Reconstruction of the subglottic larynx with a myoperiosteal flap: clinical and experimental study.

The literature describes numerous techniques for reconstruction of the subglottic larynx. The use of rigid bone grafts or flaps has been associated with problems because the rigid bone cannot conform to the defect and form an airtight seal. We have performed subglottic reconstruction using the sternocleidomastoid myoperiosteal flap with very optimistic results on long-term follow up. The sternocleidomastoid myoperiosteal flap is a relatively simple procedure that can be used for a large variety of defects. The pliable periosteal flap used for closing the defect can be molded over a stent to form an airtight seal. We have demonstrated bone formation in the periosteum which is crucial to the stability of the airway and long-term success of the procedure. The sternocleidomastoid myoperiosteal flap yields a pliable, durable tissue capable of airtight closure and a tension-free suture line. This technique will make the closure of subglottic defects a much more practical task.

Diagnostic imaging techniques in thyroid cancer.

With the refinement of fine-needle aspiration, the specific applications of thyroid imaging techniques need to be reevaluated for efficiency and cost containment. No thyroid imaging test should be routinely obtained. Radionuclide scanning is most beneficial in evaluating the functional status of thyroid nodules when fine-needle aspiration is inadequate, the findings are benign, or when there is no discrete nodule that is palpated in an enlarged gland. When fine-needle aspiration is unavailable or unreliable, radionuclide scanning becomes a first-line diagnostic tool. Ultrasonography should be used primarily for identifying a solid component of a cystic nodule, determining the size of nodules on thyroxine suppression that are not easily palpable, or for performing guided fine-needle aspiration. Computerized tomography and magnetic resonance imaging both have a definite role in the evaluation of thyroid tumors. Magnetic resonance imaging is superior to computerized tomography for the evaluation of metastatic, retrotracheal, or mediastinal involvement of large thyroid tumors or goiters. Careful selection of the diagnostic techniques will ensure more accurate diagnosis and reduce unnecessary patient costs in the treatment of thyroid cancer.

The sternocleidomastoid myoperiosteal flap for esophagopharyngeal reconstruction and fistula repair: clinical and experimental study.

Despite advances in head and neck surgery, reconstruction of the pharynx and cervical esophagus continues to be troublesome. Classic pedicled flaps are often too bulky and difficult to position for repair of pharyngeal and esophageal fistulas. An ideal flap would be local, well-vascularized, compact, and capable of being sutured into a tension-free, water-tight seal. In selected cases, the sternocleidomastoid myoperiosteal flap can meet these requirements in a single-stage procedure for repair of fistulas as well as selected cases of primary pharyngeal reconstruction. The use of this flap is described in five patients. Two patients underwent laryngectomy with partial pharyngectomy that left inadequate mucosa for primary closure. A sternocleidomastoid myoperiosteal flap was used to add width to the remaining mucosa. Both patients healed within 3 weeks and remained stricture free. Three other patients who underwent radiation followed by tumor resection and standard primary closure of the pharynx developed fistulas. Two fistulas were repaired successfully with the sternocleidomastoid myoperiosteal flap, and both patients were able to eat a general diet on the eighth postoperative day. Reconstruction was also performed in dogs to histologically evaluate the epithelialization capacity of the periosteum. There was total epithelialization of the flap at 4 weeks after reconstruction.

Experience with the sternocleidomastoid myoperiosteal flap for reconstruction of subglottic and tracheal defects: modification of technique and report of long-term results.

Subglottic or tracheal reconstruction may be required in cases of subglottic stenosis, invasive thyroid carcinoma, or trauma. The sternocleidomastoid myoperiosteal flap uses clavicular periosteum on a muscle pedicle to provide vascularity. Clavicular periosteum is fibrous, durable, and will conform to the shape of the trachea, forming bone to provide stability to the airway. The procedure is relatively simple and involves single-staged reconstruction. After 4 years' experience with this flap, we present the results from a series of 11 patients who underwent subglottic or tracheal reconstruction with the sternocleidomastoid myoperiosteal flap. Ten of 11 patients were successfully decannulated. The average time from reconstruction to decannulation was 50.3 days. Follow-up ranged from 12 to 40 months. We also describe modifications of the initial technique that have been introduced to improve the flap's versatility and effectiveness.

Nonrecurrent laryngeal nerves and their clinical significance.

The anomalous position of a nonrecurrent laryngeal nerve predisposes the nerve to injury during thyroidectomy and to compression by a thyroid mass. We present three cases in which a seemingly benign thyroid mass traumatized a nonrecurrent laryngeal nerve resulting in either vocal cord paralysis or a vague pressure sensation over the larynx. Some of these patients feel as if they need to clear a foreign body and present with a chronic cough. Normally the nerve is protected from thyroid masses as it passes through the tracheoesophageal groove. In all three patients, surgical excision of the thyroid mass and release of the nerve resulted in recovery of the nerve and resolution of the symptoms. We have found that small, benign, or otherwise asymptomatic lesions of the thyroid gland have a greater tendency to cause vocal cord paralysis in patients with nonrecurrent laryngeal nerves. The surgeon must always be aware of the possibility of the presence of a nonrecurrent laryngeal nerve.

Paranasal sinus malignancy: a comprehensive update.

A retrospective analysis of 60 cases of paranasal sinus cancer in patients admitted between 1970 and 1985 was undertaken. Forty-six tumors originated in the maxillary sinus, and 14 originated in the ethmoid sinuses. Computed tomography, magnetic resonance imaging, and endoscopic sinus examination aided in early diagnosis of sinus cancer. Computed tomography aided in staging tumors; Caldwell-Luc alone was inadequate for staging tumors invading deeper sites such as the orbits or pterygoid muscle. There were 15 early (T1 or T2) and 31 advanced (T3 or T4) maxillary sinus cancers. Multimodality therapy incorporated radiation, surgery, and chemotherapy. The 5-year survival rate was 49%. We prefer preoperative radiotherapy for advanced lesions and postoperative radiotherapy for early lesions. The use of preoperative radiation therapy has increased our globe salvage rate. All but one of the patients who developed recurrent disease showed recurrence at the primary site prior to developing regional or distant metastasis. Radiation therapy, combined with aggressive surgical management to remove all tumor, provided the best survival rates in advanced lesions.

Variable histotoxicity of histoacryl when used in a subcutaneous site: an experimental study.

Histoacryl (butyl-2-cyanoacrylate) is one of the least histotoxic cyanoacrylate derivatives and is used as a tissue adhesive. Clinical applications primarily include skin closure (blepharoplasty incisions, etc.). In a recent study, we demonstrated that Histoacryl elicits minimal histotoxicity when used to glue bone grafts to rabbit-ear cartilage. Acute inflammation was limited to areas where Histoacryl escaped from between the bone graft and ear cartilage to contact well-vascularized soft tissue. In this study, Histoacryl was applied between bone graft and cartilage in one rabbit ear and adjacent to well-vascularized soft tissue with no graft in the opposite ear. Histologic analysis revealed minimal if any inflammation when small amounts of glue was used in the nonvascular region between bone graft and cartilage. However, subcutaneous implantation contacting well-vascularized soft tissue resulted in increased acute inflammation and prolonged foreign-body giant-cell response. Further studies are required to rule out any long-term problems associated with subcutaneous implantation of Histoacryl.

An evaluation of fibrin tissue adhesive concentration and application thickness on skin graft survival.

OBJECTIVES: To examine the effects of fibrinogen concentration and application thickness of fibrin tissue adhesive on skin graft survival. STUDY DESIGN: Prospective controlled study. METHODS: Ten domestic pigs were included in the study. A 20 x 5-cm area of skin was harvested bilaterally along the flanks of the animals using a Padgett dermatome. The harvested grafts were trimmed into four 4 x 4-cm squares. Donor sites were treated according to group assignment and the non-meshed grafts were placed on the side opposite their initial orientation and secured with staples. Both single- and multiple-donor human fibrin tissue adhesive preparations, with low and high average fibrinogen concentrations of 30 mg/mL and 60 mg/ mL, were used. Adhesive preparations were applied in either a thin layer (0.015 mL/cm2) or a thick layer (0.06 mL/cm2) using a spray applicator. A constant thrombin concentration of 10 U/mL was used in the study. No adhesive was used in the control group and grafts were stabilized with staples. No topical dressings were applied to any of the treatment sites. Animals were sacrificed 4 weeks after graft application. RESULTS: Based on statistical analysis, thickness of adhesive application had a significant effect on skin graft survival. Percent mean graft survival in the control and thin application groups was found to be 92% and 97.8% respectively; the mean survival rate in the thick application group was 63.1%. Fibrinogen concentration, when evaluated independently within the thin and thick application groups, was found to have no significant effect on graft survival. CONCLUSION: Independent of fibrinogen concentration, a thin layer of fibrin tissue adhesive, when applied between two opposing surfaces, does not interfere with and may support the healing process, whereas a thick layer of adhesive inhibits skin graft healing.

Mandibular reconstruction using bone morphogenetic protein 2: long-term follow-up in a canine model.

OBJECTIVE: To determine the degree of bone resorption and stability of 3-cm, full-thickness canine mandibular defects reconstructed with recombinant human bone morphogenetic protein 2 (rhBMP-2) and a bioerodible particle carrier followed for 30 months after reconstruction. STUDY DESIGN: Nine dogs, divided into three groups, underwent reconstruction of surgically created 3-cm, full-thickness defects of the body of the mandible. METHODS: Mandibular reconstruction was performed via a combined intraoral and extraoral approach. Using standard plating techniques, a unilateral full-thickness, 3-cm defect was created in the body of the mandible. After stabilizing the defects with titanium reconstruction plates, test implants composed of rhBMP-2 and poly(lactide-co-glycolide) bioerodible particles were placed in the mandibular defects of six animals. Reconstruction plates were removed from test animals at 10 weeks. Three short-term test animals were sacrificed 3 months after reconstruction. Three long-term test animals were sacrificed 30 months after reconstruction to determine the degree of resorption and long-term stability of the rhBMP-2-induced bone. Control implants (carrier without rhBMP-2) were used in three animals and were sacrificed at 3 months. At 9 months, long-term animals were advanced to a solid diet. Masticatory function and body weight were monitored periodically to assess diet tolerance. Roentgenographic photodensitometry was performed on serial dental roentgenograms of the reconstructed segments to determine bone density and the degree of bone resorption over 30 months. After sacrifice, reconstructed segments were harvested and embedded in plastic for histological analysis and histomorphometry to determine the percentage of the defect replaced by mineralized bone (area density) and degree of resorption from 3 to 30 months after reconstruction. The main outcome measures were bone density and bone height determined from serial roentgenograms and percentage of the reconstructed segment replaced by mineralized bone (area density) determined from histomorphometry. RESULTS: Control animals without rhBMP-2 showed no evidence of bone formation across the defect. Histological examination revealed good bone formation in two of three of the short-term test animals with a mean area density of 41.0%. The long-term test animals treated with rhBMP-2 demonstrated good bone formation that was comparable to that of normal host bone by 3 months. The roentgenographic photodensity measurements stabilized at 5 months without evidence of persistent bone resorption. The height of the reconstructed segment (rhBMP-2-induced bone) initially decreased, then stabilized by 11 months after reconstruction with no indication of resorption or failure. Histological examination of the long-term test animals revealed good bone formation across the mandibular defects. However, there were localized areas of thinning of the cortical bone as compared with the short-term test animals sacrificed at 3 months. Histological examination verified the loss of height of the bone in the reconstructed segments. The area density (mean) of the long-term test animals was 56.5%. Despite the decrease in height of the induced bone, there was an increase in area density of the bone over time. CONCLUSIONS: This study demonstrated that rhBMP-2 in a bioerodible particle carrier induced new host bone formation across critical-size mandibular defects. The newly formed bone successfully integrated with existing host bone creating a stable union capable of withstanding the forces of masticatory function in a canine. There was some evidence of early bone resorption (thinning of the cortical bone and decrease in height) in the rhBMP-2-induced bone. The rhBMP-2-induced bone stabilized by 11 months after reconstruction and no further resorption was noted. The percentage of area of the defect replaced by rhBMP-2-induced bone (area density) increased over 30 months. (ABSTRACT TRUNCATED)

Rationale for elective neck dissection in 1990.

Elective neck dissection has long been a subject of debate among surgeons. The proponents of elective neck dissection base their rationale on studies that show a 30% incidence of occult disease in those situations for which elective neck dissection is recommended. One hundred eighty-two patients with advanced stages of squamous cell carcinoma of the head and neck were studied. All patients had preoperative computed tomography or magnetic resonance imaging, and all patients had some form of radical neck dissection. The sensitivity of clinical exam was compared with the sensitivity of computed tomography or magnetic resonance imaging in ability to detect nodal disease. The sensitivity of clinical exam alone was 71.7%, while the sensitivity of computed tomography or magnetic resonance imaging was 91.1%. Based on physical exam alone, there would be a 39% rate of occult disease; if computed tomography or magnetic resonance imaging data is combined with physical exam, the occult disease rate would drop to 12%. All centers performing elective neck dissection must reassess their rationale or restudy their occult disease rate with computed tomography or magnetic resonance imaging.

A histologic analysis of three-dimensional versus two-dimensional tissue expansion in the porcine model.

OBJECTIVE: Recently, a two-dimensional Silastic Dacron stretching skin device has been developed for scalp reduction surgery. Attached subgaleally, this device stretches skin over time, while avoiding the visible volumetric distention that is typical of three-dimensional tissue expanders. Unlike three-dimensional expanders, the histological changes observed with a two-dimensional stretching device have not been described in the literature. The present study compares the histological effects of two-dimensional and three-dimensional skin tissue expansion in the porcine model. STUDY DESIGN: A university Institutional Review Board-approved study in which 16 domestic piglets were used. The 16 piglets were divided evenly into four cohorts as follows: 1, 1-week control cohort; 2, 1-week experimental cohort; 3, 4-week control cohort; and 4, 4-week experimental cohort. METHODS: Tissue expanders (three-dimensional) and Dacron Silastic tissue stretchers (two-dimensional) were surgically inserted into the lateral skin of 16 domestic pigs. Animals were killed at either 1 or 4 weeks based on group assignment. Light microscopic ocular micrometry and stereological point counting were used to determine the depth of the epidermis, dermis, and subdermal adipose tissue layer; width of the panniculus muscle; diameter of sweat gland follicles; percentage ratio of dermal collagen, blood vessels, and tissue space; and epidermal mitotic index in 100 specimens. One-way ANOVA was used to evaluate statistical differences. RESULTS: Both tissue expanders yielded increased values compared with control subjects, with respect to epidermal, dermal, and fat widths and blood vessel counts, whereas adnexal structures in the panniculus muscle width were unaltered. CONCLUSIONS: Although statistically the two types of expansion produced histologically similar changes, the degree of change varied according to the type of expander that was used and the duration of tissue expansion. Most notably, three-dimensional expansion produced more tissue gain per unit area expanded at both the 1-week and the 4-week time intervals, and early (1-week) two-dimensional tissue expansion stimulated a greater angiogenic response than three-dimensional expansion. These findings will assist the surgeon in understanding the physical changes that occur with these two forms of tissue expansion, as well as the potential clinical advantages and shortcomings of each method.

Bone-inducing implants in head and neck surgery: an experimental study.

The use of autologous bone for head and neck reconstruction requires a separate harvesting procedure which provides limited quantities of bone that may become infected or undergo resorption after being implanted. In this study, a collagen/ceramic carrier containing osteoinductive factor extract (OFE) was used in a rabbit facial augmentation model. Bone-inducing activity of these implants were evaluated in subcutaneous, intramuscular, and subperiosteal sites. Implants with (test) and without OFE (control) were placed on opposite sides of the face in 40 rabbits, and were harvested at 21 days. Bone formation was evaluated by implant alkaline phosphatase determinations and histomorphometry. Osteoblastic activity, bone formation, and preservation of facial augmentation were noted in the OFE implants, showing maximal bone formation when implanted subperiosteally. Control (no OFE) and demineralized bone implants showed no bone formation. Before these implants can be used clinically, novel bone-inducing factors must be manufactured by recombinant deoxyribonucleic acid (DNA) methodology to verify activity of the homogeneous molecule which would be free of other proteins or infectious agents.

Management of the aging forehead.

Browlifting and forehead procedures are a critical element in the contemporary surgical management of the aging face. Esthetics of the upper third of the face will dictate brow position and its relationship to the supraorbital rim and eyes. Treatment of deformities of the upper third of the face can be varied according to the sex and age of the patient as well as contour of the hairline and forehead. The indications, advantages, disadvantages, and techniques of the coronal forehead, modified pretrichal forehead, midforehead, and direct browlifting procedures are discussed.

Esophageal stethoscope. Another possible cause of vocal cord paralysis.

Hoarseness after endotracheal intubation can result from compression of the anterior branch of the recurrent laryngeal nerve as it passes behind the thyroid cartilage to innervate the lateral cricoarytenoid muscle. This usually occurs when the cuff of the endotracheal tube lies in the larynx instead of the trachea. When a nasogastric tube is positioned in the midline, resultant postcricoid inflammation can result in vocal cord immobility. This may result from neuropraxia of the posterior branch of the recurrent laryngeal nerve that innervates the posterior cricoarytenoid and interarytenoid muscles, or inflammatory spasm of the interarytenoid muscles themselves. We present a case of vocal cord paralysis after general anesthesia that may have been caused by an esophageal stethoscope. The mechanism for vocal cord immobility could be similar to that of a midline nasogastric tube with resultant postcricoid inflammation. We describe measures that can be taken to prevent vocal cord paralysis after intubation of the larynx or esophagus.

The bilobed deltopectoral advancement flap.

The bilobed deltopectoral advancement flap is a versatile reconstructive option for selected cervical defects. This modified version of Bakamjian's classic deltopectoral flap utilizes thin anterolateral neck skin to cover complex anterior neck defects. It offers the safety of a minimally rotated pedicle to reduce the chance of flap necrosis from kinking, and the convenience of a single-stage procedure. We have used this flap six times in our clinical experience. Typically, the defects were located in the anterior cervical region, and many of them were reconstructed following total laryngectomy and radical neck dissection. There was no incidence of flap necrosis in the patients, including those who had had preoperative irradiation.

Histotoxicity of cyanoacrylate tissue adhesives. A comparative study.

Cyanoacrylate derivatives have been used as surgical adhesives for many years. Shorter-chain derivatives (methyl- and ethyl-cyanoacrylate) have proved to be histotoxic. Longer-chain derivatives (butyl- and isobutyl-cyanoacrylate) are much less histotoxic. Many surgeons continue to use ethyl-2-cyanoacrylate (Krazy Glue) despite the availability of a less toxic derivative, butyl-2-cyanoacrylate (Histoacryl). In this study, the histotoxicity and bone graft-cartilage binding ability of Krazy Glue and Histoacryl were compared. Bone grafts harvested from the anterior wall of the maxillary sinus were placed in a subcutaneous pocket and glued to auricular cartilage in the rabbit. Krazy Glue and Histoacryl were used in opposite ears, harvesting specimens at 1, 2, 4, 12, 24, and 48 weeks. The Krazy Glue-treated ears developed seromas with histologic evidence of acute inflammation, tissue necrosis, and chronic foreign body giant cell reaction. The Histoacryl-treated ears showed mild acute inflammation and mild foreign body giant cell reaction. The Krazy Glue was completely degraded within 12 months, while some Histoacryl was still present at 1 year. Histoacryl had minimal histotoxic effect and good bone graft-cartilage binding ability, whereas Krazy Glue demonstrated severe histotoxicity.

Severe hypertrichosis of the external ear canal during minoxidil therapy.

Minoxidil is a potent peripheral vasodilator used to treat patients with severe hypertension that is unresponsive to other medications. Hypertrichosis of the forehead, face, neck, shoulders, upper part of the arms, and legs is a frequent side effect that occurs in the majority of patients that use this drug. This phenomenon appears to be due to increased blood flow to hair follicles, with resultant excessive hair growth. We describe a patient with severe hypertrichosis of the external ear canal resulting in chronic otitis externa and hearing loss.

Use of alar batten grafts for correction of nasal valve collapse.

OBJECTIVE: To determine the efficacy of alar batten grafts for the correction of internal and external nasal valve collapse. DESIGN: In this retrospective study, a questionnaire was used to ask patients to rate their nasal breathing before and after application of alar batten grafts. SETTING: Private practice and academic tertiary referral medical center. PATIENTS: The questionnaire was given to 63 patients who underwent application of alar batten grafts between 1980 and 1995. Forty-six patients (73%) responded and were included in the study. INTERVENTION: Alar batten grafts were applied into a precise pocket via a limited endonasal incision or via the external rhinoplasty approach. The grafts consisted of curved septal cartilage or auricular cartilage and were applied to the site of maximal lateral nasal wall collapse. The convex surface of the cartilage was oriented laterally to allow maximal lateralization of the collapsed portion of the lateral nasal wall. In most cases, alar batten grafts were applied caudal to the existing lateral crura and extended from the lateral one third of the lateral crura to the piriform aperture. OUTCOME MEASURES: The degree of nasal airway obstruction was determined by subjective scoring on a scale from 1 (no obstruction) to 5 (complete obstruction) before and after surgery. The patency of the internal airway was also assessed on physical examination. RESULTS: The results of the study revealed that all but 1 of the 46 patients experienced an improvement in their nasal airway obstruction. The mean improvement in nasal airway obstruction was 2.5 on a scale of 5. Patients that had the least improvement had intranasal scarring in the region of the internal nasal valve, loss of vestibular skin, or excessive narrowing at the piriform aperture. Physical examination revealed a significant increase in the size of the aperture at the internal or external nasal valve after the application of the alar batten grafts. There was minimal postoperative fullness in the supraalar region, where the alar batten grafts were applied. With time, this fullness decreased, leaving little evidence of the graft and an overall improvement in the aesthetic result. CONCLUSIONS: Alar batten grafts are effective for long-term correction of internal and external nasal valve collapse that is not complicated by intranasal scarring in the region of the nasal valve, loss of vestibular skin, or excessive narrowing at the piriform aperture.

Demineralized bone. Implant resorption with long-term follow-up.

The osteoinductive properties of demineralized bone have stimulated its use in facial skeletal augmentation and reconstruction. Demineralized bone has been shown to induce phenotypic conversion of mesenchymal cells into osteoblasts, with bone formation within 29 days (osteoinduction). In this clinical study, 75 demineralized bone implants were followed up from 1 to 48 months (average follow-up, 14.3 months). There were 41 major dorsal implants, with an average degree of resorption of 50.7%. Eight dorsal implants were followed up for more than 24 months, with an 82.5% degree of resorption. Overall resorption for all implants was 49%. Major factors contributing to implant resorption included lack of surrounding mesenchymal cells and inadequate contact between host tissue and bone-inducing surface area. Other factors included infection, poor vascularity, and compression of the implant. Demineralized bone has an unacceptably high resorption rate and should only be used in highly selective cases where the implant can be positioned in a site rich in primitive mesenchymal or bone-forming cells.

Parietal occipital nape of neck flap. A myocutaneous flap for selected head and neck reconstruction.

Reconstruction in head and neck surgery has been greatly advanced with the use of the pectoralis major and trapezius myocutaneous flaps. Most surgical defects can be repaired with one of these flaps alone, or in conjunction with cutaneous flaps. Specific problems, however, occur that cannot be successfully reconstructed by these standard flaps. The traditional scalp flaps are cutaneous flaps. Use of these flaps is limited because of their shortened arc of rotation and accompanying forehead deformity. Three patients underwent reconstruction with a parietal occipital nape of neck myocutaneous flap. Its advantages include the following: large segments of hairless skin from the contralateral side of the neck can be used, an extensive arc of rotation and distance can be achieved with excellent vascularity in the overlying skin, and cosmetic results are superior. Angiographic studies were used to demonstrate the vascular pattern and supply to this flap. Cadaver dissections were performed to determine the pattern of distribution of the perforating vessels to the skin from underlying muscle.