Cosmetic surgery of the neck as an office procedure

A simple office procedure to eliminate permanently double chin deformity and senile neck cords and with nearly invisible scars is described. Postoperative complications are mitigated by the use of autogenous fat grafts and constant aspiration of the wound cavity both during and after surgery. Most patients are able to resume their normal activities in several days.     

Lung volume reduction surgery as an emergency and life-saving procedure

Lung volume reduction surgery (LVRS) is emerging as a promising and unique therapeutic option for rigorously selected patients with severe debilitating emphysema. A 51 yr old man with generalized emphysema developed bilateral pneumothoraces during his first holiday abroad. Due to respiratory insufficiency, intubation and mechanical ventilation were necessary. In total, six chest tubes were inserted but massive air leak persisted and his respiratory condition deteriorated due to bronchopneumonia and sepsis. The patient was transferred to Belgium. As a last resort, bilateral LVRS was performed through a median sternotomy. The most diseased areas of the upper lobes containing the air leak were resected bilaterally and a pleurectomy was associated. Three months after operation, there was a remarkable improvement in spirometric values with an increase in forced expiratory volume in one second of almost 100%. The results were sustained after a follow-up of 18 months. In this dramatic case, lung volume reduction surgery proved to be effective, and was even a life saving procedure.     

Microsurgical tubal anastomoses performed as an outpatient procedure by minilaparotomy are less expensive and as safe as those performed as an inpatient procedure

OBJECTIVE: To study the efficacy of methotrexate (MTX) plus low dose corticosteroids for induction of remission in generalized Wegener's granulomatosis (WG) and to possibly identify predictive factors for the outcome under this therapy. METHODS: We conducted a prospective, open label study, including 17 patients with not immediately life threatening, generalized WG. Treatment consisted of intravenous MTX 0.3 mg/kg once weekly plus daily oral low dose prednisone for initial diagnosis of WG in 11 and for a generalized relapse of WG in 6 patients. Interdisciplinary, standardized assessments of disease activity and extent were done 3-monthly. RESULTS: Within a median treatment period of 24.5 months remission could be achieved in 10/17 patients (59%), their median corticosteroid dose during that time was 1.75 mg/day. Seven patients with a median concomitant prednisone dose of 7.5 mg/day did not respond, among them 4 patients who were treated for a relapse of WG. Signs of de novo glomerulonephritis occurred in 5 of the 7 nonresponders. Significant side effects, including opportunistic infections, did not occur. CONCLUSION: Weekly low dose MTX in combination with low dose corticosteroids leads to an acceptable remission rate of almost 60% without significant side effects. Patients treated for a relapse of WG and patients with a need for a higher concomitant prednisone dose seem to be at risk for nonresponse, with a high likelihood of developing de novo glomerulonephritis.     

Safety of direct laryngoscopy as an outpatient procedure

Diminished systolic function or inappropriate hypertrophy are considered risk factors for outcome following the Fontan procedure. These parameters are difficult to assess in univentricular hearts that do not conform to the uniform shapes prescribed by conventional 2-dimensional imaging volume algorithms. Three-dimensional echocardiography requires no geometric assumptions and has been validated in both normal and distorted left ventricles. To assess the feasibility and accuracy of this technique in patients with univentricular hearts, we compared 2- and 3-dimensional echocardiographic estimates of ventricular volume, ejection fraction, and mass in patients with functionally single left ventricles with results obtained by magnetic resonance imaging (MRI). Twelve patients with functionally single left ventricles (6 months to 22 years) underwent examination by all 3 modalities. Correlation and agreement with MRI were calculated for volumes, ejection fraction, and mass. Three-dimensional echocardiographic comparison with MRI yielded a bias of 3.4 +/- 5.5 ml and 14.2 +/- 8.3 ml for systolic and diastolic volumes, respectively. Agreement analysis for mass showed a bias of 5.8 +/- 8.4 grams. Two-dimensional echocardiography showed less agreement for both volumes and mass (bias of -2.9 +/- 8.1, 2.9 +/- 10.4 ml and -8.3 +/- 12.0 g for volume and mass, respectively, p >0.05). Ejection fraction by 3-dimensional echocardiography showed significantly closer agreement with MRI (bias of 4.4 +/- 5.3%) than 2-dimensional echocardiography (bias of 8.5 +/- 10.3%, p = 0.04). Thus, 3-dimensional echocardiography provides estimates of ventricular volumes, ejection fraction, and mass that are comparable to MRI in this select group of patients with single ventricles of left ventricular morphology.     

Peroperative transluminal angioplasty as a supplementary procedure to arterial reconstruction surgery

Patients with affections of the vascular system of the lower extremities at several levels present a complicated problem for vascular surgery. The authors submit their experience with a combination of vascular reconstruction and peroperative transluminal angioplasty. In 25 patients, mean age 64 years, they performed 29 of these combined operations, 10 times on account of claudications, 11 times on account of pain at rest, 8 times on account of trophic defects. The pelvic vessels were dilated 6 times; the dilated vessels as well as the reconstruction remained patent. Peroperative angioplasty of the superficial femoral artery was performed 6 times, occlusion occurred once. Twelve times they dilated the distal portion of the popliteal artery or the vessels of the leg, 3 times the dilated portion became occluded. None of the patients lost the limb, one patient died from acute myocardial infarction shortly after operation. The authors describe the technique of peroperative transluminal angioplasty, evaluate the results and discuss the advantages and disadvantages of this method.     

Temporary gastrostomy as an alternative procedure for nasogastric suction

Based on personal experience with 70 cases of temporary tube gastrostomy - used as an alternative procedure to nasogastric suction in 50 cases and as a double-purpose tube in 20 cases of radical esophagectomy - pertinent problems concerning indication, technique, advantages, and possible complications are presented. The results indicate that temporary gastrostomy is a safe procedure, reduces cardiopulmonary disorders, and increases the patient's comfort. The procedure is therefore strongly recommended for patients with poor cardiopulmonary reserve and for the age group above 60 years. Temporary gastrostomy is also indicated in younger patients, if prolonged gastric distension with the necessity of decompression is anticipated.     

Intraoperative facial nerve monitoring in acoustic neuroma surgery

Intraoperative facial nerve monitoring simultaneously using electromyography and mechanical pressure sensors is being used in retrosigmoid and translabyrinthine approaches for acoustic neuroma resection. Insulated electrified microsurgical instruments and air drills are used to stimulate the facial nerve with a pulsed, constant current through bone and tumor, before the facial nerve is visually encountered. Electrical stimulation is used to help locate the facial nerve, map the course of the facial nerve within tumor, warn the surgeon of unexpected facial nerve locations, and help predict facial nerve function postoperatively. In 57 unmonitored cases a House-Brackmann (H-B) grade I or II result was obtained in 77 percent of small, 81 percent of medium, and 60 percent of large tumors. In 64 monitored cases H-B grade I or II was obtained in 88 percent of small, 79 percent of medium, and 90 percent of large tumors. Overall, facial nerve outcomes were better after monitored procedures (p < 0.02). A modified H-B classification for acute facial nerve injury is introduced to grade facial weakness immediately postoperatively and until function is stable at 1 year. In the unmonitored group there were five (9%) cases with a complete facial paralysis, facial nerve intact (i.e., acute H-B grade VIA) and seven (13%) cases with the facial nerve transected (i.e., acute H-B grade VIB). In the monitored group there were five (8%) acute H-B grade VIA and two (3%) acute H-B grade VIB results. In the unmonitored group of large tumors, there were statistically more patients with an acute H-B grade VIB result (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Pyriform sinus fistula appearing as a neck tumor in the neonatal period: a case report

Pyriform sinus cyst and fistula is a relatively rare tumor of the neck, even less is the neonatal period. We experienced a case of this one, and preoperative diagnosis was made by using endoscopy and cine-esophagography. A dyeing method that confirmed the fistula tract of cyst lead us to successful resection.     

Endoscopic application in aesthetic and reconstructive facial bone surgery

Twenty-three cases of endoscopically assisted facial bone surgery were performed over the past 3 years. Our series is consistent with 16 cases of aesthetic contouring surgery and 12 treatments of facial bone fracture, including three cases for recontouring of frontal bone, three cases for recontouring of zygoma, endoscopically assisted correction of three zygomatic and blowout fractures, four cases for rhinoplasty and septoplasty for deviated nose, and three cases for mandible contouring surgery. To accomplish this technique, a rigid 4-mm, 30-degree down-angled endoscope was used. The frontal bone or zygomatic arch was approached endoscopically through two or three small incisions on the frontal or temporoparietal scalp. All endoscopic instruments were then manipulated through these incisions. The approach for endoscopically assisted rhinoplasty is the same as with standard rhinoplasty procedures. The approach for zygoma complex and maxillary sinus needs an intraoral incision. Recontouring of zygoma, mandible, and nasal dorsum by an air-driven burr and rasp was performed with endoscopic visual assistance. A plate and screw fixation for zygomatic arch fracture requires an additional small skin incision over the plate for the trocar method. The duration of follow-up ranged from 6 months to 30 months. The postoperative course was satisfactory with a few complications. The extra time needed for the endoscopic procedures was less than 1 hour. Endoscopically assisted facial bone surgery can be performed with adequate visualization and direct manipulation of all facial bones. Complications usually associated with extensive incisions in the bicoronal approach may be avoided. Poor visualization in the conventional approach for operation of orbit, nose, maxillae, and mandible may be avoided by use of the endoscope. This technique may prove to be ideal for aesthetic surgery for facial skeleton with smaller scar and less morbidity.     

Proplast implants used in otology and in facial reconstructive surgery

Proplast, a self-stabilising alloplastic material, was evaluated in ear surgery and in facial reconstructive surgery. Proplast implants were used on 33 patients to reconstruct the ossicular chain (total or partial ossicular replacement prosthesis), or to rebuild the mastoid cavity. The lack of extrusion over a 24-month period is encouraging. In facial reconstructive surgery 11 patients received Proplast implants to augment and restore facial contours. Contamination with saliva remains a problem, owing to the high porosity of Proplast, which could harbour infection. When Proplast was sterile when implanted, no extrusion appeared over a 12-month period. Although the patients presented here were followed up for a relatively short time, they provide reason for some optimism that the vexed question of alloplastics applied in the field of ear, nose and throat surgery may be solved.     

Tc-99m-HMPAO single photon emission computed tomography (SPECT) as an ancillary test in the diagnosis of brain death

Lipomatosis has not previously been reported in minor salivary glands. Its occurrence in the parotid gland is well recognized. We present the first reported case of lipomatosis of the minor salivary glands in the nasal cavity. We also review the tumours of the minor salivary glands, lipomas and lipomatosis of the parotid, and the few reported cases of lipomas of the sinonasal tract.     

Topical papaverine and facial nerve dysfunction in cerebellopontine angle surgery

We retrospectively investigated the predictive value of lymphocyte subset changes in the peripheral blood of 37 consecutive liver transplant recipients for rejection and infection, both bacterial and cytomegalovirus, during a period of 2 years. Total lymphocyte count correlated with biopsy-proven rejection. There was moderate elevation of CD16+ count during the course of bacterial infection.     

Results of the double stapling procedure in colorectal surgery

In this report we review our results with the double stapling technique (DST) in 162 patients with colorectal diseases in an attempt to identify some of the potential pitfalls of this new technique. Among these 162 patients, there were 125 patients with colorectal cancer, 25 with chronic ulcerative colitis (UC), 9 with familial adenomatous polyposis (FAP), 2 with adult Hirschsprung's disease, and 1 with sigmoid colon fistula. A total of 46 anastomoses (28 for rectal cancer, 13 for UC, 3 for FAP, and 2 for adult Hirschsprung's disease) were performed at or near the dentate line. Of these, 10 had protective diverting colostomy or ileostomy. The results showed that 6 patients with rectal cancer had anastomotic leakage (3.7%); however, 4 of the 6 patients had also received preoperative irradiation. All the leaks healed after the patients had undergone diverting colostomy, but 7 patients with rectal cancer suffered from neurogenic bladder postoperatively (4.3%). Wound infection occurred in 4 patients (2.5%), anastomotic bleeding in 3 (1.9%), and anal pain in 1 (0.6%), respectively. One patient with rectal cancer and multiple liver metastases died of disseminated intravascular coagulation (DIC). These results thus suggest that the double stapling technique provides a safe anastomosis at or near the dentate line not only for rectal cancer but also for UC, FAP, and adult Hirschsprung's disease.     

Hydroxyapatite paste (BoneSource) used as an onlay implant for supraorbital and malar augmentation

Calbindin D28K, an intracellular calcium-binding protein, acts as Ca2+ buffering system in the cytoplasm. By means of this property, calbindin may protect neurons against large fluctuations in free intracellular Ca2+ and, hence, may prevent cell death. Although axotomy causes a massive influx of calcium into the lesioned neurons, resection of the hypoglossal nerve does not induce extensive neuronal cell death in rats. Even several weeks after axotomy, about 70% of the motoneurons survive despite permanent target deprivation. The mechanisms responsible for this remarkable survival rate are unknown. In this study, we have looked at the modification of calbindin immunoreactivity in axotomized hypoglossal motoneurons. In non-axotomized motoneurons, no calbindin is detectable by immunocytochemistry. Axotomy induced an increase of calbindin immunoreactivity in lesioned motoneurons. This increase, visualised by the number of calbindin-immunoreactive neurons extended from 1 day to 28 days. At this time most, but not all, motoneurons located on the side of the lesion were calbindin-positive as shown by retrograde labeling and immunoquenching. From 14 days post operation, calbindin immunoreactivity decreased and reached its basal value after 35 days post operation. At that time, only fibres were still calbindin immunoreactive. Interestingly, calbindin-immunoreactivity was also increased in almost all cell nuclei, compatible with a nuclear regulation. These data are consistent with the hypothesis that, as a reaction to axotomy, motoneurons trigger an increase in calbindin expression which acts as a compensatory Ca(2+)-buffering system, enabling neurons to maintain Ca2+ homeostasis and the survival of many motoneurons after axotomy.     

Revision rhinoplasty for monographs in facial plastic surgery contemporary rhinoplasty

Revision rhinoplasty represents the amalgamation of years of knowledge, judgment, technique, communication, self-critique, and patient selection. The surgeon's ego, economics, or personality should not persuade or dissuade him or her from undertaking revision rhinoplasty. This decision should be made after critical evaluation of his/her skills at technical execution, and communicating with the patient, as well as the patient's perception and expectations. If any concern exists, delay. Re-evaluation and referral become prudent. These patients may already be angry. They are obviously dissatisfied with their results and have frequently had attempts at revision by the previous surgeon. All these factors complicate the psychological aspects of an already difficult task. One other realization is the fact that this now becomes your result if it is the revision of a colleague's surgery. When comfortable with all of these factors, revision rhinoplasty can then be undertaken. The need for revision may be subtle or grotesque and can result from a multitude of factors: unrecognized deformities at the primary surgery; misunderstood consequences of technique; poor technique; unfavorable healing; postsurgical injury; the inevitable need for revision surgery in a difficult nose; and poor aesthetic judgment. Revision of one's own results is emotionally more difficult, but functionally and technically easier. A complete understanding of the primary surgery, access to the initial photographs, and a rapport with a patient who is willing to return are all helpful in achieving a satisfactory result. In approaching the correction of postoperative deformities, it is important to have an understanding of the anatomic abnormality as well as the aesthetic deformity. Recognizing the anatomic cause of the postsurgical deformity is more relevant to their avoidance and to the maturation of the surgeon than to their correction and the desired aesthetic result except when functional abnormalities exist and need correction. Ultimately it is the deformity that needs to be corrected, and this may or may not require the restoration of anatomic normalcy.     

Management and rehabilitation of the facial nerve in parotid surgery

The facial nerve is the single most important consideration in the surgical management of most parotid disorders. Its surgical anatomy should be well known by the head and neck surgeon. Very few conditions of the parotid gland necessitate the sacrifice of the facial nerve. When this decision is made, the benefits to be derived should be very thoughtfully measured against the tremendous cosmetic and functional sequelae that follow, and the patient should understand preoperatively to the fullest the magnitude of this decision and all its consequences. Most facial nerve deficits resulting from injury or sacrifice of the nerve can be and are best repaired by either direct anastomosis or autografting using a donor sensory nerve. Such restorations of the neuromuscular mechanism yield a physiologic result that is as close to the preinjury state as possible, and this is reflected in cosmetic and functional recoveries that are generally superior to any other of a variety of rehabilitative techniques. In all patients with a paralyzed face, extremely close attention must be given the involved eye to minimize the hazards of corneal injury.     

Ultraviolet spectrophotometric analysis of barbiturates. Current assessment as an emergency screening procedure

Several laboratory methods are currently available for the detection of barbiturates, but few are suitable for emergency use, The authors evaluated use of an ultraviolet spectrophotometric method as a screening procedure and compared the results with results obtained by other barbiturate methods (colorimetric, gas-liquid chromatographic, and immunochemical), Procedure time was approximately 40 minutes, sensitivity 0.2 mg/dl, precision (coefficient of variation) 5.4%, recovery 97.8% for phenobarbital, and there was good correlation with results obtained by gas-liquid chromatography and the EMIT system for phenobarbital. The authors recommend ultraviolet spectrophotometry as an excellent screening procedure for assessing the severity of barbiturate intoxication.