Which venous system to choose for anastomosis in head and neck reconstructions?

It has been postulated that venous thrombosis in free flap surgery necessitates the use of 2 venous anastomoses into different venous systems. We retrospectively analyzed a single surgeon's 10-year experience (August 1993 to August 2003) in primary free flap reconstruction for malignant tumors of the head and neck. Of 492 primary reconstructions that did not need a vein graft, vein loop, or cephalic turnover procedure, 251 used the internal jugular venous system as venous outflow, 140 used the subclavian system as outflow, and 101 used both. Two hundred thirty-eight of 251 (95%) of flaps utilizing the internal jugular venous system for outflow were successful compared with 129 of 140 (92%) of flaps utilizing the subclavian system. Where both venous systems were used the success rate was 101 of 101 (100%) (P < 0.05). Where possible, a second venous anastomosis should be performed utilizing both venous drainage systems.     

Planned neck dissection following chemoradiotherapy for advanced head and neck cancer: Is it necessary for all?

In the absence of large-scale randomized trials evaluating dissection versus observation of the involved neck after neoadjuvant chemoradiotherapy, there is a need to collect data that will either support or ultimately refute a role for planned posttreatment neck dissection. A significant percentage of patients with extensive (N2 or N3) neck disease who demonstrate a complete response to chemoradiation therapy may harbor residual occult metastases, and identification of this subset of patients remains a clinical challenge. Because surgical salvage rates are greatly diminished when occult nodal disease becomes clinically manifest, planned posttreatment neck dissection is advocated but may not be necessary in all patients. The role of positron emission tomography chemoradiotherapy (PET-CT) in this scenario remains unproven but holds promise in being able to identify which patients may be harboring residual disease in the neck after chemoradiotherapy. The implementation of as yet unidentified molecular tumor markers in combination with PET-CT may ultimately prove to be effective in identifying patients who will best benefit from posttherapy neck dissection. Correlation of imaging results and pathologic node status will be important in determining the accuracy and, therefore, the value of this imaging modality for predicting the presence or absence of residual disease.     

Minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema: is it effective for stage III and IV?

This is the first report on the effectiveness of minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema. Fifty-two patients (age: 15 to 78 years old; 8 males, 44 females) were treated with lymphaticovenular anastomoses under local anesthesia and by postoperative compression using elastic stockings. The average duration of edema of these patients before treatment was 5.3 +/- 5.0 years. The average number of anastomosis in each patient was 2.1 +/- 1.2 (1-5). The patients were followed for an average of 14.5 +/- 10.2 months, and the result were considered effective (82.5%) even for the patients with stage III (progressive edema with acute lymphangitis) and IV (fibrolymphedema), but others showed no improvement. Among these cases, 17 patients showed reduction of over 4 cm in the circumference of the lower leg. The average decrease in the circumference excluding edema in bilateral legs was 41.8 +/- 31.2% of the preoperative excess length. These results indicate that minimal invasive lymphaticovenular anastomosis under a local anesthesia is valuable instead of general anesthesia.     

Femoral head–neck modularity: Curtain calls and caveats

There are practical and fiscal benefits of head–neck modularity. Taper corrosion occurs with all head sizes and rarely necessitates revision. The role of design and manufacturing variables continues to be investigated and debated. The utilization of ceramic heads has increased but the cost–utility ratio needs scrutiny. Changes in surgical practice, including smaller incisions and the increased use of cementless, tapered titanium stems are challenges to consistent and adequate taper assembly. Surgical taper assembly is variable and important regardless of the head material. Standardization of surgical taper assembly is desirable for all head materials: taper assembly has been implicated in ceramic head fracture as well as in fretting and corrosion.     

Is the recipient vein really the main concern? A cohort study of head and neck reconstruction

The aim of this study was to verify the role of the venous drainage system in the pathogenesis of complications in microsurgical head and neck reconstruction. In a nonrandomized cohort study, 52 consecutive cases of complex head and neck microsurgical reconstruction were evaluated. The patients were divided in two groups based on the treatment: the deep (DVDG; n = 30) and superficial (SVDG; n = 22) venous drainage groups. The complications evaluated included vascular obstruction with partial or total loss of the microsurgical flap, inadequate healing (fistulas or suture dehiscence), and infections. The arterial anastomotic site, neoplastic recurrence, use of medications and neoadjuvant radiotherapy, flap selection, tumor histology, smoking/alcoholism, and systemic diseases had no effect on postoperative complications, while the venous component influenced the overall complication rate (chi‐square test, P = 0.006). A protective effect was achieved in the DVDG when the overall complication rate was considered—relative risk (RR) 0.65, 95% confidence interval (CI) 0.45–0.94. The recipient vein should be the surgeon's main concern as it influenced the outcomes of patients undergoing complex microsurgical head and neck reconstruction. A protective effect was observed when the internal jugular vein drainage system was used for this purpose. © 2009 Wiley‐Liss, Inc. Microsurgery 2009.     

The beverage maté: a risk factor for cancer of the head and neck

BACKGROUND: Maté is a tealike beverage consumed habitually in South America and among South Americans throughout the world. It is brewed from the dried leaves and stemlets of the perennial tree Ilex paraguariensis (yerba maté), a species that belongs to the Aquifoliaceae family. Maté consumption has been associated with an increased rate of oral, oropharyngeal, esophageal, and laryngeal cancers. The purpose of this study is to review the literature and discuss the role of Maté consumption as a risk factor for head and neck cancers. MATERIALS AND METHODS: We performed a thorough review of the relevant literature linking maté consumption with head and neck cancer and the proposed carcinogenicity of maté. Case control studies on maté-drinking populations and in vivo and in vitro studies on the carcinogenicity of maté were reviewed. The populations included in many of these studies also used alcohol and tobacco products, confounding the influence of maté as an independent risk factor. RESULTS: Evidence in the literature suggests that maté consumption is carcinogenic and plays a role in the development of cancers of the oral cavity, pharynx, larynx, and esophagus. CONCLUSIONS: The exact mechanism of carcinogenesis of maté is unknown. Both chemical and thermal carcinogenesis mechanisms have been suggested. Available information suggests that maté drinking is a risk factor for upper aerodigestive tract cancer.     

Radiological staging for squamous carcinoma of the head and neck: a standardised practice?

The choice of investigations for radiological staging of squamous carcinoma of the head and neck can be highly variable. The aims of this study were to establish the practice amongst otolaryngologists in Scotland, to determine what, if any, consensus of practice exists and also to stimulate debate in this controversial area. The results of a postal survey to which there was a 65% response rate are reported. Of the primary sites, the greatest consensus on the need for imaging was of the nasopharynx, oropharynx and hypopharynx. For metastatic disease, all respondents imaged the chest but most did not image the abdomen or skeleton. The results for the other sites and imaging modalities chosen are discussed. A protocol for radiological staging based on the survey findings and interpretation of the literature is suggested.     

Cystic metastasis from head and neck squamous cell cancer: A distinct disease variant?

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) commonly spreads to regional deep cervical nodes. In most cases, these metastases present as firm, solid masses in the designated lymph node chains. A distinct subset of metastatic nodes present as cystic masses, with most of the volume made up of a liquid center surrounded by a thin solid rim. It has been observed that certain squamous cell carcinoma (SCC) subsites are more likely to produce metastases that are cystic. These sites predominantly include primary tumors of tonsil tissue from Waldeyer's ring. In the past, these cystic cancers often have been erroneously diagnosed as branchiogenic carcinomas, that is, a branchial cleft cyst that has undergone malignant degeneration. Today, most authors have concluded that so-called branchiogenic carcinomas are actually cystic metastases in the neck probably arising from an oropharyngeal primary SCC. The purpose of this work is to consider the phenomenon of cystic lymph node metastasis in head and neck cancer in depth. METHODS: A review of the relevant English-language literature linking cystic metastasis and head and neck cancer was performed. RESULTS: These studies indicate that lateral cystic masses in adults often represent an occult primary cancer originating in the epithelium within Waldeyer's ring. CONCLUSIONS: Adult patients who are initially seen with a lateral cystic neck mass must be presumed to have a cancer until proven otherwise. The mass should be biopsied by fine-needle aspiration (FNA). However, negative FNA findings may be misleading; therefore, an excisional biopsy and examination under anesthesia with directed biopsies of Waldeyer's ring and bilateral tonsillectomy should be considered a part of the diagnostic workup.     

A ten-year experience of multiple flaps in head and neck surgery: how successful are they?

Ablative surgery in the head and neck often results in defects that require free flap reconstruction. With improved ablation/reconstructive and adjuvant techniques, improved survival has led to an increase in the number of patients undergoing multiple free flap reconstruction. We retrospectively analyzed a single institution's 10-year experience (August 1993 to August 2003) in free flap reconstruction for malignant tumors of the head and neck. Five hundred eighty-two flaps in 534 patients were identified with full details regarding ablation and reconstruction with a minimum of 6-month follow-up. Of these 584 flaps, 506 were for primary reconstruction, 50 for secondary reconstruction, 12 for tertiary reconstruction, and 8 patients underwent two flaps simultaneously for extensive defects. Overall flap success was 550/584 (94%). For primary free flap surgery, success was 481/506 (95%), compared with 44/50 (88%) for a second free flap reconstruction and 9/12 (75%) for a third free flap reconstruction ( P < 0.05). Eight extensive defects were reconstructed with 16 flaps, all of which were successful. More than one free flap may be required for reconstruction of head and neck defects, although success decreases as the number of reconstructive procedures increases.