Hyperbaric oxygen as an adjunct in zygomycosis: randomized controlled trial in a murine model.

Zygomycosis was induced by injecting CD-1 mice with 5 mg of intraperitoneal deferoxamine and then 10(6) CFU of intravenous and intrasinus Rhizopus arrhizus. The addition of hyperbaric oxygen (2.0 atm absolute twice daily) to amphotericin B did not improve survival over that achieved with amphotericin B and placebo air treatments.

Recurrent Merkel cell carcinoma of the upper extremity.

We report a case of recurrent Merkel cell carcinoma (MCC) of the upper extremity, treated aggressively with wide local excision, regional lymphadenectomy, and immediate reconstruction. Five years after surgery, there is no clinical or diagnostic evidence of locoregional recurrence or distant disease. The patient's upper extremity and hand remain fully functional, without evidence of median or ulnar nerve dysfunction. No donor site morbidity has been noted.

30-year retrospective review of frontal sinus fractures: The Charity Hospital experience.

BACKGROUND AND OBJECTIVES: The optimal method of treating frontal sinus fractures has remained undetermined. The purpose of this retrospective review is to compare the mechanism of injury, diagnostic techniques, methods of fracture management, complications, and long-term results in different types of frontal sinus fractures. METHODS AND MATERIALS: Over 4,000 records of patients with frontal bone or skull fractures, treated during a 30-year period in an academic nonprofit tertiary Level I trauma center, were considered. From these, the authors selected 150 patients with frontal sinus fractures--with complete records and adequate follow-up time--and conducted a retrospective review. RESULTS AND/OR CONCLUSIONS: For anterior fractures, observation alone had a high rate of complications (18.2%). Reconstruction with obstruction of the nasofrontal ostia by vascularized tissue was found to be the best treatment, followed by osteogenesis (9.1%) or obliteration (7.7%). Cranialization was the safest form of management for posterior table fractures that were either comminuted or involved the nasofrontal ostia. The preferred obliteration materials were vascularized flaps, cancellous bone, temporalis muscle, and fat; hydroxyapatite cement was a good alloplastic alternative.

Malar augmentation: a 5-year retrospective review of the silastic midfacial malar implant.

OBJECTIVES: To determine the effectiveness and safety of the Silastic midfacial malar implant and to review indications, patient selection, technique, and complications of malar augmentation. DESIGN: Five-year retrospective review of clinical cases with at least 2-year follow-up. PATIENTS: A cohort of 60 consecutive private patients with complaints of malar hypoplasia or facial asymmetry. SETTING: A plastic surgery clinic. INTERVENTION: Silastic midfacial malar implants were fitted in each patient. Most underwent implantation via the canine fossa approach and in conjunction with another facial plastic procedure. MAIN OUTCOME MEASURES: Subjective patient satisfaction, photographic grading using a visual analog scale, and complications. RESULTS: Of the 60 patients, 51 (85.0%) reported an excellent result after at least a 2-year follow-up. Ten patients (16.7%) had some form of undesirable sequelae; however, only 4 (3.4%) of 118 implants had to be revised. Photographically, all 60 patients graded postoperative improvement. CONCLUSIONS: Findings support the contention that the Silastic midfacial malar implant is a safe and effective alloplastic alternative to treat malar hypoplasia and facial asymmetry. The complication and revision rates are acceptable. Relative technical ease of insertion makes malar augmentation an excellent adjunct for rhytidectomy and rhinoplasty.

Management of late extrusions of cochlear implants.

OBJECTIVES: The study aimed to identify the important principles in repairing and preventing delayed cochlear implant extrusions. STUDY DESIGN: The study design was a retrospective, international database review and three case presentations from the authors' local database. SETTING: The study was conducted at a tertiary referral center. PATIENTS: Cochlear Corporation's database of 8,665 implantees in North and South America and Israel was studied. A subset of this database, consisting of 74 patients implanted through the Louisiana State University/Eye, Ear, Nose and Throat (LSU/EENT) project, is analyzed separately and provides the case reports. INTERVENTION: Surgical repair of skin breakdown over the edge of three cochlear implants using a two-layer, pericranial and scalp rotation flap technique was performed. MAIN OUTCOME MEASURES: A functioning cochlear implant with a healthy skin covering was measured. RESULTS: The three LSU/EENT cases reported here used a pericranial flap to repair the capsule of the implant and a large scalp rotation flap to repair the skin defect. A novel pericranial tuck-under technique is especially useful for the Nucleus Mini-22 implant. With this technique, the authors have had a 100% success rate (3 of 3). The basic principles used in the repair and in the initial implant surgery are discussed. CONCLUSIONS: The following conclusions were reached: 1) avoid skin closure lines parallel to the cochlear implant edge that are closer than 1.5 cm from the implant edge; 2) excise enough skin and scar around the dehiscence to achieve principle 1; 3) design a large, well-vascularized anterior- or posterior-based scalp rotation flap to cover this defect; and 4) close the implant capsule defect with a well-vascularized pericranial flap.

Posterior cervical rhytidectomy: a valuable adjunct in facial rejuvenation surgery.

OBJECTIVE: To describe the aesthetic indications and operative technique of posterior cervical rhytidectomy as a staged procedure after extended cervical-facial rhytidectomy. DESIGN: The senior author's series of patients requiring posterior cervical rhytidectomy is reviewed, including preoperative and postoperative aesthetic results. SETTING: A private practice plastic surgery clinic. PATIENTS: Eleven patients who underwent staged posterior cervical rhytidectomy after extensive cervical-facial rhytidectomy are presented, with follow-up ranging from 3 months to 8 years. During this same duration, 941 primary and 256 secondary cervical-facial rhytidectomies were performed. INTERVENTIONS: The preoperative and postoperative results are presented along with a description of the pertinent anatomy and the senior author's operative technique. Potential complications are reviewed. A discussion is included on ways to minimize these untoward sequelae. OUTCOME MEASURE: The aesthetic postoperative results are reviewed, and representative clinical photographs are presented. RESULTS: Staged posterior cervical rhytidectomy is a safe and effective means of improving certain stigmata of previous cervical-facial rhytidectomy in patients requiring extensive facial rejuvenation. CONCLUSIONS: Posterior cervical rhytidectomy is a valuable surgical adjunct in selective patients who demonstrate redundant skin and soft tissue in the posterior cervical region.

Transverse glabellar flap for obliteration/isolation of the nasofrontal duct from the anterior cranial base.

Management of fractures involving the nasofrontal duct region of the frontal sinus has focused on preserving function when possible or obliterating the sinus and duct when fracture patterns potentiate ductal obstruction and possible transcranial seeding of bacteria. When frontal sinus preservation is in doubt, controversy surrounds the use of cranialization versus obliteration, and the method of obliteration. Perioperative and late postoperative infections are uncommon, but their occurrence jeopardizes an often complex reconstruction and can be life threatening. This paper describes the design and indications for a pedicled transverse glabellar muscle flap for obliteration of the nasofrontal duct, thereby isolating the anterior cranial base from the aerodigestive system. This vascularized muscle flap utilizes the corrugator supercilii and procerus muscles, which are introduced into the sinus via a small, surgically created window in the superomedial orbital wall without disturbing the central facial aesthetic contours. Six patients with comminuted fractures at the nasofrontal duct level associated with displaced posterior frontal sinus fractures have been treated with the transverse glabellar flap. Follow-up ranges from 8 to 30 months. There have been no early or late postoperative complications. The transverse glabellar flap is a reliable and versatile method of partitioning the upper aerodigestive tract from the anterior cranial base with vascularized tissue, thus minimizing the risk of infectious complications. The resulting donor site deformity is more acceptable than that seen with the traditional pedicled galeal frontalis flap.

Ethmoid bone sandwich grafting for caudal septal defects.

OBJECTIVE: To evaluate a new technique for correction of severe caudal septal defects. DESIGN: For all patients, preoperative photographs were graded with regard to the severity of caudal septal defects. Preoperatively, nasal airway breathing surveys were conducted and nasal tip projection (NTP) measurements were recorded. The caudal septal defects were then repaired with use of the ethmoid bone sandwich grafting technique. Photographs, NTP measurements, and an airway survey were then repeated 6 and 12 months postoperatively. Preoperative and postoperative assessments were compared and analyzed. Lateral nasal roentgenograms were obtained in five of 10 patients to assess resorption of the bone grafts. Complications were noted if present. SETTING: Urban medical center. PATIENTS: Ten volunteers with severe caudal septal defects causing both cosmetic and functional problems. All patients had undergone at least one previous submucous resection. OUTCOME MEASURES: Durability and degree of correction, maintenance of NTP, airway improvement, and morbidity. RESULTS: After 1 year, all patients maintained satisfactory correction of their caudal septal defect based on postoperative photographic grading and physical examination findings. The NTP was maintained in eight of 10 patients. Two patients experienced loss of NTP after 1 year that was not present 6 months postoperatively. Average airway improvement was 126.7% after 1 year. Postoperative roentgenograms showed only minor (< 10%) bone graft resorption. The only complication was a granuloma. CONCLUSIONS: The ethmoid bone sandwich grafting technique corrected severe caudal septal deviations while maintaining or strengthening structural support of the caudal septal strut without loss of NTP, airway compromise, or morbidity.

An epidemiologic study of maxillofacial trauma at University Medical Center in Lafayette, a regional referral center.

The authors retrospectively reviewed maxillofacial trauma admissions at University Medical Center in Lafayette, Louisiana, a Level II trauma center, over the 2-year period from July 1, 1990 to June 30, 1992. This study encompassed 208 fractures in 166 patients. All patients in this study group required surgical intervention for their maxillofacial injury. Variables examined in this cohort included age, race, gender, seasonal variation, fracture location, mechanism of injury, associated injuries, seatbelt utilization, substance abuse, surgical management, complications, operative duration, hospital stay, hour of presentation, and preoperative imaging modalities. The purpose of our study is to provide an epidemiologic review of maxillofacial trauma in the Acadian community of southwestern Louisiana.

Local anesthesia in blepharoplasty: a new look?

Forty volunteers were asked to compare pain from injection of buffered versus unbuffered local anesthetics given for upper lid and lower lid blepharoplasty. The concentration of the solution was 1 part 8.4% sodium bicarbonate to 5 parts local anesthetic. The surgeons performing the operations were asked to identify any difference in onset of action, hemostasis, or duration of action. Thirty-five of the 40 patients found the buffered anesthetic to be less painful and better tolerated. No difference in hemostasis or duration of action was noted between the buffered or unbuffered solutions, but the buffered solution produced faster onset of action.

Impact tolerances of the rigidly fixated maxillofacial skeleton.

A study was designed to determine how soon an athlete who undergoes rigid fixation of a facial fracture can return to full competition. The impact resistance of a rigidly fixated malar complex fracture was studied and compared with that of an intact malar complex. Twelve fresh human cadaver heads were used. A custom-designed impact device was used to deliver a blow of a specific energy to each intact malar complex. The subsequent fractures were rigidly fixated at three points using titanium miniplates and screws. A second impact of identical energy was delivered. The forces generated and the subsequent displacement of hard and soft tissues were recorded after each impact. It was concluded from this study that an impact to a rigidly fixated malar complex fracture produced less force and greater displacement of hard and soft tissues than an impact of identical energy to an intact malar complex. The potential for sustaining more severe maxillofacial injuries after an initial facial fracture should be seriously considered. The results suggest that sufficient time should be allowed for the bony healing of a facial fracture to occur, even after rigid fixation, before an athlete can resume full contact activities.

Local anesthesia in rhinoplasty: a new twist?

Twenty volunteers were asked to compare pain upon injection during septorhinoplasty using buffered versus unbuffered local anesthetics. The concentration of the buffer was one part sodium bicarbonate to five parts local. The surgeons performing the operation were asked to identify any difference in hemostasis or duration of anesthesia. Eighteen of twenty patients found the buffered anesthetic to be less painful and better tolerated. No difference in hemostasis or duration of action was noted between the buffered or unbuffered solution, however, faster onset of action was noted with the buffered solution. The addition of sodium bicarbonate as a buffering agent to the local anesthetics lidocaine and bupivacaine can significantly reduce pain upon injection. A solution of 5cc 2% lidocaine with 1:100,000 epinephrine, 5cc 0.25% bupivacaine with 1:200,000 epinephrine, and 2cc of 7.5% sodium bicarbonate mixed just prior to injection is a safe, effective, less painful local anesthetic with rapid onset of action and full efficacy.