Reconstruction of the radial forearm free flap donor site using integra artificial dermis.

Autologous skin grafting to the donor site in patients who undergo radial forearm free flap reconstruction (RFFF) is associated with cosmetic and functional morbidity. Integra artificial dermis (Integra Lifesciences, Plainsboro, NJ) is a bovine collagen based dermal substitute that can be used as an alternative to primary autologous skin transplantation of the donor site. We describe a staged reconstruction using Integra followed by ultrathin skin grafting that results in highly aesthetic and functional outcomes for these defects. A retrospective review of 29 patients undergoing extirpative head and neck oncologic resection were examined. Integra graft placement was performed at the time of RFFF harvest followed by autologous split thickness skin grafting at 1 to 5 weeks postoperatively. Healing fully occurred within 4-6 weeks with negligible donor site complications, excellent cosmesis, and minimal scar contracture. Composite reconstruction with Integra artificial dermis offers advantages over traditional methods of coverage for select cases of radial forearm free flap donor site closures.

A review of the endoscopic approach to the pituitary through the sphenoid sinus.

PURPOSE OF REVIEW: The refinement of minimally invasive endoscopic techniques has resulted in 'pure' endoscopic endonasal trans-sphenoidal surgery, which is a new approach for the removal of pituitary tumors. RECENT DEVELOPMENTS: This procedure is performed via a wide anterior sphenoidotomy with detachment of the septum from the sphenoid face, and avoids the use of a trans-sphenoidal retractor and any intraoral or nasal incisions. Straight and angled endoscopes are used throughout the procedure to provide a wide view of the sella and are manipulated by a co-surgeon. This technique represents an improvement over pituitary microsurgery, with decreased post-operative morbidities and a shortened postoperative stay, and it eliminates the need for packing while providing an opportunity to monitor the sella after surgery. The technique has been established as being efficacious and safe. It incorporates image-guided surgery, with the fusion of computer tomography and magnetic resonance imaging, and employs new and dedicated instrumentation. Training in endoscopic techniques is required. SUMMARY: Future advancements in intraoperative imaging, cranial base reconstruction, and robotics will make this technique even more successful.

Accuracy of transnasal cannulation and dilation of the maxillary ostium in cadavers with intact uncinates.

BACKGROUND: Transnasal cannulation of the natural ostium in patients with an intact uncinate process is complicated by the lack of direct visualization of the ostium. Accuracy of transnasal dilation of the maxillary ostium was evaluated for a malleable-tipped balloon device that was bent to specific angles for avoiding the fontanelle during cannulation. METHODS: Transnasal cannulation and dilation of 42 cadaver maxillary sinus ostia was attempted by 6 surgeons including 3 with very limited clinical experience using the study device. All physicians received procedure training including the technique to shape the balloon device into the recommended 135° maxillary configuration. Tissue dissection was prohibited. Canine fossa trephination and transantral endoscopy were used to evaluate cannulation and dilation outcomes. Physician operators were blinded to transantral images and results were documented by two observers. RESULTS: Appropriate transnasal cannulation and dilation of natural maxillary sinus ostia occurred in 92.9% (39/42) of attempts. Two failures emanated from procedural deviations. In one deviation, the bend angle was changed to 90° and the device tip did not cannulate the ostium. In the second, the device was passed through a preexisting hole in the uncinate and cannulated the natural ostium. A third failure occurred when the device was passed through the fontanelle creating a false lumen. CONCLUSION: Using recommended procedural techniques and a malleable-tipped balloon device, newly trained and experienced physicians alike can perform uncinate-preserving transnasal cannulation and dilation of the maxillary ostium with a high rate of success.

Use of three-dimensional computerized tomography reconstruction in complex facial trauma.

Technological advances in computerized tomography (CT) have reduced data acquisition and reconstruction times so that three-dimensional (3D) CT images of maxillofacial injuries may be economically and quickly generated. 3DCT was judged superior to multiplanar two-dimensional CT in demonstrating the spatial relationships of fracture fragments in complex mandibular and midfacial trauma. Although 3DCT failed to demonstrate soft-tissue injuries well, the surgeon's improved appreciation of the disrupted bony architecture facilitated preoperative planning. 3DCT facilitates the evaluation of complex mandibular and midfacial fractures.

Hypocomplementemic urticarial vasculitis with angioedema, a rare presentation of systemic lupus erythematosus: rapid response to rituximab.

We report a case of hypocomplementemic urticarial vasculitis and recurrent angioedema in a patient with systemic lupus erythematosus unresponsive to mycophenolate mofetil, high-dose methylprednisolone, and intravenous immunoglobulin that responded rapidly to rituximab. Rituximab is a monoclonal antibody against CD20 transmembrane protein on the surface of mature and malignant B cells. No adverse effects occurred during or after therapy, and the patient was discharged from the hospital for outpatient rituximab infusion and follow-up care.