Establishment of Safety of Hemostatic Net Application Utilizing Laser-Assisted Fluorescence Angiography With SPY-Q Software Analysis.

BACKGROUND: The hemostatic net, which was initially described as a method to decrease hematoma rates in facelift and necklift procedures, has since increased in practice and applicability. However, despite its demonstrated safety and efficacy, there exists significant skepticism with regard to its necessity; in particular, there is concern that the transcutaneous sutures may restrict dermal perfusion. OBJECTIVES: The goal of this study was to assess flap perfusion, both before and after application of the hemostatic net, to determine if there was an objective decrease in tissue perfusion in relation to application of the hemostatic net, as measured by laser-assisted angiography (LAA). METHODS: Eight patients underwent cervicofacial flap reconstruction of cutaneous malignancy defects, after which a hemostatic net was applied. All patients underwent evaluation with LAA both before and after application of the net. The average relative and absolute perfusion of different zones of the flap were calculated. RESULTS: The average absolute change in relative perfusion was +6.41%, +0.31%, and +3.28% for zones 1, 2, and 3, respectively, after application of the hemostatic net. There was no statistical difference in relative tissue perfusion after application of the net. There were no instances of delayed healing, infections, ischemia, necrosis, or hematoma. One patient developed a seroma after the net was removed. No patients had scarring or residual track marks from the transcutaneous sutures. CONCLUSIONS: With LAA, we were able to objectively demonstrate no significant decrease in tissue perfusion after the application of the hemostatic net.

Repair of a large primary subtemporal encephalocele in a 3-year-old child: case report.

Primary encephaloceles (PEs) present only rarely in the temporal region; in the rare instance that they project through the floor of the middle fossa they are secondary. In this case report the authors report on the management of a giant PE extending through the floor of the middle fossa.An 8-month-old boy presented to the authors' service with a large PE projecting into his neck through a missing left middle fossa floor; the lesion was causing significant meta-, dys-, and hypoplasia of the structures of the anterolateral neck on that side. Surgical goals for this patient included the following: 1) removal of potentially epileptogenic and dysfunctional tissue; 2) preservation of cranial nerves; 3) prevention of cognitive decline or iatrogenic deficit; 4) prevention of CSF leak; 5) reconstruction of skull base; 6) prevention of airway and swallowing compromise; and 7) cosmesis. After a multidisciplinary evaluation with ENT, plastic surgery, and neurology, an operation was performed using a preauricular infratemporal approach when the patient was 3 years old. Gliotic tissue was resected and amygdala, hippocampus, and middle cerebral artery were preserved.The immediate results of the operation showed good immediate outcome. Seizure freedom and neurodevelopment outcomes remain to be seen at follow-up.

Continuous Postoperative Antibiotic Irrigation via Catheter System Following Immediate Breast Reconstruction.

Breast reconstruction with implantable devices is now the most common type of technique utilized following mastectomy. Because infections are one of the most common complications for the procedure and currently no one method has been proven to stand above the rest, we designed and implemented a novel technique that employed 24 hours continuous triple-antibiotic irrigation via a catheter-based system. From August 2009 to March 2012, 79 patients underwent tissue expander-based reconstruction from a single plastic surgeon. Forty-five consecutive patients underwent breast reconstructive surgery with implant-based reconstruction alone; the remaining 34 patients underwent breast reconstructive surgery with tissue expansion and closed continuous postoperative antibiotic irrigation. Incidences of infection, seroma, hematoma, and premature explantation were recorded. Both the rate of premature explant (20% vs 2.9%; P = 0.037) and surgical site infections (22.2% vs 5.8%, P = 0.060) decreased. Twenty-four hour continuous antibiotic irrigation is a useful adjunct to tissue expander breast reconstruction.

Nasal Sculpting: Calculated and Predictable Tip Elevation With Cephalic Trim.

BACKGROUND: Rhinoplasty techniques to affect nasal tip rotation are well described. Cephalic alar trim is a powerful method for achieving tip elevation. Previous studies and texts provide aesthetic guidelines for nasolabial angles. Often, surgeon experience determines the degree of lower lateral cartilage resection to achieve optimal results. This study analyzes the change in tip elevation with measured resections of the lower lateral cartilages. This can aid the surgeon in accurately predicting the effect of cephalic alar trim on tip elevation. METHODS: Ten fresh cadaveric dissections were performed to determine the change in nasolabial angles after cephalic trim of the lower lateral cartilage. Closed rhinoplasty technique was performed using marginal and intercartilaginous incisions to expose the lower lateral cartilage. Caliper measurements of the lower lateral cartilage were recorded. Serial cephalic trim was performed in 25% increments. True lateral photographs were obtained before and after each serial excision. Nasolabial angle measurements were obtained using a digital goniometer for digital photo analysis. RESULTS: Four female and 6 male cadavers were evaluated. The mean initial nasolabial angle was 106° ± 2°. The mean lower lateral cartilage width was 9.45 ± 1.38 mm. Serial 25% reductions in lower lateral cartilage height resulted in a mean total nasolabial angle change of 7.4°, 12.9°, and 19.6°, respectively. The mean incremental change in the nasolabial angle was 6.47° ± 1.25°. CONCLUSION: The nasolabial angle is an essential aesthetic feature. Cephalic trim is a key maneuver in affecting the nasolabial angle. A 25% lower lateral cartilage cephalic trim correlates with an average change in the nasolabial angle of 6.47°. Knowledge of the cephalic trim to nasolabial angle relationship aids in achieving desired tip elevation.

Scalp reconstruction: a review of the literature and a unique case of total craniectomy in an adult with osteomyelitis of the skull.

OBJECTIVE: Osteomyelitis of the skull is a rare condition that can lead to systemic illness, bone loss, intracranial complications, and mortality. Osteomyelitis of the skull typically presents as the boney invasion of an overlying infection of the scalp or sinuses, and it is typically treated with antibiotics and proper wound care. Surgical debridement of the affected bone in the form of a craniectomy may be initiated to stop the progression of the infection when antibiotics fail and the underlying bone becomes grossly eroded. METHOD: The authors present the case of a 54-year-old woman who required a total craniectomy after developing full-thickness osteomyelitis. A free omental flap along with dermal grafts and split-thickness skin grafts were utilized for soft tissue coverage. A semi-rigid helmet was used to provide durable protection to the brain. RESULTS: Omental free flap with skin graft coverage provided this patient with durable and long-term soft tissue coverage for a total craniectomy defect, as well as the ability to regain mental status. CONCLUSIONS: Many factors must be analyzed when approaching composite defects of the scalp. Modality of treatment must be customized to the individual, and the decisions should be based on whether the defect is composed of soft tissue, bone or both, its size, etiology, and presence of a cerebral spinal fluid leak. The goals of treatment are restoration of durable soft tissue coverage, protection of vital underlying structures and control of cerebral spinal fluid leaks.

Traumatic dislocation of the mandibular condyle into the middle cranial fossa in an elderly patient.

Dislocation of the mandibular condyle into the middle cranial fossa is a rare traumatic injury caused by transmission of upward force through the condyle onto the glenoid fossa resulting in fracture of the fossa and superior displacement of the condylar head. This type of injury occurs when the "safety mechanisms" of the mandible fail or are absent. The authors present the case of a 72-year-old female patient with multiple comorbidities who suffered a subcondylar fracture of the left mandible and dislocation of the right mandibular condyle into the middle cranial fossa after a fall. Bilateral external fixation of the mandible to the zygomatic arch was utilized to minimize operative time and provide definitive treatment. Many factors must be taken into account when determining the treatment modality for this type of injury, and the final decision should be tailored to each individual case based on several factors including the length of time between injury and presentation, concomitant neurologic deficit, age, and stability of the patient. The goals of treatment are reduction of the dislocation, avoidance of neurologic injury, and restoration of mandibular function. A multidisciplinary effort is necessary to optimize patient care.

The importance of ulceration of cutaneous melanoma of the head and neck: a comparison of ear (pinna) and nonear sites.

OBJECTIVES/HYPOTHESIS: To compare clinicopathologic and prognostic factors associated with ear melanomas and nonear melanomas of the head and neck (H&N). STUDY DESIGN: Post hoc analysis of the database from a multi-institutional, prospective, randomized study. METHODS: Clinicopathologic factors were assessed and correlated with survival and recurrence. Univariate and multivariate analysis of prognostic factors affecting disease-free survival (DFS) and overall survival (OS) were performed. RESULTS: Of 405 patients with H&N melanomas ≥ 1.0 mm Breslow thickness, 59 patients had melanomas of the ear. Most were Caucasian (96.6%) males (79.7%) with a mean age of 52 years. The mean Breslow thickness was 2.5 mm; 34.5% had signs of ulceration. Sentinel lymph node (SLN) positivity was seen in 7.1%. The incidence of locoregional and distant recurrence were similar. OS for ear melanoma was significantly impacted by ulceration status (P = .013), whereas both ulceration and SLN positivity predicted survival in nonear melanoma (P < .001 and P = .015, respectively). Thicker melanomas in the nonear group demonstrated significantly decreased DFS, whereas other factors in both groups lost their predictive value (P = .035). CONCLUSIONS: In the Sunbelt Melanoma Trial, ulceration was the strongest predictor of overall survival in melanoma of the ear. Ulceration and SLN status correlated with poorer OS in nonear melanoma of the H&N, whereas increasing depth correlated with poorer DFS in those same patients. Recurrence and survival were not impacted by anatomic site, but the prognostic significance of ulceration, thickness, and SLN status in the H&N may vary with the site of the melanoma.

Squamous cell carcinoma of the head and neck in never smoker-never drinkers: a descriptive epidemiologic study.

BACKGROUND: While the attributed risk factors for the vast majority of patients with squamous cell carcinoma of the head and neck (SCCHN) are smoking and alcohol abuse, there appears to be a rising proportion of SCCHN patients who report no significant smoking or drinking history. This study reports the demographic and potential risk factors of a large series of never smoker-never drinker (NSND) patients. METHODS: All subjects were participants in a prospective epidemiologic study of incident SCCHN. We obtained demographic data, clinical characteristics, and potential etiologic factors for 172 NSND patients and 1131 ever smoker-ever drinker (ESED) patients. RESULTS.: NSND patients were more likely to be female and to present at extremes of age, but overall were significantly younger than ESED patients. NSND patients had a higher proportion of oral cavity and oropharyngeal cancers than ESED patients had. Eleven percent of NSND patients (17% of NSND men) reported regular use of noncigarette tobacco products or marijuana, 41% (45% of NSND women) reported regular environmental exposure to tobacco smoke, 24% (36% of NSND men) reported regular occupational exposures to carcinogens/toxins, and 30% had a history of gastroesophageal reflux disease. More than half the NSND patients with an oropharyngeal primary were serologically positive for human papillomavirus type 16. CONCLUSION: NSND patients with SCCHN are commonly young women with oral tongue cancer, elderly women with gingival/buccal cancer, or young to middle-aged men with oropharyngeal cancer. While several exposures studied may be important to the etiology of a subset of these cancers in NSND patients, it is likely that no single known factor is responsible for a majority of SCCHN in NSNDs.