Saving the Exposed Deep Brain Stimulation Implant: A Comprehensive Review of Implant Extrusion and Reconstructive Options.

INTRODUCTION: Deep brain stimulation (DBS) for the treatment of Parkinson disease is susceptible to complications, such as hardware extrusion, most commonly at the scalp and chest. The authors describe their experience with the management of hardware extrusion and reconstruction with one of the largest single-institution experience and suggest an evidence-based treatment algorithm for the management of such cases. METHODS: A retrospective review of hospital records was performed to identify patients who underwent DBS-related surgery and reconstruction from January 2015 to April 2020. Management of these patients involved culture-directed antibiotics, local wound debridement, various forms of reconstruction, and hardware removal when indicated. RESULTS: Ninety-four patients with 131 DBS-related procedures were included. Twelve patients (12.8%) had hardware extrusion, of which 6 occurred primarily at the scalp and 6 occurred primarily at the chest. Primary closure of scalp wounds (odds ratio, 0.05 [0.004-0.71], P = 0.035) was negatively associated with treatment success. The type of reconstruction of chest wounds did not affect its success ( P = 0.58); however, none of them involved a new surgical bed, such as contralateral or hypochondrial placement. CONCLUSIONS: Hardware extrusion is a significant complication of DBS-related surgery. Management of extrusion at the scalp should involve the use of tension-free, well-vascularized locoregional flaps as opposed to primary closure. Implantable pulse generator extrusions at the chest can be managed with both primary closure and repositioning in a new surgical bed. Extruded DBS implants may be salvaged with appropriate reconstructive considerations, and the authors suggest an evidence-based treatment algorithm.

Use of hemisphincter pharyngoplasty in the management of velopharyngeal insufficiency after pharyngeal flap: an outcome study.

Superiorly based pharyngeal flaps (PFs) are commonly used for the treatment of velopharyngeal insufficiency (VPI) in patients with cleft palate. However, failure may occur with recurrence of hypernasality and surgical revision may be necessary. Hemisphincter pharyngoplasty using either unilateral or bilateral posterior tonsillar pillars with the underlying palatopharyngeus muscle can be used to narrow the incompetent lateral portals. We retrospectively reviewed 22 patients diagnosed with VPI after PF surgery, who underwent hemisphincter pharyngoplasty from 1995 to 2007. Seventeen patients with complete speech assessment records were evaluated for the surgical outcome. Overall velopharyngeal function improvement was 88.2%. Symptoms of airway obstruction developed in 41% of the patients perioperatively. All of them improved gradually except 1 patient who needed continuous positive airway pressure mask treatment for obstructive sleep apnea. It is concluded that hemisphincter pharyngoplasty for narrowing of the incompetent portals is an effective treatment of VPI after PF.

Endoscopic management of orbital floor fractures.

The management of orbital floor fractures involves several issues. Different surgeons have diverse opinions about who needs surgery and how best to do it. This is especially so with regard to use of transantral diagnostic and therapeutic endoscopic surgery over traditional lower eyelid approaches. Transantral endoscopy provides precise and complete information about the orbital floor fracture and makes possible the repair of these fractures under unobstructed vision at all times, minimizing the risk of implant misplacement and, hence, enophthalmos. Contrary to popular belief, this technique is versatile and is applicable for most cases of primary repair of orbital floor fractures of variable sizes of defect, regardless of whether they are blowout or trap-door fractures or whether they are associated with other fractures. The great strength of this procedure is that improved visualization is accomplished while obviating the need for lower eyelid incisions and their associated risk of complications. This technique is safe in trained hands, giving predictably good results in suitable patients.

Management of severe hidradenitis suppurativa with biologic therapy and wide excision.

Hidradenitis suppurativa (HS) is a chronic inflammatory follicular occlusive disease that involves the intertriginous areas. Treatment methods include conventional topical and systemic medication, radiotherapy, biologic agents, and surgical excision. Of late, there has been an increased focus on the use of biologic agents in patients with moderate to severe HS. Here, we present the case of a 46-year-old man with Hurley stage III HS for whom wide excision was ultimately curative, after aggressive medical therapy with the use of infliximab and adalimumab had succeeded in limiting the body surface area affected by the disease. This case demonstrates the effective treatment of severe HS with a combination of biologic therapy and surgery.

Progressive Cheek Swelling in an Older Woman.

An 87-year-old woman presents with sudden-onset worsening right facial swelling and pain and generalized maxillary alveolar hyperplasia. What is your diagnosis?

Computer-aided design and rapid prototyping-assisted contouring of costal cartilage graft for facial reconstructive surgery.

Complex 3-D defects of the facial skeleton are difficult to reconstruct with freehand carving of autogenous bone grafts. Onlay bone grafts are hard to carve and are associated with imprecise graft-bone interface contact and bony resorption. Autologous cartilage is well established in ear reconstruction as it is easy to carve and is associated with minimal resorption. In the present study, we aimed to reconstruct the hypoplastic orbitozygomatic region in a patient with left hemifacial microsomia using computer-aided design and rapid prototyping to facilitate costal cartilage carving and grafting. A three-step process of (1) 3-D reconstruction of the computed tomographic image, (2) mirroring the facial skeleton, and (3) modeling and rapid prototyping of the left orbitozygomaticomalar region and reconstruction template was performed. The template aided in donor site selection and extracorporeal contouring of the rib cartilage graft to allow for an accurate fit of the graft to the bony model prior to final fixation in the patient. We are able to refine the existing computer-aided design and rapid prototyping methods to allow for extracorporeal contouring of grafts and present rib cartilage as a good alternative to bone for autologous reconstruction.

Maxillary artery injury associated with subcondylar mandible fractures: a novel treatment algorithm.

Mandible fractures commonly occur in patients who have sustained blunt facial trauma, and the subcondylar region is the most frequently fractured due to its intrinsic biomechanical weakness. The maxillary artery lies in close relation to the medial cortex of the subcondyle and is vulnerable to injury by the sharp edges of the fracture fragments during the initial trauma or during operative fracture reduction. Maxillary artery injuries and subcondylar fractures may be an underdiagnosed phenomenon. Yet, this is of clinical significance as the maxillary artery caliber is usually of significant caliber and may lead to substantial hemorrhage. Surgical access to the artery for hemostasis is challenging and is further compounded by small surgical incisions usually undertaken for fracture fixation, obscuring of the artery by the overlying fracture fragments, and vessel retraction following its transection. In cases where maxillary artery injury is suspected, an open surgical approach may be favored over an endoscopic one. The authors illustrate a case in which brisk hemorrhage from the maxillary artery encountered during a preauricular approach to fixation of the mandible subcondyle was successfully controlled with temporary pressure on the external carotid artery through a neck incision and direct ligation of the lacerated maxillary artery. The authors then discuss diagnosis and treatment of such maxillary artery injuries and propose a novel diagnostic and treatment algorithm.

Broad application of the endoscope for orbital floor reconstruction: long-term follow-up results.

BACKGROUND: Transantral endoscopic repair of orbital floor fracture minimizes the risk of implant misplacement and avoids complications associated with traditional lower eyelid approaches. Contrary to most publications, its application is not limited to early intervention of pure orbital blow-out fractures. The authors present their results of broad application of this technique, with longer-term patients' follow-up. METHODS: A retrospective review of 32 patients over a 10-year period (March of 1998 to June of 2008) was performed. The mean duration of follow-up was 27.5 months (range, 4 months to 10 years). Sixteen patients (50 percent) had associated zygoma, inferior orbital rim, and Le Fort I fractures. Twenty-five patients (78.1 percent) had enophthalmos, with 14 of these cases being 2 mm or more in severity. Diplopia was present in 15 patients (46.9 percent) preoperatively. Operations were performed within 2 weeks for 25 patients (78.1 percent). Twenty-eight patients required orbital floor reconstructions. Four of five patients with associated orbital medial wall fractures underwent simultaneous orbital medial wall reconstruction. RESULTS: All patients had successful reduction of orbital fractures. Two patients had residual enophthalmos of 1 mm postoperatively. Due to delay in surgery and the nature of injury, only 11 of the 15 patients with diplopia had complete resolution after surgery. One patient required drainage of recurrent sinusitis 1 year after surgery. CONCLUSIONS: In suitably selected patients with orbital floor fractures, the transantral endoscopic approach is safe and reliable. Delayed surgery or associated zygomaticomaxillary complex fractures are not contraindications for the use of this technique. Long-term follow-up showed maintenance of the surgical results.

The deep inferior epigastric perforator flap for breast reconstruction: Is this the ideal flap for Asian women?

INTRODUCTION: This study aims to evaluate the outcome and safety of the deep inferior epigastric perforator (DIEP) flap for breast reconstruction in a group of Southeast Asian women treated in our unit and to identify risk factors for breast reconstruction using the DIEP flap in this population. MATERIALS AND METHODS: This is a prospective study on 50 consecutive DIEP flap breast reconstructions by a single surgeon in an academic institution between July 1999 and July 2006. Data on patient demographics, diagnosis, procedure type, adjuvant and neoadjuvant treatments, risk factors and complications were prospectively collected and registered in a clinical database. Outcome variables include total flap loss, partial flap loss, fat necrosis and minor complications related to the donor site or flap. Known risk factors are analysed to determine if they affect outcome in terms of complication rate in this group of patients. RESULTS: Total flap loss, partial flap loss and fat necrosis complication rates were 6%, 4% and 10%, respectively. Flap complication rates were comparable to those quoted by previous studies done worldwide. Obesity (BMI >27) is a statistically significant factor associated with development of DIEP flap complications in our population. CONCLUSION: Breast reconstruction with DIEP flap is a safe and reliable method when used in Southeast Asian women, offering optimal results with less donor -site morbidity. Obesity increases the incidence of flap complication in this group of patients.