Standard operating procedures have been developed in many surgical practices to ensure quality of... more Standard operating procedures have been developed in many surgical practices to ensure quality of care as it relates to specimens removed from the body. Most of these specimens are sent to pathology. Some, such as calvarial bone harvested during craniotomy are replaced in the body. Free tissue transfer involves harvesting tissue from one body site, storage for a variable period of time outside of the body, and then insertion in another location. As with any system there is ample opportunity for accidental "misplacement." We undertook a multi-institutional study to examine the incidence, etiology, and opportunity for process improvement. Retrospective review. A retrospective review was performed at five institutions (8,382 free flaps). Thirteen (0.15%) flaps were dropped or wrapped in a towel/sponge and placed in a waste bucket. Eight radial forearm, three fibula, one latissimus dorsi, and one anterolateral thigh flap were misplaced. All flaps were retrieved, washed in sali...
Reconstruction of the lateral mandibular defect presents a complex challenge to the reconstructiv... more Reconstruction of the lateral mandibular defect presents a complex challenge to the reconstructive surgeon, often involving interconnected soft-tissue and bone requirements. This review examines the current literature on functional outcomes of lateral mandibular reconstruction and presents an algorithm on selecting an optimal reconstructive choice for patients with lateral mandibular defects resulting from oncologic ablative surgery or trauma. PubMed and Medline searches on reconstructing lateral mandibular defect were performed of the English literature. Search terms included lateral mandibular defect, outcomes of mandibular reconstruction, and free flap reconstruction of mandible. Although most of the articles presented are retrospective reviews, priority was given to the articles with high-quality level of evidence. Restoration of function, including speech and swallow, and acceptable cosmetic result are the primary objectives of lateral mandibular reconstruction. When reconstructing the mandible in a patient following tumor extirpation, the patient's overall prognosis, medical comorbidities, and need for adjuvant therapy should be considered. In the patient with aggressive malignant disease and a poor prognosis, a less complex reconstruction, such as soft-tissue flap with or without a reconstruction plate, may be adequate. In a dentate patient with favorable prognosis, a durable reconstruction, such as osseocutaneous microvascular free flap, is often preferred. Various reconstructive options are available for patients with lateral mandibular defects. Depending on the predominance of the soft-tissue or bony components of the defect, with consideration of the patient's characteristics and functional and aesthetic goals, the surgeon can wisely select from these reconstructive possibilities.
Facial plastic surgery clinics of North America, 2009
The structures of the nose are arguably the most complex within the face to reconstitute when abs... more The structures of the nose are arguably the most complex within the face to reconstitute when absent. Total nasal reconstruction has evolved to encompass advanced surgical techniques in an effort to achieve increasingly satisfactory cosmetic results while restoring nasal function that mimics the function of a patient's natural nose. In this article, the history of total nasal defects and their reconstruction, relevant nasal anatomy, etiologies of the defect, and the surgical approaches to reconstructing each of the three-layered structure of the nose (ie, nasal skin, cartilage/bone, and lining mucosa) are explored.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, Jan 27, 2015
Describe the utility of osteocutaneous forearm flaps in reconstruction of naso-orbito-ethmoid (NO... more Describe the utility of osteocutaneous forearm flaps in reconstruction of naso-orbito-ethmoid (NOE) defects. Case series with chart review. Tertiary medical centers. The study was conducted on patients treated between the years 2000 and 2014 undergoing NOE resection with reconstruction using the radial forearm flap. Decision making, technical feasibility, need for revisions, and patient disease outcomes were included to assess the durability of reconstruction over remaining survival period. Fifteen patients underwent NOE reconstruction in the timeframe studied. Five recent patients reported poor nasal airway but no diplopia or immediately clinically evident enopthalmus after NOE reconstruction in mean follow-up of 17.3 months. One-third of patients succumbed to disease in the study period, 3 without revision, and all but 2 surviving patients required revisions. Osteocutaneous radial forearm flap (OCRFF) is a cosmetically acceptable method of reconstructing NOE defects. Though a 1-st...
Lemierre syndrome, otherwise known as postanginal sepsis or necrobacillosis, is an illness that o... more Lemierre syndrome, otherwise known as postanginal sepsis or necrobacillosis, is an illness that originates as an acute pharyngitis or tonsillitis which progresses to sepsis, usually fusobacterial, due to suppurative thrombophlebitis of the internal jugular vein. Septic thromboemboli then seed various organs, resulting in multiple organ system pathology, most commonly affecting pulmonary and hepatic systems and joints. Although rare in the age of antibiotics, this disease typically affects previously healthy adolescents with varied clinical manifestations depending upon organ system involvement (A. Lemierre, Lancet March (1936) 701-703; J. Barker, H.T. Winer-Muram, S. Grey, Southern Med. J. 89 (1996) 1021-1023). Prompt diagnosis based on clinical presentation, radiologic findings, particularly CT scanning with contrast and a high index of suspicion, is necessary in order to institute often life saving therapy (J. Barker, H.T. Winer-Muram, S. Grey, Southern Med. J. 89 (1996) 1021-1023). We will present two cases of Lemierre syndrome, review it's clinical presentation, anatomic considerations, particularly it's relationship to the parapharyngeal space, radiographic findings, potential life threatening complications and finally, a unique approach to therapy.
The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for t... more The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for the majority of soft tissue defects in the head and neck. The forearm skin has many of the ideal soft tissue characteristics that optimize reconstruction and rehabilitation in these patients. The tissue is malleable, supple, and moldable in three dimensions; has a reliable pedicle; and can be harvested with a two-team approach. In some patients, the radial forearm cannot be used. An alternative is to use the adjacent tissue, which shares identical tissue characteristics. This tissue gets its vascular supply from the ulnar artery. The purpose of the report was to describe the authors' experience with the ulnar fasciocutaneous free flap in head and neck reconstruction. Prospective consecutive case series. Retrospective review of all patients undergoing ulnar fasciocutaneous free tissue transfer by a group of microvascular surgeons was performed. Thirty patients underwent free tissue tra...
The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for t... more The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for the majority of soft tissue defects in the head and neck. The forearm skin has many of the ideal soft tissue characteristics that optimize reconstruction and rehabilitation in these patients. The tissue is malleable, supple, and moldable in three dimensions; has a reliable pedicle; and can be harvested with a two-team approach. In some patients, the radial forearm cannot be used. An alternative is to use the adjacent tissue, which shares identical tissue characteristics. This tissue gets its vascular supply from the ulnar artery. The purpose of the report was to describe the authors' experience with the ulnar fasciocutaneous free flap in head and neck reconstruction. Prospective consecutive case series. Retrospective review of all patients undergoing ulnar fasciocutaneous free tissue transfer by a group of microvascular surgeons was performed. Thirty patients underwent free tissue tra...
The radial forearm free flap has become the method of choice for reconstruction of head and neck ... more The radial forearm free flap has become the method of choice for reconstruction of head and neck defects following oncologic ablation. Harvesting of a radial forearm free flap leaves a donor site defect. This is most commonly closed with a split-thickness skin graft. Morbidity, most commonly owing to a lack of graft take over the tendons, can be quite high. Recently, an acellular matrix (Alloderm) has been advocated to decrease complications at the radial forearm donor site, as well as obviate taking a split-thickness skin graft from the thigh. Tertiary referral academic centre. Retrospective chart review of 15 patients. Five patients received allogenic dermis, 10 patients received split-thickness skin grafting to the radial forearm donor site. Patients with allogenic dermis took between 12 and 16 weeks to heal completely. Patients undergoing split-thickness skin graft were completely healed within 4 to 6 weeks. Cosmesis was judged to be marginally better in the allogenic dermis gro...
The radial forearm free flap has become the method of choice for reconstruction of head and neck ... more The radial forearm free flap has become the method of choice for reconstruction of head and neck defects following oncologic ablation. Harvesting of a radial forearm free flap leaves a donor site defect. This is most commonly closed with a split-thickness skin graft. Morbidity, most commonly owing to a lack of graft take over the tendons, can be quite high. Recently, an acellular matrix (Alloderm) has been advocated to decrease complications at the radial forearm donor site, as well as obviate taking a split-thickness skin graft from the thigh. Tertiary referral academic centre. Retrospective chart review of 15 patients. Five patients received allogenic dermis, 10 patients received split-thickness skin grafting to the radial forearm donor site. Patients with allogenic dermis took between 12 and 16 weeks to heal completely. Patients undergoing split-thickness skin graft were completely healed within 4 to 6 weeks. Cosmesis was judged to be marginally better in the allogenic dermis gro...
International Journal of Pediatric Otorhinolaryngology, 1998
Lemierre syndrome, otherwise known as postanginal sepsis or necrobacillosis, is an illness that o... more Lemierre syndrome, otherwise known as postanginal sepsis or necrobacillosis, is an illness that originates as an acute pharyngitis or tonsillitis which progresses to sepsis, usually fusobacterial, due to suppurative thrombophlebitis of the internal jugular vein. Septic thromboemboli then seed various organs, resulting in multiple organ system pathology, most commonly affecting pulmonary and hepatic systems and joints. Although rare in the age of antibiotics, this disease typically affects previously healthy adolescents with varied clinical manifestations depending upon organ system involvement (A. Lemierre, Lancet March (1936) 701-703; J. Barker, H.T. Winer-Muram, S. Grey, Southern Med. J. 89 (1996) 1021-1023). Prompt diagnosis based on clinical presentation, radiologic findings, particularly CT scanning with contrast and a high index of suspicion, is necessary in order to institute often life saving therapy (J. Barker, H.T. Winer-Muram, S. Grey, Southern Med. J. 89 (1996) 1021-1023). We will present two cases of Lemierre syndrome, review it's clinical presentation, anatomic considerations, particularly it's relationship to the parapharyngeal space, radiographic findings, potential life threatening complications and finally, a unique approach to therapy.
Schwannomas are benign, slow-growing tumors that arise from nerves. Those originating from the sy... more Schwannomas are benign, slow-growing tumors that arise from nerves. Those originating from the sympathetic cervical chain are rare. We describe our experience with the clinical presentation, surgical management, and outcomes of patients with this pathology. Retrospective chart review of a case series in a tertiary referral center. Four cases of cervical sympathetic chain schwannomas were reviewed. Patients presented with either an asymptomatic neck mass discovered on routine physical examination (1 patient), an enlarging neck mass (2), or an acute onset of a Horner's syndrome (1). All patients underwent preoperative imaging (magnetic resonance imaging, computed tomography, or both). The location and soft-tissue characteristics of the mass, along with displacement of the carotid sheath vessels, were typical of a cervical sympathetic chain schwannoma. All patients underwent surgical excision of the mass. Postoperative Horner's syndrome was encountered in all patients. First bite syndrome was encountered in two patients. Cervical sympathetic chain schwannomas are rare tumors. Preoperative imaging characteristics facilitate the diagnosis. First bite syndrome can occur and may be debilitating postoperatively. Long-term prognosis is excellent.
Standard operating procedures have been developed in many surgical practices to ensure quality of... more Standard operating procedures have been developed in many surgical practices to ensure quality of care as it relates to specimens removed from the body. Most of these specimens are sent to pathology. Some, such as calvarial bone harvested during craniotomy are replaced in the body. Free tissue transfer involves harvesting tissue from one body site, storage for a variable period of time outside of the body, and then insertion in another location. As with any system there is ample opportunity for accidental "misplacement." We undertook a multi-institutional study to examine the incidence, etiology, and opportunity for process improvement. Retrospective review. A retrospective review was performed at five institutions (8,382 free flaps). Thirteen (0.15%) flaps were dropped or wrapped in a towel/sponge and placed in a waste bucket. Eight radial forearm, three fibula, one latissimus dorsi, and one anterolateral thigh flap were misplaced. All flaps were retrieved, washed in sali...
Reconstruction of the lateral mandibular defect presents a complex challenge to the reconstructiv... more Reconstruction of the lateral mandibular defect presents a complex challenge to the reconstructive surgeon, often involving interconnected soft-tissue and bone requirements. This review examines the current literature on functional outcomes of lateral mandibular reconstruction and presents an algorithm on selecting an optimal reconstructive choice for patients with lateral mandibular defects resulting from oncologic ablative surgery or trauma. PubMed and Medline searches on reconstructing lateral mandibular defect were performed of the English literature. Search terms included lateral mandibular defect, outcomes of mandibular reconstruction, and free flap reconstruction of mandible. Although most of the articles presented are retrospective reviews, priority was given to the articles with high-quality level of evidence. Restoration of function, including speech and swallow, and acceptable cosmetic result are the primary objectives of lateral mandibular reconstruction. When reconstructing the mandible in a patient following tumor extirpation, the patient's overall prognosis, medical comorbidities, and need for adjuvant therapy should be considered. In the patient with aggressive malignant disease and a poor prognosis, a less complex reconstruction, such as soft-tissue flap with or without a reconstruction plate, may be adequate. In a dentate patient with favorable prognosis, a durable reconstruction, such as osseocutaneous microvascular free flap, is often preferred. Various reconstructive options are available for patients with lateral mandibular defects. Depending on the predominance of the soft-tissue or bony components of the defect, with consideration of the patient's characteristics and functional and aesthetic goals, the surgeon can wisely select from these reconstructive possibilities.
Facial plastic surgery clinics of North America, 2009
The structures of the nose are arguably the most complex within the face to reconstitute when abs... more The structures of the nose are arguably the most complex within the face to reconstitute when absent. Total nasal reconstruction has evolved to encompass advanced surgical techniques in an effort to achieve increasingly satisfactory cosmetic results while restoring nasal function that mimics the function of a patient's natural nose. In this article, the history of total nasal defects and their reconstruction, relevant nasal anatomy, etiologies of the defect, and the surgical approaches to reconstructing each of the three-layered structure of the nose (ie, nasal skin, cartilage/bone, and lining mucosa) are explored.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, Jan 27, 2015
Describe the utility of osteocutaneous forearm flaps in reconstruction of naso-orbito-ethmoid (NO... more Describe the utility of osteocutaneous forearm flaps in reconstruction of naso-orbito-ethmoid (NOE) defects. Case series with chart review. Tertiary medical centers. The study was conducted on patients treated between the years 2000 and 2014 undergoing NOE resection with reconstruction using the radial forearm flap. Decision making, technical feasibility, need for revisions, and patient disease outcomes were included to assess the durability of reconstruction over remaining survival period. Fifteen patients underwent NOE reconstruction in the timeframe studied. Five recent patients reported poor nasal airway but no diplopia or immediately clinically evident enopthalmus after NOE reconstruction in mean follow-up of 17.3 months. One-third of patients succumbed to disease in the study period, 3 without revision, and all but 2 surviving patients required revisions. Osteocutaneous radial forearm flap (OCRFF) is a cosmetically acceptable method of reconstructing NOE defects. Though a 1-st...
Lemierre syndrome, otherwise known as postanginal sepsis or necrobacillosis, is an illness that o... more Lemierre syndrome, otherwise known as postanginal sepsis or necrobacillosis, is an illness that originates as an acute pharyngitis or tonsillitis which progresses to sepsis, usually fusobacterial, due to suppurative thrombophlebitis of the internal jugular vein. Septic thromboemboli then seed various organs, resulting in multiple organ system pathology, most commonly affecting pulmonary and hepatic systems and joints. Although rare in the age of antibiotics, this disease typically affects previously healthy adolescents with varied clinical manifestations depending upon organ system involvement (A. Lemierre, Lancet March (1936) 701-703; J. Barker, H.T. Winer-Muram, S. Grey, Southern Med. J. 89 (1996) 1021-1023). Prompt diagnosis based on clinical presentation, radiologic findings, particularly CT scanning with contrast and a high index of suspicion, is necessary in order to institute often life saving therapy (J. Barker, H.T. Winer-Muram, S. Grey, Southern Med. J. 89 (1996) 1021-1023). We will present two cases of Lemierre syndrome, review it's clinical presentation, anatomic considerations, particularly it's relationship to the parapharyngeal space, radiographic findings, potential life threatening complications and finally, a unique approach to therapy.
The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for t... more The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for the majority of soft tissue defects in the head and neck. The forearm skin has many of the ideal soft tissue characteristics that optimize reconstruction and rehabilitation in these patients. The tissue is malleable, supple, and moldable in three dimensions; has a reliable pedicle; and can be harvested with a two-team approach. In some patients, the radial forearm cannot be used. An alternative is to use the adjacent tissue, which shares identical tissue characteristics. This tissue gets its vascular supply from the ulnar artery. The purpose of the report was to describe the authors' experience with the ulnar fasciocutaneous free flap in head and neck reconstruction. Prospective consecutive case series. Retrospective review of all patients undergoing ulnar fasciocutaneous free tissue transfer by a group of microvascular surgeons was performed. Thirty patients underwent free tissue tra...
The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for t... more The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for the majority of soft tissue defects in the head and neck. The forearm skin has many of the ideal soft tissue characteristics that optimize reconstruction and rehabilitation in these patients. The tissue is malleable, supple, and moldable in three dimensions; has a reliable pedicle; and can be harvested with a two-team approach. In some patients, the radial forearm cannot be used. An alternative is to use the adjacent tissue, which shares identical tissue characteristics. This tissue gets its vascular supply from the ulnar artery. The purpose of the report was to describe the authors' experience with the ulnar fasciocutaneous free flap in head and neck reconstruction. Prospective consecutive case series. Retrospective review of all patients undergoing ulnar fasciocutaneous free tissue transfer by a group of microvascular surgeons was performed. Thirty patients underwent free tissue tra...
The radial forearm free flap has become the method of choice for reconstruction of head and neck ... more The radial forearm free flap has become the method of choice for reconstruction of head and neck defects following oncologic ablation. Harvesting of a radial forearm free flap leaves a donor site defect. This is most commonly closed with a split-thickness skin graft. Morbidity, most commonly owing to a lack of graft take over the tendons, can be quite high. Recently, an acellular matrix (Alloderm) has been advocated to decrease complications at the radial forearm donor site, as well as obviate taking a split-thickness skin graft from the thigh. Tertiary referral academic centre. Retrospective chart review of 15 patients. Five patients received allogenic dermis, 10 patients received split-thickness skin grafting to the radial forearm donor site. Patients with allogenic dermis took between 12 and 16 weeks to heal completely. Patients undergoing split-thickness skin graft were completely healed within 4 to 6 weeks. Cosmesis was judged to be marginally better in the allogenic dermis gro...
The radial forearm free flap has become the method of choice for reconstruction of head and neck ... more The radial forearm free flap has become the method of choice for reconstruction of head and neck defects following oncologic ablation. Harvesting of a radial forearm free flap leaves a donor site defect. This is most commonly closed with a split-thickness skin graft. Morbidity, most commonly owing to a lack of graft take over the tendons, can be quite high. Recently, an acellular matrix (Alloderm) has been advocated to decrease complications at the radial forearm donor site, as well as obviate taking a split-thickness skin graft from the thigh. Tertiary referral academic centre. Retrospective chart review of 15 patients. Five patients received allogenic dermis, 10 patients received split-thickness skin grafting to the radial forearm donor site. Patients with allogenic dermis took between 12 and 16 weeks to heal completely. Patients undergoing split-thickness skin graft were completely healed within 4 to 6 weeks. Cosmesis was judged to be marginally better in the allogenic dermis gro...
International Journal of Pediatric Otorhinolaryngology, 1998
Lemierre syndrome, otherwise known as postanginal sepsis or necrobacillosis, is an illness that o... more Lemierre syndrome, otherwise known as postanginal sepsis or necrobacillosis, is an illness that originates as an acute pharyngitis or tonsillitis which progresses to sepsis, usually fusobacterial, due to suppurative thrombophlebitis of the internal jugular vein. Septic thromboemboli then seed various organs, resulting in multiple organ system pathology, most commonly affecting pulmonary and hepatic systems and joints. Although rare in the age of antibiotics, this disease typically affects previously healthy adolescents with varied clinical manifestations depending upon organ system involvement (A. Lemierre, Lancet March (1936) 701-703; J. Barker, H.T. Winer-Muram, S. Grey, Southern Med. J. 89 (1996) 1021-1023). Prompt diagnosis based on clinical presentation, radiologic findings, particularly CT scanning with contrast and a high index of suspicion, is necessary in order to institute often life saving therapy (J. Barker, H.T. Winer-Muram, S. Grey, Southern Med. J. 89 (1996) 1021-1023). We will present two cases of Lemierre syndrome, review it's clinical presentation, anatomic considerations, particularly it's relationship to the parapharyngeal space, radiographic findings, potential life threatening complications and finally, a unique approach to therapy.
Schwannomas are benign, slow-growing tumors that arise from nerves. Those originating from the sy... more Schwannomas are benign, slow-growing tumors that arise from nerves. Those originating from the sympathetic cervical chain are rare. We describe our experience with the clinical presentation, surgical management, and outcomes of patients with this pathology. Retrospective chart review of a case series in a tertiary referral center. Four cases of cervical sympathetic chain schwannomas were reviewed. Patients presented with either an asymptomatic neck mass discovered on routine physical examination (1 patient), an enlarging neck mass (2), or an acute onset of a Horner's syndrome (1). All patients underwent preoperative imaging (magnetic resonance imaging, computed tomography, or both). The location and soft-tissue characteristics of the mass, along with displacement of the carotid sheath vessels, were typical of a cervical sympathetic chain schwannoma. All patients underwent surgical excision of the mass. Postoperative Horner's syndrome was encountered in all patients. First bite syndrome was encountered in two patients. Cervical sympathetic chain schwannomas are rare tumors. Preoperative imaging characteristics facilitate the diagnosis. First bite syndrome can occur and may be debilitating postoperatively. Long-term prognosis is excellent.
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Papers by Mark Wax