Faculty Bibliography

BACKGROUND: Despite numerous refinements in microsurgical technique and instrumentation, the microvascular anastomosis remains one of the most technically sensitive aspects of free-tissue transfer reconstructions. MATERIALS AND METHODS: Concurrent with the development of microsurgical techniques, various anastomotic coupling systems have been introduced in an effort to facilitate the performance and reliability of microvascular anastomoses. The microvascular anastomotic coupling device (MACD) studied here is a high-density, polyethylene ring-stainless steel pin system that has been found to be highly effective in laboratory animal studies. Despite its availability for human clinical use over the last 5 years, reported clinical series remain rare. Our clinical experience with this MACD in 29 head and neck free-tissue transfers is reported herein. RESULTS: Thirty-five of 37 (95%) attempted anastomoses were completed with 100% flap survival with a variety of donor flaps, recipient vessels, and clinical contexts. Two anastomoses were converted to conventional suture technique intraoperatively, and one late postoperative venous thrombosis occurred after fistulization and vessel exposure. CONCLUSIONS: We conclude that the MACD studied here is best suited for the end-to-end anastomosis of soft, pliable, minimally discrepant vessels. Previous radiation therapy does not appear to be a contraindication to its use. Interpositional vein grafts may also be well suited to anastomosis with the device. When carefully and selectively employed by experienced microvascular surgeons, this MACD can be a safe, fast, and reliable adjunct in head and neck free-tissue transfer reconstructions, greatly facilitating the efficiency and ease of application of these techniques

Contemporary head and neck hard tissue reconstruction incorporates bone transfers in the treatment of osseous discontinuity defects subsequent to congenital malformation, traumatic injury, ablative oncologic surgery, and failures of physiologic osteosynthesis. Bone grafts may also be applied in contour augmentation and in strengthening and stabilization roles in congenital and acquired aesthetic as well as posttraumatic deformities. The osseous healing process is dynamic and unique. An understanding of the physiology of these processes allows the reconstructive surgeon to choose techniques and donor sites appropriate to specific requirements, to maximize transplanted bone volume, to achieve consistent and reliable results, and to modulate the osseous healing process in a favorable direction

Fundamental to the choice and proper application of plating systems in osteosynthesis of the craniomaxillofacial skeleton is an understanding of the basic design and biomechanical characteristics that define them. Improper selection of systems and technical execution of rigid internal fixation is not uncommon and may result in hardware failure, dysfunction, and dysmorphology. The surgeon who is able to command the nuances of system design and discipline in application will achieve superior functional and aesthetic results that are predictable and reproducible

The trend toward function-conserving surgery in the treatment of squamous cell carcinoma of the head and neck has led to a progression from radical neck dissection to modified neck dissection and selective neck dissection has growing support. These surgical modifications have resulted from an effort to spare structures uninvolved with malignancy. Level V dissection can be associated with spinal accessory dysfunction in some patients even when the nerve remains intact. In this study, we have attempted to address the need for level V dissection by determining the prevalence of level V metastases in a large series of patients undergoing radical neck dissection. There were 1,123 patients who underwent 1,277 neck dissections between 1965 and 1986. A review of pathologic and clinical records revealed 40 patients (3%) with positive nodes at level V. The prevalence of level V metastases was greatest with hypopharynx and oropharynx primary tumors (7% and 6%, respectively). Level V metastases were found in 1% of patients with oral cancers and 2% of those with larynx cancers. Groups were divided into N0 (282), N+ (719), and subsequent N+ (276), depending on the clinical status at the time of surgery. Thirty-seven of 40 patients with posterior triangle metastases were clinically N+. The prevalence of metastases at level V was 1% for N0, 5% for N+, and 0% for subsequent N+. This large series shows minimal involvement of metastases at level V. The low likelihood of metastases at level V, even in N+ disease, should be considered when performing lymphadenectomy for squamous cell carcinoma of the upper aerodigestive tract

Although spontaneous recovery of denervated facial muscles has been anecdotally recorded in the clinical setting, it has never been fully documented. The establishment of anastomoses between the terminal trigeminal and facial nerves provides a possible explanation of this phenomenon. Mechanisms of myoneurotization have also been described, by which regenerating branches of severed peripheral motor nerves directly reach motor end plates of denervated muscles, with variable recovery of function. A case demonstrating unequivocal clinical evidence of trigeminal-facial cross-innervation is presented, and the pertinent literature is reviewed as it applies to the mechanisms of this phenomenon

Reconstruction of the tumor-ablated patient remains one of the most challenging problems for the head-and-neck surgeon. Various methods have been described, including alloplastic reconstruction, free vascularized flaps, osteomyocutaneous flaps, and allogeneic reconstruction with particulate marrow grafts. Sixteen patients who have undergone homograft mandibular replacement at the Yale New Haven Hospital are described. Eighty-one percent of these grafts were successful in restoring form and function to a high degree of patient satisfaction. Eleven of the sixteen patients had radiation therapy after initial tumor surgery; 91% of these grafts were successful