Amr N. Rabie

Designing the Anterolateral Thigh Flap without Preoperative Doppler or Imaging

The anterolateral thigh (ALT) flap is now considered a workhorse for head and neck reconstruction in many centers. However, designing and raising the ALT flap has been traditionally recognized as being difficult, tedious, and technically demanding due to its variation in perforator anatomy. Designing the ALT flap on data gained solely using the handheld Doppler can be misleading, as its specificity and sensitivity varies greatly depending on amount of subcutaneous fat and the Doppler itself. Authors have investigated multiple imaging modalities in the search of the best way to predict and map the site and size of perforators before dissecting a flap. In this article, we describe a simplified technique for the ALT flap design and dissection without the use of preoperative imaging or vascular studies. Utilizing anatomic landmarks, the location of the three perforators (A, B, and C) can be anticipated and safely dissected. We conclude that accurate use of the ABC system is one approach in consistently dissecting the ALT flap.

A novel surgical technique for management of tinnitus due to high dehiscent jugular bulb

Objectives: To assess the effectiveness of middle ear floor reconstruction in management of vascular tinnitus due to high jugular bulb with dehiscent middle ear floor. Study Design: Case series with chart review. Setting: Tertiary academic medical center. Subjects and Methods: We reviewed the medical records of seven patients with high dehiscent jugular bulb, presenting with incapacitating pulsatile roaring tinnitus that was abolished by digital compression of the ipsilateral jugular vein, from January 2002 to December 2006. The diagnosis was confirmed by CT scan of the temporal bone (bone window, coronal views). The seven patients were surgically explored, five under local anesthesia (to monitor the results with possible intraoperative revision) and two under general endotracheal anesthesia, for middle ear floor reconstruction that was done using bone dust, perichondrium, and tragal cartilage (mean follow-up 28 months). Results: Of the seven patients, tinnitus disappeared in four (57%) and decreased in one. The overall improvement was five of seven (71%). One patient had postoperative increased intracranial pressure. Conclusion: The preliminary results suggest that surgical reconstruction of the middle ear floor under local anesthesia offers valuable treatment for patients with incapacitating tinnitus due to dehiscent middle ear floor. However, the risk of sigmoid sinus thrombosis should be considered. To our knowledge, this is the first trial of multilayer reconstruction of the middle ear floor dehiscence to manage high jugular bulb causing tinnitus.

Three-dimensional Printing in Developing Countries

Summary: The advent of 3-dimensional (3D) printing technology has facilitated the creation of customized objects. The lack of regulation in developing countries renders conventional means of addressing various healthcare issues challenging. 3D printing may provide a venue for addressing many of these concerns in an inexpensive and easily accessible fashion. These may potentially include the production of basic medical supplies, vaccination beads, laboratory equipment, and prosthetic limbs. As this technology continues to improve and prices are reduced, 3D printing has the potential ability to promote initiatives across the entire developing world, resulting in improved surgical care and providing a higher quality of healthcare to its residents.

Staged scalp soft tissue expansion before delayed allograft cranioplasty: a technical report.

BACKGROUND: Hemicraniectomy is an established neurosurgical procedure. However, before cranial vault reconstruction, it is imperative that sufficient scalp soft tissue is available for coverage of the reconstructed skull. OBJECTIVE: To present 2 complex cases of posttraumatic patients requiring soft tissue expansion of the scalp before definite cranioplasty with use of a synthetic polyethylene graft. METHODS: Two patients underwent decompressive hemicraniectomy for trauma and required delayed cranioplasty. Both patients had developed significant scalp contraction and presented with a paucity of soft tissue. These patients underwent a staged cranioplasty in which we first achieved scalp-tissue expansion adjacent to the craniectomy site over a prolonged interval. In a second stage, the patient underwent definite reconstructive surgery in which the subgaleal expanders were removed and polyethylene allograft cranioplasty was performed. RESULTS: Cutaneous coverage of the underlying defect could be achieved in this setting without causing tension on the incision line secondary to the now available excess scalp tissue. CONCLUSION: Repair of a cranial defect requires detailed attention to the available scalp and its size relationship to the skull defect to achieve a successful outcome with an aesthetically pleasing, reliable, and lasting result. Preoperative scalp tissue expansion is a valuable step in taking care of patients presenting with scalp soft tissue defect. This technique reduces the morbidity associated with conventional rotational and free-flap techniques.

Effects of rhinoplasty on the internal nasal valve: a comparison between internal continuous and external perforating osteotomy.

The purpose of the study was to compare the effect of 2 widely used methods of lateral osteotomy on the internal nasal valve (INV) by measuring minimal cross-sectional area using acoustic rhinometry (AR) and computed tomography (CT) in the pre- and postoperative setting.Thirty adult patients noting nasal deformity requiring rhinoplasty were enrolled. Patients were divided into 3 groups of 10 patients. Patients in group 1 had bilateral lateral osteotomies by the internal continuous technique. In group 2, lateral osteotomies were performed by the external perforating technique. In group 3, osteotomies were performed by the external perforating technique on the left side and by the internal continuous technique on the right side in the same patient. Each patient had their INVs measured pre- and postoperatively at 6 weeks using AR and CT of the nasal bones.Lateral osteotomy decreases the INV (measured by both AR and CT scan) (P < 0.009). There was no statistically significant difference between the 2 types of osteotomies with respect to the degree of narrowing on the INV (CT-derived P = 0.24 and AR-derived P = 0.60).When comparing AR and CT data regarding the INV, we observed a measurable decrease in the nasal airway after lateral osteotomy in all patients. There was no statistically significant difference to conclude that either internal continuous osteotomy or external perforating osteotomy caused more narrowing of the nasal airway.

Use of intraoperative computed tomography in complex facial fracture reduction and fixation.

Background:Using conventional complex facial fracture management principles, confirmation of adequate facial fracture reduction can be achieved only by obtaining a postoperative computed tomography (CT) scan. If the CT scan revealed any discrepancy in fracture alignment, additional procedures for correction may be required. The concept of intraoperative CT scanning provides immediate postreduction or intraoperative information that orients the surgeon to the potential need for additional maneuvers for improved fracture reduction and osseous fixation. We assessed the early technical feasibility of real-time intraoperative CT scanning using the xCAT ENT (Xoran Technologies, Inc, Ann Arbor, MI), for monitoring of fracture reduction with the possibility of immediate intraoperative revision if needed, potentially obviating the need for revision procedures. Methods:Three adult patients were studied who were admitted from the emergency department. During their respective reconstructive procedures, the xCAT ENT was used to provide images: Axial, coronal, sagittal, and three-dimensional reformatted images with segmentation of the CT data set and mirroring of the reconstructed side to the unaffected side were used for precise measurement and comparison of the reconstruction. The scans were examined by the operating surgeon and an intraoperative decision was made as to whether immediate revision was required. Results:Facial fracture management with intraoperative CT monitoring was changed in 2 of the 3 cases. One patient who underwent immediate revision had an open reduction-internal fixation after cranialization. The second patient who had a revision had a persistent subcondylar fracture that was found not amenable to closed reduction. Conclusions:The intraoperative CT scan may positively change the outcome of facial fracture reduction especially when dealing with complex fractures. Additional studies are needed for studying its potential impact in monitoring reduction of facial fractures.

Vasopressors and reconstructive flap perfusion: a review of the literature comparing the effects of various pharmacologic agents.

IntroductionUse of intraoperative vasopressors is of debate in microvascular surgery. Anesthesia is an important factor in maintaining the rate of success of flap transfer by affecting regional blood flow and global hemodynamics. We conducted a review of the literature comparing the use of different vasoactive agents on different flaps in various human and animal models. MethodsA systematic review of the literature was performed. Bibliographies of key articles were also reviewed for additional resources. Analysis was done to determine the overall trend of how flap perfusion is affected by the use of intraoperative vasoactive medication. ResultsThe literature search identified 16 relevant articles. Flaps were studied in pigs in 7 studies, rats in 5, and humans in 4. The most common flap was the rectus abdominis musculocutaneous flap. Phenylephrine and norepinephrine were the most common pressor agents used. No significant statistical changes were noted in 8 of the 16 studies; initial ischemia followed by delayed improved perfusion was observed in 4 studies, “true ischemia” and hypoperfusion of the skin flaps was noted in 3. There was no consistency in their effect on flap perfusion: initial ischemia followed by delayed improved perfusion was observed in 4 studies, whereas true ischemia and hypoperfusion of the skin flaps was noted in 3. ConclusionsTo date, there is no reliable prospective clinical evidence that supports the absolute contraindication of pressor agents during free flap surgery. This topic will continue to be a matter for debate until more definitive data can be obtained.

Static Treatment Modalities in Facial Paralysis: A Review

INTRODUCTION Facial nerve dysfunction can be attributed to several different causes. Several techniques have been developed to help treat the appearance and functional limitation of patients with sequelae of facial nerve dysfunction. There are options regarding static techniques of facial nerve injury treatment that range from facial musculature plication or shortening, fascial sling suspension via allograft or autograft, injectables and implants (ENDURAGen, AlloDerm, LifeCell, Bridgewater, New Jersey, USA) to techniques such as brow lift, open and endoscopic facelifts, and various eyelid surgeries with upper and lower lid procedures. In this review the various static facial nerve treatment modalities are discussed. METHODS AND RESULTS A comprehensive review of the literature was performed detailing the most common static facial nerve treatment modalities and their known results and complications. CONCLUSIONS There are individual issues associated with facial palsy for which individual solutions must be carefully tailored. Despite the presence of many surgical options, the results of reconstruction are limited. With the rapid advancement of surgical techniques, approaches to the management of facial nerve dysfunction have expanded, helping surgeons to improve and utilize alternative techniques for the treatment of patients with acute and chronic facial paralysis.

Common patterns of reconstruction for Mohs defects in the head and neck.

BackgroundSkin cancer is the most common of all cancers. Mohs surgery is an effective technique for removing common types of skin cancer. The number of patients presenting for reconstruction after Mohs surgery has been increasing in recent years. Reconstructive surgeons are faced with diverse defects of different sizes and locations. The aim of this study was to examine reconstructive methods for Mohs defects to aid in preoperative planning. MethodsWe reviewed the charts of 245 patients who underwent Mohs defect reconstruction over a period of 5 years. The patients were categorized according to the reconstructive technique (eg, flap, full-thickness skin graft, split-thickness skin graft) used in relation to anatomic location and the size of the defect. ResultsOne hundred twenty-nine patients (53%) had Mohs defects of the nose. Bilobed flap reconstruction was the most common for the nasal ala (17/42 [40%]), tip (19/41 [46%]), and nasal sidewall (8/25 [32%]). Forehead flap reconstruction was most common for nasal dorsum defects (9/16 [56%]). Linear closure was the most common reconstructive technique for the cheek (18/34 [53%]), the forehead (13/20 [65%]), the chin (4/4 [100%]), the lower lip (4/4 [100%]), the upper lip (8/13 [38%]), the auricle (4/10 [40%]), the eyelid (5/8 [62%]), and the temporal region (2/5 [40%]). Composite grafting was the most common in the nasal columella (2/3 [67%]) and full-thickness skin graft for nasal sill defects (2/2 [100%]). Split-thickness skin graft was the most common in the scalp (3/6 [50%]). ConclusionsVarious options exist for Mohs repair. Understanding trends of reconstructing Mohs defects may help in planning the best method of reconstruction.

Dynamic rehabilitation of facial nerve injury: a review of the literature.

INTRODUCTION Given the morbidity caused by facial nerve paralysis, there have been consistent approaches to treatment over the past 20 years in reanimation of the facial nerve. Treatment depends on accurate clinical examination, a good understanding of the anatomic course, and appropriate diagnostic tests. There are various options when it comes to dynamic facial nerve reanimation that range from nerve grafting, nerve anastomosis, crossover techniques and muscle transfer to microneurovascular muscle flaps, and-recently-potentially new concepts with microelectromechanical systems (MEMS) technology. The various dynamic facial nerve treatment modalities are discussed. METHODS AND RESULTS A comprehensive review of the literature was performed detailing various techniques used for dynamic rehabilitation following facial nerve injury and their known results and complications. CONCLUSIONS Currently, techniques have been attempted to achieve adequate dynamic facial reanimation of the paralyzed facial nerve. Despite the advances that have occurred in the last few years, it has been classically very difficult to achieve a House-Brackmann grade better than grade III. Outcomes are improving. Ultimately, the approach depends on the surgeons experience.