Microvascular reconstruction is a surgical procedure that involves moving a composite piece of tissue from another part of the body to the head and neck.
Because of the availability of microvascular surgical procedures at City of Hope, defects caused by cancer, congenital anomalies, or acquired disorders can now be reconstructed successfully.
Thomas J. Gernon, MD, is here to explain microvascular surgical procedures, and how at City of Hope you always feel comfortable and informed.
Selected Podcast
Amazing Microvascular Reconstruction For Head and Neck Cancer
Featured Speaker:
Learn more about Thomas J. Gernon, M.D
Thomas J. Gernon, MD
Thomas J. Gernon, M.D., is an associate clinical professor in the department of surgery, specializing in head & neck surgery. Dr. Gernon joins City of Hope from the University of Arizona College of Medicine, where he was an assistant professor in the department of surgery, division of otolaryngology. Dr. Gernon graduated Phi Beta Kappa from the University of Washington (UW) in Seattle prior to receiving his medical doctorate from UW School of Medicine. While in medical school, he was inducted into the Alpha Omega Alpha (AOA) National Medical Honor Society. Dr. Gernon continued his training with an internship in general surgery at the University of Michigan in Ann Arbor, where he also pursued a residency in head and neck surgery. In 2011, he completed a fellowship in head and neck surgery and microvascular reconstruction from the University of Washington, Seattle.Learn more about Thomas J. Gernon, M.D
Transcription:
Amazing Microvascular Reconstruction For Head and Neck Cancer
Melanie (Host): Treatment of head and neck cancer can alter a patient's quality of life by changing the way they look, speak and eat. Microvascular surgery can provide a new frontier in head and neck reconstruction. My guest today is Dr. Thomas Gernon. He’s an Associate Clinical Professor in the Department of Surgery specializing in head and neck surgery at City of Hope. Welcome to the show, Dr. Gernon. Tell us a little bit about head and neck surgery. What’s going on today? How many people are you seeing generally? What are you seeing?
Dr. Thomas Gernon (Guest): We typically see a broad range of cancers of all parts of the head and neck, particularly the oral cavity, which includes the tongue, the jawbone; the maxilla, which is the upper jaw; or the mandible, which is the lower jaw. We see a lot of cancers these days related to HPV related tumors of the tonsil and the tongue base. Then, we oftentimes see salivary gland cancers involving the parotid glands, which are the major salivary gland; the submandibular gland; and the sublingual gland. We also see widely advanced or locally advanced cutaneous malignancies from sun exposure; as well as malignant melanoma and thyroid cancer. We have a surgeon here who’s very specialized in thyroid cancer. The real trends in head and neck cancer these days are the HPV-related tumors. As you know, some high profile people such as Michael Douglas or George Karl have both had tonsil and tongue base related HPV related tumors. That’s really kind of the forefront of the field at this point.
Melanie: This type of cancer can be especially scary for people as it does affect, sometimes, how they look and then speaking and eating – two of the more important things. What symptoms, first of all? Let’s actually back up and start with risk factors. Who’s at risk for these types of cancers?
Dr. Gernon: Traditional head and neck cancers of the anterior tongue, not the back of the tongue. The anterior tongue is different than the back of the tongue. So, the anterior tongue, the jawbone, the portion we all the “floor of the mouth”, which is underneath the tongue, the real true risk factors for those are smoking and drinking. That’s more of our traditional types of tumors. The incidence of those are actually decreasing as people realize that smoking and drinking are not good for you. We’re seeing a decrease in those over years. The risk for HPV-related tumors, that is something that we all get exposed to most commonly in our teenage years; and then, the virus lies dormant in that tissue and it expresses itself most typically in males more than females anywhere from 50-60 years of age. You can see a range of ages on either side of that as well. That’s why there’s a lot of emphasis on getting your children vaccinated both boys and girls against the HPV virus at this time.
Melanie: What symptoms should people be looking for if they are concerned about or if they have any of these risk factors?
Dr. Gernon: For the traditional types of tumors--the tumors of the anterior tongue and the jaw and the floor of the mouth and the upper jaw—typically, it will be a pretty painful sore on the side of the tongue or the front of the tongue that can cause difficulty with eating such that it becomes painful. Sometimes, they’ll have an ulcerated lesion that will bleed. If the tumor gets large enough, they may start to notice speech disturbances as well. If the tumor gets really large they might have difficulty with swallowing. Those are mainly for the tumors of the front of the tongue and then the jaw. The tumors of the back of the tongue and the tonsils, oftentimes patients won’t even notice they have anything going on in the tonsil or the back of the tongue. They’ll just notice a neck mass and that is typically from a lymph node that has become involved. So, they may be completely asymptomatic and then they’ll go to their doctor or they’ll see somebody and they’ll randomly notice that there’s a neck mass which is a lymph node which is very typical for that type of cancer. Some other symptoms those patients may have, though, if the tumor does get too big is really some pain and then some difficulty with swallowing.
Melanie: What is the first line of defense if they get a diagnosis and then you start treatment? I want to make sure we get into this microvascular surgery that you do. It’s absolutely fascinating. So, speak about treatments.
Dr. Gernon: It all depends on the size of the tumor at first. For tumors of the anterior tongue and the jaw, if they are small enough and it’s clinically indicated, you can often times undergo an excision of that tumor and then just close the tissue up and then the patient will do fine as far as their follow up function. If the tumor of the anterior tongue or jaw or the floor of the mouth is too large, then if you think about it if you try to just close that tissue up then you’ll have a large gap of tissue and everything you and I are doing on the phone right now is because we’re using our tongues, we’re talking, we’re communicating. You need to place, in essence, a spacer where that tumor was to prevent significant contractions such that the patient’s swallowing and speech will not be impacted. We can take tissue from other parts of the body. One typical place that we take the tissue from is the forearm, the under surface of the forearm, with an associated artery and a vein. Then, we can transplant that tissue to fill in the defect. Then we can hook up the artery in the vein from the arm with an artery in the vein from the neck. It’s literally a transplant on your own body. The great thing about that is one, it’s your own tissue so you don’t need any type of immunosuppressant drugs. When it heals, the remainder of your tongue or jaw will function well enough that your speech swallowing, although it may be somewhat impacted, over time patients typically do fairly well and their overall cosmesis looks very well from an external standpoint. We can do a lot of this through the mouth and through an incision through the neck. If the jaw is involved, oftentimes there are two bones in the leg – we are able to take the fibula bone which is the bone on the outside and its associated blood supply and transplant that to recontour it. We can break the bone and recontour it towards the shape of the normal jaw and then revascularize that tissue and then you can rebuild the jaw and the tongue and the tissue as it’s needed. That’s really something that’s been done over the past 20 to 30 years. That really minimizes the impact on patients with these types of tumors that need treatment. The other real area of treatment that we’re moving towards is these HPV-related tumors. They all seem to respond well to treatment. Most patients who get them do well. They can be treated either surgically or without surgery with chemo and radiation. Standards of chemo and radiation that we used to treat head and neck tumors with, we’re finding that these doses are often times leaving long-term side effects with patients. They will have difficulty with swallowing, difficulty with saliva production long-term down the road. We’re trying to reduce the impact of treatment. Now, we’re oftentimes treating these tumors, if it’s feasible, with use of multi-disciplinary tumor boards and staging, with the use of either robotics or with transoral laser--surgery with a laser through the mouth--to remove these tumors and decrease the subsequent therapy with radiation or chemotherapy afterwards. The patient doesn’t have long-term side effects. I mentioned earlier that the patients are often times in their 50’s. If you think about it, these patients may live quite a long time, so we’re really looking at minimizing the impact of treatment on their long-term survival. So, you want to decrease their functional morbidity in a way. That’s really where the field is moving.
Melanie: That’s absolutely fascinating. You mentioned vascularization and getting that blood supply. Is that even an issue because you’re dealing with head and neck and people think “big arteries around there”. How does that work and can it really work to improve their quality of life? Kind of wrap it up for us.
Dr. Gernon: Definitely. The microvascular aspect of it – so the vessels that we take out of the arm or the leg, they are fairly--small 3 -4 mm blood vessels and the arteries in the head and neck are actually fairly small--the ones that we use to hook up the transplant to in the neck. We have to use a microscope. We place very small sutures under the microscope and then we make sure that that anastomosis of the artery and the vein is patent and we watch the flap in an ICU setting oftentimes. We make sure that the flap has good blood flow. We have different ways of monitoring flaps. The ways that centers monitor them vary throughout the country. It’s just kind of a feel thing that you get used to as you get farther and farther out into your practice.
Melanie: How cool is that?
Dr. Gernon: It’s definitely something that really improves patient's’ qualities of life. You can remove the majority of a tongue and rebuild it with the tissue of the forearm. Six months to a year down the road oftentimes, these patients will be able to eat and drink a normal diet. Over time, oftentimes the tissue can start to look like normal tongue tissue. The skin of the arm will actually start to look like tongue tissue. That’s on a case by case basis but I’ve seen that happen where that patient is 3 or 4 years out and this is really something that’s in their rearview mirror as far as their life is concerned. They come in and get checked ups and they go home and they’re eating, drinking, speaking. They have time to spend with their loved ones and they’re having pretty much normal quality of life.
Melanie: Amazing. Why should they come to City of Hope for their care? Although you’ve given really some of the most amazing reasons. You tell the listeners.
Dr. Gernon: City of Hope, particularly the Head/Neck Cancer Division we have myself, my colleague Robert King. He is also a microvascular surgeon and then Ellie Mgamie. She trained at Memorial Sloan Kettering. We all have had excellent training in head/neck cancer treatment as far as the resection and the reconstruction are concerned. I think you can find that anywhere throughout the country. The important thing, though, is that we have a real strong team approach where we work with our radiation and medical oncologists to really come to a consensus on your treatment. We review all your films, all your treatment, all your pathology reports before any decision is made about surgery at a multi-disciplinary tumor board. We come to a consensus on what the treatment should be and we move forward as a team with that treatment. Afterwards, we all review your path report; we make sure that your post-surgical treatment or, even if you’re not undergoing surgical treatment, that the treatment is correct to the clinical stage that you have. We’re also enrolled in clinical trials which are at the forefront of treatment for head/neck cancer. We are really trying to push the field forward and give the best possible treatment we absolutely can.
Melanie: Thank you so much, Dr. Gernon. I certainly applaud all the great work that you’re doing at City of Hope. Thanks for being with us today. You’re listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Amazing Microvascular Reconstruction For Head and Neck Cancer
Melanie (Host): Treatment of head and neck cancer can alter a patient's quality of life by changing the way they look, speak and eat. Microvascular surgery can provide a new frontier in head and neck reconstruction. My guest today is Dr. Thomas Gernon. He’s an Associate Clinical Professor in the Department of Surgery specializing in head and neck surgery at City of Hope. Welcome to the show, Dr. Gernon. Tell us a little bit about head and neck surgery. What’s going on today? How many people are you seeing generally? What are you seeing?
Dr. Thomas Gernon (Guest): We typically see a broad range of cancers of all parts of the head and neck, particularly the oral cavity, which includes the tongue, the jawbone; the maxilla, which is the upper jaw; or the mandible, which is the lower jaw. We see a lot of cancers these days related to HPV related tumors of the tonsil and the tongue base. Then, we oftentimes see salivary gland cancers involving the parotid glands, which are the major salivary gland; the submandibular gland; and the sublingual gland. We also see widely advanced or locally advanced cutaneous malignancies from sun exposure; as well as malignant melanoma and thyroid cancer. We have a surgeon here who’s very specialized in thyroid cancer. The real trends in head and neck cancer these days are the HPV-related tumors. As you know, some high profile people such as Michael Douglas or George Karl have both had tonsil and tongue base related HPV related tumors. That’s really kind of the forefront of the field at this point.
Melanie: This type of cancer can be especially scary for people as it does affect, sometimes, how they look and then speaking and eating – two of the more important things. What symptoms, first of all? Let’s actually back up and start with risk factors. Who’s at risk for these types of cancers?
Dr. Gernon: Traditional head and neck cancers of the anterior tongue, not the back of the tongue. The anterior tongue is different than the back of the tongue. So, the anterior tongue, the jawbone, the portion we all the “floor of the mouth”, which is underneath the tongue, the real true risk factors for those are smoking and drinking. That’s more of our traditional types of tumors. The incidence of those are actually decreasing as people realize that smoking and drinking are not good for you. We’re seeing a decrease in those over years. The risk for HPV-related tumors, that is something that we all get exposed to most commonly in our teenage years; and then, the virus lies dormant in that tissue and it expresses itself most typically in males more than females anywhere from 50-60 years of age. You can see a range of ages on either side of that as well. That’s why there’s a lot of emphasis on getting your children vaccinated both boys and girls against the HPV virus at this time.
Melanie: What symptoms should people be looking for if they are concerned about or if they have any of these risk factors?
Dr. Gernon: For the traditional types of tumors--the tumors of the anterior tongue and the jaw and the floor of the mouth and the upper jaw—typically, it will be a pretty painful sore on the side of the tongue or the front of the tongue that can cause difficulty with eating such that it becomes painful. Sometimes, they’ll have an ulcerated lesion that will bleed. If the tumor gets large enough, they may start to notice speech disturbances as well. If the tumor gets really large they might have difficulty with swallowing. Those are mainly for the tumors of the front of the tongue and then the jaw. The tumors of the back of the tongue and the tonsils, oftentimes patients won’t even notice they have anything going on in the tonsil or the back of the tongue. They’ll just notice a neck mass and that is typically from a lymph node that has become involved. So, they may be completely asymptomatic and then they’ll go to their doctor or they’ll see somebody and they’ll randomly notice that there’s a neck mass which is a lymph node which is very typical for that type of cancer. Some other symptoms those patients may have, though, if the tumor does get too big is really some pain and then some difficulty with swallowing.
Melanie: What is the first line of defense if they get a diagnosis and then you start treatment? I want to make sure we get into this microvascular surgery that you do. It’s absolutely fascinating. So, speak about treatments.
Dr. Gernon: It all depends on the size of the tumor at first. For tumors of the anterior tongue and the jaw, if they are small enough and it’s clinically indicated, you can often times undergo an excision of that tumor and then just close the tissue up and then the patient will do fine as far as their follow up function. If the tumor of the anterior tongue or jaw or the floor of the mouth is too large, then if you think about it if you try to just close that tissue up then you’ll have a large gap of tissue and everything you and I are doing on the phone right now is because we’re using our tongues, we’re talking, we’re communicating. You need to place, in essence, a spacer where that tumor was to prevent significant contractions such that the patient’s swallowing and speech will not be impacted. We can take tissue from other parts of the body. One typical place that we take the tissue from is the forearm, the under surface of the forearm, with an associated artery and a vein. Then, we can transplant that tissue to fill in the defect. Then we can hook up the artery in the vein from the arm with an artery in the vein from the neck. It’s literally a transplant on your own body. The great thing about that is one, it’s your own tissue so you don’t need any type of immunosuppressant drugs. When it heals, the remainder of your tongue or jaw will function well enough that your speech swallowing, although it may be somewhat impacted, over time patients typically do fairly well and their overall cosmesis looks very well from an external standpoint. We can do a lot of this through the mouth and through an incision through the neck. If the jaw is involved, oftentimes there are two bones in the leg – we are able to take the fibula bone which is the bone on the outside and its associated blood supply and transplant that to recontour it. We can break the bone and recontour it towards the shape of the normal jaw and then revascularize that tissue and then you can rebuild the jaw and the tongue and the tissue as it’s needed. That’s really something that’s been done over the past 20 to 30 years. That really minimizes the impact on patients with these types of tumors that need treatment. The other real area of treatment that we’re moving towards is these HPV-related tumors. They all seem to respond well to treatment. Most patients who get them do well. They can be treated either surgically or without surgery with chemo and radiation. Standards of chemo and radiation that we used to treat head and neck tumors with, we’re finding that these doses are often times leaving long-term side effects with patients. They will have difficulty with swallowing, difficulty with saliva production long-term down the road. We’re trying to reduce the impact of treatment. Now, we’re oftentimes treating these tumors, if it’s feasible, with use of multi-disciplinary tumor boards and staging, with the use of either robotics or with transoral laser--surgery with a laser through the mouth--to remove these tumors and decrease the subsequent therapy with radiation or chemotherapy afterwards. The patient doesn’t have long-term side effects. I mentioned earlier that the patients are often times in their 50’s. If you think about it, these patients may live quite a long time, so we’re really looking at minimizing the impact of treatment on their long-term survival. So, you want to decrease their functional morbidity in a way. That’s really where the field is moving.
Melanie: That’s absolutely fascinating. You mentioned vascularization and getting that blood supply. Is that even an issue because you’re dealing with head and neck and people think “big arteries around there”. How does that work and can it really work to improve their quality of life? Kind of wrap it up for us.
Dr. Gernon: Definitely. The microvascular aspect of it – so the vessels that we take out of the arm or the leg, they are fairly--small 3 -4 mm blood vessels and the arteries in the head and neck are actually fairly small--the ones that we use to hook up the transplant to in the neck. We have to use a microscope. We place very small sutures under the microscope and then we make sure that that anastomosis of the artery and the vein is patent and we watch the flap in an ICU setting oftentimes. We make sure that the flap has good blood flow. We have different ways of monitoring flaps. The ways that centers monitor them vary throughout the country. It’s just kind of a feel thing that you get used to as you get farther and farther out into your practice.
Melanie: How cool is that?
Dr. Gernon: It’s definitely something that really improves patient's’ qualities of life. You can remove the majority of a tongue and rebuild it with the tissue of the forearm. Six months to a year down the road oftentimes, these patients will be able to eat and drink a normal diet. Over time, oftentimes the tissue can start to look like normal tongue tissue. The skin of the arm will actually start to look like tongue tissue. That’s on a case by case basis but I’ve seen that happen where that patient is 3 or 4 years out and this is really something that’s in their rearview mirror as far as their life is concerned. They come in and get checked ups and they go home and they’re eating, drinking, speaking. They have time to spend with their loved ones and they’re having pretty much normal quality of life.
Melanie: Amazing. Why should they come to City of Hope for their care? Although you’ve given really some of the most amazing reasons. You tell the listeners.
Dr. Gernon: City of Hope, particularly the Head/Neck Cancer Division we have myself, my colleague Robert King. He is also a microvascular surgeon and then Ellie Mgamie. She trained at Memorial Sloan Kettering. We all have had excellent training in head/neck cancer treatment as far as the resection and the reconstruction are concerned. I think you can find that anywhere throughout the country. The important thing, though, is that we have a real strong team approach where we work with our radiation and medical oncologists to really come to a consensus on your treatment. We review all your films, all your treatment, all your pathology reports before any decision is made about surgery at a multi-disciplinary tumor board. We come to a consensus on what the treatment should be and we move forward as a team with that treatment. Afterwards, we all review your path report; we make sure that your post-surgical treatment or, even if you’re not undergoing surgical treatment, that the treatment is correct to the clinical stage that you have. We’re also enrolled in clinical trials which are at the forefront of treatment for head/neck cancer. We are really trying to push the field forward and give the best possible treatment we absolutely can.
Melanie: Thank you so much, Dr. Gernon. I certainly applaud all the great work that you’re doing at City of Hope. Thanks for being with us today. You’re listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.