Clinical and morphological results of xenografts to use in myringoplasty

The main aim of our study was to study morphological state of the autograft from the fascia of the temporal muscle in myringoplasty. Until now, there is no consensus on issue of which fabrics are more suitable for use in the eardrum. We decided to study of use of an autograft from the fascia of the temporal muscle for myringoplasty in rabbits in the experiment, and in patients with chronic dry mesotympanitis. An electron microscopic examination of the fascia taken immediately, after 10, 20 min and 1 h after sampling. It was found that there are no gross destructive changes in the fascia structure. Minor changes are detected in the form of a light disorganization of the collagen complex, granular dystrophy with an increase in cell. Inflammatory diseases of the middle ear are widespread among population of all age groups. In the experiment, a positive result was obtained in 29 (82.8%) rabbits. In our research we performed morphological features of xenograft engraftment in an experimental animal on 3, 7, 14, 21 days and 1-3 months. In period from 3 days to 3 months after operation, the animals were euthanized by an air embolism and subjected to pathological examination. Then recovered xenograft, was examined macro and microscopically. Pieces were fixed in a 10% solution of neutral formalin. After washing with water, dehydration was carried out in alcohol and chloroform, and after, waxed with paraffin. Histological sections were stained with hematoxylin-eosin. Collagen fibers were detected by method of Vann-Gieson.

TMJ ANKYLOSIS: MANAGEMENT WITH RECONSTRUCTION AND INTERPOSITIONAL ARTHROPLASTY

Temporomandibular joint (TMJ) ankylosis is a very desolating structural condition that involves fusion of the mandibular condyle to the base of the skull. It causes difficulty in mastication and breathing. Trauma and Infections are usually responsible. If trauma occurs in young age, it leads to disturbance in growth & facial asymmetry. Treatment of temporomandibular joint (TMJ) ankylosis usually requires adequate excision of the involved ankylotic block (arthroplasty) or interpositional arthroplasty using autogenous or alloplastic materials. Early mobilization, physiotherapy & strict follow up are essential to prevent postop adhesions. In our cases fascia lata was used as an interpositional grafting material. One case was treated by gap arthroplasty, second case by costochondral graft & third case was managed with titanium condylar prosthesis.

[Split temporalis muscle flap vascularized by the superficial temporal pedicle]

INTRODUCTION

The temporalis muscle has been used for more than a century for facial reconstruction. But this flap cannot fill defects beyond the midline. Splitting the temporalis muscle in the plane of the tendon insertion allows lengthening the flap and crossing the midline.

TECHNICAL NOTE

The scalp incision is followed by a subcutaneous dissection, taking care to spare hair follicles and superficial temporal vessels. Then the temporalis muscle is detached by a strictly subperiosteal dissection and deep temporal pedicles are dissected and ligated. The flap is split in the plane of the insertion tendon up to its distal end.

DISCUSSION

This technique allows reconstructing cranio-facial defect beyond the midline with well-vascularized tissue.

A novel technique for reconstruction of the posterior wall of the external auditory canal and tympanum using pedicled temporalis myofascia

CONCLUSIONS

The procedure cleared the lesion completely and preserved the physiological function of the external auditory canal.

OBJECTIVE

To develop a novel surgical procedure to treat chronic suppurative otitis media (CSOM). To explore the merit of using pedicled temporalis myofascia (PTM) and reconstruction of the posterior wall of the external auditory canal with pedicled postauricular periosteal flap and intact skin of the external auditory canal.

METHODS

Forty-seven patients with CSOM were chosen. Open radical mastoidectomy was used to complete clean-up lesions; the fascia of PTM was used to repair the tympanic membrane. The PTM, pedicled postauricular periosteal flap, and intact skin of the external auditory canal were used in the reconstruction of the posterior wall of the external auditory canal. All subjects were followed up for over 2 years. Hearing thresholds, including air conduction (AC), bone conduction (BC), and air-bone gap (ABG) before and after surgery, and after follow-up, were compared.

RESULTS

The healing rate of postoperated tympanic membrane was 95.74% and the 2-year healing rate of tympanic membrane perforation was 95.65%. The 46 ears included in the 2-year follow-up showed significant improvement between preoperative and postoperative AC and ABG values.

Split temporalis muscle flap anatomy, vascularization and clinical applications

INTRODUCTION

For more than a century, the temporalis muscle has been used for facial reconstructions. More recently, a split temporalis muscle flap elevated on the superficial temporal pedicle has been described, for which the resulting gain of length makes crossing of the midline possible, as well as reconstruction of substance losses exceeding the midline.

MATERIALS AND METHODS

Fourteen fresh cadaveric dissections were performed to study the different techniques for splitting the temporalis muscle. Dissections with catheterization and injection of radio-opaque contrasting agent in the external carotid artery were then performed to specify the vascularization of the flap split on the superficial temporal pedicle.

RESULTS

The duplication of the superficial temporal pedicle grants greater length compared to that of the deep pedicles, 57 mm versus 40 (p = 0.036). The middle temporal artery is capable of ensuring the vascularization, and therefore the viability, of the split flap. From these results, we spoke about the limitations of this study and we have inferred the main indications.

[Lengthening temporalis myoplasty for facial palsy reanimation after parotid surgery]

AIM OF THE STUDY

Share our experience and our results of lengthening temporalis myoplasty (LTM) for facial palsy reanimation after parotid surgery.

MATERIALS AND METHODS

Study of 15 patients after they had had a lengthening temporalis myoplasty, in the same time or after a non conservative parotidectomy of facial nerve. 10 patients suffered from a parotid malignant tumor, one had a jugal epidermoid skin carcinoma invading the parotid, 2 patients had a facial palsy after removal of pleomorphic adenoma recurrence and two patients had a facial nerve schwannoma. 8 patients had a LTM surgery in the same time of the parotid tumoral removal.

RESULTS

No recurrence was observed on the 11 patients who had a carcinoma (average follow up: 27 months). The LTM surgery enabled us to obtain good results at rest for 14 patients (93%) and an intermediate result for one person. The ability to smile was described as good for 10 patients (66.6%), intermediate for 4 of them (26.6%) and unsatisfying for 1 person (6,6%). In the group rehabilitation, the results observed are similar, for the patients who had one or two surgical steps. In 3 cases, we noticed an infectious complication, which led us to operate again. In the 8 cases within lengthening was performed in the same time as parotidectomy, there was no additionnal surgical difficulty.

CONCLUSION

LTM surgery is an efficient method of rehabilitation. If possible, it should be performed in the same time as tumor removal. As the operational places are different, tumor checking-up and observation are not disturbed by this kind of rehabilitation.

[Clinical application of mandibular osteomuscular flap pedicled with temporalis to repair maxillary bone defect]

OBJECTIVE

To evaluate the clinical effect of mandibular osteomuscular flap pedicled with temporalis to repair maxillary defect.

METHODS

From March 2008 to May 2010, ten cases of maxillary defects resulted from malignant tumor resection were treated with mandibular osteomuscular flap pedicled with temporalis. Ten cases of malignant tumor included six cases of Squamous cell carcinoma,one case of duct carcinoma, osteosarcoma, chondrosarcoma and malignant melanoma. One case was repaired by mandibular osteomuscular flap only, nine cases were repaired by mandibular osteomuscular flaps combined with other soft tissue flaps.

RESULTS

All the 10 mandibular osteomuscular flaps survived completely with no complication. The patients were followed up for 12 to 36 months, with an average of 18 months. Satisfactory appearance and complete functional restoration were achieved except for one case of chondrosarcoma recurrence.

CONCLUSIONS

The mandibular osteomuscular flap pedicled with temporalis is safe and easily performed with less complication. It is an ideal method for repairing the maxillary defect.

Efficacy of temporalis muscle transfer for correction of lagophthalmos in leprosy

OBJECTIVES

Temporalis Muscle Transfer (TMT) is a surgical technique used to correct lagophthalmos in leprosy patients. We have evaluated the degree of success of TMT in achieving full lid closure, which is important in preventing damage to the cornea.

SUBJECTS AND METHODS

A retrospective study was carried out on 69 patients who had TMT done, at one centre, on 101 eyes during the period of 1998-2009. Lid gaps on direct gaze and with both gentle and forced closure, as well as voluntary muscle testing of eye lid closure, were assessed using standard measuring techniques by a qualified physiotherapist. Associated problems due to lagophthalmos were recorded both pre- and post- operatively. Data were abstracted on to a special proforma and subjected to statistical analysis using SPSS.

RESULTS

On completion of post-operative physiotherapy, 85% of the eyes could achieve full lid closure with no measurable gap. The mean (SD) lid gap on forced closure was 48 (2.8) mm pre-operatively and 0.2 (0.5) mm at the end of the in-patient stay. The mean (SD) lid gap on gentle closure was 7.9 (2.6) mm preoperatively and 2.4 (1.8) mm post-operatively. The mean (SD) vertical inter-palpebral distance, during straight gaze, was reduced from 12.6 (1.6) pre-operatively to 9.8 (1.2) postoperatively. Exposure keratitis cleared in 16 of 27 eyes (60%) and Epiphora cleared or improved in 31 eyes.

CONCLUSIONS

It is concluded that the TMT is a successful option (cosmetically and functionally) for correction of lagophthalmos.

[The effect of treatment of temporalis muscle fascia grafts with formaldehyde on the success rates of tympanoplasty]

OBJECTIVES

This study aims to investigate the effect of formaldehyde treatment of temporalis muscle fascia grafts used during tympanoplasty on the postoperative success rates.

PATIENTS AND METHODS

Fifty-four patients who underwent tympanoplasty between January 2006 and January 2007 in the Department of Otolaryngology, Medicine Faculty of Uludağ University and who were under regular follow-up were included in this prospectively planned study and divided into two groups: the study group (n=24) and the control group (n=30). Temporal muscle fascia grafts were used in all patients. The grafts were treated with formaldehyde in the study group. All the controls of the patients were performed by otomicroscopy. Audiometric tests were performed at the 6th month controls.

RESULTS

It was found out that perforation was permanently repaired in 79.2% of the study group and in 73.3% of the control group (p>0.05). We obtained an evident improvement in the average airway bone gap in both groups. We could not detect any statistical significance in the comparison of the operation duration between the groups although the operation duration in the study group was shorter (the study group: 735 seconds, the control group: 775 seconds).

CONCLUSION

The formaldehyde treatment of the temporalis muscle fascial graft used in tympanoplasty was not superior in closing perforation and operation length compared to its direct dry use. However, we concluded that the graft could be more easily manipulated during the operation.

[Reconstruction of the maxilla with pedicled temporalis muscle after maxillectomy]

INTRODUCTION

Removal of the maxilla requires adequate restoration of the maxillary structure to replace form and functions, especially vocal and eating functions. A host of reconstructive options are available to restore the maxilla, most of which include free-flap reconstruction. The aim of this study was to clinically evaluate the use of pedicled temporalis flap for reconstruction of the maxilla and to assess patient quality of life.

MATERIAL AND METHODS

In the period 2000-2007, a total of 32 patients with malignant tumours of the maxilla were operated with immediate reconstruction of the maxilla using pedicle temporalis muscle flap at the ENT department, Aarhus University Hospital. Follow-up was implemented in 2007. Twenty-seven of 28 patients alive at the time of the follow-up participated in the study. The patients were evaluated objectively as well as subjectively by answering the EORTC's standard questionnaire concerning quality of life and functional results.

RESULTS

Few patients had complaints and these where mostly minor functional deficits. The most common complaints were slightly impaired mouth opening. One temporalis muscle flap necrotized and was removed. Three patients developed oro-nasal/antral fistula, witch were later closed using local flaps.

CONCLUSION

The follow-up study of the 27 patients showed a most satisfactory result evaluated objectively as well as subjectively using the EORTC questionnaire.

Endoscope-assisted myringoplasty

INTRODUCTION

To date, myringoplasty conducted under the operating microscope has been found to have its limitations. With the introduction of the endoscope into other branches of surgery, there have been attempts at its utilisation in otology.

METHODS

Endoscope-assisted myringoplasty was carried out in 50 patients aged 18-45 years using the temporalis fascia graft. The middle ear was examined through perforation in order to exclude cholesteatoma.

RESULTS

The overall success rate of the graft uptake and improvement in conductive deafness as air-bone gap closure was achieved in 80 percent of cases.

CONCLUSION

Endoscopic myringoplasty was found to be equally effective, less morbid and very cost-effective in small central perforations. However, it is not applicable in all cases, especially in those with large perforations.

[Using pedicled mandibular osteomuscular flap in orbital reconstruction]

Represented the way of orbital floor reconstruction using coronoid process of the mandible pedicled on temporal muscle. The clinical evaluation of vascularised bone graft from coronoid process confirmed their usefulness in the face recon struction surgery.

Temporalis Tendon Transfer as Part of a Comprehensive Approach to Facial Reanimation

OBJECTIVE

To report an approach to facial paralysis in patients for whom dynamic adjacent muscle transfer is determined to be the best treatment option.

METHODS

Retrospective review of 7 consecutive patients who underwent orthodromic transfer of the temporalis muscle insertion for the treatment of long-standing facial paralysis. Patients underwent facial-retraining physical therapy before and shortly after the procedure. Outcomes measured included patient satisfaction, objective measurements of oral commissure elevation with smiling, and physician grading of preoperative and postoperative patient photographs. Medical records were reviewed for complications.

RESULTS

Patient satisfaction was high, with a mean score of 8.5 (possible score of 10). Four patients were physician graded as excellent to superb. The other 3 patients were rated as having good postoperative results. Movement was identified in every patient and ranged from 1.6 to 8.5 mm, with mean movement of the oral commissure of 4.2 mm. One patient developed postoperative salivary fluid collection that required drainage.

CONCLUSIONS

Temporalis tendon transfer is a relatively easy procedure to perform that has distinct advantages compared with other forms of facial reanimation and provides very good results. This procedure results in improved form and function, may often be performed in a minimally invasive manner, and eliminates the facial asymmetry typically produced by temporalis transfer.

Effect of ciprodex on graft healing in tympanoplasty

The present study was conducted to evaluate whether the administration of ciprofloxacin 0.3%/dexamethasone 0.1% (Ciprodex)-soaked gelfoam during tympanoplasty has adverse effects on graft healing. Records of patients who had undergone tympanoplasty with Ciprodex-soaked gelfoam packing placed in the middle and external ear canal were reviewed. The time to heal for each patient and the number of postoperative perforations/complications were recorded. Sixty-four charts met the inclusion criteria. Most procedures were primary type I tympanoplasties with temporalis fascia grafts. Healing of the tympanic membrane was documented in 95.3% of patients, and mean time to healing was 49 d. Two patients who underwent revision tympanoplasty failed to exhibit healing at any visit after surgery. Postoperative complications were infrequent. Patients with Ciprodex-soaked gelfoam packing placed during tympanoplasty showed an overall rate of healing of 95%. Although this study is limited by its retrospective design, the data suggest that the use of Ciprodex during tympanoplasty has no detrimental effect on postoperative graft healing.

Reconstruction of full-thickness cheek defects with combined temporalis myofacial and facial-cervico-pectoral flaps

OBJECTIVE

The objective of this study was to assess using the temporal myofacial flaps (TMFF) and the facial-cervico-pectoral flap (FCPF) to provide both inner and outer linings for large full-thickness cheek defects following ablative oral cancer surgery.

STUDY DESIGN

Twelve patients with malignant tumors in the buccal region were treated by extensive surgical dissection, and the cheek mucosa defects were repaired with the TMFF and the cheek skin defects were reconstructed with the FCPF. There were 9 male and 3 female patients, age range from 18 to 70 years (mean 52.8). The full-thickness cheek defects ranged from 7 x 6 cm to 10 x 8 cm in size.

RESULTS

No patient had complete loss of flap; 3 patients had minor complications (TMFF and FCPF partial necrosis and FCPF distal dehiscence) all of which settled with conservative management. Mouth opening was normal in 10 patients, and facial contour was satisfactory in 8 patients. The follow-up period varied from 6 to 26 months (mean 15.2); 3 tumors had local recurrences and 2 patients died from tumor metastasis.

CONCLUSION

We found the technique to be anatomically sound, technically easy and reliable, and believe it is a useful method for the reconstruction of large full-thickness cheek defects.

Use of Palacos®R-40 with gentamicin to reconstruct temporal defects after maxillofacial reconstructions with temporalis flaps

The temporalis muscle flap is a useful flap for the reconstruction of oral ablative defects. A complication of its use that was overlooked was the crater-like defect created when the muscle is stripped from its attachment on the temporal fossa. The cold-cure acrylic we use is Palacos R-40 with Gentamicin (Heraeus Kulzer GmbH). This material is radio-opaque, rapidly setting and contains gentamicin. We present a total of 41 cases over an 11-year period (1994-2005). We have a 97.6% (n = 40) success rate. Infection developed in only one case, which leads to the removal of the acrylic implant. The use of Palacos R-40 with Gentamicin is easy to use, it can be custom-moulded to fit and fill the defect any of shape and size. It has minimal complications and high success rate with acceptable results to the patients.

Calvarial Bone Grafts and Temporalis Muscle Flap for Midfacial Reconstruction After Maxillary Tumor Resection

Midfacial reconstruction after radical oncological resection is a challenging endeavor and several options can be employed: prosthethic devices, pedicled flaps (with or without the aid of autologous or alloplastic grafts), and microvascular flaps. Each technique has specific indications, advantages and disadvantages. The use of traditional surgical reconstructive procedures seems to be shifted nowadays by microvascular free flaps. Nevertheless, in our experience the myofascial temporalis flap associated with free calvarial bone grafts demonstrate to be a safe and versatile option in primary midfacial reconstruction. From this point of view the authors have developed a technique for one-stage reconstruction of the orbito-maxillary skeleton and soft tissues and without the use of microsurgical flaps; this surgical procedure can be used only on patients for whom a resection of the cutaneous tissues and exenteratio orbitae are not necessary. The aims of this paper is to describe the surgical technique and to show a retrospective analysis on 17 patients which underwent midfacial radical resection and immediate reconstruction with calvarial bone grafts and temporalis muscle flap along 15 years.

The "yo-yo" technique to prevent cerebrospinal fluid rhinorrhea after anterior clinoidectomy for proximal internal carotid artery aneurysms

OBJECTIVE

Resection of the anterior clinoid process is important for the exposure of aneurysms on clinoidal and supraclinoidal segments of the internal carotid artery. Cerebrospinal fluid (CSF) rhinorrhea can complicate anterior clinoidectomy when the optic strut is pneumatized and its removal communicates the subarachnoid space with the sphenoid sinus. We present a technique for repairing this defect and preventing CSF rhinorrhea.

METHODS

A suture is secured around a strip of temporalis muscle, which is then pushed through the opening in the optic strut completely into the sphenoid sinus. The ends of suture that trail the muscle are used to retract the muscle from the sphenoid sinus back into the optic strut. The suture is trimmed and the repair is covered with sealant or fibrin glue.

RESULTS

During an 8-year period in which 127 patients with proximal internal carotid artery aneurysms that required anterior clinoidectomy were treated, pneumatized optic struts were encountered in 14 patients (11%). Four patients were treated with the "yo-yo" technique, none of whom experienced CSF rhinorrhea. Before using this technique, 10 patients were managed with standard packing techniques (wax, muscle, and gel foam) and four of these patients subsequently experienced CSF rhinorrhea (40%). In these four patients, all required reoperation with either craniotomy and packing with pericranium (one patient), Couldwell-Luc procedure (one patient), or endoscopic transnasal obliteration of the sphenoid sinus with fat (two patients).

CONCLUSION

The "yo-yo" technique of tightly wedging a muscle plug into the optic strut proved to be simple, fast, and effective, preventing CSF rhinorrhea in all patients in whom it was applied. Although experience with this technique is limited, reversing the direction of packing and pulling muscle from the sphenoid sinus into the optic strut eliminated a complication that occurred in 40% of patients with standard packing techniques.

Temporomandibular joint bony ankylosis: comparison of treatment with transport distraction osteogenesis or the matthews device arthroplasty

Temporomandibular joint (TMJ) bony ankylosis with micrognathia is a rare congenital condition that is difficult to treat and may result in recurrence. In a series of affected patients, we compared two new methods of treatment: transport distraction osteogenesis and Matthews Device arthroplasty. All patients had computed tomography scan documented bilateral TMJ bony ankylosis. Group I (transport distraction osteogenesis) underwent distraction advancement of the mandible (for micrognathia) followed by resection of the condyles, recontouring of the glenoid fossas with interposition temporoparietal-fascial flaps, and transport distraction osteogenesis of mandibular rami segments. Group II (Matthews Device arthroplasty) underwent all of the above procedures except for transport distraction osteogenesis. Instead, the Matthews Devices were anchored to the temporal bone and mandibular rami. Hinged arms allowed for motion at the reconstructed TMJ. In both groups, patients underwent extensive postoperative therapy. Preoperative, postoperative, and follow-up lateral cephalograms were obtained, and incisor opening distances were recorded. All patients but one had severe micrognathia (n = 9). For group I (transport distraction osteogenesis), mean age was 6.8 years. and mean advancement was 28.5 mm. For group II (Matthews Device arthroplasty) mean age was 8.2 years, and mean advancement was 23.5 mm. In group I (transport distraction osteogenesis), mean incisor opening was 1 mm preoperatively and 27.5 mm postoperatively; however, it relapsed to 14.3 mm by 12.5 months follow-up (48% relapse). Mean incisor opening in group II (Matthews Device arthroplasty) was 3.9 mm preoperatively and 33.4 mm postoperatively and remained at 30.6 mm after 11.1 months follow-up (8% relapse). One patient in group I (transport distraction osteogenesis) underwent surgical revision because of relapse. Our data showed that for congenital TMJ bony ankylosis both transport distraction osteogenesis and Matthews Device arthroplasty techniques were successful initially; however, the Matthews Device arthroplasty avoided long-term relapse.

Advances in facial reanimation

PURPOSE OF REVIEW

Facial paralysis often has a significant emotional impact on patients. Along with the myriad of new surgical techniques in managing facial paralysis comes the challenge of selecting the most effective procedure for the patient. This review delineates common surgical techniques and reviews state-of-the-art techniques.

RECENT FINDINGS

The options for dynamic reanimation of the paralyzed face must be examined in the context of several patient factors, including age, overall health, and patient desires. The best functional results are obtained with direct facial nerve anastomosis and interpositional nerve grafts. In long-standing facial paralysis, temporalis muscle transfer gives a dependable and quick result. Microvascular free tissue transfer is a reliable technique with reanimation potential whose results continue to improve as microsurgical expertise increases. Postoperative results can be improved with ancillary soft tissue procedures, as well as botulinum toxin.

SUMMARY

The paper provides an overview of recent advances in facial reanimation, including preoperative assessment, surgical reconstruction options, and postoperative management.

Revision Tympanoplasty Including Anterior Perforations and Lateralization of Grafts

Not long ago, the restoration of a perforated tympanic membrane by grafting over an air-containing tympanic cavity seemed impossible. Fortunately, successful results are so consistent and universal today that restoration of the tympanic membrane is expected, and a failure calls for careful evaluation as to "why". If known principles are observed, few complications need occur. Usually, complications are the result of either the choice and placement of the graft used in the repair, or the presence of unresolved upper respiratory pathology. When revision tympanoplasty is necessary, use of the underplay fascial graft technique, properly applied, usually can solve any difficult problems.

Reconstruction of #7 facial cleft with distraction-assisted in situ osteogenesis (DISO): role of recombinant human bone morphogenetic protein-2 with Helistat-activated collagen implant

A case involving concomitant presentation of a #7 lateral facial cleft with a complete cleft of the ipsilateral lip, alveolus, and palate is presented. The mandibular defect was Pruzansky III with a foreshortened body, absent ramus and absent masseter. Taking advantage of developmental field theory, reconstruction of the osseous defect was undertaken using the autogenous periosteum as a source of mesenchymal stem cells. Expansion of the periosteum was followed by implantation of Helistat (Integra Life Sciences, Plainsboro, NJ) collagen sponge saturated with recombinant human bone morphogenetic protein-2. Stimulation of this distraction-induced envelope by rhBMP-2 resulted in abundant production of bicortical membranous bone in situ within 12 weeks. The neoramus was subsequently suspended from the cranial base, and a temporalis muscle transfer was used to provide motor control of the jaw. Synthesis of bone in this manner is termed DISO (distraction-assisted in situ osteogenesis). The biologic rationale and clinical implications of DISO are discussed.

Functional upgrading of partially recovered facial palsy by cross-face nerve grafting with distal end-to-side neurorrhaphy

BACKGROUND

Cross-face nerve grafting combined with functional muscle transplantation has become the standard in reconstructing an emotionally controlled smile in complete irreversible facial palsy. A special problem exists in incomplete or partially recovered facial palsies, when the little existing function should be preserved but the existing function alone is clinically insufficient.

METHODS

In this situation, cross-face nerve grafting performed by means of end-to-end coaptation to a zygomatic branch of the healthy side and by end-to-side neurorrhaphy to a corresponding branch of the incompletely paralyzed side is proposed to upgrade smile function on the latter side and contribute to more static and dynamic overall symmetry. The interposition nerve graft is set in overlength to preserve the possibility of a later muscle transplantation in case of unsatisfying functional result through the additional neuronal input. The authors have used this concept in seven patients with irreversible partial facial palsy. Three cases have a sufficiently long follow-up to be presented here. Outcome was objectively quantified with three-dimensional video analysis of facial movements.

RESULTS

In all three cases, functional improvement and a positive effect on the static and dynamic symmetry of the face could be measured. None of the patients was disappointed by the smile function achieved or wanted to undergo additional muscle transplantation.

CONCLUSION

On the basis of these first clinical experiences, the authors recommend cross-face nerve grafting with overlength and a distal end-to-side neurorrhaphy in patients with irreversible incomplete facial palsy affecting the smile.

Report of ankylosis of the temporomandibular joint: treatment with a temporalis muscle flap and augmentation genioplasty

A case of true bilateral ankylosis of the temporomandibular joint (TMJ) is presented. A 19-year-old male patient had a life-threatening ear infection at the age of ten resulting in a progressive restriction of his mouth opening. He presented with almost complete lack of mobility of the mandible. Surgical treatment was a resection of the ankylotic mass, interpositional temporalis composite muscle flaps, and early mobilization and aggressive physiotherapy. The functional results of the interpositional arthroplasty were excellent. After a two-year follow up, an augmentation genioplasty was performed in order to improve facial aesthetics.

The use of temporal polyethylene implant after temporalis myofascial flap transposition: clinical and radiographic results from its use in 21 patients

PURPOSE

The use of temporalis myofascial flap (TMF) as a pedicled flap in craniofacial reconstructive surgery is well established. The transposition of temporalis muscle results in a large hollowing of the temporal fossa that leaves the patient with a cosmetic impairment. Reconstruction of this donor site deformity is desirable. One of the established reconstructive techniques is the use of a prefabricated porous high-density polyethylene (HDPE) temporal implant. In order to evaluate results from its use, we retrospectively reviewed a series of 21 consecutive patients.

MATERIALS AND METHODS

From October 1999 to October 2004, 21 patients (7 men and 14 women) aged 32 to 85 years (mean, 65) had their surgical defects reconstructed with the use of a TMF. The majority of patients (15 of 21) had squamous cell carcinoma of the maxilla or the maxillary sinus. In 17 patients, the reconstructive procedure was performed simultaneously with the oncological resection, whereas in 4, a secondary reconstruction was performed. In 1 patient, bilateral TMFs were used to cover a total maxillectomy defect. Standard surgical approach was used in all patients during TMF elevation. The temporal defect was reconstructed with the use of a prefabricated sterile HDPE implant (Medpor; Porex Surgical Inc, College Park, GA). Fixation of the implant to the recipient infratemporal fossa was performed with black silk sutures (in 2 patients) or titanium miniscrews (in 19 patients). The manufacturer's instructions for the placement of the implant were followed in all cases. One of the 21 operated patients preoperatively received radiotherapy (RT). Of the remaining 20 patients, 5 underwent postoperative RT.

RESULTS

Eighteen patients are alive and free from disease. One died during the perioperative period from myocardial infarction and 2 more from locoregional recurrence of their disease, 18 and 27 months postoperatively. In all 21 patients, the placement of the Medpor temporal implant was successful and no immediate or perioperative complications resulting from its use were encountered, giving an overall success implantation rate of 100%. Follow-up ranged from 9 to 70 months (mean, 39). The condition of the implant was evaluated with computed tomography in 18 of the 21 patients as part of the standard postoperative assessment. Radiographic results of the recipient site did not reveal any abnormalities. In 7 patients, the contour of the HDPE implant could be manually palpated, and in 3, it could be seen to protrude subcutaneously. Esthetic results were judged satisfactory from all patients. The hemicoronal skin flap healed uneventfully in all patients and did not cause a visible scar even to bald male patients.

CONCLUSIONS

The reconstruction of the temporal defect after TMF transposition with the use of a Medpor temporal implant is an easy and safe method. The implant does not seem to cause any tissue reaction, and long-term functional and esthetic results are excellent. When properly used and the relevant manufacturers' instructions are carefully followed, the success rate of the method is extremely high.

Underlay myringoplasty: comparison of human amniotic membrane to temporalis fascia graft

Human amniotic membrane as a homograft material was compared to temporalis fascia to close tympanic membrane perforations in 50 patients with chronic otitis media. Human amniotic membrane was used in 20 patients while temporalis fascia was used in the remaining 30. Anatomical closure of the perforation and reduction of the air-bone gap was measured. The graft uptake showed a 65% success rate for the amniotic membrane and 56.7% for the temporalis fascia at 3 months post-operatively. Significant closure of air-bone gap was observed in the human amniotic group. These results indicate comparable outcomes between human amniotic membrane and the temporalis fascia graft.

Giant mucocele of the frontal sinus

Giant mucocele of the frontal sinus is a rare pathology of benign entity caused by retention of mucous secretions in the sinus. It may expand and erode the surrounding structures such as bones and cerebral parenchyma. The authors describe a patient with frontal giant mucocele involving the orbit, the ethmoid, and intracranial portion of the dura. The main presenting symptoms were diplopia and proptosis. A computed tomography scan and magnetic resonance imaging were performed to permit differential diagnosis from other pathologies such as ossifying fibroma, fibrous dysplasia, and other neoplasms. A single stage maxillofacial and neurosurgical approach to treatment was taken consisting in the removal of the mucocele and reconstruction of the eroded bones with cranial bone grafts. The dura was repaired with temporalis muscle fascia sealed with fibrin glue. Two years after surgery, the patient shows no recurrence and satisfactory morphologic and functional results.

Transethmoidal meningoencephalocele in an elderly woman. Case report

A 69-year-old woman presented with a transethmoidal meningoencephalocele manifesting as gradually developing anosmia. Examinations revealed a mass in the nasal cavity associated with multiple angiomas in her lip and orbit. Neuroimaging showed meningoencephalocele extending via the ethmoid sinus to the nasal cavity. She had no history of craniofacial trauma and intranasal or intracranial operation, and no skull base tumor was detected. Frontal base reconstruction was performed with a two-layer vascularized flap to prevent cerebrospinal fluid leakage. The dural defect was repaired with the pericranial flap, and the bony defect of the cribriform plate was reconstructed using the reversed U-shaped split temporalis musculofascial flap. Transethmoidal meningoencephalocele is a rare congenital malformation and almost half of the cases are identified in the first year of life. We should be aware of this clinical pathology and avoid unexpected rhinorrhea in elderly patients. The most important aspect of the operation is watertight closure of the patent passage to the intracranial compartment. The reversed U-shaped split temporalis musculofascial flap is useful to reconstruct the midline frontal base defect.

[Temporalis myofascial flap: technique description and results in our patients]

INTRODUCTION

Surgical treatment of intraoral and maxillary sinus carcinomas requires a reconstructution of the defect. It is better to do it in one time in order to decrease the morbidity for the patient and the sanitary cost. The temporalis myofascial flap is used for reconstruction of oral cavity, skull base, periorbital region and maxilla because of its feasibility.

MATERIAL AND METHODS

We describe the surgical technique and present our results of the reconstructions after total or partial maxillectomy using the temporalis muscle flap in 22 patients.

RESULTS

No total necrosis of the flap was seen in any case, a partial necrosis was seen in four cases.

CONCLUSION

The temporalis myofascial flap is an excellent choice for oral and maxillary reconstruction.

[Suspending of M. temporal, temporal fascia and parietal periosteum to correct late facial palsy]

OBJECTIVE

To explore a simply, effective dynamical method to correct late facial palsy.

METHODS

The method of suspending of M. temporalis, temporal fascia was reformed below: (1) To prolong flap of M. temporalis, temporal fascia by parietal periosteum. (2) To elevate the reversal level of compound flap. (3) To fill depressed temporal area by silica gel piece.

RESULTS

The compound flap is united structurally and long enough to transfer. Temporal defect is recontoured. And zygomatic area is no longer protruded.

CONCLUSIONS

The reformative method resists defect of the old one and obtains a dynamical result.

Orthodromic Transposition of the Temporal Muscle for Facial Paralysis: Made Easy and Better

The authors present a modified technique of transposition of temporal muscle for reanimation of facial paralysis. Fourteen cases illustrate the simplicity, advantages, and excellent esthetic and functional results of this method.

Temporalis Fascia in the Management of Gold Eyelid Weight Extrusion

A patient with a traumatic facial nerve palsy and resulting paralytic lagophthalmos underwent surgical implantation of a gold weight load, which extruded 4 weeks after surgery. Cicatricial contraction of the anterior lamella developed, and a full-thickness skin graft was used to correct the cicatrix. A second gold weight loading procedure was then undertaken with a temporalis fascia drape added to reduce the risk of extrusion. One year after surgery, there is no sign of migration or extrusion. Gold weight loading has emerged as the standard in management of paralytic lagophthalmos, with extrusion cited as the most serious complication. We propose temporalis fascia draping as an adjuvant procedure in the reimplantation of an extruded gold weight.

Cranioplastie par lambeau libre ostéomusculaire temporo-pariétal

PURPOSE

Advances in composite materials for craniofacial reconstruction surgery has tended to limit indications for osteomuscular free flaps which nevertheless must be used for certain septic patients. The purpose of this report was to illustrate the usefulness of the free temoroparietal osteomuscular flap in this particular situation.

CASE REPORT

A 47-year-old man underwent surgical repair of an aneurysm of the anterior communicating artery complicated by acute hydrocephaly treated by external then ventriculoperitoneal bypass. The fronto-pteryonal approach was used. The early postoperative period was complicated by osteitis of the cranial piece requiring revision. The revision procedure, performed at the end of the septic period, involved cranioplasty with acrylic cement. Recurrent infection contraindicated any new attempt for prosthetic repair. The patient was treated with a controlateral free temporoparietal osteomuscular flap to achieve cranioplasty. The postoperative period was uneventful with no infection and satisfactory healing. Flap vitality was very satisfactory. The patient's neurological status improved and no further complication developed.

DISCUSSION

In certain therapeutic situations, several diffent techniques may be required to overcome postoperative complications or manage particularly difficult cases. A free osteomuscular flap can be a useful alternative for cranioplasty. This technique is rarely used but can offer an optimal solution in selected patients, particularly for second intention revision after failure of prosthetic repair.

[Dynamic rehabilitation in facial paralysis with the surgical flap and temporalis muscle transposition without muscle lengthening: review and case report]

There are various surgical procedures for the reanimation of patients with long-standing facial paralysis. Temporalis muscle transfer is reliable for the reanimation of long-standing facial paralysis often employed when facial nerve reinnervation. It can be used as well for the immediate treatment of complete facial paralysis (more than 1 year) because temporalis muscle transposition does not interfere with neuronal regeneration. During the last few years the techniques employing the tendon of the temporalis muscle for the rehabilitation of the oral commissure gain increasing importance. The authors analyse the different options for reanimation after facial paralysis and report on a case of facial reanimation via temporalis muscle transfer.

Prise en Charge des Fistules Labyrinthiques Cholestéatomateuses: A Propos de 22 Cas

OBJECTIVE

To study the incidence, location, pre- and postoperative symptoms (hearing loss, tinnitus, vertigo, facial palsy), preoperative diagnostic imaging, and surgical treatment of labyrinthine fistulae (LF).

DESIGN

Retrospective case review.

PATIENTS

Twenty-two cases of LF over 382 mastoid operations performed in a 168-month period.

MAIN OUTCOME MEASURES

Clinical, imaging, and surgical correlation of extensive fistulae and bone fistulae.

RESULTS

LF prevalence was 5.8%. The main primary symptoms were otorrhea and hypoacusis. Only four patients presented vertigo as their main complaint. All patients underwent preoperative computed tomographic (CT) scans and preoperative audiometry. LF diagnosis was made before surgery for 100% of patients on the basis of CT scan. A second fistula was, however, misdiagnosed by imaging in two patients. With respect to surgical technique, a canal wall down procedure was performed in 77% and a conservative procedure was performed in 23%. Fistula was located in the horizontal semicircular canal in 100% of cases, and in 9%, a second fistula was operatively diagnosed. In 91% of cases, the matrix was removed, whereas it was left in the course of a canal down procedure in 9%. With a follow-up of 5.7 years, hearing remained unchanged in 80% of patients.

CONCLUSIONS

Surgery with removal of the cholesteatoma matrix and sealing of the fistula with temporalis fascia is a safe procedure that can help preserve cochlear function. The choice of a canal down procedure would be influenced by cholesteatoma characteristics rather than by the finding of an LF.

Modified house tympanoplasty for successful closure of near-total tympanic membrane perforations

OBJECTIVE

To demonstrate the use of a modified House technique in the successful closure of near-total tympanic membrane perforations.

METHODS

This is a retrospective analysis over a 25-year span of the senior author's experience with a particular technique of closing large tympanic membrane perforations. The charts of patients were reviewed and the data were analyzed.

TECHNIQUE

The modified House technique combines an underlay graft placement with an advancement ear canal skin flap. It provides vascularization and subsequent early epithelialization of a large perforation.

RESULTS

In this series, the senior author operated on 46 patients. Forty-three patients had one ear operated on and three had bilateral surgery. The closure rate was 98% (48 of 49 ears). The one failure had a subsequent successful closure at a later date.

CONCLUSION

This is a simple endaural technique that guarantees successful closure of near-total tympanic membrane perforations using locally available tragal perichondrium.

Dynamic Reconstruction of Eye Closure by Muscle Transposition or Functional Muscle Transplantation in Facial Palsy

For patients with facial palsy, lagophthalmus is often a more serious problem than the inability to smile. Dynamic reconstruction of eye closure by muscle transposition or by free functional muscle transplantation offers a good solution for regaining near-normal eye protection without the need for implants. This is the first quantitative study of three-dimensional preoperative and postoperative lid movements in patients treated for facial paralysis. Between February of 1998 and April of 2002, 44 patients were treated for facial palsy, including reconstruction of eye closure. Temporalis muscle transposition to the eye was used in 34 cases, and a regionally differentiated part of a free gracilis muscle transplant after double cross-face nerve grafting was used in 10 cases. Patients' facial movements were documented by a three-dimensional video analysis system preoperatively and 6, 12, 18, and 24 months postoperatively. For this comparative study, only the data of patients with preoperative and 12-month postoperative measurements were included. In the 27 patients with a final result after temporalis muscle transposition for eye closure, the distance between the upper and lower eyelid points during eye closing (as for sleep) was reduced from 10.33 +/- 2.43 mm (mean +/- SD) preoperatively to 5.84 +/- 4.34 mm postoperatively on the paralyzed side, compared with 0.0 +/- 0.0 mm preoperatively and postoperatively on the contralateral healthy side. In the resting position, preoperative values for the paralyzed side changed from 15.11 +/- 1.92 mm preoperatively to 13.46 +/- 1.94 mm postoperatively, compared with 12.17 +/- 2.02 mm preoperatively and 12.05 +/- 1.95 mm postoperatively on the healthy side. In the nine patients with a final result after surgery using a part of the free gracilis muscle transplant reinnervated by a zygomatic branch of the contralateral healthy side through a cross-face nerve graft, eyelid closure changed from 10.21 +/- 2.72 mm to 1.68 +/- 1.35 mm, compared with 13.70 +/- 1.56 mm to 6.63 +/- 1.51 mm preoperatively. The average closure for the healthy side was from 11.20 +/- 3.11 mm to 0.0 +/- 0.0 mm preoperatively and from 12.70 +/- 1.95 mm to 0.0 +/- 0.0 mm postoperatively. In three cases, the resting tonus of the part of the gracilis muscle transplant around the eye had increased to an extent that muscle weakening became necessary. Temporalis muscle transposition and free functional muscle transplantation for reanimation of the eye and mouth at the same time are reliable methods for reconstructing eye closure, with clinically adequate results. Detailed analysis of the resulting facial movements led to an important improvement of the authors' operative techniques within the last few years. Thus, the number of secondary operative corrections could be significantly reduced. These qualitative and quantitative studies of the reconstructed lid movements by three-dimensional video analysis support the authors' clinical concept of temporalis muscle transposition being the first-choice method in adult patients with facial palsy. In children, free muscle transplantation is preferred for eye closure, so as not to interfere with the growth of the face by transposition of a masticatory muscle. In addition, a higher degree of central plasticity in children might be expected.

Canalicular adenoma of the palate: case report and literature review

Canalicular adenoma is a rare benign salivary gland tumor of the oral cavity, typically located in the upper lip and buccal mucosa and infrequently found on the palate. The tumor is usually confined to soft tissue and rarely presents with bone erosion. A case of a large and locally-aggressive palatal canalicular adenoma is presented. The lesion presented herein was an asymptomatic ulcerated mass with significant bone erosion. The tumor was managed surgically with excision and reconstruction of the resulting palatal defect with a full temporalis muscle flap.

The inverted temporalis muscle flap for intraoral reconstruction: its rationale and the results of its application

PURPOSE

The purpose of this article was to show the discrepancies among the different parts of the temporalis muscle flap (TMF), to introduce a new rotational arc for the TMF based on these findings, and to examine the outcomes associated with the use of this modified method.

MATERIALS AND METHODS

Two models were established on 5 human skulls to mimic the situations with the usual dissection technique or the extended dissection technique for the TMF. The lengths of the anterior part, the middle part, and the posterior part of the flap were measured and analyzed for statistical significance. A new rotational arc for the TMF was introduced, in which the flap was inverted beneath the zygomatic arch, placing the temporalis fascia away from the oral side. Seventeen consecutive oral cancer cases treated with either the traditional method or the inverted method of flap transposition were reviewed and divided into 2 groups dictated by the rotational arcs of their flaps. The traditional TMF was used in 11 cases and the inverted TMF was used in 6 cases. Clinical examination and imaging studies were used for assessment of outcome, and the results from the 2 patient groups were compared.

RESULTS

The middle and posterior parts of the temporalis muscle were significantly longer than the anterior part on the skull models. However, the middle and posterior parts did not differ greatly in length. The extended dissection technique increased the flap length except for the anterior part. Both flaps were successful in closing the defects in all cases and healed well. No muscle necrosis was observed. However, the patients receiving the traditional TMF developed noticeable cheek fullness in 4 instances, sialocele in 3, significant reduction of range of mouth opening in 2, and distinct velopharyngeal insufficiency in 2, whereas only 1 case in which the inverted TMF was used developed cheek fullness.

CONCLUSIONS

The middle or posterior part of the temporalis flap is preferred over the anterior part for covering distant defects because of its extra length. The inverted TMF is simple and safe to apply. It can extend farther in the posterior oral cavity and has fewer complications than the traditional TMF.

Versatility of temporalis myofascial flap in maxillofacial reconstruction--analysis of 30 cases

Temporalis myofascial flap holds great promise for the reconstruction of various defects of the maxillofacial region-either congenital or surgical. The dependable blood supply through the middle and deep temporal arteries, proximity to the maxillofacial region, possibility to mobilize it to the oral cavity through the under surface of zygomatic arch and its fanned out nature permits the surgeon to use this flap for the reconstruction of various maxillofacial defects and even as an interposing tissue. In this series of 30 cases, we have used the temporalis myofascial flap for the reconstruction of different types of maxillofacial defects and as an interposing material in TMJ surgeries. We found that this flap is very valuable in maxillofacial reconstruction.

[The use of muscle autograft denatured by microwave for repair of gaps in removal of facial neuromas]

OBJECTIVE

To study the clinical value of muscle autograft denatured by microwave for repair of gaps in removal of facial neuromas.

METHODS

Two cases of patients with facial nerve Schwann cell neuromas were reported. The operations for removal of facial neuromas were completed, and the gaps of the nerves were repaired with muscle autograft denatured by microwave of 250 W for 120 sec.

RESULTS

The patients were followed up for two years, and the recovery of facial function on the affected sides were satisfactory.

CONCLUSION

Muscle autograft denatured by microwave technique is convenient, highly efficient for repairing facial nerve gap after removal of facial neuroma.