The Sternohyoid Flap for Facial Reanimation.

This article discusses the use of the sternohyoid muscle for facial reanimation. The report outlines the rationale for use, the technical aspects of flap harvest, and early clinical outcomes. The utility of the flap and its comparative attributes relative to the gracilis flap are discussed.

Inferior outcomes in immunosuppressed patients with high-risk cutaneous squamous cell carcinoma of the head and neck treated with surgery and radiation therapy.

BACKGROUND: Immunosuppressed patients have higher rates of cutaneous squamous cell carcinoma of the head and neck. OBJECTIVE: This study reviews the effect of immune status on disease characteristics and treatment outcomes. METHODS: Patients with cutaneous squamous cell carcinoma of the head and neck treated with surgery and postoperative radiotherapy between 2000 and 2011 were included. Immunosuppressed patients underwent prior organ transplantation or chemotherapy. Baseline variables were compared using χ(2) and unpaired t tests. Overall survival and disease-free survival were calculated using the Kaplan-Meier method. RESULTS: In this study of 59 patients, 38 (64%) were immunocompetent and 21 (36%) were immunosuppressed. Most patients had recurrent tumors (63%) and node-positive disease (61%), which were well balanced between the groups. Poorly differentiated tumors (62% vs 21%; P = .009), lymphovascular invasion (29% vs 11%; P = .08), and extracapsular extension (57% vs 41%; P = .09) were more frequent in the immunosuppressed group. Two-year disease-free survival (45% vs 62%) and 2-year overall survival (36% vs 67%) were inferior for immunosuppressed patients. LIMITATIONS: Limitations include single institution, retrospective study with small sample size, and potential referral bias. CONCLUSIONS: Immunosuppressed patients with cutaneous squamous cell carcinoma of the head and neck more frequently present with high-risk pathologic features and inferior outcomes. Early multidisciplinary assessment and alternate management strategies merit prospective investigation.

Voice outcomes following reconstruction of laryngopharyngectomy defects using the radial forearm free flap and the anterolateral thigh free flap.

OBJECTIVES/HYPOTHESIS: Patients undergoing laryngopharyngectomy with extensive pharyngeal mucosal resection or those failing chemoradiation protocols are commonly reconstructed using free tissue transfer. Radial forearm free flaps (RFFFs) and anterolateral thigh free flaps (ALTs) are two of the most commonly used free flaps for laryngopharyngectomy reconstruction. It has been suggested that alaryngeal tracheoesophageal prosthesis (TEP) speech outcomes in patients undergoing ALT reconstruction may be inferior due to the possibly bulkier neopharynx. We report the results of patients treated with ALT and RFFF with regard to postoperative TEP voice outcomes. STUDY DESIGN: Retrospective cohort study. METHODS: We identified 42 consecutive patients who were treated with total laryngopharyngectomy and free flap reconstruction utilizing either RFFFs (20 patients) or ALTs (22 patients) between April 2001 and August 2010. Evaluations with statistical analysis of standard TEP speech outcome measures (maximal sustained phonation, fluent count, syllable count) and qualitative variables were conducted. RESULTS: Patient demographics were similar between the RFFF and ALT groups, and 95% and 91% of RFFF and ALT patients received radiation therapy, respectively. Subjective voice quality did not significantly differ between the groups. Differences in outcomes of intelligibility, maximal sustained phonation time, maximum number of syllables, and fluent count, as evaluated by a single speech pathologist, were not statistically significant between RFFF and ALT patients. There was no difference in postoperative complications. CONCLUSIONS: These data indicate that reconstruction of laryngopharyngectomy defects using either the ALT or RFFF technique can produce similarly acceptable TEP voice results. LEVEL OF EVIDENCE: 2b.

Facial transplantation for massive traumatic injuries.

This article describes the challenges of facial reconstruction and the role of facial transplantation in certain facial defects and injuries. This information is of value to surgeons assessing facial injuries with massive soft tissue loss or injury.

Sternohyoid flap for facial reanimation: a comprehensive preclinical evaluation of a novel technique.

IMPORTANCE: Neuromuscular reanimation of the face provides the correct specific neural functional input and thereby prevents synkinesis. Unfortunately, this ideal situation is rarely encountered in the clinical setting. OBJECTIVES: To assess the technical feasibility of and define the surgical procedure for harvesting the sternohyoid muscle as a novel free flap for use in facial reanimation indications. DESIGN, SETTING, AND PARTICIPANTS: Fresh, postmortem, nonfixed cadavers were used to define the anatomy and perform the flap harvest procedures. Twenty-four flap harvests were performed. Angiography was performed on the pedicle of the harvested flaps to assess potential flap perfusion. Adenosine triphosphatase staining was performed on the muscle specimens to establish fiber type. MAIN OUTCOME MEASURES: The harvest technique, pedicle (arterial or venous), nerve length, and flap geometry parameters were characterized. RESULTS: The sternohyoid muscle was found to be reliably vascularized by the superior thyroid artery in all cases with an appropriate arterial and venous pedicle for vascular anastomosis. The mean arterial (5.5 cm) and venous (5.9 cm) pedicle lengths are comparable with gracilis flaps. The mean motor nerve length was 10.7 cm. The inclusion of the hyoid bone allows rigid fixation, and the muscle size, fiber type, and volume profiles all compare favorably to the gracilis flap for use in the indication of facial reanimation. Mock surgical procedures were performed to define inset parameters. This flap potentially allows single-stage cross-facial neurorrhaphies to be performed. CONCLUSIONS AND RELEVANCE: This is the first article, to our knowledge, of the sternohyoid muscle as a potential donor site for free-tissue transfer. This muscle has a predictable vascular pedicle and neural innervation along with size and fiber type parameters that make it an ideal potential free flap for facial reanimation. LEVEL OF EVIDENCE: NA.

Upper airway manifestations of granulomatosis with polyangiitis.

Upper airway manifestations, particularly sinonasal manifestations, are encountered frequently in granulomatosis with polyangiitis (GPA). Nasal endoscopy often reveals crusting, friable erythematous mucosa, and granulation. Up to 25% of patients may have a "saddle-nose" deformity as cartilage destruction worsens. Treatment is often complicated by loss of mucociliary function and necrosis, leading to refractory symptoms. Culture-directed antibiotics, topical antibiotic and saline irrigations, and occasional debridement of adherent crusts can reduce the frequency of sinonasal exacerbations and improve obstructive symptoms. Surgery should be reserved for patients unresponsive to maximal medical therapy. Saddle-nose reconstruction is possible in highly selected patients and can improve nasal breathing and resolve anosmia. Up to 20% of patients with GPA have subglottic stenosis; patients with respiratory symptoms should undergo laryngoscopy to assess the presence of subglottic narrowing. Although systemic manifestations of GPA are managed by immunosuppressive therapy, most patients with subglottic stenosis of GPA require surgical management (ie, endoscopic dilation, endoscopic or laser excision, surgical resection followed by reconstruction).

Facial nerve neurorrhaphy and the effects of glucocorticoids in a rat model.

OBJECTIVE: After nerve injury, an exaggerated neuroinflammatory process may hinder neuron regeneration and recovery. Immunomodulation using glucocorticoids may therefore improve facial nerve injury outcomes. This study aims to examine the effect of both local and systemic dexamethasone administration on facial nerve functional recovery after axotomy in a rat model. STUDY DESIGN: Randomized, placebo-controlled, blinded animal study. Setting Animal laboratory. SUBJECTS AND METHODS: Seventy-four Wistar rats underwent facial nerve axotomy with immediate neurorrhaphy. Rats were randomly assigned a postoperative group: control (no therapy); systemic dexamethasone 0.5, 1, 5, or 10 mg/kg for 3 administrations; or topically applied dexamethasone at 2 or 4 mg/mL. Blinded, standardized facial assessments and nerve conduction studies (NCS) were performed. Gross facial motion assessments were corroborated with vibrissae frequency video analysis. RESULTS: At 8 weeks, rats receiving systemic dexamethasone at 5 mg/kg attained greater eye blink closure (P = .004) and vibrissae motion (P = .012) compared with controls. Systemic dexamethasone at 0.5, 1, and 10 mg/kg and intraoperative topical application of dexamethasone at 2 or 4 mg/mL did not produce a significant improvement in facial motion compared with controls. Nerve conduction studies show a trend of increased return of compound muscle action potential amplitude levels compared with baseline among rats that received systemic dexamethasone 5 mg/kg but do not achieve statistical significance. CONCLUSION: In a rat facial nerve axotomy model, high-dose systemic dexamethasone therapy may improve functional recovery when administered in the immediate period following neurorrhaphy.

Three patients with full facial transplantation.

Unlike conventional reconstruction, facial transplantation seeks to correct severe deformities in a single operation. We report on three patients who received full-face transplants at our institution in 2011 in operations that aimed for functional restoration by coaptation of all main available motor and sensory nerves. We enumerate the technical challenges and postoperative complications and their management, including single episodes of acute rejection in two patients. At 6 months of follow-up, all facial allografts were surviving, facial appearance and function were improved, and glucocorticoids were successfully withdrawn in all patients.

Comprehensive analysis of the anterolateral thigh flap vascular anatomy.

OBJECTIVE: The anterolateral thigh (ALT) flap has become a frequently used free flap for head and neck reconstruction. Widespread use has been based on literature of ALT flap thickness performed primarily in Asian populations. To our knowledge, to date there has not been a comprehensive analysis of the anthropomorphic parameters of this flap in the Western population, in which it is often much thicker, thereby potentially limiting its utility. METHODS: Computed tomographic angiograms of 106 patients were assessed, yielding 196 lower-extremity scans examined for volumetric characteristics and vascular anatomical variations. RESULTS: Perforator vessels were located in 88.8% of scans, and most commonly located were a hybrid musculoseptocutaneous vessel (52.3%) followed by septocutaneous (33.9%) and musculocutaneous (13.8%) vessels. The midpoint perforator was located within ±2% of the midpoint of the total thigh length in only 47% of legs. The proximal and distal perforators were located 52.7 and 58.6 mm from the midpoint, respectively. Subcutaneous fat thickness differed significantly by sex, with mean male and female thicknesses of 9.9 mm and 19.9 mm (P < .001), respectively. Thickness increased with increasing body mass index, especially in women. CONCLUSION: This study used computed tomographic angiography to characterize the ALT flap vasculature and thickness, providing a degree of predictability to these 2 highly variable flap characteristics.

Split hypoglossal-facial nerve neurorrhaphy for treatment of the paralyzed face.

BACKGROUND: Several methods of neural rehabilitation for facial paralysis using 12-7 transfers have been described. The purpose of this study is to report on a series for dynamic reinnervation of the paralyzed face by using a split 12-7 nerve transposition. The goals of this procedure are to minimize tongue morbidity and to provide good facial reinnervation. METHODS: Prospective case series. Melolabial crease discursion, overall facial movement, and degree of tongue atrophy and mobility were recorded. RESULTS: Thirteen patients underwent facial reanimation using a split hypoglossal-facial nerve transfer with postoperative follow-up to 58 months (range, 6-58 months). All patients achieved excellent rest symmetry and facial tone. Of 13 patients, 10 had measurable coordinated movement and discursion of their melolabial crease. Of 13 patients, 12 had mild to moderate ipsilateral tongue atrophy. The mean time to onset of visible reinnervation was 3 months. CONCLUSION: Split hypoglossal-facial nerve transposition provides good rehabilitation of facial nerve paralysis with reduced lingual morbidity. Long-term rest symmetry and potential learned movement can be achieved. This technique may provide a favorable alternative to the traditional method of complete hypoglossal sacrifice or jump grafting.

Volume-directed facial soft tissue deficit reconstruction.

Extensive facial soft tissue volume deficits can pose a significant challenge to the facial reconstructive surgeon. These defects are typically the result of trauma, tumor extirpation, or congenital defects and produce troubling cosmetic and functional morbidities for the patient if the appropriate reconstructive paradigm is not embraced. Many options are available, ranging broadly in invasiveness, need for donor sites, and longevity of result. Several of these options include recent technologies, such as injectable fillers and implantable biomaterials, and advances in free flap design and reductions in overall free tissue morbidity propel the expanding use of microvascular free tissue transfer. With this myriad of options, the surgeon must fully evaluate the extent and depth of the soft tissue injury, weigh the advantages and disadvantages of each reconstructive option, and finally compose a flexible and graduated reconstructive strategy to suit each patient and each defect. A thorough knowledge of these techniques is paramount. The purpose of this review is to broadly highlight the spectrum of reconstructive options and strategies for facial soft tissue volume reconstruction available to the facial reconstructive surgeon.

Total parotidectomy defect reconstruction using the buried free flap.

OBJECTIVE: 1) Present an alternative method of total parotidectomy with or without neck dissection defect reconstruction that results in improved cosmesis. 2) Describe applications of free tissue transfer in parotidectomy defect reconstruction. STUDY DESIGN: Case series with chart review. SETTING: Two tertiary-care medical centers. SUBJECTS AND METHODS: A two-institution retrospective review from 2002 to 2009 was conducted for buried free flaps utilized in reconstruction of defects from total parotidectomy with or without neck dissection. Patients with temporal bone or skin resections were excluded. Demographic information, tumor characteristics, surgical interventions, flap details, and adjunctive facial reconstructive techniques were recorded. Postoperative cosmetic results were evaluated by patient and physician satisfaction. RESULTS: Eighteen patients with a mean age of 57.4 years underwent flap reconstruction. Total parotidectomy was performed in all cases, 11 cases required facial nerve sacrifice, and 14 cases included neck dissection. The anterolateral thigh flap was the most often utilized free flap. Mean flap area was 65.5 cm(2). Adjunctive static facial reanimation was employed in eight patients. All flaps survived. Ten patients underwent adjuvant radiation. Free flap reconstruction resulted in cosmetic patient and surgeon satisfaction, despite adjuvant radiation therapy. CONCLUSION: Free flap reconstruction of total parotidectomy (with or without neck dissection) defects is safe and effective. It does not preclude adjunctive facial reanimation and provides sufficient tissue bulk to match the contralateral facial contour despite radical resections and adjuvant radiation therapy in most cases.

Outcomes of vascularized bone graft reconstruction of the mandible in bisphosphonate-related osteonecrosis of the jaws.

OBJECTIVES/HYPOTHESIS: To describe the clinical entity and therapeutic challenges of bisphosphonate-related osteonecrosis of the jaws (BRONJ). The use of vascularized bone grafts for reconstruction of the mandible in extensive BRONJ is proposed. STUDY DESIGN: Multi-institutional retrospective review. METHODS: Patients undergoing mandible reconstruction with vascularized bone grafts after segmental mandible resection for BRONJ were evaluated. Mandible reconstruction was only performed on patients with intractable pain, fistulae, or pathologic fracture and after failure of comprehensive conservative therapy. No patients had a history of primary or metastatic head and neck malignancy or radiation therapy. Bone union was established with follow-up radiography. RESULTS: Eleven patients met inclusion criteria. Mean patient age was 61.3 years. Median follow-up was 13.9 months. All patients had undergone therapy with bisphosphonates and had no other identifiable cause of mandible osteonecrosis. Preoperatively, pathologic mandible fractures were present in 73% of patients, and 36% had orocutaneous fistulae. Fibula osteocutaneous flaps were used in all cases with no failures. In all patients, bony union was demonstrated clinically and radiographically. Postoperative wound complications occurred in 36% of patients but were all treated successfully with conservative therapy. There was no BRONJ recurrence within the study follow-up period. CONCLUSIONS: Osteonecrosis is a significant complication of bisphosphonate therapy, and current literature does not support vascularized reconstruction. We demonstrate that vascularized bone graft reconstruction with the fibula free flap offers a high success rate of bony union and fistula closure and should be offered to selected patients with advanced cases of BRONJ.

Facial paralysis rehabilitation: state of the art.

PURPOSE OF REVIEW: Surgical management of facial paralysis continues to undergo evolution. Advances made in management reflect the challenging nature of facial paralysis and the drive to ever improve outcomes. RECENT FINDINGS: Recent advances have been made in neuronal transfers using the masseteric nerve, minimally invasive static procedures, and dynamic transfer of the temporalis tendon. SUMMARY: Continued evolution of techniques for the management of facial paralysis is reflected in the current literature. Broader application of neuronal transfers, minimally invasive static procedures, and orthodromic temporalis tendon transfer, among other techniques, indicates a vibrant field of surgeons who pursue ever better results for patients with facial paralysis.

Arguing the ethics of facial transplantation.

While 7 face transplants have been performed around the world, to date, there remains debate regarding the validity of this procedure. We submit that performing a facial transplant-in the appropriately selected patient-is technically defensible and ethically sound. By outlining the technical and ethical boundaries of the debate, responding to the key arguments against the procedure, and describing its motivations and potential benefits, we state our justification of facial transplantation.

The technical and anatomical aspects of the World's first near-total human face and maxilla transplant.

OBJECTIVE: To discuss the technical and anatomical analysis and design of an osteocutaneous allograft transplant incorporating the donor maxilla and the execution of the operative protocol during the transplant. METHODS: The Cleveland Clinic reported the world's first successful combined face and maxilla transplant in December 2008. Unlike the 3 prior face transplants, this surgical procedure was done as a salvage operation in a patient who had undergone 23 major reconstructive procedures. The additional complexity due to significant postoperative scarring and recipient vessel depletion presented a unique challenge in this case. The extensive 3-dimensional losses of facial structures in multiple tissue planes required a Le Fort III osteomyocutaneous allotransplant incorporating the donor maxilla. RESULTS: We report the first successful transfer of a complete bony framework and soft-tissue envelope. The allograft has shown excellent integration and no long-term rejection. The traditional conception based on anatomical studies suggested that this transfer would require independent dissection of the internal maxillary vascular system. This was not required in our patient whose allograft was based solely on the facial arterial system and its arcades. CONCLUSIONS: Successful near-total face and maxilla allograft transplant can be accomplished based on the facial arterial system and its arcades. This presents a novel method for reconstructing massive facial injuries with significant involvement of the facial skeleton.

Analysis of outcomes of vascularized flap reconstruction in patients with advanced mandibular osteoradionecrosis.

OBJECTIVE: To examine outcomes of vascularized bone flap reconstruction of end-stage osteoradionecrosis of the mandible. STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary care academic hospital. SUBJECTS: Patients with end-stage radiation-induced osteoradionecrosis (ORN) refractory to conservative therapy with wound complications including chronic infections, fistula formation, and pathologic fracture were included. RESULTS: Outcomes of 33 patients were prospectively collected and analyzed, making this the largest series on this subject in the literature and the only one with planned data collection. Data on preoperative variables including radiation dose, sub-site location, treatment date, and prior therapy, along with intraoperative issues and postoperative outcomes, were tracked and are presented. ORN was seen to develop in a bimodal distribution based on the timing of interval surgical intervention. The extent of local soft tissue injury often required the use of contralateral recipient vessels. Local wound complication rates were higher than that seen in primary reconstructions. CONCLUSIONS: Successful reconstruction was achieved in all of the patients in this series. Long-term resolution of infectious complication and disease resolution was seen in 91 percent of the patients in this series.

Prospective analysis of outcomes and complications of 300 consecutive microvascular reconstructions.

OBJECTIVE: To prospectively follow up patients requiring microvascular reconstruction of head and neck defects to determine preoperative factors predictive of surgical complications. METHODS: A prospectively collected database comprising 300 consecutive microvascular head and neck reconstructions performed by a single surgeon (D.S.A.) in a tertiary care hospital over a 6-year period was reviewed in a retrospective manner. Data collected included preoperative medical and surgical history (presence of documented cardiac disease, diabetes mellitus, and hypertension) and previous cancer treatment (surgery or radiation therapy). Postoperative data, including early or late complications, hematocrit during hospitalization, and functional status, were also collected. A multiple linear regression was used to identify predictors of surgical complications and secondarily crossed to determine the strength of the prediction. Statistical significance was set at P = .05. RESULTS: Patients were stratified into 4 groups based on (1) previous radiation therapy, (2) previous surgery, (3) no previous radiation therapy or surgery, and (4) both previous radiation therapy and previous surgery, with an increased predictability of complications with both. Diabetes also added to the predictability of complications, with a smaller effect. Cardiac disease and hypertension were not predictive. CONCLUSIONS: Previous radiation therapy and surgery are positive predictors for wound complications after microvascular reconstruction. Diabetes may add further risk in this setting.

Technical considerations in patients requiring a second microvascular free flap in the head and neck.

OBJECTIVE: To identify the difficulties associated with performing a second free flap reconstruction in the head and neck as well as the techniques used to achieve successful reconstruction. DESIGN: A retrospective review of a prospectively maintained patient database. PATIENTS: The study population comprised 33 patients who required a second free flap in the head and neck. MAIN OUTCOME MEASURES: Several variables were analyzed in this cohort. Patient-related factors included the following: the availability of recipient vessels, the need to access the contralateral side of the neck, history of neck surgery, history of radiation therapy, and type of free flap used. Complications associated with the reconstruction were also reported. RESULTS: In this cohort of 33 patients, 34 free flap reconstructions were performed. All were successful, and there were no flap-related complications. Owing to the paucity of good recipient vessels in many cases, the contralateral side of the neck was commonly used, but no patients required vein interposition grafts. CONCLUSIONS: Second free flap reconstructions in the head and neck can be safely accomplished. We have found that the availability of recipient vessels is the most important consideration in these patients. The dissection of the contralateral side of the neck is often required, but the use of flaps with long pedicles obviates the need for vein interposition grafts. Compared with the success rate in this study, the relevant literature suggests that flap survival rates are lower when interposition grafts are used. Modifications in flap-harvesting techniques and inset geometry can also be used to facilitate insets in complicated surgical fields that have been reoperated on.