Multiple free transplants in microsurgery for cervicofacial reconstruction

Microsurgical techniques open the way for much creativity and originality for cervicofacial reconstruction and tumoral repair. Between 1976 and 1994, we performed 481 free transplants for cervico-facial reconstruction. A recently developed strategy has been the use of multiple free transplants, either simultaneously or successively. Between 1990 and 1994, we operated and reconstructed 9 patients using multiple free cervico-cephalic transplants after multitissular and agressive exeresis for tumoral or traumatic lesions. In 3 cases, the transplants were made simultaneously and in the 6 others successively. Three patients received 3 free transplants and 6 patients had 2. In 8 cases, each of the transplants was micro-anastomosed on different vessels. In one case, the two transplants were anastomosed in series, the most distal portion being connected to the most proximal portion (in comparison with the cervical vessels). One death occurred at 6 weeks due to infectious complications. The final result for the 8 other patients was good both morphologically and functionally. Indications for multiple free transplants include: complex tissue loss, multiple and massive tissue loss of the cervicocephalic region. This situation occurs particularly in case of voluminous tumours invading several structures, in multiple tumours and in firearm wounds. These series of patients allowed a definition of recommended techniques in case of difficulties in these very elaborate surgical procedures and confirmed that if the strategy is correctly planned, it is possible to greatly improve the quality of survival in these patients in terms of aesthetics, morphology and function.     

Somatic gene therapy in squamous epithelial carcinomas of the head-neck area

Gene therapy is an important new approach to the treatment and prevention of human diseases. Somatic gene therapy involves the introduction of novel genetic material into somatic cells to express therapeutic gene products. Two main strategies in somatic gene therapy of cancer are applied: the genetic correction of the defect, or the elimination of cancer cells by cytotoxic drugs or the immuno system. Gene transfer can be accomplished by physical and chemical methods or nonreplicating viruses. The different transfer systems vary strongly in their efficiency of transfection, plasmid maintenance, and protein expression. The clinical application could be performed in two ways: Firstly, by in vivo application of genome modifying substances injected directly into the tumour; secondly, by ex vivo application of genetically modified tumour cells as a tumour vaccine. The following review will discuss some of the gene therapy strategies that could be effective in managing head and neck cancer.     

Fetal surgery in the head-neck area. Current status and new possibilities with the endoscope

Fetal surgery is defined as the intrauterine surgical correction of malformations that endanger the unborn child's life in prenatal stages of development or lead to death or severe damage of the child postnatally. Such surgery is a clinical reality now. Indications for intrataurine surgical procedures also exist for head and neck abnormalities, especially in the upper respiratory tract. These include exposure and temporary obstruction of the fetal trachea for correction of pulmonary hypoplasia in cases with congenital diaphragmatic hernias, prenatal tracheotomy in cases of laryngeal atresia for the correction of lethal pulmonary overdistension, and resection of embryonic tumors that obstruct the respiratory tract. The relatively high surgical risk resulting in particular from preterm labor occurring postoperatively may be reduced by employing minimally invasive techniques. Endoscopic procedures render opening of the uterus unnecessary and are of particular importance. In part of the procedures, only endoscopic surgery has led to therapeutic success rates justifying its clinical use. Further reduction of the operative risk suggests prenatal interventions, even in cases with non-lethal conditions. More diseases of the head and neck may thus be included in the spectrum of indications. One example is prenatal correction of a cleft lip and palate, which until now has only been performed in animal experiments. The particular characteristics of fetal wound healing allow this to take place without scarring up to a certain stage in pregnancy. This offers the prospect of a surgical correction that is invisible externally and avoids growth-impeding scars. The particular ethical and legal aspects of fetal surgery are discussed.     

In vivo fluorescence microscopy for the assessment of microvascular reperfusion injury in small bowel transplants in rats

With the use of in vivo fluorescence microscopy we have analyzed microvascular reperfusion injury of small bowel isograft transplants in rats. Following 1 hr cold storage in University of Wisconsin solution, the small bowel was transplanted heterotopically, and the intestinal microcirculation was quantitatively analyzed 20-60 min after onset of reperfusion. The intestinal grafts' capillary perfusion of both the mucosa and the circular and longitudinal muscles was not found altered when compared with the intestinal capillary perfusion of sham-operated controls. In contrast, leukocyte-endothelial cell interaction, including leukocyte rolling (40 +/- 5%) and sticking (280 +/- 100 mm-2) in submucosal postcapillary venules, was significantly increased when compared with nontransplanted controls (12 +/- 8% and 20 +/- 10 mm-2, P < 0.01 and P < 0.05, respectively). Leukocyte-endothelial cell interaction was associated with a marked alteration of lymphatic capillary drainage, as indicated by the low functional density of lymphatic microvessels of 10.2 +/- 6.1 cm-1 (P < 0.01 vs. sham-operated controls (39.2 +/- 6.1 cm-1)). From these results we propose that leukocyte-endothelial cell interaction, not capillary "no-reflow," is the primary step in the manifestation of microvascular reperfusion injury following a short period of cold ischemia in small bowel grafts.     

Diagnosis and therapy of vascular malformations in the head-neck area and their differentiation form hemangiomas]

The classification of vascular anomalies is controversial since the same terms are applied for different lesions. The biological classification according to Mulliken and Glowacki is based on the correlation of cellular features of vascular lesions during infancy and childhood with the physical examination and natural history. On this basis, two main categories of vascular anomalies can be distinguished: 1. Hemangiomas with endothelial proliferation and clinical course of rapid postnatal growth followed by slow involution. 2. Vascular malformations as developmental anomalies with normal endothelial cell cycles. These are subdivided according to the part of the vascular system involved.     

Rhabdomyosarcoma in the area of the head-neck. A synopsis of some cases, therapeutic possibilities and prognoses

BACKGROUND: Soft tissue sarcoma represent approximately 7% of all neoplasms in children up to 14 years. The most common type (approx. 50%) among them is the rhabdomyosarcoma (RMS). Within the head and neck, which accounts for approx. 35% of all RMS, the tumor can be found ubiquitiously. Preferred localizations are the orbita, the paranasal sinuses, and the soft tissue of cheek and neck. The prognosis of RMS was formerly poor but has markedly improved since defined multimodal therapy was established in the Seventies (for example the Intergroup Rhabdomyosarcoma Study, IRS, in 1972; the International Society of Paediatric Oncology, SIOP, in 1975, or the German "Cooperative Weichteil-Sarkom-Studien", CWS, in 1981). The therapy of choice for RMS, according to the CWS, is chemotherapy because very often a good remission of the tumor is achieved. The main role of surgery is first to obtain biopsy specimens for histological diagnosis, and second aim is the complete resection of the primary and resectable metastases, for example by a neck dissection. Severe mutilation by radical surgery, especially in childhood, should be avoided in favor of multidrug chemotherapy and radiation in the interest of patient well-being. PATIENTS: Our retrospective study shows the treatment and results of 11 patients with a rhabdomyosarcoma of the head and neck within 25 years (1972-1997). RESULTS: Five of the 11 patients, who were treated in the years 1972-77, died (average 13 months, range 3-72 months). Five of the six patients, who were treated since 1991, have survived to date, one had a relapse of the tumor. Four special cases of patients are discussed in greater detail. CONCLUSION: Although the achieved mean survival time is encouraging nowadays (a 5-year survival rate of approx. 70% for all RMS is described) fatal cases are typical for this malignancy. Early diagnosis, localization, histological subtype, and prompt initiation of adequate treatment is decisive for a successful outcome.     

The effect of an implantable Doppler probe on the salvage of microvascular tissue transplants

One hundred forty-seven flaps in 135 consecutive patients undergoing microvascular transplantation were monitored using a miniature Doppler ultrasonic probe. Using a modification of a technique described previously by Swartz, the probes were secured to the outflow vein of the flap with Vicryl mesh. Twenty instances of thrombosis or spasm were detected in 16 patients, and all flaps were salvaged (100 percent). There were four false positive and no false negative results. This probe allows for safe, continuous monitoring of flap blood flow, which permits the rapid detection and hence rapid treatment of postoperative complications. Our experience suggests that a significant improvement in the salvage rate of microvascular transplants may be attainable with the use of this device.     

Mandibular reconstruction using a microvascular method in the transplantation of a fibular flap

The best results in mandibular reconstruction are achieved by transplantation of vascularised bone. This transplant has an own blood supply therefore its surviving is not influenced by the non-sterile environment of the oral cavity and the insufficient blood supply of the operated area (caused by scar or radiation). A new promising method for reconstruction of a wide segmented defect of the mandible is vascularised fibular flap transplantation. Eight consecutive patients treated with fibular flap transplantation in 1993 and 1994 were reviewed. Osteo- and osteo-cutan flaps were used for reconstruction of the composite tissue defects. The authors report on the surgical technique and their first experiences. The authors consider the application of the fibular flap the most successful procedure of all types of reconstruction of segmented mandibular defect.     

Gunshot injuries in the head-neck area--basic principles, diagnosis and management

Bullet wounds are a rare occurrence during times of peace. Recently, however, there has been a general increase in the number and severity of this type of trauma in our case load. First, the possible firearms and the individual types of ammunition will be discussed. Based on this background, the possible types of wounds are presented. Principally, one distinguishes ricocheting shots from grazing ones, and those leaving bullets lodged in the body from those with perforating wounds. The extent of tissue damage depends on internal lacerations, on the compression of the tissue and on the temporary cavitation along the projectile path. In contrast to other types of injuries, which are caused by a blow or impact to the face or skull, gunshot traumas are characterized by an irregular path, as well as, by localized destruction of bones with associated effects. In this connection, the severity of the bullet wound also depends upon the extent of involvement of the viscerocranium. As causes of gunshot wounds during times of peace, suicidal intent, the negligent handling of firearms and especially brutal crimes are those which come into consideration first and foremost. The diagnostic aspect of firearm wounds, beside anamnesis, comprises comprehensive X-ray diagnostics for a complete picture. From the therapeutic side, tetanus serum and antibiotics as a prophylactic are recommended initially. The operative treatment should take place depending on the injury with the removal of a possible projectile. Bullet wounds always require an interdisciplinary approach to treatment.     

Effect of gene polymorphism on detoxifying glutathione-S-transferase enzymes on chromosomal stability of squamous epithelial carcinomas in the area of the head-neck]

Angiogenic growth factors constitutes a potentially novel form of therapy for patients with ischemic vascular disease. The feasibility of using recombinant formulations of angiogenic growth factors to augment collateral artery development by stimulation of capillary growth in animal models of myocardial and hindlimb ischemia has now been well established. In the case of vascular endothelial growth factor (VEGF) similar results may be achieved by gene transfer. Further laboratory and clinical studies may yield promising insights into the fundamental basis for native as well as therapeutic angiogenesis, and at the same time more explicitly define the manner in which therapeutic angiogenesis may be successfully incorporated into clinical practice.     

Lymphoscintigraphy with double tracer technique in carcinomas of the head-neck region

BACKGROUND: Lymphoscintigraphy has been used since the early 1960s to demonstrate lymphatic drainage of head and neck tumors, but did not prove satisfactory. With the increasing importance of highly sophisticated neck dissection procedures, lymphoscintigraphy may have greater diagnostic impact. This assumes that lymphoscintigraphy will allow an accurate correlation of lymphatic drainage with anatomic structures. In this paper, we report on a method of lymphoscintigraphy with simultaneous body contouring. METHODS: Double-tracer lymphoscintigraphy was performed in 78 patients with squamous cell carcinoma. Patients received 100 MBq 99mTc-colloid in 0.1-0.2 ml in 3-4 peritumoral localizations. Ten patients were injected during surgery. Two milliliters of perchlorate solution were given orally in order to block the thyroid. Twenty minutes later patients received 50 MBq 99mTc-pertechnetate i.v. for body contouring. Planar images were obtained over 5 min each at 30 min and 4-6 h after injection from anterior, right lateral and left lateral using a LFOV-gamma camera. RESULTS: The thyroid was not visualized in any of the patients. In 28 of 78 patients (36%), the injection site was the only focal activity seen. In 50 of 78 patients (64%), lymph drainage was observed. Thirty-six of 78 patients (46%) showed unilateral lymphatic drainage, and 14 of 78 (18%) showed bilateral drainage. In all 50 patients showing lymphatic drainage, lymph nodes could be easily assigned to the six cervical lymph node compartments described. CONCLUSIONS: Double-tracer lymphoscintigraphy enables an accurate correlation of cervical lymph nodes and anatomic structures of the head and neck region. These findings suggest that the impact of these studies on the preoperative planning for neck dissection should be reevaluated.     

Pectoralis major myocutaneous flap for reconstruction of defects following resections in head and neck area

Pectoralis major myocutaneous flap (PMMF) has become the standard for reconstruction of major defects in head and neck area. Eleven cases, operated over a three year period, in which PMMF was used for reconstruction have been reviewed retrospectively. Nine patients had oral squamous cell carcinoma, one had a basal cell carcinoma of the external ear and one had lost skin and soft tissue of neck following synergistic gangrene. Ten of the eleven flaps survived (success rate 91%). One of the three rib grafts used to reconstruct mandible got infected and had to be removed. Three patients developed wound infections and one had a temporary orocutaneous fistula which closed spontaneously. This brief experience confirms the reliability and efficiency of PMMF for head and neck reconstruction.     

Tissue preparation in combined scapula flap for microsurgical reconstruction of defects of the oromaxillofacial area]

Nowadays, in congenital or acquired large oro-maxillofacial defects microsurgical reconstruction is mainly performed by revascularized osseous, osteocutaneous, or osteomyocutaneous distant flaps. The aim of reconstruction includes not only restoration of stable continuity and esthetic contour, but also the restoration of a functioning "chewing organ". For reconstruction in maxillary and midface defects, we prefer the scapular flap for a single-step reconstruction. Tissue prefabrication results in osseointegrated implants and thin mucosal linings with stable soft tissue conditions at the time of microsurgical reconstruction. Following dental restoration, full oral function is given. This single-stage procedure improves the psychosocial situation of the patient considerably when compared with conventional multi-stage reconstruction.     

Late functional outcome after reconstruction of the upper aerodigestive tract with free transplanted microvascular anastomosed jejunum

Since 1983, 90 autologous jejunal transplantations for reconstruction of the upper digestive tract have been performed in 89 patients (9 females, 80 males, average age 56.3 years). 73 patients were operated primarily, in 16 patients a recurrent tumor had been treated. One patient received a second jejunal graft after necrosis. In these heterogenous patients, the primary tumor was located in the hypopharynx 48 times, in the larynx 21 times, in the oropharynx 19 times and twice in the oral cavity. There was nearly always tumor stage III or IV without distant metastases. Following locoregional tumor resection, speech restoration was achieved 35 times by a siphon-like tube, and the upper digestive tract was reconstructed using a patch 18 times and by a tube 28 times. A combination of tube or patch with a siphon-like tube was employed 9 times. In only two of 16 patients with recurrent tumor, speech reconstruction was performed, in the other 14, the upper digestive tract was reconstructed. In those patients, in whom speech reconstruction (by siphon tube or by combination with tube/patch) was intended, this was achieved in 81.5%. Successful functional reconstruction of the upper digestive tract (by patch, tube, combination) could be achieved in about 60% of these patients.     

Pedicled external spermatic fascia flap for urethroplasty in hypospadias and closure of urethrocutaneous fistula

PURPOSE: To prevent the development of urethrocutaneous fistula after urethroplasty for hypospadias or recurrence after closure of a urethrocutaneous fistula, the authors developed a new simple technique wherein the readily available external spermatic fascia (ESF) surrounding the testis and cord is used as a pedicled blanket flap to cover the neourethra or the site of closure of a urethrocutaneous fistula. RESULTS: In three patients who had urethroplasty for hypospadias incorporating our ESF flap procedure, no urethrocutaneous fistula developed. It was also effective for closure of urethrocutaneous fistula in five patients, some of whom had had recurrent fistula formation.     

Factors influencing malnutrition in children waiting for liver transplants

Nutrition deficiencies are common in children with chronic liver disease. To determine whether age, hepatic dysfunction, or energy intake influences this malnutrition, we evaluated the nutritional status of 49 children aged 2.5 mo to 13 y (mean: 35 mo; median: 12 mo). The children were divided into two groups according to age: group 1-29 patients aged < or = 1 y (mean: 7 mo; median: 7 mo); and group 2-20 patients > 1 y (mean: 75 mo; median: 59 mo). Hepatic dysfunction was defined according to the Malatack criteria. Seventy-two-hour dietary intakes were recorded by a nutritionist. Nutritional status was assessed by anthropometric measures when the patients were enrolled on the waiting list for liver transplants. We evaluated the following indexes: weight, height, fat body mass, and lean body mass on the basis of height-age (age at which height reached 50th Italian height percentile). Mean height Z scores were low in both groups, but the difference was not significant. Mean weight Z scores and mean percentages of fat body mass were significantly lower (P < 0.001) in group 1 than in group 2 patients. In group 2, lean body mass and fat body mass were significantly lower (P < 0.05) in patients with moderate-to-severe hepatic failure than in patients with mild hepatic dysfunction. The mean energy intake was in the range of the recommended daily allowances for age but was insufficient for both groups of patients. The evidence of significant acute and chronic malnutrition confirmed the need for nutritional support, especially for younger and older children with moderate-to-severe hepatic dysfunction. We emphasize the necessity of accurate assessment of nutritional status by simple anthropometric measurements to be sure of the effects and adequacy of the nutritional intervention.