Endoskopisches Stirn- und Schläfenlift

Endoscopic forehead lifting is a widely accepted treatment for brow ptosis. The procedure safely and effectively corrects horizontal forehead rhytids, brow ptosis, upper eyelid dermatochalasis and periorbital crow’s feet. The result is a refreshed and more open facial expression. A thorough understanding of basic facial anatomy is the key to successful cosmetic surgery. The procedure is based on a subperiostal and preperiosteal mobilisation of the temporal and frontal soft tissues and a detachment of the periosteum of the orbital rim. An upper eyelid blepharoplasty and selective incomplete or complete myotomies of the corrugator and procerus muscles may be incorporated in the operation. Most surgeons prefer to fixate the elevated soft tissue planes to the calvarium by sutures, titanium or resorbabale polyglactid anchors. While initial enthusiasm for this procedure seems to be declining in several countries, few ENT-surgeons are familiar with this technique in Europe. This article reviews the surgical anatomy of the forehead and temporoparietal region by means of cadaver dissection and describes the surgical procedure for German speaking readers.     

Endoscopic forehead lifting: surgical anatomy and technique

Endoscopic forehead lifting is a widely accepted treatment for brow ptosis. The procedure safely and effectively corrects horizontal forehead rhytids, brow ptosis, upper eyelid dermatochalasis and periorbital crow's feet. The result is a refreshed and more open facial expression. A thorough understanding of basic facial anatomy is the key to successful cosmetic surgery. The procedure is based on a subperiostal and preperiosteal mobilisation of the temporal and frontal soft tissues and a detachment of the periosteum of the orbital rim. An upper eyelid blepharoplasty and selective incomplete or complete myotomies of the corrugator and procerus muscles may be incorporated in the operation. Most surgeons prefer to fixate the elevated soft tissue planes to the calvarium by sutures, titanium or resorbabale polyglactid anchors. While initial enthusiasm for this procedure seems to be declining in several countries, few ENT-surgeons are familiar with this technique in Europe. This article reviews the surgical anatomy of the forehead and temporoparietal region by means of cadaver dissection and describes the surgical procedure for German speaking readers.     

Surgical management of chronic sialorrhea in pediatric patients: 10-year experience from one tertiary care institution

Background

Chronic sialorrhea is a common problem for pediatric patients with disorders that affect swallowing. While many patients are successfully treated with medical therapies such as Robinul and Scopolamine, a number of such children are not able to tolerate the side effects of these medications. In these cases, surgical treatments can include Botulinum toxin A (Botox) injections into the major salivary glands, sublingual or submandibular gland excision (SMGE), submandibular duct ligation, parotid duct ligation (PDL), or any combination of the above procedures. The purpose of this study is to report on the 10-year experience with the surgical management of chronic sialorrhea at one tertiary care institution, and compare the efficacy of open surgical procedures versus Botox injections for reduction in salivary flow.

Methods

A retrospective chart review identified 27 pediatric patients with chronic sialorrhea; 21 of whom underwent Botox injections and 15 of whom underwent surgical procedures. Preoperative and follow-up clinic notes were reviewed to determine the level and severity of drooling as well as the effectiveness of sialorrhea reduction, as assessed by the Teacher Drooling Scale (TDS).

Results

42% of those receiving Botox injections reported a reduction in drooling, with the average pre- and post-Botox TDS of 4.3 and 3.9, respectively (p = 0.02 by the Wilcoxon signed rank test). Nine of the patients receiving Botox injections (43%) required multiple injections, with an average duration of effect of 3.9 months, and 7 patients (33%) eventually required surgery. All of the children who underwent surgery (7 bilateral SMGE with PDL, 6 SMGE only, and 2 PDL only) experienced a reduction in drooling, with average pre- and post-operative TDS of 4.5 and 2.2, respectively. This reduction was significant by the Wilcoxon signed rank test (p = 0.001).

Conclusions

The ten-year experience at our institution demonstrates the safety, efficacy and long-term control of drooling in the patients undergoing surgery for intractable sialorrhea.     

Effect of Botulinum Toxin Type A on a Rat Surgical Wound Model

Objectives

The tension on a wound is one of the important factors that determine the degree of fibrosis and scar formation. We hypothesized that local botulinum toxin type A (Botox) induced paralysis of the musculature subjacent to a surgical wound with a skin defect would minimize the repetitive tensile forces on the surgical wound''s edges, and this will result in a decreased fibroplastic response and fibrosis of the wound.

Methods

This is a prospective randomized experimental study. Two distinct surgical wounds were made to the dorsum of 15 adult rats, respectively. One of the 2 wounds was injected with Botox, and the other wound was used as a control, and this was done for all the rats'' wounds. We evaluated the wound size, the degree of fibrosis and inflammation, the blood vessel proliferation, the thickness of the wound and the expression of transforming growth factor (TGF)-β1 in the wounds.

Results

There were significant differences of wound size at the 3rd and 4th week between the Botox and control groups (P<0.05). The Botox group showed less infiltration of inflammatory cells than the control group at the 2nd week (P<0.05). The Botox group showed a smaller number of fibroblasts and less fibrosis than the control group at the 4th week (P<0.05). The Botox group showed much strong collagen density than the control group at the 8th week (P<0.05). For the immunohistochemical staining, there was a lower transforming growth factor (TGF)-β1 expression in the Botox group than that of the control group at the 4th week (P<0.05).

Conclusion

The wounds of the Botox-treated group showed a larger wound size, less infiltration of inflammatory cells and less fibrosis, a much greater amount of collagen and a lower expression of TGF-β1 than did the control group. Botox might be used to decrease the fibrosis of a surgical wound without damaging the epithelial growth in situations for which decreased fibrosis is necessary, such as for treating laryngeal, tracheal and nasal stenosis.     

Advances in facial reanimation

PURPOSE OF REVIEW: Facial paralysis often has a significant emotional impact on patients. Along with the myriad of new surgical techniques in managing facial paralysis comes the challenge of selecting the most effective procedure for the patient. This review delineates common surgical techniques and reviews state-of-the-art techniques. RECENT FINDINGS: The options for dynamic reanimation of the paralyzed face must be examined in the context of several patient factors, including age, overall health, and patient desires. The best functional results are obtained with direct facial nerve anastomosis and interpositional nerve grafts. In long-standing facial paralysis, temporalis muscle transfer gives a dependable and quick result. Microvascular free tissue transfer is a reliable technique with reanimation potential whose results continue to improve as microsurgical expertise increases. Postoperative results can be improved with ancillary soft tissue procedures, as well as botulinum toxin. SUMMARY: The paper provides an overview of recent advances in facial reanimation, including preoperative assessment, surgical reconstruction options, and postoperative management.     

Palpebral capillary hemangioma and amblyopia. Apropos of 2 cases

Periorbital capillary hemangiomas of childhood can produce visual axis occlusion and anisometropia, resulting in amblyopia. We report our experience performing surgical resection of periorbital capillary hemangiomas. Partial resection of hemangiomas was performed in two infants under five months of age, and permitted clearing of the visual axis. This immediate effect is necessary to prevent amblyopia. Surgical resection should be considered a treatment option for managing periorbital capillary hemangiomas which threaten vision.     

Bioresorbable screws for facial bone reconstruction: A pilot study in rabbits

Rigid fixation using plates and screws is an accepted mode of repair for facial fractures and osteotomies. To avoid potential complications associated with metal implants, bioresorbable implants are being developed. A study was performed to assess the strength over time of three bioresorbable polymeric screws for facial bone reconstruction. Screws of each polymer type and a titanium control were implanted in the periorbital bones of eight rabbits. Rabbits were euthanized at various time intervals. Pull-out testing and histological analysis were performed. Results showed varying degrees of resorption and screw pull-out strength dependent on time and polymer type, and no change in the control. This study demonstrates that bioresorbable screws can be used in bone, although the optimal choices for human implantation are yet to be determined.     

Aesthetic analysis of the ideal eyebrow shape and position

The aesthetic importance of the eyebrow has been highlighted for centuries. In this paper, we investigated ideal eyebrow. Eyebrows and eyelids, varies among different races, ages and genders. It is considered to be of primary importance in facial expression and beauty. We present one form of the ideal eyebrow aesthetic and discuss methods of optimising surgical results. For the modern acceptable concept of the ideal brow, the medial brow should begin on the same vertical plane as the lateral extent of the ala and the inner canthus and end laterally at an oblique line drawn from the most lateral point of the ala through the lateral canthus. The medial and lateral ends of the brow lie approximately at the same horizontal level. The apex lies on a vertical line directly above the lateral limbus. Individual perceptions and expectations also differ from person to person. The brow should over lie the orbital rim in males and be several millimetres above the rim in female. Male tend to have a heavier, thicker brow with a little arch present. There are some pitfalls in brow aesthetics. Overelevation creates an unnatural, surprised and unintelligent look which is the most common surgical mistake in brow lifting. Medial placement of the brow peak would create an undesired ‘surprised’ appearance. Moreover, a low medial brow with a high lateral peak induces an angry look. Overresection of the medial brow depressors may lead to widening and elevation of the medial brow, which creates an insensitive look and can also lead to glabellar contour defects. It is impossible to define an ideal eyebrow that is suitable for every face. However, one must consider previously described criteria and other periorbital structures when performing a brow surgery.     

Myobloc for facial wrinkles

During the past decade, the injection of neuromuscular blocking agents produced by the anaerobic spore-forming bacterium Clostridium botulinum exotoxin has become one of the most popular therapeutic options for reducing or eliminating facial wrinkles, especially those in the glabellar area, forehead, and lateral orbital regions (crow’s feet). In December of 2000, the Food and Drug Administration approved the use of Botulinum toxin type B (BoNT-B; Myobloc) in the United States for the treatment of cervical dystonia. Off-label use of BoNT-B also has occurred subsequent to Food and Drug Administration approval, with facial wrinkles as the typical indication. There is a dearth of research in the literature assessing the efficacy and safety of BoNT-B for this purpose but, like Botulinum toxin type A (BoNT-A; Botox), local intradermal injection of BoNT-B appears to enhance dynamic facial wrinkles by inducing chemical dernervation of striated muscle, leading to temporary flaccid paralysis. This article reviews a pilot study involving the use of Botulinum type B for the treatment of facial wrinkles. The efficacy, safety, and duration of Myobloc is discussed.     

Recurrent periorbital cellulitis in a child. A random event or an underlying anatomical abnormality?

We present a case of recurrent periorbital cellulitis in a child. From the age of 2 years the child was admitted with periorbital cellulitis a total of six times with the first five episodes responding to conservative management with intravenous antibiotics. On the sixth admission endoscopic surgical treatment was carried out. Two abnormalities were noted: an anatomically abnormal uncinate process and an isolated abscess in an ethmoidal cell. It is believed that the abnormal uncinate process caused obstruction of the osteomeatal area, predisposing to recurrent peri-orbital cellulitis. We discuss the importance of early imaging and surgery in recurrent periorbital cellulitis.     

Intraoperative monitoring of facial and cochlear nerves during acoustic neuroma surgery.

The likelihood of successful preservation of facial and cochlear nerve function during acoustic neuroma surgery has been improved by the advent of intraoperative monitoring techniques. The facial nerve is monitored by recording EMG from facial muscles, with no muscle relaxants used; mechanical irritation of the nerve during surgery causes increased EMG activity, which can be detected in real time using a loudspeaker. Brief episodes of activity associated with specific surgical maneuvers aid the surgeon in avoiding damage to the nerve, whereas prolonged tonic EMG activity may reflect significant neural injury. Electrical stimulation with a hand-held probe elicits evoked EMG responses, which can be used to locate and map the nerve in relation to the tumor. The threshold for eliciting evoked EMG responses provides a rough indicator of the functional status of the nerve. Different nerves in the posterior fossa (trigeminal, facial, spinal accessory) can be identified in multichannel recordings by the spatial distribution and latency of responses to electrical stimulation. The ability to elicit EMG responses from low amplitude stimulation of the facial nerve at the brain stem after tumor removal is a reasonable predictor of postoperative facial function. Cochlear nerve function is assessed by recording the ABR from ear canal and scalp electrodes or the CNAP with an electrode placed directly on the nerve at the brain stem root entry zone. The ABR is a well-known, noninvasive technique that can be adapted to intraoperative use relatively easily but is of limited utility owing to the delay inherent in signal averaging. Direct CNAP recordings require placement of an intracranial electrode in such a way as to contact the cochlear nerve without interfering with surgical access but have the distinct advantage of rapid feedback on changes in cochlear nerve status.     

Validation of the Synkinesis Assessment Questionnaire

OBJECTIVE: To validate the Synkinesis Assessment Questionnaire (SAQ), a newly developed patient-graded instrument to evaluate facial synkinesis. STUDY DESIGN: This was a prospective clinical questionnaire validation study. METHODS: A total of 65 patients with facial nerve disorders were recruited from the Facial Nerve Center. In 28 patients (group I), the SAQ, a preliminary 10-item instrument, was administered at the initial visit and repeated within 3 weeks without any medical or surgical intervention. In 37 patients (group II), the SAQ was administered before botulinum toxin therapy for facial synkinesis and again 2 weeks after Botox therapy. In addition, the instrument was administered to 20 healthy subjects without facial nerve dysfunction (group III). The reliability, validity, and responsiveness of the SAQ were assessed. RESULTS: Test-retest reliability for the SAQ was high (Spearman's rank correlation r = 0.876, P < .0001). Internal consistency of the instrument was assessed by calculating the Cronbach alpha value. This analysis supported the deletion of one item from the final SAQ. The Cronbach alpha for the final SAQ was 0.859. Construct validity analysis showed a statistically significant improvement in SAQ scores (P < .001) after successful administration of botulinum toxin for treatment of facial synkinesis. There was a highly statistically significant difference (P < .0001) in SAQ scores between normal subjects (group III) and patients with facial synkinesis (group II). CONCLUSIONS: The SAQ is a simple, patient-graded instrument designed to assess facial synkinesis. Instrument analysis suggests that it is a reliable and valid instrument for the assessment of facial synkinesis. The validated SAQ is the first dedicated instrument designed to assess facial synkinesis.     

Prognosis of facial paralysis caused by fracture of the petrous bone

The final outcome of 33 facial palsies (4 bilateral, 25 unilateral) after temporal bone fracture is reviewed. 11 immediate and 22 delayed paralysis were found. Out of the 22 delayed palsies 20 did heal spontaneously. The remaining two patients underwent tympanotomy because of CSF otorrhea. Simultaneously decompression of the facial nerve was performed. 17 of 22 delayed palsies showed complete and 5 incomplete recovery with slight functional defects only. 7 of 11 facial palsies with immediate onsets after injury were treated surgically (6 cases by transmastoid approach, 1 case by transmastoid as well as trans-middle-cranial-fossa approach); in 2 of these patients neural function did not recover. The remaining 4 immediate facial palsies healed spontaneously but showed incomplete recovery. Because it has not been proven yet that the prognosis of traumatic facial palsy can be improved by immediate surgical treatment early surgical intervention should be indicated restrictively. If necessary, reconstruction of the nerve can be done even 6 months after trauma with unchanged prognosis.     

Jugular bulb diverticular and facial paralysis]

The authors report a case where a woman presents a right jugular bulb procidence already known and responsible of a perception deafness. Secondarily, a right facial paralysis is appeared progressively and not regressive even with medical treatment. When the computed tomography as shown an intrapetrous diverticular, the facial paralysis treatment was surgical to decompress the facial nerve. The literature study shoes the rarity of this association facial paralysis and jugular bulb procidence (only two cases), more often responsible of deafness, tinnitus, and vertigo. The diagnosis is given by computed tomography. M.R.I. has not still be evaluated. Then the authors insist on the progressive character of the facial paralysis and on the necessity of a surgical treatment.     

Point-touch technique of botulinum toxin injection for the treatment of spasmodic dysphonia.

Intralaryngeal injections of botulinum toxin (Botox), under electromyographic guidance, have emerged as an effective treatment for adductor spasmodic dysphonia. To remain effective, these injections must be repeated every 3 to 9 months as the symptoms recur. One drawback to the current method is the need for electromyographic confirmation of needle placement into the thyroarytenoid muscle. This report describes an anatomic approach to Botox injection that requires only flexible nasopharyngeal endoscopy and careful evaluation of the anatomic landmarks. This technique has been used successfully on 13 patients, and objective pretreatment and posttreatment measures are reported.     

Intraoperative diagnosis of facial nerve schwannoma at parotidectomy

OBJECTIVE: Our objective was to provide a diagnostic algorithm for facial nerve schwannomas presenting as a parotid mass. STUDY DESIGN: The study is a case report and literature review. METHODS: A clinical case of a patient with an asymptomatic parotid mass diagnosed as a facial nerve schwannoma intraoperatively is presented. The patient's presentation and the diagnostic algorithm and surgical rationale are discussed. A review of the literature on facial nerve schwannomas is presented. CONCLUSIONS: Intraparotid facial nerve schwannomas are an extremely rare entity and are rarely diagnosed preoperatively. Most of these benign lesions can be managed conservatively with the goal of preserving facial nerve function. Intraoperatively, fine-needle aspiration and/or conservative biopsy in a nonstimulating portion of the lesion can be used to make the diagnosis.     

Local anesthetics for facial plastic procedures.

The use of local anesthetic in facial plastic surgical procedures is well established as an effective and safe mode of anesthesia delivery. Local infiltration of anesthesia may be used alone for minor surgical procedures, or it may be used with general anesthesia or intravenous sedation and analgesia for more complex, lengthy procedures. When considered independently, the use of local anesthetic agents has undeniable limitations. Local anesthetics can cause toxicity and side effects. Injection of local anesthetics for subcutaneous infiltration frequently is painful until sensory anesthesia occurs. Local anesthetics have limited efficacy with respect to the intensity and duration of sensory blockade that can be achieved. In some situations, use of local anesthesia with the maintenance of an awake patient also may be undesirable for the surgeon and impractical for the patient. Despite these shortcomings, local anesthetics are fundamentally ideal for use in facial plastic surgery.     

Selective laryngeal adductor denervation-reinnervation: a new surgical treatment for adductor spasmodic dysphonia

During the past decade, botulinum toxin (Botox) has emerged as the accepted treatment for adductor spasmodic dysphonia (ASD). This therapy, which produces bilateral weakness of the thyroarytenoid muscle, undoubtedly produces physiologic effects that are beneficial to patients with ASD. However, it also has important limitations, including the need for repeated injections, the unpredictable relationship between dosage and response, and the possibility of short-term swallowing and voice problems. In this study, we will report our preliminary experience with a new surgical treatment for ASD. In this new procedure, the adductor branch of the recurrent laryngeal nerve is selectively denervated bilaterally, and its distal nerve stumps are reinnervated with branches of the ansa cervicalis nerve. Each of the patients was followed for at least 12 months; the median follow-up is 36 months. The outcome of the operation in 21 consecutive patients is reported. Nineteen of the 21 patients were judged to have an overall severity of dysphonia that was "absent to mild" following the procedure. Only 1 patient underwent further treatment with Botox postoperatively. The implications of this new procedure for ASD are discussed.     

Botulinum neurotoxin for pharyngeal constrictor muscle spasm in tracheoesophageal voice restoration

OBJECTIVES/HYPOTHESIS: The purpose of the study was to evaluate the effectiveness of Botulinum neurotoxin (Botox) for elimination of pharyngeal constrictor muscle spasm in tracheoesophageal voice restoration. STUDY DESIGN: A retrospective review was made of 62 patients between 1991 and 2002 who had Botox as the initial treatment for pharyngeal constrictor muscle spasm. METHODS: One hundred units of Botox properly diluted in 3 mL saline was instilled unilaterally under electromyographic guidance after fluoroscopic identification and marking of the contracted pharyngeal constrictor muscles. The patients were divided into three groups based on their response to the first Botox injection: group I, complete relaxation of the pharyngeal constrictors resulting in fluent voice, intratracheal phonation pressure of 20 to 40 cm H2O, and the ability to say 15 to 20 uninterrupted syllables; group II, hypertonic or incomplete relaxation of the pharyngeal constrictors resulting in intratracheal phonation pressure of 45 to 70 cm H2O and the ability to say 7 or 8 syllables; and group III, failure to produce relaxation of the pharyngeal constrictors. RESULTS: After the first injection of Botox, 49 (79%) patients were in group I or II (41 in group I and 8 in group II) and group III consisted of 13 patients. Thirty-four patients (55%) had group I (28) or II (6) responses for greater than 6 months. A second Botox injection enabled 6 of the 13 failures to move into group I. In all, 8 pharyngeal constrictor muscle myotomies (13%) were ultimately required in the 62 patients. The group I speaker for the longest period has enjoyed 11 years of fluency and successful daily use of a tracheostoma valve after two Botox injections. CONCLUSION: Botox relaxation of the pharyngeal constrictor muscles has proven to be effective, has replaced secondary pharyngeal myotomy for the initial treatment of pharyngeal muscle spasm, and is the only treatment in patients who are not candidates for elective surgery. Radiographic assessment, electromyographically monitored injection, and the number of Botox units appear to be important to successful outcomes.     

Periorbital myectomy for essential blepharospasm

Essential blepharospasm is considered to be an incomplete form of Meige dystonic syndrome. Different medical and surgical treatments have been tried with a low success rate on a long-term basis. We are presenting a patient in whom the recently described technique of periorbital myectomy was applied.