A qualitative and quantitative analysis of autologous human multipotent adult stem cells derived from three anatomic areas by marrow aspiration: tibia, anterior ilium, and posterior ilium

The purpose of this article was to compare the yields of stromal multipotent stem cells (CD34+ and CD105+) and hematopoetic multipotent stem cells (CD44+) obtained from different areas via bone marrow aspiration (BMA). Sixty 60-mL bone marrow aspirates were taken from the tibial plateau, the anterior ilium, and the posterior ilium using a single point-of-care BMA technique and a single BMA concentration (BMAC) device. A 1-mL portion of each sample was used to determine CD stem cell concentrations and the nucleated cell count. The remaining BMA was centrifuged to separate the more mature red blood cell precursors from the stem cells and then concentrate the latter into a BMAC. The BMAC yield of 10 mL was analyzed with flow cytometry and nucleated cell counts to derive a concentration factor for the BMAC. The yield of total nucleated cells was equal between the anterior and posterior ilium and more than twice that obtained from the tibial plateau. The CD44+ and CD105+ cell yields were also nearly equal between the anterior and posterior ilium but more than twice that of the tibial plateau; however, the ratios between the three different stem cell types in BMAC obtained from the different areas suggest varying potentials for tissue development. The ilium is the preferred donor site for obtaining autologous stem cells at the point of care. The tibial plateau yielded only half as much bone marrow multipotent/progenitor stem cells as did the anterior and posterior ilium. The composition of the BMAC from each site suggests that the potential for differentiation into various cell types changes depending on the source of bone marrow, but that BMAC represents 6.5 ± 1.0 concentration factor from BMA

Immediate Microsurgical Bone and Nerve Reconstruction in the Irradiated Patient: A Case Report

Microsurgical reconstructive techniques have revolutionized the treatment of large head and neck defects. These defects were once forever life altering because of the considerable morbidity to both the form and function of the patient. As time has progressed, microsurgical technique has improved dramatically and has become institutionalized in our training programs. Free flap outcomes in head and neck reconstruction have improved dramatically, and optimization of these outcomes is now key. One overlooked area has been neurosensory reconstruction. In our practice we have focused on this detail, which has proved to be quite important to the patient. This case report details one such case in which a mandibular resection was performed to treat osteoradionecrosis. We, as the reconstructive team, elected to perform a double-barrel fibular free flap procedure with simultaneous inferior alveolar nerve reconstruction using a 70-cm processed nerve allograft. Normal neurosensory function returned in this patient. As the state of the art advances with continued successful osseous and soft tissue reconstruction in the head and neck, we propose concomitant neurosensory functional reconstruction always be considered

Minimally Invasive Cervical Access in Head and Neck Microvascular Surgery

Free flap reconstruction often involves extensive cervical access for microvascular anastomosis where management of pathology would otherwise not require cervical approach. This study reports a minimally invasive alternative technique. Investigators designed a prospective case series with subjects who underwent microvascular reconstruction between 2015 and 2020, using a small 2 cm incision for vessel access, just below the mandible where facial artery/vein cross. Study variables were subject demographic characteristics, type and location of pathology/defect, and free flap types. Outcomes examined were flap success, postoperative facial weakness using House-Brackmann scale, and esthetic result with Visual Analog Scale. Descriptive statistics computed for study variables. Study sample was 43 subjects, mean age of 48 years with 20 males and 23 females. There were a total of 43 flaps with 100% success using our technique. One subject had House-Brackmann level 2 postoperative facial weakness that resolved within 1 week. Mean Visual Analog Scale score for scar satisfaction was 9.23/10, standard deviation 0.83. This minimally invasive approach represents an alternative to extensive open cervical access for microvascular anastomosis, offering minimal morbidity and excellent esthetic results

The Trigeminal Nerve Injury

Trigeminal nerve branches are never far from the operating field of the oral and maxillofacial surgeon. Increasingly the surgeon is required to provide accurate diagnosis and grading of trigeminal nerve injury, and surgical management by oral and maxillofacial surgeons will become common. Although trauma and ablative procedures for head and neck pathology can cause injuries, dentoalveolar surgical procedures remain an important cause of injury to the fifth cranial nerve, with the third division being the main branch affected. Oral and maxillofacial surgeons should be aware of strategies of avoiding iatrogenic injury, and know when referral and surgical management are appropriate

Use of soleus musculocutaneous perforator-based propeller flap for lower extremity wound coverage after osteocutaneous fibula free flap harvest

Background Osteocutaneous fibula free flap (OCFFF) donor sites are often covered with skin grafts, with an additional donor site, more postoperative care, and increased cost. The authors examine posterior tibial artery (PTA) based pedicled propeller flaps (PPF) as an alternative for OCFFF donor site coverage. Patients and methods Retrospective review of 16 consecutive patients from 30 to 79 years old, who underwent OCFFF reconstruction of head and neck defects (11 mandibular, 5 maxillary), with the closure of donor site with PPF based on a perforator from PTA. Mean donor site defect measured 12.9 x 5.1 cm, PPF was an elliptical design, and rotated 180 degrees in a propeller fashion, to cover donor site defect. Visual analog scale (VAS) was used to assess esthetic results, functional outcomes assessed using mobility and range of motion (ROM), and secondary complications including infections, hematomas, and seromas were recorded. Follow-up period was noted in months postoperatively. Other information collected included underlying head and neck pathology. Results Average dimension of PPF measured 13.9 x 4.1 cm. Successful closure of donor site defects in 14 of 16 patients, with two flaps having partial necrosis, one requiring a secondary skin graft. Follow-up was 6 to 10 months, esthetic results with mean VAS 8.8 of 10, full ROM, and mobility noted. No secondary complications were observed. The most common pathology noted was squamous cell carcinoma (6 of 16 patients). Conclusion PPFs based on the soleus branch of the PTA represent an excellent alternative to skin grafts for the closure of OCFFF donor site defects

Concurrent presence of secretory carcinoma and Warthin’s tumor in ipsilateral parotid gland

•Synchronous tumors in salivary glands should be considered during workup.•Consider malignancy in lesions with aggressive features like pain and rapid growth.•Intraoperative frozen sections are a useful adjunct in salivary gland masses. The presence of synchronous benign and malignant salivary gland neoplasms is very rare. The authors present a previously unreported combination of Secretory Carcinoma (SC) and Warthin’s Tumor (WT) within the same parotid gland. The patient presented with increasingly painful enlargement of the left parotid gland. CT scan with contrast revealed a heterogeneous solid/cystic mass in the superficial lobe. Fine needle aspiration cytology favored pleomorphic adenoma (PA) and patient underwent superficial parotidectomy without complication. Final pathology revealed concomitant presence of SC and WT. Stains were positive for S100 and mammaglobin, and FISH revealed the presence of t(12;15) (p13;q25) translocation, resulting in the ETV6-NTRK3 fusion gene. It is important for surgeons and pathologists to note the potential for co-existing benign and malignant pathology within the same salivary gland, as this can have an impact on management and prognosis for patients

Synchronous Reconstruction of a Total Mandibulectomy Defect With a Single Fibula Osteocutaneous Free Flap

Osteoradionecrosis (ORN) is a well-known and usually late complication of radiation therapy in the treatment of head and neck cancer. Although the therapy can be life extending, it also produces tissue toxicity in ipsilateral and contralateral tissues in an acute and chronic fashion. In the most severe cases of ORN, such as the one presented in this report, bilateral disease results in the need for total mandibulectomy and creates a tremendous reconstructive challenge. The advent of microvascular surgery and free tissue transfer has caused an evolution of the management protocol for severe ORN cases. This report describes a unique case of total mandibulectomy with synchronous reconstruction using a single vascularized fibula osteocutaneous flap with subsequent dental implant reconstruction and prosthetic rehabilitation

Recurrent Malignancy in Osteoradionecrosis Specimen

Osteoradionecrosis (ORN) is a well-known complication of head and neck radiation therapy. Statistically, the mandible is the most commonly affected site. The incidental finding of malignancy in the resection specimen has been documented but is somewhat rare. The aim of this review is to investigate the presence of recurrent carcinoma and sarcoma or new primary malignancies in resection specimens previously diagnosed and treated as ORN. This study is a retrospective case series. We conducted a chart review of all cases managed at the University of Miami Miller School of Medicine/Jackson Memorial Hospital. The inclusion criteria included a history of head and neck carcinoma treated with radiation of at least 6,000 cGy; clinical diagnosis of ORN; and surgical intervention with osseous resection for treatment of ORN. The study endpoint measured included microscopic evidence of malignancy in the resected ORN specimen. Additional data collected included gender, age, and type of primary pathology. A total of 564 patients met the inclusion criteria. Of these patients, 14 had microscopic evidence of cancer in the specimen (2.48%) and 5 had a proven second primary malignancy in the foregut (1 in the lung, 0.18%, and 4 in the oropharynx, 0.70%). In 1 of the 14 patients, a high-grade sarcoma was diagnosed and the patient died within 1 year of diagnosis. In the treatment of our ORN patient population, a total of 19 malignancies were found collectively (3.37%). Of the 564 patients, 352 were men and 212 were women. The median age was 46 years (range, 33 to 97 years). Head and neck squamous cell carcinoma represented 531 cases in our sample, followed by 28 cases of salivary gland carcinoma and only 5 cases of sarcoma. Although the finding of malignancy in ORN patients is relatively rare (3.37% in this study), oral and maxillofacial surgeons should be cognizant of its potential presence. The treatment of malignant disease is different than that of ORN, and a multidisciplinary treatment approach is recommended if a malignancy is diagnosed in an ORN patient