Underappreciated Utility of the Purse-String Suture in Head and Neck Skin Cancer Defect Reconstruction.

BACKGROUND: The purse-string suture (PSS) is a simple, reversible method for reconstructing skin cancer defects. Its utility may be underappreciated in head and neck reconstructive surgery. OBJECTIVE: To evaluate the utility of the PSS as an adjunct to the reconstructive ladder when reconstructing head and neck skin cancer defects. MATERIALS AND METHODS: This prospective nonrandomized cohort included 109 consecutive adult patients with head and neck defects resulting from skin cancer resection. The PSS was placed in every patient after resection. Patients were evaluated before and after suture placement, and final reconstructive methods were recorded. RESULTS: The PSS resulted in a mean defect area reduction of 77.1% (p < .001) and was used in the final reconstruction in 79 (72.5%) patients. The PSS reduced the number of patients requiring adjacent tissue transfer (11), regional tissue transfer (3), and free tissue transfer (1) by 69.4%, 70%, and 80%, respectively. Fifty patients underwent reconstruction in the operating room. After intraoperative placement of the PSS, it was determined that 22 (44.0%) of these defects could have been reconstructed in the clinic (p = .003). CONCLUSION: The PSS dramatically reduces defect size, simplifies reconstructive techniques, and often permits reconstruction to be performed in the clinic rather than the operating room.

Effect of Mandible and Maxilla Osteotomies on Velar, Oropharyngeal, and Hypopharyngeal Diameter.

PURPOSE: There is a lack of anatomic comparisons between maxillomandibular advancement (MMA) and other bony surgical treatments of obstructive sleep apnea (OSA). Surgical procedures were simulated in cadavers to evaluate their ability to expand the posterior airway space (PAS). MATERIALS AND METHODS: The following bony advancement surgeries were performed on each of 9 cadavers: genioglossal advancement (GGA); genioplasty with advancement of the genioglossus, geniohyoid, and anterior digastric muscles (GPA); bilateral sagittal split osteotomy; Le Fort I maxillary advancement; Le Fort I maxillary anterior impaction osteotomy (LFAI); MMA; MMA plus GPA; and MMA plus LFAI. Bony advancements were performed at increasing distances and change in PAS anteroposterior (AP) diameter was measured at the levels of the velum, oropharynx, and hypopharynx. RESULTS: Change in PAS varied in a linear fashion with advancement surgical maneuvers. GPA led to a greater increase in AP distance at the levels of the oropharynx and hypopharynx compared with GGA. LFAI showed a greater increase in AP distance at the velum compared with MMA. All maxillary movements showed greater AP expansion in the PAS at the velum compared with mandibular advancements. CONCLUSIONS: Static AP expansion of the PAS at the levels of the velum, oropharynx, and hypopharynx occurs in a roughly linear and predictable pattern with different bony surgical procedures used in OSA surgery. MMA alone and MMA plus GPA had the overall greatest effect at all airway levels. GPA had a greater effect on expansion of the oropharynx and hypopharynx compared with GGA.

Surgical Treatment of Vestibular Schwannoma: Does Age Matter?

OBJECTIVE: For older patients (>65 years) who undergo surgical treatment of vestibular schwannoma (VS), the reported rates of facial nerve preservation, hearing preservation, and complications are inconsistent. Many surgeons believe that older patients have worse outcomes than their younger counterparts and advise against surgical treatment. We analyzed a consecutive series of patients with VS treated with surgery to determine whether age was a factor in outcome. METHODS: We retrospectively reviewed all patients treated for VS at our institution from January 1, 2000, to July 1, 2012. We examined how sex, age (≥65 years and <65 years), race, tumor size, tumor laterality, body mass index, Charlson Comorbidity Index, smoking status, surgical approach, and preoperative hearing and symptoms were associated with outcomes. RESULTS: Two-hundred forty-three patients underwent resection of VS, including 23 patients ≥65 years (mean 68 ± 4 years) and 220 patients <65 years (mean 47 ± 11 years). The average tumor size was 16.5 mm. Older patients had a significantly lower body mass index of 26.6 vs. 29.8 (P = 0.03) and were more likely to have a CCI ≥2 (52.2% vs. 18.2%, P ≤ 0.00, preoperative facial numbness (34.8% vs. 10.1%, P = 0.03), and dizziness (78.3% vs. 49.3%, P = 0.03). There were no significant differences after surgery in facial nerve outcome, hearing preservation outcome, or general surgical complications between the 2 cohorts. CONCLUSIONS: With no difference in surgical complications, facial nerve outcome, or hearing preservation rates between older and younger patients in our series, age alone may not be an absolute contraindication to surgical management of VS.