Simultaneous transfer of free fibula and radial forearm flaps for complex oromandibular reconstruction.

Several composite free flaps have been described for use in oromandibular reconstruction. Particularly in extensive defects, there may be no single flap which combines sufficient bone stock with thin, pliable, soft tissue. By combining two free flaps, the best osseous and soft-tissue elements may be independently selected, to yield a result superior to that achievable with one free flap alone. Thirteen patients underwent reconstruction of extensive oromandibular defects using the free fibula for mandibular reconstruction and the free radial forearm flap for oral lining and soft-tissue reconstruction. Mandibular defects were usually extensive, involving over half of the mandibular contour. Soft-tissue defects were all complex and involved multiple surfaces of the oral, oropharyngeal, and nasopharyngeal mucosa. All patients were operated on in the supine position by two surgical teams (extirpative and reconstructive) working simultaneously. Each free flap was supplied by its own set of recipient vessels. The mean total operating time was 12 hr. Postoperative courses were without mortality or significant morbidity. There were no flap failures. Soft-tissue and osseous reconstructions healed completely. Aesthetic contour was judged good to excellent in 11 patients. Soft and solid diets were achieved in five patients, with six patients on a purée or liquid diet. Oral competence was present in 11 patients. Speech was excellent to good in six patients and fair in four patients. The mean follow-up has averaged 18 months. Three patients have died of recurrent disease, and two of unrelated causes. The remaining eight patients are currently free of disease. In combining the free flaps, the best tissue for bone and soft-tissue reconstruction was selected independently. The two-team approach avoided excessive operating time and operating team fatigue. The added degree of freedom provided by the two free flaps with their independent pedicles made insetting easier, compared to working within the limitations of a single composite flap. For extensive oromandibular defects, the simultaneous free fibula and radial forearm free flaps provided ideal osseous and soft-tissue reconstruction, with acceptable operating times and reasonable functional results.

Complex dislocation of the index metacarpophalangeal joint with entrapment of a sesamoid.

Entrapment of a sesamoid in a complex dislocation of the index metacarpophalangeal joint is a rare finding that may make even open reduction difficult. A case of unusual anatomic derangement of the volar plate is reported that highlights the underlying pathophysiology of complex dislocations.

Total lower lip reconstruction with a sensate composite radial forearm-palmaris longus free flap and a tongue flap.

The technique of total lower lip reconstruction with a composite radial forearm-palmaris longus free flap was further refined in this report. A ventral tongue flap enhanced the lip aesthetics by recreating the vermilion. Lip suspension was enhanced by securing the palmaris tendon to the malar eminences as well as to the cut ends of the orbicularis oris muscle. The patient achieved oral continence as well as dynamic movement of the lip during speaking and swallowing.

Transverse lag screw fixation of the midline mandibulotomy.

Transverse lag screw osteosynthesis of the midline mandibulotomy is a rapidly performed technique that results in reestablishment of mandibular integrity and avoids placement of hardware directly beneath a suture line. We have performed transverse lag screw osteosynthesis in four patients over the past 14 months. All patients received postoperative radiotherapy. Soft-tissue and bone healing have been uneventful.

Endoscopic-assisted carpal tunnel release: a coupling of endoscopic and open techniques.

Endoscopic-assisted carpal tunnel release (CTR) is a blending of the techniques of the open and endoscopic methods of carpal tunnel release. Endoscopic-assisted CTR increases visualization and safety over commonly performed endoscopic techniques while retaining the advantage of a smaller, more distally located scar and less dissection.

Metastatic cutaneous squamous cell carcinoma of the head and neck region.

Cutaneous squamous cell carcinoma has a relatively low metastatic rate (0.5% to 16%), but patients with the disease should always be evaluated for possible regional nodal involvement. We reviewed the records of 37 patients with metastatic disease among the 388 patients with head and neck cutaneous squamous cell carcinoma who were treated at New York University Medical Center between 1961 and 1992. In this group of patients the most common primary sit was the cheek or preauricular region and the most common metastatic site was the level I neck lymph nodes. Seven patients (18%) had metastases at initial presentation. Among the remaining patients the average time to the development of metastases was 19 months. Nineteen patients (51%) had recurrence at the primary site before metastasis; 11 (30%) developed metastases with control of the primary tumor. Analysis of the records of 31 patients treated for cure revealed that 13 were treated by surgery, 2 by radiation therapy, and 16 by a combination of surgery and radiation therapy. During the mean follow-up period of 49 months, 11 (35%) of these 31 patients died of their disease. Recurrence of the primary tumor appeared to increase the risk for nodal and distant metastases.

Poorly differentiated pediatric head and neck neuroblastoma: a diagnostic dilemma.

Primary pediatric head and neck neuroblastoma is rare, with metastatic disease being the more common mode of involvement in this anatomic region. Poorly differentiated neuroblastoma initially presenting in head and neck locations presents a diagnostic dilemma, especially when evidence of primary disease in typical abdominal, retroperitoneal and thoracic sites is lacking. This tumor cannot easily be distinguished from the other common pediatric small round cell malignancies that may originate in or metastasize to the head and neck. Recent years have seen great strides in the immunohistochemical as well as cytogenetic characterization of certain pediatric small round cell lesions. A never before reported solitary, poorly differentiated neuroblastoma of the right parotid gland in a 20-month-old female is presented in order to familiarize the otolaryngologist with the modern diagnostic armamentarium available for the accurate characterization, and thus appropriate workup and treatment of this disease.

Metastatic basal cell carcinoma of the head and neck.

Metastases are occasionally associated with cutaneous squamous cell carcinoma but only rarely with basal cell carcinoma. There are approximately 200 cases of metastases from basal cell carcinoma reported in the world literature. We describe 6 additional cases. All of our patients demonstrated recurrence at the primary site before they developed their metastases. Metastases presented in subcutaneous tissue, cervical lymph nodes, bone, and lung between 1.5 and 14 years after initial treatment of the primary lesion. The long interval seen in these patients between the initial treatment of the primary and the development of metastases underscores the need for long-term follow-up in what is often thought to be a nonaggressive, nonmetastasizing malignancy.

Problems in postoperative management after anterior cricoid split.

OBJECTIVE: Describe complications and postoperative management problems associated with the anterior cricoid split. DESIGN: Retrospective case series. SETTING: Urban referral hospital. PATIENTS: Nine consecutive patients with acquired subglottic stenosis believed amenable to the anterior cricoid split. INTERVENTION: The anterior cricoid split was performed on 10 occasions between June 1989 and June 1992. MAIN OUTCOME MEASURE: Extubation or decannulation. RESULTS: Six of nine patients underwent decannulation, with success. Management problems included those related to surgery or postoperative endotracheal stenting, preexisting medical conditions, and postoperative sedation requirement. CONCLUSIONS: The number of postoperative complications and management problems was highest in those patients with both bronchopulmonary dysplasia and preexisting tracheotomy.

Nasal pyriform aperture stenosis and the holoprosencephaly spectrum.

Recent reports have described congenital nasal pyriform aperture stenosis, but do not address its etiology in detail. We describe a child with nasal pyriform aperture stenosis, submucus cleft palate, and hypoplastic maxillary sinuses. Chromosome analysis revealed a ring chromosome 18. Awareness of the association of midline facial defects with midline brain defects allowed us to predict that features of the holoprosencephaly sequence would be found. Subsequent evaluation revealed growth hormone deficit. Eventually the child manifested a single central incisor. We review the association between midline facial defects and holoprosencephaly to remind the otolaryngologist of the need to look at the whole patient as he treats specific upper airway problems.