Small nasal defects.

The nose occupies an important feature of a person's central face. The size, shape, and proportions of the various characteristics of the face provide a visual basis suggesting the character of the person. Scars, asymmetries, and any abnormalities of the central face are easily recognizable and noted by even a casual observer. Over the centuries, therefore, much attention has been paid to reconstruction of facial and nasal abnormalities of both acquired and congenital etiologies. The purpose of this article is to address the reconstruction of smaller defects of the nose, encompassing surface areas of 1.5 to 2 centimeters.

The effectiveness of a "critical pathway" in the management of laryngectomy patients.

BACKGROUND: This is a retrospective review of medical and financial records to test the hypothesis that the use of a critical pathway specifically designed for the management of laryngectomy patients will result in improved patient care, decreased length of hospitalization, and optimal allocation of resources. METHODS: Thirty patients undergoing laryngectomy before the implementation of the laryngectomy critical pathway were compared with 30 patients after implementation of the pathway. Clinical outcomes, length of hospitalization, and cost analyses were performed. RESULTS: Adjusting for two outliers, the average length of stay for pathway patients was 7.3 days vs 12 days for prepathway patients. A total estimated cost-savings of $204,000 was ultimately achieved. CONCLUSIONS: Our laryngectomy critical pathway has resulted in improved patient care and optimized allocation of medical resources.

Basal cell carcinoma metastatic to the parotid: report of a new case and review of the literature.

Basal cell carcinoma is the most common of the cutaneous malignancies, accounting for 65 to 75% of all skin cancers. The natural history of this disease is one of chronic local invasion. Metastatic basal cell carcinoma is a rare clinical entity, with a reported incidence of only 0.0028 to 0.5%. Approximately 85% of all metastatic basal cell carcinomas arise in the head and neck region. We present a case of basal cell carcinoma that spread to the parotid gland in a man who had multiple lesions on his scalp and face. We also review the literature on metastatic basal cell carcinoma of the head and neck, and we discuss its epidemiology, etiology, histopathology, and treatment.

Squamous cell carcinoma of the anterior nasal cavity: a dual institution review.

Thirty-two patients with squamous cell carcinoma of the anterior nasal cavity were identified at two university hospitals. A retrospective review was conducted to identify clinical presentation, initial therapy, recurrence rates, and factors affecting survival. Treatment included surgery (n = 15), radiation therapy (n = 9), or combination therapy (n = 8). The primary lesions involved either the septum, vestibule, columella, anterior floor, or a combination of these subsites. The primary tumor involved a single nasal subsite in 22 patients and multiple nasal subsites in 10 patients. All patients had de novo squamous lesions, and all tumors were staged N0 at initial diagnosis. Six patients received prophylactic neck irradiation, and none underwent elective neck dissection. Overall, 18 (56%) patients had recurrent disease after primary therapy (5 local and 13 regional). The 5-year disease-free survival was 42%, and the 5-year overall survival was 50%. None of the patients receiving prophylactic neck irradiation had a regional recurrence. Involvement of 2 or more nasal subsites significantly decreased survival (P < 0.05). Squamous cell carcinoma of the anterior nasal cavity is an aggressive disease, and combined therapy initially with strong consideration for prophylactic radiation to the facial and cervical lymphatics is advocated.

Operative times, postanesthesia recovery times, and complications during sinonasal surgery using general anesthesia and local anesthesia with sedation.

OBJECTIVE: The goal was to compare complication rates and recovery times in patients undergoing elective septoplasty or endoscopic sinus surgery using local anesthesia with sedation (LAS) versus general anesthesia (GA). METHODS AND PATIENTS: A retrospective chart review of a consecutive sample of 177 patients undergoing elective septoplasty or endoscopic sinus surgery between July 1, 1994, and June 30, 1996, was carried out at our university-based outpatient surgery unit. Outcome measures included total operative time, surgical time, recovery time, and perioperative complications. RESULTS: Total operative and recovery times were shorter in patients undergoing LAS. The frequency of emesis, epistaxis, and nausea were less in the LAS population than in the GA population. Three patients who underwent GA required unplanned admissions. CONCLUSION: This study suggests that in selected patients undergoing sinonasal surgery, LAS may result in shorter total operative times, shorter recovery times, and less frequent nausea, emesis, and epistaxis than GA.

Restoration of lower eyelid support in facial paralysis.

Lower eyelid dysfunction in the patient with facial paralysis is frequently the result of several deleterious factors, including the loss of orbicularis tone, involutional changes in the canthal ligaments, the effect of aging on the midfacial soft tissue structures, and malposition of the lower eyelid punctum. This dysfunction is manifested as lagophthalmos, ectropion, and epiphora. Fortunately, there are several surgical methods by which the various abnormalities can be corrected or compensated for. This article addresses the management of the lower eyelid and several of the current methods available to the surgeon for management of the lower eyelid in facial paralysis.

Management of the central nasal support complex in naso-orbital ethmoid fractures.

Central nasal support structures are frequently injured in patients with naso-orbital ethmoid fractures. Diagnosis of these injuries can be difficult and, to optimally manage them, a thorough understanding of the complex anatomy is essential. The goal of surgical repair is to reestablish the aesthetics and function to this region without complication. Appropriate imaging and classification of the central nasal support injury and classification of the naso-orbital ethmoid fractures must be accomplished prior to formulating a successful treatment plan. This article reviews the anatomy, patient assessment, imaging, and classification systems. Currently accepted management of specific injuries are outlined.

Evaluation of the efficacy of 2- versus 3-dimensional computed tomography.

Simulated 3-dimensional (3-D) representation of computerized data is a valuable diagnostic tool in evaluation of tumors of the central nervous system. Several reports exist regarding the clinical value of 3-D imaging, but there is little objective evidence to quantify improved performance from the images. The purpose of this study was to quantify the efficacy of simulated 3-D versus 2-D image interpretation in a nonclinical model. A 3-tiered, 3-D model was constructed, and objects were placed in varied positions. CT was then performed on each of the models. Fifty-three subjects were shown the CT images and asked to reconstruct the model as depicted by either 2-D or simulated 3-D images. Performance between subject groups was different depending on clinical experience. In addition, it was found that the 3-D representation of data allowed for a significantly faster performance of the task of image interpretation and reconstruction of the model.

Angiosarcoma: current review.

Angiosarcoma (AS) is a rare malignant tumor of the skin and soft tissues. Due to this lesions's histopathologic similarity to other soft tissue and skin neoplasms, several names had been previously used to describe AS. In the following article, we present a comprehensive review of the literature and prior studies pertaining to AS. The purpose of this article is to provide the reader with a better understanding of the causative factors, clinical findings, and histological features of this uncommon but potentially lethal tumor. Furthermore, we discuss present therapeutic options and outcomes as well as summarize recent advances in AS tumor biology and cytogenetics.

Dopamine-secreting glomus vagale: a case report and histopathologic correlation.

BACKGROUND: Catecholamine secretion by head and neck paragangliomas is uncommon. Dopamine secretion by these tumors has not routinely been assessed. This case report describes a dopamine-secreting glomus vagale and evaluates seven other paragangliomas immunohistochemically for their ability to synthesize dopamine. METHODS: Light microscopic and immunohistochemical studies were performed on eight tumors, and biochemical testing for serum/urine catecholamines was performed on two patients. RESULTS: One patient (case report) had elevated serum dopamine which corrected following surgery. Five tumors stained strongly positive for the presence of tyrosine hydroxylase, the critical enzyme in the biosynthesis of dopamine. CONCLUSION: This case report describes the ability of a glomus vagale to secrete dopamine. Other paragangliomas express the enzymatic machinery necessary to begin catecholamine synthesis. Now that dopamine is routinely screened during catecholamine determination, other cases may be identified.

Plating techniques and plate orientation in repair of mandibular angle fractures: an in vitro study.

A biomechanical model utilizing polystyrene mandibles was devised to evaluate the fixation efficacy of various plating techniques for repair of mandibular angle fractures. A simple angle fracture was created in the mandible models at a standardized location and was repaired using five different plating techniques. Each experimental group consisted of 15 mandibles, with fracture site, plate placement, load application, and fracture displacement measurement standardized to ensure consistency among experimental groups. Measurement of fracture distraction under load application generated a load deformation curve and corresponding slope for each technique. Comparison of load deformation slopes allowed assessment of fixation stability. When applied with a subapical, medially placed monocortical tension band, bicortical compression plating demonstrated the most stable fracture fixation. The data show that biplanar plate placement in both monocortical noncompression and bicortical compression techniques yields a stronger fixation than monoplanar placement.

The aging face.

Aging is an inevitable process. Most patients identify the concept of self-image in their facial appearance. The face is also our interface with the outside world. Changes in the face secondary to aging are the most apparent. Some aspects of aging are fairly uncontrollable, and these are largely based on hereditary factors. Other factors are somewhat controllable and are largely the result of exposure to the elements and harmful habits. The processes of facial aging are slowly becoming understood. Although different patients appear to age at different rates, biologic aging does not seem necessarily to follow chronologic aging in the same fashion in different individuals. However, a fundamental pattern as well as sequence in aging is fairly predictable and describable. The effects of ultraviolet radiation and involutional changes are manifested in the skin as wrinkles. Involutional changes in the suspensory structures in the face result in skin laxity and dependency. In this article, the various factors involved in aging are reviewed. The effects of these factors in different regions are discussed, with representative illustrations to represent concepts.

Transconjunctival blepharoplasty.

Cosmetic blepharoplasty is directed at the surgical correction of undesirable changes of the eyelids that are usually of an acquired nature and caused by aging. The goals are to improve the appearance and, many times, the function of the eyelids. Just as important as attaining these goals is avoiding any complications or undesirable sequelae of a blepharoplasty procedure. In this article, the technique and application of transconjunctival blepharoplasty are reviewed. The differences in the preseptal and retroseptal approaches are discussed and illustrated. The transconjunctival technique can be expanded through the use of various other techniques in order to apply it to a wider variety of patients. These expanded techniques of transconjunctival blepharoplasty allow the surgeon to manage excess skin and rhytids more effectively. Transconjunctival blepharoplasty, therefore, represents a technique in the armamatarium of surgeons performing cosmetic blepharoplasty that has gained new popularity. The technique can be effectively applied to a wide variety of patients. Transconjunctival blepharoplasty allows the surgeon to accomplish many of the esthetic goals of blepharoplasty while reducing the incidence of many of the associated problems, i.e., lid malposition and a visible cutaneous scar.

Comprehensive management of nasoethmoid-orbital injuries.

Fractures of the nasoethmoid-orbital region present some of the more formidable challenges to the reconstructive surgeon in regard to aesthetic and functional restorations. As the severity of injury escalates, the surgical difficulties increase, making acceptable results of therapy difficult to achieve. Optimal management involves not only repair of the skeleton of the central midface, but also restoration of function and aesthetics of the orbits, frontal sinus, anterior cranial fossae, and the overlying soft tissue. Detailed physical examination and radiographic imaging are necessary to properly diagnose the extent of injuries. Various surgical techniques, such as interfragmentary wiring, microplate fixation and transnasal wiring, are utilized. This article reviews injuries of the nasoethmoid-orbital region, and describes the pertinent anatomy and classification of injuries. Currently accepted methods of evaluation and repair of specific injuries are outlined.