Technique of The Buccal Fat Pad Flap as an Alternative for the Surgical Defect of Pleomorphic Adenoma

Pleomorphic adenoma (PA) is the most common benign salivary gland neoplasm, and its malignant transformation rarely occurs. Diagnosis is based on clinical features of local or regional malignancy or distant metastasis, and histological identification of invasion and cellular atypia. Buccal fat pad, also called Bichat fat pad, is an excellent option to create tissue coverage over surgically treated areas, providing great blood supply. Thus, this study aims to report a surgical treatment of a patient who reported to the Oral and Maxillofacial Surgery and Traumatology service of a hospital in the city of Fortaleza, presenting a large lesion in the right side of the palate. Clinical examination revealed a nodular volume increase with smooth surface, sessile insertion, firm to palpation and coloration similar to the mucosa, no pain complaints, and 2 years of evolution. Orthopantomographic examination did not reveal alterations in the adjacent anatomical structures. After clinical and radiographic evaluation, an incisional biopsy was performed and histopathological diagnosis was PA. Patient was submitted to surgery for tumor excision with narrow surgical margins, including oral lining mucosa to reduce recurrence chances. In the same surgical act, after the excision of the lesion, the right buccal fat pad pedicle flap was sutured onto the residual mucosa in order to act as a framework for re-epithelialization of the palatal mucosa, phenomenon of metaplasia, and reduction of patient's morbidity. Surgical piece obtained was sent to anatomopathological study, confirming initial diagnosis. After 12-month follow-up, patient is esthetically and functionally rehabilitated, and satisfied with clinical and surgical plans executed. Address correspondence and reprint requests to Jair Queiroz de Oliveira Neto, Resident in Oral and Maxillofacial Surgery, Hospital IJF—Institute Dr. Jose Frota, Fortaleza, Ceara, Brazil; E-mail: Jairqueiroz_neto@hotmail.com Received 29 January, 2018 Accepted 9 July, 2018 The authors report no conflicts of interests. © 2018 by Mutaz B. Habal, MD.

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Rare Median Cleft-Lip Repair With Novel Surgical Procedures Using Bilateral Cleft Margin Flaps

Reports of median cleft lip with nasal anomalies are few, and descriptions of concomitant surgical repair of a median cleft lip and bifid nose deformity are similarly rare. These surgical repair techniques mainly involve the use of normal neighboring structures. Reconstruction of the columella and nasal base is especially important. A new surgical procedure was examined using bilateral cleft margin flaps for patients with a rare median cleft lip. Two patients with a rare median cleft lip were indicated for the procedure. One patient was 3 months old at surgery, and the other patient was 6 months old. These patients underwent single-stage reconstruction of the lip and nose. The new surgical procedure is characterized by the reconstruction of the columella, which involves creating a supportive structure using a cleft margin flap; subsequently, an anterior covering is created using a hinge flap from the nasal tip. Upper lip formation is performed by repair of the orbicularis oris muscle and rotation advancement of a cutaneous and mucosal flap from the lateral segments. The postoperative follow-up period was 4 to 5 years. The postoperative appearance was satisfactory in both patients. Furthermore, no significant complications were observed postoperatively. In conclusion, the surgical procedure with bilateral cleft margin flaps described in this report allows for successful reconstruction of a median cleft lip. This procedure is effectively tissue saving and results in satisfactory outcomes, which are maintained over a long term. Address correspondence and reprint requests to Keisuke Imai, MD, Department of Plastic and Reconstructive Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka 534-0021, Japan; E-mail: imai-k@abox3.so-net.ne.jp Received 21 March, 2018 Accepted 9 July, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Posterior Distraction First or Fronto-Orbital Advancement First for Severe Syndromic Craniosynostosis

Purpose: Posterior calvarial vault expansion using distraction osteogenesis is performed for syndromic craniosynostosis as the first choice. This procedure allows far greater intracranial volume than fronto-orbital advancement (FOA). This study aimed to determine the most suitable timing of posterior distraction or FOA to sufficiently increase the intracranial volume and remodel the skull shape. Patients and Methods: From 2014 to 2017, the authors performed posterior distraction in 13 patients with syndromic craniosynostosis. Data on premature suture fusion, age at first visit, age at surgery, skull thickness, and complications were collected. Results: Five patients underwent posterior distraction at approximately 12 months of age and had no complications, including cerebrospinal fluid leakage or gull wing deformity. However, during the waiting period for the operation, the skull deformity continues to extend upward (turribrachycephaly). To prevent progress of the skull deformity, the authors performed the operation at approximately 6 months of age in 7 patients. However, in 3 of 7 patients whose lambdoid sutures were opening, gull wing deformity occurred. From these results, in a patient with severe Beare–Stevenson syndrome, the authors performed FOA first at 5 months of age, followed by posterior distraction at 12 months of age, and achieved favorable results. Conclusions: Treatment patterns are patient specific and should be tailored to premature suture fusion, specific skull deformity, and required intracranial volume of each patient. Address correspondence and reprint requests to Yoshiaki Sakamoto, MD, Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ward, Tokyo 160-8582, Japan; E-mail: ysakamoto@z8.keio.jp Received 20 February, 2018 Accepted 9 July, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Perinasal Osteotomy With Distraction Osteogenesis for a Mild Syndromic Craniosynostosis

Le Fort II and III procedures have generally been performed for syndromic craniosynostosis with midfacial hypoplasia and skeletal class III malocclusion. However, some patients have midfacial hypoplasia without malocclusion. Perinasal osteotomy was performed with distraction osteogenesis to move the midface forward in 2 patients (a 17-year old female patient with Crouzon-like disease and a 15-year-old female patient with Antely–Bixler syndrome) with mild midface hypoplasia without malocclusion. The success of the procedure was assured by 3 features: the intermaxillary sutures were fixed by a mini metal plate to prevent separation during distraction; the distraction wires were fixed through the bone of the piriform aperture with the mini metal plates to prevent the wires from coming off; and the osteotomy line was designed in front of the palatomaxillary suture to avoid suture damage. These were expected to secure the procedure. Perinasal osteotomy with distraction osteogenesis is considered one of the recommended procedures for mild midfacial hypoplasia as seen in mild syndromic craniosynostosis without malocclusion. Address correspondence and reprint requests to Shinji Kobayashi, MD, Department of Plastic and Reconstructive Surgery, Kanagawa Children's Medical Center, Mutsukawa 2-138-4, Minami-ku, Yokohama, Kanagawa, Japan; E-mail: skobayashi@kcmc.jp Received 18 March, 2018 Accepted 9 July, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Epidemiologic Assessment of Microtia in Over 23 Million Consecutive United States Births

Purpose: Conflicting data exist regarding the incidence, demographics, and abnormalities associated with microtia. Using a large national cohort database, a comprehensive evaluation of microtia in the United States was performed. Methods: The Kids' Inpatient Database was reviewed over a 15-year consecutive period. Information regarding patient demographics, comorbidities, postoperative complications, and hospital setting was collected. Statistical tests were analyzed using independent t tests and χ2 analysis. Results: A total of 23,479,792 births over 15 consecutive years from 1997 to 2012 were included in the study. Microtia was identified in 1563 births. Incidence of microtia was higher in males (P

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Lesions of the Parotid Gland and Buccal Artery After Buccal Fat Pad Reduction

The significant increase in esthetic surgery, especially buccal fat pad reduction, has led to a corresponding increase in lesions and postoperatory after-effects from this surgical procedure. The aim of this study is to discuss the immediate and mediate risks of removing the Bichat ball, as well as describing a clinical study in which this surgical procedure resulted in lesions of the parotid gland and buccal artery, which was confirmed via nuclear magnetic resonance. The facial lesions were remedied via exploratory surgery by opening a new orifice of the glandular duct in the buccal cavity followed by drainage and compressive surgical bandages. Address correspondence and reprint requests to Laudimar Alves de Oliveira, PhD, Departamento de Odontologia, Faculdade de Ciências da Saúde, Campus Darcy Ribeiro, Asa Norte, Universidade de Brasília, Brasília-DF, 70.910-900, Brazil; E-mail: laudimar.oliveira@gmail.com Received 29 January, 2018 Accepted 2 July, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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An international comparison of diagnostic and management strategies for vestibular schwannoma

Abstract

Objective

To compare international diagnostic and management strategies for vestibular schwannoma (VS).

Methods

A web-based questionnaire was sent to 130 otolaryngologists, mainly identified through the European Skull Base Society. It contained questions on general information including guideline usage as well as questions on diagnosis (focussing on selection of patients for MRI) and management of VS, including case scenarios. Descriptive statistics were reported.

Results

Thirty-six otolaryngologists working in 11 different countries completed the questionnaire (response rate: 28%). Guidelines for diagnosis and management of VS are used by 44% and 42% of respondents, respectively. In the diagnostic strategy for VS, different types and combinations of audiovestibular function tests are used when deciding whether a patient should undergo an MRI. Respondents apply 18 different definitions of asymmetrical hearing loss. Variation was also apparent from reported considerations on management of VS. Most respondents (84%) prefer a wait-and-scan strategy in case of a small intrameatal VS (Koos 1). Variety in management strategies increases for patients with a medium to large sized VS (Koos 2, 3 and 4). The details of each management strategy (wait-and-scan, microsurgery, stereotactic radiosurgery and fractionated radiotherapy) also differ among respondents.

Conclusions

A large variation in diagnostic and management strategies for VS was identified between respondents. More evidence and/or consensus seem warranted to reduce uncertainties for patients, and differences in outcome and costs that might result from the variety of strategies currently being applied.

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