Ravelo V. Argamaso

Glossopexy for Upper Airway Obstruction in Robin Sequence

A modified glossopexy is described with results of the operation in 24 patients who were specifically selected based on nasopharyngoscopic examination of the upper airway. Only patients with documented glossoptosis on endoscopy were selected for glossopexy. The procedure is designed to use two points of attachment for the tongue, one at the mandibular alveolus and the other at the lower lip. The genioglossus is also released to lengthen the tongue. All patients had resolution of their upper airway obstruction. There was only one partial dehiscence. The glossopexies were all released at the time of palate repair, usually before the first birthday.

The role of lateral pharyngeal wall movement in pharyngeal flap surgery.

A total of 202 patients with pharyngeal flaps were assessed with nasopharyngoscopy and multiview fluoroscopy to determine the role of lateral pharyngeal wall movement postoperatively. Variations in the construction of flaps resulted in three categories: namely, a long narrow flap with a high insertion, a short broad flap with a low insertion, and an intermediate-size flap that is inserted in a position somewhere between the first two. It was found that in all cases where there was no evidence of velopharyngeal insufficiency, the sole determiner of velopharyngeal closure was the medical excursion of the lateral pharyngeal walls to the sides of the flap. In flap failures, the causes for velopharyngeal insufficiency were inappropriate degree, level, and symmetry of the lateral pharyngeal wall motion. The success of pharyngeal flap surgery depends largely on the preoperative assessment of the velopharyngeal mechanism and the choice of a type of pharyngeal flap that will best assist closure of the velopharyngeal port during speech.

Treatment of Asymmetric Velopharyngeal Insufficiency with Skewed Pharyngeal Flap

Twenty-two patients, with hypernasal speech and asymmetric velopharyngeal insufficiency (VPI) identified preoperatively by multi-view video-fluoroscopy and nasopharyngoscopy, were managed with superiorly based pharyngeal flaps skewed to the side with reduced lateral pharyngeal wall movement. Patient age ranged from 5 to 58 years. The etiology of the VPI included cleft palate with or without cleft lip, neurogenic VPI, velocardiofacial syndrome, tumor resection or iatrogenic causes, submucous cleft palate, neurofibromatosis, and hemifacial microsomia. Follow-up, at 1 year and thereafter, showed resolution of VPI in all but two patients. An auxiliary flap to augment the primary flap was added on the side of diminished lateral pharyngeal wall motion which corrected the residual VPI. Three patients developed hyponasality. One was a child whose symptoms improved with time and growth. Two were adults, but the hyponasal resonance was mild and required no further intervention. The advantage of skewing flaps is that at least one port functions adequately for ease in respiration and for drainage of secretions, thus reducing the risk of nasal obstruction. One open port also allows access for nasoendotracheal intubation should anesthetic be required for future operations.

Free fibula flap mandible reconstruction for oral obstruction secondary to giant fibrous dysplasia

Fibrous dysplasia is a disorder of bone that may be associated with endocrinopathies and skin pigmentation. The pathologic, proliferative expansion and distortion of the skeleton is of unknown etiology. Craniofacial involvement that includes the mandible can exhibit gigantic disproportions and dysfunction. Treatment has evolved to include more aggressive strategies of resection and sophisticated reconstructive techniques. The reported case is noteworthy for the unrelenting growth of craniofacial fibrous dysplasia in an adult female with endocrinopathies, progressing to oral obstruction that required urgent treatment utilizing immediate free bone-flap reconstruction. The free fibula flap was employed to restore mandibular continuity after palliative subtotal mandibulectomy. Bony healing to dysplastic tissue occurred in the remaining mandibular segment. This case illustrates that fibrous dysplasia has the capacity for virulent regrowth subsequent to conservative resection. Defects following radical surgery for giant fibrous dysplasia of the mandible can be reconstructed with a microsurgical bone-flap technique.

Lambdoid stenosis (posterior plagiocephaly) and craniofacial asymmetry: long-term outcomes.

We recently reviewed our series of craniofacial cases involving lambdoid stenosis (posterior plagiocephaly) and positional deformation. We now have 22 cases (who underwent surgery) with greater than 1 year follow up (range 1–7 years). We were impressed by the potential severity of the craniofacial deformity that can occur in what is often considered a positional deformation caused either by intrauterine conditions or by postnatal positioning. To decide which children were candidates for craniofacial reconstruction, we reviewed our cases and determined what we considered were appropriate criteria for craniofacial surgery. Among the 22 patients selected for surgery, 16 patients had changes in facial characteristics secondary to skull base and petrous ridge deformation, which often led to mandibular malalignment. In addition, 11 children were found to have developed scolosis of the face, similar to that seen in anterior plagiocephaly. The long-term severity of these selected craniofacial deformities may be markedly reduced if these children are operated on early with craniofacial reconstruction techniques. The removal of the lambdoid sutures, which appear to apply a twisting or torque effect on the facial structures and skull base, assisted in the childrens further normal cranial development. In the children that were operated on before 1 year of age, most of the facial asymmetry was corrected. In addition, we observed that several of the children showed correction of the malignment of the ears, a common finding in these cases. Three-dimensional reconstructions have been extremely helpful in documenting the abnormalities of the skull base and sutural patterns and in planning the surgical approaches. All the patients had either a Marchac transposition or a bandeau/forehead type reconstruction. There were no long-term complications, and the esthetic results were considered good to excellent.

Pharyngeal flap revisions: flap elevation from a scarred posterior pharynx.

Twenty-one consecutive patients who had earlier superiorly based pharyngeal flap surgery and persistent velo-pharyngeal insufficiency were seen between 1976 and 1991. Patients were divided into two treatment groups, depending on the results of videofluoroscopic and naso-pharyngoscopic assessment. The first group consisted of 18 patients who had bilateral port insufficiency and required a complete reconstruction of a new superiorly based pharyngeal flap that was elevated from a scarred posterior pharyngeal wall. After an average follow-up of 6.2 years, 15 patients had normal resonance, 2 patients had improvement but continued hypernasality, and 1 patient was hyponasal. The second group consisted of 3 patients who had “patch” flaps to a unilateral port insufficiency. Postoperatively, all 3 of those patients had normal resonance. Indications for the decision to “redo” or patch flaps are described. (Plast. Reconstr. Surg. 93: 279, 1994.)

Pharyngeal Flap Surgery in Adults

The elimination of hypernasal speech in patients with cleft palate following pharyngeal flap surgery in childhood is well established. However, pharyngeal flaps in adults have been considered to yield more modest results. This study reports on 20 adult patients with cleft palate-related hypernasality who underwent pharyngeal flap surgery. Normal nasal resonance was achieved in 15 cases, hyponasality occurred in 3 cases, and hypernasality persisted in 2 cases. However, speech intelligibility was not always dramatically improved. Indications and outcome were found to be highly dependent on preoperative articulation.

Refinements of the tongue flap for closure of difficult palatal fistulas.

The posteriorly based tongue flap can be very useful to close difficult palatal fistulas, especially because the palatal sling prevents dehiscence of the tongue flap. However, special techniques may need to be employed with very large palatal fistulas or severely scarred palates. This technique has been used successfully in 5 patients. A detailed case report is presented, for which refinements of the tongue flap technique was required.

Ear reduction with or without setback otoplasty.

Ear reduction has been performed occasionally for aesthetic considerations. This series is comprised of 8 patients representing 7 bilateral reductions and 1 unilateral reduction for a total of 15 ears. Historically, surgery for macrotia consisted of resections of full-thickness wedges from the periphery of the ear. The surgical defect was repaired by directly approximating the wound edges. Additional removal of triangular or crescent-shaped segments from adjacent sides of the wound prevented the cupping of the reconstructed ear. Secondary deformities were not uncommon consequences. The most distressing were cruciform scars that defaced the lateral surface of the ear. These were frequently exacerbated by the uneven coaptation of the underlying cartilages. The current technique places the incisions at strategic locations where the scars that form are less conspicuous. The initial steps are essentially identical with the lateral transhelical approach to otoplasty for protruding ears. In some patients, both procedures have been combined during the same operative session.

Plastic techniques in neurosurgery

Principles of wound healing plastic surgery wound coverage for the neurosurgery patient repair of clavarial bone defects cranioplasty and bone-harvesting techniques congenital malformations repair techniques craniofacial reconstruction for craniosynostosis congenital facial disorders surgical techniques surgery of the skull base.