Surgical strategies in the removal of malignant tumors and benign lesions of the anterior skull base

The choice of surgical approaches to the tumors of the anterior skull base is determined by the location, dimensions of such lesions and their relations to the surrounding structures. Furthermore, the need for the reconstruction of the dura and skull base structures has an important influence on the decision about the surgical procedure. Transfacial approaches provide limited exposure, especially when tumors damage the floor of the anterior cranial fossa and involve the frontobasal dura and brain. Transcranial, craniofacial and subcranial approaches in particular may aid a surgeon in the removal of such lesions, and often these surgical procedures are the only beneficial methods. Our study comprised 15 patients. Transcranial approaches were used in ten cases. In five further cases, we adopted craniofacial or subcranial approaches. Total removal of these lesions was possible in 13 cases. Neither important complications nor death after surgery was observed except for two cases (craniofacial/subcranial approach) where the CSF leak and CNS infection were reported. We deem that the transcranial approach creates a good possibility for total removal of anterior skull base tumors, particularly of the benign lesions, and permits reconstruction of the skull base damaged by the tumor. However, in patients with large malignant tumors, the en bloc resection via the combined craniofacial/subcranial approach achieved better outcome.Parts of the materials of this research were presented at the 12th European Congress of Neurosurgery—EANS 2003, 7–12 September, Lisboa, Portugal     

Implant materials for fracture fixation: a clinical perspective

The optimum management of traumatic skeletal fractures may involve the installation of high quality surgical implants by a skilled orthopedic surgeon. Satisfactory clinical results are very dependent on the ability to maintain stable fracture fixation. Well designed contemporary implants rely on precise control of material composition and properties to achieve a well tolerated level of biological response. Metallic materials, such as 316L stainless steel, pure titanium, and titanium alloys, demonstrate an acceptable combination of strength, ductility, corrosion resistance, and biocompatibility. Polymers, composites, and biodegradable materials may offer selected opportunities for fracture fixation. An understanding of relevant clinical factors is essential to evaluate potential applications for advanced materials.     

Alloplastic cranioplasty

The use of alloplastic implants for cranial reconstruction has a long history with numerous materials used with varying degrees of success. Currently, three different alloplastic alternatives are widely used, methymethacrylate, hydroxyapatite, and metal. Each has its own advantages and indications in contemporary cranioplasty. When employed with good surgical technique and in the appropriate patient, each material can have good clinical outcomes.     

Alloplastic cranioplasty

The use of alloplastic implants for cranial reconstruction has a long history with numerous materials used with varying degrees of success. Currently, three different alloplastic alternatives are widely used, methymethacrylate, hydroxyapatite, and metal. Each has its own advantages and indications in contemporary cranioplasty. When employed with good surgical technique and in the appropriate patient, each material can have good clinical outcomes.     

Skin substitution in neck and facial burns]

The surgeon assuming the task of reconstruction of burned face must be skilled in plastic surgery. Primary surgical treatment and reconstruction are inseparable, therefore it is desirable that the treatment is performed since the day of the injury to the completion of the reconstruction by the same surgeon. In the surgical management of the facial burns relative conservatism is advisable. The excision is to be performed after the recovery of the second-degree burned areas. The above-mentioned principles are documented by the author on the basis of a few cases.     

Die Rekonstruktion von Defekten der ventralen Bauchwand

Reconstruction of the abdominal wall is of importance in many clinical situations, but may require the entire spectrum of plastic and reconstructive surgery. Indications for particular procedures depend on the clinical situation and the patient's individual profile. One has to differentiate between life-saving primary measures and secondary corrections to improve form or function. The article outlines current actual concepts of plastic surgical defect reconstruction with which the general/visceral surgeon should be acquainted, in order to integrate these concepts into a multi-disciplinary approach in pertinent clinical situations.     

Facial Nerve Neuroma: Surgical Concept and Functional Results

This study reviewed the management and outcomes of 11 facial nerve neuromas treated in our institution during the past two decades with particular emphasis on surgical concepts and functional outcomes. All patients underwent complete surgical resection of their tumor. Eight patients (73%) were followed on an outpatient basis. A retrospective chart review for pre- and postoperative clinical and radiological data was performed. All facial neuromas were multi-segment tumors. All segments of the facial nerve were represented, but 54% involved the geniculate ganglion and 45% involved the labyrinthine or tympanic portions of the nerve, or both. Depending on the extent of sensorineural hearing loss, surgical removal was performed through the middle cranial fossa or translabyrinthine approach. To obtain adequate nerve reconstruction, we combined intra- and extracranial approaches (e.g., the transmastoidal and transtemporal routes). Regardless of the type of nerve reconstruction, the best recovery achieved was moderate facial weakness (House-Brackmann Grade III) in 75% of the patients, even in a patient who was Grade IV preoperatively. The choice of treatment for facial neuromas and surgical approach depends on the extent of tumor, grade of facial palsy, and hearing function. When facial palsy is present, complete resection is clearly indicated. In patients without facial dysfunction, a conservative strategy consisting of clinical and radiological observation should be considered as a treatment option.     

Advances in the management of lower eyelid retraction

The purpose of this article is to describe the newer surgical techniques and materials available for repair of lower eyelid retraction. The anatomic basis, classification, and prevention of lower eyelid retraction are explored, as well as traditional methods of surgical management. Two case reports involving the successful use of acellular human dermis (AHD) for lower eyelid retraction are presented. Lower eyelid retraction is associated with a variety of etiologies, which mandate that the surgical repair be directed toward correction of the anatomic abnormality in each patient. Each surgical procedure and material used in the repair of eyelid retraction is associated with unique advantages and disadvantages. AHD has found multiple uses in oculoplastics, including reconstruction of the middle and posterior lamellae in eyelid retraction. An understanding of the mechanistic basis of lower eyelid retraction and familiarity with newer techniques and materials enable the oculoplastic surgeon to modify and individualize the operative repair, resulting in better surgical outcomes.     

Craniofacial dysostosis. Staging of reconstruction and management of the midface deformity.

Crouzon's and Apert's syndromes are the most common of the craniofacial dysostosis syndromes. A team approach is required to achieve effective patient management. The team evaluation begins shortly after birth and follows the patient through infancy, childhood, and adolescence into early adulthood. The role of each team member varies according to the patient's age and individual circumstances. For example, in infancy and early childhood, constant combined reassessment by the pediatrician, neurosurgeon, ophthalmologist, neuroradiologist, and craniofacial surgeon is essential. Later in adolescence, the role of the ophthalmologist, neuroradiologist, and neurosurgeon becomes less important, whereas that of the orthodontist, speech pathologist, maxillofacial surgeon, and psychosocial team becomes more dominant. Major craniofacial centers should be encouraged to develop protocols for patient management and to follow a consistent prospective process of collecting data. Meeting these objectives allows us to learn from the past. During the past decade since the introduction of the modern era of craniofacial surgery by Tessier in 1967, craniomaxillofacial surgery has advanced in many ways: through the use of autogenous cranial bone grafts for onlay or interpositional use; refinements in bone stabilization techniques that include miniplate and microplate and screw fixation rather than direct wires; the reintroduction of creative osteotomies for the management of midface deficiency (monobloc and monobloc bipartition); the development of CT scanning techniques applied to the craniofacial skeleton for both qualitative and quantitative measurement; and the presence of the dedicated craniofacial anesthetist whose meticulous monitoring, airway management, and fluid replacement allows for the safe execution of complex total midface osteotomies. The recognition of the need for a staged surgical approach to the correction of the deformities caused by Apert's and Crouzon's syndromes has clarified reconstructive goals and allowed the surgeon to take advantage of differential craniofacial growth patterns similar to those used to help the patient with congenital cleft lip and palate defects. By continuing to define our rationale for the timing of surgical intervention--for example, using cranial vault surgery in infancy to relieve increased intracranial pressure and papilledema; total midface advancement in childhood to further increase intracranial and orbital volume, improve nasal airflow, occlusion, and body image; and orthognathic surgery in adolescence to improve occlusion, speech, and aesthetics--we can avoid unproductive surgery and select the optimal timing for surgical intervention to maximize long-term functional and aesthetic results.     

Jugular foramen paragangliomas: management, outcome and avoidance of complications in a series of 75 cases

Jugular foramen paragangliomas are rare skull base tumours posing multiple complex diagnostic and management problems. We did a study to evaluate surgical technique, outcome and complications in 75 cases of tumours treated by multidisciplinary approach (i.e. combined neurosurgery, neuroradiology, ear, nose and throat surgery and intensive care unit team). Retrospective study on 75 consecutive patients with jugular foramen paragangliomas treated surgically from 1989 to 2005. Preoperative balloon occlusion test was performed in all patients as well as embolization (100%). A combined limited infratemporal and juxtacondylar approach was used in all patients. Gross total resection was achieved in 59 patients (78.7%). The most common complication was represented by lower cranial nerve deficits in five patients (6.6%), which was only temporary in three. Postoperative facial nerve weakness occurred in five cases (6.6%) and resolved in three of them. The remaining two patients underwent facial nerve reconstruction by hypoglossal/facial nerve anastomosis. Four patients (5.3%) had a postoperative cerebrospinal fluid leak, which was successfully treated by lumbar drainage. Two patients (2.7%) died because of complications related to surgical injury of lower cranial nerves: one patient developed aspiration pneumonia and septicemia and the second one developed a large cervico-bulbar hematoma that led to severe respiratory distress and ultimately global cerebral hypoxia. Paragangliomas are rare and complex skull base lesions that may be managed with low morbidity and mortality if a multidisciplinary approach is considered. Facial and lower cranial nerve postoperative deficits can be limited.     

Application of microvascular surgery in reconstructive digestive tract surgery]

In our institutes, microvascular surgery has been effectively used in reconstructive digestive tract surgery, including esophageal reconstruction and hepatic arterial reconstruction. Free jejunal transfer combined with a gastric pedicle or microvascularly augmented elongated gastric pedicle has been utilized for total esophageal reconstruction. A microvascularly augmented jejunal pedicle or colonic pedicle has been applied in thoracic esophageal reconstructive cases with gastrectomy. Moreover, microvascular surgery has been performed in the reconstruction of the hepatic arterial system in the surgical treatment of pancreatic or bile duct cancer and living related-donor liver transplantation. Some pitfalls in selection of the recipient vessels and handling the intraperitoneal vessels for microvascular anastomosis are also described. Although microvascular surgery has been carried out by plastic and reconstructive surgeons in a team surgical approach, revisions in the medical educational system to create a new-type of surgeon with practical skills and clinical experience in both digestive tract and microvascular surgery will be required in future.     

Möbius and Möbius-like patients: etiology,diagnosis, and treatment options

The surgical goal in Mobius patients is far more modest and differs from patients with unilateral developmental facial paralysis. It is impossible to restore a true smile in these mask-like, expressionless faces. Despite sophisticated microneurovascular transplantations, movement can only be restored along one vector and enhanced firmness in the cheeks, thus multiple differentiated facial animation is not achievable. A detailed neurological evaluation can identify possible motor donors or residual function, which can be used for additional dynamic restorations. Due to the multiple cranial nerve involvement a thorough clinical and electrophysiological examination is mandatory. In addition, electromyographic survey of the potential motor donors is very helpful to avoid weak wasted regeneration and prevent further downgrading of function. Because of the variety of cranial nerves involved in M?bius' syndrome, a standard procedure for dynamic restoration cannot and should not be promoted; instead, a careful preoperative objective and quantitative assessment should guide the reconstructive surgeon to the optimal reconstruction strategy. Useful movement can be restored in afflicted patients that may signal physical and psychological rehabilitation.     

Necrotizing fasciitis: a plastic surgeon's perspective

Necrotizing fasciitis is a serious life- and limb-threatening emergency that warrants early diagnosis and treatment with surgical debridement. The plastic surgeon would be involved once the debridement in complete to reconstruct the resultant defects or sometimes even in the acute stage to help with appropriate debridement. In this article we revisit the pathophysiology, microbiology, clinical features and reconstruction for defects resulting from necrotizing fasciitis and describe the management from a plastic surgeon's perspective.     

Prospective randomized studies for carotid endarterectomy

The clinical trial has become the standard method used to evaluate surgical procedures. Regarding carotid endarterectomy, clinical trials have reformed the indications for surgery as a means of decreasing the risk of stroke. The methodology and results from significant trials for the symptomatic and asymptomatic patient with carotid stenosis are described. Critical evaluation of these trials is necessary for the discerning surgeon to form a rational approach to clinical practice in carotid disease.     

Elective plastic surgery in a Jehovah's Witness: a case series and review of the literature

"Bloodless" plastic surgery in the Jehovah's Witness patient is an area that has received little attention in the surgical literature. Given the unique and firmly held beliefs of this group of patients, caring for them can be particularly challenging for the plastic surgeon. The authors report a case of bilateral breast reconstruction with saline-filled implants complicated by a postoperative hematoma and one involving a staged approach to massive breast reduction, both in Jehovah's Witness patients. A third patient involving a staged panniculectomy for a complicated wound infection is also described. The historical background, philosophical views, ethical issues, legal aspects, surgical outcomes, and management techniques relevant to caring for this unique patient population are also reviewed in detail.     

1-stage procedure in the reconstruction of frontobasal middle face fractures. Modifications and treatment modalities

This paper deals with the management of 269 patients with frontobasal fractures of which 143 were treated operatively. The close interrelation between midface and base of skull and our operative modifications are discussed. The advantages and importance of the transethmoidal approach to the base of the skull is most adventageous for reconstruction of the midface pillars. Specially for comminuted fractures, avoiding complications such as pseudohypertelorism, telecanthus and frontobasal disturbances. This also enables an accurate reposition to be made with minimal use of foreign materials such as wire ligatures and miniplates. The operation should be performed by the same surgeon in a single sitting thus combining the transethmoidal approach with the midface reconstruction. The reduction of the rate of CSF recurrent leaking to only 3,5% is ascribed to these methods.     

Amputation alternatives in the lower limb, stressing combined management of the traumatized extremity

A methods approach for the care of the traumatic lower extremity amputee is presented, emphasizing joint surgical approach, specifics of management, ideal amputation levels, and functional rehabilitation. The role of the plastic surgeon with an interest in free flaps is ever increasing and has elevated the level and quality of traumatic extremity amputation. Therefore, an understanding by the plastic surgeon of the orthopedic, prosthetic, functional, and rehabilitation principles becomes as important as the orthopedic surgeon's appreciation of current microvascular reconstruction potential. Fortunately, large numbers of traumatic amputees are not available for study in the civilian population. With better-quality extremity salvage by free flap coverage, this number is decreasing. However, the problem will never be eliminated and efforts to produce the best possible amputation must be expended by the best techniques and personnel. Prosthetic management continues to develop with exciting innovations on the horizon. Currently, the modular concept of prosthetic design (Fig. 26) is a practical, cosmetic standard. Newer space-age materials and design changes should facilitate the functional potential of the traumatic amputee. Characteristics of traumatic lower extremity amputees are youth, immaturity, arrogance, and psychological instability, but they are usually cooperative following the initial shock and reality of the situation. These young people deserve our best efforts to allow them to become integrated into society and continue an active life, albeit passive or active (Fig. 27).     

Hamartomas of the internal auditory canal: report of two cases

OBJECTIVE AND IMPORTANCE: To highlight the clinical, radiological, and surgical findings and therapeutic options for this rare entity, which may mimic a purely intrameatal vestibular schwannoma, and to define the particular aspects of preoperative differential diagnosis and surgical management. CLINICAL PRESENTATION: Two patients presented with clinical findings typical of vestibular schwannomas, i.e., tinnitus, hearing loss of 30 dB, and an intrameatal contrast-enhancing lesion on magnetic resonance imaging studies. TECHNIQUE: The lesions were exposed via a suboccipital transmeatal approach, and tumor infiltration of the cochlear and/or facial cranial nerves was identified. In view of the unclear intraoperative histology, surgical management was based on criteria of cranial nerve function. In Patient 1, after nerve decompression by subtotal tumor removal, preserved auditory brainstem responses and facial nerve electromyography indicated functional nerve preservation and facilitated the decision for partial resection. In Patient 2, minimal tumor dissection resulted in complete loss of auditory brainstem response without reversibility. Therefore, a radical tumor removal was performed that sacrificed the cochlear but preserved the facial nerve. CONCLUSION: Symptoms and signs of internal auditory canal hamartomas are congruent with other typical pathological lesions of the internal auditory canal and cerebellopontine angle. Accurate preoperative diagnosis by radiological means is not possible, but careful evaluation of the different signal intensities on magnetic resonance imaging studies may indicate this rare pathological condition. Intraoperative surgical findings of tumor infiltration of the faciocochlear cranial nerve complex may support simple observation. In view of the nonneoplastic characteristic of these lesions, a more conservative approach is justified. The decision should be based on the functional status of the cranial nerves, for which reliable electrophysiological monitoring is indispensable.     

Superior semicircular canal occlusion-Transmastoid approach

INTRODUCTIONThe condition superior semi-circular canal dehiscence was first described by Minor et al. in 1998.PRESENTATION Of CaseWe describe a novel surgical approach to the management of superior semicircular canal dehiscence. Our surgical technique involves a transmastoid rather than middle cranial fossa approach to the superior semicircular canal.CONCLUSIONWe conclude that the transmastoid approach, if anatomically feasible, carries significant advantages compared to middle cranial fossa craniotomy approach for the management of superior semicircular canal dehiscence.     

Trans-supraorbital approach to supratentorial aneurysms

OBJECTIVE: The trans-supraorbital approach has the advantage of combining the keyhole principle with cranial base surgery. The anatomic fields that can be visualized with the use of this procedure have been demonstrated in cadavers, and the advantages and potential surgical applications of this procedure are described in this report. This article is the first to describe a group of intracranial supratentorial aneurysms. METHODS: We used the trans-supraorbital approach in 22 cases of supratentorial aneurysms. In this technique, an incision is made through the eyebrow, then a 3.5-cm craniotomy is performed with en bloc extension to the orbital arch, complemented by different drilling extensions of the orbital roof according to the surgical objective. We describe the anatomic details of the experimental work as well as the clinical results. RESULTS: The trans-supraorbital technique offers an unlimited wide exposure of neurovascular structures in this microsurgical corridor. The craniotomy extension allows greater exposure than the conventional keyhole supraorbital approach, which makes the technique safe for the patient and comfortable for the surgeon. All patient outcomes were successful; no serious complications from the surgical technique occurred. Our success was achieved through better microscopic illumination in the deep field and by gaining access to the complete supratentorial vascular territory with minimal cerebral retraction and an acceptable cosmetic result. CONCLUSION: The trans-supraorbital approach is effective for gaining access to and treating supratentorial aneurysms. Also, the microsurgical field is more convenient in microscope-assisted surgery because total reliance on the endoscope is not required, and minimal brain retraction is needed. This modification of the keyhole procedure also provides multiple surgical options in this microsurgical corridor, using the principles of minimal invasiveness in cranial base surgery.