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Osteoradionecrosis (ORN) of the skull base and craniovertebral junction is a challenging complication of radiation therapy (RT). Severe cases often require surgical intervention through a multi-modal approach. With the evolution in endoscopic surgery and advances in skull base reconstruction, there is an increasing role for microvascular free tissue transfer (MFTT). We describe an endoscopic-assisted approach for the management of ORN of the skull base using fascia lata for MFTT.Retrospective case series.Between 2017 and 2021, a review of all cases in which fascia lata MFTT was utilized for skull base ORN was performed. Patient demographics, preoperative characteristics, and postoperative outcomes with long-term follow-up were reviewed.Five patients were identified. Mean duration to onset of ORN was 17 months following RT. A trial of antibiotics, hyperbaric oxygen (HBO), and/or limited debridement was attempted without success. Refractory pain and progressive osteomyelitis were unifying symptoms. All patients underwent endoscopic debridement of the affected region of ORN prior to MFTT. Vascularized fascia lata was inset through a combined endonasal and transoral corridor. There was improvement in chronic pain in the postop setting with no patients requiring continued antibiotics or HBO therapy. Mean post-op follow-up was 23 months.With continued evolution in endoscopic, minimally invasive approaches, there is an expanding indication for early surgical management in refractory ORN. Fascia lata MFTT is a novel and effective strategy for the management of ORN of the skull base and upper cervical spine with excellent postoperative outcomes and limited patient morbidity.4 Laryngoscope, 2022.

BACKGROUND Predictive models to forecast the likelihood of specific outcomes after surgical intervention allow informed shared decision-making by surgeons and patients. Previous studies have suggested that existing general surgical risk calculators poorly forecast head and neck surgical outcomes. However, no large study has addressed this question while subdividing subjects by surgery performed. OBJECTIVES To determine the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator in estimating length of hospital stay and risk of postoperative complications after free tissue transfer surgery. STUDY DESIGN A retrospective chart review of patients at one institution was performed using Current Procedural Terminology codes for anterolateral thigh (ALT) flap, fibula free flap (FFF), and radial forearm free flap (RFFF) reconstruction. Output data from the ACS NSQIP surgical risk calculator were compared with the observed rates in our patients. METHODS Incidences of cardiac complications, pneumonia, venous thromboembolism, return to the operating room, and discharge to skilled nursing facility (SNF) were compared to predicted incidences. Length of stay was also compared to the predicted length of stay. RESULTS Three hundred thirty-six free flap reconstructions with 197 ALT flaps, 85 RFFFs, and 54 FFFFs were included. Brier scores were calculated using ACS NSQIP forecast and actual incidences. No Brier score was

Osteoradionecrosis (ORN) of the mandible is a rare but devastating complication which occurs following radiation therapy for head and neck malignancies. Left untreated, ORN often results in pathologic fracture of the mandible leading to pain, trismus, difficulty eating, and overall poor quality of life. Historically, early intervention relied on hyperbaric oxygen and local debridement. Patients whose disease progressed despite therapy required segmental resection of the mandible with osseous free flap reconstruction, a highly invasive operation. Patients that presented with a moderate disease without pathologic fracture were often doomed to fail non-operative management, ultimately leading to disease progression and fracture. The traditional dichotomous treatment paradigm left a void of options for patients with moderate disease. The ideal intervention for this category of patients would provide renewed vascularity to the diseased tissue bed allowing for the osteogenesis and reestablishment of strong, load-bearing bone. The innovative technique termed the vascularized fascia lata "rescue flap" has proven to be an effective treatment for moderate ORN and will likely transform dated treatment algorithms.

OBJECTIVES To demonstrate that the anterolateral thigh fascia lata (ALTFL) rescue flap may be effectively used for management of osteoradionecrosis (ORN) in selected patients. STUDY DESIGN Retrospective case review. METHODS Retrospective chart review was performed on patients who underwent ALTFL free flap repair to various sites of ORN in the head and neck between 2011 and 2018. Inclusion criteria were patients with radiographic and clinical evidence of head and neck ORN who either failed previous hyperbaric oxygen (HBO) therapy or with extensive disease, which was unlikely to respond to conservative management. RESULTS Twenty-three patients with average age of 63 years (40-78) who underwent 24 ALTFL free flap procedures were reviewed. ORN sites were the mandible (n = 16), palatomaxilla (n = 4), skull base and cervical spine (n = 3), and calvarium (n = 2). Recipient vessels used were superficial temporal (n = 11), common facial (n = 10), and angular (n = 3). Average hospital stay was 3.0 (1-10) days. Prior HBO therapy was performed in 13 (57%) patients. There were four major complications: flap failure, recurrent mandibular infection resolved with IV antibiotic course, mandibular fracture with malunion requiring occlusal adjustment, and unresolved sequelae of ORN requiring fibular free flap. There were four minor complications: thigh hematoma, thigh seroma, and intraoral scar formation causing trismus (n = 2). The procedure was successful in 22 of 23 (95.7%) patients with radiographic arrest of ORN, resolution of symptoms, and elimination of antibiotic requirements. CONCLUSION The ALTFL rescue flap merits strong consideration in ORN management and appears to prevent progression to more extensive disease, which would require full segmental bone resection and reconstruction. LEVEL OF EVIDENCE 4 Laryngoscope, 131:2688-2693, 2021.

The facial artery and vein, frequently utilized in microvascular head and neck reconstruction, have traditionally been exposed via limited neck dissection or similar neck exploration techniques. However, when neck dissection is not required and/or increased superior pedicle reach is required, these vessels are amenable to isolation via a small aesthetically favorable incision just below the inferior mandible border at the facial notch. The technique described in the following chapter allows for facile vessel access and isolation with minimal morbidity and negligible risk to adjacent neural structures.

Introduction The reconstructive goals following radical parotidectomy include restoration of symmetry, reanimation of the face, and reestablishment of oral competence. We present our experience utilizing the anterolateral thigh (ALT) free flap, orthodromic temporalis tendon transfer (OTTT), and facial nerve cable grafting to reestablish form and function. Material and methods From 2010 to 2016, 17 patients underwent radical parotidectomy followed by immediate reconstruction. An ALT was harvested to accommodate the volume and skin defect. Additional fascia lata and motor nerve to vastus lateralis (MNVL) were obtained. Anastomosis of the ALT to recipient vessels was performed, most commonly using the facial artery and internal jugular vein. OTTT was performed by securing the medial tendon of the temporalis to orbicularis oris through a nasolabial incision. Fascia lata was tunneled through the lower lip, then secured laterally to the temporalis tendon. The MNVL was cable grafted from either the proximal facial nerve or masseteric nerve to the distal facial nerve branches. ALT fascia was suspended to the superficial muscular aponeurotic system. Results Average follow up was 19 months. Only one patient failed to achieve symmetry attributed to dehiscence of OTTT. All patients achieved oral competence and dynamic smile with OTTT activation. Facial nerve recovery was seen in 8 patients. 5 reached a House Brackman Score of 3. Two donor site seromas and two wound infections occurred. Conclusion Simultaneous ALT, OTTT, and facial nerve cable grafting provides early reestablishment of facial symmetry, facial reanimation, and oral competence with minimal morbidity.

Objective Reconstruction of maxillectomy defects offers potential quality-of-life improvement, although cavity coverage may impact surveillance of recurrent malignancy. We describe the pattern of postmaxillectomy locoregional recurrence. Study Design Retrospective review. Methods Patients from 2001 to 2011 at the University of California, San Francisco and the Cleveland Clinic. Results Among 75 patients with malignancy resulting in partial or total maxillectomy, 57 were treated with obturators and 18 underwent reconstructive surgery. Disease recurrence occurred primarily locally (19 of 22 cases of recurrence, 25% of the cohort) at a mean of 17 months postoperatively. Recurrence was associated with T4 disease, positive margins, and surveillance imaging. Four (5.3%) patients required flap mobilization/obturator removal to obtain biopsy. Salvage surgery was attempted in 13 of the 19 cases with recurrent disease (68%) and was successful in six (46%) patients. Of these, five patients initially had Brown type 1 or type 2 defects. The free flap had to be revised in one (1.3%) patient to achieve successful salvage. Conclusion Maxillectomy provides good long-term locoregional oncologic control, with cure being correlated to disease stage at presentation and negative margins after initial surgery. Patients with recurrent disease whose initial resection resulted in a Brown class 3 defect or greater were rarely successfully salvaged. Surveillance is best performed with a combination of physical exam and imaging. Obturator removal/flap mobilization rarely impedes the diagnosis of recurrent disease, and either modality should be offered to appropriate patients in the primary setting if significant quality-of-life improvement is likely. Level of Evidence 4. Laryngoscope, 2017

Objectives This study aims to introduce a novel technique for the reconstruction of the anterior skull base using a free vascularized anterolateral thigh fascia lata free flap (FLFF) anastomosed to the superior trochlear artery (STA). Methods The diameter of the STA was measured in 38 (76 sides) computed tomography angiographies (CTAs). Independently, six cadaver heads were used to measure the diameter of the supratrochlear system, and the model was applied to one of them. Results In women, the average diameter of the STA was 2.5 and 2.8 mm2 for the right and left sides, respectively; for men, it was 3.0 and 3.2 mm2, respectively. In cadavers, the average diameter of both STA was 2.5 mm2. There was no statistical difference when comparing the right and left STA diameters between the CTA from women and men (p Conclusion The STA is a constant vessel with a 2.5 to 3.0 mm2 diameter in men and women that can be used as a recipient free flap vessel. The FLFF can cover the entire skull base. This is a novel method to reconstruct the anterior skull base when local flaps are not available.

The typical presentation of infectious mononucleosis (IM) is characterized by a triad of fever, pharyngitis, and lymphadenopathy. Epstein-Barr virus (EBV) is the most common etiologic agent for IM. Humans are the reservoir for EBV, and it is transmitted via intimate contact between individuals. This case presents a 19-year-old male with recurrent cemento-ossifying fibroma of the skull base with a complicated post-operative course including bacterial meningitis, cerebrospinal fluid (CSF) leak, and intermittent fevers despite treatment with intravenous cefepime. Head computed tomography (CT) revealed a nonspecific subdural collection that could represent an empyema. However, exploratory craniotomy revealed no empyema. CT chest demonstrated bilateral hilar mediastinal lymphadenopathy and splenomegaly. Blood work for fever of unknown origin was positive for EBV immunoglobulin M, and EBV deoxyribonucleic acid 180,565 IU/mL. The diagnosis of EBV IM in this case was elusive because it presented post-operatively, symptoms aligned with the patient’s CSF leak, and he reported no sexual or sick contacts. For post-operative young patients with recurrent fevers of unknown origin, it is important to consider EBV IM in the differential. Earlier diagnosis could have saved the patient unneeded tests, prevented surgical re-exploration, and resulted in a shorter hospital stay.

Introduction Demonstrate that carefully selected free flap patients may be discharged early after surgery without increasing the rates of postoperative complications or readmissions. Methods Based on a published article in Laryngoscope 2016 of 51 free-tissue transfers, a retrospective chart review was performed on an expanded cohort who underwent free-tissue transfer for head and neck reconstruction between February 2010 and May 2018 and discharged by postoperative day 3. Results 101 patients who underwent 104 free flaps with average age of 56 (3–84) years old were reviewed. Free flap indications included orbital and maxillary defects (n = 22), palatal defects (n = 16), nasal and septal defects (n = 16), cranioplasty and scalp defects (n = 16), mandibular defects due to osteoradionecrosis (n = 14), facial contouring and parotid defects (n = 12), and complex postsurgical and radiotherapy wounds or fistula closure (n = 8). Free flaps performed were anterolateral thigh (n = 97), radial forearm (n = 2), serratus (n = 2), latissimus (n = 1), fibula (n = 1) and supraclavicular (n = 1). The recipient vessels used via minimal access approaches were facial (n = 43), superficial temporal (n = 29), angular (n = 20) and others. There were 3 flap failures (2.9%) recognized in follow-up. No flap failures or perioperative complications were associated with early discharge. There were only 2 patients readmitted and 1 watched in observation within 30 days postoperatively. Conclusion An updated review of our institutional experience with more than double the cohort size substantiates previous conclusions that early discharge after free-tissue transfer is a safe option in select patients. Moreover, earlier discharge is a critical management choice that reduces cost and decreases hospital-related adverse events.

Background In the setting of major nasal framework reconstruction, it is critical to create a stable, warp-resistant L-strut to resist the contractile forces of healing to achieve a durable outcome. Objectives The authors sought to demonstrate the effectiveness of the osseocartilaginous rib graft for nasal framework reconstruction. Methods Retrospective analysis was performed of all patients who underwent osseocartilaginous rib graft for L-strut reconstruction from 2007 to 2017 at a tertiary care hospital. Only patients with severe framework-only defects (Type IV, Daniel Classification) or total/subtotal nasal defects (Type V, Daniel Classification) were included. Primary outcome measures were: (1) maintenance of projection; (2) graft warping; and (3) graft resorption. Results Twenty-six patients aged an average of 54.6 years underwent nasal framework reconstruction with an osseocartilaginous rib graft L-strut. Eighteen patients had framework-only deformities (Daniel Type IV) and 8 had total or subtotal nasal deformities (Daniel Type V). Twelve patients underwent reconstruction for autoimmune mediated deformity, 10 for malignancy, 3 for traumatic injury, and 1 for an iatrogenic deformity. Average follow-up was 21 months. There was no observed warping of the L-strut construct, and all but 2 patients demonstrated total maintenance of projection. Resorption of the caudal cartilage graft was identified as the etiology of partial loss of projection in 2 patients. Conclusions The osseocartilaginous rib graft L-strut provides a stable, warp-resistant construct for patients lacking major dorsal and caudal support, which may be applied to reconstruction of defects due to malignancy, autoimmune, traumatic, or iatrogenic etiologies. Level of Evidence: 4

Objectives/Hypothesis To show that, for patients with few medical comorbidities and at low risk for airway compromise or fistula formation, early discharge after free tissue transfer for head and neck reconstruction is a safe and viable option. Study Design Retrospective chart review. Methods A cohort of patients who underwent free tissue transfer for head and neck reconstruction between February 2010 and December 2014 and who were discharged from the hospital by postoperative day 3 were reviewed. Results Fifty patients undergoing 51 free-tissue transfer surgeries were discharged by postoperative day 3. The surgeries performed included anterolateral thigh free flaps (ALT) (n = 46), radial forearm free flaps (n = 2), latissimus myogenous and myocutaneous free flaps (n = 1), supraclavicular free flap (n = 1), and serratus free flap (n = 1). All ALT flaps were harvested exclusively as perforator free flaps; and the vast majority used superficial temporal, angular, or facial vessels. All free flaps were viable without evidence of vascular compromise at discharge and the initial follow-up appointment. One patient required take-back for successful flap salvage. One patient experienced late flap failure (between 2–3 weeks postoperatively), requiring another surgery. This resulted in an overall success rate of 98% in this cohort. No other postoperative complications related to early discharge were identified. Conclusion In a carefully selected subset of patients undergoing free tissue transfer, early discharge has been shown to be possible without compromising patient safety or surgery success rates. Level of Evidence 4. Laryngoscope, 126:2679–2683, 2016

Objectives/hypothesis To evaluate the efficacy and reconstructive applications of angular vessel microvascular anastomosis in free-tissue transfer. Study design Retrospective cohort study. Methods A study of patients treated from January 2010 to July 2017 was performed. Four hundred thirty patients undergoing free-tissue transfer at the Cleveland Clinic by a single reconstructive surgeon were reviewed. Patients in whom free-tissue transfer was performed using angular vessels were included. Patients in whom free-tissue transfer was performed using another vascular supply of the head and neck were excluded. Primary outcome was free-flap failure. Secondary outcomes included other postoperative complications and hospital length of stay. Results Thirty-one patients underwent free-tissue transfer with microvascular anastomosis to the angular vessels during the study period. Seventy-one percent of patients underwent reconstruction immediately following tumor ablation. A variety of primary subsites were reconstructed; 58% underwent nasal reconstruction, 16% orbit/skull base reconstruction, 13% palatal reconstruction, 6% maxillary reconstruction, and 6% mandible reconstruction. Eighty-seven percent of patients underwent free-tissue transfer from an anterolateral thigh donor site. Ninety-seven percent of patients had successful free-tissue transfer with a viable flap during the follow-up period; only one patient experienced flap failure attributed to vascular insufficiency. Average length of stay was 4.7 days, and the most common length of stay was 3 days. Conclusions The angular vessels provide excellent arterial supply and venous drainage to serve as a viable option for microvascular anastomosis during free-tissue transfer for head and neck reconstructive surgery. They are an ideal vascular source for central face and skull base reconstruction. Level of evidence NA Laryngoscope, 130:2589-2592, 2020.

Gene duplication is a major driver for the increase of biological complexity. The divergence of newly duplicated paralogs may allow novel functions to evolve, while maintaining the ancestral one. Alternatively, partitioning the ancestral function among paralogs may allow parts of that role to follow independent evolutionary trajectories. We studied the REDUCED COMPLEXITY (RCO) locus, which contains three paralogs that have evolved through two independent events of gene duplication, and which underlies repeated events of leaf shape evolution within the Brassicaceae. In particular, we took advantage of the presence of three potentially functional paralogs in Capsella to investigate the extent of functional divergence among them. We demonstrate that the RCO copies control growth in different areas of the leaf. Consequently, the copies that are retained active in the different Brassicaceae lineages contribute to define the leaf dissection pattern. Our results further illustrate how successive gene duplication events and subsequent functional divergence can increase trait evolvability by providing independent evolutionary trajectories to specialized functions that have an additive effect on a given trait.

Effective rearing methods are needed to recover the federally endangered Salt Creek tiger beetle, Cicindela (Ellipsoptera) nevadica lincolniana Casey, a subspecies that occurs exclusively in saline wetlands and seeps along Little Salt Creek in Lancaster County, Nebraska. Experiments were initiated to determine soil type and salinity concentrations appropriate for stimulating female oviposition in laboratory settings to produce larvae and/or adults for reintroduction to native habitats. In 2013, there were highly significant differences between native soil and a sand/loess soil mixture, but no differences between two salinity levels, 0.354 M and 0.5 M. In 2014, using only a sand/loess soil mixture, there were again no differences between the test salinity levels. A sand/loess soil mixture of either 0.354 M or 0.5 M salinity was determined to be optimum for egg production.

Background Donor site morbidity is an important consideration in the overall decision-making algorithm for fasciocutaneous free flap reconstruction of the head and neck. Methods A retrospective case series was conducted of donor site complications occurring within 30 days of surgery among 226 consecutive anterolateral thigh (ALT) or radial forearm free flap (RFFF) microvascular free tissue transfers performed by multiple reconstructive surgeons between 2005 and 2010. Results A greater number of donor site complications occurred among patients undergoing RFFF versus ALT free flaps (40; 35.4%; vs 14; 12.4%; p

Treatment of advanced parotid or cutaneous malignancies often requires sacrifice of the facial nerve as well as resection of the parotid gland and surrounding structures. In addition to considerations regarding reinnervation and dynamic reanimation, reconstruction in this setting must take into account unique factors such as soft tissue volume deficits and the high likelihood of adjunctive radiation therapy. Furthermore, considerations of patient comorbidities including advanced age and poor long-term prognosis often influence reconstructive modality. The optimal reconstructive technique would provide potential for restoration of facial tone and voluntary movement as well as immediate restoration of facial support and function. Beyond considerations of facial movement and rest position, restoration of lost soft tissue volume is critical to obtain facial symmetry. To control long-term volume in the setting of adjunctive radiation therapy, vascularized tissue is required. In this chapter, we describe a comprehensive approach to the management of radical parotidectomy and similar facial defects that addresses these concerns and also describes management strategies over time. Specific techniques employed include anterolateral thigh free flaps, nerve grafting utilizing motor nerves to the vastus lateralis muscle, and orthodromic temporalis tendon transfer. Further considerations relative to the eye, forehead, and long-term facial refinement are also discussed.

Objective The anterior-lateral thigh (ALT) free flap is a flexible reconstructive option with fascia lata, fasciocutaneous, and musculocutaneous options. The objective of this study is to evaluate ALT fascia lata free flap reconstruction of isolated hard palate defects. Methods Retrospective chart review of all palate reconstructions with ALT free flap from 2008-2017 by a single surgeon, at a tertiary academic institution. Patients with defects limited to the hard palate were selected for review. Results Forty-eight patients were identified, of which 14 patients had limited palatal defects repaired with fascia lata free flaps and were selected for review. The average hospital stay for all patients was 2.8 days (range 1-4 days). Eighty-five percent of patients were started on an oral diet from post-operative day (POD) one. Ten of 14 were extubated at the end of the case, with four being extubated on POD one. One patient suffered donor site morbidity, which required intervention (one seroma requiring drainage). Two patients underwent minor palatal revisions with local tissue rearrangement for recurrent fistula. No patients suffered long-term velopharyngeal inadequacy (VPI) or dysphagia, and all reported normal nasal respiration. Conclusion The ALT fascia lata free flap is a versatile reconstructive option for hard palate defects, with minimal morbidity, short hospital stays, and excellent long-term results.

Gene duplication is a major driver for the increase of biological complexity. The divergence of newly duplicated paralogs may allow novel functions to evolve, while maintaining the ancestral one. Alternatively, partitioning the ancestral function among paralogs may allow parts of that role to follow independent evolutionary trajectories. We studied the

The angular artery, its perforating branches, and their zones of tissue perfusion have been described extensively for facial reconstruction. Various cutaneous and mucosal flaps with either anterograde or retrograde perfusion play an important role in facial and oral reconstruction. However, these flaps share the limitations of pedicled nature and donor-site intolerance. Free-tissue transfer (FTT) has transformed capabilities and outcomes in head and neck reconstruction. While less constrained by tissue volume and subtype, FTT has its own limitations, including pedicle reach for anastomosis to inflow and outflow vasculature in upper face reconstruction. The angular vessels, owing to their relatively high central location and accessibility via a camouflaged nasolabial fold incision, may have value in midface and nasal reconstruction.To detail a technique for consistently locating the angular vessels while preserving the integrity of adjacent neuromuscular structures and to evaluate the caliber and consistency of the angular artery and vein for their usability in microvascular anastomosis.We conducted a PubMed literature search for the terms angular artery, melolabial flap, nasolabial flap, retroangular flap, and any associations with FTT. We also performed 26 anatomic cadaveric dissections on 13 fresh cadavers to evaluate the angular arteries and veins.Vessel caliber, length, and variability were analyzed and utility for use in FTT was assessed. A total of 26 angular arteries and 26 angular veins were included in the analysis. Anatomic relationships were used to develop a surgical schema for dissection and isolation of the angular vessels specifically for FTT.The angular vessels have consistent anatomic relationships facilitating localization and have a consistent caliber amenable to use in microvascular FTT. The mean (SD) artery diameter was 2.34 (0.67) mm prior to dilation and 3.21 (0.87) mm after dilation. The diameters of the vein before and after dilation were 3.57 (0.53) mm and 6.40 (0.81) mm, respectively. There was no statistical difference between the vessels on the right and left sides.We describe for the first time the anatomic cadaveric dissection and analysis of the angular arteries and veins specifically to determine compatibility with regard to FTT. We found good FTT compatibility.NA.

Microvascular free tissue transfer is used for complex composite tissue defects in previously treated fields, in particular after treatment of malignant disease. The increasing incidence of skin cancer in the general population has increased the number of patients with massive tumors that require the expertise of the free flap reconstructive surgeon. We herein examine a number of the recent advances in the field that use free tissue transfer for orbitomaxillary and scalp reconstruction, including maxillary reconstruction, virtual surgical planning in head and neck reconstruction, and scalp reconstruction. Advanced computer algorithms allow planning of these procedures at a savings of time and cost. Free tissue transfer is a reconstructive modality that is often at the top of the reconstructive ladder and, in some instances, is the reconstructive method of choice. The ability to harvest composite tissue that matches the tissue defect in composition, surface area, and volume makes free tissue transfer a versatile modality.

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. Laryngoscope, 124:397–400, 2014

This review describes a general approach and philosophy in the management of massive facial trauma with extensive tissue loss, with particular highlight on the role of free tissue transfer.

Method of direct clinical monitoring of tissue perfusion in free tissue reconstruction of pharyngeal defects.To describe a novel and effective method of incorporating a cutaneous skin paddle into laryngopharyngectomy reconstruction for direct clinical monitoring of anterolateral thigh free flaps.Retrospective review of pharyngoesophageal reconstruction for laryngopharyngectomy defects performed between August 1, 2008, and March 1, 2011, using the anterolateral thigh flap.Tertiary care academic medical center.Consecutive patients undergoing laryngopharyngectomy where free tissue transfer is indicated.Anterolateral thigh free flap reconstruction with suprastomal cutaneous monitoring paddle.Postoperative complications, including flap failure, fistula, and stricture. Postoperative functional outcomes of swallowing and vocal capability were also measured.Twenty-one patients (mean age, 62.2 years; range, 39-81 years) underwent total laryngectomy with near-total or total pharyngectomy and immediate reconstruction with an anterolateral thigh free flap. The reconstructions included a cutaneous monitor paddle distal to the pharyngoesophageal anastomosis. Twenty patients were treated for squamous cell carcinoma and received either adjuvant or neoadjuvant radiation therapy. There were no partial or total flap losses. A late pharyngocutaneous fistula occurred at 6 weeks in 1 patient (5%), requiring exploration, and anastomotic stricture occurred in 4 patients (19%). All patients except 1 were able to swallow solid foods at a mean follow-up of 11.1 months. Nineteen patients (90%) underwent tracheoesophageal puncture and attained an intelligible voice. One patient (5%) had stomal stenosis requiring surgical management.The suprastomal cutaneous monitoring paddle enables direct monitoring of an otherwise buried reconstructive flap. This method allows direct clinical observation for microvascular compromise without a need for further procedures and without any increase in morbidity or compromise of speech and swallow functions.4.

Background Limited data exists on cardiac complications following head and neck free flaps. Design A retrospective review was performed on patients that underwent free flap reconstruction from 2012 to 2015. Results 368 flaps were performed. 12.5% of patients experienced a cardiac event. Hypertension, coronary artery disease, heart failure, venous thromboembolism, and anticoagulation were associated with cardiac complications. ASA class was not predictive of cardiac events. 7.6% of patients required anticoagulation, which exhibited a strong association with surgical site hematoma. Cardiac complications led to a significantly increased length of stay. Conclusions There is a significant rate of cardiac events in this cohort. When estimating risk, a patient's total burden of comorbidities is more important than any one factor. ASA Class fails to demonstrate utility in this setting. Cardiac events have implications for quality-related metrics including length of stay and hematoma rate.

Introduction The purpose of our study was to describe a novel technique for reconstruction of orbital defects after maxillectomy using a non-anatomic titanium mesh suspension of orbital contents for both support and volume correction. This construct is then articulated with a layered fibula osteocutaneous free flap that restores orbital rim, zygoma, and maxillary alveolus. We herein present our application of this technique, including refinements over time and long-term outcomes. Methods A retrospective review was performed on 12 patients who underwent reconstruction of Brown class III orbitopalatomaxillary defects with extensive orbital involvement (at minimum complete orbital floor and rim absent) with titanium mesh sling and a layered fibula free flap. Results Primary reconstruction was accomplished in all 12 patients. The mean postoperative length of stay was 8 days (6-14 days). There were no free flap failures or perioperative re-explorations. Patients were routinely extubated on postoperative day #1 and began oral intake by postoperative day #3. At a mean follow-up length of 48 months, unrestricted eye function was accomplished in all patients. Midfacial symmetry was accomplished in 10 of 12 patients; 2 patients had moderate asymmetry due to extirpation of facial musculature and/or soft tissue. Minor revisions were necessary for lower lid ectropion and exposure of the titanium plate. Two patients required adipofascial free flap coverage of exposed intraoral bone after radiation therapy. Conclusions This technique provides excellent restoration of eye position and function and also allows for implant-based prosthetic rehabilitation. It has become our procedure of choice for orbitomaxillary reconstruction.

Reconstruction of maxillectomy defects offers potential quality-of-life improvement, although cavity coverage may impact surveillance of recurrent malignancy. We describe the pattern of postmaxillectomy locoregional recurrence.Retrospective review.Patients from 2001 to 2011 at the University of California, San Francisco and the Cleveland Clinic.Among 75 patients with malignancy resulting in partial or total maxillectomy, 57 were treated with obturators and 18 underwent reconstructive surgery. Disease recurrence occurred primarily locally (19 of 22 cases of recurrence, 25% of the cohort) at a mean of 17 months postoperatively. Recurrence was associated with T4 disease, positive margins, and surveillance imaging. Four (5.3%) patients required flap mobilization/obturator removal to obtain biopsy. Salvage surgery was attempted in 13 of the 19 cases with recurrent disease (68%) and was successful in six (46%) patients. Of these, five patients initially had Brown type 1 or type 2 defects. The free flap had to be revised in one (1.3%) patient to achieve successful salvage.Maxillectomy provides good long-term locoregional oncologic control, with cure being correlated to disease stage at presentation and negative margins after initial surgery. Patients with recurrent disease whose initial resection resulted in a Brown class 3 defect or greater were rarely successfully salvaged. Surveillance is best performed with a combination of physical exam and imaging. Obturator removal/flap mobilization rarely impedes the diagnosis of recurrent disease, and either modality should be offered to appropriate patients in the primary setting if significant quality-of-life improvement is likely.4. Laryngoscope, 127:2534-2538, 2017.

Parotidectomy is a commonly performed procedure for both benign and malignant lesions. When a significant portion of the gland is resected and the lost tissue volume is not replaced, a disfiguring contour defect can result. This defect can be disfiguring and have a profound impact on quality of life. Large defects are best replaced with vascularized tissue to provide stable volume.

Objective To further delineate the anatomy of the motor nerve to the vastus lateralis (MNVL) in the context of its use as a possible interpositional nerve graft in facial nerve rehabilitation.Methods Twelve fresh human cadaveric thighs were dissected to investigate the anatomic location and branching pattern of the MNVL muscle.Results There were 3 to 6 primary nerve branches (mean, 4.4) supplying the vastus lateralis. The mean primary branch length was 93.8 mm (range, 51-196 mm), and each primary branch had a mean of 2.3 subsequent branches. There were 2 larger caliber branches (>2 mm in diameter) supplying the proximal and distal muscle. The nerve branches are variable in their relation to the vascular pedicle and perforating vessels of the descending branch of the lateral circumflex femoral artery.Conclusion The nerve to the vastus lateralis is a readily available, redundant motor nerve suitable for facial nerve cable grafting.

Background Extirpation of aggressive parotid or cutaneous facial tumors often involves facial nerve sacrifice and the creation of a large soft-tissue defect. We describe a method for single-stage reconstruction during radical parotidectomy to restore facial form and function without additional morbidity. Methods We conducted a review of immediate reconstruction/reanimation of radical parotidectomy defects with the use of anterolateral thigh (ALT) fat and fascia flaps for facial contouring, orthodromic temporalis tendon transfer (OTTT), cable grafting of the facial nerve, and fascia lata lower lip suspension. Results Five patients (mean age, 67.4 years) underwent extirpation of malignant tumors with facial nerve sacrifice resulting in large soft-tissue deficits. All patients had ALT free tissue transfer to correct facial contour defects and OTTT to restore facial form and function. Four patients underwent cable grafting of facial nerve branches. Branches of the motor nerve to the vastus lateralis harvested from the ALT surgical site were used for cable nerve grafting in 3 patients. Fascia lata from the same ALT harvest site was used for lower lip suspension to the OTTT in 4 patients. There were no donor site complications. All patients achieved midfacial symmetry at rest, oral competence with dynamic corner-of-mouth movement, and full eye closure. Conclusions Tumor clearance, symmetric facial appearance, as well as dynamic facial rehabilitation were accomplished in a single-stage procedure using the method described herein. The ALT free flap provides versatile options for soft-tissue defects as well as access to motor nerves optimal for grafting without additional morbidity. Patients undergoing extirpation of malignant tumors requiring facial nerve sacrifice can undergo immediate free tissue contour reconstruction and facial reanimation procedures with no additional morbidity.

Background Improved control of cutaneous malignancies using Mohs micrographic pathologic clearance has been well established. However, surgical margin control of advanced and complex cutaneous tumors of the head and neck is commonly performed by far less reliable frozen section margin analysis. Objective To describe a routine and ideal collaboration between dermatologic surgery and facial plastic surgery/head and neck surgery in which the Mohs micrographic method is used intraoperatively to achieve marginal clearance during resection and reconstruction. Methods A single-institution retrospective analysis was performed of patients who underwent intraoperative Mohs micrographic surgery. Intraoperative margins (peripheral and deep) of tissue specimens were analyzed by the Mohs surgeon. Results Twenty-six patients underwent large cutaneous tumor resection using intraoperative Mohs micrographic surgery. Most lesions were basal (48%) or squamous (34%) cell carcinoma. A mean (SD) of 2.1 (0.98) resection layers were required before negative margins were achieved. Conclusions We demonstrate the intraoperative technique and utility of Mohs micrographic analysis via an efficient collaborative effort. Well established for accuracy greater than intraoperative frozen section margin analysis, intraoperative Mohs micrographic surgery provides an optimal method of intraoperative margin assessment of cutaneous malignancies.

Large cutaneous tumors of the head and neck provide challenges for complete excision and optimal reconstruction. Collaborative intraoperative Mohs micrographic surgery offers efficient and reliable extirpation of large cutaneous malignancies of the head and neck and immediate reconstruction of resultant defects.

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.

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.Case series with chart review.Two tertiary-care medical centers.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.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.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.

To show that, for patients with few medical comorbidities and at low risk for airway compromise or fistula formation, early discharge after free tissue transfer for head and neck reconstruction is a safe and viable option.Retrospective chart review.A cohort of patients who underwent free tissue transfer for head and neck reconstruction between February 2010 and December 2014 and who were discharged from the hospital by postoperative day 3 were reviewed.Fifty patients undergoing 51 free-tissue transfer surgeries were discharged by postoperative day 3. The surgeries performed included anterolateral thigh free flaps (ALT) (n = 46), radial forearm free flaps (n = 2), latissimus myogenous and myocutaneous free flaps (n = 1), supraclavicular free flap (n = 1), and serratus free flap (n = 1). All ALT flaps were harvested exclusively as perforator free flaps; and the vast majority used superficial temporal, angular, or facial vessels. All free flaps were viable without evidence of vascular compromise at discharge and the initial follow-up appointment. One patient required take-back for successful flap salvage. One patient experienced late flap failure (between 2-3 weeks postoperatively), requiring another surgery. This resulted in an overall success rate of 98% in this cohort. No other postoperative complications related to early discharge were identified.In a carefully selected subset of patients undergoing free tissue transfer, early discharge has been shown to be possible without compromising patient safety or surgery success rates.4. Laryngoscope, 126:2679-2683, 2016.

Purpose To determine the proportion of solid organ transplant recipients developing periocular nonmelanoma skin cancer and to describe the morbidity of these cancers in transplant recipients. Design Cohort study. Participants Consecutive patients undergoing solid organ transplantation at the Cleveland Clinic between 1990 and 2008. Methods The charts of all patients receiving a solid organ transplant from 1990–2008 evaluated in the dermatology department for a subsequent biopsy-proven head and neck malignancy through April 2015 were reviewed. Patients with a periocular region nonmelanoma skin cancer (NMSC) or a nonperiocular NMSC causing a complication requiring eyelid surgery were included. Charts were reviewed for demographic data; transplant date, type, and source; immunosuppressive agents received at diagnosis; and type of NMSC, number of nonperiocular NMSCs, ophthalmologic findings, and periocular sequelae after the repair. Main Outcome Measures Primary outcome measures included the type, location, final defect size, tumor-node-metastasis classification, presence of perineural invasion, and reconstruction technique(s) used for each periocular NMSC. Secondary outcome measures included the type and treatment of ocular sequelae due to nonperiocular facial NMSC. Results A total of 3489 patients underwent solid organ transplantation between 1990 and 2008. Of these, 420 patients were evaluated in the dermatology clinic for biopsy-proven NMSC of the head and neck during the study period, and 11 patients (15 malignancies) met inclusion criteria. Nine patients developed 12 periocular malignancies and 3 patients required eyelid surgery for facial malignancies outside the periocular zone. All 11 patients developed a squamous cell carcinoma (14 malignancies), and 1 patient (1 malignancy) also developed a periocular basal cell carcinoma. There was orbital invasion in 4 cases and paranasal and/or cavernous sinus invasion in 3 cases. Two patients underwent exenteration. Seven cases required reconstruction with a free flap or graft. Periocular sequelae included lower eyelid ectropion (6 malignancies), dry eye and/or exposure symptoms (8 malignancies), unilateral vision loss (3 malignancies), and facial nerve paresis (5 malignancies). Conclusions Squamous cell carcinoma affecting the periocular region represents a risk of solid organ transplantation and may produce significant ocular morbidity, including the need for major eyelid reconstruction, globe loss, and disfiguring surgery.

Free tissue transfer is a versatile and valuable method for reconstructing select head and neck defects following trauma or oncologic resection. Microvascular reconstructive cases are among the longest, most technically challenging, and most labor-intensive operations performed by departments of otolaryngology/head and neck surgery. However, technical advances, increased experience, and robust training programs have permitted realization of microvascular success rates in excess of 97% at most high-volume centers. Given this unprecedented degree of success, research emphasis has shifted to advancing techniques, expanding indications, and increasing efficiencies.Although numerous topics are important for discussion, this update focuses on recent notable advances in reconstruction. These include expanding utility of the anterolateral thigh free flap in soft tissue reconstruction, prefabricated plating for fibula free flap mandibular reconstruction, use of venous couplers, and postoperative free tissue monitoring techniques.Improvements in technique, technology, and monitoring continue to improve success rates, reduce operative time and associated morbidity, improve overall functional outcomes, and improve patient-specific quality of life. These highlighted recent advances, amongst others, promote further advancement and simplification of reconstructive capabilities.