Autologous free dermal fat graft. Reconstruction of facial contour defects.

OBJECTIVE: To examine the use of autologous free dermal fat grafts (FDFGs) in the reconstruction of soft-tissue facial contour defects, an 8-year, retrospective, computerized medical chart review was conducted for 21 patients who underwent reconstruction with FDFGs. SETTING: Section of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Oregon Health Sciences University, Portland, or affiliated hospitals. PATIENTS: Twenty-one patients identified in the chart review were included in the retrospective evaluation. Follow-up periods ranged from 11 to 94 months. Five patients were unavailable for follow-up at the chart review, but all five had satisfactory results at their last evaluation. DESIGN: Soft-tissue augmentation was performed using autologous FDFGs harvested from the abdomen following in situ de-epithelialization with a high-speed dermabrader. Facial contour defects resulted from tumor extirpation, congenital deformity, trauma, or degenerative disease. MAIN OUTCOME MEASURES: Outcome was considered satisfactory when the patient and the surgeon were pleased with the long-term results at the last evaluation. RESULTS: Complications, including graft resorption (five patients) and epithelial cyst formation (two patients), were observed in seven patients and resulted in an unsatisfactory outcome. The remaining 14 patients demonstrated satisfactory results as determined by the patient and the surgeon at the last evaluation. CONCLUSIONS: Successful long-term augmentation of facial contour defects may be achieved with autologous FDFGs in an appropriate patient population. Careful patient selection and proper surgical technique are essential for satisfactory long-term results. Guidelines are provided for the augmentation of facial contour defects with autologous FDFGs.

Assessment of survival and microscopic changes in porcine skin flaps undergoing immediate intraoperative tissue expansion.

The technique of rapid intraoperative tissue expansion has been used with increasing frequency in the clinical setting over the last several years. This technique takes advantage of the skin's ability to immediately stretch and increase in surface area when expanded under a constant load. Sixteen random-pattern, rapidly expanded skin flaps on 10 domestic male pigs were studied to assess the predictive value of the fluorescein test for flap viability after rapid intraoperative tissue expansion. Partial fluorescence was found to be a more accurate predictor of flap survival in the experimental rapidly expanded flaps when compared to full fluorescence. Partial fluorescence was found to under-predict flap survival by 0.3 to 0.5 cm, whereas full fluorescence was found to under-predict flap survival by 2.5 cm. Additionally, histologic and ultrastructural changes were examined in rapidly expanded skin from the hip region in three pigs. The only microscopic change noted between control and experimental flaps was dilated capillaries in the dermis of expanded skin, which was noted by electron microscopy. Collagen and elastic tissue changes were not demonstrated in rapidly expanded pig skin by electron microscopy, direct immunofluorescence, collagen, and elastic tissue stains.

Head and neck lymphoma in patients with the acquired immune deficiency syndrome.

A marked increase has recently been noted in the incidence of lymphoma in patients with AIDS. These lymphomas are generally high-grade, of B-cell origin, and often involve extranodal sites. Reported here are twenty patients with AIDS in whom symptoms and physical findings developed related to the head and neck region as a result of lymphoma. The tumor was observed in a variety of sites, including the nasopharynx, orbit, submandibular triangle, anterior and posterior cervical triangles, supraclavicular fossa, and the hypopharynx. Sixteen tumors were large cell nonHodgkin's B-cell lymphomas, three were small cell nonHodgkin's B-cell lymphomas, and one was Hodgkin's disease, mixed cellularity. All were treated with combination chemotherapy. A high degree of suspicion for lymphoma is required in treating any patient with AIDS who has a rapidly enlarging mass in the head and neck. If needle aspiration is nondiagnostic, excisional biopsy should be performed after a complete head and neck evaluation. Although the development of lymphoma associated with AIDS portends a grave prognosis, prompt diagnosis will allow an improved chance of remission of the lymphoma.

Nasal reconstruction with articulated irradiated rib cartilage.

Nasal structural reconstruction is a formidable task in cases where there is loss of support to both the nasal dorsum and tip. A multitude of surgical approaches and materials have been used for the correction of the saddle-nose deformity with varying degrees of success. Articulated irradiated rib cartilage inserted through an external rhinoplasty approach was used to reconstruct nasal deformities in 18 patients over a 6-year period. Simultaneous use of a midline forehead flap to reconstruct the overlying soft tissue was required in four cases. Follow-up ranged from 1 to 6 years (mean, 2.8 years). Results were rewarding in most cases with marked improvement in nasal support and airway. Revision and/or replacement secondary to trauma or warping of the graft was required in four cases. None of the patients exhibited infection, extrusion, or noticeable resorption. A description of the surgical technique, review of all the cases, and recommendation for continued use of this graft material are discussed.

Tonsillectomy and adenoidectomy: an inpatient or outpatient procedure?

Concern over the rising cost of health care has created a trend toward outpatient surgery. Because adenotonsillectomy is such a frequently performed procedure, there is pressure on many otolaryngologists to do this operation on an ambulatory basis. A prospective study was undertaken to evaluate the incidence and severity of postoperative hemorrhage, protracted emesis, and fever at specified times within the first 24 hours after surgery. Over a 1-year period, 1000 tonsillectomy and/or adenoidectomy patients were studied. There was a 2.1% incidence of serious complications within the first 6 postoperative hours. The incidence of serious hemorrhage, fever, and protracted emesis was 0.7% each. The incidence of significant complications between the 6th and 24th postoperative hours was 1.7%. Hemorrhage occurred in 0.4% of the patients, fever in 0.7%, and protracted emesis in 0.6%. The total incidence of hemorrhage during this time period was 1.1%. There were no deaths. The greatest percentage of complications occurred within the first 6 postoperative hours. Based on this study, outpatient tonsil and adenoid surgery should be followed by at least 6 hours of postoperative observation before discharge. The choice to perform ambulatory tonsil and adenoid surgery depends on the professional judgment of the operating physician based on this and other recent studies, the sophistication of the physician's ambulatory surgery center, and the medical and social background of the patient.

Radiation injury to the temporal bone.

Osteoradionecrosis of the temporal bone is an unusual sequela of radiation therapy to the head and neck. Symptoms occur many years after the radiation is administered, and progression of the disease is insidious. Hearing loss (sensorineural, conductive, or mixed), otalgia, otorrhea, and even gross tissue extrusion herald this condition. Later, intracranial complications such as meningitis, temporal lobe or cerebellar abscess, and cranial neuropathies may occur. Reported here are five cases of this rare malady representing varying degrees of the disease process. They include a case of radiation-induced necrosis of the tympanic ring with persistent squamous debris in the external auditory canal and middle ear. Another case demonstrates the progression of radiation otitis media to mastoiditis with bony sequestration. Further progression of the disease process is seen in a third case that evolved into multiple cranial neuropathies from skull base destruction. Treatment includes systemic antibiotics, local wound care, and debridement in cases of localized tissue involvement. More extensive debridement with removal of sequestrations, abscess drainage, reconstruction with vascularized tissue from regional flaps, and mastoid obliteration may be warranted for severe cases. Hyperbaric oxygen therapy has provided limited benefit.

Civilian external peer review: lessons learned.

Since 1986, the Department of Defense has contracted with an outside agency for Civilian External Peer Review (CEPR). From January, 1986 to December, 1988, records indicate that approximately 350,000 discharges from Army hospitals have been included in the study. Initially, the small number of positive findings prevented generalizations; as the total number of cases screened has increased, several valuable lessons have been learned suggesting avenues for improving care. Additionally, a great deal has been elucidated concerning the process of large-scale clinical peer review.

Mycobacterial cervical lymphadenitis: a persistent diagnostic problem.

The most common manifestation of mycobacterial infection encountered in otolaryngologic practice is cervical lymphadenitis. Mycobacterial cervical lymphadenitis, or scrofula, remains a diagnostic and therapeutic challenge because it mimics other pathologic processes, and because of the inconsistent reliability of physical and laboratory findings. Twenty-five cases of scrofula were treated at our institution from 1973 to 1986. Positive chest x-ray was exhibited by five (20%) patients. Histologic examination of the excisional biopsy was the most reliable test with 100% positive specimens. This study emphasizes the marked variability in clinical presentation of scrofula and the importance of surgical excisional biopsy for histologic diagnosis.