Head and Neck Surgery and Technology: Perfect Together

Blake Norton is eternally grateful to his dentist for detecting the throat cancer that ultimatelybecame quite serious. “That was in 2003,” says the 71-year-old sound engineer, who won hisfirst of many Emmy Awards for technical work on the beloved children’s show “Sesame Street.”

Initially he was treated by a community otolaryngologist near his home in Bloomingdale, NJ. But the lesions kept returning. “My doctor said he was sending me to his ‘guru’ — a super-specialist in Newark— for more advanced care,” says Norton.

That would be Soly Baredes, MD, professor and chair of the Department of Otolaryngology-Head and Neck Surgery at Rutgers New Jersey Medical School (NJMS). The department specializes in the treatment of cancers and other disorders of the ear, nose, mouth, throat, neck, face and voice.

Self-effacing and quiet, Baredes is nonetheless a visionary. He’s assembled a ‘dream team’ of specialists who go beyond general otolargynology to offer the latest interventions, including surgical oncology, skull base cancer surgery, otology/neurotology, pediatric otolaryngology, transoral robotic surgery via the da Vinci system, and microvascular reconstructive surgery. The practice is known throughout New Jersey and beyond as the state’s major destination for tertiary (superspecialty) clinical care.

Technology defines the future of surgery. Next-generation tools allow surgeons to perform complicated procedures in hard-to-reach areas that previously could be accessed only through open surgery. New tools—robots, lasers, endoscopes, minuscule cameras, 3D printers, and more—widen the boundaries for minimally invasive surgery and reconstruction.

The technology lends itself particularly well to head and neck surgery, which poses unique challenges. In addition to correcting a

defect or removing a lesion, a primary concern is preserving the ability to breathe, speak, and eat. The patient’s appearance must also be considered. How do you recreate a face that’s been ravaged by trauma or a malignancy that required the removal of part of the jaw? Surgeons do this and more with the help of amazing new tools and techniques.

“There’s so much to learn. I’ve had a whole education since my training,” Baredes says only half-kiddingly. “The main advantage to this technology is the option of operating minimally invasively, through the oral cavity. We avoid splitting the jawbone and that’s much easier on patients. Procedures can be performed more precisely, safely, quickly, and with less pain, resulting in better outcomes.”

He adds a caveat: “As great as these tools are, they can’t be used on all patients all the time. Many tumors require more radical techniques. So we look for the right situations, tailoring the approach to each individual.”

Blake Norton fit the criteria perfectly. For several years Baredes had treated him for recurrent small tumors. But in 2013, the cancer became worse. “I felt a lump in my throat, which I never had before,” notes Norton, who admits he was once a smoker. Some 62,000 people are diagnosed with head and neck cancer each year in the U.S.

Norton had aggressive growths in the base of the tongue and the cancer had spread to his lymph nodes. “He needed extensive surgery. Fortunately we were able to do much of it robotically,” explains Baredes. “Before the robot these tumors would have required cutting through his jaw.”

Norton is Baredes’ only patient to undergo two separate robotic procedures for two separate tumors, both at University Hospital. The first was in May 2013, when a large lesion on the tongue was removed. In a second procedure in October, another tumor was removed from the tongue robotically and a selective neck resection was performed—open surgery to remove malignant nodes. He had chemotherapy and radiation.

While recovery was difficult, Norton feels and looks great and has no loss of function. Now semi-retired, he works as a sound engineer on the Metropolitan Opera’s live-to-theater broadcasts. It’s a rigorous schedule, particularly for someone who’s survived cancer. A selfconfessed ‘techie,’ he’s thankful he could benefit from robotic surgery— so thankful that he had T-shirts made for himself and Baredes that say “da Vinci Groupie.”

Surgical resection of head and neck cancer can result in significant disfigurement. Advances in microvascular reconstruction, however, have ushered in a new era for reconstruction. Using tiny tools and microscopes, surgeons “rebuild” parts of the body by transferring bone, and tissue and blood vessels—called flaps—from one area to another. While microvascular reconstruction has been done for many years, the

newest techniques use evolutionary, three-dimensional (3D) modeling to precisely map the surgery.

In visionary mode, Baredes added this new dimension to his team, bringing Richard Chan Woo Park, MD, on board in 2013. Park, an assistant professor, specializes in head and neck microvascular reconstruction. As an added bonus, he’s become adept at using 3D modeling to plan facial reconstructions. Park is the only otolaryngologytrained surgeon in New Jersey combining these techniques to do transformative work.

“Previously people with head and neck cancers were left with holes or defects — missing bone, tissue, tongue or throat,” says Park, who’s also fellowship-trained in head and neck oncology and surgery. “I wanted to be a one-stop shop where I could not only remove tumors but also fix the defect.” A crucial step in this type of reconstruction is connecting the free flap artery and vein to the neck. “Think of free flap microvascular surgery as an organ transplant,” adds Park. “However, instead of transplanting someone else’s liver or kidney we’re transplanting a patient’s own bone from the leg to the jaw.”

In June 2016 Baredes and Park teamed up to treat Wendy Hoffman, who’d had several recurrences of cancer of the tongue. The cancer had

invaded her mandible, the bone in her jaw. In a complex procedure, Baredes removed the cancerous section of the mandible and a large section of her tongue. Park reconstructed the mandible using bone from her lower leg, and even used a section of skin to recreate part of the tongue.

Park explains how 3D modeling is used to plan the surgery. First he gets CT scans of the face and leg and uploads them. He shares the scans with a team at 3D Systems Healthcare, a company specializing in 3D printing, and they meet online to virtually plan the procedure. “The CT scans are used to prepare a detailed plan, like a map,” Park says. “Customized cutting guides show us exactly where to make the cuts both in the fibula and jaw. They’re like cookie cutters.”

The company even provides a custom, pre-bent titanium plate to which the fibula is attached. “In the old days you had to bend this by hand,” says Park. “It took a lot of trial and error to try and get it right. This saves time and ensures a good cosmetic and functional outcome.”

Now a few months post-surgery, Hoffman is finishing radiation. Her appearance is good and she’s able to swallow and speak well, says Park. She will return to the hospital for dental implants.

Another patient who’s happy to share his story is Samuel Nyamwange. This Kenyan émigré was working in a Newark parking garage in February 2015 when he was shot in the face during a robbery. The bullet entered his right cheek, shattering his teeth and the right side of his cheekbone and hard palate (the roof of the mouth). He had an opening between the nasal and oral cavities and was unable to speak or eat.

Nyamwange was lucky to be brought to a place with the technology and surgical expertise to put him back together. Again, Park planned the surgery with virtual 3D modeling. In an eight-hour procedure he reconstructed the hard palate using a section of the fibula bone from Nyamwange’s right leg. With the help of Shahid Aziz, DMD, MD, associate professor of surgery at NJMS and professor of oral surgery at Rutgers School of Dental Medicine, they were able to position dental implants during the same operation. It was a true, one-stop shop, resulting in one delighted patient.

“The procedure went flawlessly,” says Park. “This advance planning pays off. Post surgery he’s doing well, he looks great and he can chew and swallow without issues. It’s very rewarding to be able to help patients in this way.” ●