Jesse E. Smith

Hydroxyapatite Cement in Craniofacial Reconstruction

OBJECTIVES: To evaluate the long-term efficacy of hydroxyapatite cement in craniofacial reconstruction, specifically examining the role (if any) of radiation, implant location, and cement type. STUDY DESIGN: A retrospective chart review was conducted of all patients presenting to the senior surgeon (Y.D.) for craniofacial reconstruction from September 1997 to April 2004. METHODS: Data were collected including type of cement used, size of defect, complications, need for removal of cement, reason for defect, and pathologic results of examination of removed cements. RESULTS: One hundred two patients were identified who underwent craniofacial reconstruction with hydroxyapatite cements, 7 of whom required complete implant removal (6 Norian and 1 Mimix), and 4 (2 Norian and 2 Bone source) of whom required partial implant removal for foreign body reaction. Five of the removals were in patients who underwent postoperative radiation. CONCLUSIONS: Hydroxyapatite cements are safe in craniofacial reconstruction. The highest risk of implant infection comes from reconstruction in the area of the frontal sinus, immediately beneath coronal incisions, and in patients who receive postoperative radiation treatment. Based on our results, there does appear to be a statistically significant difference in rates of infection and foreign body reaction between the different types of hydroxyapatite cement. We would not recommend implantation of this material in contact with the frontal sinus. Caution should be exercised when it is placed directly beneath an incision or in patients receiving postoperative radiation, particularly if a boost dose is given. EBM RATING: C

The versatile extended pericranial flap for closure of skull base defects.

OBJECTIVE: We sought to demonstrate the technical aspects of the extended pericranial flap and its versatility in reconstruction of a variety of skull base defects. STUDY DESIGN: We conducted a retrospective chart review of 32 patients who underwent reconstruction of skull-base defects with an extended pericranial flap by the senior author (Y.D.) from September 1997 to July 2003. METHODS: Patients with skull base defects after trauma or extirpative surgery were reconstructed with either a lateral- or an anterior-based vascularized extended pericranial flap. Variables and outcomes measured included: the size and anatomical location of the defect, need for other flaps, preoperative and/or postoperative radiation therapy and/or chemotherapy, bone flap necrosis, hardware exposure, wound dehiscence, postoperative cerebrospinal fluid (CSF) leak, and meningitis. RESULTS: There was no evidence of flap failure, 2 cases of transient (3 to 4 days) CSF leak without resultant meningitis, 3 patients with hardware exposure, and 2 patients with hydroxyapatite infection. The 2 transient cases of CSF leak both resolved without further surgical intervention or the placement of a lumbar drain. CONCLUSION: Both the lateral and anteriorly based extended pericranial flaps are reliable and versatile flaps associated with minimal morbidity and a low rate of complications when used to reconstruct defects of the anterolateral skull base. (Otolaryngol Head Neck Surg 2004;130:704-11.)

The utility of the temporalis muscle flap for oropharyngeal, base of tongue, and nasopharyngeal reconstruction:

OBJECTIVE: To determine the efficacy of temporalis muscle flap reconstruction of various defects of the oropharynx, nasopharynx, and base of tongue. STUDY DESIGN: Retrospective chart review of a consecutive series of 24 patients who underwent a total of 26 temporalis flaps (2 bilateral) by the senior author (Y.D.) from September 1997 to August 2003 for reconstruction of defects of the oropharynx, nasopharynx, and base of tongue. METHODS: Variables and outcomes that were examined included defect location, size, adjunctive therapy, complications, and ability to tolerate oral intake at follow-up. RESULTS: There was no evidence of flap failure in our series of patients. There were 2 cases of minor flap loss related to early prosthetic rehabilitation. Two cases of transient frontal nerve paralysis were noted. A 30.8% rate of complication (all minor) was noted in this study. At a mean follow-up of 12 months, 54.2% of patients were tolerating a full diet, 37.5% were tolerating most of their nutrition by mouth, and 8.3% were g-tube dependent. CONCLUSION: The temporalis muscle flap represents an excellent alternative in reconstruction of otherwise difficult-to-reconstruct defects of the nasopharynx, oropharynx, and base of tongue. Donor site aesthetics are well accepted by patients with primary hydroxyapatite cement cranioplasty with or without secondary lipotransfer.

Lipotransfer as an Adjunct in Head and Neck Reconstruction

Objectives To present our technique of lipotransfer and to evaluate a single centers experience in the use of lipotransfer as an adjunct to head and neck reconstruction.

Temporalis muscle flap for reconstruction of skull base defects.

The temporalis muscle flap (TMF) is a valuable reconstructive technique utilized in a variety of challenging defects. However, its use for repair of skull base defects is less commonly reported.

Lip and Perioral Trauma

The management of perioral injuries is a complex topic that must take into consideration the unique anatomy, histology, and function of the lips to best restore form and function of the mouth after injury. Basic reconstructive principles include three-layered closure for full-thickness lip lacerations. Additionally, special care is needed to ensure an aesthetic repair of the cosmetically complex and important vermillion border, philtrum, and Cupids bow. Infraorbital and mental nerve blocks provide lip anesthesia for laceration repair without distorting crucial aesthetic landmarks. Prophylactic antibiotics are usually indicated in perioral injuries due to wound contamination with saliva. Perioral burn management is controversial; however, most lip burns can first be managed conservatively. Splinting, plasties, and other reconstructive options are available after secondary healing of perioral burns. Hypertrophic scars are common in the perioral area after trauma. The mainstays of treatment for hypertrophic scars on the lips are silicone elastomer sheeting and intralesional steroid injections. For large perioral defects, a myriad of reconstructive options are available, ranging from primary closure, cross-lip flaps, and local tissue transfer, to free tissue transfers such as radial forearm free flaps, innervated gracilis free flaps, anterolateral thigh free flaps, and osteocutaneous free flaps.

Inverting papilloma of the base of tongue with malignant transformation.

CASE REPORT A 48-year-old otherwise healthy man presented to his primary care physician with complaints of persistent globus sensation, dysphagia, neck pain, and otalgia. Over the course of 2 years, the patient was referred to 3 otolaryngologists, the last of whom took the patient to the operating room for a direct laryngoscopy and biopsy. The patient was unable to be intubated in the operating room and underwent emergent tracheotomy to secure his airway. The patient was then referred to our clinic because of suspected malignancy. In the office, an ill-defined tongue base induration was noted by palpation. Fiberoptic laryngoscopy showed a fullness of the tongue base, but there were no mucosal abnormalities. A computed tomography scan (CT) of the neck, with intravenous contrast, showed a mild asymmetry of the base of the tongue (Fig 1). The epiglottis appeared thickened, and there was a mass noted within the base of tongue, approximately at the level of the hyoid bone. The remainder of the patient’s metastatic work-up, including liver function and thyroid function tests, and a CT of the chest, was normal. The patient was taken back to the operating room for an examination under anesthesia and direct laryngoscopy with biopsy samples; this procedure confirmed both the fiberoptic examination and CT findings. Deep and directed biopsies were performed, and samples were sent for both frozen and permanent sections.

Interim fixation of mandible fractures

The mandible provides structural support for the teeth and a route for neural and vascular supply to the dentition, as well as sensory perception for the lower one-third of the face. Although the mandible is the largest and strongest facial bone, fractures frequently result as a sequela of facial trauma because of the mandible’s physical prominence in the lower face. Vehicular accidents and assaults are the leading causes of mandibular fractures. 1‐3 Open reduction and internal fixation are often the treatment of choice for significantly displaced mandible fractures. 4 Yet reduction of these displaced bony fragments, and their subsequent stabilization during plating, can be difficult and occasionally cumbersome, involving several instruments and multiple hands in a small operative field. Thus, reduction and plating techniques for open repair of mandible fractures often require two surgeons or at least one surgeon and a skilled technician. To lessen the technical assistance needed and to assist with reduction prior to plating, several methods have been proposed in the literature. These involve the use of towel clamps, screws, and wires. 5 However, in theory, these are not completely optimal. With towel clamp and modified towel clamp techniques, the surgeon is still required to manipulate large clamps while drilling and plating. 5 One must also remember that a large clamp remains in the operative field, possibly compromising direct visualization, especially when operating through a small incision. The screw-wire osteosynthesis technique described by Dym and coworkers was used on more than 40 unfavourable mandible angle fractures as the sole source of repair. 6 This technique uses 8-mm screws and 24-gauge wire at the angle of the mandible. Dym and colleagues reported no complications for their small cohort. 6

Complications of Facial Trauma of the Fronto-orbital Region

Traumatic injuries to the orbitofrontal region place some of the most important structures of the face at risk: the eyes, frontal skull, and brain. A thorough knowledge of complications from resultant trauma, and from attempted surgical corrections, is necessary to offer patients the best outcomes, ensuring proper healing with excellent long-term results.

The versatility of the extended pericranial flap for skull-based defects

factors. From this point, a dedifferentiation of the chondrocytes could be observed. In cell culture, the chondrocytes expressed collagen I and X without expression of collagen III. After 6 days of cell culture, the chondrocytes expressed collagen II. The chondrocytes showed a constantly low expression of the FGF2-receptor, but a constantly high expression of VEGF, MMP2, and MMP9. The cells never expressed the EGF-receptor. The proportion of the IGF-receptor–expressing cells diminished significantly during cell culture. Conclusions: With ongoing culture and dedifferentiation of the chondrocytes, significant changes in the expression patterns of various collagens and the IGF-receptor were detected. The latter could play an important role in the differentiation of human chondrocytes.