Orthodromic temporalis tendon transfer: anatomical considerations.

OBJECTIVES: To define (1) at-risk structures during the orthodromic temporalis tendon transfer and (2) achievable tendon length without temporal releasing incisions or perioral lengthening materials. METHODS: Ten fresh cadavers provided 20 hemifaces for dissection. Measurements and photographic documentation were used to examine the parotid duct, masseteric artery, inferior alveolar nerve, internal maxillary artery, and mobilized tendon relative to adjacent landmarks. RESULTS: The parotid duct was found in a reproducible region posterior to the melolabial crease and inferior to a parotid duct reference line. The masseteric artery was found posterior to the posterior-most attachment of the tendon at its exit from the sigmoid notch (mean, 14.5 mm). The inferior alveolar nerve was found posterior to the anterior edge of the ascending ramus (mean, 18.3 mm). The internal maxillary artery coursed superiorly from posterior to anterior along the medial mandible near the coronoidectomy site. The tendon reached beyond the melolabial crease in 17 of 20 hemifaces (85%). CONCLUSIONS: The parotid duct reference line and the melolabial crease allow estimation of the parotid duct location. Anatomical relationships between the tendon, parotid duct, neurovasculature, and anatomical landmarks underscore the importance of deliberate soft-tissue retraction and subperiostial elevation to minimize injury. The tendon alone usually provides adequate length for orthodromic suspension.

The importance of auricular prostheses for speech recognition.

OBJECTIVES: To examine the effects of an auricular prosthesis on sound levels at the entrance of the ear canal by measuring the auricular prosthesis transfer function (APTF) and to determine the effect of the prosthesis on speech recognition in noisy hearing conditions. METHODS: Eight prostheses were used to measure the APTF. A microphone at the entrance of the ear canal measured sound pressure levels with the prosthesis present or absent while the head was rotated 360 degrees at 30 degrees increments. The Hearing in Noise Test was modified by the APTF to simulate the absence of an auricular prosthesis. Speech recognition was measured by testing 11 subjects with the unmodified Hearing in Noise Test and the modified Hearing in Noise Test. RESULTS: The APTF changed with the head's position relative to the speaker. The mean (SD) maximal gain provided by an auricular prosthesis was 8.1 (2.7) dB at 4.6 (1.0) kHz and 9.7 (1.7) dB at 11.5 (0.9) kHz at 0 degrees rotation. During speech testing, the auricular prosthesis improved the mean (SD) signal to noise ratio by 1.7 (1.7) dB at 0 degrees (P< .001), 0.9 (2.2) dB at 90 degrees (P=.04), and 0.5 (2.3) dB at 180 degrees (P=.52). CONCLUSIONS: The acoustic gain provided by an auricular prosthesis increases speech recognition in noisy environments. Auricular prostheses not only restore aesthetics but also improve hearing.

The perichondrial cutaneous graft: a facial reconstructive option for the ages (ages 1 week to 94 years).

OBJECTIVES/HYPOTHESIS: The perichondrial cutaneous graft (PCCG) possesses unique characteristics that make them a propitious reconstructive option in facial plastic surgery. The PCCG is easily harvested from the conchal bowl. Notable characteristics are that it does not contract, unexcelled color match for resurfacing facial skin, and minimal donor site morbidity. This free graft frequently offers an expeditious solution to an otherwise more complicated reconstructive effort. STUDY DESIGN: Retrospective review of an academic otolaryngology and facial plastic surgery practice. METHODS: : Patients requiring head and neck reconstruction for cutaneous deficiencies were studied. The PCCG is harvested from the anterior conchal bowl. This is technically easy, and the perichondrium is tightly adherent to the dermis in this area. The donor site is closed by resecting a fenestra of conchal cartilage and rotating a posterior auricular interpolated island flap into the defect (the "flip-flop-flap"). The posterior auricular defect is easily closed in a linear fashion. The main outcome measures were cosmetic result, graft survival, donor site morbidity, and complications. RESULTS: There are 406 PCCGs in our series. Patients ranged in age from 7 days to 94 years. There were 170 grafts used for trauma and 236 used for reconstruction after skin cancer resection. Over the past 30 years in observing these grafts, there are no contractions noted in infants and children, growth with maturity is noteworthy. Cosmesis is excellent and in most cases superior to other skin grafting techniques. We have had four total failures and six partial losses of less than 30% for the PCCG. All complete failures were in patients with a smoking history. CONCLUSIONS: The PCCG is a very reliable flap for reconstruction of facial defects. It has been used in elderly and heavy smoking patients with minimal complications, attesting to its viability. The graft provides excellent cosmesis and it is an expeditious alternative to commonly used local flaps. It is especially useful in pediatric patients because the graft actually expands with growth. This is in contrast to the disadvantages of split thickness and full thickness skin grafts that predictably contract with maturity. Local flaps often lack adequate laxity for common implementation and make the PCCG a propitious choice in the pediatric patient.

Lingual hematoma and heparin-induced thrombocytopenia: a case report.

Lingual hematoma is a rare but potentially fatal cause of upper airway obstruction. Patients receiving anticoagulants such as heparin can suffer from significant complications of these medications. Not only does heparin exert effects directly on the coagulation cascade, but it has the potential to cause thrombocytopenia by stimulating formation of antibodies against platelets. We present the case of a patient being treated with heparin for a deep-vein thrombosis, who subsequently developed heparin-induced thrombocytopenia and lingual hematoma, necessitating tracheotomy.

Anterior palate sensory impairment after septal surgery.

BACKGROUND: This study was performed to present a series of patients who experienced anterior palatal sensory impairment after nasal septal surgery. This phenomenon has not been reported in the English literature to date. METHODS: We reviewed 107 septal surgeries done by the same surgeon over a 3-year period. One hundred one surgeries were septoplasty by technique of submucous resection, three surgeries were septal perforation repairs using a mucosal advancement flap from the nasal floor, two surgeries were excisions of benign septal neoplasms, and one surgery was a closed reduction of a nasal septal fracture. RESULTS: Overall, 3/107 patients (2.8%) experienced postoperative numbness of the anterior palate. Two of these patients underwent septoplasty, and the third patients underwent repair of septal perforation. A chisel was used to resect a portion of the maxillary crest posterior to the nasal spine in 11 patients, including the 3 patients who reported postoperative numbness. Suction cautery was also used in one of the 3 patients to address bleeding of the nasopalatine artery. Two patients reported concomitant palatal paresthesias with numbness, and both had recovery of normal sensation at 3 months follow-up. The third patient, in whom cautery was used, continued to experience numbness 1 year postoperatively. CONCLUSION: Sensory impairment of the anterior palate may result from surgery of the nasal septum and appears to be associated with chisel of the maxillary crest. Cautery should be avoided near the nasopalatine foramen. The relevant surgical anatomy of the nasopalatine nerve is reviewed and discussed in the context of these cases.

A new device for creating and positioning an autogenous cartilage framework during microtia reconstruction.

OBJECTIVE: This paper describes the fabrication and use of a three-dimensional appliance, known as the microtia surgical positioner, to more accurately position and better sculpt the autogenous rib cartilage graft during microtia reconstruction. STUDY DESIGN: The authors introduce a new device design and surgical application. METHODS: An impression and plaster cast were made from the patient's auricular defect. On this cast, the artist then created a wax baseplate and an esthetically pleasing wax sculpture of an ideal ear similar to the patient's normal contralateral ear. The surface contour of the patient's auricular defect locked the wax baseplate into a stable position, the ear sculpture was then properly positioned on the baseplate, and the two pieces were joined. The artist made a silicone mold of the wax prototype and casted the clear acrylic resin surgical positioner using that mold. Finally, an opening along the helical portion was drilled in the positioner. Intraoperatively, the positioner locked into the surface contour of the patient's auricular defect, thus assuring accurate positioning of the cartilage graft. The surgeon marked the correct helix position with the device's helix and helical port and used the positioner as a model to guide the carving and assembly of the cartilage framework. RESULTS: Our group successfully created and used a microtia surgical positioner. The positioner guided accurate superior-inferior, anterior-posterior, and rotational placement of the helical portion of the cartilage graft. The surgical positioner also significantly contributed to detailed sculpting of the graft. CONCLUSIONS: : Medical artists and surgeons may cooperate to fabricate and use a surgical positioner to guide accurate placement of the cartilage framework and assist with sculpting of the graft for total auricular reconstruction.

The use of "inside-out" lateral osteotomies to improve outcome in rhinoplasty.

OBJECTIVE: To evaluate the anatomic effects of the transnasal nasal "inside-out" lateral osteotomy in comparison to a continuous lateral osteotomy to widen the excessively narrow bony nasal pyramid. DESIGN: A series of 4 fresh cadavers were used. Lateral osteotomies were performed on each cadaver. On one side, a continuous lateral osteotomy was performed with a curved, guarded 4-mm osteotome. On the contralateral side, a straight 2-mm osteotome was used to perform the transnasal perforating inside-out lateral osteotomy. The soft tissue was then dissected off the nasal dorsum and the effects were noted. Specifically, the following factors were assessed: (1) the continuity of the internal and external periosteum; (2) any change, without manipulation, of the position of the lateral nasal walls; (3) the mobility of the fragments; and (4) the effect of any of the preceding factors on the nasal airway. RESULTS: All 4 cadavers showed identical results. The external and internal periostea were significantly disrupted on each of the sides with continuous osteotomies. The periosteum was completely preserved on the sides, which underwent inside-out lateral osteotomies, with the exception of the 3 or 4 holes created by the 2-mm osteotome. In each of the sides with continuous osteotomies, the lateral nasal wall was demonstrably unstable, as the segment was, to varying degrees, displaced inwardly. The inside-out lateral osteotomized segments were uniformly lateralized and stable to gentle palpation. Finally, these changes corresponded to a visible effect on the diameter of the nose in the region of the nasal valve. The inward displacement of the segments undergoing continuous osteotomies narrowed the airway. However, the contralateral inside-out osteotomized segments were lateralized, which widened the diameter of the valve. CONCLUSIONS: The inside-out lateral osteotomy is an effective technique for lateral repositioning of the bony lateral sidewall of the nose. It is reproducible and accurate and appears to provide greater preservation of the periosteal support of the bony segments than a continuous osteotomy. This technique provides a more predictable long-term result, with preservation and/or improvement of the nasal airway. The procedure is ideal for managing the bony nasal segment that needs lateralization, particularly in revision rhinoplasties or after trauma.