Puneet Tuli

Submental tracheal intubation in oromaxillofacial surgery

Background: Oromaxillofacial surgical procedures present a unique set of problems both for the surgeon and for the anesthesist. Achieving dental occlusion is one of the fundamental aims of most oromaxillofacial procedures. Oral intubation precludes this surgical prerequisite of checking dental occlusion. Having the tube in the field of surgery is often disturbing for the surgeon too, especially in the patient for whom skull base surgery is planned. Nasotracheal intubation is usually contraindicated in the presence of nasal bone fractures seen either in isolation or as a component of Le Fort fractures. We utilized submental endotracheal intubation in such situations and the experience has been very satisfying. Materials and Methods: The technique has been used in 20 patients with maxillofacial injuries and those requiring Le Fort I approach with or without maxillary swing for skull base tumors. Initial oral intubation is done with a flexo-metallic tube. A small 1.5 cm incision is given in the submental region and a blunt tunnel is created in the floor of the mouth staying close to the lingual surface of mandible and a small opening is made in the mucosa. The tracheal end of tube is stabilized with Magil′s forceps, and the proximal end is brought out through submental incision by using a blunt hemostat taking care not to injure the pilot balloon. At the end of procedure extubation is done through submental location only. Results: The technique of submental intubation was used in a series of twenty patients from January 2005 to date. There were fifteen male patients and five female patients with a mean age of twenty seven years (range 10 to 52). Seven patients had Le Fort I osteotomy as part of the approach for skull base surgery. Twelve patients had midfacial fractures at the Le Fort II level, of which 8 patients in addition had naso-ethomoidal fractures and 10 patients an associated fracture mandible. Twelve patients were extubated in the theatre. Eight patients had delayed extubation in the post-operative ward between 1 and 3 days postoperatively. Conclusion: In conclusion, the submental intubation technique has proved to be a simple solution for many a difficult problem one would encounter during oromaxillofacial surgical procedures. It provides a safe and reliable route for the endotracheal tube during intubation while staying clear of the surgical field and permitting the checking of the dental occlusion, all without causing any significant morbidity for the patient. Its usefulness both in the emergency setting and for elective procedures has been proved. The simplicity of the technique with no specialized equipment or technical expertise required makes it especially advantageous. This technique therefore, when used in appropriate cases, allows both the surgeon and the anesthetist deliver a better quality of patient care.

Frontal reconstruction with frontal musculocutaneous V-Y island flap

Background: Defects of the frontal region are mostly caused by the ablation of tumors. When the treatment of such a defect cannot be achieved by the approximation of its margins, some of the solutions may alter the form or the continuity of the frontal aesthetic unit. Methods: With the intent of reconstructing frontal defects with proper skin, a musculocutaneous island flap of the frontal belly of the occipitofrontalis muscle based on the supratrochlearis or the supraorbitalis vessels was planned for a V-Y application in a single procedure. It was used in 31 patients. Results: The treated frontal defects ranged from 1.5 per 1.5 cm to 4.5 per 5.5 cm and, depending on the depth of the resection, exposed periosteum, bone, or dura mater. All the vessels were identified and preserved and the flaps were viable and sufficient for the defects. Three cases presented 1 cm2 of superficial skin necrosis with spontaneous healing that caused hypochromic scars. In eight patients the extirpation of the tumor compromised the rami temporales of the nervus facialis and caused postoperative asymmetry of the facial mimicking. All the followed patients presented normal sensitivity to touch stimuli on the flap skin and presented loss of sensitivity on the scalp distally to the flap and to the donor site. Conclusion: The frontal musculocutaneous island V-Y flap based on the supratrochlearis or the supraorbitalis vessels is safe and permits frontal reconstruction in a single procedure with proper maintenance of the aesthetic unit.

Lateral approach to the levator veli palatini: a preliminary report.

The abnormal anatomy in the cleft palate has been of interest to surgeons for a long time. Different authors have independently evolved the techniques of radical reconstruction of the palatal musculature and have suggested the medial approach to dissect the levator. We hereby report the technique in which the levator is identified through the lateral incision of the soft palate. This lateral approach helps in the complete release of the levator from all abnormal attachments and ensures reconstruction of an effective sling. This technique is of particular benefit in a palate re-repair.

A simple solution to a complex position in cleft surgery.

Correct positioning of the surgeon and patient in palate surgery is a problem often faced by the craniofacial surgeon. To achieve the best result, it is essential that the surgeon has direct visualization and sufficient access to the field. We describe a simple solution to this complex problem, which has been used by Dr. Ian Jackson for the last 20 years. We believe the Jackson method of positioning offers good visualization of both anterior and posterior parts of the palate, while minimizing the strain associated with neck extension during conventional positioning in cleft surgery.

Rabbit as a distraction model—pitfalls

The principles of distraction osteogenesis have been successfully applied to the craniofacial skeleton of different animals. The rabbit, in particular, has been evaluated as a model by enumerable authors. To our knowledge, however, none of the studies either report the causes of premature euthanization or the pitfalls leading to the untimely death of the animal. We here describe our experience with 30 rabbits used as a model for mandibular distraction osteogenesis and suggest precautions to take in order to avoid unforeseen problems. Thirty skeletally mature New Zealand white rabbits were used. Fifteen animals had bilateral distraction devices placed on the anterior mandible, and another 15 underwent unilateral distraction osteogenesis. In both groups, 12 animals were euthanized prematurely due to complications that included excessive weight loss (malnutrition), anesthesia/animal-related problems, and distraction device failure. The remaining 18 animals tolerated the operative procedure well. Indisputably, rabbit is an excellent choice for craniofacial experiments, but because of its complex anatomy and physiology, an unexpected outcome frequently occurs. We believe that the following suggestions in relation to the pre-operative selection of a suitable animal model, operative technique, and management of eating problems may help the researcher to choose an appropriate animal and avoid complications leading to early death.

Delayed buccal fat pad herniation: An unusual complication of buccal flap in cleft surgery.

Buccal musculomucosal flap is commonly used in cleft palate surgery for providing additional lining when nasal mucosa is inadequate. We report an unusual complication of progressively increasing fat herniation from the sutured donor site which started appearing on the third postoperative day. This necessitated excision of the protruding fat pad on the seventh postoperative day. The possible mechanism and precautions for prevention of this complication are discussed.

Can we choose preoperatively between submental orotracheal intubation and tracheostomy in transfacial cranial base surgery

Sir, The ideal approach to skull base tumors is a perplexing problem and invariably involves a multiteam approach. Many complex approaches such as LeFort I osteotomy with down fracturing of the hard palate, LeFort I osteotomy with splitting of the hard palate (maxillary swing), extended maxillectomy, median mandibulotomy with glossotomy, and the mandibular swing transcervical approach have been described in the literature [1]. However, the management of the airway in these cases is a challenge because of the need to maintain the teeth in occlusion and at the same time keep the endotracheal tube out of the operating field. Therefore, these complex situations preclude the conventional orotracheal and nasal intubation. The use of submental intubation as an alternative to tracheostomy has been reported in the literature, yet it has many caveats [2–4]. We feel it is difficult to decide preoperatively whether to proceed with submental orotracheal intubation or tracheostomy in a given clinical situation and hereby report our experience in six cases (Table 1). In all six patients, submental orotracheal intubation was done with a disposable flexometallic tube. After the completion of the operative procedure, the submental orotracheal tube was changed to an orotracheal tube. None of the patients was extubated in the operating room and all extubations were done in the intensive care unit. In three patients, postoperative tracheostomy was done; this decision was jointly taken by the anesthesia and the operating team. The indications for tracheostomy in these cases were persistently poor gag reflex, deteriorating neurological status and anticipated complications from long-term intubation. A critical analysis of the data was done to find out the reasons for postoperative tracheostomy as the same procedure could have been done initially during the first operation as an elective procedure. From the results, we found that, in patients where LeFort I osteotomy was combined with another additional approach like maxillary swing–transsphenoidal approach or both, the operating time was more than 6 h and the lesion was extensive; a tracheostomy in the postoperative period was needed. We understand that it is hard to draw any definite conclusion from our report as there are many variables ranging form patient pathology to skill of the operating surgeon and this makes any comparative analysis difficult. However, we suggest that, in cases where a the lesion is extensive and an additional procedure like maxillary swing will be needed to complement the LeFort 1 osteotomy and the surgery is likely to be prolonged to 6 h or more, a prophylactic tracheotomy may be considered. Eur J Plast Surg (2009) 32:57–58 DOI 10.1007/s00238-008-0299-y

White board to aid indexing of clinical photographs

. Fuerderer S, Eysel-Gosepath K, Schröder U, Delank KS, Eysel P. Retropharyngeal obstruction in association with osteophytes of the cervical spine. J Bone Joint Surg 2004;86B:837–40. . Strasser G, Schima W, Schober E, Pokieser P, Kaider A, Denk DM. Cervical osteophytes impinging on the pharynx: importance of size and concurrent disorders for development of aspiration. AJR 2000;174:449–53. . Ozgocmen S, Kiris A, Kocakoc E, Ardicoglu O. Osteophyte-induced dysphagia: report of three cases. Joint Bone Spine 2002;69:226–9.

A simple and cost-effective protocol for the management of anterolateral thigh free-flap donor site

Sir, The perforator-based anterolateral thigh flap was first described by Song et al.[1] Minimal donor site morbidity and functional impairment has led various authors to use this flap for a wide variety of defects.[2] The management of the donor site poses a unique problem as a large area of skin (upto 800 cm2) can be harvested. Primary closure of the donor site with mobilization of surrounding skin is possible only in a few cases when the size of the defect is less than 8 x 8 cm2. [2]

Appeal for an “e-Group” to Be Formed

Plastic surgery has achieved great heights in the past few decades as the members of the community have continued to share their ideas, clinical acumen, surgical skills, and new research. We are a rather small community, so it is all the more important that we reach out and grow together. Although the Internet and other sources of telecommunication have helped a lot in knowledge sharing within the community, a lot more can be done. The problems faced by plastic surgeons in developing countries are different from those faced by their counterparts in the developed world. We believe that the formation of an ‘‘e-group’’ of plastic surgeons all over the world, under the Editorial Board of Aesthetic Plastic Surgery (it being the most widely circulated journal of aesthetic plastic surgery), could go a long way in nurturing cooperation within the fraternity. In this group, each member would fill in his or her particulars and areas of interest. The members of the proposed e-group could be further divided into subgroups such as breast surgeons, facial plastic surgeons, and the like. The members of a subgroup could discuss difficult clinical problems among themselves and pose their queries to experts in that field. This discussion within the subgroup could be moderated by a specialist nominated by the editor. Such an online discussion would provide surgeons working in the peripheral centers of a developing country easy access to the best advice in the world. All forthcoming events such as continuing medical education programs, workshops, and conferences could be communicated to all the members of the group. Information about training programs and fellowships could be sent to all the members of this e-group. We think such an e-group not only would help plastic surgeons all over the world in sharing ideas, knowledge, and expertise, but also would go a long way toward bridging the gap between the privileged (developed) and the not so privileged (developing countries). Shall Aesthetic Plastic Surgery again be the leader in this endeavor?