Evaluating the Reliability and Quality of YouTube Videos Regarding Medial Collateral Ligament Knee Injury as a Patient Education Resource.

OBJECTIVES: The purpose of this study was to assess the educational reliability and quality of videos shared on YouTube regarding medial collateral ligament (MCL) injuries of the knee. METHODS: Using the search keywords "medial collateral ligament" on YouTube, the first 50 videos were evaluated by two independent reviewers. Video characteristics were extracted, and each video was categorized by upload source and content type. Three scoring systems were used to evaluate the videos: the Journal of the American Medical Association (JAMA) Benchmark Score to assess a video's reliability; the Global Quality Score (GQS) to assess educational quality; the novel MCL Specific Score (MCL-SS) to assess MCL-specific content quality. Linear regression analyses were conducted to explore relationships between video characteristics and scores. RESULTS: Collectively, the videos were viewed 5,759,427 times with a mean number of views per video of 115,189 ± 177,861. The mean JAMA score was 1.8, GQS was 2.1, and MCL-SS was 5.6, indicating both poor reliability and quality. Only videos uploaded by physicians showed a statistically significantly higher mean MCL-SS (P = .032) but were still of low quality with a mean MCL-SS of 9.2 ± 5.9. Multivariate linear regression revealed that videos uploaded by physicians were statistically significant predictors of greater MCL-SS (ß = 4.108; P = .029). Longer video durations were statistically significant predictors of greater GQS (ß = .001; P = .002) and MCL-SS (ß = .007; P < .001). CONCLUSIONS: YouTube videos regarding MCL injuries, despite their popularity, were found to be on average of poor overall reliability and quality as measured by JAMA, GQS, and MCL-SS. LEVEL OF EVIDENCE: III - Cross-sectional Study.

Quality and Reliability Analysis of YouTube as a Source for Patient Education on Dupuytren's Contracture.

Purpose: This study seeks to assess the quality and reliability of YouTube videos on Dupuytren's contracture. Methods: The first 50 unique videos on Dupuytren's contracture were evaluated by searching YouTube for Dupuytren's contracture. Video metrics, source, and content type were recorded. Video reliability was assessed using the Journal of American Medical Association (JAMA) Benchmark criteria. Video educational quality was assessed using the Global Quality Score (GQS) and a Dupuytren's Contracture-Specific Score (DC-SS). Results: The total number of views for all 50 videos evaluated was 1,908,608 (mean, 38,172.16 ± 5,502.45 views). The mean reliability (JAMA) score was 2.21 ± 0.69 (range 0-4), the mean educational quality (GQS) score was 2.80 ± 1.28 (range 1-5), and the mean disease-specific (DC-SS) score was 6.05 ± 2.17 (range 0-15). Nonphysician health care professionals had the most popular videos, but the lowest DC-SS. GQS varied based on the video source, with physician-uploaded videos having the highest average quality scores. Physician source was an independent positive predictor of higher quality (GQS) (ß = 0.477). Conclusions: Videos on Dupuytren's contracture were frequently viewed on YouTube but had overall low educational quality and reliability. Of the videos that discussed collagenase as a treatment option, 40% failed to mention percutaneous needle aponeurotomy. Patients may be exposed to an incomplete set of treatment options. Educational content on YouTube should be interpreted cautiously and proper in-office education and high-quality resources for Dupuytren's contracture should be provided by physicians. Type of Study/Level of Evidence: Therapeutic IV.

The Effect of Pitch and Loudness Auditory Feedback Perturbations on Vocal Quality During Sustained Phonation.

OBJECTIVE: Dysphonia is a reduction in vocal quality that impacts communication and is often an early sign of a voice disorder. There is little information regarding the effects of auditory feedback control of loudness and pitch on voice quality. In this study, we used both loudness-shift and pitch-shift paradigms to study the relationship between auditory feedback control and vocal quality as measured by smoothed cepstral peak prominence (CPPS), which reflects the harmonicity of the voice signal. STUDY DESIGN: Experimental, mixed design. METHODS: We applied 200 ms loudness-shifts (± 0, 3, or 6 dB) and pitch-shifts (± 0, 50, and 100 cents) to auditory feedback during sustained vowel production in 25 healthy adults. We then measured CPPS before and after the loudness-shift or pitch-shift to investigate the effect of changes in auditory feedback on vocal harmonicity. RESULTS & CONCLUSIONS: Results showed that, on average, CPPS significantly decreased between the first half of the measured segment and the last half of the segment in the absence of auditory feedback shifts, suggesting that voice quality may be reduced across longer vowels over time. Upward and downward shifts in loudness auditory feedback caused a relative increase in CPPS, indicating an improvement in vocal harmonicity, even in cases when vocal intensity was reduced. Pitch alterations had inconsistent and minimal effects. We propose that there may be a control mechanism for voice quality that increases harmonicity of the voice signal to improve voice audibility (ie, ability to be heard) in the presence of unpredictable variability in voice intensity.

Auditory-Motor Control of Fundamental Frequency in Vocal Vibrato.

PURPOSE: The purpose of this study was to investigate how classically trained singers use their auditory feedback to control fundamental frequency (fo) during production of vocal vibrato. Two main questions were addressed: (1) Do singers produce reflexive foresponses to sudden perturbation of the fo of their auditory feedback during production of vibrato indicative of feedback control? (2) Do singers produce adaptive foresponses to repeated perturbation of the fo of their auditory feedback during production of vibrato indicative of feedback and feedforward control? In addition, one methodological question was addressed to determine if adaptive fo responses were more precisely assessed with or without an auditory cue for fo during the repeated fo perturbation paradigm. METHOD: Ten classically trained singers produced sustained vowels with vibrato while the fo and harmonics of their auditory feedback were suddenly perturbed by 100 cents to assess reflexive control or repeatedly perturbed by 100 cents to assess adaptive control. Half of the participants completed the repeated perturbation experiment with an auditory cue for fo, and the other half completed the experiment without an auditory cue for fo. Acoustical analyses measured changes in mean fo in response to the auditory feedback perturbations. RESULTS: On average, participants produced compensatory responses to both sudden and repeated perturbation of the fo of their auditory feedback. The magnitude of the responses to repeated perturbations was larger than the responses to sudden perturbations. Responses were also larger in the cued, repeated fo perturbation experiment than in the uncued, repeated fo perturbation experiment. CONCLUSIONS: These findings indicate that classically-trained singers use both feedforward and feedback mechanisms to control their average fo during production of vibrato. When compared to prior studies of singers producing a steady voice, the reflexive fo responses were larger in the current study, which may indicate that the feedback control system is engaged more during production of vibrato.

Task-Dependent Modulation of Auditory Feedback Control of Vocal Intensity.

Auditory feedback control of fundamental frequency (fo) is modulated in a task-dependent manner. When voice pitch auditory feedback perturbations are applied in sentence versus sustained-vowel production, larger and faster vocal fo responses are measured in sentence production. This task-dependency reflects the scaling of auditory targets for pitch for the precision required in each speech task. When the range for the pitch auditory target is scaled down for precision (as in the sentence-production task), a greater degree of mismatch is detected from the feedback perturbation and a larger vocal response is measured. The purpose of this study was to determine whether auditory feedback control of vocal intensity is also modulated in a task-dependent manner similar to the control of vocal pitch. Twenty-five English speakers produced repetitions of a sentence and a sustained vowel while hearing their voice auditory feedback briefly perturbed in loudness (+/- 3 or 6 dB SPL, 200 ms duration). The resulting vocal intensity responses were measured, and response magnitudes were robustly larger in the sentence (mean: 1.96 dB) than vowel production (mean: 0.89 dB). Additionally, response magnitudes increased as a function of perturbation magnitude only in sentence production for downward perturbations but decreased in magnitude by perturbation magnitude for upward perturbations. Peak response latencies were robustly shorter in sentence (mean: 184.94 ms) than in vowel production (mean: 214.92 ms). Overall, these results support the hypothesis that auditory feedback control of pitch and loudness are modulated by task and that both pitch and loudness auditory targets are scaled for the precision required for the speaking task.

The Effects of Masked and Delayed Auditory Feedback on Fundamental Frequency Modulation in Vocal Vibrato.

PURPOSE: Although relatively precise control over the extent and rate of fundamental frequency (fo) modulation may be needed for optimal production of vibrato, the role of auditory feedback in controlling vibrato is not well understood. Previous studies altered the gain and timing of auditory feedback in singers producing vibrato and showed inconsistent effects on the extent and rate of fo modulation, which may have been related to small sample sizes or limited analyses. Therefore, the purpose of this study was to further investigate whether the gain or timing of auditory feedback impacts control of vibrato in a larger sample of speakers and with advanced statistical analyses. METHOD: Ten classically-trained singers produced sustained vowels with vibrato while their auditory feedback was masked with pink noise or multi-talker babble to reduce the gain of their auditory feedback and while their auditory feedback was delayed by about 200 or 300 milliseconds to alter the timing of their auditory feedback. Acoustical analyses measured changes in the extent and rate of fo modulation in the masked and delayed trials relative to control trials. Bayesian modeling was used to analyze the effects of noise-masked, babble-masked, and delayed auditory feedback on the extent and rate of fo modulation. RESULTS: There was compelling evidence that noise masking increased the extent of fo modulation, and babble masking increased the variability in the rate of fo modulation (ie, jitter of fo modulation). Masked auditory feedback did not affect the average rate of fo modulation. Delayed auditory feedback did not affect the extent, rate, or jitter of fo modulation. CONCLUSIONS: The current study demonstrated that reducing the gain of the auditory feedback with noise masking increased the extent of fo modulation but did not affect the average rate of fo modulation in classically-trained singers producing vibrato. Reducing the gain of the auditory feedback with babble masking and altering the timing of auditory feedback with imposed delays did not affect the average extent or rate of fo modulation. However, babble masking increased the jitter of fo modulation rate, which suggests that modulated auditory feedback may affect the periodicity of fo modulation from one modulation cycle to the next. These findings clarify the role of auditory feedback in controlling vibrato and may inform the current reflex-resonance models of vibrato.

Meniscus cell regional phenotypes: Dedifferentiation and reversal by biomaterial embedding.

Meniscus injuries are common and a major cause of long-term joint degeneration and disability. Current treatment options are limited, so novel regenerative therapies or tissue engineering strategies are urgently needed. The development of new therapies is hindered by a lack of knowledge regarding the cellular biology of the meniscus and a lack of well-established methods for studying meniscus cells in vitro. The goals of this study were to (1) establish baseline expression profiles and dedifferentiation patterns of inner and outer zone primary meniscus cells, and (2) evaluate the utility of poly(ethylene glycol) diacrylate (PEGDA) and gelatin methacrylate (GelMA) polymer hydrogels to reverse dedifferentiation trends for long-term meniscus cell culture. Using reverse transcription-quantitative polymerase chain reaction, we measured expression levels of putative meniscus phenotype marker genes in freshly isolated meniscus tissue, tissue explant culture, and monolayer culture of inner and outer zone meniscus cells from porcine knees to establish baseline dedifferentiation characteristics, and then compared these expression levels to PEGDA/GelMA embedded passaged meniscus cells. COL1A1 showed robust upregulation, while CHAD, CILP, and COMP showed downregulation with monolayer culture. Expression levels of COL2A1, ACAN, and SOX9 were surprisingly similar between inner and outer zone tissue and were found to be less sensitive as markers of dedifferentiation. When embedded in PEGDA/GelMA hydrogels, expression levels of meniscus cell phenotype genes were significantly modulated by varying the ratio of polymer components, allowing these materials to be tuned for phenotype restoration, meniscus cell culture, and tissue engineering applications.

Intraoperative use of optical coherence tomography to differentiate normal and diseased thyroid and parathyroid tissues from lymph node and fat.

The purpose of this study is twofold: (1) to determine the feasibility of optical coherence tomography (OCT) to differentiate normal and diseased tissue of the neck region intraoperatively and (2) to evaluate how accurately a cohort of test subjects can identify various tissue types when shown a sample set of OCT images. In this in vivo, prospective, single institutional study, an OCT imaging system (Niris, Imalux, Cleveland, OH) was used to image parathyroid, thyroid, lymph node, and fat tissue in 76 patients during neck surgery. Biopsies were performed for comparison of OCT images with histology in select cases (n = 20). Finally, a group of either surgeons or scientists familiar with OCT (n = 17) were shown a sample of OCT images and asked to identify the tissue. A total of 437 OCT images were analyzed, and characteristic features of each tissue type were identified. OCT demonstrated distinct differences in structural architecture and signal intensity that allows differentiation between thyroid and parathyroid tissues, lymph nodes, and fat. OCT images were also compared with histology with good correlation. There was no difference in correctly identifying OCT-imaged tissue type between surgeons and scientists. This study is the first in vivo OCT imaging study to evaluate both normal and diseased tissues that may be encountered during neck surgery. OCT has the potential to become a valuable intraoperative tool to differentiate diseased and normal thyroid tissue intraoperatively to obtain an "optical biopsy" in real time without fixation, staining, or tissue resection.

The Effect of Pitch Auditory Feedback Perturbations on the Production of Anticipatory Phrasal Prominence and Boundary.

Purpose In this study, we investigated how the direction and timing of a perturbation in voice pitch auditory feedback during phrasal production modulated the magnitude and latency of the pitch-shift reflex as well as the scaling of acoustic production of anticipatory intonation targets for phrasal prominence and boundary. Method Brief pitch auditory feedback perturbations (±200 cents for 200-ms duration) were applied during the production of a target phrase on the first or the second word of the phrase. To replicate previous work, we first measured the magnitude and latency of the pitch-shift reflex as a function of the direction and timing of the perturbation within the phrase. As a novel approach, we also measured the adjustment in the production of the phrase-final prominent word as a function of perturbation direction and timing by extracting the acoustic correlates of pitch, loudness, and duration. Results The pitch-shift reflex was greater in magnitude after perturbations on the first word of the phrase, replicating the results from Mandarin speakers in an American English-speaking population. Additionally, the production of the phrase-final prominent word was acoustically enhanced (lengthened vowel duration and increased intensity and fundamental frequency) after perturbations earlier in the phrase, but more so after perturbations on the first word in the phrase. Conclusion The timing of the pitch perturbation within the phrase modulated both the magnitude of the pitch-shift reflex and the production of the prominent word, supporting our hypothesis that speakers use auditory feedback to correct for immediate production errors and to scale anticipatory intonation targets during phrasal production.

Mechanisms of voice control related to prosody in autism spectrum disorder and first-degree relatives.

Differences in prosody (e.g., intonation, rhythm) are among the most obvious language-related impairments in autism spectrum disorder (ASD), and significantly impact communication. Subtle prosodic differences have also been identified in a subset of clinically unaffected first-degree relatives of individuals with ASD, and may reflect genetic liability to ASD. This study investigated the neural basis of prosodic differences in ASD and first-degree relatives through analysis of feedforward and feedback control involved in the planning, production, self-monitoring, and self-correction of speech by using a pitch-perturbed auditory feedback paradigm during sustained vowel and speech production. Results revealed larger vocal response magnitudes to pitch-perturbed auditory feedback across tasks in ASD and ASD parent groups, with differences in sustained vowel production driven by parents who displayed subclinical personality and language features associated with ASD (i.e., broad autism phenotype). Both ASD and ASD parent groups exhibited increased response onset latencies during sustained vowel production, while the ASD parent group exhibited decreased response onset latencies during speech production. Vocal response magnitudes across tasks were associated with prosodic atypicalities in both individuals with ASD and their parents. Exploratory event-related potential (ERP) analyses in a subgroup of participants during the sustained vowel task revealed reduced P1 ERP amplitudes in the ASD group, with similar trends observed in parents. Overall, results suggest underdeveloped feedforward systems and neural attenuation in detecting audio-vocal feedback may contribute to ASD-related prosodic atypicalities. Importantly, results implicate atypical audio-vocal integration as a marker of genetic risk to ASD, evident in ASD and among clinically unaffected relatives. Autism Res 2019, 12: 1192-1210. © 2019 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals, Inc. LAY SUMMARY: Previous research has identified atypicalities in prosody (e.g., intonation) in individuals with ASD and a subset of their first-degree relatives. In order to better understand the mechanisms underlying prosodic differences in ASD, this study examined how individuals with ASD and their parents responded to unexpected differences in what they heard themselves say to modify control of their voice (i.e., audio-vocal integration). Results suggest that disruptions to audio-vocal integration in individuals with ASD contribute to ASD-related prosodic atypicalities, and the more subtle differences observed in parents could reflect underlying genetic liability to ASD.

Modulation of auditory-vocal feedback control due to planned changes in voice fo.

Previous studies have demonstrated that voice fundamental frequency (fo), or pitch, relies on auditory feedback to monitor and correct for errors in production. When voice-pitch auditory feedback is unexpectedly perturbed, individuals typically produce a compensatory change in fo that opposes the direction of the pitch-perturbation. Studies comparing steady vowel vocalizations and speech tasks have demonstrated task-dependent modulation of the compensatory response, but the effects of planning to volitionally change fo during active vocalization have yet to be explored. Ten musicians and ten non-musicians were asked to perform two vocal tasks. Both tasks started off at a conversational fo. In one task, pitch-shifted feedback was presented when the participants were planning to hold fo constant (steady fo), and in the other, feedback was shifted while participants were in the planning stage prior to raising fo (raised fo) from a steady state. Acoustical analyses of fo were performed to measure the peak magnitude and latency of both the compensatory response as well as the voluntary fo change. Results showed that planning to change pitch modulates the mechanisms controlling feedback-based error correction of fo, and musicality affects how individuals incorporate modulations in auditory feedback with the feedforward plans to increase voice fo.

Is It Worth Discriminating Against Patients Who Smoke? A Systematic Literature Review on the Effects of Tobacco Use in Foot and Ankle Surgery.

Although numerous studies have linked smoking with lower extremity wound and bone healing complications, a comprehensive study on the effects of smoking in foot and ankle surgery has not yet been reported. The purpose of the present study was to report the results of our systemic literature review, identifying the effects of tobacco use on common foot and ankle procedures. The systematic literature review was performed according to guidelines set by the PRIMSA statement (Preferred Reporting Items for Systematic Review and Meta-Analyses). Smoking, as a single risk factor, was analyzed and used to compare adverse outcomes in the postoperative setting of foot and ankle surgery. We reviewed 528 abstracts that met our initial identification criteria. After an extensive review process, 46 of the articles (8.71%) met the eligibility requirements to be included in the present study. Distal bunionectomy with osteotomy, first metatarsophalangeal joint arthrodesis, Lapidus bunionectomy, toe amputation, transmetatarsal amputation, Syme's amputation, open reduction internal fixation (ORIF) of calcaneal fractures, ankle fracture ORIF, pilon fracture ORIF, subtalar arthrodesis, rearfoot arthrodesis, tibiocalcaneal arthrodesis, ankle arthrodesis, total ankle arthroplasty, and plastic surgery procedures and their respective negative association with smoking was identified and described in our review. Our systematic literature review revealed that procedures involving arthrodesis, fracture ORIF, and plastic surgery were associated with negative outcomes in smokers. Procedures that did not involve osseous unions such as total ankle arthroplasty and amputations did not appear to have negative outcomes associated with smoking.

Host lysozyme-mediated lysis of Lactococcus lactis facilitates delivery of colitis-attenuating superoxide dismutase to inflamed colons.

Beneficial microbes that target molecules and pathways, such as oxidative stress, which can negatively affect both host and microbiota, may hold promise as an inflammatory bowel disease therapy. Prior work showed that a five-strain fermented milk product (FMP) improved colitis in T-bet(-/-) Rag2(-/-) mice. By varying the number of strains used in the FMP, we found that Lactococcus lactis I-1631 was sufficient to ameliorate colitis. Using comparative genomic analyses, we identified genes unique to L. lactis I-1631 involved in oxygen respiration. Respiration of oxygen results in reactive oxygen species (ROS) generation. Also, ROS are produced at high levels during intestinal inflammation and cause tissue damage. L. lactis I-1631 possesses genes encoding enzymes that detoxify ROS, such as superoxide dismutase (SodA). Thus, we hypothesized that lactococcal SodA played a role in attenuating colitis. Inactivation of the sodA gene abolished L. lactis I-1631's beneficial effect in the T-bet(-/-) Rag2(-/-) model. Similar effects were obtained in two additional colonic inflammation models, Il10(-/-) mice and dextran sulfate sodium-treated mice. Efforts to understand how a lipophobic superoxide anion (O2 (-)) can be detoxified by cytoplasmic lactoccocal SodA led to the finding that host antimicrobial-mediated lysis is a prerequisite for SodA release and SodA's extracytoplasmic O2 (-) scavenging. L. lactis I-1631 may represent a promising vehicle to deliver antioxidant, colitis-attenuating SodA to the inflamed intestinal mucosa, and host antimicrobials may play a critical role in mediating SodA's bioaccessibility.

Optical coherence tomography of the larynx using the Niris system.

OBJECTIVES: To present our experience using the first commercially available optical coherence tomography (OCT) device for use in the head, neck, and upper aerodigestive tract and to determine the feasibility and efficacy of this system in comparison with our previous experience using other research OCT systems. METHODS: Using the Niris OCT imaging system (Imalux, Cleveland, OH), we obtained OCT images of benign and premalignant laryngeal disease in 33 patients undergoing surgical head and neck endoscopy. This imaging system has a spatial depth resolution of 10 to 20 mum and a depth scanning range of 2.2 mm, obtaining images of 200 x 200 pixels at a maximum frame rate of 0.7 Hz. The scanning mechanism of the device is located at the distal end of a flexible probe that is placed in contact or near-contact with the area of interest. The tip of the probe was inserted through a rigid laryngoscope, and still images were obtained. RESULTS: OCT images of arytenoids, aryepiglottic folds, piriform sinus, epiglottis, and true and false vocal cords were obtained. In patients whose OCT images were taken from normal tissue, the normal microstructures were clearly identified, as well as disruption of the latter in malignant pathologies. CONCLUSIONS: The device can easily be incorporated into the operating room and requires minimal set-up and staff to operate. OCT imaging with this device potentially offers an efficient, quick, and reliable imaging modality in guiding surgical biopsies, intraoperative decision making, and therapeutic options of various laryngeal pathologies and premalignant disease.

Solitary fibrous tumor of the larynx.

BACKGROUND: True mesenchymal, non-cartilaginous neoplasms of the larynx are rare. Extrapleural solitary fibrous tumor (SFT) is a localized neoplasm characterized by proliferation of thin-walled vessels and collagen-producing cells and is considered within the "hemangiopericytoma-solitary fibrous tumor" spectrum. SFT primary in the larynx is exceptional. DESIGN: Case report set in a comparison with other cases reported in the English literature (MEDLINE 1966 to 2007). RESULTS: A 49-year old white male presented with difficulty breathing, progressive over the past 2 years. He denied dysphagia and weight loss. Past medical history was significant for asthma. He denied cigarette smoking or alcohol abuse. There were no cervical deformities on physical exam. Fiberoptic laryngoscopy was performed upon stabilization of respiratory function. A smooth, round, submucosal mass measuring 2.3 cm in greatest diameter arising from the inferior surface of left true vocal cord was causing near total obstruction of the endolaryngeal space. The mass was excised. The surface mucosa was intact and unremarkable. A cellular, spindle cell neoplasm was arranged in loose fascicles, associated with heavy collagen fiber deposition. The collagen was wiry and heavy. Cells were bland with cytoplasmic extensions. The nuclei were vesicular to hyperchromatic and elongated with inconspicuous nucleoli. Vessels were prominent and delicate, with patulous spaces. Mitotic figures were easily identified, but atypical forms were not present. The cells were strongly and diffusely immunoreactive with CD34 and bcl-2, while non-reactive with cytokeratin, EMA, actin, ALK-1, S100, desmin, and CD117. These findings confirmed a diagnosis of extraplural solitary fibrous tumor. Without further disease, the patient is alive without evidence of disease, 12 months after surgery. CONCLUSIONS: The characteristic histologic pattern of solitary fibrous tumor can be noted in extrapulmonary locations. Development in the larynx is uncommon, but the tumor presents as a polypoid mass with characteristic histologic and immunophenotypic features. Conservative local excision is the treatment of choice to yield an excellent prognosis.

Role of free tissue transfer in skull base reconstruction.

OBJECTIVE: Free tissue transfer to the skull base provides a watertight seal to prevent CSF leakage and donor tissue tailored to the individual defect. STUDY DESIGN AND SETTING: Retrospective chart review of 38 patients who underwent free tissue transfer to the skull base between November 1995 and October 2005 at an academic, tertiary referral center. RESULTS: There were 23 male and 15 female patients (average age, 58.1 years) with skull base defects resulting from oncologic resection or head trauma most frequently. Donor sites included the radial forearm (25), rectus abdominis (12), latissimus dorsi (4), anterolateral thigh, scapula, serratus anterior, and ulna (1 each). Seven patients required a second free tissue transfer indicated for flap death (3), partial flap necrosis (2), pneumocephalus (1), or tumor recurrence (1). Two patients died in the immediate postoperative period. CONCLUSIONS: Free tissue transfer is a robust option in the repair of post-surgical and post-traumatic skull base defects.

Second osteocutaneous fibular free flaps for head and neck defects.

OBJECTIVE: To analyze the morbidity of a second fibular free tissue transfer when necessary in rare instances when the initial fibular flap fails. CASE DESIGN: Retrospective analysis of a case series. METHODS: A database of patients who underwent resection of head and neck malignancies with resultant free flap reconstruction was analyzed retrospectively. All patients undergoing fibular free flaps were studied, and those needing a second fibular osteocutaneous flap were identified. The morbidity from the second flap was evaluated by a standard questionnaire. RESULTS: Seven patients underwent a second fibular osteocutaneous flaps for reconstruction; data were available from six. The indications for the second flap were perioperative flap loss (5 patients), osteoradionecrosis (1), and recurrent tumor (1). Follow-up began at 3 months; mean follow-up was 44 (range 9-67) months. The morbidity of harvesting a second fibular flap was similar to that of a unilateral harvest. Four of six patients rated their overall morbidity as low; one patient indicated an intermediate morbidity, and one patient rated their morbidity from the procedure as major. The only donor site morbidities were episodes of mild cellulitis that resolved with outpatient antibiotics. CONCLUSION: Harvest of a second fibular osteocutaneous is a reasonable option for reconstruction when a second flap becomes needed. The morbidities are comparable with those encountered with a unilateral fibular flap harvest.