Management of the cleft lip nasal deformity.

Management of the cleft lip nasal deformity offers a unique and ongoing challenge in facial plastic surgery. Although there has been no consensus regarding the optimal timing and technique for surgical repair of this deformity, the authors have found a three-tiered approach to be satisfactory. This approach involves a primary rhinoplasty performed at the time of the initial cleft lip repair to address reconstruction of the nasal floor and sill, columellar lengthening, repositioning of the alar base, and repositioning of the skin and mucosa of the lower lateral cartilage. Following alveolar bone grafting, an intermediate rhinoplasty is often performed at 6 to 10 years of age through an open approach to correct the cartilaginous lower nasal deformity. A delayed rhinoplasty is then performed in the later teenage years to correct the bony dorsal deformity and the various causes of nasal obstruction.

Safety of steroid injections in the treatment of nasofrontal recess obstruction.

A retrospective review was undertaken to determine if steroid injection is a safe and effective intervention in the management of chronic nasofrontal recess obstruction. Seventy-four patients were identified who had undergone prior endoscopic sinus surgery and subsequently developed nasofrontal recess obstruction that was treated with injection of Kenalog 20 mg/mL (Bristol-Myers Squibb Co., Princeton, NJ) directly into the polyps or fibrosis. The study included 38 men and 36 women with a mean age of 45.4 years. These patients collectively underwent 687 injections, an average of 9.3 injections per patient. The indication was polyposis in 70 patients and fibrosis in 17 patients, with 13 sharing both indications. These patients also required 112 office procedures to maintain nasofrontal recess patency, an average of 1.5 procedures per patient. Three patients eventually required frontal sinus obliteration. The mean follow-up period from the initial injection was 50.1 months, and no complications were reported. Therefore, nasofrontal steroid injection appears to be safe and effective in the treatment of nasofrontal recess obstruction.

A two-layer closure of sino-orbital fistula.

A two-layer closure of sino-orbital fistulae using tension-free local flaps is described. For small fistulae, the opening is first closed with a mucosal turnover flap; this is combined on the orbital surface with a local rotational advancement flap of the orbital skin. For larger fistulae where a mucosal turnover flap cannot be fashioned, a two-stage, delayed, composite mucocutaneous rotational flap is used. The advantages of these techniques are: (1) a mucous membrane to provide nasal or sinus lining, insulating the raw ventral surface of the skin flap; (2) each flap has an independent blood supply; (3) local flaps are used, avoiding the use of a pedicle flap from forehead; (4) excellent cosmesis since tissues outside the orbital rim are not disturbed; and (5) does not require refitting of exenteration prosthesis since the integrity of the orbital rim is maintained. The authors have used these techniques in six patients with chronic sino-orbital fistulae of the exenterated socket. In one patient, a wound dehiscence occurred and a small fistula measuring 3 to 4 mm in diameter persisted. The fistulae of the remaining five patients were successfully closed.

Revision endoscopic ethmoidectomy for chronic rhinosinusitis.

In summary, revision endoscopic surgery for chronic rhinosinusitis can be performed safely by using the middle turbinate (or portion thereof) or the anterior wall of the sphenoid as a landmark. These cases are more difficult and may be more prone to bleeding and scarring. The surgeon should be thoroughly familiar with and not hesitate to switch to conventional techniques in the event of excessive bleeding, proptosis, or a loss of landmarks. Aggressive postoperative care and follow-up, including office endoscopic "touch-up" procedures, may be necessary to maintain control of aggressive disease, along with continued medical management and any indicated immunotherapy.

Experience with surgical management of velopharyngeal incompetence.

Accurate mapping of the defect of velopharyngeal closure in patients with velopharyngeal incompetence is paramount to the planning of an operative procedure that will have a successful outcome. Nasoendoscopy and videonasoendoscopy are valuable tools for examination of the abnormal pattern of velopharyngeal movement in patients with velopharyngeal incompetence. On the basis of the knowledge of the observed defect in velopharyngeal closure for the particular patient, a pharyngeal flap operation is planned. The flap width, level of placement of the flap base, and control of the lateral port size vary to suit each individual velopharyngeal closure defect. Postoperative speech results in 86 patients are reported.

Minimal standards for reporting the results of surgery on patients with cleft lip, cleft palate, or both: a proposal.

This article proposes a set of minimal standards for reporting the results of surgery on patients with cleft lip with or without cleft palate and cleft palate only. These standards do not represent what is technically possible, only what is considered minimally acceptable for presentation in a public forum. They have a clinical focus and should be attainable by any well-constituted cleft palate team. As the title indicates, this document is a proposal. It is hoped that the readership will respond to the recommendations presented so that some set of standards can be adopted in the near future. Once adopted, these standards should be reviewed and updated periodically.

Delayed mandibular reconstruction following removal of a mesenchymal chondrosarcoma. Report of a case.

An unusual case of mesenchymal chondrosarcoma is presented. Initially seen when the patient was 8 years old, the lesion was repeatedly biopsied and curetted with a diagnosis of odontogenic fibroma. In 1971 a diagnosis of osteosarcoma of the chondroblastic type was made. At that time, the patient underwent a partial mandibulectomy with immediate graft. The patient did well until 1981, when a recurrence of the lesion was noted. The microscopic diagnosis at this time was mesenchymal chondrosarcoma. The treatment of this lesion as a staged procedure with initial resection of the mandible and placement of a silicone rubber mandibular prosthesis is discussed. The second stage of the procedure was definitive mandibular reconstruction, with an allogeneic mandible as a crib for autologous particulate cancellous bone from the iliac crest. Although the prognosis of mesenchymal chondrosarcoma is usually grave, this case is unusual because of its long history of multiple procedures performed prior to the definitive treatment of the lesion 14 years after its discovery. Two-year follow-up since the definitive mandibular reconstruction shows adequate range of motion, excellent healing, and no recurrence.

Delayed cricoid reconstruction by use of a free graft of autogenous "patient banked" cartilage.

Avulsed cartilage may be "banked" or preserved by subcutaneous implantation in the traumatized patient for delayed reconstruction of the defect when immediate reconstruction is contraindicated. The perichondrium of the avulsed cartilage should be preserved if possible. In the reconstructive procedure the cartilage graft must be surrounded by vascularized flaps developed from adjacent neck tissue. These vascularized flaps increase the local vascular supply for revascularization of the free graft. In addition, they allow complete separation of the free graft from the airway to minimize the possibility of secondary infection arising from the airway. Mucosal coverage of the defect does not appear to be necessary as long as well-vascularized soft tissue is available for complete coverage of the defect. The use of this technique may be considered for patients with avulsion of portions of the laryngeal cartilages when immediate reconstruction is contraindicated or when the viability of adjacent soft tissue necessary for reconstruction is uncertain. The success of this procedure may be related to the adequacy of the closure or separation of the airway from the free cartilage graft, and the ability to provide coverage of the graft with vascular tissue to allow graft revascularization. This new technique follows the traditional principles vital for successful management of laryngotracheal injuries. This procedure provides an additional method of therapy for those patients with an avulsion injury of the laryngeal cartilage. Additional surgical procedures must be performed utilizing the indications and principles presented here before this method is universally accepted for the management of severe laryngotracheal injury.

Cryotherapy for chronic vasomotor rhinitis: technique and patient selection for improved results.

Current methods of therapy of chronic vasomotor (non-allergic) rhinitis are frequently unsuccessful. This led to the development of a standardized technique of intranasal cryotherapy (longer freeze duration and larger area of therapy than previously reported) which was utilized in 50 patients. Indications for cryotherapy included: failure of medical therapy in anatomically normal patients with mucosal disease caused only by vasomotor rhinitis. Minimal follow-up was 2 years. Obstructive symptoms (subjective and objective evaluation) were eliminated in 92% and markedly improved in the remaining 8%. Excessive drainage (subjective) was relieved in 47%, markedly improved in 41%, and minimally improved (therapeutic failure) in 12%. Complications were minor; however, increased postoperative pain, drainage and healing duration (compared to prior series) were encountered. This cryotherapy technique provides significantly improved results in the treatment of vasomotor rhinitis when proper patient selection and technique are utilized.

Delayed skin grafting.

The use of skin grafts on granulating wounds is an established practice. Delaying the application of a full- or split-thickness skin graft may be an advantageous alternative method of surgical reconstruction in selected cases. Partial healing by secondary intention is useful for filling in deeper defects and usually produces a wound that is much smaller and of more normal contour than the original defect. Contraction of the graft bed is markedly influenced by location, tissue laxity, surface tension lines, motion, and wound geometry. Proper wound care, correct surgical preparation of the defect, and timing of the graft procedure are all important considerations in maximizing the overall result. Through-and-through defects and wounds produced over areas with little underlying support (eyelids and lip) often need flap reconstruction or immediate grafting to prevent undesirable functional and cosmetic results. By combining delayed healing and conventional reconstructive techniques, major tissue loss can often be restored while minimizing patient morbidity.

Delayed skin grafting in facial reconstruction. When to use and how to do.

To assess the effectiveness of delayed skin grafting for the reconstruction of facial defects following Mohs excision of cutaneous malignant neoplasms, an analysis was done on 40 patients. All grafts in this series survived. Satisfactory results were obtained in 95% of the patients. Complications were minor and uncommon. Results of this study demonstrate indications for the use of delayed skin grafting to include recurrent or aggressive primary lesions and defects that are large, deep, and favorably located. Advantages of delayed skin grafting are as follows: improved recipient bed vascularity providing high survival of a thicker graft; provision of additional tissue bulk; reduced length of time for healing; less contracture than with granulation healing; and elimination of additional scarring adjacent to the defect. In properly selected patients, this technique offers an additional method of reconstruction of facial defects.

Bilateral congenital lacrimal sac mucoceles with nasal extension and drainage.

A newborn infant with bilateral mucoceles of the lacrimal sacs also had submucosal masses along the floor of the nose beneath the inferior turbinates communicating with the mucoceles. Drainage of the mucoceles was performed by needle aspiration and wide marsupialization of the nasal masses into the nose under direct visualization. To our knowledge, this is the first time that intranasal extension of mucoceles has been reported, and the first time that lacrimal sac mucoceles have been successfully treated via direct nasal drainage. We advocate careful nasal evaluation in cases of congenital lacrimal sac mucoceles to determine whether intranasal extension is common and whether intranasal drainage can be curative.

Study of intranasal ostium external dacryocystorhinostomy.

A rigid endoscope was used to directly examine, measure, and photograph the intranasal ostium created by an external dacryocystorhinostomy (DCR). This technique was used to examine 19 patients who underwent 22 standard external DCRs. All patients had clinically successful results, documented by a positive Jone I dye test following surgery. The dimension of the bony opening created at surgery was measured and averaged 11.84 mm in diameter. The average diameter of the healed intranasal ostium was only 1.80 mm. No statistically valid correlation between the size of the bony opening and the final size of the healed intranasal ostium could be established. Thus, a large surgical anastomosis did not necessarily result in a large healed intranasal ostium. Excellent functional results were obtained even when the intranasal ostium was quite small. Other indications for the use of this technique are discussed.

External dacryocystorhinostomy. A prospective study comparing the size of the operative and healed ostium.

This study compares the size of the operative anastomosis with the size of the healed intranasal ostium resulting from 22 external dacryocystorhinostomies. The area of the healed intranasal ostium was approximately 2% of the area of the surgical anastomosis. No correlation was found between the size of the surgical anastomosis and the size of the healed ostium. In all cases, excellent functional results were obtained, regardless of the size of the healed ostium. This study suggests the size of the surgical anastomosis is not directly related to the success of the procedure, although it must be large enough to technically perform the procedure.

Auricular malignant neoplasms. Identification of high-risk lesions and selection of method of reconstruction.

A prospective study of 17 auricular malignant neoplasms was conducted comparing recommended margins for conventional surgical excision to the actual margins obtained after microscopically controlled excision (Mohs' chemosurgery technique) to identify lesions at high risk for inadequate excision with conventional excision. High-risk lesions included all tumors larger than 1 cm, morpheaform basal cell carcinoma, and multiply recurrent lesions of any size. Successful excision by conventional surgery would have resulted in a defect notably larger than the actual Mohs' defect in all cases. The excess tissue excised by conventional surgery averaged 180% larger than the actual defect in primary lesions and 347% larger in recurrent lesions. Methods of reconstruction used include the following: secondary intention (granulation), primary closure, skin grafts, local flaps, and meatoplasty. The incidence, indications, and usual results obtained are discussed in detail. Mohs' chemosurgery technique provides substantial benefit and should be considered in all recurrent lesions and primary lesions larger than 1 cm to reduce recurrence and minimize the resultant deformity.