The new Chief of the Division of Head and Neck Reconstructive Surgery in the Department of Otolaryngology at the University of Pittsburgh spoke about his specialty: Head and Neck Microvascular Reconstruction in the Eye & Ear Foundation’s December 5th webinar.
Department Chair Dr. José P. Zevallos introduced Matthew Spector, who has only been in his new role for about a month. “I am thrilled that Dr. Spector is here,” Dr. Zevallos said. “One of my goals has been to recruit the best and brightest head and neck surgeons and other otolaryngologists to the University of Pittsburgh. I can say wholeheartedly that we have accomplished just that by bringing Matthew Spector on board.”
Dr. Spector has over 10 years of experience as a head and neck microsurgeon. He has led the country in terms of high volume, efficiency of care, and innovation in head and neck reconstruction, Dr. Zevallos said. “In the short time he’s been here, he has really transformed the way we do these very complex cases,” he added.
The Reconstructive Ladder
How do we think about reconstruction? Dr. Spector said it is a lot like building anything – whether a house or type of construction. There are different ladders or rungs that you can do ranging from the very simple to very complicated.
When it comes to reconstruction, secondary intention used to be the starting point. Secondary intention is when you kind of leave it. You remove something, maybe a mole that the dermatologist scrapes off. Your body, as resilient as it is, can grow the tissue back together. It is sewed up, so there are a lot of stitches.
Primary closure, a couple rungs above, involves skin grafts.
Free tissue used to be at the top of the ladder because it was the most complex. It was very difficult and not a lot was known about it in the beginning.
Free Flap Basics
Dr. Spector referenced a publication done at the University of Michigan by Dr. Baker, who trained him. It was a seminal paper about reconstruction in which he rebuilt a tongue with a flap from the groin. Back in 1976, this was a 24-hour case that involved three faculty microsurgeons.
Today, this surgery can take less than eight hours for the entire case, with reconstruction taking less than four hours. Only a single surgeon is needed.
What is a free flap? It is an autologous (from self) tissue transfer/transplantation of tissue (skin, bone, muscle, fat, etc) from one site of the body to another, in order to reconstruct an existing defect.
The most common one is a forearm flap, in which the skin from the wrist is taken. It comes with an artery in a vein. It is extremely small. It can be sewn very carefully under the microscope. A vein coupler is used to couple the veins together. This is essentially plumbing, Dr. Spector said. “We hook up new plumbing and then this piece of skin and fat is a transplant.” Since it’s from your own body, there is no rejection. It takes about 98% of the time.
Lots of different pieces can be used. Flaps have been taken from the back of the abdomen, arms, legs, or the back of the thigh.
Reconstructive Consideration
Surgeons consider many factors when it comes to reconstruction. What is the defect? Depending on what is needed, surgeons can move up fat, muscle, or bone. What are the reconstructive needs? Surgeons consider things like the volume/area and tissue type.
The goal is to maximize functional outcome and minimize donor site morbidity. This means taking into account patient preference and socioeconomic means. Dr. Spector is very careful with musicians. A guitarist, for example, involves complex finger movements. Therefore, Dr. Spector would want to be careful with parts of the arm. If the patient is a runner, he is very careful with their legs. “I want them to be able to continue to do what they enjoy,” he said.
A lot of times with tongue reconstruction, speech patterns can change. When rebuilding a tongue, Dr. Spector is thinking about how to prevent the tongue from being too big or too little, and how to maintain the protrusion and elevation of the tongue. A forearm is a common reconstruction used for this.
Surgery
There are always three steps to these free flap cases. First, the flap is harvested. Next, it is sewn in, and then the blood vessels are hooked up. A two-team approach is used in Pittsburgh. Two faculty members, along with trainees, a scrub tech, and fellow, work together to help patients.
National guidelines were created – some developed in Pittsburgh – to help surgeons determine how much of the tongue to take.
When patients wake up from surgery, they are very swollen; everything is distorted. The body’s response to inflammation is always swelling.
Functional Outcomes
Dr. Spector has been charged by Dr. Zevallos to help build this program and continue to offer it to patients. He also has to research it to ensure that optimum reconstruction is always done.
A few years ago, Dr. Spector wrote a paper with one of his partners, a mentor at Michigan, about how to know whether you have built the tongue properly. What are the metrics surgeons can use to know that patients are happy, satisfied, able to speak and swallow again?
People were given surveys asking how understandable their speech was. Could they go up to someone they have never met and ask questions? Could they ask someone for directions on the street? How well are they understood? What the researchers learned was that if patients could elevate their tongue better, they had a better score. “As surgeons, we want to give a patient 2 cm of elevation of their tongue so they can have a better functional outcome,” Dr. Spector said.
The same thing happens with eating in public, which is a big thing. People were asked questions like if they went out to dinner, would they do it in public? If their spouse wanted to go somewhere new, did they want to eat at home or were they willing to go to a restaurant and try something new? What kinds of things did they eat at a restaurant? Were they limited on the menu?
If patients can lift their tongue up and have protrusion of the tongue past the teeth, the farther they can get out, the better. People who could protrude their tongue better were able to eat in public or were more comfortable doing so.
“These are really good targets that we’ve published,” Dr. Spector said. “Nationally, other surgeons are looking towards this type of research to determine their metrics.”
Case Examples
New technology like 3D modeling, 3D printing, and biomedical engineering can be used to help rebuild the jaw, max, and upper cheeks. All this technology is available in Pittsburgh.
Dr. Spector shared a few case examples. One was a total glossectomy, in which part of the abdomen was used to rebuild the tongue. A young woman whose cancer involved the bone in the teeth had part of her shoulder blade used for the reconstruction.
“Patients that have head and neck cancer come in all shapes and sizes,” Dr. Spector said. A young woman he treated about three years ago had a tumor of her parotid gland – one of the saliva glands. This is a very sensitive location because it involves the facial nerves. He drew on her cheek in the clinic as he wanted her to really understand what it would be like to have these incisions and what things would look like. These surgeries can be life changing and disfigurement is a possibility. Dr. Spector believes in being honest with his patients and telling them what he is thinking. With this young woman, part of her back was used. Everything looks good and one cannot tell she had surgery.
Four years ago, a boy underwent a similar surgery. The contour is right, and the color match is pretty good, Dr. Spector said. The incisions are visible, but that could not be helped as the patient had no extra fat on him. His ear is a little further out on the side, but this can be dealt with when he is older, if he wants.
Head and Neck Cancer Care
Patients have a multidisciplinary team that includes a medical oncologist and radiation oncologist. In Pittsburgh, dental integration with the head and neck cancer care is ahead of the curve, Dr. Spector said.
“We are very thankful for the work the Eye & Ear Foundation is doing, because that will drive the next generation of treatments for these complex cancers,” Dr. Zevallos said at the end of the webinar.