Richard L. Arden

Facial nerve rehabilitation after radical parotidectomy

Objective: Examine functional outcomes in patients undergoing radical parotidectomy and facial nerve grafting. Identify factors that may affect rehabilitation in these patients. Study Design: Retrospective chart review and photographic analyses of 12 patients undergoing radical parotidectomy with interposition nerve grafts for facial nerve reconstruction. Methods: Data obtained for each patient regarding age, sex, histology of parotid neoplasm, cable graft source, administration of postoperative radiotherapy, and treatment for eye rehabilitation. Functional outcomes were assessed with the House‐Brackmann grading system at 6 months, 1 year, and 2 years after surgery. Results: All nerve grafts were harvested from cervical plexus sensory nerves with microscopic epineural repair performed for all neurorrhaphies. Overall, 9 of 12 patients achieved a grade III 2 years after surgery. All patients under age 30 obtained a grade III. Of the seven patients receiving postoperative radiation, five achieved a grade III. Older patients often required surgical procedures to facilitate eye closure. Conclusions: Facial nerve rehabilitation after radical parotidectomy can be successfully achieved with cervical plexus interposition nerve grafts. Postoperative radiotherapy did not appear to affect return of function, and younger patients consistently achieved good functional outcomes after nerve grafting. Older patients frequently require surgical procedures for eye rehabilitation after radical parotidectomy. Key Words: Radical parotidectomy, facial nerve, facial nerve rehabilitation, interposition nerve grafts, functional outcome.

Nasal alar reconstruction: A critical analysis using melolabial island and paramedian forehead flaps

Objectives: To qualitatively and quantitatively describe aesthetic and functional outcomes following Mohs ablative surgery involving the alar subunit, using a paramedian or subcutaneous melolabial island flap. Study Design: Retrospective review. Methods: A single surgeons results in 38 consecutive patients were analyzed. Objective measures (alar rim thickness, donor scar width and length), subjective assessment (seven aesthetic parameters) by three academic otolaryngologists, and patient satisfaction questionnaires were evaluated. Student t test was used to ascertain statistically significant differences between reconstructive groups. Results: Questionnaire results demonstrate a significant (P = .026) difference in donor site rating favoring melolabial group responses. Objective scar measurements and subjective ratings of textural quality and alar notching also favored melolabial reconstructions. Conclusions: More favorable aesthetic and functional outcomes are seen with single subunit cutaneous alar defects reconstructed with the melolabial island flap than with deep composite or extensive unilateral nasal defects reconstructed with the paramedian forehead flap.

Reflex sympathetic dystrophy of the face: Current treatment recommendations

Reflex sympathetic dystrophy (RSD) of the face is an infrequently reported clinical pain syndrome characterized by dysesthesia, hyperalgia, hyperpathia, and allodynia. Treatment strategies, extrapolated from RSD and causalgia of the extremities, remain variable and poorly defined. Sympathetic blockade is generally the diagnostic and therapeutic treatment of choice; however, the frequency, timing, and duration of injections; need for neurolytic blocks; and role of sympathectomy are not well understood. The objectives of this report are to highlight the clinical behavior of facial RSD and contrast its essential differences from extremity RSD in response to standard treatment regimes. The case studies of two patients with this syndrome, following vascular surgery in the neck, are retrospectively reviewed with existent reported cases. Age, gender, etiology, symptoms, onset, triggers, and examination findings; timing, duration, and method of treatment; and outcome are summarized, forming the database for this study. Findings demonstrate an infrequent association of vasomotor and sudomotor changes with facial RSD, and lack of progression to a dystrophic or an atrophic stage, in contrast to extremity RSD. Furthermore, treatment response to sympathetic blockade is durable and less critically dependent on timing. The authors conclude that facial RSD has a favorable prognosis and should be managed conservatively with nonneurolytic stellate ganglion blocks, even when initiated as a delayed and repetitive injection series.

Bone autografting of the craniofacial skeleton: Clinical and biological considerations

Bone grafting in the craniofacial region is an important reconstructive technique and has become widely used in otolaryngology-head and neck surgery. The success of bone grafting has greatly improved since the first recorded transplantation of a piece of dog skull to repair a defect in a Russian soldier’s skull by Van Meek’ren in 1682.’ The patient was excommunicated as a result of the procedure, and 2 years later Van Meek’ren removed the graft so the patient could return to his church. In 1820, Von Walther performed the first recorded human autologous bone graft.’ Interest in bone grafting was increased in 1867 by the publication of the experimental work of Ollier,3 which stressed the role of periosteum in the regeneration of bone. In 1878, Macewen4 reported a successful transplant of human bone allograft, and in 1912 he published a report of the repair of a mandibular defect with an autogenous rib graft.’ By 1923, bone grafting had become more widely used, and Albee’ published his experiences with over 3,000 bone graft operations. Since that time, many methods of bone transfer and aspects of bone grafting physiology have been studied and characterized, but still many more questions remain unanswered. Today, bone is a frequently transplanted tissue, with over 100,000 bone graft or bone implant procedures being performed each year in the United States alone.7 Autologous bone transplants are preferable to allografts (homologous bone) in their ability to be recognized as self, and thus avoid the

Protein associated with the sensory cell layer of the rainbow trout saccular macula

A protein has been detected that is associated with the saccular hair cell layer of the rainbow trout, Salmo gairdnerii R. By one- and two-dimensional SDS polyacrylamide gel electrophoresis, the molecular weight and isoelectric point of this protein are estimated to be 13.6 and 8.8 kDa, respectively. The 13.6 kDa protein cannot be detected electrophoretically in brain, gill, liver, and fractions containing the basal lamina, non-sensory epithelium, and saccular nerve. This protein does not bind antibodies to bovine myelin basic protein, while trout myelin basic proteins in the same molecular weight range do. In addition, the protein does not bind concanavalin A or react with the periodic acid-Schiff reagent. The 13.6 kDa band represents about 1% of the total protein in saccular sensory epithelium, and may be a marker protein for the hair cell layer.

Complete post-traumatic ptosis: a mechanism for recovery?

Traumatic blcphnroptosis, although considered relatively rare, is an entity which demands recognition if one is to achieve optimal results. Reports of levator injury following orbital, ocular, and adnexal surgery, as well as in cataract and blepharo‐plasty procedures, are well described. In most cases eventuating in complete ptosis, levator disinsertion is the anatomic correlate, the ptosis is usually permanent, and surgical intervention is often indicated.

Transcolumellar Transcrural Approach to Transsphenoidal Hypophysectomy

INTRODUCTION Evolution and refinements of surgical approaches to the sella turcica have spanned just over a century, with the first approach credited to Caton and Pau1,l who used a lateral subtemporal craniotomy. The need for improved visualization of the optic chiasm prompted the successful clinical application of frontal craniotomy for this purpose by Krause in 19092. The potential for reducing the inherent operative morbidity of a transcranial procedure was realized by Cushing,3 who developed the sublabial transseptal transsphenoidal approach. Around this time, Hirsch4 described the more direct but limited endonasal transseptal approach. As clinical experience with the transsphenoidal route grew, largely through the influence of Hardy,5 concurrent with technical improvements in optics and instrumentation, interest in other techniques that further reduced morbidity and improved exposure evolved. Transseptal approaches to the sphenoid can broadly be categorized into three initial routes: sublabial, transcolumellar, and endonasal (Table I). With the sublabial approach, wide midline exposure is achieved without external scarring, but at the expense of increased operating distance and soft tissue collapse within the field of vision. Furthermore, the sublabial premaxillary dissection necessary for exposure contributes to soft tissue trauma, sensory disturbances of the upper central dentition, potential interference with denture wear, and possible disturbances of nasal form (with maxillary cresthasal spine resections). Transcolumellar approaches also provide wide midline access to the sphenoid at shorter operating distances and without manipula-

Marlex mesh suspension of the floor of mouth in the glossectomee

Oncological resections for advanced oral cavity malignancies can result in communicative defects into the neck. Reconstitution of the volume loss with bulky myocutaneous flaps frequently results in poorly positioned soft tissue mounds that provide inadequate lingual-palatal valving for speech and swallowing. The combined forces of gravity, wound contraction, and dependent muscular vectors, together with denervation atrophy, often result in poor functional outcomes. A simple static technique of Marlex mesh suspension of the floor of mouth is described, which anatomically replaces the mylohyoid muscular sling, and thereby favorably repositions the neotongue in the glossectomee patient. A clinical case summary highlights the technical details and application in this desperate population.

Nonunion of the mandible and osteomyelitis

Summary The panelists all agree that a miniplate used alone on a posterior body (angle) fracture is insufficient and that this is the cause of subsequent infection and nonunion. The problem is further compounded by an unfavorable line of fracture and tooth extraction. Alternative treatments as addressed by the panelists include the application of stronger mandibular plates, especially the reconstruction type that will not rotate the upper border of the mandible. The respondents also suggest the use of a tension band to stabilize the upper border. Other factors such as noncompliance, comminution, and poor dental status and dental extraction are mentioned but not considered as significant as the choice of plate. As for the second set of questions, the panelists like the use of Clindamycin and incision and drainage of the infection. However, from that point there is divergence. If the mandible is stable incision and drainage can be used alone. If the mandible is unstable (mobile) then as several panelists describe, the plate should be removed and replaced with a larger reconstruction plate. These same panelists suggest that regardless of intraoperative findings, the small plate should be automatically replaced with a reconstruction plate. In general, acute infection will respond to conservative management, but when the infection does not clear and there is bone mobility, then additional measures are indicated. Traditionally, the biphase has been employed, but more recent experience shows that the reconstruction plate can be equally effective. In answer to question set 3, the panelists seem fairly aggressive in treating the patient. Although one panelist would treat with incision and drainage and wait 10 to 14 days, several others prescribe a short preoperative course of antibiotics, exploration, and fixation with a reconstruction plate. Timing in the use of bone grafts varied among the respondents from immediately to six months after infection. Traditionally, surgeons should wait for infection to completely disappear, and in the case of osteomyelitis this could be several months. On the other hand, if bone grafting can be performed sooner, we await such reports in the literature. The popularity of reconstruction plate fixation is evident and this technique seems to be supplanting the biphase method.

Survival of composite chondrocutaneous grafts by vessel implantation: a study in the rabbit ear model.

Composite chondrocutaneous graft reconstruction or reattachment has limited applicability, is traditionally restricted to small segmental losses, and is dependent on the status of the recipient bed and graft periphery for successful revascularization. Surgical enhancement of composite graft survival was experimentally investigated in the rabbit ear model through transposition and appositional placement of an adjacent vascular pedicle. Fluorescein‐derived surface‐survival determinations, microangiographic vessel‐counting methods, and histologic analysis were used to study the effects of vascular augmentation, pedicle design variations, and angiogenic substance in sixty 8‐cm2, full‐thickness auricular grafts. A statistically significant survival advantage was demonstrated for the implanted grafts, without derived benefit from angiogenic substance, secondary to perivascular angiogenesis from the implanted pedicle.