Reconstruction of the external ear using implant-supported alloplasts-Our experience.

Surgical reconstruction of the missing external ear is difficult, and the results are often far from satisfactory. An implant-retained auricular prosthesis is a suitable alternative. Microtia, malformation, deformity, and partial or complete loss of the external ear may be due to various congenital or acquired factors. A case series of three patients treated with implant-retained auricular prostheses is presented in this article. For each missing pinna, two titanium implants were placed in the temporal bone. After 6 months of osseointegration, the implants were loaded. All three cases were rehabilitated with a bar and clip retained prosthesis. There were two male and one female patient with an average age of 16.6 years. One patient had unilateral absence of external ear and two had bilateral absence. A total of 10 implants were placed, 4 on the right side and 6 on the left. The average post rehabilitation follow-up was 18 months. Peri-implant tissue reactions were observed at two sites. The implant-retained auricular prosthesis is an alternative treatment approach with good retention and patient satisfaction. Long-term follow-up is required to assess delayed sequelae.

Feasibility and Reliability of Microvascular Reconstruction in the Vessel-depleted Previously Operated Neck.

BACKGROUND: Microvascular reconstruction of defects in the head and neck has always been a challenge in patients who have undergone previous neck dissection, owing to the prior resection of potential recipient blood vessels used for free flap perfusion. OBJECTIVE: The objective of the study is to evaluate the reliability and safety of free flap reconstruction in patients who have had previous neck dissection. MATERIALS AND METHODS: Twenty-four free flaps were performed in 22 patients with a previous history of neck dissection for head-and-neck squamous cell carcinoma. These included patients who underwent salvage surgery for recurrent cancer as well as patients undergoing secondary reconstruction following previous oncological resections. Flap includes 12 radial forearm free flaps, 5 fibula flaps, 1 rectus abdominis flap, and 6 anterolateral thigh flaps. RESULTS: In cases with the previous history of selective neck dissection, recipient vessels on the ipsilateral/same side of the previously operated neck were used, while contralateral vessels were used in patients with a history of modified radical or radical neck dissection. Vein grafts were not necessary, except for one case. In our series, we did not have any flap loss or considerable increase in operative time. CONCLUSIONS: Free flap reconstruction of head-and-neck defects is highly successful in patients with a history of previous neck dissection, despite a relative scarcity of recipient blood vessels. Careful planning and relying on flaps with a long vascular pedicle obviates the need to perform a suitable vein graft. In our present series, careful planning and the right choice of a free flap with a long vascular pedicle contributes to the absence of free flap failure. In our experience, previous neck dissection should not be considered as a contraindication to microvascular reconstruction of previously operated oncologic defects.

Anterior Tonsillar Fossa Approach to Elongated Styloid Process.

AIM: To demonstrate the efficacy of a new novel anterior tonsillar fossa approach in management of elongated styloid process syndrome. MATERIAL AND METHOD: We operated upon 20 patients with confirmed, symptomatic elongated styloid process. None of these patients gave a previous positive history of trauma or any other procedure relating to tonsillar area. All these patients had undergone treatment or were under treatment for neuralgia/TMJ dysfunction syndrome. Diagnosis was confirmed by clinical examination followed by radiological findings. RESULTS: 12 patients underwent bilateral styloidectomy (60%) and 8 patients, underwent unilateral styloidectomy (40%). The length of stolid process ranged from 34mm to 62mm (mean 44 mm). Post operative follow up period ranges from 6 months to 12 months.17 patients (85%) were asymptomatic & had complete remission of symptoms over a follow up period of 12 months. 2 patients had partial remission of symptoms & 1 patient was lost to follow-up. CONCLUSION: Our anterior tonsillar fossa approach to elongated styloid is safe & adequate in effective surgical management & more so with an additional advantage of not requiring tonsillectomy which is often performed in trans-pharyngeal technique.

Vascular Analysis of Radial Artery Perforator Flaps.

BACKGROUND: Radial forearm free flap with all its present day modifications is the workhorse of soft tissue reconstruction in head & neck. Although there are several advantages, it requires the sacrifice of a major artery of forearm. There are several modifications of harvesting a forearm flap based on perforator principles. A clear understanding of vascular anatomy of individual perforators relative to its vascular territory & flow characteristics is essential for both flap harvest & design. The purpose of this cadaveric observational anatomical study was to determine the location, size & vascular territory of the radial artery cutaneous perforators. MATERIALS AND METHODS: 12 fresh human cadavers & 24 cadaveric forearms were dissected to determine the total number, location, size & vascular territory of radial artery adipo-fascio cutaneous perforator. The cutaneous territory of distally dominant perforators was analyzed using methylene blue injections & three-dimensional computed tomographic angiogram. RESULTS: In the 12 fresh human cadavers & 24 forearm specimens, a total of 222 perforators were dissected for an average of 18.5 radial artery perforators per forearm. Of the total 222 perforators dissected 118 were smaller than 0.5mm in diameter (53.15%) these were not clinically significant. 104 perforators were greater than 0.5mm in diameter (46.84%) these were clinically significant. Of the 222 radial artery perforators dissected, 127 perforators (57.20%) were radially distributed & 95 perforators (42.79%) had ulnar distribution. A total of 90 perforators (40.54%) were identified on distal side (Radial styloid) & 132 perforators (59.45%) were identified on proximal side (Lateral epicondyle). Mean number of perforators on radial side was 10.6 & 7.9 on ulnar side, a comparison of both using student t paired test gives a P value of 0.006, which was statistically significant. Comparison of mean number of perforators on the distal side was 7.5 & proximal side was 11.0, Student Paired t test gives a P value of 0.003, which was statistically significant. Comparison of mean Diameter of perforators between the Distal side (1.11) & Proximal side (0.86) using Student Paired t test gives a P value of 0.01 which was statistically significant. A chi square test was done to compare mean diameter of perforators on distal side, which were more than 1mm (80%) & less than 1mm (20%) & on proximal side more than 1mm (35.6%) & less than 1mm (64.4%). Chi square value of 42.406 was obtained, degree of freedom value was 1& P value of <0.001 was achieved which was found to be highly significant. Methylene blue injections into the proximal part of radial artery demonstrated clusters both in proximal & distal forearm & also cutaneous territory of flap. Three- dimensional computed tomographic angiography reveals a network of linking vessels found to communicate between adjacent perforators & running parallel to radial artery. Large network of linking vessels could be found between fascia & dermis, which also explains the ability to harvest forearm flap at the supra-fascial level. CONCLUSION: Increase in knowledge of vascular territory of radial artery perforators with regards to numbers, size, location, and cutaneous territory can lead to expanded use of radial forearm flap based on either distal or proximal perforator alone, without sacrificing the radial artery.