Over the past 10 years, a total of 20 patients underwent the tracheojejunal fistulization for voice reconstruction following pharyngolaryngoesophagectomy with free jejunum reconstruction for advanced hypopharyngeal cancer. For voice reconstruction, a 2-cm inferiorly based tracheal flap was obtained from the membranous part of the trachea by removing 4 cartilaginous tracheal rings. After the completion of digestive continuity with the jejunal autograft, a side-to-side anastomosis was created by approximating the incised margin of the transplanted jejunal mucosa to that of the tracheal flap. The tracheal flap was tubed to construct the tracheojejunal fistula. The incised margin of the transplanted jejunal serosa was additionally sutured to the lateral wall of the fistula to reinforce the approximation of the fistula and the transplanted jejunum. Sixteen (80%) of 20 patients retained phonatory function. Patients with the tracheojejunal phonation could speak at 1 month postoperatively on average. The average value of maximum phonation time in 16 tracheojejunal speakers was 11 seconds. As far as the swallowing function is concerned, fifteen of 16 patients could swallow without aspiration problem.

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Recently, we devised a novel method for simultaneous reconstruction of neopharyngoesophagus and phonation following laryngopharygoesophagectomy. In this method, the harvested jejunum is divided into two segments (i.e., one segment for neopharyngoesophagus, and the other for tracheo-neoesophageal shunt). This shunt was called “Elephant trunk shunt (ETS)” because the shape resembles the trunk of an elephant. This paper reviewed our experiences of this method. In several cases, permanent tracheostoma had been in trouble with cutaneous contracture or collapse of jejunal mucosa, which can be solved by further refinement of the procedure. Using a lineal stapler for producing the “elephant trunk” simplified the operative procedure, inducing shorter operating time.

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A surgical technique for creating a phonatory shunt after pharyngolaryngoesophagectomy using a free ileocolic graft (tracheoileocecal shunt: TIC shunt) was reported. Between 1989 and 1998, a total of fifteen patients underwent TIC shunt operation. Five of these patients were able to produce excellent voices, seven had moderate and one had poor voice. Major postoperative complications included one graft necrosis, one anastomotic leakage and one kinking of the vein.
Good functional results are obtained by the TIC shunt operation in laryngectomized patients.

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The importance of preserving intact mandibular continuity in postoperative oral function is well recognized, although numerous advances in mandibular reconstruction and dental implant have been made.
The extent of resection of the mandibular bone is determined depending upon the clinicopathologic assessment of the tumor, such as the site, size and histologic type of the primary tumor, extent and pattern of mandibular invasion, and associated soft tissue involvement. For assessment of mandibular invasion, conventional radiography (dental, occulusal and panorex views), CT, MRI, and ²⁰¹T1-^99mTc dual SPELT are the preferred adjunctive diagnostic methods. ²⁰¹T1-^99mTc dual SPELT provides more specific information about early invasion of the mandible.
Patients with central cancer of the mandible can usually be treated by segmental mandibulectomy or hemimandibulectomy. Patients with tumor abutting on the mandible without apparent bony invasion may be treated by marginal resection. Patients with tumor radiographically showing erosive type of mandibular resorption may be treated by marginal mandibulectomy, and patients with tumor showing invasive type of bony resorption by segmental mandibulectomy or hemimandibulectomy. Patients who have had previous radiotherapy may be treated by segmental mandibulectomy or hemimandibulectomy.
In marginal resection, the periosteum all around the resected mandible is included in the surgical specimen, and “mandibular swing” approach is combined for lesions involving posterior oral cavity.
Intraoperative frozen section analysis of the deep soft tissue margins of resection is done, and cytological control of the margins of the mandible is also obtained to secure the safety.

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Seventy-nine patients with oral and oropharyngeal cancer who underwent mandibular resection from 1974 through 1997 were studied. Primary sites of disease were lower gingiva in 43 cases, floor of the mouth in 25 cases, buccal mucosa in 6 cases and oropharynx in 5 cases. Five-year cumulative survival rates were 41%, 50%, 33%, 0%, respectively. Methods of mandibular resection of these patients were as follows: segmental resection in 43, marginal resection in 24, and hemimandibulectomy or subtotal mandibulectomy in 12. Five-year cumulative survival rates were 53%, 50%, 0%, respectively. There were 25 patients who had recurrence at the primary site, but only five patients were strongly suspected of recurrence at the surgical margin of the bone. It was suggested that wider resection of soft tissue is necessary. On the other hand, marginal resection of the mandibule could be adopted to more patients because there was no recurrence in the bone after marginal resection. Since 1990, reconstruction of the mandibule has been performed using vascularized bone graft in 10 cases with segmental resection and one with marginal resection, obtaining good results. However postoperative masticatory function remained unsatisfactory, and so improvement there of is necessary.

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The use of distraction osteogenesis has gained widespread orthopedic acceptance. This method has recently been applied to craniof acial deformities such as hemifacial microsomia and micrognathia. On the other hand, vascularized bone grafts for mandiblar reconstruction were performed after tumor resection on the patients with oral tumors. However, it is difficult to improve a masticatory function in the cases with severe contracture of intraoral space after surgery, or resection of mandibular condyle. For these cases, distraction osteogenesis and/or transport distraction osteogenesis, a technique used to reconstruct missing bone and soft tissues in segmental deformities, is used. Furthermore, in order to accommodate dentures, alveolar bone augmentation are performed using internal distraction appliance.
In this paper, the procedures of distraction osteogenesis for cases with mandibular bone defects after tumor resection on the patients with oral tumors are reported.

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The new stage classification, which appeared in the fifth edition of the UICC TNM Classification of Malignant Tumours for nasopharyngeal carcinoma (NPC), was evaluated. The new classification was applied retrospectively to 69 patients with nasopharyngeal squamous cell carcinoma treated at the Keio University Hospital in 1980-1996. The results were also compared with those obtained by the former classification for NPC in the fourth edition of the TNM Classification of Malignant Tumours. In the stage grouping, the new classification classified 13.0% of patients in stage I, 36.2% stage II, 23.2% stage III and 27.5% stage IV. The new classification separated the patients more equally than the former classification, which classified 68.1% of patients in stage IV. Down staging was observed in 45 cases. With the new classification, the 5-year overall survival rates for stage I, II, III and IV were 87.5%, 77.8%, 50.0% and 47.4% respectively. Significant differences were observed among these stages (p<0.01). The new classification seemed to be more prognostically useful than the former classification to treat NPC patients appropriately.

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The record of 59 patients with poorly-differentiated squamous cell carcinoma of the nasopharynx who were treated with radiation therapy between 1980 and 1998 were retrospectively analyzed to clarify whether 1997 UICC classification may be reasonable for suggesting the treatment outcome compared with 1987 UICC classification. Since X-CT and/or MRI were indispensable to classification of the tumor extent according to the 1997 classification, the tumors which were treated before clinical induction of these diagnostic imagings cannot be reclassified into a new stage. The number of patients who classified into the new Stage IV decreased because patients with stage IV tumor according to the 1987 classification were divided into 5 new stages; stage II b, III, IVa, IVb and IVc. Nevertheless many patients with curable tumors were classified into new stage IV. Tumor volume in lymph node was a more important prognostic factor than level of cervical lymph node metastasis. It was necessary to make a new TNM classification for nasopharyngeal cancer in due consideration of histological types and/or histological grading, because the first choice of treatment for nasopharyngeal cancer was radiation therapy and tumors which are different in natural history and radiosensitivity can appear at the nasopharynx.

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From January 1988 to September 1995, 29 patients with nasopharyngeal carcinomas were examined with MR imaging and CT before and after radiotherapy. In our series, 66% of the patients (19 of 29) were classified as stage T4 when MR imaging as well as CT was used in T staging based on the fourth edition of the UICC stage classified system. In the fourth edition, only one of 7 patients with T1-T3 disease had local recurrence, while 5 of 18 patients with T4 tumors recurred locally. In the fifth-edition system, only one of 7 patients with T1-T2 disease had local recurrence, while 5 of 18 patients with T3-T4 tumors recurred locally. However, the local control rate was similar between T3 and T4 tumors.
In the fifth edition, T2 is divided into T2a and T2b according to the presence of infiltration of tumor beyond the pharyngobasilar fascia. All 7 patients without invasion of the pharyngobasilar fascia had local control. However, it was impossible to detect obliteration of the pharyngobasilar fascia with CT, meaning that MRI is indispensable for classifying the stage based on the fifth edition. It was also difficult to identify invasion of the sinus of Morgagni with CT, but MR imaging identified it much more clearly. MR imaging was also better than CT at detecting invasion of the posterior, posterolateral, and superolateral part of the skull base.
According to the fourth edition, 6 of 15 patients with N2c or N3 disease had distant metastases, while only 1 of 9 patients with N1-2b disease did. Based on the fifth edition, 4 of 5 patients with N3 disease had distant metastases. The fifth edition incorporated deep invasion of tumors investigated with CT and MR imagings into its Tstage classification and is more rational than the fourth edition. It expected to be a better prognostic factors.

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In the fifth edition of the TNM classification T3 category of hypopharyngeal cancer has cha nged.
The tumor that measures more than 4cm in greatest dimension, or with fixation of the hemlilarynx has been classified as T3. T2 that measured more than 4cm in the fourth edition has been changed to T3 in the fifth edition.
The purpose of this study was to assess whether there is a difference of local progress of disease between T3 with laryngeal fixation (T3-LF) and T3 that measures more than 4cm in greatest dimension (T3-GD)
Eighty-nine patients with hypopharyngeal cancer who underwent surgery between 1982 and 1998 were examined retrospectively to select T3-GD from operative specimens and compare the difference between T3-LF and T3-GD. Among 89 patients, there were 31 cases of T3-LF and 22 cases of T3-GD. In 31 cases of T3-LF, there were 22 pirformis sinus cancer (PSC) and 9 postcricoid cancers (PCC). The average age was 63 years. There were 27 males and 4 females. In 22 cases of T3-GD, there were 8 PSC and 14 PCC. The average age was 58 years. There were 12 males and 10 females. In the former group, PSC was dominant and in the latter one PCC was dominant. 5-year cumulative survival rates of T3-LF and T3-GD were 30.4% and 50.4% respectively. T3-GD tended toward longer survival compared with T3-LF, but there was no statistical difference between them. It is not irrational to add T3-GD to T3-LF in the T3 classification of hypopharyngeal cancer.

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The fifth edition of the TNM classification contains some changes of the T category and stage IV grouping concerning hypopharyngeal carcinoma.
In a retrospective study, the clinical courses of 94 patients with carcinoma of the hypopharynx were comparatively evaluated according to the fourth and fifth editions of the TNM classification by UICC.
In reclassifying the primary tumor, 18 cases (19%) were assigned to the new T category. Consequently, 5 cases (5%) had a change in assigned clinical stage.
Despite the change in the T classification, application of the new T category to the stage gouping led to minor changes in the distribution within Stages I-III and these tumors could be assigned to Stage IV in most cases (Stage IVA, 58%; Stage IVB, 10%).
On the basis of the fourth edition of the TNM classification, the following overall 5-year survial rates for 84 operated cases were calculated: Stage II, 63%; Stage III, 78%; and Stage IV, 42%.
The calculations based on the fifth edition yielded the following: Stage II, 75%; Stage III, 68%; Stage IVA, 47%; and Stage IVB, 23%.
At the time of diagnosis, the majority of the patients with carcinoma of the hypopharynx will be assigned to Stage IV.
Although the distribution within the three substages of Stage IV was not homogenous, the prognostic relevance was shown in the survival rates.
In conclusion, it can be said that the prognostic relevance of the revised stage grouping for carcinoma of the hypophaynx could be corroborated by 84 documented cases.

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T classification of gingival carcinomas includes the controversial point in T4 criteria. Carcinomas originating in the mucous membrane and invading neighboring tissues can be regarded as T4. Alveolus and gingiva compose a special structure such as bone lines oral mucous membrane just several millimeters below the mucosal surface. Thus some interpretations for T4 criteria are possible in gingival cancer. This paper reports the result of a comparative study on the validity of UICC criteria, Japan Society for Head and Neck Cancer (JSHNC) criteria, level of mandibular canal (LMC) criteria, sinus and nasal floor (SNF) criteria in T classification of gingival cancer. A total of 1187 cases of lower gingival cancers collected in Japan Society for Oral Tumors from 24 clinical centers and 37 cases of upper gingival cancers and hard palate cancers from a single clinical center was analyzed. Data were analyzed with reference to distribution of T-goups, survival rate, multivariate analysis and treatment choice. T classification by UICC criteria did not make sense showing high distribution in T4. JSHNC criteria showed an incomplete revision in T distribution and survival rate. LMC criteria and SNF criteria made great revision. Result of factor analysis by multivariate analysis showed that high coefficient of determination was observed in bone invasion level, tumor size and deep soft tissue invasion of the primary site. Multivariate analysis by mathematical quantification method II revealed that LMC criteria had good factor loading toward T size and well reflects the basic concept of UICC criteria signifying that T-groups are determined by surface tumor size. Analysis of bone invasion mode and bone invasion level in lower gingival carcinomas also showed LMC criteria can offer an adequate guide for treatment choice in mandibular bone surgery. The present several analyses can be summarized by the fact that LMC criteria is the most proper in lower gingival cancer and SMF criteria in upper gingival cancer and hard palate cancer for T classification.

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The TNM classification (UICC) of salivary gland cancer was revised in 1977. In this study, the validity of this new TNM classification and clinical staging was evaluated. Reclassification was conducted according to the new classification based on the clinical data of a total of 1683 patients registered by the Salivary Gland Division of Japan TNM Classification Committee. The 5-and 10-year survival rates according to TNM class were calculated in 1074 patients whose prognosis could be followed up. Finally, the distribution of the total patient population was analyzed using the new staging and the survival curves for each disease stage.
The variance of the patients for T1 to T4 was appropriate using the new T classification. The 5-and 10-year survival rates corresponded well to the degree of progression of T and N. However, there were only 9 patients in stage 3 and marked non-uniformity in the staging was observed. The separation of the survival curves for each stage was poor, and no significant differences between the survival curves of stages 2 and 3 and stages 3 and 4 were observed.
In conclusion, the results of the present study confirm that the new TNM classification system is valid. However, a significant problem was observed with respect to the new clinical staging.

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There was a total of 300 cases of head and neck reconstruction during the last 10 years. Reconstruction was performed by 241 free microneurovascular tissue transfers and 40 island flaps. Free tissue transfers were composed of 77 anterolateral thigh flaps or tensor fascia lata musculocutaneous flaps, 48 abdominal flaps including deep inferior epigastric perforator flaps (DIEP flap), 19 radial forearm flaps, 15 connected tensor fascia lata MC flap-anterolateral thigh flaps, 13 latissimus dorsi MC flaps, and 12 groin flaps. In addition, 29 vascularized iliac bone grafts, 11 vascularized fibula grafts, 23 nerve grafts, and 12 rectus femoris muscle flaps were used with combined to anterolateral thigh flap or tensor fascia lata MC flap.

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In this article, plastic and reconstructive surgical methods developed for obtaining improved functional and aesthetic results in head and neck reconstruction are described. 1) Maxillary reconstruction: Role of buttress reconstruction in zygomaticomaxillary skeletal defects with the vascularized costal cartilages, scapula bone, and/or rib was recognized to be very important. 2) Tongue reconstruction: Satisfactory results were achieved for dynamic reconstruction of the tongue and deglutition muscles using the rectus abdominis myocutaneous flap with motor nerve coaptation following subtotal glossectomy. 3) Superior mediastinal reconstruction: An adequate combination of reconstructive techniques including digestive tract restoration, creation of superior mediastinal tracheostoma, wrapping the major vessels, and obliteration of dead spaces provided good results in superior mediastinal reconstruction.

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The omental flap is useful for reconstructive surgery. It is used extensively to cover difficult, infected wounds or complex cavities. A composite stomach-omental flap was used for reconstruction of head and neck.
The composite full-thickness gastric wall and omental flap was used in 2 cases. One was reconstruction of the buccal mucosa, and the other was reconstruction of the oral base. In the case of reconstruction of the oral base, the flap was used as a bridge flap, that is, the distal end of the right gastroepiploic vessels was anastomosed to the vessels of the free fibula flap. The composite gastric seromuscular patch and omental flap was used in 2 cases. One was a case of cerebrospinal fluid leakage, and the other was that of defect of the orbit.
The composite stomach-omental flap is useful for the reconstruction of head and neck not only because it has a long pedicle of vessels but also because it can provide an immediate airtight or watertight seal. Furthermore, it is useful for the reconstruction of difficult and complex defects because it can be used as a bridge flap.

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Although an antimesenteric incision can be used to conform the diameter of the oral end of a jejunal graft to that of a pharyngeal defect, technical problems and swallowing problems may arise after end-to-side pharyngojejunal anastomosis. The high vascularity of jejunal grafts after longitudinal paramnesenteric incisions was investigated, and a simple operative procedure for correcting large pharyngeal defects with free jejunal grafts was developed.
The shape of the pharyngeal defects was classified as oblique or horizontal. For reconstruction of oblique defects, a longitudinal incision is made at the corner of the side opposite the highest point of the defect. Defects of the hypopharynx can be reconstructed with end-to-eod anastomosis of a free jejunal graft regardless of the location of the most extensive point of the defect or of the recipient vessels. For reconstruction of horizontal defects, a longitudinal incision is made at the anterior part of the transferred jejunum.
Incisions 2 to 8cm long have successfully been used to transfer 54 free jejunal grafts whose diameters were less than those of the pharyngeal defects. Oblique defects (26 cases) included extensive defects that reached the level of torus of the auditory tube, and horizontal defects (28 cases) included extremely wide defects after total glossectomy with laryngectomy. Transfer was successful with end-to-end pharyngojejunal anastomosis in all patients, despite minor postoperative leakage in 5 patients (9.2%).
This method allows defects of the lower pharyngeal space to be reconstructed with end-to-end anastomosis of free jejunal grafts regardless of the location of the defect or of the recipient vessels. This method is simpler and more effective than other methods and has few postoperative complications.

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Recontruction of cranio-maxillo-facial region such as maxilla and mandible restores both form and masticating function as primary surgical objectives. this includes support for the orbital floor, anterior contour projection, separation of oral and nasal cavities, obliteration of dead space from the maxillary and/or ethmoid sinuses, and support for maxillary and mandibular denture or dental implants. The separated osteocutaneous scapular flap preserving the angular branch includes the ability to design multiple skin paddles (scapular, para-scapular, and ascending scapular flap) and two separated bone flaps (the lateral border and tip of the scapula) allowing improvement in three-dimensional spatial relationships for maxillary reconstruction. In addition, the scapular osteocutaneous free flap can be combined with such other flaps as the latissimus dorsi flap and the serratus anterior flap because the vascular supplies of these flaps also originate from the subscapular vessels.
The essential elements of the maxillectomy defect are the body components of the hard plate, the anterior alveolar ridge, the anterior maxillary wall, and the medial nasal wall. Extending the defect into the orbit also entails loss of orbital rim, orbital floor, and medial nasal wall, and, occasionaly, the skin of the anterior cheek.
We have performed maxillary reconstruction using the separated osteocutaneous scapular flap preserving the angular branch and the combined flaps with subscapular vessels. That is to say specifically, we use the lateral border of the scapula supplied by the periosteal branches of the circumflex scapular artery for reconstruction of the zygomatic body and anterior maxillary wall, and so the tip of the scapula supplied by the angular branch for reconstruction of the orbital rim and floor. The scapular or para-scapular flaps are used for reconstruction of the medial nasal wall or hard palate.
For mandibular reconstructions intraoral lining as well as external tissues, the scapular osteocutaneous flap is preferred. Especially, for the anterior mandibular defects, the reconstruction requires two greenstick breaks in the lateral border of scapular bone bi-pedicled with the periosteal branches of the circumflex scapular artery and the angular branch.
The authors report the operation method of both maxillary and mandibular reconstruction and show the good results.

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Maxillary reconstruction was performed by the hemifacial dismasking method and the free rectus abdominis myocutaneous flap with vascularized costal cartilages, during the extended total maxillectomy. This degloving technique is useful not only for cosmetic appearance but also for infection because of no incision of the midfacial skin. This method enables reconstruction of the natural appearance in the orbito-zygomatic region.

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Major problems of pectoral major myocutaneous flap are unstable vascularization and limited range of advancement. These point were improved and the usefulness and indication of this modified flap in head and neck reconstruction were discussed. The skin island contained the perforator of an anterior intercostal branch of the internal thoracic artery which is located in the 4th intercostal space and approximately 2cm inside the areola, and the skin island was collected from the area not exceeding the inferior margin of pectoral major muscle at the 7th rib. As a result, the frequency of partial necrosis of this flap decreased to 6% (4/71 cases). In addition, the pedicle was produced by only a blood vessel and the flap was advanced through the subclavian route. This resulted in the extension of the reaching point by approximately 8cm from that of Ariyan's original method. Therefore, this flap was evaluated to be applicable to surgery reaching to the infraorbital margin, superior part of the auricle, middle cranial base, and nasopharynx.

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