAL 27, and UM-SCC1 in a dose-dependent fashion. EXPERIMENTAL DESIGN: HNSCC cells were treated with curcumin and assayed for in vitro growth suppression using 3-(4,5-dimethylthiozol-2-yl)-2,5-diphenyl tetrazolium bromide and fluorescence-activated cell sorting analyses. Expression of p16, cyclin D1, phospho-Ikappabeta, and nuclear factor-kappabeta (NF-kappabeta) were measured by Western blotting, gel shift, and immunofluorescence. RESULTS: Addition of curcumin resulted in a dose-dependent growth inhibition of all three cell lines. Curcumin treatment resulted in reduced nuclear expression of NF-kappabeta. This effect on NF-kappabeta was further reflected in the decreased expression of phospho-Ikappabeta-alpha. Whereas the expression of cyclin D1, an NF-kappabeta-activated protein, was also reduced, there was no difference in the expression of p16 at the initial times after curcumin treatment. In vivo growth studies were done using nude mice xenograft tumors. Curcumin was applied as a noninvasive topical paste to the tumors and inhibition of tumor growth was observed in xenografts from the CAL27 cell line. CONCLUSIONS: Curcumin treatment resulted in suppression of HNSCC growth both in vitro and in vivo. Our data support further investigation into the potential use for curcumin as an adjuvant or chemopreventive agent in head and neck cancer.

Comparison of quality of life outcomes in laryngeal cancer patients following chemoradiation vs. total laryngectomy.

OBJECTIVE: To evaluate quality of life issues in patients with laryngeal cancer after treatment with either chemoradiation or total laryngectomy and radiation therapy. METHODS: Forty-nine patients with a history of stage II-IV laryngeal squamous cell carcinoma treated primarily with either chemoradiation or by total laryngectomy with postoperative radiation completed the University of Washington Quality of Life instrument, version 4. Patients were identified on a volunteer basis in an academic university head and neck clinic setting. Each patient completed the above instrument, and statistical analysis was performed by Wilcoxon and chi 2 tests. RESULTS: Instruments were completed by all 49 patients: 15 patients who underwent primary chemoradiation and 34 patients who underwent a total laryngectomy followed by radiation. Domains reported in both treatment groups without significant differences were appearance, activity, recreation, moods, taste, saliva, anxiety, and general questions. However, there were significant differences between the 2 groups in the domains of pain, swallowing, chewing, speech, and shoulder function. The laryngectomy patients reported greater impairment of speech (P = 0.001), and shoulder function (P = 0.018), whereas the chemoradiation patients suffered from greater pain, difficulty swallowing (P = 0.061), and problems chewing (P = 0.027). CONCLUSIONS: Most patients with laryngeal cancer, whether treated primarily with chemoradiation or total laryngectomy, reported excellent functional outcomes and health-related quality of life. Pain, swallowing, chewing, saliva, and shoulder function were recorded as significant factors affecting their daily quality of life.

Treatment of advanced oropharyngeal cancers with chemotherapy and radiation.

We conducted a retrospective chart review of treatment outcomes in 17 adults who had been selected to undergo concomitant chemotherapy and radiation (chemo/XRT) for late-stage oropharyngeal cancers. All patients had been treated at the West Los Angeles VA Medical Center between March 1, 1998, and Sept. 30, 2000. Nine patients had a primary tumor at the base of the tongue, five had a primary tumor in the tonsillar area, and three had a tumor that affected both sites. Of this group, 15 patients completed one to three cycles of chemo/XRT, and the remaining two died during therapy. At the most recent follow-up, 9 of the 17 patients (52.9%) were documented to still be alive; seven patients had earlier died as a result of their primary tumor or a distant metastasis, and one patient had been lost to follow-up after completing treatment. At study's end, the duration of post-treatment survival ranged from 2 to 36 months (mean: 12.5). Based on the results of our small series, we conclude that chemo/XRT is a valid alternative to surgery with postoperative radiation and to radiation alone. Chemo/XRT yields acceptable rates of local control and allows for organ preservation with tolerable side effects.

Tracheotomy tube placement in children following cardiothoracic surgery: indications and outcomes.

PURPOSE: To review the indications for and outcomes of children requiring tracheotomy tube placement following cardiothoracic surgery, charts were reviewed retrospectively at a tertiary care center for fifteen children who had undergone tracheotomy tube placement following cardiothoracic surgery between 1994 and 2000. Outcomes Measure: Morbidity and/or mortality associated with tracheotomy tube placement in this patient population, duration of tracheotomy tube, and rate of decannulation. RESULTS: Fifteen out of approximately 3000 children undergoing cardiothoracic surgery required tracheotomy tube placement over a 6-year period. Indications included diaphragmatic paresis (DP) (7 patients), vocal cord paresis (VP) alone (3 patients), DP and VP (2 patients), subglottic stenosis (SS) and DP (1 patient), VP and SS (2 patients), and cerebrovascular infarct (1 patient). The mean age at the time of tracheotomy tube placement was 36.5 months (range, 0.75-108 months). The mean duration of intubation between cardiothoracic procedure and tracheotomy was 31.6 days (range, 0-72 days). Six patients were successfully decannulated following a mean of 7.4 months of tracheotomy tube dependence. All 6 decannulated patients had DP necessitating tracheotomy and ventilatory support. Eight patients continue to be tracheotomy tube-dependent, and one patient died of unrelated causes. There was no short-term or long-term morbidity or mortality associated with tracheotomy tube placement. CONCLUSION: Tracheotomy tube placement is rarely indicated following cardiothoracic surgery in children. The most common indication is DP, which is usually transient. Most children will eventually be candidates for decannulation.