Leonard R. Rubin

Reanimation of the Long-standing Partial Facial Paralysis

Those unfortunate people who suffer from permanent partial facial paralysis have great difficulty finding surgeons who can offer corrective operations. Improving their function is a most delicate procedure. Great care must be exercised to avoid injuring nerves and muscles which are still operating, although in a greatly diminished state. The pathogenesis must be understood before attempting any corrective procedure. Adequate time must elapse from the moment of injury to surgical intervention, thus allowing for maximal nerve and muscle regeneration. This paper describes techniques that could improve facial movements. The most frequently used procedure is shortening of the levator and/or the zygomatic muscles that are partially atrophied. It must be understood that total reanimation is impossible as of this time.

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

Reanimation of the Hemiparalytic Tongue

Tongue hemiparesis is the inevitable result when the freshly severed 12th nerve is anastomosed to the trunk of a paralyzed 7th nerve in the technique commonly used by neurosurgeons, head and neck surgeons, otologists, and plastic surgeons to treat unilateral facial paralysis. This author has reactivated hemiparalytic tongues after research on cats. The technique has now been proved to be successful on two human beings. The reanimation is based on a simple Z-plasty of tongue muscle across the midline. Two principles are established: (1) placing a normal muscle in direct contact with a denervated muscle stimulates axons from the normal side to penetrate into the denervated side, eventually restoring function, and (2) transposition of a flap of muscle from the normal side containing extrinsic tongue muscles could provide a motor apparatus to activate the paralytic side. Biopsy slides taken from the paralyzed side of the cat tongues after 18 months showed sprouting of multiple nerves. Nerve sprouting can be found in human tongues 1 year after Z-plasties. The two patients who experienced atrophy and hemiparesis after the 12th-7th nerve hookup regained full range of tongue movements by 2 months and 4 months, respectively, demonstrating that with time, motor axons from the normal side innervated the atrophic muscle side to form new neuromotor junctions resulting in tongue movements. EMGs of the reanimated tongue showed normal activity in both sides of the tongue. Biopsies of the interface between the normal and former paralyzed side taken 1 year later showed nerves crossing the scar barrier. Apparently, the role of additional extrinsic muscle to the paralyzed side played a minor role.

Repair of avulsion wounds of the hands and feet by the flap graft technic

Abstract 1. 1. Forty-nine cases of flap graft closures were performed for deep wounds of the hands and feet, with good functional results. 2. 2. The very early cover of exposed infected tendon and bone is advocated by the use of this technic. 3. 3. The flap graft technic is quick and sure of take in covering wounds of the hands and feet with a fat-containing skin cover. 4. 4. The principles of multiple blood transfusions and penicillin therapy are believed to be important adjuncts in the graft take. 5. 5. Early physical therapy for optimal function is a full time job for a trained nurse or assistant who understands the problems. The author wishes to thank Colonel George Dixon, Major Arthur Weinberg and Captain Benjamin Hoffman for their assistance and advice in this series of cases; Sergeants Schwone and Ryan for their tireless labors in doing dressings and making mechanical apparatuses.

One preventable cause of spontaneous deflation of inflatable mammary prostheses.

Spontaneous “overnight” deflation of inflatable prostheses is rather uncommon, but we have had a 5.7 percent incidence of it in a 24-month period in which we used implants with a suturable tab and fastened them to the subjacent fascia. At exploration we found these tabs had torn the bag of the implant, usually at the vulcanized seam. We now believe that fixing a suture tab on a breast implant to underlying fascia may cause undue stresses upon the implant at that point and result in an otherwise avoidable deflation.

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.

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.