Publications by authors named "Michael A Fritz"

41 Publications

Free Tissue Transfer for Skull Base Osteoradionecrosis: A Novel Approach in the Endoscopic Era.

Laryngoscope 2022 Aug 3. Epub 2022 Aug 3.

Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.

Objectives: Osteoradionecrosis (ORN) of the skull base and craniovertebral junction is a challenging complication of radiation therapy (RT). Severe cases often require surgical intervention through a multi-modal approach. With the evolution in endoscopic surgery and advances in skull base reconstruction, there is an increasing role for microvascular free tissue transfer (MFTT). We describe an endoscopic-assisted approach for the management of ORN of the skull base using fascia lata for MFTT.

Study Design: Retrospective case series.

Methods: Between 2017 and 2021, a review of all cases in which fascia lata MFTT was utilized for skull base ORN was performed. Patient demographics, preoperative characteristics, and postoperative outcomes with long-term follow-up were reviewed.

Results: Five patients were identified. Mean duration to onset of ORN was 17 months following RT. A trial of antibiotics, hyperbaric oxygen (HBO), and/or limited debridement was attempted without success. Refractory pain and progressive osteomyelitis were unifying symptoms. All patients underwent endoscopic debridement of the affected region of ORN prior to MFTT. Vascularized fascia lata was inset through a combined endonasal and transoral corridor. There was improvement in chronic pain in the postop setting with no patients requiring continued antibiotics or HBO therapy. Mean post-op follow-up was 23 months.

Conclusions: With continued evolution in endoscopic, minimally invasive approaches, there is an expanding indication for early surgical management in refractory ORN. Fascia lata MFTT is a novel and effective strategy for the management of ORN of the skull base and upper cervical spine with excellent postoperative outcomes and limited patient morbidity.

Level Of Evidence: 4 Laryngoscope, 2022.
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August 2022

Free vascularized fascia lata flap for total columella reconstruction.

Am J Otolaryngol 2022 Jan-Feb;43(1):103226. Epub 2021 Sep 11.

Division of Facial Plastic and Microvascular Surgery, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, OH, United States of America. Electronic address:

Introduction: Despite their relatively small size, columellar defects, including both external and internal elements, are exceedingly difficult to reconstruct. Local, regional, and distant flaps have been described for reconstruction. Herein, we present a novel technique for reconstruction of the columella using vascularized free fascia lata from the anterolateral thigh with structural replacement and skin grafting.

Methods: This novel technique utilizes a small anterolateral thigh flap, formed into vascularized fascia lata without the overlying subcutaneous fat or skin. The fascia lata is inset into the columellar and caudal septal defect after a cartilage framework is constructed and is microsurgically anastomosed to either distal facial or angular vessels. A skin graft from the ALT donor site is then secured over the fascia.

Results: This technique has been applied successfully in patients with either isolated columella or in multi-subunit reconstruction following total rhinectomy with no flap or reconstructive failures. Given the low morbidity of flap harvest and minimal access incisions, this has been reliably accomplished with short (1-2 day) hospital stays.

Conclusion: Rapid and aesthetically acceptable reconstruction of total nasal columella defects in isolation or with additional nasal subunit reconstruction, is possible utilizing this novel technique. Here we discuss pearls and pitfalls of its use following surgical resection of malignancy.
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February 2022

Anterolateral Thigh Fascia Lata Rescue Flap: A New Weapon in the Battle Against Osteoradionecrosis.

Laryngoscope 2021 12 6;131(12):2688-2693. Epub 2021 Aug 6.

Facial Plastic and Microvascular Surgery, Cleveland Clinic, Cleveland, Ohio, U.S.A.

Objectives: To demonstrate that the anterolateral thigh fascia lata (ALTFL) rescue flap may be effectively used for management of osteoradionecrosis (ORN) in selected patients.

Study Design: Retrospective case review.

Methods: Retrospective chart review was performed on patients who underwent ALTFL free flap repair to various sites of ORN in the head and neck between 2011 and 2018. Inclusion criteria were patients with radiographic and clinical evidence of head and neck ORN who either failed previous hyperbaric oxygen (HBO) therapy or with extensive disease, which was unlikely to respond to conservative management.

Results: Twenty-three patients with average age of 63 years (40-78) who underwent 24 ALTFL free flap procedures were reviewed. ORN sites were the mandible (n = 16), palatomaxilla (n = 4), skull base and cervical spine (n = 3), and calvarium (n = 2). Recipient vessels used were superficial temporal (n = 11), common facial (n = 10), and angular (n = 3). Average hospital stay was 3.0 (1-10) days. Prior HBO therapy was performed in 13 (57%) patients. There were four major complications: flap failure, recurrent mandibular infection resolved with IV antibiotic course, mandibular fracture with malunion requiring occlusal adjustment, and unresolved sequelae of ORN requiring fibular free flap. There were four minor complications: thigh hematoma, thigh seroma, and intraoral scar formation causing trismus (n = 2). The procedure was successful in 22 of 23 (95.7%) patients with radiographic arrest of ORN, resolution of symptoms, and elimination of antibiotic requirements.

Conclusion: The ALTFL rescue flap merits strong consideration in ORN management and appears to prevent progression to more extensive disease, which would require full segmental bone resection and reconstruction.

Level Of Evidence: 4 Laryngoscope, 131:2688-2693, 2021.
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December 2021

Primary Infectious Mononucleosis Masquerading as Post-operative Fever in a Young Patient with Cemento-ossifying Fibroma of the Skull Base.

Cureus 2019 Dec 8;11(12):e6327. Epub 2019 Dec 8.

Neurosurgery, Neurological Institute, Cleveland Clinic - Taussig Cancer Center, Cleveland, USA.

The typical presentation of infectious mononucleosis (IM) is characterized by a triad of fever, pharyngitis, and lymphadenopathy. Epstein-Barr virus (EBV) is the most common etiologic agent for IM. Humans are the reservoir for EBV, and it is transmitted via intimate contact between individuals. This case presents a 19-year-old male with recurrent cemento-ossifying fibroma of the skull base with a complicated post-operative course including bacterial meningitis, cerebrospinal fluid (CSF) leak, and intermittent fevers despite treatment with intravenous cefepime. Head computed tomography (CT) revealed a nonspecific subdural collection that could represent an empyema. However, exploratory craniotomy revealed no empyema. CT chest demonstrated bilateral hilar mediastinal lymphadenopathy and splenomegaly. Blood work for fever of unknown origin was positive for EBV immunoglobulin M, and EBV deoxyribonucleic acid 180,565 IU/mL.  The diagnosis of EBV IM in this case was elusive because it presented post-operatively, symptoms aligned with the patient's CSF leak, and he reported no sexual or sick contacts. For post-operative young patients with recurrent fevers of unknown origin, it is important to consider EBV IM in the differential. Earlier diagnosis could have saved the patient unneeded tests, prevented surgical re-exploration, and resulted in a shorter hospital stay.
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December 2019

Early discharge after free-tissue transfer does not increase adverse events.

Am J Otolaryngol 2020 Mar - Apr;41(2):102374. Epub 2019 Dec 10.

Cleveland Clinic, Head and Neck Institute, Cleveland, OH, USA.

Introduction: Demonstrate that carefully selected free flap patients may be discharged early after surgery without increasing the rates of postoperative complications or readmissions.

Methods: Based on a published article in Laryngoscope 2016 of 51 free-tissue transfers, a retrospective chart review was performed on an expanded cohort who underwent free-tissue transfer for head and neck reconstruction between February 2010 and May 2018 and discharged by postoperative day 3.

Results: 101 patients who underwent 104 free flaps with average age of 56 (3-84) years old were reviewed. Free flap indications included orbital and maxillary defects (n = 22), palatal defects (n = 16), nasal and septal defects (n = 16), cranioplasty and scalp defects (n = 16), mandibular defects due to osteoradionecrosis (n = 14), facial contouring and parotid defects (n = 12), and complex postsurgical and radiotherapy wounds or fistula closure (n = 8). Free flaps performed were anterolateral thigh (n = 97), radial forearm (n = 2), serratus (n = 2), latissimus (n = 1), fibula (n = 1) and supraclavicular (n = 1). The recipient vessels used via minimal access approaches were facial (n = 43), superficial temporal (n = 29), angular (n = 20) and others. There were 3 flap failures (2.9%) recognized in follow-up. No flap failures or perioperative complications were associated with early discharge. There were only 2 patients readmitted and 1 watched in observation within 30 days postoperatively.

Conclusion: An updated review of our institutional experience with more than double the cohort size substantiates previous conclusions that early discharge after free-tissue transfer is a safe option in select patients. Moreover, earlier discharge is a critical management choice that reduces cost and decreases hospital-related adverse events.
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August 2020

Predictive value of the ACS NSQIP calculator for head and neck reconstruction free tissue transfer.

Laryngoscope 2020 03 30;130(3):679-684. Epub 2019 Jul 30.

Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, U.S.A.

Background: Predictive models to forecast the likelihood of specific outcomes after surgical intervention allow informed shared decision-making by surgeons and patients. Previous studies have suggested that existing general surgical risk calculators poorly forecast head and neck surgical outcomes. However, no large study has addressed this question while subdividing subjects by surgery performed.

Objectives: To determine the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator in estimating length of hospital stay and risk of postoperative complications after free tissue transfer surgery.

Study Design: A retrospective chart review of patients at one institution was performed using Current Procedural Terminology codes for anterolateral thigh (ALT) flap, fibula free flap (FFF), and radial forearm free flap (RFFF) reconstruction. Output data from the ACS NSQIP surgical risk calculator were compared with the observed rates in our patients.

Methods: Incidences of cardiac complications, pneumonia, venous thromboembolism, return to the operating room, and discharge to skilled nursing facility (SNF) were compared to predicted incidences. Length of stay was also compared to the predicted length of stay.

Results: Three hundred thirty-six free flap reconstructions with 197 ALT flaps, 85 RFFFs, and 54 FFFFs were included. Brier scores were calculated using ACS NSQIP forecast and actual incidences. No Brier score was <0.01 for the entire sample or any subgroup, which indicates that the NSQIP risk calculator does not accurately forecast outcomes after free tissue reconstruction.

Conclusion: The ACS NSQIP failed to accurately forecast postoperative outcomes after head and neck free flap reconstruction for the entire sample or subgroup analyses.

Level Of Evidence: 4 Laryngoscope, 130:679-684, 2020.
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March 2020

Osseocartilaginous Rib Graft L-Strut for Nasal Framework Reconstruction.

Aesthet Surg J 2020 03;40(4):NP133-NP140

Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH.

Background: In the setting of major nasal framework reconstruction, it is critical to create a stable, warp-resistant L-strut to resist the contractile forces of healing to achieve a durable outcome.

Objectives: The authors sought to demonstrate the effectiveness of the osseocartilaginous rib graft for nasal framework reconstruction.

Methods: Retrospective analysis was performed of all patients who underwent osseocartilaginous rib graft for L-strut reconstruction from 2007 to 2017 at a tertiary care hospital. Only patients with severe framework-only defects (Type IV, Daniel Classification) or total/subtotal nasal defects (Type V, Daniel Classification) were included. Primary outcome measures were: (1) maintenance of projection; (2) graft warping; and (3) graft resorption.

Results: Twenty-six patients aged an average of 54.6 years underwent nasal framework reconstruction with an osseocartilaginous rib graft L-strut. Eighteen patients had framework-only deformities (Daniel Type IV) and 8 had total or subtotal nasal deformities (Daniel Type V). Twelve patients underwent reconstruction for autoimmune mediated deformity, 10 for malignancy, 3 for traumatic injury, and 1 for an iatrogenic deformity. Average follow-up was 21 months. There was no observed warping of the L-strut construct, and all but 2 patients demonstrated total maintenance of projection. Resorption of the caudal cartilage graft was identified as the etiology of partial loss of projection in 2 patients.

Conclusions: The osseocartilaginous rib graft L-strut provides a stable, warp-resistant construct for patients lacking major dorsal and caudal support, which may be applied to reconstruction of defects due to malignancy, autoimmune, traumatic, or iatrogenic etiologies.

Level Of Evidence: 4:
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March 2020

Comprehensive approach to reestablishing form and function after radical parotidectomy.

Am J Otolaryngol 2018 Sep - Oct;39(5):542-547. Epub 2018 Jun 7.

Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA.

Introduction: The reconstructive goals following radical parotidectomy include restoration of symmetry, reanimation of the face, and reestablishment of oral competence. We present our experience utilizing the anterolateral thigh (ALT) free flap, orthodromic temporalis tendon transfer (OTTT), and facial nerve cable grafting to reestablish form and function.

Material And Methods: From 2010 to 2016, 17 patients underwent radical parotidectomy followed by immediate reconstruction. An ALT was harvested to accommodate the volume and skin defect. Additional fascia lata and motor nerve to vastus lateralis (MNVL) were obtained. Anastomosis of the ALT to recipient vessels was performed, most commonly using the facial artery and internal jugular vein. OTTT was performed by securing the medial tendon of the temporalis to orbicularis oris through a nasolabial incision. Fascia lata was tunneled through the lower lip, then secured laterally to the temporalis tendon. The MNVL was cable grafted from either the proximal facial nerve or masseteric nerve to the distal facial nerve branches. ALT fascia was suspended to the superficial muscular aponeurotic system.

Results: Average follow up was 19 months. Only one patient failed to achieve symmetry attributed to dehiscence of OTTT. All patients achieved oral competence and dynamic smile with OTTT activation. Facial nerve recovery was seen in 8 patients. 5 reached a House Brackman Score of 3. Two donor site seromas and two wound infections occurred.

Conclusion: Simultaneous ALT, OTTT, and facial nerve cable grafting provides early reestablishment of facial symmetry, facial reanimation, and oral competence with minimal morbidity.
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December 2018

Fascia Lata Free Flap Reconstruction of Limited Hard Palate Defects.

Cureus 2018 Mar 21;10(3):e2356. Epub 2018 Mar 21.

Head and Neck Institute, Cleveland Clinic.

Objective  The anterior-lateral thigh (ALT) free flap is a flexible reconstructive option with fascia lata, fasciocutaneous, and musculocutaneous options. The objective of this study is to evaluate ALT fascia lata free flap reconstruction of isolated hard palate defects. Methods  Retrospective chart review of all palate reconstructions with ALT free flap from 2008-2017 by a single surgeon, at a tertiary academic institution. Patients with defects limited to the hard palate were selected for review. Results Forty-eight patients were identified, of which 14 patients had limited palatal defects repaired with fascia lata free flaps and were selected for review. The average hospital stay for all patients was 2.8 days (range 1-4 days). Eighty-five percent of patients were started on an oral diet from post-operative day (POD) one. Ten of 14 were extubated at the end of the case, with four being extubated on POD one. One patient suffered donor site morbidity, which required intervention (one seroma requiring drainage). Two patients underwent minor palatal revisions with local tissue rearrangement for recurrent fistula. No patients suffered long-term velopharyngeal inadequacy (VPI) or dysphagia, and all reported normal nasal respiration. Conclusion The ALT fascia lata free flap is a versatile reconstructive option for hard palate defects, with minimal morbidity, short hospital stays, and excellent long-term results.
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March 2018

Fascia Lata Free Flap Anastomosed to the Superior Trochlear System for Reconstruction of the Anterior Skull Base.

J Neurol Surg B Skull Base 2017 Oct 8;78(5):393-398. Epub 2017 May 8.

Department of Otolaryngology-Head and Neck Surgery and Center for Skull Base Surgery, Augusta University, Augusta, Georgia, United States.

 This study aims to introduce a novel technique for the reconstruction of the anterior skull base using a free vascularized anterolateral thigh fascia lata free flap (FLFF) anastomosed to the superior trochlear artery (STA).  The diameter of the STA was measured in 38 (76 sides) computed tomography angiographies (CTAs). Independently, six cadaver heads were used to measure the diameter of the supratrochlear system, and the model was applied to one of them.  In women, the average diameter of the STA was 2.5 and 2.8 mm for the right and left sides, respectively; for men, it was 3.0 and 3.2 mm , respectively. In cadavers, the average diameter of both STA was 2.5 mm . There was no statistical difference when comparing the right and left STA diameters between the CTA from women and men (  < 0.208 and < 0.492, respectively). An FLFF advanced through the nose was anastomosed to the STA to reconstruct the anterior skull base.  The STA is a constant vessel with a 2.5 to 3.0 mm diameter in men and women that can be used as a recipient free flap vessel. The FLFF can cover the entire skull base. This is a novel method to reconstruct the anterior skull base when local flaps are not available.
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October 2017

Large orbital defect reconstruction in the setting of globe-sparing maxillectomy: The titanium hammock and layered fibula technique.

Microsurgery 2018 May 14;38(4):354-361. Epub 2017 Aug 14.

Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

Introduction: The purpose of our study was to describe a novel technique for reconstruction of orbital defects after maxillectomy using a non-anatomic titanium mesh suspension of orbital contents for both support and volume correction. This construct is then articulated with a layered fibula osteocutaneous free flap that restores orbital rim, zygoma, and maxillary alveolus. We herein present our application of this technique, including refinements over time and long-term outcomes.

Methods: A retrospective review was performed on 12 patients who underwent reconstruction of Brown class III orbitopalatomaxillary defects with extensive orbital involvement (at minimum complete orbital floor and rim absent) with titanium mesh sling and a layered fibula free flap.

Results: Primary reconstruction was accomplished in all 12 patients. The mean postoperative length of stay was 8 days (6-14 days). There were no free flap failures or perioperative re-explorations. Patients were routinely extubated on postoperative day #1 and began oral intake by postoperative day #3. At a mean follow-up length of 48 months, unrestricted eye function was accomplished in all patients. Midfacial symmetry was accomplished in 10 of 12 patients; 2 patients had moderate asymmetry due to extirpation of facial musculature and/or soft tissue. Minor revisions were necessary for lower lid ectropion and exposure of the titanium plate. Two patients required adipofascial free flap coverage of exposed intraoral bone after radiation therapy.

Conclusions: This technique provides excellent restoration of eye position and function and also allows for implant-based prosthetic rehabilitation. It has become our procedure of choice for orbitomaxillary reconstruction.
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May 2018

Locoregional recurrence following maxillectomy: implications for microvascular reconstruction.

Laryngoscope 2017 11 9;127(11):2534-2538. Epub 2017 May 9.

Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco Medical Center, San Francisco, California, U.S.A.

Objective: Reconstruction of maxillectomy defects offers potential quality-of-life improvement, although cavity coverage may impact surveillance of recurrent malignancy. We describe the pattern of postmaxillectomy locoregional recurrence.

Study Design: Retrospective review.

Methods: Patients from 2001 to 2011 at the University of California, San Francisco and the Cleveland Clinic.

Results: Among 75 patients with malignancy resulting in partial or total maxillectomy, 57 were treated with obturators and 18 underwent reconstructive surgery. Disease recurrence occurred primarily locally (19 of 22 cases of recurrence, 25% of the cohort) at a mean of 17 months postoperatively. Recurrence was associated with T4 disease, positive margins, and surveillance imaging. Four (5.3%) patients required flap mobilization/obturator removal to obtain biopsy. Salvage surgery was attempted in 13 of the 19 cases with recurrent disease (68%) and was successful in six (46%) patients. Of these, five patients initially had Brown type 1 or type 2 defects. The free flap had to be revised in one (1.3%) patient to achieve successful salvage.

Conclusion: Maxillectomy provides good long-term locoregional oncologic control, with cure being correlated to disease stage at presentation and negative margins after initial surgery. Patients with recurrent disease whose initial resection resulted in a Brown class 3 defect or greater were rarely successfully salvaged. Surveillance is best performed with a combination of physical exam and imaging. Obturator removal/flap mobilization rarely impedes the diagnosis of recurrent disease, and either modality should be offered to appropriate patients in the primary setting if significant quality-of-life improvement is likely.

Level Of Evidence: 4. Laryngoscope, 127:2534-2538, 2017.
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November 2017

Perioperative cardiac complications in patients undergoing head and neck free flap reconstruction.

Am J Otolaryngol 2017 Jul - Aug;38(4):433-437. Epub 2017 Apr 6.

Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA.

Background: Limited data exists on cardiac complications following head and neck free flaps.

Design: A retrospective review was performed on patients that underwent free flap reconstruction from 2012 to 2015.

Results: 368 flaps were performed. 12.5% of patients experienced a cardiac event. Hypertension, coronary artery disease, heart failure, venous thromboembolism, and anticoagulation were associated with cardiac complications. ASA class was not predictive of cardiac events. 7.6% of patients required anticoagulation, which exhibited a strong association with surgical site hematoma. Cardiac complications led to a significantly increased length of stay.

Conclusions: There is a significant rate of cardiac events in this cohort. When estimating risk, a patient's total burden of comorbidities is more important than any one factor. ASA Class fails to demonstrate utility in this setting. Cardiac events have implications for quality-related metrics including length of stay and hematoma rate.
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May 2018

Short-stay hospital admission after free tissue transfer for head and neck reconstruction.

Laryngoscope 2016 12 26;126(12):2679-2683. Epub 2016 Jul 26.

Head and Neck Institute, Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio, U.S.A.

Objectives/hypothesis: To show that, for patients with few medical comorbidities and at low risk for airway compromise or fistula formation, early discharge after free tissue transfer for head and neck reconstruction is a safe and viable option.

Study Design: Retrospective chart review.

Methods: A cohort of patients who underwent free tissue transfer for head and neck reconstruction between February 2010 and December 2014 and who were discharged from the hospital by postoperative day 3 were reviewed.

Results: Fifty patients undergoing 51 free-tissue transfer surgeries were discharged by postoperative day 3. The surgeries performed included anterolateral thigh free flaps (ALT) (n = 46), radial forearm free flaps (n = 2), latissimus myogenous and myocutaneous free flaps (n = 1), supraclavicular free flap (n = 1), and serratus free flap (n = 1). All ALT flaps were harvested exclusively as perforator free flaps; and the vast majority used superficial temporal, angular, or facial vessels. All free flaps were viable without evidence of vascular compromise at discharge and the initial follow-up appointment. One patient required take-back for successful flap salvage. One patient experienced late flap failure (between 2-3 weeks postoperatively), requiring another surgery. This resulted in an overall success rate of 98% in this cohort. No other postoperative complications related to early discharge were identified.

Conclusion: In a carefully selected subset of patients undergoing free tissue transfer, early discharge has been shown to be possible without compromising patient safety or surgery success rates.

Level Of Evidence: 4. Laryngoscope, 126:2679-2683, 2016.
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December 2016

Controversies in Parotid Defect Reconstruction.

Facial Plast Surg Clin North Am 2016 Aug 24;24(3):235-43. Epub 2016 May 24.

Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, 2233 Post Street, 3rd Floor, San Francisco, CA 94115, USA. Electronic address:

Reconstruction of the parotid defect is a complex topic that encompasses restoration of both facial form and function. The reconstructive surgeon must consider facial contour, avoidance of Frey syndrome, skin coverage, tumor surveillance, potential adjuvant therapy, and facial reanimation when addressing parotid defects. With each defect there are several options within the reconstructive ladder, creating controversies regarding optimal management. This article describes surgical approaches to reconstruction of parotid defects, highlighting areas of controversy.
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August 2016

Microvascular Reconstruction of the Parotidectomy Defect.

Otolaryngol Clin North Am 2016 Apr;49(2):447-57

Department of Facial Plastic and Reconstructive Surgery, Boston University, 830 Harrison Avenue, Moakley Building Ground Floor, Boston, MA 02118, USA.

Parotidectomy is a commonly performed procedure for both benign and malignant lesions. When a significant portion of the gland is resected and the lost tissue volume is not replaced, a disfiguring contour defect can result. This defect can be disfiguring and have a profound impact on quality of life. Large defects are best replaced with vascularized tissue to provide stable volume.
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April 2016

Periocular Skin Cancer in Solid Organ Transplant Recipients.

Ophthalmology 2016 Jan 29;123(1):203-8. Epub 2015 Oct 29.

Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio.

Purpose: To determine the proportion of solid organ transplant recipients developing periocular nonmelanoma skin cancer and to describe the morbidity of these cancers in transplant recipients.

Design: Cohort study.

Participants: Consecutive patients undergoing solid organ transplantation at the Cleveland Clinic between 1990 and 2008.

Methods: The charts of all patients receiving a solid organ transplant from 1990-2008 evaluated in the dermatology department for a subsequent biopsy-proven head and neck malignancy through April 2015 were reviewed. Patients with a periocular region nonmelanoma skin cancer (NMSC) or a nonperiocular NMSC causing a complication requiring eyelid surgery were included. Charts were reviewed for demographic data; transplant date, type, and source; immunosuppressive agents received at diagnosis; and type of NMSC, number of nonperiocular NMSCs, ophthalmologic findings, and periocular sequelae after the repair.

Main Outcome Measures: Primary outcome measures included the type, location, final defect size, tumor-node-metastasis classification, presence of perineural invasion, and reconstruction technique(s) used for each periocular NMSC. Secondary outcome measures included the type and treatment of ocular sequelae due to nonperiocular facial NMSC.

Results: A total of 3489 patients underwent solid organ transplantation between 1990 and 2008. Of these, 420 patients were evaluated in the dermatology clinic for biopsy-proven NMSC of the head and neck during the study period, and 11 patients (15 malignancies) met inclusion criteria. Nine patients developed 12 periocular malignancies and 3 patients required eyelid surgery for facial malignancies outside the periocular zone. All 11 patients developed a squamous cell carcinoma (14 malignancies), and 1 patient (1 malignancy) also developed a periocular basal cell carcinoma. There was orbital invasion in 4 cases and paranasal and/or cavernous sinus invasion in 3 cases. Two patients underwent exenteration. Seven cases required reconstruction with a free flap or graft. Periocular sequelae included lower eyelid ectropion (6 malignancies), dry eye and/or exposure symptoms (8 malignancies), unilateral vision loss (3 malignancies), and facial nerve paresis (5 malignancies).

Conclusions: Squamous cell carcinoma affecting the periocular region represents a risk of solid organ transplantation and may produce significant ocular morbidity, including the need for major eyelid reconstruction, globe loss, and disfiguring surgery.
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January 2016

Recent advances in head and neck free tissue transfer.

Curr Opin Otolaryngol Head Neck Surg 2015 Aug;23(4):297-301

aDepartment of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California bHead and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Purpose Of Review: Free tissue transfer is a versatile and valuable method for reconstructing select head and neck defects following trauma or oncologic resection. Microvascular reconstructive cases are among the longest, most technically challenging, and most labor-intensive operations performed by departments of otolaryngology/head and neck surgery. However, technical advances, increased experience, and robust training programs have permitted realization of microvascular success rates in excess of 97% at most high-volume centers. Given this unprecedented degree of success, research emphasis has shifted to advancing techniques, expanding indications, and increasing efficiencies.

Recent Findings: Although numerous topics are important for discussion, this update focuses on recent notable advances in reconstruction. These include expanding utility of the anterolateral thigh free flap in soft tissue reconstruction, prefabricated plating for fibula free flap mandibular reconstruction, use of venous couplers, and postoperative free tissue monitoring techniques.

Summary: Improvements in technique, technology, and monitoring continue to improve success rates, reduce operative time and associated morbidity, improve overall functional outcomes, and improve patient-specific quality of life. These highlighted recent advances, amongst others, promote further advancement and simplification of reconstructive capabilities.
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August 2015

Inferior outcomes in immunosuppressed patients with high-risk cutaneous squamous cell carcinoma of the head and neck treated with surgery and radiation therapy.

J Am Acad Dermatol 2015 Aug 29;73(2):221-7. Epub 2015 May 29.

Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Immunosuppressed patients have higher rates of cutaneous squamous cell carcinoma of the head and neck.

Objective: This study reviews the effect of immune status on disease characteristics and treatment outcomes.

Methods: Patients with cutaneous squamous cell carcinoma of the head and neck treated with surgery and postoperative radiotherapy between 2000 and 2011 were included. Immunosuppressed patients underwent prior organ transplantation or chemotherapy. Baseline variables were compared using χ(2) and unpaired t tests. Overall survival and disease-free survival were calculated using the Kaplan-Meier method.

Results: In this study of 59 patients, 38 (64%) were immunocompetent and 21 (36%) were immunosuppressed. Most patients had recurrent tumors (63%) and node-positive disease (61%), which were well balanced between the groups. Poorly differentiated tumors (62% vs 21%; P = .009), lymphovascular invasion (29% vs 11%; P = .08), and extracapsular extension (57% vs 41%; P = .09) were more frequent in the immunosuppressed group. Two-year disease-free survival (45% vs 62%) and 2-year overall survival (36% vs 67%) were inferior for immunosuppressed patients.

Limitations: Limitations include single institution, retrospective study with small sample size, and potential referral bias.

Conclusions: Immunosuppressed patients with cutaneous squamous cell carcinoma of the head and neck more frequently present with high-risk pathologic features and inferior outcomes. Early multidisciplinary assessment and alternate management strategies merit prospective investigation.
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August 2015

Short-term donor site morbidity: A comparison of the anterolateral thigh and radial forearm fasciocutaneous free flaps.

Head Neck 2016 04 18;38 Suppl 1:E945-8. Epub 2015 Jul 18.

Cleveland Clinic Head and Neck Institute, Cleveland, Ohio.

Background: Donor site morbidity is an important consideration in the overall decision-making algorithm for fasciocutaneous free flap reconstruction of the head and neck.

Methods: A retrospective case series was conducted of donor site complications occurring within 30 days of surgery among 226 consecutive anterolateral thigh (ALT) or radial forearm free flap (RFFF) microvascular free tissue transfers performed by multiple reconstructive surgeons between 2005 and 2010.

Results: A greater number of donor site complications occurred among patients undergoing RFFF versus ALT free flaps (40; 35.4%; vs 14; 12.4%; p < .001). Wound dehiscence occurred significantly more frequently among patients undergoing RFFF versus ALT free flap reconstruction (34; 30%; vs 6; 5%; p < .001). Tendon exposure occurred in 16 of the 113 RFFFs (14.1%). Seromas occurred more commonly in the ALT group (6; 5%; vs 2; 1.7%; p = .280).

Conclusion: Although short-term donor site morbidity was low in both groups, the ALT was associated with a significantly lower incidence of wound dehiscence with or without tendon exposure. © 2015 Wiley Periodicals, Inc. Head Neck 38: E945-E948, 2016.
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April 2016

Minimizing morbidity in microvascular surgery: small-caliber anastomotic vessels and minimal access approaches.

JAMA Facial Plast Surg 2015 Jan-Feb;17(1):44-8

Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, Medical Center, San Francisco.

Importance: Minimizing morbidity when performing free flap reconstruction of the head and neck is important in the overall reconstructive paradigm.

Objective: To examine the indications and success rates of free tissue transfer using small-caliber facial recipient vessels and minimal access incisions.

Design, Setting, And Participants: Retrospective medical record review of patients with head and neck defects undergoing free tissue transfer from May 2010 to June 2013 at 2 tertiary care academic medical centers.

Interventions: Free tissue transfer using small-caliber recipient vessels and minimal access approaches.

Main Outcomes And Measures: Postoperative complications, including flap failure, requirement for revision surgery, and nerve dysfunction.

Results: Eighty-nine flaps in 86 patients met inclusion criteria. Fifty flaps used the facial artery and vein distal to the facial notch, and 33 flaps used the superficial temporal vascular system. Six flaps used the angular artery and vein. A variety of flap donor sites were included. In most cases, free tissue transfer was indicated for the reconstruction of defects secondary to extirpation of malignant neoplasia. Overall success rate was 97.7% with 2 instances of total flap loss and 1 partial loss. One patient had transient nerve weakness (frontal branch), which resolved during a follow-up of 9 months.

Conclusions And Relevance: Free tissue reconstruction of head and neck defects can be safely and reliably accomplished using small-caliber recipient vessels, such as the superficial temporal, distal facial, and angular vessels. Minimal access approaches for microvascular anastomosis may be performed with excellent cosmesis and minimal morbidity.

Level Of Evidence: 4.
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October 2015

Anterolateral thigh adipofascial flap in mucosal reconstruction.

JAMA Facial Plast Surg 2014 Nov-Dec;16(6):395-9

Head and Neck Institute, Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio.

Importance: This study describes a reliable technique for mucosal reconstruction of large defects using components of a common free flap technique.

Objective: To review the harvest technique and the varied scenarios in which the anterolateral thigh adipofascial flap (ALTAF) can be used for mucosal restoration in oral cavity and nasal reconstruction.

Design, Setting, And Participants: A retrospective review of the medical records of 51 consecutive patients was conducted. The patients had undergone ALTAF head and neck reconstruction between January 2009 and June 2013. Each case was reviewed, and flap survival and goal-oriented results were evaluated.

Results: Thirty patients met the inclusion criteria and were included in the analysis. The mean patient age was 60.6 years. Reconstruction sites included the tongue, palate, gingiva, floor of the mouth, and nasal mucosa. All mucosal reconstructions maintained function and form of replaced and preserved tissues. One patient (3%) experienced flap failure that was reconstructed with a contralateral adipofascial flap with excellent outcome. Three patients (10%) required minor flap revisions. There were no other complications.

Conclusions And Relevance: The ALTAF is a versatile flap easily harvested for use in several types of mucosal reconstructions.
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February 2016

Use of angular vessels in head and neck free-tissue transfer: a comprehensive preclinical evaluation.

JAMA Facial Plast Surg 2014 Sep-Oct;16(5):348-51

Head and Neck Institute, Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio.

Importance: The angular artery, its perforating branches, and their zones of tissue perfusion have been described extensively for facial reconstruction. Various cutaneous and mucosal flaps with either anterograde or retrograde perfusion play an important role in facial and oral reconstruction. However, these flaps share the limitations of pedicled nature and donor-site intolerance. Free-tissue transfer (FTT) has transformed capabilities and outcomes in head and neck reconstruction. While less constrained by tissue volume and subtype, FTT has its own limitations, including pedicle reach for anastomosis to inflow and outflow vasculature in upper face reconstruction. The angular vessels, owing to their relatively high central location and accessibility via a camouflaged nasolabial fold incision, may have value in midface and nasal reconstruction.

Objectives: To detail a technique for consistently locating the angular vessels while preserving the integrity of adjacent neuromuscular structures and to evaluate the caliber and consistency of the angular artery and vein for their usability in microvascular anastomosis.

Design And Setting: We conducted a PubMed literature search for the terms angular artery, melolabial flap, nasolabial flap, retroangular flap, and any associations with FTT. We also performed 26 anatomic cadaveric dissections on 13 fresh cadavers to evaluate the angular arteries and veins.

Main Outcomes And Measures: Vessel caliber, length, and variability were analyzed and utility for use in FTT was assessed. A total of 26 angular arteries and 26 angular veins were included in the analysis. Anatomic relationships were used to develop a surgical schema for dissection and isolation of the angular vessels specifically for FTT.

Results: The angular vessels have consistent anatomic relationships facilitating localization and have a consistent caliber amenable to use in microvascular FTT. The mean (SD) artery diameter was 2.34 (0.67) mm prior to dilation and 3.21 (0.87) mm after dilation. The diameters of the vein before and after dilation were 3.57 (0.53) mm and 6.40 (0.81) mm, respectively. There was no statistical difference between the vessels on the right and left sides.

Conclusions And Relevance: We describe for the first time the anatomic cadaveric dissection and analysis of the angular arteries and veins specifically to determine compatibility with regard to FTT. We found good FTT compatibility.

Level Of Evidence: NA.
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June 2015

Auto flow-through technique for anterolateral thigh flaps.

JAMA Facial Plast Surg 2014 Mar-Apr;16(2):147-50

Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.

IMPORTANCE The vascular supply of anterolateral thigh (ALT) free flaps is variable, and the pedicle length and ability to capture perforators to the flap may be limited by the anatomic configuration. We describe the reasoning behind performing the auto flow-through procedure, as well as the steps to carry this procedure out. OBSERVATIONS A retrospective medical chart review was performed within our health care system database to identify patients in whom the auto flow-through technique was used during reconstruction with an ALT free flap. The auto flow-through technique was applied to 3 separate ALT free flaps to incorporate perforators from 2 separate vascular systems. This technique allowed for more robust vascularity of the flap and/or optimized pedicle length that would have otherwise necessitated vein grafts. All patients had successful ALT free flap reconstruction and went on to have good functional results. CONCLUSIONS AND RELEVANCE The auto flow-through technique is an adaptation of the flow-through flap, which allows for capture of vascular perforators from separate sources when this configuration is present in the ALT free flap. This technique is especially useful when operating in a vessel-depleted neck or when maximizing pedicle reach is necessary. This technique allows the ALT to be used in challenging reconstruction cases regardless of the vascular branching pattern of the pedicle. LEVEL OF EVIDENCE 4.
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November 2014

Application of autologous free tissue transfer in the management of massive traumatic tissue loss.

Otolaryngol Clin North Am 2013 Oct 24;46(5):903-13. Epub 2013 Aug 24.

Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic Foundation, A71, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Electronic address:

This review describes a general approach and philosophy in the management of massive facial trauma with extensive tissue loss, with particular highlight on the role of free tissue transfer.
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October 2013

Voice outcomes following reconstruction of laryngopharyngectomy defects using the radial forearm free flap and the anterolateral thigh free flap.

Laryngoscope 2014 Feb 15;124(2):397-400. Epub 2013 Oct 15.

Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.

Objectives/hypothesis: Patients undergoing laryngopharyngectomy with extensive pharyngeal mucosal resection or those failing chemoradiation protocols are commonly reconstructed using free tissue transfer. Radial forearm free flaps (RFFFs) and anterolateral thigh free flaps (ALTs) are two of the most commonly used free flaps for laryngopharyngectomy reconstruction. It has been suggested that alaryngeal tracheoesophageal prosthesis (TEP) speech outcomes in patients undergoing ALT reconstruction may be inferior due to the possibly bulkier neopharynx. We report the results of patients treated with ALT and RFFF with regard to postoperative TEP voice outcomes.

Study Design: Retrospective cohort study.

Methods: We identified 42 consecutive patients who were treated with total laryngopharyngectomy and free flap reconstruction utilizing either RFFFs (20 patients) or ALTs (22 patients) between April 2001 and August 2010. Evaluations with statistical analysis of standard TEP speech outcome measures (maximal sustained phonation, fluent count, syllable count) and qualitative variables were conducted.

Results: Patient demographics were similar between the RFFF and ALT groups, and 95% and 91% of RFFF and ALT patients received radiation therapy, respectively. Subjective voice quality did not significantly differ between the groups. Differences in outcomes of intelligibility, maximal sustained phonation time, maximum number of syllables, and fluent count, as evaluated by a single speech pathologist, were not statistically significant between RFFF and ALT patients. There was no difference in postoperative complications.

Conclusions: These data indicate that reconstruction of laryngopharyngectomy defects using either the ALT or RFFF technique can produce similarly acceptable TEP voice results.

Level Of Evidence: 2b.
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February 2014

Suprastomal cutaneous monitoring paddle for free flap reconstruction of laryngopharyngectomy defects.

JAMA Facial Plast Surg 2013 Jul-Aug;15(4):287-91

Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Importance: Method of direct clinical monitoring of tissue perfusion in free tissue reconstruction of pharyngeal defects.

Objective: To describe a novel and effective method of incorporating a cutaneous skin paddle into laryngopharyngectomy reconstruction for direct clinical monitoring of anterolateral thigh free flaps.

Design: Retrospective review of pharyngoesophageal reconstruction for laryngopharyngectomy defects performed between August 1, 2008, and March 1, 2011, using the anterolateral thigh flap.

Setting: Tertiary care academic medical center.

Participants: Consecutive patients undergoing laryngopharyngectomy where free tissue transfer is indicated.

Interventions: Anterolateral thigh free flap reconstruction with suprastomal cutaneous monitoring paddle.

Main Outcome Measures: Postoperative complications, including flap failure, fistula, and stricture. Postoperative functional outcomes of swallowing and vocal capability were also measured.

Results: Twenty-one patients (mean age, 62.2 years; range, 39-81 years) underwent total laryngectomy with near-total or total pharyngectomy and immediate reconstruction with an anterolateral thigh free flap. The reconstructions included a cutaneous monitor paddle distal to the pharyngoesophageal anastomosis. Twenty patients were treated for squamous cell carcinoma and received either adjuvant or neoadjuvant radiation therapy. There were no partial or total flap losses. A late pharyngocutaneous fistula occurred at 6 weeks in 1 patient (5%), requiring exploration, and anastomotic stricture occurred in 4 patients (19%). All patients except 1 were able to swallow solid foods at a mean follow-up of 11.1 months. Nineteen patients (90%) underwent tracheoesophageal puncture and attained an intelligible voice. One patient (5%) had stomal stenosis requiring surgical management.

Conclusions And Relevance: The suprastomal cutaneous monitoring paddle enables direct monitoring of an otherwise buried reconstructive flap. This method allows direct clinical observation for microvascular compromise without a need for further procedures and without any increase in morbidity or compromise of speech and swallow functions.

Level Of Evidence: 4.
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March 2014

Free anterolateral thigh fascia lata flap for complex nasal lining defects.

JAMA Facial Plast Surg 2013 Jan;15(1):21-8

Division of Facial Plastic and Reconstructive Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Objective: To introduce a novel technique for the reconstruction of complex nasal lining defects using the free vascularized anterolateral thigh fascia lata flap.

Methods: Free anterolateral thigh fascia lata flaps were used to replace nasal lining in 5 patients with total or subtotal rhinectomy defects. We performed a retrospective medical record review.

Results: No flap failure or lining loss was observed, and harvest site morbidity was negligible. Patients achieved satisfactory nasal form and patent nasal airways without a need for repeated revisions. In 2 patients, the anterolateral thigh flap was used simultaneously to restore the midface contour or to repair anterior skull base defects.

Conclusions: In this case series, we demonstrate the novel use of vascularized fascia lata to provide viable nasal lining in total and subtotal nasal defect reconstruction. Potential advantages offered by this technique compared with more established methods include (1) single-stage replacement of nasal lining, structure, and skin coverage; (2) fewer additional stages of reconstruction to achieve functional and aesthetic results; (3) thin lining to allow for optimal airway contour; (4) less harvest site morbidity; and (5) development of composite soft tissue, cutaneous, and/or muscle flaps to repair adjacent defects.
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January 2013

Motor nerve to the vastus lateralis.

Arch Facial Plast Surg 2012 Sep-Oct;14(5):365-8

Objective To further delineate the anatomy of the motor nerve to the vastus lateralis (MNVL) in the context of its use as a possible interpositional nerve graft in facial nerve rehabilitation.Methods Twelve fresh human cadaveric thighs were dissected to investigate the anatomic location and branching pattern of the MNVL muscle.Results There were 3 to 6 primary nerve branches (mean, 4.4) supplying the vastus lateralis. The mean primary branch length was 93.8 mm (range, 51-196 mm), and each primary branch had a mean of 2.3 subsequent branches. There were 2 larger caliber branches (>2 mm in diameter) supplying the proximal and distal muscle. The nerve branches are variable in their relation to the vascular pedicle and perforating vessels of the descending branch of the lateral circumflex femoral artery.Conclusion The nerve to the vastus lateralis is a readily available, redundant motor nerve suitable for facial nerve cable grafting.
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September 2015

Orbitomaxillary reconstruction using the layered fibula osteocutaneous flap.

Arch Facial Plast Surg 2012 Mar-Apr;14(2):110-5

Division of Facial Plastic and Reconstructive Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

Objective: To describe a surgical technique for total palatomaxillary and orbital reconstruction using a fibula osteocutaneous free flap in a layered fashion.

Methods: Case series from a tertiary care facial plastic and reconstructive surgical practice including patients with postextirpative Brown 3a and 3b orbitopalatomaxillary defects undergoing immediate microvascular reconstruction. Application of the layered fibula free flap to composite maxillary defects permits single-stage, optimal reconstruction of contiguous orbitomaxillary defects, reconstitution of midface 3-dimensional contour, and restoration of the anterior alveolar arch with robust bone, thereby providing for potential sequential dental rehabilitation with osseointegrated implants.

Results: This technique demonstrates excellent long-term symmetry, support, function, and aesthetic contour. Although patients may need minor, adjunctive procedures, this technique is flexible in design and offers reliable outcomes with a minimum of morbidity.

Conclusion: The fibula osteocutaneous free flap, because of its design flexibility and ability to provide structural support, is an excellent reconstructive option for total maxillary defects, including those that involve the orbit.
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July 2012