Bertram E. Bromberg

Carotid-cavernous sinus fistula occurring after a rhinoplasty. Case report.

We report a case of carotid-cavernous sinus fistula which developed after elective nasal surgery. As the carotid-cavernous sinus fistula is a rare but major complication of craniofacial injury, surgeons who operate in this area should by aware of the entity.

Pharyngo-Palatoplasty with free transplantation of the palmaris longus

Abstract In order to produce a valvular action in conjunction with velum elevation and sphincteric contraction, the denervated palmaris longus muscle with its tendon split into two has been transplanted to the posterior pharyngeal wall and the tendons passed around the lateral walls into the soft palate. The results in three cases have been good.

Implant reconstruction of the orbit

W E have strongIy advocated the use of poIyethylene in facial reconstructive surgery since 1948. In 1955 Rubin and Walden presented an evaIuation of our resuIts covering seven years which was subsequently pubhshed in Plastic and Reconstructive Surgery. The advantages of poIyethyIene were pointed out in that paper and for the sake of emphasis are repeated again : I. It can be carved to accurateIy reproduce the anatomic structure desired with an attention to detail far surpassing that obtainabIe with either human bone or cartilage. 2. Its use markedly reduces the operating and anesthesia time as it may be entireIy prepared prior to surgery thus eIiminating the need for extended surgery to procure the cartiIage or bone repIacement from the patient. 3. The possibility of warping, breaking, and dissoIving of the “feathering” at the edges is eliminated. In addition, there is no aIteration in size after the insertion of the impIant. 4. Defects of unIimited size or myriad shapes can easiIy be repIaced by this synthetic in marked contrast to the Iimitations of bone or cartiIage. It is not the purpose of this report to champion the cause of a synthetic materia1 which now has withstood the test of time, but rather to offer a technic that we have deveIoped for its use in a specific area of the face. Twentyfour impIants have been utiIized in the orbita and periorbita1 areas of sixteen patients during the last ten years without the Ioss of a single reptacement. The primary indications for repIacement in the orbita and maIar area are deformity and dipIopia. For the most part, deformity and dipIopia resuIt from compIications of fractures invoIving the orbita bones. In other instances deformities are congenita1 or resuIt from inffammatory reactions or modalities of treatment, such as destruction of bone subsequent to radiation therapy of tumors in earIy years. CertainIy the improvement in the treatment of fractures of the zygoma and malar compound has reduced markedly the number of deformities residual in this area. In 1946, we reported over I ,000 fractures of which I 09 were malar compound fractures and fractures of the zygomatic arch. Of the total series (1,304) there were onIy thirty-two residuat deformities severe enough to necessitate secondary reconstructive procedures. Transient dipIopia is common in simpIe maIar compound fractures and wiI1 usuaIIy disappear even if no treatment of the fracture is undertaken. This transient dipIopia has been accurately described by Barclay [a and apparentry resuIts from reflex inhibition or damage to the inferior oblique muscIe of the eye on the injured side. Persistent dipIopia is seen more often in the severe type of comminuted injury aIthough the “bIowout” injury, in which the orbita ffoor is independentIy damaged, as described by Converse and Smith [8], can be associated with this compIication as we11 as enophthaImos. BarcIay suggests that persistent dipIopia is due, in the majority of cases, to fibrosis and adhesions in the region of the inferior rectus and inferior oblique muscles which prevents free rotation of the eyebaI1. In addition, residua1 deformity of the orbita floor as a resuIt of severe comminution or inaccurate restoration does not permit these muscIes to function at their optimum Iengths. It is beIieved that the improvement in vision after an orbita Boor implant is due to reIease of adhesions and the prevention of subsequent adhesions as a resuIt of the smooth surfaces. The floor impIant also improves the muscuIar efficiency by permitting the muscles to more nearIy approximate their optimum

Use of a Silastic testicular implant in reconstruction of the temporomandibular joint of a 5-year-old child

Abstract A coned-out Silastic testicular implant was placed following the uneventful removal of an ankylosed temporomandibular joint in a 5-year-old boy. Postoperative examinations revealed a marked improvement in the patients ability to open his mouth. The use of the testicular implant was of particular importance because, when placed over the remaining portion of the ramus, it established a pseudocondylar shape.

Total nasal reconstruction: a further application of the delto-pectoral flap.

Abstract A new 2 stage method of nasal reconstruction, using a delto-pectoral flap, as a carrier for supraclavicular skin is detailed.

Advantages of a tracheotomized anesthesia technic in the pharyngeal flap operation.

Abstract 1. 1. A tracheotomy anesthesia technic as a technical aid to the pharyngeal flap operation is discussed. 2. 2. Over fifty pharyngeal flap operations are evaluated, and the technic of the flap application is described. 3. 3. The advantages and disadvantages of this technic are reviewed.

Abdominal injuries, with special reference to errors in early handling.

Abstract We believe that present world conditions emphasize the importance of the care of the injured. As regards abdominal injuries, we have presented a list of principles and observations, known well to those of this organization, but worth formulating and recording again. 1. 1. Treat shock patients properly. Blood is the principal agent, and sufficient amounts should be available. 2. 2. Remember the possibility of autotransfusion. 3. 3. Bronchial suction will save lives and reduce pulmonary complications. 4. 4. Two-thirds of abdominal injuries with no external signs are serious. 5. 5. Perforations may be caused by the proctoscope, gastroscope, curette and by cancer. 6. 6. Gastric and rectal tubes are diagnostic and reduce drainage into the peritoneal cavity; however, do not irrigate the stomach or rectum when the patient is first seen. 7. 7. A portable x-ray unit is essential. 8. 8. Be alert for free air in the peritoneal cavity. 9. 9. ACTH, blood and antibiotics often mask serious symptoms. 10. 10. Regardless of the ability of the surgeon and optimum operating conditions, a minimum of two hours is consumed in exploratory laparotomy and the subsequent repair procedure. 11. 11. A foreign body should be removed, if practical, at the time of laparotomy, but the operation is primarily to repair the damage created by the object. 12. 12. Test bowel patency with the thumb and index finger after anastomosis. 13. 13. Do not use antibiotics in the abdomen. 14. 14. Colostomies will retract; therefore, leave them long and have them emerge through stab wounds. 15. 15. Remember disruption when closing abdominal wounds. 16. 16. Postoperatively, give nothing by mouth until the patient passes gas from below. (This may occur one to five days postoperatively.) 17. 17. Anticoagulants are impractical in the early care of abdominal injuries. 18. 18. We want to emphasize what has been the experience of the Committee on Trauma of the American College of Surgeons, namely, that in order to administer adequate emergency care to the injured it is essential to make frequent checks on our emergency wards, have frequent meetings of interested members of our hospital staffs and to issue periodic bulletins outlining standard procedures and calling attention to advances in new methods and therapeutic agents.

Elective Tracheostomy in Infants and Children

Abstract Elective tracheostomy in children may be performed with safety if the surgeon is thoroughly acquainted with the anatomy of the region and the occasional anomalous situation. Practically all tracheostomy tubes in use today for children and infants are excessive in length. These unanatomical tubes should be revised for use in children between the ages of the newborn to twelve years, and in no instance should they be longer than 5.5 cm. The 90 degree tube, although unsatisfactory in some instances, still possesses the best arc. The tracheostomy tube should be of a smaller diameter than the trachea. Serious consideration must be given to the performance of an elective tracheostomy in the following situations: (1) when there has been a difficult endotracheal intubation; (2) in surgery about the pharynx, larynx, tongue or mandible, when permanent or temporary respiratory obstruction may be a consequence; (3) in prolonged comatose states; and (4) in trauma to the respiratory tract or lungs, such as in a burn, when efficient respiratory toilet is essential. Proper equipment set up conveniently in trays and including Y-tubes and marked catheters must be on hand at all times. It is only by such continued and diligent attention to detail, as has been described, that the tragedies so frequently associated with this procedure may be averted.

Prevention of functional deformities in surgery for prognathism

Abstract In cases in which bilateral horizontal ramisection is indicated for prognathism, it is believed that open bite can be prevented by reattachment of the masseter and internal pterygoid muscles bilaterally. This prevents stretching of these muscles. Four such cases have been successfully treated with a follow-up as long as ten years in one case with no open bite in any case. One case is discussed in which this procedure along with a pharyngeal flap and tracheotomy for anesthesia were simultaneously performed.