High-Density Porous Polyethylene Implant Cranioplasty: A Systematic Review of Outcomes

Porous polyethylene has been widely used in craniofacial reconstruction due to its biomechanical properties and ease of handling. The objective of this study was to perform a systematic review of the literature to summarize outcomes utilizing high-density porous polyethylene (HDPP) implants in cranioplasty. A literature search of PubMed, Cochrane Library, and Scopus databases was conducted to identify original studies with HDPP cranioplasty from inception to March 2023. Non-English articles, commentaries, absent indications or outcomes, and nonclinical studies were excluded. Data on patient demographics, indications, defect size and location, outcomes, and patient satisfaction were extracted. Summary statistics were calculated using weighted averages based on the available reported data. A total of 1089 patients involving 1104 cranioplasty procedures with HDPP were identified. Patients' mean age was 44.0 years (range 2 to 83 y). The mean follow-up duration was 32.0 months (range 2 wk to 8 y). Two studies comprising 17 patients (1.6%) included only pediatric patients. Alloplastic cranioplasty was required after treatment of cerebrovascular diseases (50.9%), tumor excision (32.0%), trauma (11.4%), trigeminal neuralgia/epilepsy (3.4%), and others such as abscesses/cysts (1.4%). The size of the defect ranged from 3 to 340 cm2. An overall postoperative complication rate of 2.3% was identified, especially in patients who had previously undergone surgery at the same site. When data were available, contour improvement and high patient satisfaction were reported in 98.8% and 98.3% of the patients. HDPP implants exhibit favorable outcomes for reconstruction of skull defects. Higher complication rates may be anticipated in secondary cranioplasty cases.

Real-time tissue perfusion assessment using fluorescence imaging topography scanning system: A preclinical investigation

BACKGROUND AND OBJECTIVES

We previously developed a real-time fluorescence imaging topography scanning (RFITS) system for intraoperative multimodal imaging, image-guided surgery, and dynamic surgical navigation. The RFITS can capture intraoperative fluorescence, color reflectance, and surface topography concurrently and offers accurate registration of multimodal images. The RFITS prototype is a promising system for multimodal image guidance and intuitive 3D visualization. In the current study, we investigated the capability of the RFITS system in intraoperative fluorescence vascular angiography for real-time assessment of tissue perfusion.

STUDY DESIGN/MATERIALS AND METHODS

We conducted ex vivo imaging of fluorescence perfusion in a soft casting life-sized human brain phantom. Indocyanine green (ICG) solutions diluted in dimethyl sulfoxide (DMSO) and human serum were injected into the brain phantom through the vessel simulating tube (2 ± 0.2 mm inner diameter) by an adjustable flow peristaltic pump. To demonstrate the translational potential of the system, an ICG/DMSO solution was perfused into blood vessels of freshly harvested porcine ears (n = 9, inner diameter from 0.56 to 1.27 mm). We subsequently performed in vivo imaging of fluorescence-perfused vascular structures in rodent models (n = 10). 5 mg/ml ICG solutions prepared in sterile water were injected via the lateral tail vein. All targets were imaged by the RFITS prototype at a working distance of 350-400 mm.

RESULTS

3D visualization of 10 µg/ml ICG-labeled continuous moving serum in the brain phantom was obtained at an average signal-to-background ratio (SBR) of 1.74 ± 0.03. The system was able to detect intravenously diffused fluorescence in porcine tissues with an average SBR of 2.23 ± 0.22. The RFITS prototype provided real-time monitoring of tissue perfusion in rats after intravenous (IV) administration of ICG. The maximum fluorescence intensity (average SBR = 1.94 ± 0.16, p < 0.001) was observed at T_peak of ~30 seconds after the ICG signal was first detected (average SBR = 1.19 ± 0.13, p < 0.01).

CONCLUSIONS

We have conducted preclinical studies to demonstrate the feasibility of applying the RFITS system in real-time fluorescence angiography and tissue perfusion assessment. Our system provides fluorescence/color composite images for intuitive visualization of tissue perfusion with 3D perception. The findings pave the way for future clinical translation.

Consensus Conference Statement on the General Use of Near-infrared Fluorescence Imaging and Indocyanine Green Guided Surgery: Results of a Modified Delphi Study

BACKGROUND

In recent decades, the use of near-infrared light and fluorescence-guidance during open and laparoscopic surgery has exponentially expanded across various clinical settings. However, tremendous variability exists in how it is performed.

OBJECTIVE

In this first published survey of international experts on fluorescence-guided surgery, we sought to identify areas of consensus and nonconsensus across 4 areas of practice: fundamentals; patient selection/preparation; technical aspects; and effectiveness and safety.

METHODS

A Delphi survey was conducted among 19 international experts in fluorescence-guided surgery attending a 1-day consensus meeting in Frankfurt, Germany on September 8th, 2019. Using mobile phones, experts were asked to anonymously vote over 2 rounds of voting, with 70% and 80% set as a priori thresholds for consensus and vote robustness, respectively.

RESULTS

Experts from 5 continents reached consensus on 41 of 44 statements, including strong consensus that near-infrared fluorescence-guided surgery is both effective and safe across a broad variety of clinical settings, including the localization of critical anatomical structures like vessels, detection of tumors and sentinel nodes, assessment of tissue perfusion and anastomotic leaks, delineation of segmented organs, and localization of parathyroid glands. Although the minimum and maximum safe effective dose of ICG were felt to be 1 to 2 mg and >10 mg, respectively, there was strong consensus that determining the optimum dose, concentration, route and timing of ICG administration should be an ongoing research focus.

CONCLUSIONS

Although fluorescence imaging was almost unanimously perceived to be both effective and safe across a broad range of clinical settings, considerable further research remains necessary to optimize its use.

Artificial intelligence image recognition of melanoma and basal cell carcinoma in racially diverse populations

BACKGROUND

Artificial intelligence (AI) image recognition models have been relatively successful in diagnosing cutaneous manifestations in individuals with light skin tone. However, when these models are tested on the same cutaneous manifestations in individuals with darker or brown skin tone, the performance of the model drops due to a paucity of such images available for model training.

OBJECTIVE

The objective of this study was to improve the performance of AI models in recognizing cutaneous diseases in individuals with darker skin tone.

METHODS

Unsupervised computer darkening of skin color with preservation of the dermatological disease/lesion characteristics in images of light-skinned individuals with basal cell carcinoma (BCC), and melanoma was performed.

RESULTS

Training an AI model on these artificially "darkened" images as compared to training on the original "light-skinned" images resulted in a higher sensitivity, specificity, positive predictive value, negative predictive value, F₁ score and area under the receiver-operating characteristic curve of the AI model in differentiating between BCC and melanoma in individuals with brown skin tone.

CONCLUSION

Use of unsupervised image to image translation in medical AI image recognition models has the potential to significantly improve their accuracy in diagnosing diseases in individuals with racially diverse skin tone.

Treatment Strategies of Complications of Breast Implants Associated With Ventriculoperitoneal Shunts: A Case Report and Review of the Literature

ABSTRACT

Breast augmentation is among the most commonly performed cosmetic procedures in the United States. As these patients age or develop comorbidities, surgeons across many other disciplines will inevitably encounter these patients in their own practices. Consequently, surgeons must be aware of the potential interactions between breast implants and devices commonly used in their fields. This case, the second of its kind encountered by our own department, describes a woman who suffered one such interaction: migration and coiling of a ventriculoperitoneal shunt around her breast implant. A systematic review was conducted to characterize breast-related ventriculoperitoneal shunt complications reported in the literature and generate an algorithm for management of the most commonly reported scenarios. Recognition of potential complications will aid surgeons in appropriate operative planning and prevention of these adverse events.

An Anatomical Study of the Foramen Ovale for Neuromodulation of Trigeminal Neuropathic Pain

OBJECTIVE

Neuromodulation for trigeminal pain syndromes such as trigeminal neuropathic pain (TNP) necessitates accurate localization of foramen ovale (FO). The Härtel-type approach is very well-established and safe, ideal for temporary cannulation of the FO for ablative procedures such as balloon microcompression. A key shortcoming of the Hartel approach for placement of neuromodulation leads is the limited opportunity for secure anchoring. The aim of this study is to introduce a novel surgical approach for the treatment of TNP by investigating key osseous landmarks and their spatial relationships to the FO.

MATERIALS AND METHODS

Sixteen sides of cadaver heads were dissected to investigate a surgical route of the FO via transoral gingival buccal approach. Alveolar arch of the maxilla and zygomaticomaxillary suture were selected to serve as an osseous landmark for the surgical guidance to the FO. Through the intraoral route, a needle simulating electrode was traversed to aim the FO from the inferior lateral to the superior medial direction to target specific fibers of the aimed division of the nerve.

RESULTS

Visual identification and access to the trigeminal nerve at the external opening of FO was successful in all 16 hemifacial cadavers. A needle successfully targeted different regions of the trigeminal nerve by changing the angle of the trajectory allowing the needle to reach a specific division of the trigeminal nerve.

CONCLUSIONS

This study provides a novel means of approaching the FO via transoral gingival buccal access.

Large Septal Perforation Repair Using Inferior Turbinate Sliding Advancement Flap

A surgical technique for closure of septal perforations is described, along with an illustrative case report. The technique consists of a posterolaterally based sliding advancement flap of the nasal mucosa covering the inferior turbinate, inferolateral nasal wall, and floor of nose. It has proven effective in closure of several large septal defects as illustrated in the case report.

Intraoperative Fluorescence Imaging and Multimodal Surgical Navigation Using Goggle System

Intraoperative imaging is an invaluable tool in many surgical procedures. We have developed a wearable stereoscopic imaging and display system entitled Integrated Imaging Goggle, which can provide real-time multimodal image guidance. With the Integrated Imaging Goggle, wide field-of-view fluorescence imaging is tracked and registered with intraoperative ultrasound imaging and preoperative tomography-based surgical navigation, to provide integrated multimodal imaging capabilities in real-time. Herein we describe the system instrumentation and the methods of using the Integrated Imaging Goggle to guide surgeries.

Fluorescence Imaging Topography Scanning System for intraoperative multimodal imaging

Fluorescence imaging is a powerful technique with diverse applications in intraoperative settings. Visualization of three dimensional (3D) structures and depth assessment of lesions, however, are oftentimes limited in planar fluorescence imaging systems. In this study, a novel Fluorescence Imaging Topography Scanning (FITS) system has been developed, which offers color reflectance imaging, fluorescence imaging and surface topography scanning capabilities. The system is compact and portable, and thus suitable for deployment in the operating room without disturbing the surgical flow. For system performance, parameters including near infrared fluorescence detection limit, contrast transfer functions and topography depth resolution were characterized. The developed system was tested in chicken tissues ex vivo with simulated tumors for intraoperative imaging. We subsequently conducted in vivo multimodal imaging of sentinel lymph nodes in mice using FITS and PET/CT. The PET/CT/optical multimodal images were co-registered and conveniently presented to users to guide surgeries. Our results show that the developed system can facilitate multimodal intraoperative imaging.

Management options of non-syndromic sagittal craniosynostosis

There have been various effective surgical procedures for the treatment of non-syndromic sagittal craniosynostosis, but no definitive guidelines for management have been established. We conducted a study to elucidate the current state of practice and establish a warranted standard of care. An Internet-based study was sent to 180 pediatric neurosurgeons across the country and 102 craniofacial plastic surgeons in fourteen different countries, to collect data for primary indication for surgical management, preference for timing and choice of surgery, and pre-, peri-, and post-operative management options. The overall response rate from both groups was 32% (n=90/284). Skull deformity was the primary indication for surgical treatment in patients without signs of hydrocephalus for both neurosurgeons and craniofacial surgeons (80% and 63%, respectively). Open surgical management was most commonly performed at six months of age by neurosurgeons (46%) and also by craniofacial surgeons (35%). Open surgical approach was favored for patients younger than four months of age by neurosurgeons (50%), but endoscopic approach was favored by craniofacial surgeons (35%). When performing an open surgical intervention, most neurosurgeons preferred pi or reversed pi procedure (27%), whereas total cranial vault remodeling was the most commonly performed procedure by craniofacial surgeons (37%). The data demonstrated a discrepancy in the treatment options for non-syndromic sagittal craniosynostosis. By conducting/comparing a wide survey to collect consolidative data from both groups of pediatric neurosurgeons and craniofacial plastic surgeons, we can attempt to facilitate the establishment of standard of care.

Syndromic lipomatosis of the head and neck: a review of the literature

INTRODUCTION

Patients with syndromic causes of lipomatosis of the head and neck, although rare, often present late in the course of the disease in a myriad of ways, including concomitant airway obstruction, severe functional limitations, and/or significant cosmetic defects. The goal of this report was to review the literature and present a concise overview of the major syndromes causing lipomatosis of the head and neck.

METHODS

A literature search was performed to gather information on syndromic lipomatosis of the head and neck region. PubMed was searched for the following conditions: Familial multiple lipomatosis (FML), multiple symmetrical lipomatosis (MSL), congenital infiltrating lipomatosis of the face (CIL-F), and Nasopalpebral lipoma-coloboma syndrome (NLCS). Data gathered included results of surgical cases of the head and neck region.

RESULTS

A total of 48 reports comprising 172 cases of syndromic lipomatosis of the head and neck region were deemed eligible for review. Eighty-five percent of patients were male with an average age of 35 years. Seventy-four percent of cases appeared in the neck region, whereas 23 % presented in the face and scalp. 89 % of cases were treated with surgical excision, with 11 % of cases treated with liposuction. The most common complications were hematoma and seroma in MSL, recurrence in FML, neuropraxia in CIL-F, and mild telecanthus in NLCS.

CONCLUSIONS

Syndromic causes of lipomatosis are generally benign in nature but difficult to control long term. Because these conditions include frequent recurrence and subsequent difficulty in clearing the disease, the authors advocate early and aggressive surgical excision of syndromic lipomatosis.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Dentition, bone loss, and the aging of the mandible

BACKGROUND

Facial aging is a dynamic process with impact on both the soft tissues and the bones. Despite a growing body of evidence, controversy still exists regarding absolute characteristics of the aging facial skeleton.

OBJECTIVE

The purpose of this study was to investigate various mandibular measurements in different age groups and to delineate the relation of the dentition to these parameters.

METHODS

Ninety Caucasian mandibles were assessed for the following distance landmarks: gonion-gonion, infradentale-gnathion, mental foramen-mandibular crest, mental foramen-inferior mandibular border, gnathion-gonion, condyle-gonion, and gonial angle. The measurements were compared according to age, sex, and dentition.

RESULTS

The number of teeth decreased significantly with increasing age in males (P = .002) and females (P < .001). There were no other statistically significant differences between age groups for the rest of the parameters. The infradentale-gnathion distance (P = .005) and the mental foramen-mandibular crest distance (P < .001) was found to increase with total number of teeth. Other parameters did not show a significant relation to dentition. All parameters were significantly larger in the male subgroups with the exception of gnathion-gonion distance and gonial angle. Bilateral mandibular measurements were symmetric except for the gonial angle, which was more obtuse on the right side in males (P = .007) and females (P = .018).

CONCLUSIONS

Our findings support previous evidence that dentition is the main determinant of the morphology of the mandible. The skeletal characteristics are variable among individuals, and a longitudinal study is required to better understand age-related changes of the mandible.

Childhood dermatofibrosarcoma protuberans: role of preoperative imaging

Dermatofibrosarcoma protuberans (DFSP) is especially challenging to recognize and diagnose in children. Prompt and definitive treatment is essential based on the tumor's high rate of recurrence. Our purpose is to increase physician awareness and recognition of DFSP in the pediatric population with the largest case series of childhood DFSP to our knowledge thus reported in the literature. We also propose that magnetic resonance imaging (MRI) may be useful in the preoperative assessment. The records of 10 patients with primary DFSP between the ages of 8 months and 16 years were reviewed. Only 1 of 10 patients was given the correct diagnosis at the initial medical evaluation. Of the 10 cases, 5 were congenital. The average delay in diagnosis was 5 years. Of the patients, 5 had preoperative MRI to delineate the size and extent of the tumor. In the two cases with the largest tumors preoperative MRI significantly altered surgical planning and execution. Thus, preoperative MRI may be helpful in planning for successful surgical clearance of large tumors and preventing local recurrence. All 10 cases were treated with Mohs micrographic surgery and no recurrences were noted with a follow-up range of 6 weeks to 17 years.

Trigeminal Trophic Syndrome-Report of Four Cases and Review of the Literature

BACKGROUND

Trigeminal trophic syndrome is a unilateral, frequently crescent-shaped neurotrophic ulceration of the face occurring after injury to the trigeminal nerve. The appearance of the ulcers resembles other disease entities such as granulomatous disease, neoplasm, vasculitis, infection, and factitial dermatitis.

OBJECTIVES

The objectives of this study are to increase awareness of this disorder and to emphasize the importance of eliciting a thorough neurologic history when evaluating facial ulcerations.

METHODS

Four cases are reported and, using MEDLINE, the English and non-English literature from 1982 to 2002 is reviewed.

RESULTS

Including this report, there have been 60 cases of trigeminal trophic syndrome reported from 1982 to 2002. The age at presentation ranged from 14 months to 93 years. Time of onset from injury to the trigeminal ganglion or its branches and the development of the ulcers ranged from 2 weeks to 30 years. One-third of the patients had undergone trigeminal nerve ablation for the treatment of trigeminal neuralgia and another third had a history of stroke. Other causes included craniotomy, head trauma, herpes infection.

CONCLUSION

The majority of cases of trigeminal trophic syndrome are associated with a history of stroke or trigeminal nerve ablation. Successful surgical outcome can be achieved if the underlying neurologic pathology is addressed before the reconstructive procedure.

Relationship of obesity and specimen weight to complications in reduction mammaplasty

Obesity and specimen weight have both been associated with a higher incidence of complications for patients undergoing reduction mammaplasty. However, obesity has been arbitrarily and inconsistently defined, and the degree of obesity has not been considered in these previous studies. Because insurance companies are increasingly demanding weight loss before authorizing surgery, the relationship of obesity and breast size to complications is of great importance. Upon critical review of the literature, a number of fundamental questions remain unanswered. If complications are more frequent in the obese patient, are these complications directly proportional to the degree of obesity? Also, if the patient is required to lose weight before surgery, is weight loss effective in reducing complication rates? In an attempt to clarify these issues, 395 patients who underwent reduction mammaplasty over a 10-year period were reviewed retrospectively. Patients were arbitrarily divided into five groups in which, depending on their degree of relative obesity, they were classified as less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, or greater than 20 percent above average body weight. To evaluate the relationship of specimen weight to complications, patients were also arbitrarily divided into five groups according to weight of the breast reduction specimen, which was classified as less than 300 g, 300 to 600 g, 600 to 900 g, 900 to 1200 g, and greater than 1200 g reduction per breast. Complications were then divided into local and systemic and major and minor. When bilateral reductions alone were analyzed (n = 267), there was a statistically significant increase in complication rate in the obese (p = 0.01). However, when the obese population was further subdivided according to their degree of obesity (less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, and greater than 20 percent above average body weight), no further correlation was found. However, the relationship between specimen weight per breast and complications was much stronger with a direct correlation existing between increasing specimen weight and the incidence of complications. Although this study has shown that patients who are average body weight have fewer complications than obese patients after breast reduction surgery, it has not shown an increasing incidence of complication with increasing degrees of obesity. The implications of these findings and their relationship for denying patients surgery on the basis of weight alone are discussed in detail.

Orbital extension of a frontal sinus osteoma in a thirteen-year-old girl

Osteomas are uncommon, slow-growing, benign osteogenic neoplasms that arise most frequently in the craniofacial skeleton. (1,2) Osteoma is the most common benign tumor of the nose and paranasal sinuses and the most common neoplasm of the frontal sinus. (3-5) Paranasal sinus osteomas originate in the sinus wall, fill the lumen with well-defined mature osseous tissue, and occasionally extend into the orbit where they give rise to orbital signs and symptoms. Osteomas most commonly become symptomatic in the second to fifth decade in life, but orbital involvement has rarely been reported in patients aged 18 years and younger. (2,6-10) We report a case of a frontal sinus osteoma with orbital extension in a 13-year-old girl.

Reconstruction of the irradiated contracted socket with an expanded superficial temporalis fascial flap

PURPOSE

To describe the reconstruction of an irradiated contracted socket with an expanded superficial temporalis fascial flap and oral mucosa.

METHODS

A superficial temporalis fascial flap was first expanded with tissue expansion techniques and then rotated into the orbit to revascularize the socket. The mucosal surface of the socket was secondarily grafted with buccal and hard palate mucosa.

RESULTS

The expanded superficial temporalis fascial flap was used to revascularize the socket for grafting with hard palate and buccal mucosa. This resulted in the successful retention of an ocular prosthesis.

CONCLUSION

The expanded superficial temporalis fascial flap is a useful technique in reconstruction of the contracted socket.

Lip augmentation with AlloDerm acellular allogenic dermal graft and fat autograft: A comparison with autologous fat injection alone

Many surgical options exist for lip augmentation, none of which consistently provide safe, lasting, and predictable volume gains. We describe and evaluate the use of AlloDerm acellular allogenic dermal graft in combination with fat autograft and compare the postoperative results with those of autologous fat injection alone. Analysis of the preoperative and 1- and 3-month postoperative photographs was done using digital imaging software. Outcome measures included vermilion show and horizontal lip projection from the soft tissue pogonion-subnasale plane. A 61% mean increase in vermilion show was observed in lips augmented with AlloDerm/fat injection, in comparison to a mean increase of 13% in lips augmented with fat injection alone. Lip projection demonstrated a mean increase of 1 mm in AlloDerm/fat lips at 3 months. Postoperatively, no evidence of resorption was seen in lips augmented with AlloDerm/fat between the 1- and the 3-month follow-ups, however, a 9% decrease in vermilion show occurred in lips augmented with fat injection over the same period. No complications occurred in either group. We conclude that AlloDerm in conjunction with autologous fat injection constitutes a safe, reliable, and lasting method of lip augmentation providing increased vermilion show compared to that with autologous fat injection alone.

The microdissection cautery needle versus the cold scalpel in bicoronal incisions

Craniofacial procedures commonly use scalp incisions to optimize surgical access and aesthetic results. Although the use of traditional electrocautery instruments on hair-bearing tissue has been limited secondary to the width of resulting alopecia, needle-tipped electrocautery devices with decreased energy transmission have been developed. This study investigates the cosmetic effect of such instruments on scalp incisions. Twelve children undergoing craniosynostotic correction via bicoronal incisions were included. One side of the incision was completed with the cold scalpel whereas the contralateral portion was effected using the Colorado MicroDissection Needle (Colorado Biomedical Inc., Evergreen, CO, U.S.A.) according to optimal usage instructions. At the conclusion of the study period, precise measurements of the resultant width of alopecia were obtained from the parietal and temporal regions bilaterally, and were analyzed statistically. Also, parents completed a questionnaire concerning subjective observations of the surgical incision and its healing. The portions of the incision completed with the Colorado MicroDissection Needle demonstrated a wider area of peri-incisional alopecia (5.8 +/- 1.8 mm) than that produced by the cold scalpel (3.5 +/- 0.87 mm). Not only was this increased width significant statistically (P < 0.05), in addition the disparity was noted by the majority of parents (10 of 12) either on the patient questionnaire or with nonsuggestive verbal questioning. The benefit of the hemostatic incisional technique of electrocautery with even needle-tipped instruments must be weighed carefully against its cosmetic consequences.

Structural stability of the rotary door myocutaneous flap

This canine study examines the structural stability of extensive laryngotracheal reconstruction with the sternohyoid myocutaneous rotary door flap (RDF) and modifications of the RDF with subdermal collagen and collagen hydroxyapatite matrix. The postreconstruction stability of the RDF and these modifications were tested and compared by measuring immediate postmortem airway stability during application of negative intraluminal pressures. Comparisons between controls and experimental specimens demonstrated that the RDF provides structural stability to secure airway patency under physiologic pressures. Biocompatible matrix adds further structural support in maintenance of the reconstructed lumen. This study validates that the RDF provides adequate rigid support for extensive laryngotracheal reconstruction without the requirement of skeletal support.

Expanded superficial temporalis fascial flap for orbital reconstruction in a postirradiated orbit: a patient report

The temporalis musculofascial flap can be pre-expanded to increase its area prior to transfer. The large size of the preexpanded flap enabled orbital reconstruction to be carried out in a postirradiated orbit in a three-year-old girl. The flap was split, transferred in two parts, and covered with a buccal mucosal graft. A prosthetic shell was satisfactorily fitted postoperatively.

Complex regional pain syndrome of the breast in a patient after breast reduction

Complex regional pain syndrome (CRPS) is characterized by devastating pain, swelling, and cutaneous discoloration that result from vasomotor dysfunction caused by an abnormally accelerating sympathetic loop reflex after trauma or surgery. Although in the extremities CRPS is well documented as reflex sympathetic dystrophy, it only has been reported anecdotally in the breast after modified radical mastectomy and never reported after breast reduction. We report CRPS in the right breast of a 27-year-old woman after revision breast reduction surgery. The patient had signs of CRPS and symptoms of pain, swelling, epidermal scaling, and cutaneous temperature changes lasting more than 1 year. Liquid crystal thermographic scanning revealed a persistent, clinically significant hypothermic region in the affected breast. Intravenous phentolamine temporarily relieved the symptoms. Subsequent sympathetic blockade of the stellate ganglion alleviated chronic CRPS symptoms. Surgeons should be alert that CRPS may need to be considered in the differential diagnosis of chronic disproportionate pain after breast surgery. Early identification and treatment will help alleviate persistent CRPS symptoms and avoid soft-tissue changes.

Transnasal transseptal endoscopic approach to the sphenoid sinus

A modified transseptal approach to the sphenoid sinus and pituitary gland utilizing rigid endoscopy has been developed by the Departments of Otolaryngology, Plastic Surgery, and Neurosurgery at The Cleveland Clinic Foundation. When compared with alternate approaches or the nonendoscopic transseptal procedure, the modified approach provides better visualization and increased illumination of the surgical sites. Other advantages include a decrease in operating time, dissection, bleeding, and postoperative morbidity without compromising nasal function in the postoperative period.

Endoscopic approach for benign tumor ablation of the forehead and brow

Resection of benign tumors of the forehead and brow raises aesthetic concerns. An endoscopic subperiosteal approach to benign bony and soft-tissue tumors in the supraorbital and frontotemporal regions permits extirpation of these masses without producing visible facial scars. Therefore, this technique was used for tumor resection in 4 patients. This procedure demonstrated magnified visualization of the masses, and safe access for excisional biopsy and bony contouring. In addition to more acceptable surgical scars, patients experienced no significant postoperative morbidity and a reduced incidence of swelling, discomfort, and scalp anesthesia. Therefore, we conclude that the endoscopic subperiosteal approach is a favorable alternative for resection of suitable tumors.

Comparison of ossification of demineralized bone, hydroxyapatite, Gelfoam, and bone wax in cranial defect repair

Demineralized bone allografts in the repair of calvarial defects are compared with other common bone fillers. This study uses a video-digitizing radiographic analysis of calvarial defect ossification to determine calcification of bone defects and its relation to postoperative clinical examination and regional controls. The postoperative clinical results at 3 months demonstrated that bony healing was greatest in bur holes filled with demineralized bone and hydroxyapatite. Radiographic analysis demonstrated calcification of demineralized bone-filled defects compared to bone wax- and Gelfoam-filled regions. Hydroxyapatite granules are radiographically dense, thus not allowing accurate measurement of true bone healing. The results suggest that demineralized bone and hydroxyapatite provide better structural support via bone healing to defined calvarial defects than do Gelfoam and bone wax.

Treatment of recurrent cerebrospinal fluid rhinorrhea with a free vascularized omental flap: a case report

Cerebrospinal fluid fistulas after pericranial surgery are a major source of morbidity. A patient who underwent transsphenoidal sinus surgery for a recurrent pituitary adenoma was presented. The patient developed a chronic CSF leak despite standard management, including subarachnoid CSF drainage and transnasal endoscopic closure of the dura. Successful closure of the CSF fistula was obtained using a free omental flap to the sphenoid sinus. This case is the first reported use of a free microvascularized omental flap in an intracranial position for treating chronic CSF rhinorrhea. A description of the indications and the surgical technique for free omental closure of CSF fistulas was provided. The etiology, diagnosis, and management of CSF rhinorrhea are reviewed for the reconstructive surgeon.

Split calvarial bone graft in cranio-orbital sphenoid wing reconstruction

Sphenoid wing defects of the posterior orbit and frontal and middle cranial fossae, secondary to tumor ablation, create difficulties in orbital and cranial base reconstruction. Autogenous split calvarial bone grafts harvested at the time of neurosurgical tumor ablation were used to reconstruct sphenoid wing defects in nine patients between July 1983 and January 1993. Meningioma is the most common tumor resected in this series, followed by fibrous dysplasia. Patient follow-up ranged from 1 to 5 years with a mean of 3 years. Calvarial bone grafting was performed to restore continuity of frontal bone, supraorbital ridge, orbital roof, and lateral wall and floor. All patients demonstrating proptosis showed either complete resolution or significant improvement postoperatively by exophthalmometry. Postoperative pulsatile exophthalmos occurred transiently in one patient but resolved spontaneously. Postoperative diplopia occurred in two patients, which subsequently resolved within 6 weeks. There were no incidents of postoperative osteomyelitis or bone graft loss within the reported postoperative period. Conventional and three-dimensional computed axial tomographic scans did not demonstrate bony resorption resulting in structural instability in any of the cases with this reconstructive method.

"False" migration of rigid fixation appliances in pediatric craniofacial surgery

Osseous fixation techniques have been widely used to provide rigid stabilization in the craniofacial skeleton. Reported sequelae of its usage has been limited to palpation of the screw-plate system and radiological imaging artifacts. Over the past 3 years we have identified miniplates, microplates, and wire sutures on the inner cranial table of the growing child. The observation of "false" migration of these appliances has provided the impetus to review these patients in more detail. Twenty patients underwent secondary cranial remodeling within a two-year period; 7 of these patients were seen to have "false" migration. There were no untoward sequelae in removal of these appliances, and no adverse neurological symptoms were seen.

Optic nerve decompression in cranial base fibrous dysplasia

Fibrous dysplasia of the anterior cranial base involves the bony orbit and optic canal. Although fibrous dysplasia is benign, it may produce a mass effect along the course of the optic nerve, inducing visual disturbances. Optic canal decompression in patients without clinical signs of optic neuropathy is controversial. We describe five patients with extensive fibrous dysplasia of the anterior cranial base involving the orbit and optic canal. These patients underwent transcranial optic canal decompression before signs of severe visual loss during correction of dystopias and craniofacial deformity induced by fibrous dysplasia. Cranial orbital reconstruction was performed by means of split rib and cranial bone grafts. Postoperative follow-up did not reveal disturbances in visual function, extraocular motility, or evidence of cerebrospinal fluid fistulas. This suggests that early, radical resection of orbital fibrous dysplasia with optic canal decompression may be effective in preventing visual loss with minimal risk of other neurological sequelae. Subsequent orbital reconstruction involving split-thickness rib and cranial bone grafting yields satisfactory cosmetic results.

Presurgical orthopedic premaxillary alignment in cleft lip and palate reconstruction

Premaxillary malposition is a difficult problem in cleft lip and palate repair. Orthopedic palatal devices are excellent in positioning the premaxilla, though they are somewhat cumbersome and require complex techniques in adjusting precisely the position of the premaxilla prior to repair. A new technique has been developed for premaxillary repositioning in conjunction with palatal shelf expansion and obturation. The procedure implements microplate fixation anterior to the premaxillary segment and linked to a palatal splint by adjustable elastics. The microplate is inserted through a nasal floor incision and secured by a tight submucosal tunnel through minimal dissection between the prolabium and premaxilla. The last hole of each microplate protrudes through the mucosa and is attached to a pin-retained palatal splint by an elastic chain. Differential tension is applied to the chains to allow gradual repositioning of the protruding maxilla while the splint expands and maintains positioning of the lateral palatal segments. These elastic retractors can be adjusted by staff in the outpatient office. During the past 2 years, this technique has been used successfully in 21 consecutive patients with unilateral or bilateral cleft lip and palate. Its technical ease and design allows simple adjustments to control premaxillary positioning and growth before definitive surgical closure.

Fibromuscular temporalis graft implantation for rhinitis sicca

A surgical technique is described of implanting temporalis fascia and muscle beneath the nasal mucosa to reduce nasal dryness and to attempt to normalize the nasal airflow in selected patients with rhinitis sicca secondary to prior nasal surgery. The surgical technique is described in detail and is illustrated in a case report.

Serum tumor markers of head and neck cancer: current status

The serum level of a variety of substances shows significant changes in head and neck cancer patients. Such substances are collectively called biochemical tumor markers. To date, most markers lack a high degree of specificity and sensitivity. However, serial measurement of markers showing elevated pretreatment levels may help in monitoring response to therapy. Other potential uses of tumor markers include earlier detection of recurrence and/or metastasis, and possible prediction of prognosis. Measurement of more than one marker seems to enhance the diagnostic accuracy of the test. Some markers show significant correlations with various immune parameters in head and neck cancer patients and may have a possible role in potentiating the immunodepressed status of such patients. A review of currently reported tumor markers in head and neck cancer showing their nature, sources, uses, and limitations is presented.

Rigid endoscopic repair of paranasal sinus cerebrospinal fluid fistulas

The advent of functional transnasal endoscopic sinus surgery has brought new opportunities in the repair of difficult cerebrospinal fluid leaks of the paranasal sinuses. The following four case reports illustrate the repair of cerebrospinal fluid leaks with the use of rigid transnasal endoscopy for enhanced angled visualization and illumination. A description of surgical techniques and instrumentation involving transnasal endoscopy in repair of sphenoidal and ethmoidal cerebrospinal fluid fistulas is reported. A discussion of etiology, diagnoses, and conservative versus surgical management of cerebrospinal fluid rhinorrhea is presented.

Facial fuzz and funny findings. Facial hair causing otalgia and oropharyngeal pain

Three patients with referred otalgia and/or oropharyngeal pain due to ectopic facial hair found in either the external auditory canal or oropharynx were treated at the Cleveland Clinic Foundation, Department of Otolaryngology and Communicative Disorders. In each of these patients, annoying symptoms were relieved by simple removal of the misplaced facial hair. Sensory nerve innervation of the external ear and oropharynx and their interrelationship in referred pain are described in detail following the case reports.

Evaluation of syncope from head and neck cancer

Five patients suffering from recurrent syncope in association with metastatic squamous cell carcinoma of the head and neck were examined. Two patients had exhaustive diagnostic work-up for syncope, which eventually disclosed previously undiagnosed, recurrent squamous cell carcinoma. Case reports describe glossopharyngeal neuralgia, a well recognized cause of syncope in the head and neck cancer patient, characterized by acute unilateral head or neck pain preceding each syncopal episode. The literature on the diagnosis of syncope is reviewed, and the syncopal mechanisms unique to the head and neck cancer patient are analyzed and discussed. A diagnostic approach to syncope in head and neck cancer is proposed.