Technical tips for a cosmetic approach to parotid surgery.

PURPOSE: Recently, skin incisions have tended to be smaller if surgical exposure is not greatly compromised, especially for benign lesions of the head and neck. An incision in a visible area of the neck needs to be moved to hidden or less prominent sites or away from the head and neck. For aesthetic considerations, the preauricular broken/postauricular trichophytic skin incision was developed for parotid surgery. PATIENTS AND METHODS: This retrospective clinical study enrolled 36 patients (20 women and 16 men) with benign preneural parotid tumors. Six months after surgery, patients were specifically asked to rate their satisfaction with their postoperative appearance on a scale of 1 to 10, with higher scores meaning better patient satisfaction, and whether they would consent to the operation again. RESULTS: All patients were satisfied with the cosmetic outcome: 24, 9, and 3 patients rated the procedure 8, 9, and 10, respectively. CONCLUSIONS: The preauricular broken/postauricular trichophytic skin incision provides generous access to the parotid gland, which is at least as good as the access provided by a Blair incision. It is an aesthetically superior incision that allows good surgical access and improved contour reconstruction.

Piezosurgery to perform hyoid bone osteotomies in thyroglossal duct cyst surgery.

Ultrasonic bone-cutting surgery has been introduced as a feasible alternative to the conventional sharp instruments used in craniomaxillofacial surgery because of its precision and safety. The device used is unique in that the cutting action occurs when the tool is used on mineralized tissues and stops on soft tissues. This work describes the use of piezosurgery for hyoid bone resection in thyroglossal duct cyst surgery, briefly reviews the literature on the surgical technique, and reports our experience with 12 cases.

Tracheostomy in maxillofacial surgery: a simple and safe technique for residents in training.

BACKGROUND: Tracheostomy is a frequently performed surgical procedure and may be required under emergency, semiurgent, or elective conditions. In maxillofacial surgery, it is indicated in congenital, inflammatory, oncologic, or traumatic respiratory obstruction and prolonged intubation. This article presents a simplified tracheostomy procedure based on anatomic markers that gives the best compromise between minimum invasiveness and safety. PATIENTS AND METHODS: A retrospective study analyzed the clinical aspects, treatment methods, and clinical course of 198 patients who underwent tracheostomies performed by residents in training under the supervision of surgeons between October 2002 and December 2007 at the Maxillofacial Surgery Department of Carlo Poma Hospital, Mantova, and the Maxillofacial Unit, Head and Neck Department, University of Modena and Reggio Emilia, Italy. Tracheostomies were performed in 127 patients (64.14%) with neoplastic diseases (tumors of the tongue base, tonsils, and oral and pharyngeal regions) and in 71 patients with trauma (35.86%). The patients were followed up for 3 to 65 months. RESULTS: Acceptable clinical healing and outcomes were obtained in all patients. Intraoperative complications occurred in 35 patients (17.7%): bleeding in 32 patients (16.2%) and pretracheal or paratracheal tube placement in 3 patients (1.51%). Postoperative complications after tracheostomy closure included tracheostomy dehiscence in 5 patients (2.52%) and subcutaneous emphysema in 26 patients (13.12%). Tracheostomy dehiscence occurred in 3 patients with neoplasia (1.51%) and in 2 patients with trauma (1.01%). No symptomatic tracheal stenosis developed. CONCLUSIONS: The standardized surgical technique presented here reduces the associated surgical risk when the correct anatomic markers are used and important structures are recognized and handled correctly.

The bilobed flap in skin cancer of the face: our experience on 285 cases.

BACKGROUND: This article describes how many of the defects caused by oncological surgery can be closed with an easily estended flap. PATIENT AND METHOD: The Zitelli bilobed flap was used to treat 285 consecutive patients with basal cell carcinomas (BCCs) or squamous cell carcinomas (SCCs); 167 men (58.60%) and 118 women (41.40%) between 45 and 98 years of age. Histologically, 247 BCCs (86.6%) and 38 SCCs (13.4%) were documented. Regarding the site, 148 (51.9%) involved the nose, 51 (17.9%) the cheeks, 36 (12.6%) the preauricular region, 27 (9.5%) the perilabial region and chin and 23 (8.1%) the periorbital region. To measure long-term satisfaction patients responded to a telephone survey consisting of a single global question. RESULTS: The size of the defect following tumour removal was between 1 and 4cm. Carcinomas up to 1cm were treated using a one step procedure with a cryostat test of the surgical margins; all others cases were treated using two step procedure after excision and histological in sano resection. Completely acceptable aesthetic and functional deficits were obtained in 275 (96.4%) patients over a 6-72-month follow-up. Ten (3.6%) patients suffered postoperative complications. Two cases of local infection; one case of completely flap necrosis and seven cases of partial revision due to flap necrosis occurred. The level of satisfaction with the surgical long-term result reported by the patients was high. CONCLUSION: In our experience the bilobed Zitelli flap for covering defects in the area of the face showed very few complications and good aesthetic results.

Usefulness of fine-needle aspiration in parotid diagnostics.

PURPOSE: Fine needle aspiration (FNA) is a safe diagnostic technique that is widely employed for lesions of the head and neck. Among head and neck sites, the parotid gland is unique in the number, diversity, and peculiarity of its pathological processes. This complexity has prompted a great deal of discussion regarding the application of FNA to parotid masses, primarily focusing on the reliability of FNA as a diagnostic tool in guiding patient management. METHODS: This review presents an analysis of the usefulness of FNA in differential diagnosis of parotid pathologies. RESULTS: Recent studies have confirmed a wide range of accuracy rates for FNA evaluation of parotid masses, varying from 79% to 97%. These data cannot be uniformly anticipated across all diagnostic scenarios. FNA is notoriously unreliable in recognising the malignant nature of parotid carcinoma providing its precise classification and establishing its grade. A few malignant neoplasms are particularly prone to diagnostic error: acinic cell carcinoma is frequently interpreted as benign, and low-grade lymphomas are often discounted as inflammatory processes. CONCLUSIONS: FNA cytology is useful in avoiding surgery (inflammatory lesions) or limiting surgical procedures (benign tumours). For planning the extent of surgery of malignant parotid tumours, the histological subtype and/or grade should be determined; therefore, a histological diagnosis by frozen section analysis is required. Moreover, reliance on FNA findings at the expense of clinical, radiographic, and intraoperative findings is unwarranted. Regardless of whether FNA is used routinely or selectively in patients with parotid masses, the findings should contribute to, and not replace, the overall diagnostic impression.

Surgical treatment of lip cancer: our experience with 106 cases.

PURPOSE: To report our experience with 106 cases of lip cancer. PATIENTS AND METHODS: We treated 106 patients with stages T1, T2, or T3 lip cancer (76, 22, and 8 cases, respectively). For the 34 T1 lesions up to 1 cm in diameter, we used a V or W excision. In the 42 T1 lesions greater than 1 cm and the 20 T2 lesions, we used the staircase technique. In 2 T2 cases, the carcinoma was located on the labial commissure and was treated with the Fries technique. For the 8 T3 cases, we used the Bernard-Freeman-Fries technique. In 28 patients, a lip shave was performed and tumor was removed. The 7 patients who were N+ at diagnosis underwent modified radical neck dissection and radiotherapy. RESULTS: Ten patients died during the follow-up period of 11 to 65 months: 8 of unrelated causes and 2 of new upper aerodigestive tract carcinoma. None of the patients died of their lip cancer. CONCLUSIONS: Lip cancer is a frequent disease of the oral cavity. Although general agreement has been reached concerning stage T and N+ surgical treatment, unresolved questions remain with regard to N0 treatment. We present our experience and suggestions.

A simple method of identifying the spinal accessory nerve in modified radical neck dissection: anatomic study and clinical implications for resident training.

PURPOSE: The major complication of neck dissection and surgery at the posterior triangle of the neck is the shoulder syndrome, which results from spinal accessory nerve injury. Erb's point (the great auricular nerve) and the point where the spinal accessory nerve enters the trapezius muscle are used to identify the spinal accessory nerve in the posterior nerve triangle. MATERIALS AND METHODS: Measurements were made during unilateral neck dissections in 30 patients to identify the relationship between the spinal accessory nerve and great auricular nerve and the distance between the entrance of the accessory nerve in the trapezious and clavicle. RESULTS: The distance between the spinal accessory nerve and Erb's point was ranging from 0 to 3.8 cm (mean 1.53 cm). The distance between the spinal accessory nerve entering the trapezious muscle and the clavicle was between 2.5 and 7.3 cm (mean 4.8 cm). CONCLUSIONS: Since the great auricular nerve (Erb's point) represents a constantly identifiable landmark, it allows simple and reliable identification of the course of the spinal accessory nerve. Also useful, but of secondary importance in our opinion, is identifying the nerve at the point where it enters the trapezius muscle.