Free dermal fat graft reconstruction of the head and neck: An alternate reconstructive option.

OBJECTIVES: Ablative procedures of the head and neck often result in significant facial and cervical irregularities and cosmetic asymmetry. The deformity resulting from ablative procedures of the head and neck is a significant source of cosmetic morbidity and postoperative dissatisfaction. Reconstruction of post-ablative defects in the head and neck can employ a broad range of techniques, ranging from primary closure to free tissue transfer. The free dermal fat graft (FDFG) is one such option and has been used to repair volume defects of varying sizes after common head and neck procedures such as parotidectomy. However, its use is largely undocumented in the literature. We seek to further illustrate the FDFG as an alternate method of reconstruction of head and neck defects. STUDY DESIGN: Non-randomized retrospective analysis. METHODS: The medical records of all patients who underwent primary autologous abdominal FDFG reconstruction of head and neck defects by a single surgeon at Vanderbilt University Medical Center from January 1997 to August 2010 were reviewed. All patients were called in order to assess their post-operative cosmetic satisfaction. RESULTS: Sixty-two patients were analyzed. Only three patients were found to have post-operative complications directly related to the FDFG. No complications were found at the donor site. Based on a telephone survey, the majority of patients were satisfied post-operatively with their cosmetic outcomes in the primary site and donor site. CONCLUSIONS: From our experience the FDFG is a cosmetically and functionally advantageous option for reconstruction of ablative procedures of the head and neck.

Comparison of ventilation and voice outcomes between unilateral laryngeal pacing and unilateral cordotomy for the treatment of bilateral vocal fold paralysis.

BACKGROUND/AIMS: Rehabilitation of the bilaterally paralyzed human larynx remains a complex clinical problem. Conventional treatment generally involves surgical enlargement of the compromised airway, but often with resultant dysphonia and risk of aspiration. In this retrospective study, we compared one such treatment, posterior cordotomy, with unilateral laryngeal pacing: reanimation of vocal fold opening by functional electrical stimulation of the posterior cricoarytenoid muscle. METHODS: Postoperative peak inspiratory flow (PIF) values and overall voice grade ratings were compared between the two surgical groups, and pre- and postoperative PIF were compared within the pacing group. RESULTS: There were 5 patients in the unilateral pacing group and 12 patients in the unilateral cordotomy group. Within the pacing group, postoperative PIF values were significantly improved from preoperative PIF values (p = 0.04) without a significant effect on voice (grade; p = 0.62). Within the pacing group, the mean postoperative PIF value was significantly higher than that in the cordotomy group (p = 0.05). Also, the mean postoperative overall voice grade values in the pacing group were significantly lower (better) than those of the cordotomy group (p = 0.03). CONCLUSION: Unilateral pacing appears to be an effective treatment superior to posterior cordotomy with respect to postoperative ventilation and voice outcome measures.

Tumors of the cervical sympathetic chain--diagnosis and management.

BACKGROUND: Tumors originating from the cervical sympathetic chain are uncommon but important entities in the differential diagnosis of parapharyngeal space masses. METHODS: We conducted a retrospective review of patients presenting with tumors of the cervical sympathetic chain. RESULTS: Twenty-four patients presented between 1994 and 2010. Presenting symptoms were dysphagia (n = 7.29%), neck mass (n = 7.29%), throat fullness (n = 4.17%), and Horner syndrome (n = 2.8%). Although radiologic images showed classic lateral displacement of the carotid arteries in 10 patients (42%), in 9 patients (38%) the radiologic findings demonstrated splaying of the carotid arteries similar to carotid body tumor, and in 5 patients (20%), the findings were indeterminate. Twenty-one patients underwent surgical removal of the tumors with pathology revealing 10 paragangliomas, 10 schwannomas, and 1 neurofibroma. Horner (57%) and first-bite (33%) syndromes were the most common complications. CONCLUSIONS: Although anterolateral displacement of the carotids is suggestive of a sympathetic tumor, absence of these findings does not rule out this entity. To this end, we have included in this review a guide to preoperative radiologic diagnosis of parapharyngeal space lesions.

AlloDerm and DermaMatrix implants for parotidectomy reconstruction: a histologic study in the rat model.

BACKGROUND: We analyzed tissue incorporation, immune response, and neovascularization of AlloDerm and DermaMatrix in a rat model of postparotidectomy reconstruction. METHODS: In 8 male Sprague-Dawley rats, 3-dimensionally folded AlloDerm implants were placed in the left postparotidectomy bed and 3 in the anterior dorsum as controls. The same was done for DermaMatrix on the right side and posterior dorsum. Two animals were euthanized at 4, 8, and 12 days. A blinded pathologist assessed the degree of fibroblast proliferation, neovascularization, and inflammation. RESULTS: When compared with the dorsum, DermaMatrix implants in the parotid bed had significantly higher numbers of inflammatory cells at 8 and 12 days (p = .049 and .0046). AlloDerm acted more consistently between the postparotidectomy bed and dorsum. CONCLUSIONS: AlloDerm reacts similarly when comparing the postparotidectomy bed to the dorsum. DermaMatrix induces a more marked inflammatory reaction in the postparotidectomy bed when compared with the dorsum.

Natural history of cervical paragangliomas: outcomes of observation of 43 patients.

OBJECTIVE: To evaluate the outcomes, growth rate, and symptoms of nonoperated cervical paragangliomas. DESIGN: Retrospective review of clinical and radiologic records and images. SETTING: Tertiary academic medical center. PATIENTS: We studied all patients presenting with cervical paragangliomas between 1993 and 2010 who were observed rather than operated on. MAIN OUTCOME MEASURES: Growth of tumors and need for surgical removal. RESULTS: Forty-three patients with 47 tumors were identified. Mean patient age was 56 years (age range, 17-86 years). Thirty patients were asymptomatic (70%) (22 diagnosed by imaging for other reasons and 8 for workup of a neck mass), and only 5 presented with cranial nerve abnormalities (12%). No patients presented with lymphadenopathy, rapid growth, or pain. Reasons for observation were patient preference (n = 15; 35%), advanced age of patient (n = 12; 28%), and preexisting contralateral cranial nerve deficits (n = 11; 26%). Twenty-eight of the 47 tumors were suspected carotid body tumors based on imaging (60%), and 19 were suspected vagal tumors (40%). The mean greatest dimension at presentation was 2.6 cm (range, 1-7.2 cm). During a mean follow-up of 5 years (range, 1-17 years), 19 tumors remained stable in size (42%); 17 grew (38%); and 9 regressed (20%). Of the 17 tumors that grew, the mean growth was 0.2 cm/y. CONCLUSIONS: Observation of cervical paragangliomas is an option in selected patients who do not present with worrisome symptoms. The natural history of paragangliomas in these patients is typically little to no growth over time. Regular follow-up is important to ensure minimal change and stable symptoms.

Complications of alloderm and dermamatrix for parotidectomy reconstruction.

BACKGROUND: AlloDerm and DermaMatrix are 2 acellular dermal implants currently used by reconstructive surgeons at our institution for reconstruction of parotidectomy defects. We looked at the postoperative complication rates following subcutaneous implantation of these acellular dermal implants for parotid bed reconstruction. METHODS: A retrospective analysis was conducted following approval by the Institutional Review Board at Vanderbilt University Medical Center. All parotid and reconstructive operations were performed between 2001 and 2009 by 1 of 4 surgeons in the Department of Otolaryngology-Head and Neck Surgery. Data were collected to determine operative variables and postoperative course. Operative variables assessed were tumor type, type of implant used, type of parotidectomy (total or subtotal), and duration of Jackson Pratt (JP) drain placement. RESULTS: One hundred patients were analyzed. Sixty-nine AlloDerm implants were associated with 5 complications (7%), whereas 31 DermaMatrix implants were associated with 8 complications (26%) (p = .0107). When comparing total parotidectomies, the complication rate was 1 of 20 for AlloDerm (5%) and 1 of 12 for DermaMatrix (8%) (p = .7061). When looking at subtotal parotidectomies, the incidence of complications was found to be 4 of 49 for AlloDerm (8%) and 7 of 19 for DermaMatrix (37%) (p = .004). CONCLUSIONS: Our study suggests that DermaMatrix was associated with increased postoperative complications compared to AlloDerm, especially in the subset of patients undergoing subtotal parotidectomy.

Removal of obstructing T-tube and stabilization of the airway.

Although they are extremely effective in maintaining tracheal and subglottic patency, T-tubes themselves can result in airway obstruction from plugging. Many practitioners educate patients on placing a small (5.0) endotracheal tube (ETT) through the tracheal limb of the T-tube if they develop airway obstruction. Unfortunately, this can be a difficult task to complete during acute airway obstruction. In this article, we describe a simple set of steps for rapid relief of airway obstruction and stabilization of the airway in the event of T-tube obstruction. This method requires removal of the T-tube with a Kelly clamp and stabilization of the airway with a tracheostomy tube. Although it is simple, we hope that this technique will prevent morbidity and mortality from acute airway obstructions related to T-tubes.

Perineural extension to the skull base from early cutaneous malignancies of the midface.

OBJECTIVE: To document the clinical progression of four patients with a past history of complete removal of early midface cutaneous malignancies that presented years later with isolated recurrence along the distribution of the infraorbital nerve, and to discuss the diagnostic role of early imaging to identify perineural invasion. STUDY DESIGN: The study is a retrospective chart review, review of radiographic findings, and review of the literature. RESULTS: The authors report four cases of isolated perineural invasion along the infraorbital nerve resulting from previously excised cutaneous malignancies. CONCLUSIONS: Pain followed by anesthesia in the distribution of second division of the trigeminal nerve should alert the practitioner about possible perineural recurrence that may require imaging and open exploration to establish the diagnosis.

Thyroid cancer in pregnancy.

We report a case of papillary thyroid cancer in pregnancy and discuss the various diagnostic and therapeutic challenges inherent to this condition. Several case series are reviewed. In addition, we examine the effect of pregnancy on the development and progression of thyroid malignancy.

Retention, distribution, and effects of intraosseously administered ibandronate in the infarcted femoral head.

UNLABELLED: The local distribution, retention, and effects of intraosseous administration of ibandronate in the infarcted femoral heads were studied. Intraosseous administration effectively delivered and distributed ibandronate in the infarcted femoral heads and decreased the femoral head deformity in a large animal model of Legg-Calve-Perthes disease. INTRODUCTION: Bisphosphonate therapy has gained significant attention for the treatment of ischemic osteonecrosis of the femoral head (IOFH) because of its ability to inhibit osteoclastic bone resorption, which has been shown to contribute to the pathogenesis of femoral head deformity. Because IOFH is a localized condition, there is a need to explore the therapeutic potential of local, intraosseous administration of bisphosphonate to prevent the femoral head deformity. The purpose of this study was to investigate the distribution, retention, and effects of intraosseous administration of ibandronate in the infarcted head. MATERIALS AND METHODS: IOFH was surgically induced in the right femoral head of 27 piglets. One week later, a second operation was performed to inject (14)C-labeled or unlabeled ibandronate directly into the infarcted head. (14)C-ibandronate injected heads were assessed after 48 h, 3 weeks, or 7 weeks later to determine the distribution and retention of the drug using autoradiography and liquid scintillation analysis. Femoral heads injected with unlabeled ibandronate were assessed at 7 weeks to determine the degree of deformity using radiography and histomorphometry. RESULTS: Autoradiography showed that (14)C-Ibandronate was widely distributed in three of the four heads examined at 48 h after the injection. Liquid scintillation analysis showed that most of the drug was retained in the injected head, and almost negligible amount of radioactivity was present in the bone and organs elsewhere at 48 h. At 3 and 7 weeks, 50% and 30% of the (14)C-drug were found to be retained in the infarcted heads, respectively. Radiographic and histomorphometric assessments showed significantly better preservation of the infarcted heads treated with intraosseous administration of ibandronate compared with saline (p < 0.001). CONCLUSIONS: This study provides for the first time the evidence that local intraosseous administration is an effective route to deliver and distribute ibandronate in the infarcted femoral head to preserve the femoral head structure after ischemic osteonecrosis. In a localized ischemic condition such as IOFH, local administration of bisphosphonate may be preferable to oral or systemic administration because it minimizes the distribution of the drug to the rest of the skeleton and bypasses the need for having a restored blood flow to the infarcted head for the delivery of the drug.

Local bioavailability and distribution of systemically (parenterally) administered ibandronate in the infarcted femoral head.

Recent studies show that bisphosphonates can decrease the development of femoral head deformity following ischemic osteonecrosis by inhibiting osteoclast-mediated bone resorption. Given the potential new indication, improved understanding of pharmacokinetics of bisphosphonates as it applies to the infarcted head would be beneficial. The purpose of this study was to investigate the local bioavailability and the distribution of ibandronate in the infarcted head at the avascular and vascular phases of the disease process. Ischemic osteonecrosis of the femoral head was surgically induced in 15 piglets. One, 3, and 6 weeks following the induction of ischemia, which represent various stages of revascularization and repair, 14C-labeled ibandronate was administered intravenously. Twenty-four hours following 14C-drug administration, the level of radioactivity and its distribution in the infarcted heads were determined using liquid scintillation analysis and autoradiography. A significant correlation was found between the extent of revascularization and the level of radioactivity measured in the infarcted heads (r=0.80, P<0.05). The radioactivity level in the infarcted heads measured by liquid scintillation was similar to the negative controls at 1 week when revascularization was absent, but it increased significantly at 6 weeks when extensive revascularization was present (P