Publications by authors named "Molly E Heft Neal"

10 Publications

  • Page 1 of 1

Lip and Perioral Trauma: Principles of Aesthetic and Functional Reconstruction.

Facial Plast Surg 2021 Feb 22. Epub 2021 Feb 22.

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan.

Successful management of lip and perioral trauma requires a nuanced understanding of anatomy and surgical techniques. Surgical correction is particularly challenging in instances of tissue loss, due to a narrow tolerance for aesthetic deformity and highly specialized functions of the perioral region, including facial expression, communication, and oral competence. Restoring continuity of the orbicularis oris musculature is critical for dynamic sphincter function of the upper and lower lips. Lip and perioral tissue symmetry are also critical for aesthetic balance, and failure to restore a natural appearance can adversely affect personal identity, with attendant psychological trauma. This discussion of lip and perioral trauma management encompasses lip and perioral anatomy, evaluation of injuries, reconstructive techniques, and prevention and management of complications. Perioral injuries are classified by size, depth, and extent of injury, and the corresponding reconstructive approaches are a function of complexity. These approaches proceed sequentially up rungs of the reconstructive ladder including primary repair, local flaps, grafting, regional flaps, as well as microvascular free tissue transfers. Procedures may be single stage or require multiple stages or subsequent refinement. Regardless of the defect size or location, the guiding principle of repair in the perioral region is restoring natural function and aesthetic appearance. This still-evolving area of facial plastic and reconstructive surgery lends itself to artistry and technical precision, offering opportunities for further innovation to improve the outcomes of patients with lip and perioral trauma.
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http://dx.doi.org/10.1055/s-0041-1725110DOI Listing
February 2021

Head and Neck Reconstruction in the Vessel Depleted Neck.

Front Oral Maxillofac Med 2020 Aug;2

Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan.

Microvascular free tissue transfer has revolutionized reconstruction and subsequently functional outcomes in the head and neck, but requires suitable recipient vessels for successful results. Recipient vessels can be significantly compromised by prior surgery, radiation therapy, or existing and/or underlying vascular disease in the neck. When further microvascular reconstruction is required in the vessel-depleted neck, identification of appropriate vessels for anastomosis can be difficult and can present complex decisions for the surgeon as well as the patient. In this article, we review the available literature on the vessel depleted neck and the possible vessel options. We present critical strategies for preoperative treatment planning and vessel selection in these patients. We also discuss the benefits and limitations of arterial and venous options while commenting on our unique institution's experiences. The external carotid branches as well as the available subclavian artery branches are presented in detail. The venous anatomy is also described, with particular focus on the accompanying veins and cephalic vein. We provide guidance on the selection and modification of free flaps to achieve the greatest function and cosmetic outcomes in the vessel depleted neck. Our collection of advanced management techniques will provide surgeons with more options to manage the complexity of the vessel depleted neck, and to further help patients understand the risk and benefits of these selections.
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http://dx.doi.org/10.21037/fomm-20-38DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682923PMC
August 2020

Time to Surgery and Survival in Head and Neck Cancer.

Ann Surg Oncol 2021 Feb 9;28(2):602-603. Epub 2020 Nov 9.

Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health System, Ann Arbor, MI, USA.

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http://dx.doi.org/10.1245/s10434-020-09336-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7651805PMC
February 2021

Prognostic Significance of Oxidation Pathway Mutations in Recurrent Laryngeal Squamous Cell Carcinoma.

Cancers (Basel) 2020 Oct 22;12(11). Epub 2020 Oct 22.

Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA.

Organ preservation protocols are commonly used as first line therapy for advanced laryngeal cancer. Recurrence thereafter is associated with poor survival. The aim of this study is to identify genetic alterations associated with survival among patients with recurrent laryngeal cancer undergoing salvage laryngectomy. Sixty-two patients were sequenced using a targeted panel, of which twenty-two also underwent transcriptome sequencing. Alterations were grouped based on biologic pathways and survival outcomes were assessed using Kaplan-Meier analysis and multivariate cox regression. Select pathways were evaluated against The Cancer Genome Atlas (TCGA) data. Patients with mutations in the Oxidation pathway had significantly worse five-year disease specific survival (1% vs. 76%, = 0.02), while mutations in the HN-Immunity pathway were associated with improved five-year disease specific survival (100% vs. 62%, = 0.02). Multivariate analysis showed mutations in the Oxidation pathway remained an independent predictor of disease specific survival (HR 3.2, 95% CI 1.1-9.2, = 0.03). Transcriptome analysis of recurrent tumors demonstrated that alterations in the Oxidation pathway were associated a positive Ragnum hypoxia signature score, consistent with enhanced pathway activity. Further, TCGA analyses demonstrated the prognostic value of oxidation pathway alterations in previously untreated disease. Alterations in the Oxidation pathway are associated with survival among patients with recurrent laryngeal cancer. These prognostic genetic biomarkers may inform precision medicine protocols and identify putatively targetable pathways to improve survival in this cohort.
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http://dx.doi.org/10.3390/cancers12113081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690434PMC
October 2020

Predictors of survival in patients undergoing oropharyngeal surgery for cancer recurrence after radiation therapy.

Eur Arch Otorhinolaryngol 2020 Jul 19;277(7):2085-2093. Epub 2020 Mar 19.

Department of Otolaryngology Head and Neck Surgery, University of Michigan, 1500 East Medical Center Dr., Ann Arbor, MI, 48109-5312, USA.

Purpose: The incidence of oropharyngeal squamous cell carcinoma continues to rise with the majority of patients receiving definitive or adjunctive radiation. For patients with locoregional recurrence after radiation, optimal treatment involves salvage surgery. The aim of this study is to identify factors that predict survival to ultimately improve patient selection for salvage surgery.

Methods: Retrospective cohort study at an NCI-designated cancer center. We analyzed patients with a history of head and neck radiation who presented with persistent/recurrent or second primary disease requiring salvage oropharyngeal resection from 1998-2017 (n = 120). Patients were stratified into three classes based on time to recurrence and presence of laryngopharyngeal dysfunction. Primary outcomes were 5-year overall survival (OS) and disease specific survival (DSS).

Results: Median OS was 27 months (median follow-up 20 months). Five-year OS was 47% for class I (recurrence > 2 years), 26% for class II (recurrence ≤ 2 years), and 0% for class III (recurrence ≤ 2 years and laryngopharyngeal dysfunction), (p < 0.0001). Five-year DSS showed significant differences between classes (p < 0.0001). On multivariate analysis, class remained predictive of OS (p = 0.04- < 0.001) and DSS (p = 0.04-0.001). Adjuvant radiation after salvage surgery with negative margins showed superior OS (71% vs. 28%, p = 0.01) and DSS (83% vs 37%, p = 0.02) compared to surgery alone and was a significant predictor of improved survival on multivariate analysis (HR 0.1, p = 0.04).

Conclusion: This study identified a subset of patients with oropharyngeal cancer recurrence within two years of initial treatment and with laryngopharyngeal dysfunction who have poor outcomes for salvage surgery.
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http://dx.doi.org/10.1007/s00405-020-05913-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292755PMC
July 2020

ASO Author Reflections: Nodal Disease in Recurrent Oropharynx.

Ann Surg Oncol 2020 Feb 28;27(2):458-459. Epub 2019 Oct 28.

Department of Otolaryngology Head and Neck Surgery, University of Michigan Health System, Ann Arbor, MI, USA.

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http://dx.doi.org/10.1245/s10434-019-08014-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173697PMC
February 2020

The Natural Growth Rate of Residual Juvenile Angiofibroma.

J Neurol Surg B Skull Base 2018 Jun 26;79(3):257-261. Epub 2017 Oct 26.

Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States.

 Examine the postoperative growth rate of residual juvenile angiofibroma (JA) in a large series of patients relative to pediatric growth parameters and other prognostic factors. Establish an algorithm for postoperative surveillance of patients with JA.  Retrospective case series.  Tertiary referral academic center.  Pediatric patients undergoing surgical resection of JA between September 2005 and June 2015.  Postoperative recurrence and tumor growth rates.  Thirty-eight patients were identified with a mean follow-up of 24.1 months. Sixty-eight percent (26/34) of patients achieved gross total resection, and 32% (12/38) had persistent postoperative disease. Of those with postoperative residual tumor, all had preoperative skull base involvement and residual blood supply from the internal carotid artery following embolization. Sixty-seven percent (8/12) of patients with postoperative residual tumor demonstrated radiographic stability of disease with scans being completed approximately every 6 months. Radiographic rates of disease progression ranged from 4.1 to 9.22 mm/year.  Patients with preoperative skull base involvement and residual vascularity following preoperative embolization are more likely to have residual postoperative disease, and a longer postoperative follow-up is warranted in these patients. Progression of residual disease occurred approximately 7.5 months postoperatively. Younger patients may be more likely to need further intervention for postoperative residual disease, and postoperative imaging at 6-month intervals appears appropriate.
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http://dx.doi.org/10.1055/s-0037-1607419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5951706PMC
June 2018

A Case Report and Systematic Review of Eosinophilic Angiocentric Fibrosis of the Paranasal Sinuses.

Ann Otol Rhinol Laryngol 2017 May 1;126(5):415-423. Epub 2017 Mar 1.

3 University of Pittsburgh Department of Otolaryngology, Pittsburgh, Pennsylvania, USA.

Objective: There is a paucity of literature discussing prognostic factors or comparing outcomes in eosinophilic angiocentric fibrosis (EAF). This review aims to analyze tumor and patient characteristics as possible prognostic markers and compare surgical approaches.

Methods: Systematic literature review and case report analyzing available cases of EAF located within the paranasal sinuses.

Results: The literature search yielded 39 articles meeting criteria for a total of 59 cases (including 1 from our institution). Median patient age was 46 years. The most common presenting symptoms were nasal obstruction (69%, n = 41) and change in external nasal appearance (39%, n = 32). The majority of cases (85%) were treated with surgical resection alone or in combination with medication. Of surgical patients, 62% underwent a complete resection with a recurrence rate of 20%. Median follow-up duration was 2 years. Endoscopic approach showed a significant positive correlation with complete resection ( P = .045). Patient sex ( P = .6), tumor location (range, P = .32-.98), lateral rhinotomy ( P = .26), septoplasty ( P = .84), and external rhinoplasty ( P = .28) were not significantly correlated with total resection. Insufficient sample size precluded calculation of predictors of recurrence following surgery.

Conclusion: This review suggests that an endoscopic approach to EAF tumor is a viable option, frequently yielding complete resection.
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http://dx.doi.org/10.1177/0003489417696510DOI Listing
May 2017

Juvenile Nasal Angiofibromas: A Comparison of Modern Staging Systems in an Endoscopic Era.

J Neurol Surg B Skull Base 2017 Feb 6;78(1):63-67. Epub 2016 Jul 6.

Department of Otolaryngology, Eye & Ear Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States; Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States.

 To compare the clinical utility of four juvenile nasal angiofibroma (JNA) staging systems in a large cohort of patients.  Retrospective case series.  Tertiary referral academic center.  Pediatric patients undergoing surgical resection of JNAs between January 2008 and June 2015.  Intraoperative blood loss and transfusions, number of staged operations, postoperative residual disease, and recurrent disease.  In total, 34 patients were identified; all underwent preoperative embolization followed by surgery. Of the 34 patients, 33 (97%) underwent an exclusively endoscopic surgical approach, with 6 (18%) requiring planned staged operations. Ten (29%) patients had residual disease and three (9%) required further surgical resection. Using the area under the curve (AUC) of receiver operating characteristic curves, the University of Pittsburgh Medical Center (UPMC) staging system was most predictive of patients who required staged procedures, received intraoperative transfusions, and had residual postoperative disease (AUC: 0.89, 0.88, 0.86, respectively).  The UPMC JNA staging system accounts for both route of skull base extension and tumor vascularity, which are two important tumor attributes in the age of preoperative embolization and endoscopic endonasal surgery. The UPMC staging system is a reliable modern staging system that closely reflects prognostic information and aids in surgical planning.
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http://dx.doi.org/10.1055/s-0036-1584903DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5288123PMC
February 2017