Search

Objective: The radial forearm free flap has become the method of choice for reconstruction of head and neck defects following oncologic ablation. Harvesting of a radial forearm free flap leaves a donor site defect. This is most commonly closed with a split-thickness skin graft. Morbidity, most commonly owing to a lack of graft take over the tendons, can be quite high. Recently, an acellular matrix (Alloderm) has been advocated to decrease complications at the radial forearm donor site, as well as obviate taking a split-thickness skin graft from the thigh., Material and Methods: Tertiary referral academic centre. Retrospective chart review of 15 patients. Five patients received allogenic dermis, 10 patients received split-thickness skin grafting to the radial forearm donor site., Results: Patients with allogenic dermis took between 12 and 16 weeks to heal completely. Patients undergoing split-thickness skin graft were completely healed within 4 to 6 weeks. Cosmesis was judged to be marginally better in the allogenic dermis group. Allogenic dermis placement had a greater impact on hand function owing to prolonged healing, whereas patients with split-thickness skin graft required wound care at the thigh for a 2- to 3-week period owing to the harvesting of the skin graft., Conclusions: Allogenic dermis may be a viable alternative to split-thickness skin grafting and radial forearm free flap donor sites. Prolonged healing with subsequent increased health care services use needs to be addressed.

Objective: Proper management of the clinically negative neck (N0) in patients with squamous cell carcinoma (SCC) of the oral cavity (OC) is controversial. Detecting cervical metastasis in these patients is important, because cervical lymph node metastasis is associated with an unfavourable prognosis. Conventional radiographic studies, such as computerized tomography (CT) and magnetic resonance imaging (MRI), may augment physical examination. However, there are still limitations of these modalities in detecting the presence of metastatic cervical disease. Positron emission tomography (PET) is a functional imaging modality that has recently been used in patients to detect head and neck neoplasms. We report using PET in the evaluation of the N0 neck in 11 consecutive patients with SCC of the OC who underwent neck dissection., Method: The results of PET scans were correlated with the pathologic findings of 19 neck dissections., Results: Four patients (36%) undergoing 7 neck dissections (37%) had pathologic evidence of disease. Positron emission tomography scans were positive in all of these patients and in all pathologically confirmed cervical metastasis. Seven patients (64%) undergoing 12 neck dissections (63%) had no pathologic evidence of cervical metastasis. Positron emission tomography scans were negative for malignancy in all of these seven patients. In the patient with SCC of the OC with a clinically N0 neck, we found PET to have an overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 100%. Computerized tomography demonstrated 40%, 88%, 67%, 70%, 69%, respectively. In all statistical categories except specificity (p = .1), PET demonstrated statistical significance (p < .05) over CT., Conclusion: Positron emission tomography appears to be a promising diagnostic aid that may be applied when evaluating the N0 neck for patients with SCC of the OC.

Objective: To describe the role of the lateral-arm free flap in reconstruction of head and neck defects following ablative oncologic surgery and to discuss the anatomy of this flap as well as indications for its use., Design: A prospective study of all patients undergoing a lateral-arm free flap was performed. Up to 3 years of follow-up was obtained., Setting: Tertiary referral centre., Method: A total of 12 lateral-arm free flaps were utilized to reconstruct defects ranging in size from 4 x 7 to 10 x 7 cm. Maximum width of the flap was 7 cm. A mean area of 55 cm2 was harvested., Main Outcome Measures: Flap survival, morbidity, speech intelligibility, and oral function and intake were assessed., Results: The vascular pedicle was reliable with vessel diameters of 1.5 mm, and length of 6 to 7 cm. All flaps survived, and minimal donor site morbidity was encountered. Nine patients maintained good speech with adequate intelligibility while 10 patients maintained adequate oral intake., Conclusions: Functional results can be obtained with the lateral-arm free flap. A consistent pedicle of good length and size was found. It is our flap of choice in older, thinner individuals when the width of the donor site is less than 7 cm, which allows for primary closure.

The craniofacial approach for resection of tumors of the nose, paranasal sinuses and orbit is well established. The operation must combine good access, sound oncologic resection, and acceptable cosmesis. Many techniques have been described that encompass all of these factors. Usually some sacrifice in cosmesis is inevitable. Most techniques also suggest removal of a plate of bone with subsequent replacement. With the removal of the tumor there is a communication between the nasal chamber and the extradural space (or brain if dura has been resected). This is usually closed with an inferiorly based pericranial flap. We have utilized a technique that hinges the bone flap laterally on the temporalis muscle. This results in the bone flap remaining vascularized. By maintaining a viable vascular bone flap this may allow for better wound healing and a decreased incidence of complications. Furthermore, we describe a technique of a contralaterally-based pericranial flap that is more extensive than the anteriorly based flaps. It may also be inset without fear of vascular compromise. Use of this technique in four patients will be described.

Over a 14-year period, from 1971 to 1985, there were 15 patients referred to the Princess Margaret Hospital in Toronto for postoperative radiotherapy to the cervical lymph nodes following radical neck surgery for metastatic cancer. An intensive investigation failed to yield a primary site in any patient. All of the patients had extensive neck disease with significant indications for postoperative radiotherapy (massive neck nodes, invasion of extra nodal structures or fixation to unresectable adjacent structures). Of this highly selected group of patients with advanced neck disease: 4/15 (27%) died within one year of uncontrolled local disease, a further 2/15 (13%) died within four years of metastatic/recurrent disease, 6/15 (33%) died of intercurrent disease and 3/15 (20%) were alive with at least four years follow-up. Although all patients presented with advanced disease, survival and significant palliation was possible in this select group of patients.

Carotid body tumors are encountered rarely and can present a difficult surgical problem. We reviewed the records of 16 patients with 19 tumors, who were entered in the Head and Neck Tumour Registry of the University of Toronto. There were no functionally secreting tumors and no patients with metastases. Most tumors were identified pre-operatively by clinical examination and angiography. However, five were found at open biopsy and required a second procedure. The mortality rate was 0 following embolization. One patient suffered a severe CNS complication and one patient a TIA. The major morbidity resulted from cranial nerve palsies in seven out of 16 patients. Recently, we have utilized a new method for resection of these highly vascular tumors that results in less blood loss and an increased ease of removal.

Goitres of the thyroid gland whose major component resides substernally would appear to have a different presentation and management protocol than those goitres that reside mainly in the neck. These goitres, as opposed to their supraclavicular counterparts, usually present with symptoms referrable to compression of the trachea or esophagus. Even in those patients who are asymptomatic, a precise history may elicit pertinent findings. Furthermore, these goitres do not respond to suppression and require surgical removal. The trans-cervical approach is the most desirable, but the surgeon must be willing to enter the chest on that rare occasion. We reviewed the charts of 938 patients undergoing thyroid surgery who were registered in the Head and Neck Tumour Registry of the University of Toronto. Approximately 2.4% of patients had substernal goitres. Their history, pathology and ultimate surgical management will be discussed.