Akram Rahal

Nontuberculous Mycobacterial Adenitis of the Head and Neck in Children: Experience From a Tertiary Care Pediatric Center†

Objective To describe our experience with the diagnosis, surgical treatment, and outcome of nontuberculous mycobacterial (NTM) adenitis of the head and neck in children, and to present a preliminary report about the use of NTM skin tests in our institution.

Mitomycin C in sinus surgery: preliminary results in a rabbit model.

Mitomycin C (MMC) is an antineoplastic agent with an antiproliferative effect on fibroblasts. It is routinely used topically in ophthalmology. The goal of this research project is to evaluate if topically applied MMC at the site of a maxillary antrostomy will inhibit the healing process of the mucosa and reduce the risk of postoperative stenosis. Antrostomies were carried out in both maxillary sinuses of 10 rabbits. For each rabbit, MMC is applied at the site of the antrostomy on one side while the other side serves as control. Antrostomies are re-evaluated 3 weeks later and their areas measured precisely. Seven of 10 control antrostomies were closed compared to only 1 of the 10 treated with MMC (p = .014). Comparison of the areas of the control and treated sides also proved to be statistically significant (p = .0039). Topical application of MMC was not associated with any systemic side effects and did not cause any permanent microscopic changes since the mucosa re-epithelialized normally. These results suggest that MMC slows the postoperative healing process of the nasal mucosa of the rabbit without affecting re-epithelialization. This could allow antrostomies to heal with a wider diameter, decreasing the risk of postoperative stenosis. Our next step will be to reproduce these results following functional endoscopic surgery on humans.

Single-Puncture Arthrocentesis―Introducing a New Technique and a Novel Device

F b rthrocentesis of the temporomandibular joint was ntroduced in 1991 by Nitzan et al and has since ained widespread popularity among practitioners ho treat temporomandibular joint disorders. It is onsidered by many as the first-line surgical treatment or patients who do not respond to conservative treatent (physical therapy, occlusal splint therapy, pain edication, and lifestyle and behavioral changes). It is egarded as a minimally invasive procedure and is asily performed in an office setting. It allows lavage f the joint space and lysis of adhesions via hydraulic istension. The traditional procedure uses 2 needles inserted hrough 2 separate puncture sites. These 2 needles ust triangulate and be exactly placed in the upper oint space for the procedure to be efficient. One of he needles serves for the inflow of the lavage olution and the second as the outflow. It is recogized that the procedure can be sometimes very hallenging. The blind insertion of the second (outow) needle can sometimes be difficult. Multiple unctures through the temporomandibular joint apsule are often necessary, which often leads to xtra-articular leak of the lavage solution and dereases the intra-articular pressure required for lysis f the adhesions. We have developed a new device where two 18auge needles 1.5 inches long are each bent 30 derees toward their respective opening and welded

Facial artery musculomucosal flap for reconstruction of skull base defects: A cadaveric study

Failure in skull base defects reconstruction following tumor resection can have serious consequences such as ascending meningitis and pneumocephaly. The nasoseptal flap showed a very low incidence of cerebrospinal fluid leak but is not always available. The superiorly pedicled facial artery musculomucosal (FAMM) flap has been successfully used for reconstruction of head and neck defects. Our objective is to show that the FAMM flap can be used as a new alternative in skull base reconstruction.

Lengthening temporalis myoplasty for facial paralysis reanimation: an objective analysis of each surgical step.

IMPORTANCE Lengthening temporalis myoplasty is a dynamic procedure used to reanimate the middle third of the paralyzed face. Since its original description, it has been progressively modified over the years, with a reduction in the number of surgical steps. However, these modifications can decrease lengthening needed for the tendon to reach the oral commissure and upper lip without tension or overcorrection. OBJECTIVES To evaluate the maximal lengthening of the temporalis tendon that is possible with this technique and to assess the contribution of each surgical step to total lengthening. DESIGN, SETTING, AND PARTICIPANTS Cadaveric dissection study from September 16 to 23, 2013, at a tertiary referral center using 10 cadaveric hemifaces. MAIN OUTCOMES AND MEASURES Surgical exposure was obtained using coronal and melolabial incisions. The original surgical technique was broken down into 7 steps. Measurement of temporalis tendon lengthening relative to a fixed point was performed by a single surgeon after each surgical step using a millimeter ruler. RESULTS Each surgical step resulted in progressive temporalis tendon lengthening for a median maximal total lengthening of 43.5 mm. The steps that contributed most to this lengthening were coronoidotomy and intraoral temporalis tendon dissection (median, 12.0 mm), incision of temporalis fascia insertion over the orbital rim (median, 6.5 mm), and zygomatic osteotomy with dissection of masseteric fibers (median, 11.5 mm), which represent the first and last 2 steps of the procedure, respectively. CONCLUSIONS AND RELEVANCE Modifications of lengthening temporalis myoplasty must be considered with caution because the maximal lengthening potential can be obtained only when performing all 7 surgical steps. These modifications must be chosen appropriately based on the lengthening required for the temporalis tendon to reach the oral commissure and upper lip without tension or overcorrection. LEVEL OF EVIDENCE NA.

A Novel Technique for Malar Eminence Evaluation Using 3-Dimensional Computed Tomography

OBJECTIVE To describe a novel method to locate the malar eminence using 3-dimensional computed tomography (3D-CT), and a new axis system for evaluation of malar eminence symmetry. METHODS A retrospective case series was carried out in 42 disease-free white adult patients. The 3D-CT reconstructions of the face were obtained, and the soft-tissue maxillozygion was used to locate the malar eminence. Other skeletal and soft-tissue landmarks (frontozygomatic suture, zygion, and orbitale) were evaluated. A patient-oriented axis system was constructed using 3 sagittal midline landmarks (nasion, subspinale, and basion). Coordinates were obtained for each landmark, and symmetry was evaluated. RESULTS Twenty-one men and 21 women with mean ages of 41.1 and 41.3 years, respectively, were included. The malar eminence was easily localized using the 3D-CT technique for soft-tissue maxillozygion identification. Clinical asymmetry at the level of the soft-tissue maxillozygion was 40.5% (95% CI, 25.0%-56.0%). Other landmarks showed a prevalence of clinical asymmetry ranging from 24.0% to 50.0%. CONCLUSIONS The malar eminence can be easily and precisely located using the 3D-CT soft-tissue maxillozygion landmark. A reliable patient-oriented axis system can be defined using nasion, subspinale, and basion. The prevalence of malar eminence asymmetry in our study was 40.5%.

The submental island flap for soft-tissue head and neck reconstruction: step-by-step video description and long-term results.

Summary: A clinical case of a man undergoing radical parotidectomy with skin resection for an intraparotid recurrence of squamous cell carcinoma is presented. A step-by-step video description of the regional submental island flap, based on the right submental vessels, is presented and discussed. Long-term results at 1 year in terms of color match at the recipient and donor sites are excellent, along with no functional consequence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Precise Anatomical Study of Rhinoplasty Description of a Novel Method and Application to the Lateral Crural Steal

IMPORTANCE The prediction of nasal tip position in terms of projection, rotation, and length is a major challenge in rhinoplasty. Studies using preoperative and postoperative photographs lack accuracy owing to variable position, and computer-simulated models lack clinical applicability. OBJECTIVES (1) To describe an accurate and reproducible technique to study the effect of surgical manipulations on the nasal tip; and (2) to describe the effect on the nasal tip cartilages of the lateral crural steal (LCS). DESIGN, SETTING, AND PARTICIPANTS Cadaveric study in a tertiary hospital center using 10 cadaveric specimens. INTERVENTIONS Heads were placed in a Mayfield head holder, and a 12.2-megapixel camera was fixed on a tripod in a perfectly still position and focused on the surgical field during all surgical manipulations. An external rhinoplasty approach was performed for all specimens, and a 4-mm LCS was achieved. MAIN OUTCOMES AND MEASURES Measures include tip projection, tip rotation, and nasal length using preoperative and postoperative photographs. RESULTS Our method was successfully performed on all specimens: LCS resulted in a significant mean increase in projection using the Goode ratio (mean, 0.05; P = .005) and rotation (mean, 13.2°; P = .005). However, absolute tip projection variation was inconsistent, ranging from -1.0 mm to 0.6 mm. Nasal length was significantly shortened in all cases (mean, 1.3 mm, P = .005). CONCLUSIONS AND RELEVANCE We describe the first technique for precise anatomical study of tip position in rhinoplasty on cadaveric specimens. This technique was successfully applied to 10 consecutive nasal tips. We have shown a significant increase in projection using the Goode ratio and rotation with LCS. However, the effect on absolute projection is inconsistent. LEVEL OF EVIDENCE NA.

Superiorly based facial artery musculomucosal flap: A versatile pedicled flap

The superiorly based facial artery musculomucosal (FAMM) flap is pedicled on the angular artery. This flap offers a well‐vascularized mucosal surface allowing closure of medium size defects, most frequently within the oral cavity and intranasal region.

Decreasing Revision Surgery in FAMM Flap Reconstruction of the Oral Cavity: Traditional Versus Modified Harvesting Technique: Modified vs. Traditional FAMM Flap

To compare the surgical and functional outcomes between two harvesting techniques for the inferiorly based facial artery musculomucosal (FAMM) flap for oral cavity and oropharynx reconstructions.