Long-term experiences by using modified facial degloving technique / A módosított "facial degloving" technikával szerzett hosszú távú tapasztalataink.

Összefoglaló. Bevezetés: Az orrmelléküreg-daganatok kezelésében a legfrissebb nemzetközi ajánlások alapján továbbra is a sebészi reszekció az elsodlegesen választandó módszer. Bár az endoszkópos technikák fejlodésével a külso feltárással járó mutétek bizonyos esetekben háttérbe szorultak, napjainkban még mindig a Weber-Fergusson-féle metszést tartják a legszélesebb feltárást biztosító technikának, annak ellenére is, hogy a módszer stigmatizáló hegeket és deformitásokat hagy a páciensek arcán. Módszer: A "facial degloving" eljárást mint alternatív, hegmentes technikát eloször az 1970-es években publikálták, azóta számos módosítását írták le. A szerzok az orrmelléküregi tumorok eltávolítására már 8 éve kizárólag az általuk módosított technikát alkalmazzák. 2012 és 2019 között Klinikánkon 34 beteg esett át a módosított "facial degloving" mutéten. A módszer alapja egy felso szájpitvari behatolásból a középarc területén kialakított oszteoplasztikus lebeny, melynek felemelésével széles rálátás nyílik az orrüregre és melléküregeire, valamint az elülso koponyaalapra is. A mutéti terület a daganat eltávolítását követoen jó kozmetikai eredménnyel rekonstruálható. Eredmények: A szerzok akusztikus rinometriai vizsgálatokkal és az arckifejezéseket ábrázoló posztoperatív képi dokumentációval támasztották alá eredményeiket. Az operált oldalon sem az orrbemenet beszukülését (orrlégzés gátoltsága), sem pedig az arcmozgás zavarait, az arc aszimmetriáját nem észlelték. Betegeik túlélését Kaplan-Meier-görbén ábrázolták. Megbeszélés, következtetés: Habár az eredeti "facial degloving" technikának számos módosítását publikálták, az itt bemutatott módszer (oszteoplasztikus lebeny, melyben a középarc lágy részeinek integritása megtartott) rövidebb hospitalizációs idot és kevesebb komplikációt eredményezett. A bemutatott módosított "facial degloving" technika véleményünk szerint megfelelo és biztonságos sebészi reszekciót biztosít orrmelléküregi rosszindulatú daganatok esetén, továbbá kombinálható endoszkópos technikákkal, és szükség esetén nyitott mutétté alakítható, akár orbitalis kiterjesztéssel. Orv Hetil. 2021; 162(10): 392-398. INTRODUCTION: The widely used external approach (Weber-Fergusson's incision) for the removal of maxillo-ethmoidal tumors leaves stigmatizing scars and deformities on the patient's face. As an alternative technique, the scarless facial degloving approach was first described in the 1970's, and since then, several modifications have been developed. METHOD: We have been using our modified facial degloving technique for eight years now with maxillo-ethmoidal tumors. Between 2012 and 2019, 34 consecutive patients have been operated with our modified facial degloving approach at the Department of Oto-Rhino-Laryngology and Head-Neck Surgery, University of Szeged, Hungary. We describe our method which provides a wide surgical approach via an osteoplastic flap for the whole nasal and paranasal region, with good cosmetic results. RESULTS AND CONCLUSION: We have evaluated our results with acoustic rhinometry and photo-documentation of the facial mimic postoperatively. Neither narrowing of the nasal cavity on the operated side (loss of nasal breathing function), nor facial movement dysfunction was visible in our patients. We represent our patients' survival in Kaplan-Meier curve. Although several modifications of the original facial degloving approach have been published, in our technique, the novel osteoplastic flap and the intact soft tissue of the nasal and midfacial region results in shorter hospitalization time and fewer complications. Our modified facial degloving technique offers proper and safe surgical resection for tumors of the maxillo-ethmoid region. It can be routinely combined with endoscopic techniques, and, if necessary, can be converted to an open approach. Orv Hetil. 2021; 162(10): 392-398.

Esthetically Favorable Surgical Alternative for the Removal of Sinonasal Malignant Tumors-The Modified Facial Degloving Technique.

PURPOSE: The widely used external approach (Weber-Fergusson incision) for the removal of maxillary ethmoid tumors leaves stigmatizing scars and deformities on the patient's face. As an alternative technique, the scarless facial degloving approach was first described in the 1970s; since then, several modifications have been developed. PATIENTS AND METHODS: The authors have been using a modified facial degloving technique for 7 years to remove maxillary ethmoid tumors. This article is a retrospective methodologic review. The inclusion criteria for this retrospective study were patients who underwent the modified facial degloving technique for management of malignant maxillary ethmoid tumors. The exclusion criteria were patients who did not undergo a surgical procedure (who received primary chemoradiation therapy) and patients who underwent an endoscopic surgical procedure for an early-stage localized tumor. The authors describe their method, which provides for a wide surgical approach using an osteoplastic flap for the entire nasal and paranasal region, with good cosmetic results. They present the adaptability of their method for 3 malignant maxillary ethmoid tumors in different locations. RESULTS: From 2012 through 2016, 23 consecutive patients underwent surgery with the modified facial degloving approach at the Department of Otorhinolaryngology, Head and Neck Surgery at the University of Szeged (Szeged, Hungary). The authors evaluated their results with acoustic rhinometry and photographic documentation of postoperative facial expressions. Neither narrowing of the nasal cavity on the operated side (loss of nasal breathing function) nor facial movement dysfunction was visible in these patients. CONCLUSION: Although several modifications of the original facial degloving approach have been published, in the present technique, the novel osteoplastic flap and the intact soft tissue of the nasal and midfacial region result in shorter hospitalization time and fewer complications. No functional or esthetic distortion was visible. No severe complications were observed; the patients' only complaint was the dryness of the nasal mucosa and temporary crusting of the nose. The present modified facial degloving technique offers proper and safe surgical resection for tumors of the maxillary ethmoid region. It can be routinely combined with endoscopic techniques and, if necessary, can be converted to an open approach.

Secondary correction of nasal deformities in cleft lip and palate patients: surgical technique and outcome evaluation.

BACKGROUND: Nasal deformity associated with cleft lip and palate is a highly challenging reconstructive problem in rhinoplasty. In the literature, several operative solutions and evaluation methods have been described, however these do not offer a standard procedure for the surgeon. Our aim was to standardize our surgical technique-as much as the uniqueness of each case allowed it-based on the most frequent deformities we had faced; and to evaluate our results via a postoperative patient satisfaction questionnaire. Between 2012 and 2014 12 consecutive patients with combined cleft lip and palate deformities underwent secondary nasal and septal correction surgery with the same method by the same surgeon. The indications of surgery were, on one hand, difficult nasal breathing and altered nasal function (tendency for chronic rhinosinusitis) and on the other hand the aesthetic look of the nose. No exclusion criteria were stated. In our follow-up study we evaluated our results by using a modified Rhinoplasty Outcome Evaluation (ROE) questionnaire: patients answered the same four questions pre- and postoperatively. Data were statistically analyzed by t-test. RESULTS: Based on the questionnaire, all patients experienced improvement of nasal breathing function, improved appearance of the nose and less stigmatization from the society. According to the t-test, all scores of the four questions improved significantly in the postoperative 4-6 months, compared with the preoperative scores. CONCLUSIONS: In our opinion with our standardized surgical steps satisfactory aesthetic and functional results can be achieved. We think the modified ROE questionnaire is an adequate and simple method for the evaluation of our surgical results.

Epicutaneous patch test--a new diagnostic option to prevent the rejection of silicone-covered cochlear implants in children.

OBJECTIVES: Cochlear implantation (CI) is a revolutionary method for hearing rehabilitation in patients with severe or profound sensorineural hearing loss. One of the surgical complications may be the necrosis of the skin flap above the receiver-stimulator coil, resulting in device extrusion. Our aim was to find the plausible causes of the silicone covered implant rejection. PATIENTS AND METHODS: Authors present four cases of cochlear implant rejection, briefly describe their dermato-surgical solutions and analyse their innovative method - the epicutanoeus patch testing with silicone samples. RESULTS: They observed positive skin reaction in three of the four cases. CONCLUSION: Authors analyse the applicability and results of their surgical solutions and the epicutaneous testing in connection with the prevention of skin flap necrosis and rejection of silicone-covered cochlear implants.

Extended lower trapezius myocutaneous flap to cover a deep lateral neck defect on irradiated skin: a new application.

Defects of the skin and underlying soft tissue of the neck are uncommon, and the surgeon's main objective is to achieve reliable long-term coverage of the exposed vital organs with well-vascularised tissue harvested from a distant donor site. We present a patient whose extended irradiation site together with the previous unsuccessful attempt to cover it with a latissimus dorsi myocutaneous flap, needed an extended lower trapezius myocutaneous flap, which seemed to be the only way in which to close the large and deep cervical defect.

Peroral endoscopic removal: as a minimally invasive long-term surgical treatment of a regurgitated giant polisegmented fibrovascular polyp of the esophagus.

Giant fibrovascular polyps (FVP) are relatively rare benign neoplasm of the upper part of the esophagus. Without previous history, their diagnosis might be difficult as the endoscopic findings are sometimes misinterpreted. The present report describes a case, in which the patient regurgitated his giant polypoid mass into his mouth and captured it between his teeth and buccal surface until the emergency endoscopic removal. Although the adequate therapy for these lesions is mainly the open surgical resection, most often via cervical esophagotomy, in our case the polyp was removed successfully by peroral endoscopic operation, as a minimally invasive surgical treatment. After 5 years of follow-up, the patient is doing well, without recurrence of his polyp.

Minimally invasive peroral endoscopic removal of a regurgitated giant polysegmented fibrovascular polyp of the esophagus.

Giant fibrovascular polyps (FVP) are relatively rare benign neoplasms of the upper part of the esophagus. Without a previous history, their diagnosis might be difficult because the endoscopic findings are sometimes misinterpreted. The present report describes a case in which the patient regurgitated a giant polypoid mass into his mouth and captured it between his teeth and buccal surface until emergency endoscopic removal. Although the adequate therapy for these lesions is open surgical resection, most often via cervical esophagotomy, in our case the polyp was removed successfully by peroral endoscopy with minimally invasive surgery. After 5 years of follow-up the patient is doing well, without recurrence.

Cholesterol granuloma of the maxillary sinus resembling an invasive, destructive tumor.

The case of a maxillary sinus cholesterol granuloma posing as a malignant tumor is presented. The patient was referred to the authors' clinic with symptoms typical of maxillary sinusitis, but physical examination suggested the presence of neoplasm. Radiology also resulted in confusing, tumor-like pictures. Histological examination of a preoperative tissue sample identified the process as a cholesterol granuloma, which was removed by a classic Caldwell-Luc operation. The patient has been symptom free since the operation. The pathogenesis of cholesterol granuloma is described, and the problems of establishing a diagnosis without preoperative histology are discussed.

ALA (5-aminolevulinic acid)-induced protoporphyrin IX fluorescence in the endoscopic diagnostic and control of pharyngo-laryngeal cancer.

Photodynamic diagnosis is a modern method for the fluorescence imaging of superficial pharyngeal and laryngeal tumours. 5-aminolevulinic acid (ALA)-induced protoporphyrin IX fluorescence benefits the tumour selective accumulation of protoporphyrin; therefore, tumours can be differentiated from healthy tissue. ALA-induced fluorescence of laryngo-pharyngeal tumours and precancerous and benign lesions were evaluated by endoscopy. At the Department of Otorhinolaryngology, Head and Neck Surgery, Szeged, Hungary, 31 patients underwent ALA-induced protoporphyrin fluorescence imaging. After topical application of ALA, mesopharyngeal tumours were visualised by direct fluorescence endoscopy. Laryngeal and hypopharyngeal tumours were examined with a laryngomicroscope with the patients under general anaesthesia after inhalation of an ALA solution. Intensity of PPIX fluorescence was classified and compared with pathological findings. The examination of all 13 laryngeal and 12 pharyngeal tumours resulted in a middle or strong intensity of red fluorescence, but for one cancer, four precancerous and two benign lesions. Healthy tissues showed green autofluorescence. Margins of mesopharyngeal and vocal cord tumours were clearly outlined under fluorescent vision, giving a helpful contribution to diagnosis and therapy even in clinically non-visible tumours. Laryngomicroscopy combined with laser surgery also indicated PPIX fluorescence examination visualising margins of the tumour intermediately with the endoscope. The ALA-induced PPIX fluorescence imaging method revealed a sensitivity of 96%. This method is applicable for detecting early superficial tumours, margins of tumours and follow-up after surgery/radiation therapy in the laryngo-pharynx.