Closure of difficult palatal fistulas using a "parachuting and anchoring" technique with the tongue flap.

The tongue flap has been described in reconstructing palatal defects. Nevertheless, properly securing the flap to the palatal defect has continued to pose a challenge, especially because the flap becomes mobile with normal activities (i.e., speech and swallow). For this reason, alternative fixation schemes have been discussed in literature, but do not always solve the problem. In this article, we offer an alternative method for positioning and securing the tongue flap into the palatal defect. The authors of this article believe that advantages of this technique include an increase in flap security and immobility and a decrease in postoperative maxillomandibular fixation requirement. Although unanswered questions still remain regarding improved flap retention with this method, we believe that the "parachuting and anchoring" technique provides an alternative method that can most definitely add to the surgeon's armamentarium.

Correction of frontonasoethmoidal encephalocele: the HULA procedure.

BACKGROUND: The frontonasoethmoidal encephalomeningocele deformity involves central herniation of a glial mass that "pushes outward" and deforms the medial orbit, medial canthus, nasomaxillary process, and nasal structures without resulting in hypertelorbitism. The authors studied a modification of the "Chula" repair, called the HULA procedure (H = hard-tissue sealant, U = undermine and excise encephalocele, L = lower supraorbital bar, A = augment nasal dorsum), which provided complete correction of the midline hard and soft-tissue structures using an intracranial and extracranial approach. METHODS: Filipino patients with frontonasoethmoidal encephalomeningoceles were treated by a civilian/military humanitarian team at Tripler Army Hospital (n = 12). Operative technique followed the four steps of the HULA frontoethmoidal encephalocele procedure. Postoperative and follow-up assessments were based on examination, photographic images, computed tomography scans, parental surveys, Whitaker score, and developmental testing. RESULTS: Patient ages ranged from 5 to 12 years; 67 percent were female and 33 percent male. Sixty-seven percent required excisions of poor-quality, hyperpigmented skin along with the large glial mass; the other 33 percent had a "closed" resection of the smaller mass through a gingivobuccal sulcus incision. No patients manifested cerebrospinal fluid leaks, infection, or elevated intracranial pressures postoperatively. Skeletal correction showed improved medial orbit distance, with a mean correction of 14 mm (42 percent). Whitaker score was 1.3 (no or minor soft-tissue revision necessary). Parental survey showed a high degree of satisfaction with the aesthetic and functional outcomes. Follow-up developmental tests showed normal global evaluations for all but one child with normal memory and attention skills. CONCLUSION: The authors' outcomes demonstrated that the HULA technique was a safe and effective approach for the complete correction of frontonasoethmoidal encephalomeningoceles.

Endoscope-assisted temporoparietal fascia harvest for auricular reconstruction.

BACKGROUND: Reconstruction of microtia may require a temporoparietal fascia flap. The authors modified existing endoscopic temporoparietal fascia harvest techniques and applied them to auricular reconstruction to reduce incision size, scarring, and visible alopecia. Flap design was altered to include posterior occipital circulation to improve perfusion and decrease venous congestion. Cases of open and endoscope-assisted auricular reconstruction techniques have not been compared in the literature. METHODS: Seventeen patients underwent Medpor auricular reconstruction with temporoparietal fascia flaps (eight open and nine endoscope-assisted). Physical outcome (scar size, location, appearance, and complication rate), flap size, surgical times, and blood loss were compared. Equipment and dissection techniques are reviewed. RESULTS: No flap complications occurred with either group. Endoscope-assisted incision length was 18 to 25 mm, compared with 150 to 200 mm using the open technique. No significant alopecia was noted in the endoscopic group, whereas most open patients had visible alopecia. Open surgical time averaged 325.9 minutes, and endoscopic surgical time averaged 276.5 minutes. Estimated blood loss averaged 56.3 cc for open and 45.6 cc for endoscopic procedures. Open temporoparietal fascia flap size averaged 8.87 x 9.75 cm, whereas endoscopic temporoparietal fascia flap size averaged 7.9 x 10.2 cm. Standard endoscopic brow-lift instruments were used. The optimal superior access port placement was the upper one-third/lower two-thirds junction of the flap. CONCLUSIONS: The endoscope-assisted temporoparietal fascia harvest technique for auricular reconstruction can minimize scarring, alopecia, and surgical time, with comparable blood loss. Flap size is comparable to that of the traditional open approach. The authors recommend a broadly based pedicle instead of one based solely off the superficial temporal artery.

The effect of topical mitomycin C on full-thickness burns.

BACKGROUND: Burns result in substantial morbidity because of fibroblast proliferation and contracture. Mitomycin C is a chemotherapeutic agent known to suppress fibroblast proliferation. It is used in ophthalmologic disorders and reduces scarring in upper aerodigestive surgery. No study of the effect of mitomycin C on cutaneous burns has been performed. This study examined burn healing in the presence of topical mitomycin C by evaluation of wound appearance, contraction, and histology in a pig model. METHODS: Standardized full-thickness burns were produced on the flanks of three pigs. One animal received no further therapy and was an external control. Two animals underwent placement of topical mitomycin C, 0.4 mg/ml, on selected burn sites for 5 minutes. This was repeated 2 and 4 weeks after injury. Evaluation was performed at 2 and 6 months using a clinical assessment scale and a visual analogue scale. Scar length and histologic analysis were also evaluated. RESULTS: Clinical assessment scale and visual analogue scale scores showed improved appearance in the untreated external control wounds versus the untreated internal control and treated wounds (p < 0.001). Wound contraction was not significantly different between groups. Histologic characteristics between groups were similar except for epidermal hyperplasia, which was decreased in the untreated external control (p < 0.05) at 2 months after treatment. CONCLUSIONS: Topical mitomycin C treatment of full-thickness burn wounds at 0.4 mg/cc for three courses does not improve, and may worsen, clinical appearance and scarring during early healing. There is no difference in histology during the long-term healing process. Scar contraction was unchanged.

What is the incidence of hypertelorism in Filipino frontonasal encephalocele patients?

It is unclear whether Filipinos with sincipital encephaloceles have true orbital hypertelorism or just telecanthus. Knowing this determines whether orbital osteotomies or medial canthoplasty are more appropriate corrective procedures. To evaluate this, 56 sequential Filipino sincipital encephalocele patients (28 female and 28 male, average age 66.6 months, age range 4 days to 21.8 years) were evaluated for orbital width. Soft tissue measurements of inner and outer canthal position and CT measurements of medial and lateral orbital wall position were obtained. Normative data curves by age and sex for orbital bony and soft tissue distances in normal Filipino children were developed. Data was plotted on these curves and analyzed to determine if encephaloceles were associated with medial widening alone or true hypertelorism. Inner canthal measurements for male were approximately +2.8 standard deviation (SD) and female +2.3 SD wider than average. Medial orbital wall dimensions were wider for male +1.5 SD and female +1.4 SD. Lateral orbital measurements for both male and female clustered around the normative mean (males -0.5 SD and females -0.8 SD). Female outer canthal measurements also clustered around the normative mean (+0.6 SD wider) while male outer canthal measurements averaged approximately +1.1 SD wider than mean. As expected, measurements were wider medially when compared to normative data. However, lateral bony and soft tissue widening was minimal or approached normative averages. This suggests the problem is medial widening only and less invasive procedures such as medial canthoplasty or nasal bony contouring may be the most appropriate surgical management.

Outpatient extended abdominoplasty in the patient with massive weight loss.

BACKGROUND: Extended abdominoplasty in the patient with massive weight loss has traditionally been performed as an inpatient procedure. To date, there has been no report on the safety of outpatient extended abdominoplasty in the patient with massive weight loss. OBJECTIVE: The authors sought to evaluate the safety of outpatient abdominoplasty in this growing population of patients. METHODS: A retrospective chart review was performed of all the senior author's (C.M.B.) patients with massive weight loss who underwent extended abdominoplasty from November 2004 to August 2006. Each case was evaluated for demographic information, patient weight (pre-gastric bypass, pre-contour), body mass index (pre-gastric bypass, pre-contour), weight of specimen, anesthesia type, estimated blood loss, operating room time, length of stay, and drain management. The complications were compared with historical control subjects. RESULTS: A total of 19 patients, 16 female and 3 male, underwent extended abdominoplasty after massive weight loss. The average weight loss was 142 pounds. The average pre-gastric bypass body mass index was 52 kg/m(2). The average pre-contour body mass index was 29 kg/m(2). The average operative findings were as follows: estimated blood loss, 130 mL; specimen weight, 3288 g; and operative time, 132 minutes. There was no perioperative blood transfusion. All patients (100%) were discharged the same day. Overall complications in 5 patients (26%) included stitch abscess (5%), partial umbilical necrosis (5%), superficial wound dehiscence (10%), and seroma and bleeding (5%) in the same patient. CONCLUSIONS: With appropriate patient selection and operative techniques, outpatient extended abdominoplasty can be performed safely in the patient with massive weight loss.

Complications of facial suspension sutures.

BACKGROUND: Barbed suture suspension has gained popularity as an inexpensive, "non-surgical" facial rejuvenation procedure. Initial studies on this procedure have reported minimal complications. OBJECTIVE: In this article, we review and evaluate several cases involving complications resulting from barbed suture suspension. METHODS: Four case histories of patients who required removal of suspension sutures because of symptomatic suture, failure, settling, or infection are summarized. The suspension sutures involved were examined after removal and compared to suture withdrawn through bovine muscle. RESULTS: Two patients reported chronic foreign body sensation. One patient had facial weakness. One patient had obvious dimpling. One patient had localized infection resulting from suture placement. On removal, the barbs on the suspension sutures appeared to be reflected against the direction of lift. Additionally, some sutures were clearly mobile. Forced withdrawal of new suture through bovine muscle did not result in similar anteversion of suture barbs. This would suggest the barb orientation noted at surgery was not the result of the removal process. Identification can be difficult, as the suture in some cases is clear. Once the sutures had been identified, they were easily pulled out without the need for additional surgical access. CONCLUSIONS: Suture suspension may gradually fail due to eversion of suture barbs or migration through tissues. Although the complication rate for this technique has been reported to be low, we believe that surgeons performing this procedure should be aware the rate may be higher than indicated in the literature.

Low fistula rate in palatal clefts closed with the Furlow technique using decellularized dermis.

BACKGROUND: Despite the advances in cleft palate closure over the past 20 years, postoperative fistulas are still a significant problem. Fistula rates average 10 to 23 percent, and it has been suggested that wide clefts have a higher rate of fistula formation. METHODS: In an attempt to improve closure rates, the authors placed decellularized dermal graft within the closure of 31 consecutive palatal cleft closures using the Furlow technique, with one attending surgeon. A retrospective review of this series of patients was analyzed for cleft width, Veau type, and rate of healing. RESULTS: Average cleft width was 12.2 mm (range, 8 to 15 mm). There were one Veau type I, five Veau type II, 20 Veau type III, and six Veau type IV patients. The average age at time of palate repair was 11.75 months (range, 8 to 28 months). One patient (Veau type IV, 15-mm width) developed fistula (3.2 percent fistula rate overall). There was no evidence of rejection, scarring, or impaired palatal motion by examination. CONCLUSIONS: A low fistula rate was obtained in Furlow technique palatal cleft repairs using decellularized dermis when compared with historical controls. Decellularized dermis may provide an additional barrier to wound breakdown in the postoperative period and may improve fistula rate.

Considerations for the head-injured air-evacuated patient: a case report of frontal sinus fracture and review of the literature.

Head and neck injuries are not uncommon in combat environments and may be increasing due to survivable injuries from the use of kevlar helmets and body armor. With the current capability of rapid evacuation from the battlefield, acutely injured patients with frontal sinus injuries may undergo further barometric challenges. Proper care during transport can prevent the occurrence of secondary injury (increased intracranial pressure, tension pneumocephalus) that would complicate the patient's management at the next level of care. Management principles (importance of low-level flight/pressurized cabin, preflight use of decongestants, avoidance of valsalva, and ability to manage complications either procedurally or by landing) are reviewed. In addition, we propose a simple mechanism for pressure equilibration of a compromised frontal sinus during air evacuation using an angiocatheter placed through the wound before closure.

Comprehensive head and neck trauma screening: the USS Cole experience.

A prospective study was designed to determine the incidence of occult head and neck injuries after initial triage of patients following the USS Cole terrorist bombing. All 39 patients evacuated to Landstuhl Regional Medical Center underwent comprehensive head and neck examinations, regardless of known diagnoses at the time of arrival. Appropriate interventions were performed, and detailed summaries were added to the patients' records. Initial triage listed nine of 39 patients as having sustained head and neck injuries. After screening by an otolaryngology team, 23 of 39 patients were identified as having head and neck injuries requiring further care. The majority of head and neck injuries were not initially reported to the head and neck trauma service. Our conclusion is that occult head and neck injuries are common after blast injuries. Early identification and intervention by a subspecialty head and neck trauma team can aid in achieving optimal outcomes after blast injury.

Otologic blast injuries due to the Kenya embassy bombing.

Otologic injuries are frequently associated with large blasts. On August 7, 1998, a large truck bomb exploded next to the U.S. Embassy in Nairobi, Kenya. Initial patient findings and care are reviewed. Five months later, an otologic screening and care mission was then sent to comprehensively screen all remaining blast victims on site in Nairobi and to determine degree of persistent injury. Surgical care appropriate for an outpatient environment was provided. Five of 14 tympanic membranes without intervention failed to heal, while 3 of 3 with previous intervention had. Blast injury severity did not correlate to distance from blast epicenter. This may be due to channeling of the blast through the embassy building and an unpredictable pattern of blast overpressure within the building. It is recommended that comprehensive otologic screening be performed after blast events to identify occult injuries and improve outcomes. Early intervention for tympanic membrane perforation (suctioning, eversion of perforations, and paper patch) is recommended.

Unilateral temporal muscle hypertrophy: a rare clinical entity.

Isolated unilateral temporal muscle hypertrophy is a rarely reported clinical entity with an unclear etiology. Consideration of a broad differential diagnosis combined with a detailed histologic and radiologic work-up will help the physician diagnose the underlying pathology. We report a new case of this uncommon entity, and we review the pertinent literature.

Kikuchi's disease: a case report and review of the literature.

Kikuchi's disease is a necrotizing lymphadenitis that is prevalent in Asia and is being increasingly recognized in other areas of the world. It usually occurs in women in their late 20s or early 30s and manifests as a posterior cervical adenopathy. It resolves spontaneously, usually over a period of several weeks to 6 months. Its initial clinical appearance is commonly similar to that of a lymphoma, and it can be pathologically misdiagnosed as such. Kikuchi's disease might be associated with systemic lupus erythematosus. We report a case of Kikuchi's disease that occurred in a 36-year-old Asian woman. We discuss the clinical features, differential diagnosis, radiographic evaluation, and pathology of this case, and we review the literature in an effort to assist otolaryngologists in diagnosing this benign and uncommon entity.