Michael Evan Sachs

Degloving approach for total excision of inverted papilloma

Inverted papilloma, because of its insidious and aggressive clinical course, must be completely excised. Previously, the customary procedure advocated for this goal was a lateral rhinotomy. The degloving approach, which consists of lifting the soft tissues from the mid portion of the face, thereby furnishing unlimited exposure to the pyriform fossae and the lateral nasal walls, offers an excellent alternative to the lateral rhinotomy technique.

Metastatic Basal Cell Carcinoma of the Head and Neck

Five new cases of metastatic basal cell carcinoma are presented to highlight the potential of this tumor to develop malignant metastases. Histologic criteria of the primary and metastatic site are presented along with a review of the pertinent world literature.

THE NEW TONGUE

Rehabilitation of major resections of the tongue has always posed a serious problem. This paper presents the feasibility and rationale of rehabilitating partial glossectomies by the use of the pectoralis major myocutaneous flap and the fabrication of a “new tongue” by the use of this flap. The criteria for these techniques in benign and malignant tumors of the tongue are outlined. The segmental innervation of the pectoralis major muscle from a variety of three to five nerve branches permits the development of a skin-muscle flap that may be transposed with its nerve supply intact or totally denervated, depending upon the status of the hypoglossal nerves and tongue in the operative field. This presents the possibility of transposing a skin-muscle flap into a glossal wound with a completely intact nerve supply where the new flap is under constant instruction in its new physiologic environment. It also presents the possibility of neurotization of the denervated section of the muscle flap by axones from the intact segment of tongue. A third possibility is the fabrication of a “new tongue” by the transfer of the hypoglossal nerves into the denervated segment of the peripheral aspect of the myocutaneous flap. This variety and combination of rehabilitative techniques introduces a new phase into the rehabilitation of the tongue.

Nonsurgical fat removal in cosmetic blepharoplasty: a new technique.

A new technique of minimally invasive fat removal during cosmetic blepharoplasty is described. This lipolytic diathermy technique has been used successfully in more than 100 patients during the last 3 years and is compared with routine excisional fat removal. The main advantage of this technique lies in its ability to dissolve the fat without surgical excision, thus obviating the inherent complications that arise from such dissection. The technique uses a diathermy unit to cause lipolysis of the fat pockets within their intact septal compartments and can be used for both upper and lower lid herniated fat. This procedure has been found to be exceptionally efficient and predictable and adds another level of safety to cosmetic blepharoplasty.

Mini alar myocutaneous flaps for nasolabial-columella reconstruction.

A new midfacial myocutaneous flap that is particularly useful in nasolabial-columella reconstruction is described. The mini alar flap is a randomized myocutaneous island flap incorporating portions of the orbicularis oris, levator labi superioris alae (labial portion), levator labi superioris, and zygomaticus minor, based on a vascular supply from the terminal branches of the facial artery. The flaps allow for a bilateral elipse of skin and underlying muscle to be transferred from the lateral nasal area into the midportion of the columella and the upper lip for reconstruction of ablative, traumatic, or congenital defects. The primary advantage of the mini alar flap lies in the ability to transpose moderate quantities of viable, well-matched tissue with minimal donor area deformity.

Temporalis Muscle Transfer: A Vascular Bed for Autogenous Dermis-Fat Orbital Implantation

Nine patients with contracted avascular sockets who were unable to wear prostheses, and whose prospects for maintaining viable autogenous dermis-fat grafts were diminished, underwent temporalis muscle transfer into the orbit through a window in the lateral orbital wall. The temporalis transposition was used as a vascular bed for dermis-fat orbital implantation. Postoperatively, seven of nine patients were able to wear satisfactory prostheses and four of nine patients had amelioration of their superior sulcus deformities.

Intralaryngeal Release for Tracheal Anastomosis

An operation for obtaining additional length in order to achieve end-to-end anastomosis of the trachea without significant suture-line tension is described. The intralaryngeal procedure lengthens the larynx approximately 1 to 2 cm without restricting its function. It is an expedient, effective technique when used primarily, or adjunctively, with a suprahyoid or mediastinal release.

Reconstruction of the Horizontal Palpebral Aperture After Failed Ectropion Surgery with Temporal Migration of Punctum

&NA; Involutional ectropion of the lower lid is the result of progressive stretching and elongation of the lid margin and medial and lateral canthal tendons. The relative laxities of the components of the lower lid‐canthal tendon complex will determine the location and extent of the ectropion. Whereas inadequate canthal tightening or horizontal lid shortening will result in recurrent ectropion, overzealous lid shortening without tendon plication will result in a noticeably narrower horizontal palpebral fissure, a persistent ectropion, or temporal migration of the punctum. We used lateral cantholysis, medial canthal tendon plication, and punctal rotation to return the punctum to its normal position and temporalis muscle to support the lower lid in eight cases in which previous procedures had failed to correct the lid malposition. In all eight cases there was improvement of the lid position. In one case of severe medial ectropion, the punctal eversion was not completely corrected. This technique is not recommended as an initial procedure for ectropion repair. It is only used to manage previous surgical failures. It is a new application and combination of wellaccepted techniques.

A composite hair-bearing and non-hair-bearing sideburn flap.

A versatile and dependable composite hair-bering and non-hair-bearing flap is described that allows for immediate reconstruction in the highly visible temple and preauricular areas. A combined hair-bearing and non-hair-bearing flap is transferred from the postauricular region to the area of the temple and laterally to the orbit. Modification of the flap by harvesting additional tissue from the posterior conchal region assures greater reconstructive potential and variability.