Modified retrograde approach to upper eyelid static loading.

OBJECTIVES/HYPOTHESIS: Upper eyelid static weight loading is a technique commonly used to treat paralytic lagophthalmos. The traditional approach using the pretarsal crease incision leads to interruption of the anterior levator muscle fibers that attach to the face of the tarsus at its upper two thirds. This disruption can lead to permanent upper eyelid blepharoptosis. The retrograde approach avoids this problem but results in an incision at the lid margin, the dependent aspect of the weight. This increases the risk of implant extrusion. We hypothesize that a newly described modified retrograde approach is a safe and effective approach that avoids the pitfalls of previously described techniques. STUDY DESIGN: Retrospective review. METHODS: Eight patients were evaluated with preoperative and 3 to 6 month postoperative photographs with the eyes in the open and closed positions for the degree of lagophthalmos and blepharoptosis present. Patients were also evaluated for development of complications such as implant extrusion, pain, or infection. The surgical technique uses a supratarsal skin crease incision, supramuscular dissection to the lid margin, entry into the tarsal plane at its inferior-most aspect, creation of a pocket for implant insertion, and layered closure. RESULTS: All patients had complete correction of lagophthalmos. No patients experienced infection, extrusion, or eye pain after surgery. All patients had less than 2-mm ptosis after surgery, with no patients experiencing any visual field disruption. CONCLUSIONS: The modified retrograde approach to upper eyelid static loading for paralytic lagophthalmos provides advantages over other techniques described. It is a safe, efficacious procedure, well tolerated by patients.

Quality-of-life impact of participation in a head and neck cancer support group.

OBJECTIVE: To assess if participation by patients in a head and neck cancer support group improves perceived quality of life (QOL). STUDY DESIGN AND SETTING: Subjects for this study included 47 patients at a tertiary Veterans Affairs Medical Center who were previously treated for head and neck cancer. This was a quasi-experimental, post-test study comparing the QOL of 24 patients who participated in a head and neck cancer support group with 23 patients who did not participate. The validated University of Michigan Head and Neck Quality of Life (HNQOL) instrument was used to evaluate head and neck cancer-related QOL. RESULTS: Patients who participated in the head and neck cancer support group exhibited significantly better scores in the domains of eating, emotion, and pain as well as in the global bother and response to treatment questions of the HNQOL instrument compared with those patients who did not participate. Additional subgroup analysis comparing age, type of treatment, and length of time since cancer diagnosis suggests that these variables were less important predictors of QOL than was support group participation. CONCLUSIONS: Our findings suggest that patient participation in a head and neck cancer support group is associated with improved QOL. SIGNIFICANCE: Support groups may be beneficial in improving QOL after head and neck cancer treatment.

Perioral rejuvenation and lip augmentation.

In general, the aging process of the face is a process of atrophy, most noticeable in the perioral region. This article discusses rejuvenation of the perioral region, including fillers, surgery, and facial resurfacing, as correction for this process. Detailed techniques for each of the approaches are outlined. Composition of the various fillers is discussed in conjunction with their respective outcomes and duration of effect. Clinical preoperative, intraoperative, and postoperative photographs are presented.

Intravenously administered abciximab in the management of early cerebral ischemia after carotid endarterectomy: case report.

OBJECTIVE AND IMPORTANCE: Cerebral ischemia is the most worrisome perioperative complication of carotid endarterectomy (CEA). The stroke rate occurring with CEA is estimated to range from 2.3 to 6.3%. Numerous treatment options are available to the neurosurgeon in this scenario, although no "gold standard" exists. CLINICAL PRESENTATION: A 61-year-old woman presented with acute left arm weakness 40 minutes after an uneventful CEA for symptomatic carotid stenosis. Emergent angiography demonstrated vascular irregularities in a "moth-eaten" pattern along the arteriotomy closure, suggestive of platelet-fibrin aggregates ("white clot"). INTERVENTION: Abciximab was immediately administered intravenously in the angiography suite, with subsequent improvement of the visualized vascular irregularities on a second angiogram performed 12 minutes after infusion and complete resolution of the presumed platelet-fibrin aggregates on a third angiogram performed the next day. The patient had no further episodes of cerebral ischemia. She was discharged home on the fifth postoperative day with improving left arm weakness, which had completely resolved by her 2-month follow-up visit. CONCLUSION: To our knowledge, this is the first reported case of abciximab administered intravenously in the setting of acute thromboembolic brain ischemia after CEA. For the unique situation in which an acute thrombus, or white clot, is thought to be the cause of cerebral ischemia, we believe that abciximab may offer an effective and potentially safer alternative than fibrinolytics and may be a more appropriate drug to use from a physiological perspective.

Surgical management of a ruptured posterior choroidal intraventricular aneurysm associated with moyamoya disease using frameless stereotaxy: case report and review of the literature.

OBJECTIVE AND IMPORTANCE: Prevention of rebleeding is the most important aspect of the management of hemorrhagic moyamoya disease, because rebleeding causes significant morbidity and mortality. CLINICAL PRESENTATION: A 26-year-old male patient with a history of moyamoya disease since the age of 3 years and multiple strokes was in a semicomatose state at presentation. He was found to have intraventricular and periventricular hemorrhages abutting the atrium of the right ventricle. His hospital course was complicated by a second hemorrhage. Both bleeding events were believed to be secondary to a ruptured right lateral posterior choroidal aneurysm. INTERVENTION: The aneurysm was excised and revealed histopathology consistent with a true saccular aneurysm. Frameless stereotactic guidance was used during surgery to minimize damage to collateral vessels and to shorten the surgical corridor. CONCLUSION: The management of hemorrhagic moyamoya disease should be modified based on the source of hemorrhage and its relation to a specifically located aneurysm. In the case of aneurysms arising from the choroidal artery, the general belief is that most of these represent pseudoaneurysms and have a tendency to regress spontaneously. Because of the rebleeding risk, we recommend early intervention in treating ruptured intracranial aneurysms using the least invasive surgical techniques.

Role of panendoscopy to identify synchronous second primary malignancies in patients with oral cavity and oropharyngeal squamous cell carcinoma.

BACKGROUND: Tobacco use increases the risk for squamous cell carcinoma (SCC) of the upper aerodigestive tract. The reported incidence of synchronous second primary tumors in head and neck cancer is approximately 10%. Therefore, patients with oral cancer have routinely undergone "panendoscopy" consisting of direct laryngoscopy, bronchoscopy, and esophagoscopy. Recent studies indicate increasing numbers of upper aerodigestive tumors occurring in nonsmoking populations who may have a lesser risk for second primary tumors. The purpose of this study was to evaluate the utility of performing "panendoscopy" to identify second primary tumors in these patient populations. METHODS: A retrospective study of 64 consecutive patients at a university head and neck surgery practice was performed. A cohort of patients with oral cavity or oropharyngeal SCC with no tobacco history who underwent diagnostic panendoscopy were compared with similarly staged patients with a current or past history of tobacco use. Operative reports were examined for synchronous primaries, and epidemiologic data were collected. Subgroup analysis of incidence of synchronous primaries with regard to smoking status, age, sex, T classification, N classification, and location of primary tumor was also carried out. Student's t test statistical analysis was used to ascertain significance. RESULTS: No synchronous second primary malignancies were discovered in the nonsmoking patients. In all, 12.1% of smoking patients were diagnosed with synchronous primary cancers on panendoscopy, and this difference was significant (p = .0392). CONCLUSIONS: Routine panendoscopy of the upper aerodigestive tract in patients who have never smoked is unlikely to result in identification of synchronous second primary tumors.

Transient magnetic resonance imaging signal alterations in the brainstem after microvascular decompression for trigeminal neuralgia: case report.

OBJECTIVE AND IMPORTANCE: We present a case of transient signal alterations along the brainstem path of the trigeminal nerve after microvascular decompression in a patient with trigeminal neuralgia. Such signal changes have been previously reported to represent infarction, but in our patient, they seemed to represent reactive neural and nuclear changes attributable to operative manipulation. CLINICAL PRESENTATION: A 43-year-old woman presented with gradually increasing, medically refractory recurrent trigeminal neuralgia 16 months after initial successful microvascular decompression for trigeminal neuralgia. Repeat microvascular decompression resulted initially in complete pain relief; however, her pain suddenly returned on the 3rd postoperative day. Magnetic resonance imaging (MRI) of this recurrent pain revealed new signal alterations along the brainstem path of the trigeminal nerve. Other than marked reduction in her trigeminal neuralgia, the patient had no postoperative alterations of trigeminal sensory or motor function. INTERVENTION: The patient's residual postoperative trigeminal neuralgia was successfully treated with carbamazepine. Because of the absence of worrisome signs and symptoms corresponding to the MRI signal alterations, no additional therapy was elected. Follow-up MRI in 1 month revealed near-complete resolution of the postoperative signal alterations along the brainstem path of the trigeminal nerve. CONCLUSION: MRI signal alterations along the brainstem path of the trigeminal nerve after microvascular decompression may be only reactive and do not always represent infarction. Depending on the clinical picture, observation may be all that is necessary in such cases.

Carotid embolectomy in the treatment of a paradoxical embolus.

Development of a paradoxical embolus to the carotid circulation through a patent foramen ovale is uncommon but well documented. Previous surgical experience with this entity is limited. Treatment for this condition typically involves anticoagulation or the use of an inferior vena cava filter with concurrent closure of the patent foramen itself. We report successful surgical treatment of a woman with a paradoxical embolus lodged in her left carotid artery. In addition, we provide a brief review of this rare topic and treatment rationale.

Recurrence of pediatric cerebral arteriovenous malformations after angiographically documented resection.

Angiographically confirmed surgical resection is believed to be the 'gold standard' for cure in the treatment of intracranial arteriovenous malformations (AVMs). However, rare exceptions of recurrent AVMs have been documented. We are aware of 11 reported cases of recurrent AVMs in which complete resection of the initial lesion was confirmed by postoperative angiography. Eight of these cases were in the pediatric population. In this report, we present 2 additional cases of such recurrent lesions, review the clinical and scientific literature on this rare phenomenon and provide suggested management guidelines.