Vertical PAP Flap: Simultaneous Longitudinal Profunda Artery Perforator Flaps for Bilateral Breast Reconstructions.

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Melkersson-Rosenthal syndrome: a facial nerve center perspective.

OBJECTIVES: Melkersson-Rosenthal syndrome (MRS) is a rare neuro-mucocutaneous granulomatous disorder of unknown etiology, characterized by the triad of facial palsy, lingua plicata (fissured tongue), and orofacial edema. Few articles in the literature report series with more than 20 patients or focus on the facial nerve dominant presentation of MRS. METHODS: We performed a retrospective review of the patients diagnosed with MRS at a university-based Facial Nerve Center. RESULTS: Twenty-one patients were identified from 1971 to 2010. The age of presentation ranged from 22 to 67 years (mean 44.1). Seven (33.3%) were male and 14 (66.7%) were female. All (100%) patients had facial paralysis. Fourteen (66.7%) patients who initially presented with unilateral paralysis subsequently developed metachronous contralateral paralysis (alternating unilateral facial paralysis). One (4.7%) patient had simultaneous bilateral facial paralysis. The number of episodes per patient ranged from 1 to 8 (mean 3.1). Laterality was relatively equal: 35 episodes occurred on the right side and 31 on the left. The patient with most episodes of facial paralysis had four on the left and four on the right (metachronous). This was followed by three patients with six episodes each. The age of first incidence of facial paralysis ranged from 2 to 60 years (mean 34.4, median of 39). The mean interval between episodes was 4.7 years (range 0-30, median 3). Six (28.5%) of the patients reported a family history of MRS. CONCLUSIONS: MRS is a rare disease of unknown pathogenesis in which oligosymptomatic forms predominate. Patients with this disease may present to different specialties complaining of different symptoms, and frequently, not all the classic features of the triad will be present. In our series of facial paralysis patients diagnosed with MRS, a higher proportion had the full triad of symptoms than has been previously reported in the literature.

Revision septoplasty: a prospective disease-specific outcome study.

OBJECTIVES/HYPOTHESIS: 1) Study outcomes of revision septoplasty using a validated disease-specific questionnaire and a patient satisfaction survey; 2) assess the effect of surgery on the use of medication to treat nasal congestion; and 3) report on sites of persistent septal deviation identified at revision septoplasty. STUDY DESIGN: Prospective, single-center outcome study of patients with symptomatic nasal obstruction and persisting septal deviation despite prior septal surgery. METHODS: The Nasal Obstruction Symptom Evaluation (NOSE) scale was administered preoperatively and at 3 and 6 months following revision surgery. Patients were also questioned regarding ease of breathing and medication use preoperatively and postoperatively, as well as satisfaction with the surgical outcome. Anatomic site(s) of residual septal deviation were recorded intraoperatively. RESULTS: Thirty-nine patients completed the study. Mean NOSE scores decreased significantly from 75.9 preoperatively to 14.9 3 months after revision surgery. Mean Ease-of-Breathing scores over this interval improved from 3/10 preoperatively to 8.5/10. Both results were sustained at 6 months (P <0.0001). Patient satisfaction was very high, and many patients required less medication to treat symptoms of nasal congestion postoperatively. Deviations persisting from prior surgery most commonly involved the dorsal or caudal septum. CONCLUSION: In patients who experience ongoing nasal obstruction with a persistent septal deviation despite prior septoplasty, revision surgery significantly improves disease-specific quality of life, results in high patient satisfaction, and may diminish the need for nasal medications postoperatively. Caudal or dorsal deflections may be more difficult to correct, leading to the need for revision surgery. LEVEL OF EVIDENCE: 2C.

Cadaveric study of the posterior pedicle nasoseptal flap: a novel flap for reconstruction of pharyngeal defects and velopharyngeal insufficiency.

BACKGROUND: The posterior pedicle nasoseptal flap has been the workhorse for endoscopic reconstruction of medium to large cranial base defects, with excellent outcomes and minimal flap failures. The authors present the anatomical foundations for the use of the nasoseptal flap for reconstruction of soft palate and pharyngeal defects and for surgical treatment of velopharyngeal insufficiency in a cadaveric model. METHODS: Posterior pedicle nasoseptal flaps were endoscopically harvested and transposed to the naso/oropharynx in seven cadavers. The reach and relationships of the flap with nasopharyngeal and oropharyngeal structures were documented. RESULTS: A total of nine nasoseptal flaps (bilateral in two specimens) were transposed into the nasopharynx and oropharynx. The most anterior aspect of the flap was visualized transorally several millimeters inferior to the soft palate in all specimens. Six flaps were sutured transorally to the posterior pharyngeal wall and three were sutured to defects of the soft palate. The width of a fully harvested flap (entire septal mucosa) was more than twice the width of the posterior nasopharyngeal/oropharyngeal wall in all specimens. Nasoseptal flaps were easily tailored endoscopically and transorally with standard instrumentation to fit the defects. CONCLUSIONS: In a cadaveric model, the nasoseptal flap can be transposed into the nasopharynx and upper oropharynx and is a potential alternative for pharyngeal reconstruction and surgical treatment of velopharyngeal insufficiency in patients in whom traditional flaps are not available. The application of this technique for reconstruction of pharyngeal and velar defects is novel, and further studies evaluating clinical outcomes are needed.

Demonstration of transoral surgery in cadaveric specimens with the medrobotics flex system.

OBJECTIVES/HYPOTHESIS: Using human cadavers, we investigated the feasibility of using a new robotic platform, the Medrobotics Flex System, for laryngeal access and flexible tool delivery to facilitate the performance of pharyngolaryngeal procedures without laryngeal suspension. Our initial trials specifically assess the utility of this experimental robotic system for epiglottectomy and base of tongue resection. STUDY DESIGN: Feasibility; Level of evidence: NA. METHODS: Using standard mouth retractors, the Flex™robot was driven via the physician controller to the supraglottic region. Non-crossing, flexible endoscopic tools were inserted through the robot's external tool channels to retract, cauterize, and remove tissue in each procedure type. Mock surgical procedures were performed on the laryngopharyngeal complex including epiglottectomy, base of tongue resection, and vocal cord excision. Time-to-tissue exposure was noted for each procedure. Each epiglottectomy was timed to determine operation duration. RESULTS: Epiglottectomy, base of tongue resection, and vocal cord excision were successfully performed without suspension laryngoscopy. Individual surgeons improved the procedure time significantly (P = 0.03) between first and second attempts. Epiglottectomies were performed in an average time of 42 minutes (N = 5, σ = 28 minutes). CONCLUSIONS: The Medrobotics Flex System demonstrates great potential as a surgical tool in head and neck oncology. Compared to other surgical robots, the Flex System offers facilitated access, vision, and triangulation of flexible tools for procedures in the endolarynx. LEVEL OF EVIDENCE: N/A.

Traumatic thyroid hematoma associated with thyroid carcinoma.

Thyroid hematoma secondary to blunt trauma is uncommon, and no consensus exists for its management. We describe the case of a 46-year-old man who presented with neck swelling after he had sustained a blunt-trauma injury to his neck while playing soccer. Imaging revealed a large mass consistent with a thyroid hematoma. The patient was admitted for observation and followed up with serial imaging. He was eventually discharged without surgical intervention. However, he later underwent a thyroid lobectomy to treat compressive symptoms and for cosmetic reasons. Pathology revealed that the patient had a papillary thyroid carcinoma, which might have predisposed him to the hemorrhage. Thyroid hematoma secondary to blunt trauma has been documented in normal thyroid glands and in glands with preexisting benign pathology, but to the best of our knowledge, no report associating this condition with a thyroid carcinoma has previously been reported in the literature. A neoplasm should be suspected in a case of thyroid hematoma that fails to resolve with conservative treatment. The management of this condition is surgeon- and case-specific, and the overall prognosis is good.

A transoral highly flexible robot: Novel technology and application.

OBJECTIVES/HYPOTHESIS: Organ preservation surgery is a major focus in head and neck oncology. Current approaches are aimed toward improving quality of life and decreasing treatment-related morbidity. Transoral robotic surgery was developed to overcome the limitations of traditional surgical approaches. The most widely used robotic system is the da Vinci Surgical System. Although the da Vinci offers clear surgical advantages over traditional approaches, its rigid operative arms prevent complex maneuverability in three-dimensional space. The ideal surgical robot would configure to the anatomy of the patient and maneuver in narrow spaces. We present the first cadaveric trials of the use of a highly flexible robot able to traverse the nonlinear upper aerodigestive tract and gain physical and visual access to important anatomical landmarks without laryngeal suspension. STUDY DESIGN: Feasibility. METHODS: Using human cadavers, we investigated the feasibility of visualizing the endolarynx transorally with a highly flexible robot without performing suspension of the larynx. Two fresh and four preserved human specimens were used. RESULTS: Unhampered visualization of the endolarynx was achieved in all specimens without performing laryngeal suspension. Standard mouth retractors facilitated the delivery of the robot into the endolarynx. CONCLUSIONS: The flexible robot technology mitigates laryngeal suspension and the limitations of current robotic surgery with rigid line-of-sight-directed instruments. Having demonstrated the feasibility of physical and visual access to the endolarynx, future work will study the feasibility of using the highly flexible robot in transoral robotic procedures with flexible instrumentation placed in the robot's available working ports.

Endoscopic anatomy of the palatovaginal canal (palatosphenoidal canal): a landmark for dissection of the vidian nerve during endonasal transpterygoid approaches.

OBJECTIVES/HYPOTHESIS: Demonstrate the endoscopic anatomy of the palatovaginal (PV) canal and artery for identification and dissection of the vidian nerve during endoscopic transpterygoid approaches. Evaluate the length of the PV canal and its relation with the vidian nerve. Show that the traditionally known PV canal is a misnomer and should be renamed. STUDY DESIGN: Experimental study: anatomical and radiological. METHODS: Dissection of eight cadaveric heads was performed to demonstrate the endoscopic anatomy of the PV canal. Computed tomography scan analysis of 20 patients was used to evaluate the length of the PV canal, the angle formed between this canal and the vidian nerve, and the distance between the vidian canal and the PV canal. Study of 10 dry skull bases was performed to verify the structures involved in the formation of the PV canal. RESULTS: Anatomic steps and foundations for dissection of the vidian nerve using the PV canal as a landmark were described. The mean length of the PV canal was 7.15 mm. The mean proximal distance between the vidian and the PV canal was 1.95 mm, and the mean distal distance was 4.14 mm. The mean angle between those canals was 48 degrees. The osteology study showed the vaginal process of the sphenoid bone did not contribute to the formation of the PV canal. CONCLUSIONS: Our anatomic investigations, radiologic studies, and surgical experience demonstrate the important anatomic relationship of the PV canal with the vidian canal and the relevance of the PV canal as a surgical landmark in endoscopic endonasal transpterygoid approaches. Anatomically, PV canal is a misnomer and should be replaced with palatosphenoidal canal.

Posterior pedicle lateral nasal wall flap: new reconstructive technique for large defects of the skull base.

BACKGROUND: Indications for expanded endoscopic approaches continue to grow, resulting in larger and more complex skull base defects. Reconstructive developments, however, have lagged our extirpative capabilities. As the complexity of clinical scenarios continues to escalate, challenging our current reconstructive strategies, we are compelled to develop alternative techniques to prevent cerebrospinal fluid leaks and protect neurovascular structures. In this article we show the anatomic basis for a new posterior pedicled flap from the lateral wall of the nose (Carrau-Hadad [C-H] flap) for the reconstruction of median skull base defects and present our early clinical experience. METHODS: Using a cadaveric model, we designed a posterior pedicle flap comprising the nasal inferolateral wall mucoperiosteum. We applied this information clinically, to reconstruct transmural skull base defects. RESULTS: In our cadaveric model, we harvested and transposed C-H flaps into various defects of the planum sphenoidale, sella turcica, clivus, and nasopharynx. Then, we used the C-H flap in four patients, successfully reconstructing their clival (n = 3) and sellar (n = 1) surgical defects. All patients healed uneventfully. CONCLUSION: Our anatomic study and early clinical experience support the use of the posterior pedicle lateral nasal wall flap to reconstruct large cranial base defects resulting from endoscopic skull base surgery in properly selected patients.

Anterior pedicle lateral nasal wall flap: a novel technique for the reconstruction of anterior skull base defects.

OBJECTIVES: Expansion of the clinical indications for ablative endoscopic endonasal approaches has behooved us to search for new reconstruction alternatives. We present the anatomic foundations of a novel anterior pedicled lateral wall flap (Hadad-Bassagaisteguy 2 or HB2 flap) for the vascularized reconstruction of anterior skull base defects. STUDY DESIGN: Anatomic description. Feasibility study. Technical report METHODS: Using a cadaveric model, we investigated the feasibility of harvesting an anteriorly based mucoperiosteal flap from the lateral nasal wall. We then applied the techniques developed in the anatomical laboratory to reconstruct two patients with defects resulting from the endoscopic endonasal resection of esthesioneuroblastomas and one patient with an extensive meningoencephalocoele of the anterior cranial fossa. RESULTS: HB2 flaps were harvested and transposed to reconstruct anterior skull base defects in cadaveric specimens, and subsequently, in three patients. The HB2 flap provided adequate coverage in the cadaveric model, as well as clinically in our three patients. Their postoperative healing was uneventful. CONCLUSIONS: The HB2 flap is a feasible alternative for the reconstruction of anterior skull base defects in select patients.

Prevertebral corridor: posterior pathway for reconstruction of the ventral skull base.

OBJECTIVE: Regional vascularized flaps, such as the pericranial and temporoparietal fascia flaps, are currently used for reconstruction of skull base defects after endoscopic endonasal surgery whenever local vascularized flaps, such as the nasoseptal flap, are not available. Two different transposition pathways, infratemporal transpterygoid and subfrontal, have been proposed for regional flaps. The objective of this study was to describe and assess the feasibility of the transposition of a vascularized pedicled flap from the occipital galeopericranium via the prevertebral space corridor into the nasopharynx. METHODS: Ten heads were injected with colored silicone. An endoscopic endonasal anterior craniofacial resection and panclival approach were performed in each specimen. The occipital flap was harvested using a previously described technique. The prevertebral corridor, extending from the neck to the nasopharynx, was dissected superficial to the paraspinal muscles. Computed tomography-based image guidance was used to assess the relationship between the corridor and adjacent neurovascular structures. Length of the corridor and pedicle and area of the donor flap were measured. RESULTS: The flap was harvested and successfully transposed into the nasopharynx using the proposed corridor in all studied specimens (10 heads, 20 sides). All flaps provided complete coverage of the skull base defects. The average length of the pedicle was 70.5 (SD, 6.5) mm, and the average length and width of the flap were 99.9 (SD, 14.6) mm and 59.3 (SD, 10.9) mm, respectively. The average length of the prevertebral corridor was 49.7 (SD, 4.8) mm. CONCLUSIONS: The occipital flap has favorable anatomic characteristics for use in skull base reconstruction. Transposition of the flap via the prevertebral corridor is a suitable option for vascularized reconstruction of expanded endonasal skull base defects when other local or regional flaps are not available. Additional clinical studies are necessary to define its role in endoscopic endonasal surgery.

Transparapharyngeal and transpterygoid transposition of a pedicled occipital galeopericranial flap: a new flap for skull base reconstruction.

OBJECTIVES: We present the anatomic and cadaveric foundations for novel modifications of the occipital galeopericranial flap for reconstruction of ventral skull base defects. STUDY DESIGN: Anatomic description. METHODS: Using cadaveric dissections and measurements, we investigated the feasibility of transposing pedicled occipital galeopericranial flaps into the nasal cavity and skull base. Two fresh and five preserved human specimens were dissected. RESULTS: Pedicled occipital flaps were transposed into the nasal cavity via a transparapharyngeal-transpterygoid corridor into the nasopharynx. It was demonstrated that the pedicled occipital galeopericranial flap reaches the anterior skull base. CONCLUSIONS: Pedicled occipital flaps transposed into the nasal cavity can reach the anterior skull base and provide another option for vascularized reconstruction in selected patients.

Nasoseptal "rescue" flap: a novel modification of the nasoseptal flap technique for pituitary surgery.

OBJECTIVES: The introduction of the pedicled nasoseptal flap (NSF) has decreased postoperative cerebrospinal fluid (CSF) leak rates from >20% to <5% during expanded endoscopic skull base surgery. The NSF must be raised at the beginning of the operation to protect the posterior pedicle during the expanded sphenoidotomy. However, in most pituitary tumor cases, an intraoperative CSF leak is not expected but at times encountered. In these cases, a "rescue" flap approach can be used, which consists of partially harvesting the most superior and posterior aspect of the flap to protect its pedicle and provide access to the sphenoid face during the approach. The rescue flap can be fully harvested at the end of the case if the resultant defect is larger than expected, or if an unexpected CSF leak develops. This technique minimized septum donor site morbidity for those patients without intraoperative CSF leaks. RESULTS: The rescue flap technique allows for binaural and bimanual access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. If an intraoperative CSF leak is encountered, the rescue flap is then converted into a normal nasoseptal flap for skull base reconstruction. If no leak is obtained, then the patient does not suffer additional donor site morbidity from the full flap harvest. CONCLUSIONS: This new technique allows for sellar tumor removal prior to the nasoseptal harvest, thereby eliminating donor site morbidity for those pituitary tumor patients who do not have an intraoperative CSF leak.

Combined approach for extensive maxillectomy: technique and cadaveric dissection.

BACKGROUND: Currently described endoscopic techniques for subtotal resections of the maxilla include endoscopic medial maxillectomy and extended endoscopic medial maxillectomy; however, a complete resection of the maxilla is sometimes warranted. We describe a combined transoral and endoscopic technique for total and subtotal maxillectomy in an attempt to decrease the morbidity of traditional approaches. METHODS: Technical note, Feasibility, Human cadaveric dissection. RESULTS: Ten total and subtotal maxillectomies were performed in human specimens without the need of facial incisions or transfixion of the nasal septum. The pterygopalatine and infratemporal fossas were accessed and dissected in all cases. CONCLUSIONS: A combined transoral and endoscopic approach is feasible and can be used in selected patients when other minimally endoscopic techniques are not indicated. The benefits of no facial incisions and/or transfixion of the nasal septum, potential improvement in hemostasis, and visual magnification may help to decrease the morbidity of traditional open approaches.

Bilateral giant submandibular sialoliths and the role for salivary endoscopy.

Salivary stones larger than 15 mm are classified as giant sialoliths. They are uncommon in the practice of otolaryngology, and their management has always been a therapeutic challenge. Traditionally, when they cannot be retrieved by marsupialization, removal of the salivary gland has been advocated. Sialendoscopy and the recent development of combined endoscopic and external approaches for extraction of large stones with preservation of the major salivary glands are promising. We present the first case of simultaneous bilateral giant sialoliths, and the first report that associates giant sialoliths and the use of salivary endoscopy. In this case, both giant stones were removed with the assistance of a salivary endoscope and without removing the submandibular glands.

Endoscopic endonasal dissection of the infratemporal fossa: Anatomic relationships and importance of eustachian tube in the endoscopic skull base surgery.

OBJECTIVES: Endoscopic endonasal approaches to the pterygopalatine and infratemporal fossae are technically challenging due to the complex anatomy of these areas. This project attempts to develop an anatomic and surgical model to enhance the understanding of these spaces from the endonasal endoscopic perspective. METHODS: Eight pterygopalatine and infratemporal fossae were dissected in four adult human specimens in accordance with institutional protocols. All specimens were prepared with vascular injections using colored latex. Both the pterygopalatine and infratemporal fossae were accessed using a transpterygoid approach, which included a medial maxillectomy. Rod lens endoscopes (with 0°, 30°, and 45° lenses), surgical microscope, microsurgical and endoscopic instruments were used to complete the dissections. RESULTS: Endoscopic endonasal approaches provided adequate access to the pterygopalatine and infratemporal fossae. Dissection of the internal maxillary artery and its terminal branches, and detachment of the medial and lateral pterygoid muscles were critical steps to access deeper structures of the infratemporal fossa. The lateral pterygoid plate was the most useful landmark to locate foramen ovale, and the mandibular branch of the trigeminal nerve. The Eustachian tube, medial pterygoid plate, and styloid process were the most useful landmarks to locate parapharyngeal poststyloid structures (parapharyngeal segment of the internal carotid artery, internal jugular vein, cranial nerves IX and X). CONCLUSIONS: A medial maxillectomy coupled with a transpterygoid endoscopic approach, provides adequate access to the pterygopalatine and infratemporal fossae. The complex anatomy of the infratemporal fossa requires precise identification of surgical landmarks to assure preservation of neurovascular structures.

Pedicled facial buccinator (FAB) flap: a new flap for reconstruction of skull base defects.

BACKGROUND: The expansion of endoscopic endonasal skull base surgery has resulted in an increased demand for reconstructive options. Reconstruction with vascularized tissue has proven indispensable for reliably separating the cranial contents from the paranasal sinuses following extended endoscopic endonasal approaches (EEA). The introduction of the Hadad-Bassagasteguy flap (vascular pedicle nasoseptal flap, HBF) at our institution decreased our postoperative cerebral spinal fluid (CSF) leak rates from more than 20% to less than 5%. The HBF is not always available, as the nasoseptal area or its vascular supply can be compromised by tumor or prior surgery. In an attempt to keep pace with rapidly expanding reconstructive requirements, we present the anatomic and cadaveric foundations for novel modifications of the facial artery musculo (-mucosal) (FAM[M]) and buccinator flaps to allow vascularized reconstruction of the skull base. STUDY DESIGN: Feasibility. Cadaveric study. METHODS: Using cadaver dissections and measurements, we investigated the feasibility of transposing pedicled buccinator myo/myomucosal flaps into the nasal cavity and skull base. Both muscular and myomuscular flaps were raised, and techniques for transposition into the nasal cavity were investigated. Three fresh and six preserved human specimens were dissected. RESULTS: Pedicled facial buccinator flaps with and without mucosa were transposed into the nasal cavity using a variety of maxillary osteotomies. No facial incisions were required. It was demonstrated that the flaps reach the anterior skull base and planum sphenoidale. CONCLUSIONS: The transposition of pedicled buccinator muscle flaps with and without mucosa into the nasal cavity could reach the anterior skull base and planum sphenoidale, if the appropriate surgical technique is used. The pedicled Facial Buccinator Flap holds significant potential as a reconstructive alternative for a variety of skull base defects, alone or in combination with existing reconstructive options. 2010.