Endoscopic lipofilling for velopharyngeal insufficiency after transoral surgery: a technical note.

BACKGROUND: Velopharyngeal insufficiency (VPI) is a known complication of transoral surgery, with a reported incidence of 8.1%. The main factor related to VPI is the split of the soft palate. However, dead space resulting from transoral decompression may play a pivotal role in the pathogenesis of the dysfunction. In our experience, functionally significant dead space is almost constantly present after transoral decompression. This is probably due to malformation in children and postoperative scarring, thus configuring a nosological entity that we could define as "syndrome of the nasopharyngeal dead space." Palatal prosthesis and pharyngoplasty have been proposed, though these surgical procedures are technically tricky and with possible complications, such as OSA symptoms, snoring, and nasopharyngeal stenosis. METHODS: We proposed an effortless and minimally invasive procedure to treat this condition based on lipofilling the nasopharynx posterior wall endoscopically. To test the procedure's functional result, the submucosa of the nasopharynx posterior wall was initially filled with resorbable material, namely fibrin glue and autologous blood. The result was optimal but regressed after one month. Then, we repeated the procedure by lipofilling with autologous abdominal fat, resulting in a more stable anatomical and functional outcome at six months follow-up. RESULTS: The patient had a prompt significant improvement of his complaints (rhinolalia and oronasal regurgitation) and a correct projection of the nasopharynx posterior wall, with correct closure during phonation and absence of oronasal reflux. CONCLUSIONS: The "syndrome of the nasopharyngeal dead space" should be correctly identified after transoral surgery. It can be effectively treated with lipofilling of the posterior nasopharyngeal wall, a simple and minimally invasive procedure.

Bulky Recurrent Juvenile Nasopharyngeal Angiofibroma.

Juvenile nasopharyngeal angiofibroma is a rare and highly vascularized tumor that accounts for 0.05 to 0.5% of all head and neck neoplasms. The aim of this work was to present a case of a large recurrent juvenile nasopharyngeal angiofibroma coexisting with a facial lipoma in a 16-year-old boy. The patient was referred to our institution because of frequent unilateral epistaxis. Computed tomography revealed a hypervascular tumor with ethmoidal cell destruction and spread to the nasopharynx. Operative treatment of nasal cavity tumors was carried out using a transpalatal approach. After 6 months, the recurrence of the angiofibroma was verified radiologically. Primary as well as secondary surgical procedures were assisted with an endoscopic procedure. Accurate preoperative assessment and staging are essential for choosing a surgical procedure. The primary treatment is surgical excision. Early diagnosis, accurate staging, adequate treatment, and regular postoperative follow-up are essential in the treatment of these lesions.

Endoscopic Removal of a Nasopharyngeal Foreign Body Stuck Within the Sphenoid Bone Using the Endonasal Transseptal Approach.

ABSTRACT: Nasopharyngeal foreign bodies (FBs), which are generally caused by a strong, external force, are seldomly encountered. Removing these FBs is challenging for otorhinolaryngological surgeons because of the vital structures surrounding the nasopharynx, such as the skull base, cranial nerves, and internal carotid artery. Here, the authors report the case of a 69-year-old man referred to our hospital after accidentally cutting his face while using a grinder. Grinder fragments were deeply embedded in the face, thus becoming nasopharyngeal FBs. The authors evaluated three-dimensional volume rendering images and immediately removed these FBs using an endoscopic endonasal transseptal approach under general anesthesia. The postoperative course was uneventful. Using the endoscopic endonasal transseptal approach after evaluating preoperative three-dimensional volume rendering images may help eliminate nasopharyngeal FBs safely.

Severity of nasopharyngeal collapse before and after corrective upper airway surgery in brachycephalic dogs.

OBJECTIVE: To determine the severity of nasopharyngeal collapse in brachycephalic dogs before and after corrective airway surgery. ANIMALS: Twenty-three brachycephalic dogs (21 with clinical signs referrable to the upper airway) and nine clinically normal nonbrachycephalic dogs (controls). METHODS: Dogs were evaluated with fluoroscopy awake and standing with the head in a neutral position. The magnitude of nasopharyngeal collapse was measured as the maximum reduction in the dorsoventral dimension of the nasopharynx during respiration and expressed as a percentage. Brachycephalic dogs were anesthetized, the airway evaluated, and corrective upper airway surgery (alaplasty, staphylectomy, sacculectomy, tonsillectomy) was performed. A cohort (n = 11) of the surgically treated brachycephalic dogs had fluoroscopy repeated a minimum of 6 weeks after surgery. RESULTS: Median preoperative reduction in the dorsoventral dimensions of the nasopharynx was greater in brachycephalic dogs (65%; range: 8-100%) than in controls (10%; range: 1-24%, p = .0001). Surgery did not improve the reduction in dorsoventral diameter of the nasopharynx during respiration in brachycephalic dogs (n = 11) postoperatively (p = .0505). CONCLUSION AND CLINICAL SIGNIFICANCE: Nasopharyngeal collapse was a common and sometimes severe component of brachycephalic airway obstruction syndrome in the cohort of dogs evaluated. The lack of significant postoperative improvement may represent a type II error, a failure to adequately address anatomical abnormalities that increase resistance to airflow, or inadequate upper airway dilator muscle function in some brachycephalic dogs.

Nasopharyngeal Presentation of a Pharyngeal Cleft Cyst in a Dog.

A 2 yr old castrated male shih tzu was presented for assessment of worsening chronic snoring since first detected at 3 mo of age. An upper respiratory endoscopic examination and a computed tomographic scan showed a well-circumscribed, fluid-filled nasopharyngeal mass located in the median plane on the nasal side of the soft palate. This lesion was removed using a ventral approach to the nasopharynx by blunt-sharp dissection from the submucosal tissues of the soft palate. Histopathology revealed a cystic lesion lined by a single layer of a pseudostratified columnar ciliated epithelium, characteristic of a pharyngeal cyst. Follow-up 5 mo after surgery revealed complete resolution of the clinical signs with no evidence of local recurrence. Pharyngeal cysts are developmental abnormalities of the branchial apparatus. Most derive from the second branchial arch and cause cysts, sinuses, and fistulae to develop in the neck region. In our case, the lesion was located in the nasopharynx, leading to snoring and exercise intolerance. This condition should be included in the differential diagnosis of suspected nasopharyngeal obstruction.

MODERN APPROACHES TO CHOOSING SHAVER BLADE FOR ENDOSCOPIC SURGERY OF THE NASOPHARYNX AND PARANASAL SINUSES USING 3D MODELING.

OBJECTIVE: The aim: To determine the effectiveness of the use of 3D printed templates of shaver blades for choosing the optimal blade shape for endoscopic surgery of the nasopharynx and paranasal sinuses. PATIENTS AND METHODS: Materials and methods: The shaver blade templates with bending angles of 40º, 60º, 90º and 120° for powered endoscopic sinus surgery were made according to the manufacturer catalog using the Asiga 3D printer and Dental TOOTH material. There were examined 100 patients who underwent endoscopic powered sinus interventions (50 - adenoidectomy, and 50 - removal of the maxillary sinus cysts). The patients with each type of intervention were divided into subgroups of 25 people. The subgroups differed by the approach to choosing shaver blades: using 3D templates - in the main subgroup, and traditional -in the control. RESULTS: Results: The average number of shaver blades used for adenotomy in patients of the main group was 1.04±0.04, and in the control group - 1.36±0.09 (p<0.05). In patients of both subgroups, the 40º shaver blade, which is standard for adenotomy and recommended by most manufacturers, was most often used. In the control subgroup, it was used significantly more often. The frequency of the use of other shaver blades - 60º and 90º in both subgroups did not differ significantly and amounted to 40.0% (CI 95% 21.8; 61.1) and 36.0% (CI 95% 18.7; 57.4). CONCLUSION: Conclusions: The use of 3D templates for choosing a shaver blade reduces the number of blades used in adenoidectomy by 23.5%, for maxillary sinus cysts operation - by 18.2%.

Invasive pseudomembranous upper airway and tracheal Aspergillosis refractory to systemic antifungal therapy and serial surgical debridement in an Immunocompetent patient.

BACKGROUND: The development of respiratory infections secondary to Aspergillus spp. spores found ubiquitously in the ambient environment is uncommon in immunocompetent patients. Previous reports of invasive upper airway aspergillosis in immunocompetent patients have generally demonstrated the efficacy of treatment regimens utilizing antifungal agents in combination with periodic endoscopic debridement, with symptoms typically resolving within months of initiating therapy. CASE PRESENTATION: A 43-year-old previously healthy female presented with worsening respiratory symptoms after failing to respond to long-term antibiotic treatment of bacterial sinusitis. Biopsy of her nasopharynx and trachea revealed extensive fungal infiltration and Aspergillus fumigatus was isolated on tissue culture. Several months of oral voriconazole monotherapy failed to resolve her symptoms and she underwent mechanical debridement for symptom control. Following transient improvement, her symptoms subsequently returned and failed to fully resolve in spite of increased voriconazole dosing and multiple additional tissue debridements over the course of many years. CONCLUSIONS: Invasive upper airway aspergillosis is exceedingly uncommon in immunocompetent patients. In the rare instances that such infections do occur, combinatorial voriconazole and endoscopic debridement is typically an efficacious treatment approach. However, some patients may continue to experience refractory symptoms. In such cases, continued aggressive treatment may potentially slow disease progression even if complete disease resolution cannot be achieved.

A feasibility study in the treatment of obstructive sleep apnea syndrome and snoring: Nasopharyngeal stent.

OBJECTIVE: The objective of this study is to create a new choice of treatment with nasopharyngeal stent in isolated retro palatal obstruction and snoring for the treatment of obstructive sleep apnea syndrome (OSAS). MATERIAL AND METHOD: The study included five patients with mild OSAS and snoring. Nasopharyngeal stents were applied in these patients with drug-induced sedation endoscopy. RESULTS: With the nasopharyngeal stents, we aimed to prevent the soft palate to fall backwards while sleeping, especially at supine position in order to prevent the occurrence of apnea and hypopnea, providing a way for the airway to remain open as well as a support behind the soft palate and thus prevent snoring based on the vibration created by draught. CONCLUSION: We suggest a new alternative treatment approach to devices that need to be continuously used such as CPAP or intraoral devices or surgical methods that have many unwanted discomforts for the patients.

3D-structural change of nasopharynx following adenoidectomy: 10-year serial data in a single hospital.

PURPOSE: Scar contracture commonly refers to decreased function in the scar area, whereas scar contraction refers to shortening of the scar length compared to the original wound. Wound scar remodeling occurs during months to years of wound healing to form a mature scar. Serial reports about patients who had undergone adenoidectomy are rare. Thus, the objective of this study was to evaluate some parameters of air way passage in patients who had undergone post adenoidectomy. METHODS: Data of patients who have undergone adenoidectomy between 2000 and 2002 in our hospital were obtained. A total of 154 head and neck CT scans from an adenoidectomy group and a control group were analyzed. We measured lengths of several areas, including the width of posterior wall of nasopharynx, the widest diameter in the upper air way, the length between both Eustachian tubes, the length between both pharyngeal recesses, and the anterior to posterior diameter of the nasopharynx. This study was approved by Institutional Review Board (IRB) of the Department of Otolaryngology Head and Neck Surgery of Catholic University (approval number: UC18RESI0130). RESULTS: There were significant differences in the following parameters between the two groups: the width of posterior wall of nasopharynx and the length between both pharyngeal recesses. CONCLUSION: Extensive removal of soft tissue or injured muscle layer during surgery might be one of the reasons for the narrowing of airway. Keeping in mind not to make much injury the soft tissue or muscles during adenoidectomy is very important for the long-term outcome of this surgery.

Evaluation of the Nasopharyngeal Cannula Use After Orthognathic Surgery: Permeability of the Nasal Airways and Discomfort of the Patient With Cleft Lip and Palate.

It is believed that the use of the nasopharyngeal cannula can maintain the patent upper airway in the immediate post-operative period of orthognathic surgery. The present study is a randomized clinical trial with the objective of evaluating the difference in the use of the nasopharyngeal cannula in the post-operative period of orthognathic surgery with respect to permeability and discomfort. The sample was composed of 26 individuals with repaired cleft lip and palate randomly distributed in 2 groups with and without nasopharyngeal cannula. The evaluation was composed by Visual Analogue Scale (VAS), test with Altman mirror in 4 pre-operative periods, 6, 24, 30 hours after the operation. Rhinomanometry was also performed, a flow- pressure technique in 2 distinct moments, 6 and 24 hours after surgery. As a result, greater discomfort, greater obstruction as well as a reduction in the area of bilateral minimum nasal cross-section (ASTM) and increased resistance in the group with nasopharyngeal cannula are observed. In the intra-group comparison with the lowest ASTM values, the test group showed a significant difference between the first and the second moments (P = 0.001). It can be concluded that the nasopharyngeal cannula contributes to increase discomfort, worsens airway permeability by decreasing ASTM and increasing nasal resistance. Regarding the length of stay of the nasopharyngeal cannula, it can be said that from 6 hours onwards it does not contribute to the reduction of discomfort, airway permeability and assist in hemostasis.

Establishment of upper respiratory tract model of patients with obstructive sleep apnoea hypopnoea syndrome before and after surgical treatment and its hydrodynamics analysis.

OBJECTIVE: The study aimed to explore the method of constructing the upper respiratory tract model of patients with obstructive sleep apnoea hypopnoea syndrome (OSAHS) and its application in the detection of the changes of flow field characteristics of the upper respiratory tract before and after surgical treatment. METHODS: A 34-year-old male OSAHS patient was taken as the study subject. The improved Han-uvulopalato pharyngoplasty was adopted for treatment. A 3D model of the patient's upper respiratory tract was constructed based on CT scan results before and after surgery. The characteristics of upper respiratory tract flow field were analyzed based on computational hydrodynamics under unsteady respiratory conditions. RESULTS: A 3D model of the patient's upper respiratory tract was successfully constructed. And after the comparison, it was found that the patients' respiratory tract stenosis was significantly improved after surgical treatment. During inhalation and exhalation, the high pressure areas of the patient were located in the nasal vestibule and oropharynx respectively. Surgical treatment can significantly reduce maximum stress. The total pressure of the upper respiratory tract decreased by 16.9%, and the pressure of the nasopharynx and oropharynx decreased by 70.1% and 38.4%, respectively. CONCLUSIONS: For the oropharyngeal area, the surgical treatment had obvious efficacy for inspiration, and during expiration, it had no efficacy but with adverse symptoms being increased.

Combined endoscopic and transcervical approach for free flap reconstruction of nasopharyngeal and clival defects: A case report.

We report a case during which a new method of reconstruction for a nasopharyngeal and skull base defect was successfully performed. A 45-year-old female with granulomatosis with polyangiitis presented with computed tomography (CT) findings demonstrative of chronic clival and cervical spine osteomyelitis secondary to nasopharyngeal destruction. The posterior nasopharyngeal defect, evident as a wide area of mucosal erosion exposing the clivus centrally, was successfully reconstructed with an anterior serratus muscle-free tissue transfer via both transcervical and endoscopic transnasal approaches utilizing a laparoscopic fixation device, a previously unreported method for free flap inset, to secure the free flap. The patient tolerated this well and no major complications were encountered. At 2-year follow-up, the patient was without signs of cerebrospinal fluid leak or sequelae of infectious complications, including meningitis and osteomyelitis. A combined transcervical and endoscopic transnasal approach using a laparoscopic fixation device for free flap inset can be an effective method to reconstruct posterior nasopharyngeal defects in those patients whom local reconstructive options are not available.

Does rapid maxillary expansion affect nasopharyngeal airway? A prospective Cone Beam Computerised Tomography (CBCT) based study.

BACKGROUND AND PURPOSE: There is limited literature discussing the three dimnesional (3D) impact of rapid maxillary expansion (RME) on upper airway. The purpose of this prospective Cone Beam Computerised Tomography (CBCT) based study is to assess the immediate 3D effects and to correlate the volumteric changes in the upper naspharyngeal airway spaces secondary to RME. MATERIALS AND METHODS: Seventeen participants (8 male, 9 female, with a mean age of 12.6 ± 1.8 years), who required RME for the management of narrow maxillary arch, were recruited for this study. The prescribed expansion regimen was quarter turn (0.25 mm), twice a day until over-expansion was achieved. The mean period for the active phase was 14 days with a range of 12-21 days. Pretreatment (T1) and immediate post-expansion (T2) CBCT images were obtained and then processed using ITK snap and OnDemand3D softwar packages. Paired t-test and Interclass Correlation Coefficient (ICC) were used to assess the reproducibility of the measurements, student t-test (P < 0.05) and Pearson Correlation Coefficient (PCC) were applied to evaluate the volumetric changes in the nasopharyngeal airway spaces, linear dentolaveolar changes and correlate these changes. MAIN FINDINGS: Though, the data of one patient was excluded from the study, owing to major differences (>5 degrees) in the head and neck posture between T1 and T2 CBCT scans, the study' findings shows that bonded RME is an effective dentoalveolar expander in growing patients (P= 0.01) with an average expansion of 3.7 mm and 2.8 mm in males and females respectively. Likewise, the upper nasopharynx (UNP) expanded significantly (15.2% in males and 12% in females). In comparison, the upper retropalatal space (URP) was significantly reduced, by almost one sixth of its original volume, more in males than females, 11.2% and 2.8% respectively. A strong direct correlation between the maxillary sinus volumetric changes, and between appliance expansion and dentoalveolar expansion were evident (PCC = 0.86, 0.75, respectively). There was also a moderate correlation between changes in the UNP and URP spaces. CONCLUSIONS: RME was found to be an effective dentoalveolar expander and significantly augment the UNP and minimize the URP space. A similar comparative clinical study with long-term follow-up would be beneficial in accurately deteremining the clinical impact of RME on the airway and breathing as well as the stability of these effects.

Study on the Short-Time Remolding of Upper Airway After Uvulopalatopharyngoplasty.

OBJECTIVE: To verify the short-time remolding of upper airway in patients diagnosed with obstructive sleep disordered breathing after Uvulopalatopharyngoplasty (UPPP). METHODS: Twenty-one male adult patients aged 27 to 52 years followed up ranged from preoperation to 6 months after the operation. Lateral cephalometric radiographs (conventional and when pronouncing "i") were obtained 2 weeks preoperatively, 3 days postoperatively, and 1, 2, 3, 6 months after the surgery. The anterolateral diameters of different levels of upper airway and parameters of hyoid position of the patients were then measured. SAS 8.02 was used to analyze the differences by time. RESULTS: The study illustrated that the UPPP major affected the velopharyngeal and glossopharyngeal areas: parameters wane (P <0.05). On the other hand, UPPP leaded to the decline and retreat of hyoid. Most of the parameters remained metabolic. The nasopharynx kept statical (P >0.05) while the velopharyngeal parameters were increasing (P <0.05). The glossopharyngeal parameters increased in the first month after UPPP (P <0.05), while hypopharyngeal parameters underwent decline since 2 months after UPPP (P <0.05). The hyoid obtained decline and retreat (P <0.05) overall, while it endured a short-time climb in the first month after UPPP (P <0.05). CONCLUSION: Short-time upper airway remolding after UPPP existed.

Cellular Angiofibroma of the Nasopharynx.

Angiofibroma is a common tumor of the nasopharynx region but cellular type is extremely rare in head and neck. A 13-year-old boy presented with frequent epistaxis and nasal obstruction persisting for 6 months. According to the clinical symptoms and imaging studies juvenile angiofibroma was suspected. Following angiographic embolization total excision of the lesion by midfacial degloving approach was performed. Histological examination revealed that the tumor consisted of staghorn blood vessels and irregular fibrous stroma. Stellate fibroblasts with small pyknotic to large vesicular nuclei were seen in a highly cellular stroma. These findings identified cellular angiofibroma mimicking juvenile angiofibroma. This article is about a very rare patient of cellular angiofibroma of nasopharynx.

Size of Velopharyngeal Structures After Primary Palatoplasty.

OBJECTIVE: To describe and compare measures of velar length, velar thickness, and depth of the nasopharynx between two groups of patients with velopharyngeal dysfunction after primary palatoplasty: one received the modified Langenbeck procedure and the other the Furlow procedure. DESIGN: Comparative study involving a convenience sample of videofluoroscopic films established prospectively. SETTING: Surgeries and videofluoroscopic assessments were conducted at a craniofacial center. PARTICIPANTS: Exams from 90 participants were used: 27 (30%) operated with Furlow and 63 (70%) with Langenbeck. Three speech-language pathologists (SLPs) traced the images of the velopharyngeal port to determine the measures of interest. RESULTS: Intrajudge agreement for the SLPs ranged between 0.85 and 0.53, while interjudge agreement ranged between 0.44 and 0.51. The overall measure of velar length was significantly larger (P = .042) for the Furlow group (mean = 26.5) than the Langenbeck group (mean = 24.2 mm). There was no significant difference in velar thickness or depth of the nasopharynx between the two procedures. Although no significant difference was found between the current findings and Subtelny's norms for length, thickness, and depth, the patients presented with an overall depth:length ratio (0.89) significantly greater than Subtelny' ratio (P = .025). CONCLUSION: The findings of this study confirmed the hypothesis that patients who underwent surgery with the Furlow technique may present with significantly longer velums than patients who underwent surgery with the Langenbeck procedure. Information regarding velopharyngeal morphology was predictive of velopharyngeal dysfunction for speech for 80% of the participants and can be useful in documenting outcome of treatment.

[Endoscopic transnasal surgery for giant fibrous dysplasia of the skull base, spreading to the right orbital cavity and nasopharynx (a case report and literature review)]. / Endoskopicheskaya transnazal'naya khirurgiya gigantskoi fibroznoi displazii osnovaniya cherepa, rasprostranyayushcheisya v polost' pravoi orbity i nosoglotku (opisanie nablyudeniya i obzor literatury).

BACKGROUND: An extended endoscopic endonasal approach is increasingly used in surgical treatment of space-occupying skull base lesions. The international literature reports only 20 cases of surgical treatment for fibrous dysplasia (PD) of the skull base using the endoscopic endonasal approach. We present our experience with the endoscopic endonasal approach in surgical treatment for giant fibrous dysplasia of the skull base, spreading to the right orbital cavity and nasopharynx. CLINICAL CASE: A 26-year-old male patient presented with cranial pain, Vth nerve dysfunction on the right, right keratopathy. OD=0.2 (near acuity - 0.3), OS=1.0, OD - incomplete eyelid closure of 2 mm, conjunctival injection, mucous discharge, corneal opacity in the lower pole and paracentrally, OS - normal appearance. Severe right-sided exophthalmos (more than 15 mm), impaired nasal breathing on the right, nasal (hemorrhagic) discharge. Magnetic resonance imaging and spiral computed tomography scans revealed a bone density lesion located in the area of the orbit, nasal cavity, maxillary sinus on the right, and labyrinth of the ethmoid bone. The patient underwent endonasal endoscopic resection of the lesion. RESULTS: The lesion was resected totally, which was confirmed by control SCT. Right-sided exophthalmos partially regressed (on the right: exophthalmos of 8 mm; protrusion: OD=23 mm, OS=15 mm; the eyeball was displaced downward and outward). The visual and oculomotor functions did not change. The neurological status remained at the preoperative level. CONCLUSION: Fibrous dysplasia of the skull base is an extremely rare disease. Modern techniques expand the indications for surgery of giant tumors of the skull base using minimally invasive approaches, in particular the endoscopic endonasal approach.

Volumetric Analysis of Nasopharyngectomy via Endoscopic Endonasal, Maxillary Transposition, and Lateral Temporal-Subtemporal Approaches.

OBJECTIVE: This project develops a computer model that allows volumetric analysis of the exposure afforded by an endonasal-endoscopic approach, maxillary transposition, and lateral temporal-subtemporal approaches during a nasopharyngectomy. The model will demonstrate idiosyncracies of these approaches, including sacrifice of normal tissues, ease of instrumentation, and gate of entry. SUBJECTS AND METHODS: Computed tomographic scans of an anatomic specimen were used to create computer simulations of the endoscopic endonasal, maxillary transposition, and lateral temporal-subtemporal approaches for T1and T4 nasopharyngeal carcinoma; therefore, allowing assessment of their surgical corridor using Intuition, a software that allows a semiautomated computerized segmented volumetric analysis. RESULTS: The smallest volumes of tissue mobilization or removal were observed during the endoscopic-endonasal nasopharyngectomy. The volumes of tissue mobilization for the maxillary transposition approach were higher than those of lateral temporal-subtemporal approaches. CONCLUSIONS: This model adds to our understanding of select surgical corridors to the nasopharynx. It suggests that an endoscopic-endonasal approach requires less manipulation or resection of smaller volumes of normal tissue to expose a nasopharyngeal tumor than the lateral temporal-subtemporal and maxillary transposition approaches. It also, however, requires instrumentation through a smaller entry gate implying greater difficulty. Nonetheless, these factors should not be construed as superiority of one approach over the other. Factors that are important in the choosing of the surgical approach, such as surgeon's training and experience, invasion of neurovascular structures and method of reconstruction are not considered in this model.