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Melanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

Patients with head and neck cancers face the dual challenge of surviving their cancer and facing functional changes in swallowing, speech and sometimes appearance. Today, we are talking about the transoral minimally invasive microsurgical facial reconstruction. And my guest is Dr. Anthony Morlandt. He’s an oral and maxillofacial surgeon and an Associate Professor at UAB Medicine. Dr. Morlandt, let’s start by speaking about treatment for head and neck cancer and reconstructing the face and throat after cancer has been removed. Start with some of the goals of the reconstruction for the patient and protecting those vital structures’ function and form.

Anthony Morlandt, MD, DDS, FACS (Guest): Yeah, that’s a great question. So, when we talk about malignant disease; the first goal is survival and to make sure that there are wide surgical margins but many times the immediate goal is to cover a wound so that that patient can survive their treatments. Whether it’s radiation therapy or radiation combined with chemotherapy. So, for example, if we resect the tongue and floor of mouth and maybe a portion of the jaw to clear a cancer; that will create an open pathway between the mouth and the neck. And the carotid artery and jugular vein which have also been exposed because of the neck dissection procedure where all of the lymph nodes are removed; if those vessels are exposed to saliva; the amylase in the saliva can cause breakdown and damage to the blood vessels and result in what can be a life threatening bleed.

So, in the short-term, the big picture of microvascular reconstructive surgery for the head and neck is to create a safe wound that allows that patient to get through their treatment. And if it were just that easy, if it were just about plugging a hole or putting tissue in place; there wouldn’t be much to talk about. But and sometimes for other body sites; it is an opportunity for obturating a defect or covering hardware. But in the head and neck we need patients who can speak and chew and swallow appropriately. And when we look at quality of life data after head and neck surgery; believe it or not, appearance, cosmesis and even pain, those outcomes are much lower in priority compared to speech, chewing and swallowing.

And so, for that reason, we have to be able to incorporate many disciplines such as dentistry, prosthodontics, maxillofacial surgery, head and neck surgery, speech language pathology, occupational therapy, nutrition, swallowing; all of these different specialists have to work together to help the patients meet those outcomes.

In terms of the microsurgical reconstruction; that arose in the 1980s and 90s for head and neck surgery because the goal of transferring vascularized tissues needed to include bone in most cases and there are really no bones adjacent to the head and neck that can be used in a pedicled fashion where the blood supply is maintained.

One option that’s been reported in the past was to take a piece of the clavicle and bring the clavicle up with the pectoralis major muscle and try and use that for jaw reconstruction. Others have reported the use of the rib with the latissimus dorsi muscle, but that creates quite a bit of tethering, contracture of the head, limited mobility of the neck and all in all, it did not provide the best long-term results and so now we try to have thin tissue that functions inside the mouth. We don’t want it to be too bulky so that it interferes with speech and swallowing. We don’t want to have a piece of bone that’s not in alignment with the dental arch.

And so if I have a piece of leg bone that doesn’t line up properly with the teeth and the top jaw for example; that patient can’t chew, no matter what we do. So, the alignment is critically important. The thickness of the tissue is important and also making sure that we maintain a seal between the mouth and the pharynx and separate those from the great vessels of the neck.

And all of that is done with the overarching theme of airway preservation. Making sure that that patient doesn’t have a compromised airway after surgery in the acute phase or even long-term by external compression from heavy soft tissues.

Host: Doctor, as you are talking about this multidisciplinary approach to care for someone with these types of cancers and the many providers that are involved, and as reconstruction is an extremely demanding challenge for all of you surgeons; tell us about some of the benefits for the surgeon when you are using some of these minimally invasive techniques that you are describing, that could allow you to reach and access some of those hard to reach areas of the mouth and throat. What are some of the benefits? What are you doing?

Dr. Morlandt: Right so, what I described are the traditional ways of bringing up tissue and using that to reconstruct the jaw for example. What has happened in oral and maxillofacial surgery since the 1960s is external facial incisions have been traded for oral cavity incisions. And so, one example of that is jaw repositioning surgery for someone with a small jaw or a large jaw or an excessive overbite or overjet or other facial deformity; most of the incisions nowadays can be done from inside the mouth. And that means the jawbones are cut, osteotomized, they are moved into a new position, they may be fixated with plates and screws, the jaws can be wired together; all of it is done in a minimally invasive fashion transorally.

That hasn’t really caught on with head and neck surgery, both in malignant and benign disease and the main reason for that is because we need excellent visibility for malignant disease to create a wide margin. We also tend to operate through the neck to remove the lymph nodes around the great vessels. So, it has led to larger incisions, more scarring, more contracture, longer length of stay in the hospital and for the surgeon; it gives us more wound issues to deal with.

In the case of benign diseases such as ameloblastoma an ossifying fibroma; we’ve transitioned completely to transoral incisions to approach the mandible and to resect the mandible up to and including the entire jaw through the oral cavity and when the reconstruction is placed; it’s also done through the oral cavity with a very tiny 2 centimeter incision in the neck to provide access to the blood vessels.

The blood vessels are dissected out through that small neck incision which is provided in a natural skin crease for cosmesis and the microsurgical anastomosis is then done through that very small incision. So, that allows for a patient to recover from a jaw resection, who doesn’t need a tracheostomy, who can stay in the hospital three to four days and go home, who speaks and swallows earlier and importantly; doesn’t have any external scarring. And what I’m finding is more and more patients are demanding that.

They know that we can do things in medicine and particularly at a large advanced center like UAB; we can do things in a way that doesn’t produce a lot of deformity. And that’s what they expect and that’s one of the first things they ask is will I have any external scarring from this resection. And I’m happy that now in many cases we can say no, there’s not any or very little external scarring that’s left behind.

Host: Is this everything you are describing; is this now, do you see the standard of care, are you seeing it going on around the country and when do you want other physicians to refer to the specialists at UAB for these kinds of amazing procedures?

Dr. Morlandt: Yeah, I think in cases of malignant disease; we still are using fairly limited incisions to provide a neck dissection. The data for sentinel lymph node biopsy for squamous cell carcinoma of the oral cavity is very limited so, that has not taken hold as the standard of care in the United States. At least not in our center. Obviously, that’s different for diseases like melanoma and Merkel cell carcinoma. But for patients who have a need for cancer resection and microvascular free-flap reconstruction; we really would like to see these patients early.

If someone has an expansile destructive jaw tumor for example, like ameloblastoma or if they have osteonecrosis of the jaw; many times we can perform those operations completely transorally. And so these are individuals we’d like to see and discuss and that has changed in recent years. it used to be, a large jaw tumor that these patients would have almost the same operation as someone with head and neck cancer. And that’s hard for the surgeons because we are seeing patients who have a condition that will not metastasize, condition that is not by itself a terminal illness and we are treating them with almost the same surgery as we would someone with head and neck cancer.

So, we are trying to pare those treatments down. We are trying to make them more patient specific using 3-D navigation, 3-D surgical planning, the fabrication of low profile surgical cutting guides that can be used in surgery, and placement of dental implants and immediate dental provisionalization all done during the same operation through the open mouth and not having to use large deforming visible neck incisions.

Host: Wow. They way you describe it, it really paints a very clear picture for other providers of what it is that you are doing. Wrap it up for us. What would you like them to know about these types of procedures that you are doing there and where you see this field going in the future to treat these types of cancers?

Dr. Morlandt: I think the field or oral and maxillofacial surgeries set the tone for doing skeletal bone cuts, skeletal repositioning and osteotomies through the mouth. Other fields use natural orifice surgery all the time and minimally invasive single port robotic surgery. We have just developed this practice at UAB as well.

But I think what’s exciting about head and neck surgery in particular the benign aggressive head and neck operations we perform; is we can now also provide those in a minimally invasive fashion and it’s much better for patient’s recovery, for their quality of life, for their length of stay in the hospital, their complications and their long-term functions.

So, it’s a great service that we can provide our patients and I’d like the community to be aware of it.

Host: Well, they certainly will after hearing this Dr. Morlandt. Thank you so much for joining us. You are just an excellent guest with so much usable information and such a good educator. You are really a great educator. Thank you so much for joining us.

A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. This is UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. I’m Melanie Cole. Thanks so much for tuning in.