Salvatore C. Lettieri

Proposed Classification for the Transbasal Approach and Its Modifications

The transbasal approach offers extradural exposure of the anterior midline skull base transcranially. It can be used to treat a variety of conditions, including trauma, craniofacial deformity, and tumors. This approach has been modified to enhance basal access. This article reviews the principle differences among modifications to the transbasal approach and introduces a new classification scheme. The rationale is to offer a uniform nomenclature to facilitate discussion of these approaches, their indications, and related issues.

Frontal branch of the facial nerve: galeal temporal relationship.

BACKGROUND Risks to the frontal branch of the facial nerve, especially at the juncture of the zygomatic arch, have been well studied in connection with aesthetic procedures. The use of bicoronal incisions led to the observation that there is a second area in which injury to the frontal branch of the facial nerve is at risk: the transition plane between the area over the temporalis muscle and the pericranial region. OBJECTIVE A study was conducted to map out the frontal branch of the facial nerve as it passes through the dense galeal temporal fascia, because this is a zone of potential injury. METHODS Ten fresh frozen cadaver halves were dissected by use of a standard surgical bicoronal approach with surgical instrumentation and loupe magnification x 2.5. RESULTS In the area of interest, which included the region overlying the zygomatic arch, as well as the galeal frontalis fusion point, the nerve was found to be deep and within the fusion point. The nerve was cephalad to the sentinel vein in each instance, and the tissue was freely dissected medial and lateral to the fusion point of the galea and the temporal fascia. The fusion plane was dense and in a direct line in the vertical direction with the loose areolar plane on either side. CONCLUSION The dense tissue within the galeal temporal region needs to be approached with caution, avoiding electrocautery and using sharp dissection. The cadaver study demonstrates the close proximity of the nerve in the deeper portion of the elevated superficial flap.

Preserving Olfactory Function in Anterior Craniofacial Surgery through Cribriform Plate Osteotomy Applied in Selected Patients

OBJECTIVE: Olfaction is often sacrificed to gain access to the cranial base in anterior craniofacial surgery. We describe the long-term results of olfactory function in patients who underwent anterior craniofacial surgery and a cribriform plate osteotomy to preserve olfaction. METHODS: Between 1992 and 2004, 28 patients underwent 29 cribriform plate osteotomies in an attempt to preserve olfaction during anterior craniofacial surgery performed through modified extended transbasal approaches. Patients’ charts and office notes were reviewed retrospectively. Formal olfactory testing was available in 5 patients, but most data were based on patients’ subjective reports of olfaction. Olfactory preservation was defined by the subjective ability to detect fumes such as coffee, chocolate, roses, and orange juice regardless of the intensity of the sensation. Follow-up was based on phone calls to patients. RESULTS: Four patients were lost to follow-up and excluded. Therefore, follow-up was available in 24 patients after 25 procedures. On the basis of patients’ subjective reports, olfaction was spared in 22 patients after 23 procedures (92%) and was confirmed objectively in the five patients formally tested. After surgery, only two patients were anosmic. CONCLUSION: Olfaction can be preserved in selected patients undergoing anterior craniofacial surgery. At least 1 cm of nasal mucosa should remain attached to the cribriform plate, which can be achieved by including the nasal bone in the osteotomy of the orbital bar. A medial orbital canthopexy is therefore necessary after these procedures.

Sinonasal leiomyosarcoma: review of literature and case report.

Objectives/Hypothesis: To determine prognosis of primary sinonasal leiomyosarcomas after treatment.

Cerebral revascularization and carotid artery resection at the skull base for treatment of advanced head and neck malignancies

OBJECT Resection of cancer and the involved artery in the neck has been applied with some success, but the indications for such an aggressive approach at the skull base are less well defined. The authors therefore evaluated the outcomes of advanced skull base malignancies in patients who were treated with bypass and resection of the internal carotid artery (ICA). METHODS The authors retrospectively reviewed the charts of all patients with advanced head and neck cancers who underwent ICA sacrifice with revascularization in which an extracranial-intracranial bypass was used between 1995 and 2010 at the Barrow Neurological Institute. RESULTS Eighteen patients (11 male and 7 female patients; mean age 46 years, range 7-69 years) were identified. There were 4 sarcomas and 14 carcinomas that involved the ICA at the skull base. All patients underwent ICA sacrifice with revascularization. One patient died of a stroke after revascularization. A second patient died of the effects of a fistula between the oral and cranial cavities (surgery-related mortality rate 11.1%). Eight months after the operation, 1 patient developed occlusion of the bypass and died. Complications associated with the bypass surgery included 1 case of subdural hematoma (SDH) with blindness, 1 case of status epilepticus, and 1 case of asymptomatic bypass occlusion (bypass-related morbidity 16.7%). Complications associated with tumor resection included 3 cases of CSF leakage requiring repair and shunting, 1 case of hydrocephalus requiring shunting, 1 case of SDH, and 1 case of contralateral ICA injury requiring a bypass (tumor resection morbidity rate 33.3%). In 1 patient treated with adjuvant therapy before surgery, the authors identified only a radiation effect and no tumor on resection. In a second patient the bypass was occluded, and her tumor was not resected. The other 16 patients underwent gross-total resection of their tumor. Excluding the surgery-related deaths, the mean and median lengths of survival in this series were 13.2 and 8.3 months, respectively (range 1.5-48 months). Including the surgery-related deaths, the mean and median lengths of survival were 11.8 and 8 months, respectively (range 17 days-48 months). At last follow-up all patients had died of cancer or cancer-related causes. CONCLUSIONS Despite maximal surgical intervention, including ICA sacrifice at the skull base with revascularization, patient survival was dismal, and the complication rate was significant. The authors no longer advocate such an aggressive approach in this patient population. On rare occasions, however, such an approach may be considered for low-grade malignancies.

Patient-specific polyetheretherketone implants for repair of craniofacial defects.

Background:Large cranial defects represent reconstructive challenges. Polyetheretherketone (PEEK) implants are preoperatively tailored to the exact size of the defect and exhibit an excellent combination of strength, durability, and environmental resistance. This study presents our experience with patient-specific PEEK implants with computer modeling. Methods:A retrospective chart review was conducted on all patients who underwent cranioplasty treated by a PEEK implant between 2007 and 2012. Analysis of the preoperative and perioperative data as well as outcome analysis was performed. Results:A total of 11 patients were included. Mean age was 46 years. The indication for cranioplasty was bone flap infection and subsequent removal in 8 patients, traumatic bone loss in 2 patients, and acquired defect due to cancer resection in 1 patient. The mean time to PEEK cranioplasty since the patients last operation was 16 months. The mean defect size was 74 cm2. The mean surgical blood loss was 124 mL. The mean length of stay was 3 days. Complications included 1 postoperative bleeding that required reoperation, but the PEEK implant was successfully salvaged. The mean time to follow-up was 6 months. Conclusions:Use of patient-specific PEEK implants is a good alternative for alloplastic cranioplasty. It is associated with low morbidity as reported in our series, with additional advantages including strength, stiffness, durability, and inertness. It would be beneficial to assess the longer-term outcomes; however, it appears at first glance that PEEK implants show great promise in calvarial reconstruction.

Long-term follow-up of surgical resection of microcystic meningiomas

Microcystic meningioma is a rare tumor with myxoid and microcystic features. Our objective was to evaluate the efficacy of surgical resection of microcystic meningioma. Between December 1985 and October 2000 we treated 25 microcystic meningioma patients with surgical resection. We retrospectively analyzed the results including the long-term follow-up of this patient population. We identified 15 women and 10 men with a mean age of 53.8 years (24-76 years) who had microcystic meningiomas treated with surgery. Based on the Simpson grade, we found four Grade I (16%), 16 Grade II (64%), three Grade III (12%) and two Grade IV (8%) resections. The mean preoperative Karnofsky Performance Scale (KPS) score was 80.3 (range 60-100). The mean postoperative KPS score was 90.4 (range 60-100). At a mean follow-up of 101.7 months (range 16-221) the KPS score improved to a mean of 93.8. The recurrence/progression free survival (RFS/PFS) rates at 3 and 5 years were 96% and 88%, respectively. The 3 and 5 year RFS/PFS rates based on the Simpson grade were evaluated. The 3 year RFS/PFS rates for Grade I, II, III and IV were 100%, 100%, 66.6% and 100%, respectively. The 5 year RFS/PFS rates were 66.6%, 90%, 66.6% and 100%, respectively. Microcystic meningioma is a rare tumor, which is characterized by extracellular microcystic spaces filled by edematous fluid and peritumoral edema. Following surgical resection these tumors have a positive prognosis with a benign course. The surgical outcomes seem to be associated with the risks related to the surgical procedure.

Lower-limb reconstruction with chimeric flaps: The quad flap*

Early soft‐tissue coverage is critical for treating traumatic open lower‐extremity wounds. As free‐flap reconstruction evolves, injuries once thought to be nonreconstructable are being salvaged. Free‐tissue transfer is imperative when there is extensive dead space or exposure of vital structures such as bone, tendon, nerves, or blood vessels. We describe 2 cases of lower‐extremity crush injuries salvaged with the quad flap. This novel flap consists of parascapular, scapular, serratus, and latissimus dorsi free flaps in combination on one pedicle. This flap provides the large amount of soft‐tissue coverage necessary to cover substantial defects from skin degloving, tibia and fibula fractures, and soft‐tissue loss. In case 1, a 51‐year‐old woman was struck by an automobile and sustained bilateral tibia and fibula fractures, a crush degloving injury of the left leg, and a right forefoot traumatic amputation. She underwent reconstruction with a contralateral quad free flap. In case 2, a 53‐year‐old man sustained a right tibia plateau fracture with large soft‐tissue defects from a motorcycle accident. He had a crush degloving injury of the entire anterolateral compartment over the distal and lower third of the right leg. The large soft‐tissue defect was reconstructed with a contralateral quad flap. In both cases, the donor site was closed primarily and without early flap failures. There was one surgical complication, an abscess in case 2; the patient was taken back to the operating room for débridement of necrotic tissue. There have been no long‐term complications in either case. Both patients achieved adequate soft‐tissue coverage, avoided amputation, and had satisfactory aesthetic and functional outcomes. With appropriate surgical technique and patient selection, the quad‐flap technique is promising for reconstructing the lower extremity.

Management of Panfacial Fracture

Abstract Traumatic panfacial fracture repair is one of the most complex and challenging reconstructive procedures to perform. Several principles permeate throughout literature regarding the repair of panfacial injuries in a stepwise fashion. The primary goal of management in most of these approaches is to restore the occlusal relationship at the beginning of sequential repair so that other structures can fall into alignment. Through proper positioning of the occlusion and the mandibular‐maxillary unit with the skull base, the spatial relationships and stability of midface buttresses and pillars can then be re‐established. Here, the authors outline the sequencing of panfacial fracture repair for the restoration of anatomical relationships and the optimization of functional and structural outcomes.

Management of temporomandibular joint Coccidioidomycosis.

Purpose: The aim of this report was to present the first known case of coccidioidomycosis involving the temporomandibular joint, review the literature regarding dissemination to the mandible, and to provide treatment recommendations for this challenging condition. Methods: Coccidioidomycosis of the mandibular condyle was identified in a 30-year-old Somali male residing in Arizona. Due to the difficulty of surgical access and the anticipated temporomandibular joint morbidity of radical condylar debridement, primary medical management was performed. Results: Marked symptomatic improvement was observed after 10 days of IV antifungal therapy. Resolution of the abscess with residual bony destruction was observed on CT scan. Based on the results of this patient and review of the literature, an algorithm is presented to help guide management of coccidioidomycosis dissemination to the mandible. Conclusion: Prolonged antifungal therapy should be attempted for initial management of a Coccidioides abscess involving the condyle with early surgical intervention reserved for the more easily accessible and less functionally compromising portions of the mandible.