Likith V. Reddy

Eyelid approach to the anterior cranial base

Skull base approaches play a fundamental role in modern neurosurgery by reducing surgical morbidity. Increasing experience has allowed surgeons to perform minimally invasive approaches without straying from the premises of skull base surgery. The eyelid approach has evolved from the orbitopterional osteotomy into a more effective and targeted approach to disease of the anterior cranial fossa. In this technique, after an incision is made on the supratarsal fold, the orbicularis oculi muscle is incised, and a myocutaneous flap composed of the elements of the anterior lamella is elevated. Subperiosteal dissection is used to expose the superior and lateral walls of the orbit, the superior and lateral orbital rim, and the frontosphenoidal suture. A MacCarty bur hole is drilled, and a frontal osteotomy is fashioned medial to the supraorbital notch and extending through the orbital roof back toward the orbital half of the MacCarty bur hole, exposing the frontobasal brain. A conventional microsurgical technique is used to treat tumors and aneurysms of the anterior cranial fossa under the operative microscope. Five patients were treated for unruptured aneurysms of the anterior circulation (3 anterior communicating artery aneurysms, 1 ophthalmic artery aneurysm, and 1 posterior communicating artery aneurysm) using the eyelid approach. The mean aneurysm size was 5 mm, and all aneurysms were approached from the right side. Three tumors in the anterior fossa (2 suprasellar pituitary adenomas and 1 craniopharyngioma) were also excised using this approach. There was no surgical morbidity. Three months after surgery all patients presented excellent cosmetic results. The eyelid approach may be considered as an effective, cosmetically beneficial, and minimally invasive skull base approach to selected aneurysms and tumors of the anterior circulation.

Choice of incision for primary repair of unilateral complete cleft lip: a comparative study of outcomes in 796 patients.

Background: No one technique of cleft lip repair consistently produces ideal aesthetic and functional results. This study was carried out in a developing, high-volume center. It compares outcomes attained using two different designs of skin incision used for primary closure of unilateral complete cleft lip and sought to identify the most appropriate technique for clefts of varying morphology. Methods: Seven hundred ninety-six patients were entered into the study. In each group of slightly less than 400 patients, either a modified Millard or Pfeifer wavy line incision was used, both in conjunction with functional repair of the underlying tissues as described by Delaire. Soft-tissue measurements of the lip and nose were recorded preoperatively. Analysis was based on postoperative assessment of the white roll, vermilion border, scar, Cupid’s bow, lip length, and nostril symmetry and appearance of the alar dome and base. Results: Comparison of the two cohorts using Pearson chi-square testing for association and linear trend found a Millard incision gave significantly better results for vermilion match, whereas the Pfeifer method led to a better postoperative lip length. Preconceptions that one particular technique was better suited to certain preoperative cleft anatomical forms were not proven statistically. Conclusions: Certain preoperative anatomical features may lead the surgeon to choose one particular incision pattern in preference to another, but in this study, it was found that one technique was essentially as good as the other. This suggests that the technique for closure of the underlying tissues is probably of more importance.

Developing and Standardizing a Center to Treat Cleft and Craniofacial Anomalies in a Developing Country Like India

The range of facial deformities is enormous. All produce some degree of disfigurement and result in the impairment of function to some degree, sometimes even to the point of incompatibility with life. Congenital facial defects in India are associated with considerable superstition, social rejection, and failure to integrate into society. In India, cleft defects occur in 1 in 500 births. Congenital facial defects are a pressing problem in India owing to the limited resources to treat such patients. Poverty is a major factor for parents of such children to get appropriate treatment. Setting up an institute to treat children with cleft and craniofacial deformities in India presents problems with financing treatment for poor patients, procuring the right infrastructure, and employing well-trained human resources. The authors have set up such an institute in Hyderabad in the southern state of Andhra Pradesh in India. The logistics of setting up such a facility in a developing country and the future of funding for cleft treatment are important factors to consider while establishing a center for patients with cleft and craniofacial anomalies. The aim of setting up such centers was to provide quality comprehensive treatment for patients from all sections of society with cleft and craniofacial anomalies.

Expansile Mass of the Maxilla

A 34-year-old white woman presented at the Universi uffalo Oral and Maxillofacial Surgery Service (Buffalo, n October 2006 with a chief complaint of right-sided welling. The patient was uncertain of its duration, eported a vague sensation of nasal pressure on the aff ide. Her past medical history was significant for mild m etardation, myotonic dystrophy, cardiomyopathy, mitr alve prolapse, and repeated episodes of pneumonia. atient resided in a group home, and held a job outsid ome. A head and neck examination showed right midfa nlargement and asymmetry, with partial obliteration of asolabial fold. There was no evidence of proptosis, n bstruction, or cervical lymphadenopathy. Intraorally, the as a buccal expansion of the right maxilla extending he canine to the first molar. The area was tender to ion, and the overlying mucosa appeared normal. The iated teeth were vital and showed physiologic mob Fig 1). Panoramic, occlusal, and periapical films were of p uality because the patient was wheelchair-bound and imited ability to cooperate with the studies, but the evealed a well-circumscribed, mixed radiodense-radio

Plating Options for Fixation of Condylar Neck and Base Fractures

There are multiple plating options to consider when performing an open reduction of a condylar neck or base fracture. The literature shows that bite force is reduced significantly after a subcondylar fracture during the healing period, returning to only 60% of normal bite force at 6 weeks. This raises the question as to how much is enough when considering fixation of subcondylar fractures. All plating options presented in this article have been shown in the literature to successfully treat subcondylar fractures.

A comparative study of two different techniques for complete bilateral cleft lip repair using two-dimensional photographic analysis

Background: The aim of this study was to compare the clinical outcomes of two techniques to repair complete bilateral cleft lip by using indirect two-dimensional photographic analysis. Methods: One hundred eight bilateral cleft patients were included in this study, 54 patients operated on with the Millard technique and 54 patients operated on with the Afroze technique. Each group of patients was further separated into two subgroups containing symmetrical and asymmetrical cleft lips. All patients were photographed preoperatively and 4 years postoperatively in frontal and submentovertical views in a reproducible way. Eight measurements were performed on the photographs. From these measurements, seven ratios were calculated to compare the two techniques. Results: The outcomes of the interobserver and intraobserver measurements were analyzed using the Pearson correlation test. There was a statistically significant reliability in the intraobserver and interobserver ratios. Analysis of the ratios was performed using the independent samples t test (5 percent level of significance). The authors found that the Afroze technique was better than the Millard technique in six of the seven parameters for symmetrical clefts and in four of the seven parameters for asymmetrical clefts; however, there was no statistically significant difference seen between the two techniques. Conclusions: The Afroze technique seems to have good clinical outcomes on bilateral cleft lip patients, but more research and long-term follow-up are needed to determine the full outcome of the technique in various parameters. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Preface to the fifth edition

The AAOMS ParCare 2012 is the fifth edition of the parameters document. It reflects the contributions of opinion leaders from our specialty, with input from thousands of fellows and members, as well as the communities of interest. The AAOMS ParCare 2012 contains guidelines for treatment and expectations for outcomes of those therapies associated with eleven designated areas of Oral and Maxillofacial Surgery: