Management of orbital fractures: challenges and solutions.

Many specialists encounter and treat orbital fractures. The management of these fractures is often challenging due to the impact that they can have on vision. Acute treatment involves a thorough clinical examination and management of concomitant ocular injuries. The clinical and radiographic findings for each individual patient must then be analyzed for the need for surgical intervention. Deformity and vision impairment can occur from these injuries, and while surgery is intended to prevent these problems, it can also create them. Therefore, surgical approach and implant selection should be carefully considered. Accurate anatomic reconstruction requires complete assessment of fracture margins and proper implant contouring and positioning. The implementation of new technologies for implant shaping and intraoperative assessment of reconstruction will hopefully lead to improved patient outcomes.

African American rhinoplasty.

Rhinoplasty in patients of African descent requires a patient-specific approach, because the goals and ideal proportions differ from the white nose. This article discusses approaches to surgical correction of common anatomic variations. In addition, common pitfalls are outlined.

Prospective quality of life assessment in congenital laryngomalacia.

PURPOSE OF STUDY: Disturbances in breathing or feeding may profoundly affect parental perceptions of a newborn's health. Previous research into quality of life for patients with laryngomalacia is limited to retrospective analysis. The purpose of this study is to prospectively evaluate the quality of life of families of infants with laryngomalacia and the impact of surgical and non-surgical treatments. DESIGN AND METHOD: Pilot prospective analysis using the laryngomalacia quality of life (QOL) survey in families of infants with newly diagnosed laryngomalacia under age one year. A 29-question survey regarding severity of symptoms related to overall health, airway, and swallowing is completed at initial and post-treatment visits. Responses are quantified over a range from 1 to 5 (1 never to 5 always). RESULTS: Twenty-six families were enrolled in the study. Eleven patients were managed medically and fifteen underwent supraglottoplasty. The overall mean QOL score for patients treated medically was 2.57 (standard error, SE 0.16) on initial visit and 1.67 (SE 0.16) post-treatment (mean 3.9 months). Patients undergoing supraglottoplasty had an overall mean QOL score of 3.59 (SE 0.14) on initial visit and 2.22 (SE 0.22) post-treatment (mean 3.5 months). Analysis of variance (ANOVA) and post hoc testing revealed significant improvement between initial and follow-up visits in both treatment groups (p < 0.01). Patients who underwent supraglottoplasty had significantly higher scores at initial visit (p < 0.01). No statistically significant difference was noted between patient groups post-treatment (p > 0.05). CONCLUSIONS: Prospective QOL assessment of children with laryngomalacia and their families reveals a significant burden of disease. Quality of life improves in all patients but may improve more significantly in patients managed surgically.

Selectin blockade decreases postischemic recruitment of bone marrow stromal cells.

OBJECTIVES/HYPOTHESIS: Investigate the localization mechanisms of bone marrow stromal cells following transient ischemia-reperfusion injury in a murine flap model. STUDY DESIGN: Controlled laboratory study. METHODS: A cutaneous flap based on the inferior epigastric artery was elevated, and transient ischemia of 3.5 hours using a microvascular clamp was achieved. Fucoidan was injected intravenously 24 hours before the ischemic period. Following the period of ischemia, radiolabeled bone marrow stromal cells were injected intravenously, and radioactivity was determined postoperatively. RESULTS: Attenuation of the uptake of bone marrow stromal cells into postischemic tissue was observed in those mice treated with fucoidan as indicated by gamma counts measured in the flaps when compared with controls (P < . 001). CONCLUSIONS: Decreased uptake of radiolabeled bone marrow stromal cells into postischemic tissues pretreated with fucoidan indicates selectin-mediated bone-marrow stromal cell recruitment in a murine cutaneous flap model.

Cervicofacial advancement-rotation flap in midface reconstruction: forward or reverse?

OBJECTIVE: To present the authors' experience and outcomes in the reconstruction of midfacial defects using cervicofacial advancement-rotation flaps (CARFs) based on a method of determining forward or reverse design in relation to the proportions of the defect. STUDY DESIGN: Case series with retrospective chart review. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: Patients who underwent CARF reconstruction and the subset of patients with midfacial defects medial to the lateral canthus were included. CARF was designed in a forward fashion with an anteromedial movement for the defects with a larger vertical dimension and in a reverse fashion with a posterosuperior movement for the defects with a larger horizontal dimension. RESULTS: Thirteen of 45 patients who underwent CARF reconstruction qualified for the analysis as a subset based on defect location. CARF was used in a forward fashion in 7 patients and in a reverse fashion in 6 patients. The largest defect in this subset was measured as 9 × 6 cm, while the smallest defect was 3 × 2 cm. Average follow-up was 11.5 months. None of the patients developed partial or total flap loss. Six patients had mild ectropion, which was managed with conservative measures only. The outcome of the reconstruction was satisfactory in all cases. CONCLUSION: Designing the CARF based on the proportion of the vertical and horizontal diameters of the selected midfacial defects as described allows for closure of the defects with minimal tension and minimizes the amount of discarded healthy skin overlapping at the suture lines.

The etiology of recurrent chordoma presenting as a neck mass: metastasis vs. surgical pathway seeding.

Chordomas are rare tumors of notochordal origin that arise along the vertebral axis. These slowly growing yet highly destructive tumors are associated with an alarming rate of recurrence, although surgical resection followed by proton, proton/photon, or conventional radiotherapy has been somewhat successful in terms of recurrence-free survival. Still, recurrent disease as a result of metastasis or surgical pathway seeding does occur. We retrospectively reviewed the case of a 64-year-old woman who presented with a left neck mass at level II. She had a history of recurrent chordomas involving the occipital portion of the clivus that had been treated with multiple resections and proton-beam irradiations over a period of several years. The new mass was found to have infiltrated the superior end of the sternocleidomastoid muscle. Neck dissection was performed. Pathology revealed no lymphoid tissue in the main specimen and no evidence of chordoma in any of the lymph nodes. We believe that this latest clival chordoma might have occurred as a result of surgical pathway seeding during a previous operation anterior to the sternocleidomastoid muscle, although metastasis cannot be ruled out. We also review the literature on clival and skull base chordomas as it relates to recurrence, metastasis, and seeding.