Bernard L. Markowitz

Management of the medial canthal tendon in nasoethmoid orbital fractures : the importance of the central fragment in classification and treatment

The medial canthal tendon and the fragment of bone on which it inserts (“central” fragment) are the critical factors in the diagnosis and treatment of nasoethmoid orbital fractures. The status of the tendon, the tendonbearing bone segment, and the fracture pattern define a clinically useful classification system. Three patterns of fracture are appreciated: type I—single-segment central fragment; type II—comminuted central fragment with fractures remaining external to the medial canthal tendon insertion; and type III—comminuted central fragment with fractures extending into bone bearing the canthal insertion. Injuries are further classified as unilateral and bilateral and by their extension into other anatomic areas. The fracture pattern determines exposure and fixation. Inferior approaches alone are advised for unilateral single-segment injuries that are nondisplaced superiorly. Superior and inferior approaches are required for displaced unilateral single-segment injuries, for bilateral single-segment injuries, and for all comminuted fractures. Complete interfragment wiring of all segments is stabilized by junctional rigid fixation. All comminuted fractures require transnasal wiring of the bones of the medial orbital rim (medial canthal tendon-bearing or “central” bone fragment). If the fracture does not extend through the canthal insertion, the canthus should not be detached to accomplish the reduction.

Postoperative medical complications: Not microsurgical complications: Negatively influence the morbidity, mortality, and true costs after microsurgical reconstruction for head and neck cancer

Background: Immediate reconstruction of composite head and neck defects using free tissue transfer is an accepted treatment standard. There remains, however, ongoing debate on whether the costs associated with this reconstructive approach merit its selection, especially considering poor patient prognoses and the high cost of care. Methods: A retrospective review of the last 100 consecutive patients undergoing microsurgical reconstruction for head and neck cancer by the two senior surgeons was performed to determine whether microsurgical complications or postoperative medical complications had the more profound influence on morbidity and mortality outcomes and the true costs of these reconstructions. Results: Two patients required re-exploration of the microsurgical anastomoses, for a re-exploration rate of 2 percent, and one flap failed, for a flap success rate of 99 percent. The major surgical complication rate requiring a second operative procedure was 6 percent. Sixteen percent had minor surgical complications related to the donor site. Major medical complications, defined as a significant risk to the patient’s life, occurred in 5 percent of the patients, but there was a 37 percent incidence of “minor” medical complications primarily caused by pulmonary problems and alcohol withdrawal. Postsurgical complications almost doubled the average hospital stay from 13.5 days for those patients without complications to 24 days for patients with complications. Thirty-six percent of the true cost of microsurgical reconstruction of head and neck cancer was due to the intensive care unit and hospital room costs, and 24 percent was due to operating room costs. Postsurgical complications resulted in a 70.7 percent increase in true costs, reflecting a prolonged stay in the intensive care unit and not an increase in operating room costs or regular hospital room costs. Conclusion: Postoperative medical complications in these elderly, debilitated patients related to pulmonary problems and alcohol withdrawal were statistically far more important in negatively affecting the outcomes and true costs of microsurgical reconstruction.

Reconstructed mandibular defects : Fibula free flaps and osseointegrated implants

&NA; Twenty patients with microvascular fibula flap reconstruction of oromandibular defects were selected for implant‐retained prosthodontic rehabilitation. A total of 71 osseointegrated implants were placed within the grafted fibulas. Four patients had immediate implant placement at the time of their reconstructive surgery, and the remaining 16 patients had implants placed secondarily. One patient received postoperative radiation therapy (5940 cGy) 6 weeks following reconstruction and immediate implant placement. No implants were placed in previously irradiated flaps. A minimum 6‐month period of osseointegration was allowed prior to second stage surgery. Fiftyfour of the 71 implants were uncovered; 46 of these implants were functional, and 3 were in the process of being restored. Among the 54 implants (15 patients) that were uncovered, only 1 failed to osseointegrate, 2 implants were reburied, and 2 were removed. The follow‐up period ranged from 1 to 49 months since second stage surgery. Although a number of prosthodontic designs were used, 11 of the 15 patients were restored with removable overlay prostheses. Only those implants exposed to postoperative radiation demonstrated radiographic bone loss following functional loading.

Clinical experience with the 3M microvascular coupling anastomotic device in 100 free tissue transfers

The microvascular surgical anastomosis remains one of the most technically sensitive aspects of free-tissue transfers. To facilitate these often time-consuming, difficult anastomoses, various anastomotic coupling systems have been introduced. The 3M microvascular anastomotic coupling device, a polyethylene ring-pin device, was found to be highly successful in numerous animal studies. It has been available for use in human subjects for the last 4 years, but clinical experience remains sparse. Our clinical experience with the 3M coupler is reported in 100 free-tissue transfers. The average anastomotic time was 4 minutes. Mean follow-up was 8.6 months, and flap survival was 100 percent. The overall success rate for 3M (MACD) coupler use in microvascular anastomoses is 98.4 percent (121 of 123). Nine abandoned anastomoses were converted to sutured anastomoses intraoperatively. The overall failure rate for 3M coupler anastomoses is 1.6 percent (2 of 123). We conclude that the 3M device is best suited for minimally discrepant, soft, pliable venous microvascular anastomoses and is unsuitable for end-to-side anastomoses in clinical situations. When carefully and selectively employed by a trained microvascular surgeon, the 3M coupler can be a safe, fast, and reliable adjunct for free-tissue transfers. (Plast. Reconstr. Surg. 93: 1481, 1994.)

cost and Outcome of Osteocutaneous Free-tissue Transfer versus Pedicled Soft-tissue Reconstruction for Composite Mandibular Defects

&NA; Thirty‐nine patients underwent reconstruction of composite mandibular defects following resection for squamous cell carcinoma. Thirty‐four underwent immediate reconstruction, while 5 were reconstructed secondarily. Twenty‐one received soft‐tissue reconstruction only with a pectoralis major myocutaneous flap, 14 underwent osteocutaneous free‐tissue transfer, and 4 received a reconstruction plate with free‐tissue transfer for soft‐tissue coverage. The mandibular defects in the pectoralis major myocutaneous flap group tended to be posterolateral, while free‐tissue transfer defects were more severe, usually involving the anterior mandible. Length of surgery and duration of intensive care unit care were significantly longer for free‐tissue transfer patients, while length of hospitalization was similar. Systemic complications were more frequent in the free‐tissue transfer patients, while flap complications were more common in the pectoralis major myocutaneous flap patients. Facial appearance scores were higher for the free‐tissue transfer group by both patient and physician assessment. Social function, speech, and oral function did not differ significantly. Patients reconstructed secondarily with free‐tissue transfer reported significant improvement in appearance, oral continence, and social function, with little change in speech intelligibility, deglutition, or diet tolerance. The cost of the main hospitalization was significantly higher in the free‐tissue transfer group than in the pectoralis major myocutaneous flap group, although when the costs of subsequent hospitalizations are included, the difference in total cost narrows. Despite more adverse defects, free‐tissue transfer provided more predictable aesthetic results and expeditious return to normal social function than did pectoralis major myocutaneous flap reconstruction. The fiscal impact of these complex reconstructions is, however, significant. Cost‐containment issues are presented and recommendations are made. (Plast. Reconstr. Surg. 97: 1167, 1996.)

Reconstruction of composite through-and-through mandibular defects with a double-skin paddle fibular osteocutaneous flap.

Microsurgical reconstruction of composite through-and-through defects of the oral cavity involving mucosa, bone, and external skin has often required two free flaps or double-skin paddle scapular or radial forearm flaps for successful functional and aesthetic outcomes. A safe, reliable technique using a double-skin paddle fibular osteocutaneous flap to restore the intraoral lining, mandibular bone, and external skin is described. A large elliptical or rectangular skin paddle is designed 90 degrees to the longitudinal axis of the fibula, over the junction of the middle and distal thirds of the lower leg, based only on the posterolateral septocutaneous perforators. This skin flap can be draped anteriorly and posteriorly over the fibular bone to reconstruct both the intraoral defect and the external skin defect. The area between the two skin islands of the intraoral flap and the external flap is deepithelialized and left as a dermal bridge between the two skin islands, as opposed to the creation of two separate vertical skin paddles, each based on a septocutaneous perforator. The transverse dimension of the flap can be as great as 14 cm, extending to within 1 to 2 cm of the tibial crest anteriorly and as far as the midline posteriorly, and with a length of up to 26 cm, this flap should be more than sufficient for reconstruction of most through-and-through defects. This technique has allowed the successful reconstruction of large composite defects, with missing intraoral lining, mandibular bone, and external skin, for 16 patients, with 100 percent survival of both skin islands in all cases and without the development of any orocutaneous fistulae.

Clinical experience with a microvascular anastomotic device in head and neck reconstruction

BACKGROUND Despite numerous refinements in microsurgical technique and instrumentation, the microvascular anastomosis remains one of the most technically sensitive aspects of free-tissue transfer reconstructions. MATERIALS AND METHODS Concurrent with the development of microsurgical techniques, various anastomotic coupling systems have been introduced in an effort to facilitate the performance and reliability of microvascular anastomoses. The microvascular anastomotic coupling device (MACD) studied here is a high-density, polyethylene ring-stainless steel pin system that has been found to be highly effective in laboratory animal studies. Despite its availability for human clinical use over the last 5 years, reported clinical series remain rare. Our clinical experience with this MACD in 29 head and neck free-tissue transfers is reported herein. RESULTS Thirty-five of 37 (95%) attempted anastomoses were completed with 100% flap survival with a variety of donor flaps, recipient vessels, and clinical contexts. Two anastomoses were converted to conventional suture technique intraoperatively, and one late postoperative venous thrombosis occurred after fistulization and vessel exposure. CONCLUSIONS We conclude that the MACD studied here is best suited for the end-to-end anastomosis of soft, pliable, minimally discrepant vessels. Previous radiation therapy does not appear to be a contraindication to its use. Interpositional vein grafts may also be well suited to anastomosis with the device. When carefully and selectively employed by experienced microvascular surgeons, this MACD can be a safe, fast, and reliable adjunct in head and neck free-tissue transfer reconstructions, greatly facilitating the efficiency and ease of application of these techniques.

The role of three-dimensional computed tomography in the evaluation of acute craniofacial trauma

Three-dimensional computed tomographic (3-D CT) reformations together with their corresponding conventional axial two-dimensional (2-D) CT images of 20 patients with facial fractures were compared with 2-D CT alone to define their usefulness in the determination of facial skeletal fracture patterns. Nine surgeons with three different levels of experience and training evaluated the presence and spatial arrangement of fractures in all 2-D CT and 3-D CT scans. Comparisons were made between their evaluations of 2-D CT alone and 2-D CT plus 3-D CT scans. Statistical analyses with Friedmans test were performed. The addition of 3-D CT did not alter the interpretation of 2-D CT in 75% of evaluations. The number and accuracy of the changes made with the aid of 3-D CT reflected the experience of the observers. Overall, there was no improvement in the accuracy of interpretations with the addition of 3-D CT.

Achieving mandibular continuity with vascular bone flaps: A comparison of primary and secondary reconstruction

This retrospective study was performed to compare the functional and aesthetic results achieved in two distinct groups of patients undergoing composite reconstruction of complex head and neck defects using vascularized bone flaps. Fourteen consecutive patients undergoing reconstruction over a 30-month period (January 1988 through June 1991), nine primary and five secondary, were analyzed. The two groups were similar with respect to age, physical status, tumor type and stage, exposure to radiation, and previous history of cigarette smoking and alcohol consumption. The bone defect was similar between the two groups, but the soft tissue deficit was greater in the group of patients reconstructed secondarily. Surgery time and blood loss tended to be less in the patients reconstructed secondarily, but length of hospitalization was similar. Flap survival was 100%, although the complication rate approached 60%. Restoration of mandibular continuity and orofacial soft tissue defects with vascularized composite free flaps had a favorable impact on function and aesthetics in the group of patients reconstructed primarily. In those reconstructed secondarily the benefit was primarily cosmetic. Continued emphasis on primary reconstruction of the composite defect with composite free tissue transfers is advised.

Computed tomography versus standard radiography in the assessment of fractures of the mandible

Twenty-nine fractures of the mandible were studied by standard radiographs and axial computed tomographic scans (hard copy). Independent reviewers analyzed each study in a blinded, non-paired fashion. When radiographic diagnostic sensitivities were compared on the basis of known surgical findings, the plain films were found to have a higher diagnostic sensitivity (89%) than the hard copy computed tomograms (64%). This difference occurred primarily with images of nondisplaced fractures in posterior portions of the mandible, and is likely the result of tomographic orientation and volume averaging. Though computed tomography has emerged as the standard diagnostic test in evaluating intra-cranial and maxillofacial trauma, this study demonstrates that computed tomographic scanning alone is inadequate in excluding nondisplaced fractures of the posterior mandible.