Surgical Atlas of pediatric otolaryngology - part 9 potx

Soft Tissue Surgery 681 Figure 29–3 Repair of lip defect involving the commissure with Estlander type flap. Lip defect, in this case due to neoplasm resection. Note flap design ( A). Result after flap transposition and mucosal advancement ( B). (Reprinted with permission from Renner GJ. Reconstruction of the lip. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 345–96.) Figure 29–4 Repair of lip defect not involving the commissure using the Abbe flap. Lip defect, showing flap design ( A). Result after flap transposition and mucosal advancement with pedi- cle intact ( B). Final result follow- ing pedicle division, which is delayed ( C). (Reprinted with permission from Renner GJ. Reconstruction of the lip. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruc- tion. St. Louis: Mosby; 1995. p. 345–96.) A B A B C 682 Surgical Atlas of Pediatric Otolaryngology AURICULAR REPAIR • The pinna is particularly susceptible to injury and avulsion. The auric- ular contour has little role in terms of hearing, so reconstruction is aimed at creating an inconspicuous unit. • Fortunately, both ears are rarely seen simultaneously. Consequently, exact symmetry of the ears has a lesser priority than preserving general contour and definition. • Auricular cartilage is elastic and covered by a thin layer of skin that allows the irregular contours to be apparent. This unique relationship is difficult to recreate and every effort is made to preserve as much native tissue as possible. • Chondritis of the ear can destroy a meticulous repair and cause signifi- cant deformity. Consequently, all open injuries to the ear require sys- temic antibiotics with adequate cartilage penetration. Quinolones are used frequently in adults, but are inappropriate for pediatric use because of the potential for damage to structural cartilages. Auricular Hematomas • Auricular hematomas should be incised and drained. • The hematoma usually exists between the perichondrium and cartilage, along the anterior and posterior surfaces, and must be fully expressed. Residual blood can devitalize the cartilage and result in a characteristic auricular deformity, ie, the “cauliflower ear”. • Incisions are placed along anatomic boundaries when possible. • A bolster dressing secured with through-and-through mattress sutures applies pressure to the site to prevent re-accumulation. Lacerations • Ear lacerations are closed in layers. • Cartilage is repaired with permanent or slowly absorbing monofilament suture. • Skin closure is performed with emphasis on everting the helical rim to prevent contracture. A small Z-plasty can be created along the helical rim to minimize the notching, but is rarely performed at the acute set- ting. • Cartilage edges that cannot be covered because of skin deficiencies are trimmed to allow primary skin closure. Even if the conservative trim- ming of cartilage creates a slightly smaller ear, it is rarely conspicuous and less important than risking chondritis. Cutaneous Defects Isolated cutaneous defects of the auricle are unusual and more often arise from resection of skin lesions. Best results are generally achieved with a full thickness skin graft, which preserves auricular height, definition, and ori- entation. Helical rim defects are an exception, because of greater fibrofatty tissue producing a “cookie bite” deformity after skin grafting. Soft Tissue Surgery 683 • The skin graft is readily harvested from the periauricular, supraclavicu- lar, or upper eyelid areas. • Perichondrium or the contralateral skin must be intact as the recipient bed. When bare cartilage is exposed, it is often resected to create a vas- cularized wound bed. • A bolster dressing may be sewn in position to assure graft stability. While these dressings are often unnecessary in the face, the additional security is welcome in children. Through-and-through tacking sutures of rapid- ly absorbing gut are helpful to maintain close apposition between the graft and wound bed. Helical Rim Defects • Isolated helical rim defects are managed according to their size. 4,11 ♦ < 20% of defects can be closed using helical rim advancement flaps (Figure 29–5). ♦ > 20% of defects may require a combination of wedge resection and helical advancement. Alternatively, one may create a tubed preauric- Figure 29–5 Repair of small heli- cal rim defect using advancement flaps. Scar to be excised and inci- sion planning ( A). Advancement flaps raised ( B). Advancing and securing the flaps ( C). Final clo- sure ( D). Note: Larger rim defects may require small wedge excision of scaphoid fossa to allow closure of flaps. (Reprinted with permission from Quatela VC, Cheney ML. Reconstruction of the auricle. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 443–80. A B C D 684 Surgical Atlas of Pediatric Otolaryngology ular or postauricular pedicled flap with staged take down, delayed by 3-6 weeks (Figure 29–6). Composite Defects • Larger composite defects, such as those involving the helical rim with the antihelix and scaphoid fossa, are also treated based on their size. 4,11 ♦ < 20% of defects can be closed primarily after simple wedge or star excisions. ♦ > 20% of defects require a cartilage graft interposition with postau- ricular flap coverage and delayed pedicle division. • Composite grafts from the opposite ear can be utilized, but have ques- tionable reliability and leave a significant donor site scar. Auricular Avulsions Partial avulsion • Partial avulsions are re-anastomosed primarily (Figure 29–7). • Tremendous vascular reserve allows many near complete avulsions to survive. • If only partial viability occurs, the result may still be better than what can be achieved secondarily. • The adjacent peri-auricular skin must not be interrupted, because non–hair bearing skin may be essential in a future definitive auricu- lar reconstruction. Complete avulsion Complete avulsion of the auricle is a perplexing problem with no clear method of repair that maintains consistent results. There are several options: • Primary anastomosis, with or without microvascular repair, has been successful. In general, the successful outcomes are found as individ- ual case reports and the number of failed primary re-anastomoses is difficult to find. 12 • The amputated auricle can be de-epithelized and banked in abdominal fat for future use as a structural framework. Unfortunately, the carti- lage loses much of its form and is unable to support a vascularized cutaneous flap. More often, the banked cartilage is used only as small onlay grafts to a definitive framework from costal cartilage. • The pocket principle can be utilized. The avulsed ear is dermabraded to the dermal layer, re-attached primarily to the auricular stump, then buried under a postauricular skin flap. The buried period is only tran- sient and serves to maintain nutrients to the amputated cartilage until vascular flow can be re-established through the primary anastomosis. Once the ear is delivered from the pocket, auricular skin is regenerat- ed from the residual dermal elements and the postauricular skin is replaced in toto. 13 • The auricular stump can be closed primarily and the avulsed tissue discarded with a delayed complete reconstruction using conventional microtia repair techniques. 14 If there is significant trauma to the peri- auricular tissues, use of the temporoparietal fascia flap with costal car- tilage and a full thickness skin graft may be warranted. 15 686 Surgical Atlas of Pediatric Otolaryngology NASAL REPAIR The pediatric nose is rarely injured due to its relative small size with respect to the forehead and cheeks. The mostly cartilage and soft tissue framework further contributes to decreased damage during trauma by imparting greater elasticity. When they occur, however, nasal injuries present some unique challenges: • Cosmetically, the nose has a central position where small scars and sub- tle asymmetries are readily detected. • The juvenile nose assumes the adult proportion and shape during puber- ty and disruption of the growth centers can significantly impact this development. • Successful repair is predicated on a functional result with preservation of normal nasal physiology and patency. Nasal injuries must be viewed as a potential three-layered problem with diligent assessment of the cutaneous tissue, cartilaginous framework, and mucosal lining. Each layer requires meticulous and independent repair. Cutaneous Defects • Lacerated skin edges are closed primarily in a separate layer. • Avulsion of nasal skin is managed initially with conservative measures, but a definitive repair often requires a small transposition flap. • When electing to treat conservatively with second intention healing, one must anticipate some degree of wound contracture and be wary of dis- tortion to the alar rim. Cartilaginous Framework Injuries • The nasal septum must be evaluated for a hematoma, even if sedation or topical anesthesia with vasoconstriction is necessary. 1. Septal hematomas are typically bilateral, occurring in the potential space between the perichondrium and cartilage. 2. Untreated hematomas can devascularize the cartilage, leading to car- tilage absorption or septal perforation. In addition to the physiologic disturbance this causes, it may impact nasal growth and dorsal pro- jection. The result is a persistent juvenile nose with a saddle deformi- ty and nasal obstruction. 3. All hematomas must be drained and the mucoperichondrial flaps re- apposed with absorbable sutures, packing, or splints. In the child, this requires general anesthesia. • Cartilage lacerations should be meticulously re-approximated with per- manent or slowly absorbing monofilament suture. • Cartilage deficits are replaced using existing avulsed cartilage or conchal cartilage grafts. Avulsed cartilage may be a precious source of autologous material. • Injuries to the alar lobule and nasal sidewall may occur without cartilage violation, but repair with soft tissue alone will result in nasal obstruc- Soft Tissue Surgery 687 tion. A cartilage graft may need to be placed in a nonanatomic location to protect against future collapse. Mucosal Injuries • Lacerations of the intranasal mucosa must be specifically repaired. Left alone, they will heal through second intention but not before some degree of wound contracture with possible notching along the alar rim or vestibular stenosis. Once this has occurred, the surgical repair is sig- nificantly more challenging. • Tissue loss intranasally is a challenging problem that requires a second epithelial flap for repair. While this is usually done at a later stage, one must not delay too long lest permanent contracture, distortion, and stenosis occur. There are many options for reconstituting the internal lining, and the surgeon should be facile with several options. 16 Nasal Avulsion • Nasal avulsions are fortunately rare but less resilient than those of the ear. Nevertheless, the amputated segments are generally replaced and closed primarily. • Graft enhancement with hyperbaric oxygen 17 or medicinal leeches may be helpful. 688 Surgical Atlas of Pediatric Otolaryngology PERIORBITAL REPAIR Injuries to this region should prompt a consultation with the ophthalmol- ogist, particularly when there is hyphema, diplopia, enophthalmos, exoph- thalmos, hypophthalmos, globe injury, diminished acuity, or penetration of the orbital septum as evidenced by prolapsing orbital fat. The rudimentary examination should include visual acuity, pupillary function, range of motion, and a fluorescein stain for corneal abrasions. Eyelid Injuries Eyelid anatomy • The eyelid is uniquely devoid of subcutaneous fat and the orbicularis oculi is a thin layer of muscle fibers intimately applied to the deep surface of the thin dermis (Figure 29–8). 18 • Layered relations are important when exploring lid lacerations: 1. At the level of the upper lid margin, the sequential layers are skin, muscle, levator aponeurosis, tarsal plate, and conjunctiva. 2. More superiorly, above the crease, the sequential layers are skin, muscle, orbital septum, orbital fat, levator aponeurosis, and con- junctiva. • The lower lid is retracted via a layer of fascia, which is acted on by the inferior rectus muscle. This fascia is roughly analogous to the levator aponeurosis, but does not require repair when injured. • The gray line is the transition from conjunctiva to squamous epithe- lium and analogous to the vermilion border of the lip. The Meibo- mian glands are more internal and distinct from the gray line. Eyelid lacerations • Repair of lid lacerations should focus on meticulous layered closure and exact re-alignment of the gray line (Figure 29–9). 19 • Tarsal plate injuries are repaired with 2-3 interrupted 6-0 polyglactin sutures through the anterior 2/3 of the plate. The sutures should not penetrate the posterior surface of the tarsus. • The conjunctiva is not repaired, but is held in apposition by the tarsal repair. This prevents abrasion of the cornea by the suture. • Levator aponeurosis can be evaluated by observing for appropriate lid retraction when the patient looks upward. When clearly injured, the levator aponeurosis should be repaired separately with interrupted 6- 0 polyglactin sutures. The sutures are placed precisely at the cut mar- gin of the levator to avoid bunching of the aponeurosis, which may result in lid retraction or lagophthalmos. • Orbicularis oculi fibers are repaired using interrupted 6-0 polyglactin sutures. • Skin margins are traditionally closed with interrupted 6-0 silk suture, however, rapidly absorbing gut can be used. ♦ The first suture is placed at the gray line and is left long for retrac- tion. Sutures are placed on either side of the lash line, progressing away from the lid margin. 690 Surgical Atlas of Pediatric Otolaryngology ♦ The tails of the sutures nearest the lid margin are left long and secured under the knot of the more distal skin sutures. This tech- nique secures the ends away from the globe while leaving them long enough for easy subsequent removal. Eyelid defects • Lid defects are repaired with the same layered technique (see Figure 29–9). • Small defects of the lids that do not involve the tarsal plate or lid mar- gin can be closed in a vertical fashion to prevent lid retraction. • Small defects of the lid margin and tarsal plate can be closed primar- ily. Lateral cantholysis is performed if there is excessive tension. • More extensive lid reconstruction techniques are discussed by Putter- man. 20 Medial Periorbital Injuries The medial periorbital region contains the medial canthal tendons and lacrimal system. Injuries to this area must be explored with attention to the relative anatomy and possible disruption. Canthal anatomy • Canthal tendons are fibrous bands from each end of the tarsal plate and orbicularis muscle that attach to the bone of the medial and lat- eral orbital walls (Figure 29–10). • Medial and lateral canthal tendons separate into anterior and posteri- or limbs. • The limbs of the medial canthal tendon (MCT) straddle the lacrimal sac and attach respectively to the anterior and posterior lacrimal crest of the medial orbital wall. The anterior limb of the MCT is most prominent. • The posterior limb of the lateral canthal tendon (LCT) is most prominent and attaches at Whitnall’s tubercle, which lies 3-4 mm posterior to the orbital rim. The anterior limb fibers interdigitate with the orbicularis muscle and attach at the orbital rim. Canthal tendon injury • Repair of the canthal tendons is imperative to prevent ectropion, scleral show, canthal dystopia, and to maintain a normal intercanthal distance. 19 • Sharply cut tendons can be primarily repaired with 6-0 nylon sutures. • Avulsed tendons must be re-attached to the periosteum or underlying bone with permanent suture or wire. • The keystone principle of reattaching canthal tendons is over-correc- tion. Securing the lateral tendon a few millimeters posterior and superior to their anatomic attachment sites provides for a good out- come after gravity and tension exert their effects. Figure 29–11 Stent of the supe- rior lacrimal canaliculus into the nasal cavity. 692 Surgical Atlas of Pediatric Otolaryngology Canalicular repair • Lacrimal system injuries should be suspected in any trauma to the area of the medial canthus. Repair can be delayed 1-2 days and is often easier at that point. 19 • The puncta are dilated with lacrimal probes and cannulated with the ends of a single piece of 0.94 mm silicone tubing (Figure 29–11). • The ends are then identified in the wound and passed into the respec- tive proximal canalicular stumps after dilation. • The ends of the tubing are passed into the lacrimal sac and directed inferiorly through the nasolacrimal duct and into the nose. • The ends are retrieved from the inferior meatus and tied in a knot with tails long enough for later retrieval. • The tubing is removed after 3-4 months. Eyebrow Injuries • Brow injuries are often discounted, but there are a few points that assist with repair. • The brow should never be shaved. • Any incisions should be made oblique and parallel to the direction of the hair shafts and follicles. • Brow continuity is essential in order to be inconspicuous; it may be nec- essary to excise incomplete avulsions and re-align edges of the brow. • Brow defects can often be repaired using opposing advancement flaps of the remaining brow (Figure 29–12). [...]... delayed healing 700 Surgical Atlas of Pediatric Otolaryngology 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 197 4;27 :93 –7 Renner GJ Reconstruction of the lip In: Baker SR, Swanson NA, editors Local flaps in facial reconstruction St Louis: Mosby; 199 5 p 345 96 Quatela VC, Cheney ML Reconstruction of the auricle In: Baker... 726 Surgical Atlas of Pediatric Otolaryngology REFERENCES 1 2 3 Becker OJ Surgical correction of the abnormally protruding ear Arch Otolaryngol 194 9;50:541–60 Becker OJ Correction of the protruding deformed ear Br J Plast Surg 195 2;5:187 96 Lee D, Bluestone CD The Becker technique for otoplasty: modified and revisited with longterm outcomes Laryngoscope 2000;100 :94 9–54 C H A P T E R 32 M AXILLOFACIAL... 199 6;122:617–20 7 Eavey RD Microtia repair: creation of a functional postauricular sulcus Otolaryngol Head Neck Surg 199 9;120:7 89 93 8 Tjellstrom A Five years experience with bone-anchored auricular prosthesis Otolaryngol Head Neck Surg 198 5 ;93 :366–72 9 Davis J Severe microtia and radical auriculoplasty In: Davis J, editor Otoplasty Aesthetic and reconstruction techniques New York: Thieme-Verlag; 199 7... distortion of adjacent structures.22 • The central limb is oriented in the axis of excessive tension This is usually the pre-existing scar, which can be excised concurrently (Figure 29 13) • The lateral limbs are of identical length to the central limb and extend from the ends of the central limb at angles of ≤ 60˚ or less This should result in parallel arms  698 Surgical Atlas of Pediatric Otolaryngology. .. Press; 199 3 p 317–35 Frodel JL, Wang TD Z-plasty In: Baker SR, Swanson NA, editors Local flaps in facial reconstruction St Louis: Mosby; 199 5 p 131–50 Park SS Scar revision through W-plasty Facial Plastic Surgery Clinics of North America 199 8;6:157–61 Thomas JR, Frost TW Scar revision and camouflage In: Baker SR, Swanson NA, editors Local flaps in facial reconstruction St Louis: Mosby; 199 5 p 587 95 C... Tiny skin fenestrations are closed with a 6-0 mild chromic suture • Apply a mastoid dressing Figure 30 9 Carving of the scapha, fossa triangularis, and antitragus features 710 Surgical Atlas of Pediatric Otolaryngology Postoperative Care • Manage rib area pain as necessary with patient-controlled anesthesia • The suction drains require an hourly change of red-topped vacuum tubes that are displayed in... 2000;123:5 39 42 Ellis E, Zide MF Surgical approaches to the facial skeleton Baltimore: Williams & Wilkins; 199 5 Leone CR Jr Periorbital trauma Int Ophthalmol Clin 199 5;35:1–24 Putterman AM Cosmetic oculoplastic surgery: eyelid, forehead, and facial techniques 3rd ed Philadelphia: WB Saunders; 199 9 Koopman CF Wound healing and scar revisions in the pediatric patient In: Smith JD, Bumsted RM, editors Pediatric. .. with 1200 cases Plast Reconstr Surg 199 9;104:3 19 34 Park SS, Wang TD Temporoparietal fascial flap in auricular reconstruction Facial Plast Surg 199 5;11:330–7 Park SS, Cook TA Reconstructive rhinoplasty Facial Plast Surg 199 7;13:3 09 16 McClane S, Renner G, Bell PL, et al Pilot study to evaluate the efficacy of hyperbaric oxygen therapy in improving the survival of reattached auricular composite grafts... to estimate the amount of redundant postauricular skin to be excised Figure 31–4 An elliptical portion of skin to be excised is outlined with methylene blue and injected with local anesthetic agent 722 Surgical Atlas of Pediatric Otolaryngology • The dashed line shown on the anterior surface of the auricle marks the position of the incisions to be made on the posterior surface of the auricle (Figure... order to avoid creating a “button-hole.” 4 The new antihelix is undermined partially on the outer and inner surfaces, leaving a new antihelix attached in the middle 724 Surgical Atlas of Pediatric Otolaryngology • The outer and inner edges of the new antihelix are rolled to almost approximate each other and are sutured in place using a 4-0 white Mersilene suture (Figure 31 9) About three to five sutures . editors. Local flaps in facial reconstruc- tion. St. Louis: Mosby; 199 5. p. 345 96 .) A B A B C 682 Surgical Atlas of Pediatric Otolaryngology AURICULAR REPAIR • The pinna is particularly susceptible to injury. healing. 700 Surgical Atlas of Pediatric Otolaryngology 9. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 197 4;27 :93 –7. 10. Renner GJ. Reconstruction of the lip left long for retrac- tion. Sutures are placed on either side of the lash line, progressing away from the lid margin. 690 Surgical Atlas of Pediatric Otolaryngology ♦ The tails of the sutures nearest