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Fibular vascularized osteocutaneous free flap is the gold standard for mandibular reconstruction. The traditional method is very difficult and challenging work. This technique has so far been performed solely depending on the experience of the surgeons. Recently, several software programs that can make accurate preoperative surgical plans in a three dimensional (3D)-virtual system have been developed and used to solve this problem. The aim of this study is to describe our experience and to share several tips and pitfalls of mandibular reconstruction with virtual surgical planning (VSP).

Background and Objectives This study analyzed data from patients who were diagnosed with human papilloma virus (HPV)-associated oropharyngeal (OPC) and treated surgically to construct a machine learning survival prediction model.Subjects and Method We retrospectively analyzed the clinico-pathological data of 203 patients with HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) from 2007 to 2015.Results In the Cox proportional hazard (CPH) model, the c-index values for the training set and the test set were 0.81 and 0.59, respectively. The univariate analysis showed that contralateral lymph nodes (LNs) metastasis, lymphovascular invasion, pN, stage, surgical margin status, histologic grade, pT, and the number of metastatic LNs had significant correlations with survival. Contrastively, the multivariate analysis showed pT and histologic grade to have significant correlation with survival. In the random survival forest model, the c-index values for the training set and the test set were 0.83 and 0.87, respectively. In the DeepSurv model, the cindex values for the training set and the test set were 0.75 and 0.83. Among the three models mentioned above, Random Survival Forest and DeepSurv showed the best performance for predicting the survival of HPV-associated OPSCC patients.Conclusion We confirmed that a survival prediction model using machine learning and deep learning algorithms showed reasonable survival estimates for HPV-associated OPSCC patients.

Background and Objectives This study aimed to investigate the protective effect of polydeoxyribonucleotide (PDRN) against skin flap necrosis in a murine skin flap model.Materials and Method Twenty mice with rectangular skin flaps on the dorsum were randomly divided into the PDRN (n=10) and pentobarbital sodium (PBS) (n=10) injection groups. PDRN (8 mg/kg) was subdermally injected at 12 different points immediately after the operation. After 7 days, the flap perfusions were evaluated using a laser speckle contrast imaging (LSCI) system, and specimens were collected for immunohistochemistry analysis.Results The percentage of survival area relative to the total flap area was significantly higher in the PDRN group (60.87%±7.63%) than in the PBS group (45.23%±10.72%) (ppp

Background and Objectives The purpose of this study was to analyze the survival data of salivary gland cancer (SGCs) patients to construct machine learning and deep learning models that can predict survival and use them to stratify SGC patients according to risk estimate.Subjects and Method We retrospectively analyzed the clinicopathologic data from 460 patients with SGCs from 2006 to 2018.Results In Cox proportional hazard (CPH) model, pM, stage, lymphovascular invasion, lymph node ratio, and age exhibited significant correlation with patient’s survival. In the CPH model, the c-index value for the training set was 0.85, and that for the test set was 0.81. In the Random Survival Forest model, the c-index value for the training set was 0.86, and that for the test set was 0.82. Stage and age exhibited high importance in both the Random Survival Forest and CPH models. In the deep learning-based model, the c-index value was 0.72 for the training set and 0.72 for the test set. Among the three models mentioned above, the Random Survival Forest model exhibited the highest performance in predicting the survival of SGC patients.Conclusion A survival prediction model using machine learning techniques showed acceptable performance in predicting the survival of SGC patients. Although large-scale clinical and multicenter studies should be conducted to establish more powerful predictive model, we expect that individualized treatment can be realized according to risk stratification made by the machine learning model.

Objectives. To compare the surgical outcomes of externally monitored and conventional buried flaps with the goal of determining the usefulness of external monitoring of buried flaps.Methods. In this case-control study with propensity score matching, 30 patients were evenly divided into externally monitored buried flap and conventional buried flap groups. The total operative time for free flap reconstruction, the flap survival rate, the length of hospital stay, the initial time of a reliable visual assessment, complications, the final diet achieved, and the duration until diet initiation were compared between the groups.Results. The mean operative time for reconstruction was 115 minutes (interquartile range, 85–150 minutes) and 142 minutes (interquartile range, 95–180 minutes) in the externally monitored and conventional groups, respectively (P= 0.245). The median length of hospital stay was 24 days (interquartile range, 18–30 days) and 27 days (interquartile range, 20–41 days) in the externally monitored and conventional groups, respectively (P=0.298). The median duration until diet initiation was 15 days (interquartile range, 15–21 days) and 18 days (interquartile range, 15–34 days) in the externally monitored and conventional groups, respectively (P=0.466). The final diet, initial time of a reliable visual assessment, and complications were comparable between the groups, but the external skin paddle provided an excellent visual assessment immediately postoperatively in all cases.Conclusion. The outcomes were comparable between the groups, indicating that externalization of the cutaneous component of a buried flap may be a straightforward and useful technique for monitoring a buried anterolateral thigh free flap in laryngopharyngeal reconstructions. The salvage and false-positive rates of compromised flaps should be compared in large subject groups in future studies to prove that the use of an external skin paddle improves flap monitoring.

We performed robotic neck surgery through a transoral or retroauricular approach (RA) using the DaVinci SP and analyzed our experiences to evaluate the feasibility and safety of this system for performing RA neck surgeries. A total of 63 patients were enrolled in this study, consisting of 37 males and 26 females. All operations were successfully completed without significant complication in 63 patients with head and neck tumor. Using DaVinci SP, it is easy to insert three robotic arms into a long and narrow working space because all robotic arms and an endoscope are inserted through a single arm. Using the navigation function of the DaVinci SP, the endoscopic arm could be made into the shape of a "cobra" to secure proper visualization of the surgical site, which helps surgeons identify specific anatomic structures such as cranial nerve or vessels. We did not have any cases where robotic surgery was converted to open surgery due to severe bleeding or technical issues during surgery. The mean operative time was 207 min and the average hospital stay was 6.9 days. The time required for docking the surgical robot was within 10 min on average for DaVinci SP, which was much simpler and faster than that of the previous Si/Xi system. Based on our early experiences performing robotic head and neck surgery using the DaVinci SP, we confirmed that the system provided advanced technical advantages over the previous Si/Xi system in performing robotic surgery.

Objectives. In subset of patients, acinic cell carcinoma (AcCC) exhibits aggressive features such as recurrence, distant metastasis, and mortality. This study aimed to investigate clinicopathologic factors influencing patients’ prognosis and to identify adverse features predictive of an unfavorable prognosis.Methods. Between January 2000 and December 2016, 59 patients with AcCC were enrolled in this study.Results. The patients’ 5-year overall survival rate was 93.3%, and their 5-year recurrence-free survival rate was 80.5%. During the study period, recurrence occurred in 10 patients. The mean time to recurrence after surgery was 26 months (range, 5–60 months). During the study period, three patients died from the disease. Univariate analysis showed that sex, surgical extent, extranodal extension, T classification, and TNM stage were significantly associated with disease recurrence. Multivariate analysis showed that, among the clinicopathologic factors included in the analysis, only TNM stage displayed a statistically significant correlation with disease recurrence.Conclusion. Surgical treatment alone yielded good results for AcCC, and additional treatment did not affect the recurrence-free survival rate or the overall survival rate, even when the resection margin was less than 1 mm. Other pathologic factors did not show prognostic significance for disease recurrence or death.

Background We performed robotic parotidectomy with or without robotic neck dissection via a retroauricular approach in patients with parotid benign and malignant tumors and analyzed treatment outcomes of the patients to evaluate the safety and feasibility of robotic parotidectomy. Methods Between January 2017 and July 2018, 53 patients received robotic parotidectomy with/without robotic neck dissection through a remote access retroauricular incision without a preauricular incision. Results All operations were successfully performed in all patients without significant perioperative complications or tumor spillage. Tumors were located in the superficial lobe of the parotid gland in 40 patients, and the remaining 13 tumors were located in the deep lobe of the parotid gland. Postoperative pathologic examination revealed benign tumor in 32 patients and malignant tumors in 18 patients. The mean operation time was 226 minutes in patients who underwent only parotidectomy and 375 minutes in patients who underwent parotidectomy with robotic neck dissection. The average amount of bleeding was 23 mL, and the amount of drainage after operation averaged 171 mL. The average length of hospital stay was 6 days. Postoperative complications were limited to transient facial paralysis in three patients, all of which resolved within 1 month. All patients were satisfied with their cosmetic results at 6 months after operation. Conclusions Robotic parotidectomy with/without robotic neck dissection through a retroauricular approach was a feasible and safe technique in patients with parotid benign and malignant tumor. Specifically, we found it to be helpful in young patients with malignant parotid tumors who should receive cervical lymphadenectomy and parotidectomy, because it does not leave a visible scar on the face or neck. In the future, long-term follow-up will be necessary to validate its oncologic safety and functional outcomes.

We suggested operative techniques and indications of robotic neck surgery. To determine operative techniques and the indications for robotic neck surgery, we analyzed treatment outcomes of patients who received robotic neck surgery. Between May 2010 and July 2018, a total of 945 patients with various neck diseases visited Severance Hospital and underwent robotic neck surgery. A variety of approaches, including the retroauricular approach (RA), modified facelift approach (MFLA), transaxillary approach (TA), and transaxillary retroauricular approach (TARA), was used to remove various tumors in the neck. A total of 235 patients underwent a robotic neck dissection (elective or therapeutic) in the treatment of head and neck cancer with metastatic cervical lymph nodes. Five hundred-seventeen patients underwent robotic thyroidectomy or parathyroidectomy for thyroid or parathyroid disease, respectively. The remaining 193 patients underwent robotic neck surgery in the treatment of other neck diseases. Various neck lesions were successfully excised using RA or MFLA (including salivary gland tumors, thyroid tumors, vascular tumors, neurogenic tumors, lipomas, lymphangiomas, venous malformations, dermoid cysts, and others). Robotic neck surgery is a feasible and safe technique for the resection of various head and neck tumors. This method could be particularly useful in young patients with thyroid tumors, salivary gland tumors, and vascular tumors, among others, because it does not leave a visible scar on the face or neck. The superior visualization and articulate robotic arm that moves freely at various angles allows surgeons to perform delicate and precise surgeries.

In this study, we sought to evaluate the clinical feasibility of indocyanine green (ICG)-guided sentinel lymph node (SLN) sampling during robotic retroauricular neck dissection (RAND) in patients with cN0 oral cancer. Nine adult patients diagnosed with T1 to T2 oral squamous cell carcinoma were consecutively recruited. All of them underwent transoral partial glossectomy and robotic RAND (levels I-III) simultaneously. Twelve hours prior to surgery, ICG was injected into the 4 quadrants around primary tongue tumors. During robotic RAND, intraoperative and ex vivo ICG-stained LNs were identified using the Firefly system and examined for the presence of fluorescence. ICG-stained LNs were identified in all patients. Thirty-one ICG-stained LNs were detected in 313 retrieved LNs (9.9%). Occult metastases were detected among the ICG-stained LNs in 2 patients (22.2%). There was no metastasis identified in the ICG-unstained LNs. Upstaging rates, sensitivity, specificity, and negative predictive value of ICG-guided SLN sampling were 22.2%, 100%, 91.5%, and 100%, respectively.

Background Transoral robotic thyroidectomy (TORT) is an ideal method for minimally invasive thyroidectomy, as there is less flap dissection during the procedure and no postoperative scars. However, this method also has the limitation of present DaVinci system and some technical problems related to CO2 gas insufflation that must be resolved. We investigated the feasibility and safety of gasless TORT using the latest version of the DaVinci system (SP). Methods From October 2018 to January 2019, we performed 10 surgeries of gasless TORT using the DaVinci SP at Yonsei University Hospital. Results Nine patients underwent unilateral thyroid lobectomy and one patient received total thyroidectomy. All operations were successfully completed. Nine cases had papillary thyroid carcinoma, and one had benign nodules. The mean surgical time was 177 min, and the mean hospital stay was 6.3 days. There were no reports of transient or permanent vocal cord palsy, recurrence, or mortality during the follow-up period. Temporary hypoesthesia of the chin due to mental nerve injury was observed in 3 of 10 patients, but it recovered spontaneously within 1 months in all cases. Conclusions Gasless TORT using the DaVinci SP system is feasible and safe for selected patients and is a potential alternative approach for scarless thyroid surgery.

OBJECTIVE The purpose of this study was to evaluate the clinical usefulness of TORS and transoral robotic retropharyngeal lymph node (RPLN) dissection in tonsillar cancer patients with suspicious RPLN metastasis. METHODS From April 2008 to March 2014, 71 patients with tonsillar cancer underwent transoral robotic surgery and standard neck dissection at the Yonsei Head and Neck Cancer Center. RESULTS Three patients underwent transoral robotic ropharyngectomy with transoral robotic RPLN dissection because of suspicious RPLN metastasis. The mean age of the patients was 42 years (range, 31-50 years). There were no cases of wound infection or serious complications related to wound healing. Mild nasal regurgitation was observed during an oral diet immediately after surgery, but all patients spontaneously resolved without surgical treatment. There was no significant bleeding due to great vessel injury during surgery or swallowing difficulty due to cranial nerve IX injury. CONCLUSION Although the oncologic stability and usefulness of this technique should be confirmed based on large-scale research, RPLN can be easily accessed and resected through our approach with less morbidity compared to the conventional surgical approach. In addition, because RPLN metastasis can be performed pathologically based on obtained specimens, it will be helpful to explore whether to perform adjuvant radiation.

Background Parotidectomy is the primary treatment for parotid gland tumors. However, complications may include a prominent facial scar or infra-auricular depressed deformity, Frey's syndrome, first bite syndrome, or other facial pain, numbness, and paralysis. Acellular dermal matrix (ADM) has been widely used to prevent these complications in parotid surgery, but there have been no prospective, multi-center trials documenting its efficacy. This study evaluates the effectiveness of ADM implantation in preventing infra-auricular depressed deformity, Frey's syndrome and first bite syndrome after parotidectomy. Methods We analyzed 51 cases of standard parotidectomy and 58 cases of parotidectomy with implantation of Megaderm™ ADM through prospective multicenter trial. Acute complications including infection, seroma, hematoma, skin necrosis, and acute parotid area pain were evaluated 1 week postoperatively. Clinician grading of Frey's syndrome and blinded clinician evaluation of infra-auricular depressed deformities were conducted at 3, 6, and 12 months. Patients evaluated subjective satisfaction with neck appearance, Frey's syndrome quality, and acute parotid area pain at 3, 6, and 12 months. Results There was a higher incidence of seroma in the Megaderm™ group than in the control group at week 1. The incidence and total clinician-evaluated Frey's syndrome scores were significantly lower in the Megaderm™ group than in the control group at 3, 6, and 12 months. Both the objective and subjective evaluations of the facial contour showed a better outcome in the Megaderm™ group compared to the control group at 3, 6, and 12 months. There were no significant differences between the groups in the patient-reported Frey's syndrome quality scores at 3, 6, and 12 months, but the Megaderm™ group reported significantly less acute pain than the control group. Conclusions ADM implantation can effectively reduce the occurrence of Frey's syndrome, infra-auricular depressed deformity, and first bite syndrome after parotidectomy. ADM may be especially advantageous in complex parotidectomy cases when significant complications are expected.

Supracricoid partial laryngectomy (SCL) can have a positive impact on patients' quality of life by circumventing dysphagia and voice problems resulting from creation of a permanent stoma after conventional total laryngectomy (TL) surgery.The aim of this study was to investigate the oncologic and functional outcomes of salvage SCL for recurrent laryngeal carcinoma.Forty-five patients that underwent salvage surgery for recurrent laryngeal carcinoma between January 2004 and May 2015 after initial treatment failure were included in this retrospective study.Overall survival and disease free survival were non-significantly higher in the salvage SCL group (n = 14) than in the salvage TL group (n = 31) (87.5 versus 56.5%, 53.4 versus 41.9%). Multivariate analyses showed only positive resection margin to be significantly associated with survival and recurrence (HR 9.974, p = .007, and HR 9.196, p = .002, respectively). In the salvage SCL group, 92.8% achieved successful decannulation and all patients returned to an oral diet. All patients in the salvage TL group sustained a permanent stoma and conversation was possible only through esophageal voice or a voice prosthesis. 74.2% of patients in the group were able to tolerate an oral diet.Salvage SCL showed comparable oncologic outcomes and favorable functional outcomes relative to the classic salvage TL. This study could provide a sufficient basis of SCL as salvage treatment for recurrent laryngeal carcinoma in selected patients.

Purpose The purpose of this study was to compare the clinical and functional outcomes in patients with primary base of tongue (BOT) cancer who received definitive radiotherapy (RT) or surgery followed by radiotherapy (SRT). Materials and Methods Between January 2002 and December 2016, 102 patients with stage I-IVB primary BOT cancer underwent either definitive RT (n=46) or SRT (n=56), and treatment outcomes were compared between two groups. The expression of p16 was also analyzed. Results The RT group had more patients with advanced T stage (T3-4) disease (58.7% vs. 35.7%, p=0.021) and who received chemotherapy (91.3% vs. 37.5%, p < 0.001) than the SRT group. At a median follow up of 36.9 months (range, 3.3 to 181.5 months), the 5-year overall survival (OS) and disease-free survival (DFS) were 75.5% and 68.7%, respectively. With respect to treatment group, the 5-year OS and DFS in the RT and SRT groups did not differ significantly (OS, 68.7% vs. 80.5%, p=0.601; DFS, 63.1% vs. 73.1%, p=0.653). In multivariate analysis, OS differed significantly according to p16 expression (p16-negative vs. p16-positive; hazard ratio [HR], 0.145; 95% confidence interval [CI], 0.025 to 0.853; p=0.033). Regarding DFS, p16 expression (p16-negative vs. p16-positive; HR, 0.164; 95% CI, 0.045 to 0.598; p=0.006) showed a significant effect in multivariate analysis. Functional defects (late grade ≥ 3 dysphagia or voice alteration) were more frequently reported in the SRT than in the RT group (16.1% vs. 2.2%, p=0.021). Conclusion Despite advanced disease, patients in the RT group showed comparable survival outcomes and better functional preservation than those in the SRT group.

To report outcomes with regard to clinical aspects and medical costs of adenotonsillectomy and tonsillectomy at a single institution before and after implementation of the Diagnosis-Related Groups (DRG) payment system in Korea.We retrospectively reviewed the records of patients treated with adenotonsillectomy or tonsillectomy between July 2012 and June 2014. The Korean DRG payment system was applied to seven groups of specific diseases and surgeries including adenotonsillectomy and tonsillectomy from July 2013 at all hospitals in Korea. We divided patients into four groups according whether the fee-for-service (FFS) or DRG payment system was implemented and operation type (FFS-adenotonsillectomy (AT), DRG-AT, FFS-tonsillectomy (T), and DRG-T).A total of 1402 patients were included (485 FFS-AT, 490 DRG-AT, 203 FFS-T, and 223 DRG-T). The total medical cost of the DRG-AT group was significantly lower than that of the FFS-AT group (1191±404 vs. 1110±279 USD, P0.05). There were no significant differences in length of hospital stay or postoperative complications among groups.The Korean DRG system for adenotonsillectomy and tonsillectomy reduced medical costs and clinical outcomes were not significantly altered by the adoption of the DRG system.4.

Although there are various methods for tracheal reconstruction, such as a simple approximation with suturing and coverage with adjacent soft tissue or muscle, large defects >50% of the tracheal length still present a clinical challenge. Tissue engineering, a recent promising way to possibly resolve this problem, requires a long preparatory period for stem cell seeding on a scaffold and relatively invasive procedures for stem cell harvesting. As an alternative, we used a vascularized myofascial flap for tracheal reconstruction. In four porcine models, the deep inferior epigastric perforator (DIEP) was used in two and the superior epigastric artery perforator (SEAP) in two. Transformation of the surface of the transplanted myofascial flap was analyzed in the airway environment. The flaps failed in the DIEP group due to venous congestion. At 12 weeks postoperatively, none of SEAP group showed any signs of respiratory distress; the inner surface of the implant exhibited stratified squamous epithelium with sparse cilia. In the clinical setting, a patient who underwent a tracheal reconstruction with a vascularized myofascial flap and 2-year follow-up was in good health with no respiratory distress symptoms.

There has been a significant increase in concern towards improving aesthetic and functional outcomes without compromising the oncologic effectiveness in head and neck surgery. The aim of the current study is to assess the feasibility and oncological outcome of the retroauricular approach for endoscopic and robot-assisted selective neck dissection (SND) for oral cancer in comparison with the conventional SND. A retrospective single institute cohort study was designed. Patients undergoing an SND for oral cavity carcinoma were included and allocated into two groups: (1) retroauricular approach group for endoscopic-assisted or robot-assisted SND or (2) transcervical approach group for the conventional SND. Primary endpoint was the perioperative and postoperative treatment outcomes. Secondary endpoint was the early oncologic outcome. Sixty patients were included (17 retroauricular; 43 conventional). For the primary outcome, only a significant longer operative time in the retroauricular group was identified. No unintentional injury or conversion to the conventional surgery was recorded. There was no significant difference identified in the early oncologic outcome, including number of retrieved lymph nodes and disease-free survival. Postoperative aesthetic results were considered superior when subjectively compared to the conventional approaches. Endoscopic and robot-assisted SND via a retroauricular approach is feasible, safe, and oncologically efficient when compared with the conventional surgery in a short follow-up scenario. It can be used for selected cases with a clear cosmetic benefit. However, further research with longer follow-up and patient satisfaction analysis is mandatory.

Benefits and drawbacks of robotic surgical approaches for parapharyngeal space (PPS) tumors remain undetermined. The purpose of this study is to compare surgical outcomes of PPS tumor patients who underwent robotic surgery with those of patients who received conventional surgical treatment. We retrospectively analyzed clinicopathologic data from 136 patients who underwent surgical removal of PPS tumors via conventional or robotic approaches. We identified PPS tumors in pre- and poststyloid regions in 87 (64%) and 49 (36%) patients, respectively. There were 48 (35.3%) pleomorphic adenomas, 36 (26.5%) schwannomas, and 24 (17.6%) paragangliomas. Conventional surgical techniques were performed in 83 patients, and robotic surgical approaches were administered to 53 patients. Transcervical-parotid and transcervical approaches were most commonly performed in conventional surgery, while transoral and retroauricular approaches were the preferred surgical methods in robotic surgery for pre- and poststyloid PPS tumors, respectively. Robotic surgery resulted in less estimated blood loss during poststyloid PPS tumor surgery. Postoperative cranial nerve complications were noted in 36 of 83 cases (43.4%) in the conventional surgery group and in 17 of 53 cases (32.1%) in the robotic surgery group. Intraoperative tumor spillage of pleomorphic adenoma showed no significant differences between the two groups (13.6% in conventional vs. 15.4% in robotic surgery). The mean follow-up time was 4.9 ± 3.4 years, and recurrences were observed in two patients during follow-up without a significant difference between the two groups (4.5% in conventional vs. 3.8% in robotic surgery). Robotic surgery in PPS tumors is feasible through transoral, retroauricular, or combined approaches and provides treatment outcomes comparable to those of conventional open surgery.

This study aimed to evaluate the feasibility and safety of the DaVinci SP system for performing transoral robotic surgery (TORS) in patients with head and neck cancer. From October 2018 to April 2019, the medical records of 41 patients who underwent TORS using the DaVinci SP system were retrospectively reviewed. During TORS, three robotic arms could be used to perform a geometric resection of the lesion in a narrow working space. The mean total operation time was 60 min, and the average time required to set up the robotic system was 10 min or less. All patients successfully underwent TORS. All robotic arms were inserted through a single port, which widened the working space around the patient’s head and allowed the operative assistant an easy approach to the patient during the operation. The joggle joint of the robotic arms aided easy manipulation within the confined working space. The joggle joints of the endoscopic arm were controlled through the navigation system, which was very helpful in securing superior visualization of the surgical site, especially in the area of the larynx and the hypopharynx. The study confirmed that the DaVinci SP system provided technical advantages above the Si and Xi systems for performing TORS. It was especially helpful in ensuring proper visualization of the surgical field and in performing precise surgery during surgery to the tongue base or the hypopharyngeal lesion.

The purpose of this study was to evaluate the treatment outcomes of patients who underwent surgery with curative intention after the diagnosis of salivary duct cell carcinoma (SDC) in the head and neck area and to analyse the prognostic factors and treatment failure pattern. Fifty-nine patients treated between March 2003 and December 2018 were enrolled in the study. The mean follow-up period was 45.5 months (range 12–189 months). The 5-year overall survival rate was 54.7% and the 5-year disease-free survival rate was 56.8%. Nineteen recurrences occurred during the study period: four loco-regional recurrences and 15 distant metastases. During the study period, 10 patients died of disease relapse and 5 patients died of other medical caused. On univariate analysis, lymphovascular invasion (LVI) (P = 0.031) showed the most significant correlation with mortality. On multivariate Cox regression analysis, LVI showed the most significant correlation with patient survival (P = 0.027). LVI was the most significant prognostic factor related to the 5-year overall survival rate of SDC patients. The development of novel therapeutic agents is necessary to improve the survival rate of these patients with LVI.

Purpose The purpose of this study was to evaluate the clinical outcomes of patients treated with radiotherapy (RT) for a carcinoma of the external auditory canal (EAC) and middle ear. Materials and methods The records of 32 patients who received RT from 1990 to 2013 were reviewed retrospectively. The Pittsburgh classification was used to stage all the cancers (early stage, T1/T2 [n=12]; advanced stage, T3/T4 or N positive [n=20]). Twenty-one patients (65.6%) were treated with postoperative RT and 11 patients (34.4%) were treated with definitive RT. The median radiation doses for postoperative and definitive RT were 60 Gy and 64.8 Gy, respectively. Chemotherapy was administered to seven patients (21.9%). Results The 5-year overall survival and disease-free survival rates for all patients were 57% and 52%, respectively. The disease control rates for the patients with early stage versus advanced stage carcinomawere 55.6% (5/9) and 50% (6/12) in the postoperative RT group and 66.7% (2/3) and 37.5% (3/8) in the definitive RT group, respectively. Overall, 15 cases (14 patients, 46.7%) experienced treatment failure; these failures were classified as local in four cases, regional in one case, and distant in 10 cases. The median follow-up period after RT was 51 months (range, 7 to 286 months). Conclusion Patients with early stage carcinoma achieved better outcomes when definitive RT was used. Advanced stage carcinoma patients experienced better outcomes with postoperative RT. The high rate of distant failure after RT, with or without surgery, reflected the lack of a consensus regarding the best therapeutic approach for treating carcinoma of the EAC and middle ear.

Purpose Thunderbeat (TB) is an integrated energy device incorporating ultrasonic and bipolar technology that provides rapid cut and precision dissection and reliable vessel sealing compared with conventional electrosurgery (ES). The present study compared the surgical outcomes of TB and ES for harvesting the anterolateral thigh free flap (ALTFF). Patients and Methods The present prospective cohort study compared TB and ES in patients who had undergone head and neck reconstruction using ALTFFs. The baseline characteristics, including age, gender, body mass index, primary tumor site (recipient site), and T stage, were measured. Patients who had undergone reconstruction after previous unsuccessful head and neck cancer treatment using radiation were included in the salvage surgery group. The primary outcome variables were the harvesting time, blood loss, and flap failure. The interval until the start of an oral diet and the percutaneous endoscopic gastrostomy (PEG) insertion rate were analyzed to compare the functional outcomes. After identifying the confounding variables, multivariate approaches were used to adjust for the confounding variables. Results No significant differences were found in the demographics and disease-related factors such as age, gender, body mass index, anatomic distribution, and T stage of the primary disease, between the 2 groups. The operation time and bleeding volume were reduced by 32.4 and 33.1%, respectively, in the TB group compared with those in the control group. The postoperative drainage volume, duration, flap failure rate, and intensive care unit and total hospital stays were nearly identical between the 2 groups. No statistically significant differences were found in the functional outcomes (PEG insertion and oral diet start day) between the 2 groups. Conclusions The results of the present study have shown that TB is a useful supportive tool for head and neck reconstruction surgery because it decreases the operation time with surgical outcomes comparable to those with conventional ES.

Live models that resemble surgical conditions of humans are needed for training free-flap harvesting and anastomosis. Animal models for training purposes have been available for years in many surgical fields. We used the female (because they are easy to handle for the procedure) Yorkshire pigs for the head and neck reconstruction by harvesting the deep inferior epigastric artery perforator or the superior epigastric artery perforator flap. The anastomosis site (neck skin defect or tracheal wall defect) was prepared via the dissection of the common carotid artery and the internal jugular vein, in which 3.5× loupe magnification was used for anastomosis as we use on human cases in real life. This procedure demonstrates a new training method using a reliable learning model and provides a detailed anatomy in a live scenario. We focused on the ischemia time, harvesting, vessel anastomosis, and designing the flap to fit the defect site. This model improves tissue handling and with the use of proper instruments can be repeated many times so that the surgeon is fully confident before starting the surgery on humans.

This study aimed to identify prognostic clinicopathologic factors that could predict treatment failure and to analyze clinical data from p16+ oropharyngeal squamous cell carcinoma (OPSCC) patients who underwent surgery. Data from p16+ OPSCC patients who underwent surgery at Severance Hospital of Yonsei University were retrospectively reviewed. The average smoking history was 14.6 pack-years (range 0–94 pack-years). Of the 188 patients, 73 (38.8%) underwent transoral robotic surgery (TORS) for surgical treatment of their primary lesions, and the remaining 115 patients (61.2%) underwent conventional surgery. Extracapsular nodal spread was detected in 87 patients (46.3%). At histologic examination, 67 patients (35.6%) showed positive surgical margins, and 121 patients (64.4%) had negative surgical margins. Postoperative adjuvant treatment was performed for 167 patients (88.8%). During the follow-up period, there were 18 recurrences including 2 local recurrences, 10 regional recurrences, and 6 distant metastases. During the study period, 17 deaths occurred. The univariate analysis showed that the American Joint Committee on Cancer (AJCC) 8th-edition staging system, lymphovascular invasion, more than four metastatic lymph nodes, and a smoking history of more than 10 pack-years were significantly associated with treatment failure. In the multivariate analysis, only the AJCC 8th-edition staging system was significantly associated with the patient’s survival. Surgical treatment methods including TORS for p16+ OPSCC patients showed excellent oncologic results, and many previously known clinicopathologic factors did not show a significant relationship with patient prognosis. Only the newly revised AJCC 8th-edition staging system showed a significant relationship with patient survival, and this should be considered in the setting of p16+ OPSCC treatment guidelines in the future.

Objectives/Hypothesis As an evolvement of the robotic application to the thyroidectomy, we sought to seek the potential role of robotic thyroidectomy with the retroauricular (RA) approach prior to future comparative study between RA and transaxillary thyroidectomy. This study aims to verify the surgical feasibility of robotic RA thyroidectomy. Study Design Case series with planned data collection. Methods A total of 87 patients who underwent robotic RA thyroidectomy for clinically suspicious papillary thyroid carcinoma or benign lesions from January 2013 to May 2014 were retrospectively reviewed and analyzed. Results All robotic surgeries via RA approach were successfully performed, without any significant intraoperative complications or conversion to open surgery. Based on patient-reported outcome questionnaires, all patients were satisfied with their postoperative surgical scars. Conclusion Robotic RA thyroidectomy is technically feasible and safe, with satisfactory cosmetic results for patients where indicated. Level of Evidence 4. Laryngoscope, 2015

Objectives: The aim of this study is to describe the feasibility as well as oncologic outcomes of robot-assisted neck dissection (RAND) through a modified facelift incision in an American population. Study Design: Retrospective case series. Setting: University tertiary care hospital. Methods: All patients who underwent RAND between November 2012 and December 2014 were included. Medical records were reviewed for demographics, medical histories, staging, operative information, postoperative hospital course and complications, and oncologic outcomes. Results: There were 11 RANDs identified among 10 patients. Five patients had known nodal metastasis at the time of surgery. Two patients had been previously irradiated. The average time of surgery was 284.4 ± 72.3 minutes, including other associated procedures. The average lymph node yield was 28.5 ± 9.3 nodes. There were no major complications. Average follow-up was 19.4 months. There was 1 supraclavicular recurrence in a previously irradiated patient. All patients are currently alive and without evidence of disease. Conclusions: Robot-assisted neck dissection is a safe and feasible procedure that can be performed by surgeons with familiarity with neck dissection and robot-assisted surgery and who have been trained in RAND. Appropriate oncologic outcomes can be obtained in a patient wishing to avoid a noticeable scar.

To investigate the treatment outcomes of parotid gland cancer at a single center over a 10-year period and to evaluate the prognostic significance of maximum standardized uptake value.Retrospective case series with chart review.Academic care center.Ninety-eight patients with primary parotid gland cancer who were surgically treated at Yonsei University HeadNeck Cancer Clinic between January 1999 and December 2008 were analyzed. Patient data were collected retrospectively from medical charts. The investigators analyzed the association of clinicopathological factors and maximum standardized uptake value on (18)F-fluorodeoxyglucose positron emission tomography-computed tomography scan with disease-specific survival.Mean patient age was 49.7 years. Mean follow-up was 48.8 months. Thirty-three, 40, 30, and 23 patients had stage I, II, III, and IVA disease, respectively. Mucoepidermoid carcinoma was the most common histologic type (34.7%), followed by acinic cell carcinoma (27.6%). Eighteen patients (18.4%) experienced recurrences (mean recurrence gap, 20.6 months; range, 2-87 months). Five- and 10-year disease-specific survival rates were 93.6% and 81.8%, respectively. In the univariate analysis, pathologic T stage, pathologic lymph node status, resection margin, external parenchymal extension, and maximum standardized uptake value were significantly associated with disease-specific survival. Pathologic lymph node status and maximum standardized uptake value were independent prognostic factors in the multivariate analysis.Our single-center experience with parotid gland cancer treatment is consistent with the literature. Cervical lymph node metastasis and high maximum standardized uptake value are associated with poor survival in parotid gland cancer.

Background Functional restoration of the facial expression is necessary after facial nerve resection to treat head and neck tumors. This study was conducted to evaluate the functional outcomes of patients who underwent facial nerve cable grafting immediately after tumor resection. Methods Patients who underwent cable grafting from April 2007 to August 2011 were reviewed, in which a harvested branch of the sural nerve was grafted onto each facial nerve division. Twelve patients underwent facial nerve cable grafting after radical parotidectomy, total parotidectomy, or schwannoma resection, and the functional facial expression of each patient was evaluated using the Facial Nerve Grading Scale 2.0. The results were analyzed according to patient age, follow-up duration, and the use of postoperative radiation therapy. Results Among the 12 patients who were evaluated, the mean follow-up duration was 21.8 months, the mean age at the time of surgery was 42.8 years, and the mean facial expression score was 14.6 points, indicating moderate dysfunction. Facial expression scores were not influenced by age at the time of surgery, follow-up duration, or the use of postoperative radiation therapy. Conclusions The results of this study indicate that facial nerve cable grafting using the sural nerve can restore facial expression. Although patients were provided with appropriate treatment, the survival rate for salivary gland cancer was poor. We conclude that immediate facial nerve reconstruction is a worthwhile procedure that improves quality of life by allowing the recovery of facial expression, even in patients who are older or may require radiation therapy.

Background In this study, we compared the treatment outcomes of postoperative 3D conformal radiotherapy (RT) and intensity-modulated radiotherapy (IMRT) for patients with maxillary sinus carcinoma. Methods Fifty-four patients underwent surgery and postoperative RT, of whom 27 (50%) had squamous cell carcinoma and 14 (26%) had adenoid cystic carcinoma. Nineteen patients (35%) were treated with IMRT and 35 patients (65%) received 3D conformal RT. The median radiation dose for 3D conformal RT and IMRT were 62.1 and 63 Gy, respectively. Results IMRT produced significantly superior radiation dose distribution to planning target volumes (PTVs) than 3D conformal RT. Over a median follow-up of 60 months, IMRT provided better 3-year locoregional recurrence-free survival (89.2% vs 59.5%; p = .035) and distant metastasis-free survival (94.7% vs 55.3%; p = .042) rates than 3D conformal RT. Conclusion Postoperative IMRT for patients with maxillary sinus carcinoma resulted in excellent disease control, and should be considered as the first treatment option in these cases. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

We sought to seek the potential role of endoscopic thyroidectomy with the retroauricular (RA) approach prior to future comparative study with the robotic RA thyroidectomy. Therefore, this study aims to verify the surgical feasibility of endoscopic RA thyroidectomy. Eighteen patients who underwent endoscopic RA thyroidectomy for clinically suspicious papillary thyroid carcinoma or benign lesions from January to December 2013 were retrospectively reviewed and analyzed. All endoscopic operations via RA or modified facelift approach were successfully performed, without any significant intraoperative complications or conversion to open surgery. Based on patient-reported outcome questionnaires, all patients were satisfied with their postoperative surgical scars. Endoscopic RA thyroidectomy is technically feasible and safe with satisfactory cosmetic results for patients where indicated.

PURPOSE Decision to perform concurrent ipsilateral thyroidectomy on patients with hypopharyngeal cancer is important, and unnecessary thyroidectomy should be avoided if oncologically feasible. We hypothesized that concurrent ipsilateral thyroidectomy is not routinely required to prevent occult metastasis. This study aimed to determine the prevalence of histological thyroid invasion in patients with hypopharyngeal cancer, and to refine the indications for prophylactic ipsilateral thyroidectomy in patients with hypopharyngeal cancer. MATERIALS AND METHODS A retrospective review of the medical records from the Department of Otolaryngology at Yonsei University College of Medicine was conducted from January 1994 to December 2009. A total of 49 patients underwent laryngopharyngectomy with thyroidectomy as a primary treatment of hypopharyngeal cancer. RESULTS The incidence of thyroid gland involvement was 10.2%. The most common route of invasion was direct extension through the thyroid cartilage. Thyroid cartilage invasion (p=0.034) was the most significant factor associated with thyroid invasion. Disease-specific survival at 5 years was lower in patients with than without thyroid gland invasion (26.7% vs. 55.2%, respectively; p=0.032). Disease-free survival at 5 years was also lower in patients with than without thyroid gland invasion (20.0% vs. 52.1%, respectively; p=0.024). CONCLUSION Ipsilateral thyroidectomy in combination with total laryngopharyngectomy is indicated when invasion of the thyroid cartilage is suspected in patients with hypopharyngeal cancer.

Primary hyperparathyroidism results from the overproduction of parathyroid hormone by 1 or more autonomously hyperfunctioning parathyroid glands and often causes hypercalcemia. Once this condition has been diagnosed, the treatment of choice is surgical removal. There have been many attempts to remove the hyperfunctioning gland with minimally invasive surgical techniques, with cure rates comparable with those of conventional techniques. On the basis of our initial surgical experiences of robotic thyroidectomy and other head and neck surgeries via a retroauricular (RA) approach, we have recently successfully performed robotic excision of a huge parathyroid tumor via an RA approach on a 44-year-old woman who had been diagnosed with a parathyroid adenoma. It is the first to describe in detail the successful completion of a robotic parathyroidectomy via an RA approach.

Conventional operations for various surgical neck lesions adopted the transcervical scar, which were disfiguring and caused various postoperative morbidities. The advent of the surgical robotics as a result of advancement in technology led to a technical breakthrough in the field of head and neck surgery. Together with the application of the robot, we have seen the promising role of the retroauricular (RA) approach from its versatile applications. This review will discuss in detail various robotic head and neck surgeries via RA approach.

Our aim was to evaluate the feasibility of robot-assisted neck dissection (RAND) followed by transoral robotic surgery (TORS) in treatment of cancers of the head and neck, which is expected to improve cosmesis and function. We studied 37 patients with biopsy-confirmed cNO or cN+ tumours of the oropharynx (n=22), hypopharynx (n=8), larynx (n=6), and oral cavity (n=1) who were treated by RAND then TORS from May 2010 to December 2012. Patients' characteristics and clinical details were recorded, together with operative complications and functional variables such as management of the airway and nasogastric or enterogastric feeding. All endoscopic TORS and RAND were successful, with no serious intraoperative complications or need to convert to open operation. All patients were satisfied with the cosmesis according to the answers given to a questionnaire. RAND followed by TORS in some cancers of the head and neck are feasible and showed a clear cosmetic benefit, although the longer operating time is a drawback. Studies of more patients with longer follow-up are required to evaluate long-term oncological and functional outcomes in more detail.

Background The purpose of this study was to determine prognostic factors influencing outcomes of surgical treatment in patients with T4a hypopharyngeal cancer. Methods The present study enrolled 93 patients diagnosed with T4a hypopharyngeal cancer who underwent primary surgery between January 2005 and December 2015 at six medical centers in Korea. Primary tumor sites included pyriform sinus in 71 patients, posterior pharyngeal wall in 14 patients, and postcricoid region in 8 patients. Seventy-two patients received postoperative radio(chemo)therapy. Results Five-year disease-free survival (DFS) and disease-specific survival (DSS) rates were 38% and 45%, respectively. In univariate analysis, 5-year DFS was found to have significant and positive correlations with margin involvement (p

Traditionally, total thyroidectomy was performed through an open transcervical incision; in cases where there was evident nodal metastasis, the conventional surgical approach was to extend the incision into a large single transverse incision to complete the required neck dissection. However, recent innovation in the surgical technique of thyroidectomy has offered the opportunity to reduce the patient's burden from these prominent surgical scars in the neck. Minimally invasive surgical techniques have been developed and applied by many institutions worldwide, and more recently, various techniques of remote access surgery have been suggested and actively applied.1-6 Since the advent of robotic surgical systems, some have adopted the concept of remote access surgery into developing various robotic thyroidectomy techniques. The more former and widely acknowledged robotic thyroidectomy technique uses a transaxillary (TA) approach, which has been developed by Chung et al. in Korea.7,8 This particular technique has some limitations in the sense that accessing the lymph nodes of the central compartment is troublesome. Terris et al. realized some shortcomings of robotic TA thyroidectomy, especially in their patients in the United States, and developed and reported the feasibility of robotic facelift thyroidectomy.9-13 In cases of thyroid carcinomas with lateral neck node metastases, most abandoned the concept of minimally invasive or remote access surgery and safely adopted conventional open surgical methods to remove the tumor burden. However, Chung et al. have attempted to perform concomitant modified radical neck dissection (MRND) after robotic thyroidectomy through the same TA port.14 This type of robot-assisted neck dissection (RAND) had some inherent limitations, due to fact that lymph nodes of the upper neck were difficult to remove. Over the past few years, we have developed a RAND via modified facelift (MFL) or retroauricular (RA) approach and reported the feasibility and safety of this technique.15, 16 Since then, we have actively applied such RAND techniques in various head and neck cancers. In our country, almost all cases of robotic total thyroidectomy utilize the TA approach. According to the reports made by Terris et al., robotic facelift thyroidectomy technique has been solely applied for ipsilateral hemithyroidectomy. For total thyroidectomy, Terris et al. performed the robotic surgery with bilateral RA incisions. Here, we intend to introduce our novel surgical method after successfully attempting simultaneous robotic total thyroidectomy and RAND via a single RA approach without an axillary incision. To our knowledge, this is the first to report in the medical literature.We present four cases of our surgical experience since the beginning of 2013. All patients received robotic total thyroidectomy with MRND via single RA port without axillary incision after approval from the institutional review board at Severance Hospital, Yonsei University College of Medicine. The inclusion criteria for this operation were as follows: (1) patients with malignant carcinomas of the thyroid gland with evident cervical lymph node metastasis on preoperative imaging studies which are indicated for surgery; (2) patients with no previous history of treatment for thyroid carcinoma. The exclusion criteria were as follows: (1) patients with recurred thyroid tumors; (2) patients with thyroid carcinomas that showed gross invasion to local structures or extensive extrathyroidal capsular spread; (3) patients with clinically evident neck nodal metastasis with extracapsular spread; (4) patients with past history of neck surgery of any kind. In order to assess the extent of disease, neck ultrasonography with fine needle aspiration, neck CT or MRI and PET-CT were performed as preoperative evaluation. All patients were given full information of the possible treatment options for their thyroid cancer comprising of open transcervical approach and robotic surgery via RA approach, including the advantages and disadvantages of each treatment choice and provided written, informed consents before the surgery. General clinical information of the patients is outlined in Table 1. The skin incision for the operation was designed just like the approach for robotic facelift thyroidectomy by Terris et al. and RAND, which has been first reported by our institution.11 (,) 16 The operation was performed by the following sequence. Initially, the skin-subplatysmal flap was elevated after making the skin incision to create sufficient working space. During this process, the elevated skin flap was retracted and maintained by retractors held by the assistant. After application of the self-retaining retractor (Sangdosa Inc., Seoul), neck dissection of the upper neck levels was performed under gross vision. Next, RAND through the RA incision was conducted followed by ipsilateral thyroidectomy with central compartment neck dissection (CCND) via the same approach. Finally, contralateral thyroidectomy with CCND was performed via the single RA port. During these steps, the operator is aided by the bedside assistant with long-suction tips to manipulate and direct the dissected specimen to maintain optimal surgical view or to suck out the fume created by the thermocoagulation from the Harmonic shears. The da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA) was introduced via the RA port with a facedown 30° dual-channel endoscopic arm placed in the center, and two instrument arms equipped at either side with 5-mm Maryland forceps and Harmonic curved shears. During the step of robotic contralateral thyroidectomy, a ProGrasp forceps was utilized at times, instead of 5-mm Maryland forceps. The rest of the surgery was completed with the robotic system (see Video for demonstration of operation for patient 2). Table 1 Clinical characteristics of the patients Patient Sex/age (yr) BMI Side(a) Approach Pathology(b) Tumor size(c) (cm) CCND(d) MRND(d) Drain removal day Drainage amount (ml) Hospital stay (days) 1 F/38 23.8 L RA PC 0.7 2/5 8/23 8 788 11 2 F/18 18.3 L RA PC 0.8 2/8 7/35 6 398 9 3 F/44 23.1 L RA PC 0.9 5/12 5/27 6 607 9 4 F/26 32.9 L RA PC 1.4 3/14 9/48 7 476 15 BMI body mass index, RA retroauricular approach, PC papillary carcinoma, CCND central compartment neck dissection, MRND modified radical neck dissection (a)Side refers to the site of main lesion (b)Pathology refers to the primary tumor within the thyroid gland (c)Tumor size refers to the diameter of the largest tumor in the thyroid gland (d)For each type of lymph node dissection, the number of positive nodes/total number of retrieved nodes is statedFor all of the patients, robotic total thyroidectomy with MRND (levels II, III, IV, V) via unilateral RA approach was successfully completed without any significant intraoperative complications or conversion to open or other approach methods. The total operation time was defined as the time from initial skin incision to removal of the final specimen, which was an average 306.1 ± 11.1 min (Table 2). This included the time for skin flap elevation and neck dissection under gross vision (87 ± 2.8 min), setting up the robotic system for RAND (6.8 ± 2.4 min), console time using the robotic system for RAND (59.3 ± 2.2 min), flap elevation for thyroidectomy (11.3 ± 2.5 min), robotic arms docking for ipsilateral thyroidectomy (6.3 ± 2.5 min), console time for ipsilateral thyroidectomy (61.3 ± 2.1 min), robotic arms docking for contralateral thyroidectomy (6.3 ± 2.5 min), and console time for contralateral thyroidectomy (61.8 ± 2.1 min). The working space created from RA incision was sufficient, and manipulations of the robotic instruments through this approach were technically feasible and safe without any mutual collisions throughout the entire operation. It also allowed for an excellent magnified surgical view enabling visualization of important local anatomical structures. There was no postoperative vocal cord palsy due to recurrent laryngeal nerve injury. However, two patients developed transient hypoparathyroidism, which resolved in the end without the need for calcium or vitamin D supplementation after certain period of medical management (Table 3). Also, there was no incidence of postoperative hemorrhage or hematoma formation, although a single patient developed a postoperative seroma on postoperative day 9, which was managed conservatively without the need for further surgical intervention. On average, the wound catheter was removed 6.8 ± 1 days after surgery and the patient was discharged from the hospital at an average 11 ± 2.8 days from admission (Table 1). Final surgical pathology confirmed the diagnosis of papillary carcinoma for every patient. The total number of cervical nodes retrieved from CCND and MRND was 9.8 ± 4 and 33.1 ± 11 respectively, and the number of positive metastatic nodes was 3 ± 1.4 and 7.3 ± 1.7 respectively (Table 1). In three patients (patients 2, 3, and 4), the presence of one parathyroid gland was each verified in the pathology specimen. All four patients have received high-dose (150 mCi) radioiodine ablation (RAI) therapy after the operation and are being followed up (average 11.3 months, range 9-13 months) on a regular basis with no evidence of recurrence (post-RAI, most recent, nonsuppressed thyroglobulin range 0.1-0.4 ng/ml, antithyroglobulin antibody range 13.7-147.5 IU/ml). (ABSTRACT TRUNCATED)

Recently, robot-assisted neck dissection (ND) using a transaxillary approach in thyroid cancer patients with lateral neck metastases (LNM) was demonstrated to be feasible. The aim of this study was to compare the surgical outcomes of a modified transaxillary and retroauricular (TARA) versus a conventional transcervical approach in papillary thyroid carcinoma (PTC) patients with LNM.In total, 47 patients with PTC underwent total thyroidectomy with central compartment ND and modified radical ND except Level I. Twenty-two NDs were performed via the TARA approach, and 25 unilateral NDs were performed via the conventional transcervical approach.The TARA and the open ND groups consisted of 22 and 25 patients, respectively. The operation time for ND in the TARA group was longer than that in the open ND group (209.4±38.2 minutes versus 143.1±30.5 minutes; P=.000). The mean scar satisfaction score in the TARA group was higher than in the conventional ND group (3.9±1.0 versus 2.8±1.0; P=.000). There were no differences in the mean number of retrieved lymph nodes.The robot-assisted ND via the TARA approach can be an alternative option that produces excellent esthetic results for the management of LNM in PTC patients.

Background The purposes of this study were to evaluate the oncologic outcomes of salivary gland adenoid cystic carcinoma (ACC) and to confirm the benefits of elective neck dissection. Methods We reviewed the records of 61 consecutive patients with ACC. Surgery was performed in all patients. Results The occult metastasis rate was 15.38% (4 of 26 patients) and no regional recurrence in the elective neck dissection group was identified. Among 4 clinically node positive (cN+) patients, regional metastasis was identified in 3 through therapeutic neck dissection. Regional recurrence was identified in 4 patients (4 of 31) who had never undergone elective neck treatment of clinically node negative (cN-) status, exclusively. Overall regional metastases (overall N+) were identified in 11 patients. The overall survival rate was 84.99% at 5 years, 81.13% at 10 and 15 years in (overall N-) status, contrary to 56.82% at 5 years and 28.41% at 10 years in overall N+ status (p = .025). Conclusion Careful follow-up of regional status is important, and proper therapeutic and elective neck treatment can achieve regional control in ACC. Elective neck dissection is recommendable and can provide valuable staging and prognostic information. © 2014 Wiley Periodicals, Inc. Head Neck 36: 1796–1801, 2014

Background In a previous study of robot-assisted neck dissection (RAND), we limited the indication for neck dissection in clinical N0 head and neck cancer. The purpose of this study was for us to present the comparison of the results of therapeutic RAND via a retroauricular or modified facelift approach with outcomes from conventional neck dissection in clinical node-positive head and neck cancer. Methods This study involved a total of 53 patients who underwent neck dissection for head and neck cancer. Operative and pathologic parameters were assessed. Results The RAND and the conventional neck dissection group consisted of 20 and 33 patients, respectively. The mean operative time for the RAND group was significantly longer than that of the conventional neck dissection group. The mean number of retrieved lymph nodes in the RAND group was not significantly different from the conventional neck dissection group. Conclusion Therapeutic RAND via a retroauricular or modified facelift approach was successful with satisfactory esthetic results in patients with node-positive head and neck cancer. © 2014 Wiley Periodicals, Inc. Head Neck 37: 249-254, 2015

Background Robot-assisted neck dissection in patients with head and neck cancer has been demonstrated to be feasible. We conceived a surgical technique of surgery for parotid cancer with the robotic system via a gasless modified facelift (MFL) approach. A detailed surgical technique is provided. Methods In a 28-year-old female patient with parotid cancer, the disease was treated with primary tumor resection with robotic selective neck dissection I to III via an MFL incision. Results Robot-assisted selective neck dissection I to III combined with primary tumor resection was successfully conducted without any significant intraoperative complication, applying additional incision, or conversion to open conventional neck dissection. Videographic demonstration of the robotic-assisted neck dissection is included. Conclusion Robot-assisted surgery via the MFL approach is a feasible and useful method with excellent cosmetic results for the surgical treatment in selected cases of parotid gland cancer. © 2013 Wiley Periodicals, Inc. Head Neck 36: 592–595, 2014

Background We performed transoral robotic surgery (TORS) or conventional surgery via a transoral or mandibulotomy approach in patients with tonsillar cancer and prospectively analyzed the oncologic outcomes and functional recovery of the 3 groups. Methods Between May 2008 and October 2011, 57 patients were enrolled in this prospective study. Results Although there was no significant difference in the survival rate of the TORS group (100%) and the conventional surgery group (96.7%), a higher rate of margin negativity was observed in the TORS group, especially in cases in which the tumor extends inferiorly. Patients who received TORS or conventional transoral procedures showed more rapid recovery of swallowing, shorter hospitalization, and shorter operation time than the mandibulotomy group. Conclusion Despite the weakness of this nonrandomized trial and the differences in T classification, TORS seemed to have distinct advantages over conventional transoral surgery and other conventional open surgery, but further studies are needed. © 2013 Wiley Periodicals, Inc. Head Neck 36: 1138–1145, 2014

The aim of this study was to evaluate the characteristics of malignant tumours of the minor salivary glands in the oral and sinonasal regions, to make sure that the neck was managed correctly, and to identify oncological outcomes, retrospectively, at a single hospital. A total of 60 patients were reviewed. Forty-nine patients had intraoral lesions and 11 had sinonasal lesions. Of the 60 patients, 28 had stage I to II malignant tumours, and 32 had stage III to IV tumours. Treatment was almost exclusively surgical. One of the 16 patients whose nodes were clinically clear had an elective neck dissection. Adjuvant radiotherapy was given if indicated. The mean follow-up period was 52 months (range 13-190). Sinonasal lesions were all advanced T-stage at diagnosis, had more invaded resection margins, and a higher local recurrence rate than intraoral lesions. There was no regional recurrence in those patients whose nodes were clinically invaded and who had therapeutic neck dissection, or in the patient whose nodes were clinically clear and who had an elective neck dissection. Occult metastases developed exclusively in adenoid cystic carcinomas (ACC), the rate of which was 4/16. Regional recurrence developed in 4 patients who had never had elective treatment to the neck 2 of whom mixed pattern ACC and 2 who had low grade mucoepidermoid carcinomas (MEC). The overall survival was 90% at 2 years, 77% at 5 years, and 74% at 10 years. Sinonasal minor salivary gland tumours require careful follow-up because resection margins are more likely to be invaded by tumour, and they have a higher local recurrence rate than intraoral lesions. Elective neck dissection is needed, particularly for MEC and also to prevent regional recurrence in ACC.

Purpose Robot-assisted neck dissection (ND) in patients with head and neck cancer has been developed as a plausible substitute for conventional surgery and it provides an excellent cosmetic outcome. The authors hypothesized that surgery for submandibular gland (SMG) cancer could be achieved with a gasless retroauricular (RA) approach using the robotic system. This study evaluated the feasibility of robot-assisted ND using an RA approach for SMG cancer. Patients and Methods Primary tumor resection with robot-assisted ND using an RA incision was performed in 6 patients with SMG cancer. Results All cases of robot-assisted ND combined with primary tumor resection were conducted successfully without any significant intraoperative complication, need for an additional incision, or conversion to open conventional ND. The amount and duration of drainage, length of hospital stay, number of retrieved lymph nodes, and complications were generally acceptable. The postoperative scar was completely hidden by the auricle and hair. Conclusions Robot-assisted ND with primary tumor excision using an RA approach is a feasible and useful method, with excellent cosmetic results, for surgical treatment of selected cases of SMG cancer.

Transoral robotic surgery (TORS) for oropharyngeal and laryngohypo-pharyngeal tumors is not only a functionally but also a cosmetically excellent approach. However, visible cervical scars for elective neck dissection (ND) or therapeutic ND cannot be avoided. In our experience, using the conventional neck dissection resulted in long neck scars in patients with high risk of nodal metastases. Robot-assisted neck dissection (RAND) through transaxillary approach in a well-differentiated thyroid carcinoma with lateral neck node metastasis was first reported. Complete ND of the upper neck including level I is frequently required in the surgical management of head and neck squamous cell carcinoma, so we hypothesized that a retroauricular approach could provide the surgical field required for upper ND. Initially, we developed robot-assisted selective ND through a transaxillary and retroauricular approach to hide an apparent scar and to remove lateral or posterior neck compartments after TORS in patients with pharyngeal carcinomas. From accumulation of additional experiences with RAND, we have recently attempted performing level IV and V as well as level I-III dissections through a modified facelift or retroauricular approach without an axillary incision in head and neck cancers.

Background Based on our previous experiences with endoscopic or robotic neck surgery utilizing the retroauricular (RA) or modified facelift (MFL) approach, we realized the value of verifying the feasibility of endoscopic supraomohyoid neck dissection (SOND). Therefore, the purpose of this study was to evaluate the potential role of endoscopic SOND. Methods Six patients who underwent elective endoscopic SOND of the ipsilateral neck for biopsy proven head and neck cancer from January 2011 to February 2012 were analyzed. Results All endoscopic operations via RA or MFL were successfully performed without any significant intraoperative complications or conversion to open surgery. Based on patient-reported outcome questionnaires, all patients were satisfied with the cosmetic surgical outcomes. Conclusion Endoscopic selective neck dissection via an RA or an MFL approach is technically feasible and safe with satisfactory cosmetic results for patients with clinically node-negative early-stage head and neck cancer. © 2013 Wiley Periodicals, Inc. Head Neck 36: 425–430, 2014