A Gingiva-Derived Mesenchymal Stem Cell-Laden Porcine Small Intestinal Submucosa Extracellular Matrix Construct Promotes Myomucosal Regeneration of the Tongue

In the oral cavity, the tongue is the anatomic subsite most commonly involved by invasive squamous cell carcinoma. Current treatment protocols often require significant tissue resection to achieve adequate negative margins and optimal local tumor control. Reconstruction of the tongue while preserving and/or restoring its critical vocal, chewing, and swallowing functions remains one of the major challenges in head and neck oncologic surgery. We investigated the in vitro feasibility of fabricating a novel combinatorial construct using porcine small intestinal submucosa extracellular matrix (SIS-ECM) and human gingiva-derived mesenchymal stem cells (GMSCs) as a GMSC/SIS-ECM tissue graft for the tongue reconstruction. We developed a rat model of critical-sized myomucosal defect of the tongue that allowed the testing of therapeutic effects of an acellular SIS-ECM construct versus a GMSC/SIS-ECM construct on repair and regeneration of the tongue defect. We showed that the GMSC/SIS-ECM construct engrafted at the host recipient site, promoted soft tissue healing, and regenerated the muscular layer, compared to the SIS-ECM alone or nontreated defect controls. Furthermore, our results revealed that transplantation of the GMSC/SIS-ECM construct significantly increased the expression of several myogenic transcriptional factors and simultaneously suppressed the expression of type I collagen at the wounded area of the tongue. These compelling findings suggest that, unlike the tongue contracture and fibrosis of the nontreated defect group, transplantation of the combinatorial GMSC/SIS-ECM constructs accelerates wound healing and muscle regeneration and maintains the overall tongue shape, possibly by both enhancing the function of endogenous skeletal progenitor cells and suppressing fibrosis. Together, our findings indicate that GMSC/SIS-ECM potentially served as a myomucosal graft for tongue reconstruction postsurgery of head and neck cancer. © Copyright 2017, Mary Ann Liebert, Inc

Anterolateral thigh osteomyocutaneous femur (ALTO) flap reconstruction for composite mandible and near total tongue defect utilizing a retrograde intramedullary femoral nail stabilization technique: Report of a first case

The anterior lateral thigh osteomyocutaneous free flap (ALTO) offers the advantage of reconstructing large bony and soft tissue defects. We report a novel approach for femur stabilization via retrograde intramedullary nail placement in a patient with a near total tongue and large mandibular defect who underwent ALTO reconstruction that saves operating room time and decreases risk of post-operative fracture

Considerations in the evaluation and management of oral potentially malignant disorders during the COVID-19 pandemic

Aim: The COVID-19 pandemic has resulted in society experiencing unprecedented challenges for health care practitioners and facilities serving at the frontlines of this pandemic. With regard to oral cancer, there is a complete absence of literature regarding the long-term impact of pandemics on patients with oral potentially malignant disorders (OPMDs). The objective of this article is to put forth an institutional multidisciplinary approach for the evaluation and management of OPMDs. Methods: A multidisciplinary approach was put formalized within our institution to risk stratify patients based on need for in-person assessment vs telehealth assessment during the COVID-19 pandemic. Results: With judicious risk stratification of patients based on clinical features of their OPMD and with consideration of ongoing mitigation efforts and regional pandemic impact, providers are able to safely care for their patients. Conclusions: The COVID-19 pandemic has required health care practitioners to make novel decisions that are new to us with development of creative pathways of care that focused on patient safety, mitigation efforts, and clinical management of disease processes. The care of patients with OPMDs requires special considerations especially as patients at high risk for severe COVID-19 illness are also higher risk for the development of OPMDs. © 2020 Wiley Periodicals, Inc

Use of Sleeve Neurrorhaphy at the Brainstem for Facial Nerve Reconstruction

Introduction: Neurorrhaphy at the brainstem for reconstruction of the facial nerve remains a technical challenge. Traditional suture techniques prove increasingly difficult with the tendency toward approaches with more limited dissection and when resection of the nerve extends proximally close to the brainstem. A method for secure approximation of the proximal end of the remaining nerve and the graft not requiring the placement of suture would be beneficial in these difficult cases. Methods: Case report. Results: A 30 year old man was found to have a facial nerve schwannoma upon workup for asymmetric sensorineural hearing loss and elected for surgical resection. Following removal of the tumor via translabyrinthine approach the nerve was deficient several millimeters from the brainstem to the second genu in the mastoid. Devitalized cadaveric allograph (Avance Nerve Graft, AloGen, Inc., Alachua, FL, USA) was placed and sutured to the distal end of the nerve. Given the limited remaining proximal portion at the brainstem and the anatomical constraints it was elected to perform a sleeve neurorrhaphy to secure the graft to the remaining nerve. The graft and remaining nerve were approximated and wrapped with commercially available porcine submucosa extracellular matrix (AxoGuard Nerve Protector, AloGen, Inc., Alachua, FL, USA). Gelfilm was then placed between the repair and the brainstem, the dura was closed around the graft and the mastoid defect filled with fat. Discussion: Suture neurorrhaphy remains a technical challenge especially at the brainstem and the cerebellopontine angle. The depth of repair, anatomical constraints of the craniotomy, and generally limited length of proximal remaining nerve add to the difficulty of placing sutures using traditional techniques. The use of a wrap to secure the ends of the nerve and graft to each other also acts to protect the microenvironment which may promote growth of the axons. This case report describes the use of such a wrap to approximate and secure the residual stump of facial nerve at the brainstem with devitalized cadaveric nerve graft. Conclusion: The use of sleeve neurorrhaphy provides an alternative to traditional sutures for reconstruction of the facial nerve at the brainstem. This report serves as a technical description and long term follow up of a larger cohort of patients will be required to adequately compare this technique with the current suture technique

Simultaneous maxillary and mandibular reconstruction with a single Osteocutaneous fibula free flap: A description of three cases

Large defects that comprise both the maxilla and mandible prove to be difficult reconstructive endeavors and commonly require two free tissue transfers. Three cases are presented to discuss an option for simultaneous reconstruction of maxillary and mandibular defects using a single osteocutaneous fibula free flap. The first case describes a 16-year-old male with a history of extensive facial trauma sustained in a boat propeller accident resulting in a class IId maxillary and 5 cm mandibular defect status post three failed reconstructive surgeries; the second, a 33-year-old male with recurrent rhabdomyosarcoma of the muscles of mastication with resultant hemi-mandibulectomy and class IId maxillary defects; and lastly, a 48-year-old male presenting after a failed scapular free flap to reconstruct defects resulting from a self-inflicted gunshot wound, which included a 5 cm defect of the right mandibular body and 4.5 cm defect of the inferior maxillary bone. In all cases, a single osteocutaneous fibula free flap was used in two bone segments; one to obturate the maxillary defect and restore alveolar bone and the other to reconstruct the mandibular defect. The most recent patient was able to undergo implantable dental rehabilitation. Postoperatively, the free flaps were viable and masticatory function was restored in all patients during a follow-up range of 2-4 years

Association of Clinical Risk Factors and Postoperative Complications With Unplanned Hospital Readmission After Head and Neck Cancer Surgery

IMPORTANCE Unplanned hospital readmission is costly and in recent years has become a focus of health care legislation intended to reduce health care expenditures. Greater understanding of which perioperative complications are associated with hospital readmission after surgery for head and neck cancer is needed to reduce unplanned readmissions. OBJECTIVE To determine which clinical risk factors and complications are associated with 30-day unplanned readmission after surgery for malignant neoplasms of the head and neck. DESIGN, SETTING, AND PARTICIPANTS This retrospective longitudinal claims analysis included data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from January 1, 2012, to December 31, 2014. Patients undergoing surgery for malignant tumors of the head and neck were included; those with a primary diagnosis of thyroid malignant disease and those undergoing free autologous tissue transfer were excluded. MAIN OUTCOMES AND MEASURES Clinical risk factors and complications were analyzed for association with unplanned hospital readmission using multivariable regression analysis. Statistical significance was determined using P < .05. RESULTS A total of 7605 patients (5007 men [65.8%]; mean [SD] age, 64.2 [0.2] years) were identified and included for analysis. Overall, 1472 complications occurred in 912 cases. Three hundred eighty-eight patients (5.1%) had an unplanned readmission, which was lower than the previously published overall readmission rate for noncardiac surgical procedures in the NSQIP (6.8%). Clinical factors that were independently associated with unplanned readmission were age (adjusted odds ratio [AOR], 1.12; 95% CI, 1.03-1.22), diabetes (AOR, 1.60; 95% CI, 1.01-2.43), preoperative dyspnea at rest (AOR, 2.89; 95% CI, 1.40-5.55) and with moderate exertion (AOR, 1.48; 95% CI, 1.01-2.11), long-term use of corticosteroids (AOR, 2.45; 95% CI, 1.63-3.58), disseminated cancer (AOR, 1.57; 95% CI, 1.14-2.20), and a contaminated wound (AOR, 2.05; 95% CI, 1.05-3.7). When specific complications were examined, superficial incisional surgical site infection (SSI) (AOR, 2.02; 95% CI, 1.14-3.40), deep incisional SSI (AOR, 2.57; 95% CI, 1.26-5.03), organ or space SSI (AOR, 13.27; 95% CI, 6.57-26.61), wound disruption (AOR, 3.58; 95% CI, 1.95-6.31), pneumonia (AOR, 3.39; 95% CI, 1.88-5.96), deep vein thrombosis (AOR, 5.60; 95% CI, 1.90-15.25), pulmonary embolism (AOR, 20.72; 95% CI, 7.86-55.68), urinary tract infection (AOR, 2.66; 95% CI, 1.00-6.34), stroke (AOR, 12.42; 95% CI, 3.99-36.50), sepsis (AOR, 2.64; 95% CI, 1.27-5.30), and septic shock (AOR, 4.12; 95% CI, 1.10-15.81) were all associated with 30-day unplanned hospital readmission. CONCLUSIONS AND RELEVANCE This study evaluated clinical factors and postoperative complications to determine which ones were associated with 30-day unplanned hospital readmission among patients undergoing surgery for malignant tumors of the head and neck. Further understanding of which complications are associated with unplanned readmission after head and neck surgery will allow for improved risk stratification and development of postoperative care protocols to reduce unplanned hospital readmission