The profunda artery perforator flap for head and neck reconstruction.

INTRODUCTION: The profunda artery perforator (PAP) fasciocutaneous flap is underutilized in head and neck reconstruction, with advantages including ease of harvest and minimal donor site morbidity. METHODS: Cadaveric dissection of cutaneous perforators to origin at profunda femoris system to characterize vascular anatomy. RESULTS: 22 PAP flaps were studied. Each contained 1-6 cutaneous perforators originating from the profunda system, designated into A, B, or C vascular pedicle systems. Muscular perforators did not consistently extend to skin in systems A and C, but all dissections demonstrated myocutaneous perforator in system B. Average distance from groin crease to cutaneous perforators of A, B, and C respectively was 8 cm (range 3-15 cm), 11.4 cm (range 5-17 cm), and 17.5 cm (range 12.5-22 cm). Average pedicle length was 11.07 cm (range 7-16 cm), 11.78 cm (range 9-16 cm), and 11.23 cm (range 9-15 cm). Average vena comitans diameter at origin was 3.14 mm (range 1.27-4.46 mm). Average arterial diameter at origin was 2.07 mm (range 1.27-3.82 mm). Range of maximal primary closure was 6-11 cm. CONCLUSION: PAP free flap demonstrates reliable vascular anatomy in cadavers, with adequate pedicle length and vessel diameter. All specimens contained adequate myocutaneous perforator to support free tissue transfer.

Management of Lateral Wall Insufficiency.

Lateral wall insufficiency is a commonly encountered etiology of nasal obstruction, resulting from dynamic collapse at the level of the internal or external nasal valve. Various management strategies exist to strengthen the lateral wall or stent the nasal valves to relieve nasal obstruction, and range from noninvasive devices, minimally invasive implants, or surgical reconstructive techniques. Surgical options to address the nasal valves are selected based on each patient's anatomic findings, aesthetic and functional goals, and surgeon preference. This article describes the anatomy and physiology of the nasal sidewall and nasal valves and diagnosis of lateral wall insufficiency, and provides a framework for treatment options.

Supraorbital Rim and Roof Reconstruction with Vascularized Fascia Lata and Autogenous Rib Graft.

OBJECTIVE: Describe a novel technique for reconstruction of complex defects involving supraorbital rim and orbital roof. METHODS: Retrospective chart review and description of surgical technique. RESULTS: Four patients underwent tumor resection with neurosurgery (2 intraosseous hemangioma, 1 meningioma, and 1 ossifying fibroma), with mean tumor size of 42.6 cubic centimeters on preoperative imaging. All defects involved supraorbital rim and orbital roof. Patients were reconstructed with autogenous osseous rib graft for structure and contour and anterolateral thigh fascia lata (ALTFL) free flap to provide robust vascularity to rib bone and as a barrier between skull base dura and the orbit and/or sinonasal cavities. Two patients underwent resection and reconstruction using minimal access incisions, and two underwent major cranial and skull base resections. All flaps are vascularized via superficial temporal vessels. On postoperative follow-up (mean 33.5 months, range 8-48), all patients report no vision change or diplopia, with excellent contour symmetry to contralateral orbit. Follow-up imaging (mean 29.5 months, range 3-48) demonstrated maintained orbital volume and retention of rib bone graft compared to immediate postoperative imaging. There were no complications related to graft use. Minor complications include 1 patient with cerebrospinal fluid leak managed with lumbar drain placement and 1 patient with mild enophthalmos at 7-month follow-up. CONCLUSION: We describe a series of patients who underwent a novel technique for reconstruction of complex defects involving supraorbital rim and orbital roof with autogenous osseous rib and vascularized ALTFL-free flap with excellent functional and cosmetic outcomes. This can be accomplished using minimal access techniques to minimize patient morbidity. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:654-658, 2024.

Mandibular Osteoradionecrosis: Defining the Microbial Milieu and Antimicrobial Resistance at the Time of Rescue Flap Surgery.

OBJECTIVE: To report the microorganisms and their antibiotic sensitivity profile from tissue cultures and stains at the time of anterolateral thigh fascia lata (ALTFL) rescue flap for management of mandibular osteoradionecrosis (ORN). METHODS: Retrospective chart review of patients who underwent ALTFL rescue flap for native mandibular ORN between 2011 and 2022. RESULTS: Twenty-six cases comprising 24 patients (mean age 65.4 years, 65.4% male) with mandibular ORN from whom tissue cultures and gram stain were obtained at the time of ALTFL rescue flap. 57.7% grew bacterial species, while 34.6% grew fungal species. Multibacterial speciation was noted in 26.9% of cultures. A combination of bacterial and fungal growth was also seen in 15.4% of cases. All gram-positive cocci (GPC) were pansensitive to antibiotics except for one case of Staphylococcus aureus, which was resistant to levofloxacin. Gram-negative bacilli (GNB) species were isolated in 50.0% of cases. All fungal growth was due to Candida species. No growth was noted in 23.1% of cases. Multidrug resistance was noted in 53.8% of cases when GNB was isolated. CONCLUSION: We report 76.9% of our cases of mandibular ORN had microbial growth from tissue cultures obtained at the time of the ALTFL rescue flap. Fungal growth was noted in a substantial number of cases and should be obtained as a specimen when pursuing culture-driven antibiotic therapy. Most GPCs were pansensitive to antibiotics, while GNBs were often the harbinger of multidrug resistant mandibular ORN. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:166-169, 2024.

Minimally Invasive Approach to Access Vessels for Microvascular Anastomosis in Head and Neck Reconstruction.

OBJECTIVES: To describe our technique, review indications, and evaluate the outcomes of the minimal access approach for recipient vessel identification in microvascular tissue transfer. METHODS: Retrospective chart review of all patients who underwent microvascular reconstruction using the minimal access technique between 2015 and 2021. RESULTS: We report 236 cases, comprising 214 patients with a mean age of 60.2 years (3-88). The most common primary defect sites were the mandible (22.6%), cranium (14%), maxilla (13.2%), skull base (12.8%), and nose/nasal cavity (10.6%). Indications for free flap reconstruction included head and neck cancer extirpation (32.2%), osteoradionecrosis (29.7%), acquired deformity (14.0%), chronic wound (11.9%) and oral motor dysfunction (7.2%). Free flap donor sites used were the anterolateral thigh (84.3%), fibula (7.2%), and radial forearm (6.4%). Vessels utilized include superficial temporal (49.8%), facial (38.3%), angular (11.1%), and transverse cervical (0.4%). The overall complication rate was 14% (n = 33), with surgical complications at the recipient site accounting for 67.6% (n = 25). Flap failure occurred in 3.4% of procedures. Prior head and neck surgery and free flaps were associated with an increased risk of major recipient site complications (n = 20, p = 0.0257 and n = 14, p = 0.0117, respectively). CONCLUSION: Minimal access techniques allow consistent recipient vessel identification for microvascular-free tissue transfer. These approaches may be utilized in reconstructing a broad range of head and neck defects, are low morbidity, and contribute to an overall shorter length of stay. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:2177-2181, 2024.

Managing Mandibular Osteoradionecrosis.

OBJECTIVE: Mandibular osteoradionecrosis (MORN) is a morbid complication of head and neck radiation therapy. Recent advances in surgical and medical therapies underscore the need for a shift in traditional treatment paradigms and a disease grading system that can guide appropriate management. DATA SOURCES: Pubmed/MEDLINE. REVIEW METHODS: We conducted a detailed review of publications related to MORN, specifically focusing on its staging and management techniques. Articles meeting inclusion criteria were synthesized into a final narrative review. CONCLUSION: There has been a paradigm shift away from hyperbaric oxygen therapy in the management of MORN. Growing evidence for the efficacy of pentoxifylline and tocopherol in early-stage disease and novel surgical techniques to manage moderate and late-stage disease warrant an updated staging stratification which is proposed. IMPLICATIONS FOR PRACTICE: This review summarizes the clinical efficacy of established and novel therapeutic modalities currently available in treating MORN, emphasizing the significant advances achieved over the last decade. It introduces a contemporary staging and treatment algorithm which incorporates traditional, evidence-supported surgical and medical management with effective early intervention strategies.

Positive Trends in Racial Disparities for Head and Neck Microvascular Reconstructive Surgery.

OBJECTIVE: To evaluate national trends in racial disparities for patients undergoing head and neck reconstructive surgery. METHODS: Retrospective analysis using the 2008 to 2021 American College of Surgeons National Surgical Quality Improvement Program database. Patients receiving microvascular free tissue transfer were eligible for inclusion. Pediatric patients and those treated by non-otolaryngologists were excluded. Outcomes were analyzed with univariate and multivariable models. RESULTS: A total of 5831 head and neck free flap cases were analyzed, 4869 (83.5%) were White, 560 (9.6%) were Black or African American, and 402 (6.9%) were Asian, Native American, or other groups (ANAOG). The proportion of Black or African American patients and ANAOG patients undergoing free tissue transfer increased significantly over the time period (p = 0.047 and p = 0.010, respectively). However, there was a downtrend that started around 2017. In a multivariable model, Black or African American race was not associated with readmission (OR = 0.99 [95% CI 0.74, 1.31], p > 0.05), returning to the operating room (OR = 1.20 [95% CI 0.96, 1.49], p > 0.05), or any post-operative complication (OR = 0.83 [95% CI 0.68, 1.01], p > 0.05). There were also no significant associations found in the ANAOG population on multivariate analysis (p > 0.05 for all). CONCLUSION: The percentage of free tissue transfer performed in patients from minority backgrounds with head and neck cancer has been increasing in the United States. Outcomes after head and neck microvascular reconstruction are similar when stratified by race. However, racial disparities remain and further work is necessary to reduce these disparities. LEVEL OF EVIDENCE: Level IV Laryngoscope, 2024.

Management, Referral Patterns, and Outcomes in Bell's Palsy: A Single-Institution 903 Patient Series.

OBJECTIVE: In 2013, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) published guidelines for Bell's palsy (BP), including recommendations for workup, management, and specialist referral. Patients with BP often present to primary care; however, adherence to guidelines may vary by setting. This study sought to evaluate the management of patients with BP presenting to primary care, emergency department (ED), and urgent care settings. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care center. METHODS: Retrospective chart review of patients identified by diagnosis code for BP. RESULTS: A total of 903 patients were included; 687 (76.1%) presented to ED, 87 (9.6%) to internal medicine, 77 (8.5%) to family medicine, and 52 (5.8%) to urgent care. On presentation, 804 (89.0%) patients were prescribed corticosteroids and 592 (65.6%) antiviral therapy. Steroid therapy ranged from 1 dose to greater than a 14-day course, with 177 (19.6%) receiving an adequate duration of 10 days or greater. Referrals were provided to facial plastics and/or otolaryngology for 51 patients (5.6%). For all comers, 283 (31.3%) had complete resolution, 197 (21.8%) had an incomplete resolution, 62 (6.9%) had persistent palsy, and 361 (40.0%) lost to follow-up. In assessing the association between clinic setting and management, appropriate corticosteroid therapy (p < .01), imaging (p < .01), and eye care (p < .01) were statistically significant. CONCLUSION: Adherence to guidelines for BP management varies amongst providers. In our study cohort, 15.5% of patients received medical therapy in accordance with AAO-HNS guidelines, and only 5.6% were referred to facial plastics. To facilitate more appropriate care, tertiary care institutions may benefit from system-wide care pathways to manage acute BP.

Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis.

Importance: Mandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management requires a morbid segmental resection with osteocutaneous reconstruction. Evidence of the anterolateral thigh fascia lata (ALTFL) rescue flap technique's safety, effectiveness, and long-term outcomes is needed. Objective: To determine the long-term outcomes of the ALTFL rescue flap procedure for treating patients with mandibular ORN. Design, Settings, and Participants: This was a retrospective medical record review performed at a single tertiary-level academic health care institution with patients who were appropriate candidates for the ALTFL procedure to treat mandibular ORN from March 3, 2011, to December 31, 2022. Data analyses were performed from January 1 to March 26, 2023. Main Outcomes and Measures: Patient characteristics, preoperative radiographic Notani staging, intraoperative defect size, length of stay, complication rates, and clinical and radiographic findings of progression-free intervals. Results: The study population of 43 patients (mean [SD] age, 66.1 [47-80] years; 24 [55.8%] male individuals) included 52 cases of mandibular ORN. The preoperative Notani staging of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%), stage II; and 14 (30.4%), stage III. The mean defect area was 20.9 cm2. Successful arrest of ORN disease progression was noted in the clinical and radiographic findings of 50 of the 52 (96.2%) cases, with only 2 (3.8%) cases subsequently requiring fibular free flap reconstruction. The major complication rate was 1.9% (1 case). Clinical and radiographic progression-free intervals were assessed, and no statistically significant differences were noted between Notani staging groups (log-rank P = .43 and P = .43, respectively); ie, patients with stage III disease had no significant difference in risk of clinical (HR, 0.866; 95% CI, 0.054-13.853) or radiographic (HR, 0.959; 95% CI, 0.059-15.474) progression vs those with stage I disease. Weibull profiling revealed 96.9%, 94.6%, and 93.1% successful mandibular ORN arrest at 1, 3, and 5 years, respectively. The major complication rate was 1.9%. Mean (SD) length of stay was 2.7 (0.0-7.0) days. Mean (SD) radiographic follow-up was 29.3 (30.7) months. Conclusions and Relevance: The findings of this large retrospective patient case series support the continued success of the ALTFL rescue flap technique, a safe and highly effective long-term treatment for mandibular ORN in carefully selected patients.

Evaluating compliance with process-related quality metrics and survival in oral cavity squamous cell carcinoma: Multi-institutional oral cavity collaboration study.

BACKGROUND: Process-related measures have been proposed as quality metrics in head and neck cancer care. A recent single-institution study identified four key metrics associated with increased survival. This study sought to validate the association of these quality metrics with survival in a multi-institutional cohort. METHODS: Multicenter retrospective study of patients with oral cavity squamous cell (1/2005-1/2015). Baseline patient and disease characteristics and compliance with quality metrics was evaluated. Association between compliance with quality metrics with overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) was evaluated using Cox proportional hazards models. RESULTS: Failure to comply with two or more of the quality metrics was associated with worse OS, DFS, and DSS. Adherence to all or all but one of the quality metrics was found to be associated with improved survival. CONCLUSIONS: Process-related quality metrics are associated with increased survival in patients with oral cavity squamous cell carcinoma in a multi-institutional cohort.

Recurrence and Progression of Head and Neck Paragangliomas after Treatment.

OBJECTIVE: To characterize the recurrence of head and neck paragangliomas and the factors associated with disease progression after treatment. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care center. SUBJECTS AND METHODS: In total, 173 adults with 189 paragangliomas (41.3% carotid body, 29.1% glomus jugulare, 19.0% glomus tympanicum, and 10.6% glomus vagale) treated between 1990 and 2010 were evaluated to determine the incidence and risk of recurrence using Cox proportional hazards. RESULTS: The mean (SD) follow-up duration was 8.6 (9.1) years. The incidence was 2.92 recurrences per 100 person-years. The rate of recurrence was 8.2% (95% confidence interval [CI], 3.7-12.7) after 4 years and 17.1% (95% CI, 10.2-24.0) after 10 years. Glomus jugulare tumors were more likely to recur (hazard ratio [HR], 3.69; 95% CI, 1.70-8.01; P < .001) while carotid body tumors were less likely (HR, 0.44; 95% CI, 0.21-0.97; P = .041). Radiation had a lower risk of recurrence or progression compared to surgical excision (HR, 0.30; 95% CI, 0.10-.94; P = .040). Recurrence was associated with right-sided paragangliomas (HR, 3.60; 95% CI, 1.63-7.75; P = .001). The median time to recurrence was 18.4 years. Six (3.2%) patients developed metastasis, which was more common with local recurrence (9.5% vs 1.4%, P = .015). CONCLUSIONS: Recurrence is more common with glomus jugulare tumors and less common with carotid body tumors. Radiation may have a lower risk of recurrence or progression than surgery for some paraganglioma types. Metastasis is rare but more likely with recurrent disease. Surveillance neck imaging is recommended every several years for decades after treatment.

Degree of Self-Reported Facial Impairment Correlates with Social Impairment in Individuals with Facial Paralysis and Synkinesis.

Importance: Facial paralysis leads to both aesthetic and functional deficits placing patients at risk for sociopsychological sequelae and social impairment. Objective: To examine the effect of facial paralysis and synkinesis on social impairment and quality of life (QOL). Design, Setting, and Participants: This is a cross-sectional study at a tertiary care medical center. Adults with a history of facial palsy were broadly categorized by self-reported degree of facial paralysis and synkinesis. Main Outcomes and Measures: Clinical demographic information, self-reported degrees of facial paralysis and synkinesis, and facial palsy-specific QOL as measured by the Facial Clinimetric Evaluation (FaCE) Scale and the Synkinesis Assessment Questionnaire (SAQ) were collected. FaCE and SAQ scales were evaluated as predictors of social impairment outcomes, as measured by the Brief Fear of Negative Evaluation-II (BFNE-II), the Social Anxiety Questionnaire (SAQ-A30), and Social Avoidance and Distress (SAD) scales, in addition to health utility scores from the Short-Form 6D (SF-6D). Results: Fifty-six participants with facial palsy were included (30% male; average age: 56.4 [standard deviation (SD): 15] years). Sixty-three percent of participants reported history of Bell's palsy; 37% reported other etiologies. Forty-seven percent of participants reported moderate or severe facial impairment and 46% of participants reported involuntary facial movement. Participants with moderate or severe facial impairment exhibited increased BFNE-II (p = 0.03), SAQ-A30 (p = 0.04), and SAD (p < 0.01) scores and lower health valuation on SF-6D (p = 0.04). FaCE scores moderately correlated with lower health valuation (r = 0.39, p < 0.01), and moderately and inversely correlated with SAD (r = -0.33, p = 0.01) and BFNE-II (r = -0.35, p < 0.01) scores. Furthermore, worsening FaCE scores predicted worsening SAQ (p < 0.01), SAD (p = 0.01), BFNE-II (p < 0.01), and SF-6D (p < 0.01) scores. Worse degrees of synkinesis correlated with higher BFNE-II scores (r = 0.38, p < 0.01) and worsening SAQ scores predicted worsening FaCE (p < 0.01) and BFNE-II (p < 0.01) scores. Females demonstrated significantly worse BFNE-II scores (p = 0.04) when compared with men, and female gender significantly predicted worse FaCE scores (p < 0.01). Seventy-one percent of women with self-reported moderate or severe facial impairment met criteria for social anxiety, as did 67% of women with self-reported moderate or severe synkinesis. Conclusions and Relevance: Individuals with self-reported moderate or severe facial impairment exhibit a higher degree of social impairment and poorer health valuation than those with no or mild facial impairment. Facial palsy-specific QOL moderately and inversely correlated with social impairment and moderately correlated with health valuation. Our results indicate that FaCE scores may be used as a predictor of SAD, BFNE-II, and SF-6D scores and that facial palsy QOL and its relationship with social impairment should be considered when treating patients with a history of facial palsy.

Comparative Study of Functional Nasal Reconstruction Using Structural Reinforcement.

IMPORTANCE: Nasal reconstruction after Mohs surgery is a unique challenge in that it must satisfy both functional and aesthetic goals. Despite some advocacy in the literature for using structural reinforcement to achieve both functional and aesthetic outcomes in soft-tissue reconstruction, no study has validated this claim by comparing reconstruction with and without structural support. OBJECTIVE: To evaluate the effectiveness of and need for structural reinforcement when reconstructing the nasal alar and sidewall subunits. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective review of the medical records of 190 patients 18 years or older who underwent nasal reconstruction after Mohs surgery in a tertiary care academic center between January 1, 2013, and August 31, 2015. Data on each patient included demographics, comorbidities, smoking status, details of the lesion, size of defect, subunits involved, and reconstructive technique. Patients were divided into 2 cohorts composed of those who had reconstruction with structural reinforcement (ie, cartilage grafting or suspension suture) and those with only soft-tissue reconstruction. Patients with nasal obstruction from the functional collapse of the reconstructed area and no history of nasal obstruction were included (n = 38). Patients who had a follow-up of less than 2 months, no alar or sidewall involvement, nasal obstruction secondary to turbinate hypertrophy, septal deflection or other nonstructural causes, and incomplete documentation for analysis were excluded (n = 102). MAIN OUTCOMES AND MEASURES: Rates of postoperative nasal obstruction secondary to nasal sidewall collapse and need for revision surgery. RESULTS: Of the 38 patients who met the inclusion criteria, 22 were men and 16 were women with a mean (range) age of 64.5 (35-92) years. Twenty-three patients (61%) underwent reconstruction by a facial plastic surgeon and 15 (39%) by 2 dermatologic surgeons. Three (8%) underwent reconstruction without reinforcement and experienced postoperative nasal obstruction. The mean size of reconstructed defects that resulted in nasal valve collapse was 2.1 cm in diameter (range, 1.2-2.6 cm). Defect size was associated with incidence of postoperative nasal obstruction. For defects greater than 1.2 cm in diameter, patients reconstructed without reinforcement had a statistically significant increase of nasal obstruction secondary to functional nasal collapse compared with patients reconstructed with reinforcement (3 of 14 [21%] vs 0 of 17; 95% CI, 0.005-0.358; P = .04). CONCLUSIONS AND RELEVANCE: Nasal defects greater than 1.2 cm in diameter and involving the alar and sidewalls were associated with lower incidence of postoperative nasal obstruction when a structural reinforcement technique was used in reconstruction. The findings of this study support the structural reinforcement of the nasal functional subunits during Mohs reconstructive surgery to achieve optimal outcomes. LEVEL OF EVIDENCE: 3.