Stephen M. Weber

Modern Management of Laryngotracheal Stenosis

Objectives: Laryngotracheal stenosis is a complex problem resulting most often from intubation, trauma,or autoimmune disease. Management options include dilation or airway reconstruction including laryngotracheoplasty (LTP), cricotracheal resection (CTR), and tracheal resection (TR). We describe our experience with management of this difficult problem.

Efficacy of Nodal Dissection for Treatment of Persistent/Recurrent Papillary Thyroid Cancer†

Context: Although commonly performed, data are lacking regarding efficacy and safety of lymph node dissection (LND) for recurrent/persistent papillary thyroid cancer (PTC).

Extending Multidisciplinary Management of Cleft Palate to the Developing World

The needs of patients with a cleft lip and/or palate (CL/P) extend beyond surgical repair. A multidisciplinary approach to the care of patients with CL/P is the widely accepted standard in most regions of the developed world. Patients with CL/P in developing countries have needs similar to those of patients in industrialized nations. However, the existing shortages of healthcare resources have precluded provision of the most basic care to those with a CL/P. Innovative applications of technology can facilitate the delivery of speech therapy, evaluation of audiometric data, and limited dental evaluation for these patients with a modest financial investment. One method by which this care might be provided is with the use of Internet-based modalities. This represents a near universally available method to fill a conspicuous gap in the preoperative evaluation and postoperative care of patients with CL/P in the developing world. With rapidly expanding access to the Internet, particularly with wireless-3G connectivity worldwide, it is time to expand our delivery of humanitarian care beyond surgery alone in treating patients with CL/P in medically underserved areas.

Radial Forearm Free Tissue Transfer in the Management of Persistent Cerebrospinal Fluid Leaks

Objective: Cerebrospinal fluid (CSF) leaks can occur after head trauma or skull base surgery. Persistent or spontaneous leaks should be repaired, since they put patients at risk for serious intracranial complications. Although numerous repair methods have been successful, the occasional patient develops a persistent leak. We describe our experience with free tissue transfer for repair of recalcitrant CSF leaks.

Role of free tissue transfer in skull base reconstruction

Objective Free tissue transfer to the skull base provides a watertight seal to prevent CSF leakage and donor tissue tailored to the individual defect. Study Design and Setting Retrospective chart review of 38 patients who underwent free tissue transfer to the skull base between November 1995 and October 2005 at an academic, tertiary referral center. Results There were 23 male and 15 female patients (average age, 58.1 years) with skull base defects resulting from oncologic resection or head trauma most frequently. Donor sites included the radial forearm (25), rectus abdominis (12), latissimus dorsi (4), anterolateral thigh, scapula, serratus anterior, and ulna (1 each). Seven patients required a second free tissue transfer indicated for flap death (3), partial flap necrosis (2), pneumocephalus (1), or tumor recurrence (1). Two patients died in the immediate postoperative period. Conclusions Free tissue transfer is a robust option in the repair of post-surgical and post-traumatic skull base defects.

Transoral Excision of the Submandibular Gland

Submandibular gland excision is commonly performed for indications including neoplasm, chronic sialoadenitis, and sialolithiasis. Submandibular gland anatomy is complicated by the intimate association between its duct and the lingual nerve as well as the hypoglossal nerve that lies deep to the gland. Owing to this anatomic complexity, a wide cervical exposure has been advocated. However, this approach puts at risk the marginal mandibular nerve, which typically lies within the fascia of the submandibular gland. Further, the transcervical incision leaves the patient with an obvious cutaneous scar. We have successfully utilized transoral excision of the submandibular gland to manage chronic sialoadenitis, sialolithiasis, and benign salivary gland tumors.

DuraPrep and the risk of fire during tracheostomy.

DuraPrep is a widely used, alcohol‐based surgical prep solution. The risk of surgical fire associated with incomplete drying of this agent in the context of electrosurgical procedures has been described previously. To date, there have been no reports of fire during tracheostomy associated with a flammable prep agent before entering the airway. We describe an operating room fire occurring during awake tracheostomy associated with the use of DuraPrep.

Management of Cutaneous Nasal Defects

Nasal reconstruction has reached a point in its evolution such that its goals no longer include simply filling the defect. The contemporary facial reconstructive surgeon aims for an aesthetic and functional result in the vast majority of cases. Cutaneous nasal defects most often result from oncologic surgery, such as either Mohs excision or square technique, or, less commonly, traumatic or iatrogenic injury. This article discusses the current practices in the repair of nasal defects. Although this article focuses on reconstruction of oncologic defects, the principles discussed can be effectively applied to traumatic defects, as well.

Options for Internal Lining in Nasal Reconstruction

Nasal reconstruction has been refined to the point that its goals should include full restoration of form and function in addition to providing an aesthetically-pleasing result. Contemporary facial plastic surgeons have all the tools available in their armamentarium to repair the complex composite structure of nasal lining, structure, and skin cover. Nasal defects most often result from oncologic surgery or, less commonly, nasal trauma. While defects of nasal cover are more prominent, the impact of unrepaired nasal lining defects should not be underestimated. Meticulous repair of lining, structure and cover are all required for functional, stable and aesthetic nasal reconstruction.

Immediate Gore-Tex sling suspension for management of facial paralysis in head and neck extirpative surgery.

OBJECTIVE: We sought to evaluate the functional and aesthetic outcomes of immediate facial reconstruction with a Gore-Tex (expanded polytetrofluoroethylene) sling in irradiated patients undergoing large head and neck tumor extirpation with facial nerve resection. STUDY DESIGN AND SETTING: We conducted a retrospective study of 17 patients at two academic institutions who underwent extirpative surgery with immediate Gore-Tex sling reconstruction and completed radiotherapy. Functional and aesthetic results were evaluated at three intervals. RESULTS: All patients had excellent immediate results and good or excellent intermediate-term results. At long-term follow-up, results were good to excellent in 47% and unacceptable in 35% of patients. CONCLUSION: In irradiated patients undergoing total parotidectomy with immediate facial reconstruction using Gore-Tex slings, early results are excellent, but there is a high incidence of major wound complications and unacceptable results in long-term follow-up. SIGNIFICANCE: There is a high rate of late complications associated with immediate facial reconstruction with Gore-Tex slings in irradiated patients.