Endoscopy-Assisted Frontal Sinus Obliteration.

Comminuted fractures of the anterior table of the frontal sinus involving frontonasal ducts are traditionally treated with sinus obliteration. This technique entails precise mucosa removal which requires unimpeded visualization of the bony recesses. To achieve adequate access to the mucosa, temporary removal of a large part of the frontal bone may often be necessary. This in turn increases fracture comminution requiring placement of additional hardware associated with the risk for bony malalignment, infection, plate palpability, and visibility, especially in thin-skin individuals. Endoscopy, offering magnified visualization and less invasive access, is reported to be beneficial in sinus injury management. Therefore, it may be also considered an adjunct in open-approach management of severely comminuted fractures.The authors' patient suffered from comminuted fractures of the anterior and posterior tables of the frontal sinus and nasal bone fractures with involvement of the frontonasal ducts. Due to the extent of the injury he underwent frontal sinus obliteration procedure using the pericranial flap. To avoid additional osteotomy, endoscopic approach was undertaken to achieve the complete removal of the sinus mucosa. The fracture by itself offered an "access port" for the endoscope and electrical cautery. The patient's recovery was uneventful.Endoscopy employed in frontal sinus obliteration appears to be instrumental in obtaining meticulous mucosa removal, obviating the need for additional osteotomy of the frontal bone.

Application of a Skin Adhesive to Maintain Seal in Negative Pressure Wound Therapy: Demonstration of a New Technique.

Optimal wound healing with negative pressure wound therapy (NPWT) relies on a properly sealed vacuum system. Anatomically difficult wounds impair the adhesive dressing, which results in air leaks that disrupt the integrity of the NPWT system and hinder wound healing. OBJECTIVE: The authors demonstrate a new technique using a cyanoacrylate-based tissue adhesive to maintain an airtight, durable seal in NPWT. MATERIALS AND METHODS: A 52-year-old woman with a degloving injury to the right thigh extending into the groin, resulting in massive necrosis, presented to the emergency department. Using a skin closure system, 2 polyester mesh tape strips were placed near the perineal region of the wound to reinforce the adhesive drape of the NPWT system. Skin grafts were applied over the wound after about 3 weeks of NPWT, and the skin closure system was applied in the same fashion to reinforce the adhesive drape. RESULTS: An airtight seal was consistently maintained for several days in between dressing changes. The size of the wound was visibly reduced at each dressing change. An airtight seal was maintained for 5 days after placement of the skin grafts; after 5 days, the dressing was removed without difficulty and skin irritation. The skin grafts appeared healthy with adequate tissue take. CONCLUSIONS: Maintaining an airtight seal in NPWT is crucial to wound healing. Cyanoacrylate tissue adhesives appear to be a safe and viable option for creating a durable seal in NPWT for wounds in anatomically difficult locations.

Mandibular growth following reconstruction using a free fibula graft in the pediatric facial skeleton.

BACKGROUND: Mandible reconstruction in the growing facial skeleton is challenging, especially with reconstructions necessitating free vascularized bone grafts. The need for further combined orthodontic-orthognathic intervention at skeletal maturity must be anticipated. The growth potential of these grafts and potential new problems associated with performing a sagittal split osteotomy at skeletal maturity are poorly understood. METHODS: A retrospective chart review revealed 11 patients who underwent reconstruction with a free fibula at The Hospital for Sick Children from 1990 to 2000. Radiographic and photographic studies were assessed for long-term growth of the reconstructed mandible, with follow-up ranging from 2 to 12 years. RESULTS: Of the 11 patients who underwent reconstruction with a free fibula, two had surgery at skeletal maturity, two moved out of the country, one died as a result of her malignancy, and one was lost to follow-up. The remaining five patients are being followed by the craniofacial and orthodontic services and have not reached skeletal maturity. Of the two patients who have had orthognathic surgery, the one patient whose reconstruction involved the temporomandibular joint exhibited no growth on the reconstructed side and required a 57-mm advancement on the reconstructed side. The other patient, who had preservation of the temporomandibular joint at the time of reconstruction, required only a 5-mm advancement on the reconstructed side. Both patients had significant surgical complications as a result of the initial reconstructive techniques. Technical modifications necessary at the initial reconstruction became apparent when the authors performed a sagittal split osteotomy on the reconstructed side. CONCLUSIONS: Certain technical modifications to the original free fibula reconstructed pediatric mandible should be considered in anticipation of the need for a subsequent bilateral sagittal split at skeletal maturity.