Faculty Bibliography

OBJECTIVE:We report on the case of an 11-year-old girl with atypical neurothekeoma of the left lateral alar rim that was excised and ultimately closed primarily after an unsuccessful attempt at reconstruction with a full-thickness auricular composite graft. METHODS:In this case report, we present a description of the case and a review of the literature. RESULTS:The patient underwent successful excision of neurothekeoma and subsequent auricular cartilage graft reconstruction. Reconstruction failed to adequately heal at several months postoperatively and the defect was closed primarily. CONCLUSIONS:Rapidly growing nodules of the nose can have a broad differential and requires pathological diagnosis via early biopsy. This is important because the surgical approach varies depending on the lesion and its potential for metastasis and local growth.

BACKGROUND:: The vascular anatomy of the supraclavicular artery island (SAI) flap has been investigated using both cadaveric anatomic dissections and angiographic studies. Accurate preoperative evaluation and localization of its vascular pedicle confirms its location, course, anatomic variation, and improves flap success. The objective of this report is to demonstrate the utility of multislice computed tomography (CT) angiography for confirming the presence of the vascular pedicle of the SAI flap when planning head and neck reconstruction. METHODS:: Patients were studied using 64-multislice CT angiography to localize the supraclavicular artery, including its origin and destination. Axial images, multiplanar reconstructions, and 3D volume-rendered images were analyzed on a Philips workstation. Radiologic image findings and clinical experience will be described. RESULTS:: SAI CT angiography was successfully performed in 15 patients (30 shoulders) ranging from ages 22 to 81 years. Accurate identification of the main vascular pedicle was achieved in 14/15 patients. Location, course, pedicle length, and anatomic variations were reported for 23 of 30 arteries. Mean vessel diameter was found to be 1.49 mm (range, 0.8-2.0 mm) on the right and 1.51 mm (range, 1.0-2.1 mm) on the left. The mean length of the artery was 38.3 mm on the right (range, 26.6-59.6 mm) and 38.4 mm on the left (range, 24.3-67.0 mm). In all patients, the supraclavicular artery originated off the transverse cervical artery-a branch of the thyrocervical trunk. Positioning of the patient's upper extremities at the side was helpful in the identification of the supraclavicular artery and its distribution. Contrast injection site should be contralateral to the side needed for the flap if sidedness is of importance, secondary to contrast bolus artifact. CONCLUSIONS:: Preoperative evaluation of the SAI flap with multislice computed tomography angiography is feasible in patients. A radiologic study protocol has been developed which improves ability to detect this vessel. This technique provides a noninvasive approach to the identification of the vascular anatomy and is easily standardized/reproducible. The identification of the vascular pedicle and its anatomy can be a benefit to the surgical team during preoperative design of the SAI flap; however, clinical experience confirming these radiologic findings will be needed to optimize surgical outcome.

UNLABELLED:Oropharyngeal reconstruction following head and neck oncologic resection has utilized local, regional, and free tissue transfer flap options. The modality utilized is often guided by the type of defect created as well as the surgeon's preference. In this article, the authors introduce the application of the supraclavicular artery island flap as a reconstructive modality following oropharyngeal oncologic ablation. Five patients underwent head and neck oncologic resection for oropharyngeal squamous cell carcinoma followed by single-stage reconstruction with an ipsilateral supraclavicular artery island flap. There were no flap failures and only one postoperative complication consisting of a postoperative oral-cutaneous fistula that resolved without surgical intervention. There were no donor-site complications. The supraclavicular artery island flap is a viable alternative for oropharyngeal reconstruction following head and neck oncologic resection. It is a regional flap that can be harvested without microsurgical expertise and yields reliable postoperative results. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.

BACKGROUND:Recently, the supraclavicular artery island flap has gained popularity as a regional flap for head and neck reconstruction. During clinical follow-up, some patients report referred sensation to the shoulder when there is contact with the flap skin island surface. The authors examine the anatomical origin/characteristics of the supraclavicular nerves (C3-4) to this flap and its relationship to the flap pedicle and anatomical boundaries. METHODS:SAI flap harvest and nerve dissection was performed in seven fresh frozen cadavers (n = 10) using loupe magnification in order to further elucidate the sensory nerve branches in a typical SAI flap. RESULTS:Branches of the supraclavicular nerve innervating the SAI flap were found to emerge from the deep fascia at a separate location from the vascular pedicle with the major nerve root exiting underneath the sternocleidomastoid muscle near the midpoint of the muscle belly. The nerve branches proximal to the pedicle with one branch exiting anterior to the flap and another running axially along the length of the flap. The majority (9/10) flaps had a major cutaneous nerves located 1-2 cm anterior to the pedicle. One (1/10) of the flaps had a major cutaneous nerve located 1-2 cm posterior to the pedicle toward the trapezius muscle. In 3 of the 10 flaps, smaller cutaneous nerves were also found posterior to the pedicle in a more distal location of the flap. CONCLUSIONS:The supraclavicular nerves innervating the SAI flap are easily identifiable and can be preserved or ligated, depending on the desired flap function, when present close to the pedicle. Further clinical investigation is warranted to confirm the potential benefit of using the SAI flap as a neurotized regional flap for head/neck reconstruction.

Background : Reports after the 2005 Hurricane Katrina have documented an increase in stress reactions and environmental teratogens (arsenic, mold, alcohol). Objective : To assess the incidence of cleft pathology before and after the hurricane, and the distribution of cleft cases by gender and race. Methods : Retrospective chart review of cleft lip with or without cleft palate (CL/P) and cleft palate (CP) cases registered with the Cleft and Craniofacial Team at Children's Hospital of New Orleans, the surgical center that treated cleft cases in Greater New Orleans between 2004 and 2007. Live birth data were obtained from the Louisiana State Center for Health Statistics. Results : The incidence of cleft cases, beginning 9 months after the hurricane (i.e., June 1, 2006) was significantly higher compared with the period before the hurricane (0.80 versus 1.42; p = .008). Within racial group comparisons showed a higher incidence among African Americans versus whites (0.42 versus 1.22; p = .01). The distribution of CL/P and CP cases by gender was significant (p = .05). Conclusion : The increase in the incidence of cleft cases after the hurricane may be attributable to increased stress and teratogenic factors associated with the hurricane. The increase among African Americans may have been due to comparatively higher exposure to environmental risk factors. These findings warrant further investigation to replicate the results elsewhere in the Gulf to determine whether there is a causal relationship between environmental risk factors and increased cleft pathology.

The supraclavicular artery island (SAI) flap is a viable fasciocutaneous option for the reconstruction of head and neck defects. Although authors have reported success using SAI flaps for various reconstructive indications, concerns of a tenuous blood supply and distal ischemia have previously limited its use in the posterolateral skull base. This case series reports the outcomes of 5 consecutive patients receiving SAI flaps for posterolateral skull base reconstruction. All flaps were harvested in less than 1 hour with primary closure of all donor sites. A single patient developed superficial necrosis of the distal flap, which was repaired with a full-thickness skin graft. There were no other complications, and no donor site morbidity was observed. The SAI flap is an excellent option for the reconstruction of posterolateral skull base defects. The close color match, easy harvest within 1 hour, lack of microsurgical anastomosis, and absence of donor site morbidity support its continued utilization.