John M. Lore, Jr., M.D.

Distinguished Member (Clinical Research) Medical Staff, Roswell Park Cancer Institute.
Professor Emeritus, School of Medicine, State University of New York at Buffalo.
Medical Director Emeritus, John M. Lore, Jr., Head and Neck Center, Sisters of Charity Hospital.
Former Head, Department of Otolaryngology-Head and Neck Surgery, Sisters of Charity Hospital.
University Chief, Department of Otolaryngology, Buffalo Children's Hospital and Erie County Medical Center.
Consultant, Veterans Administration Medical Center
Consultant, Roswell Park Cancer Institute
Director of Surgery, Good Samaritan Hospital, Suffern, New York.

Jesus E. Medina, M.D.

Paul and Ruth Jonas Professor and Chair, Department of Otorhinolaryngology,
University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, Oklahoma.

Illustrated by
Robert Wabnitz
Director Emeritus of Medical Illustration, University of Rochester Medical Center, Rochester, New York.
and

Margaret Pence
M.F.A. in Medical Illustration, Rochester Institute of Technology
Adjunct Professor, School of Fine Art, College of Imaging Arts and Sciences,
Rochester, New York.

ELSEVIER
SAUNDERS
ELSEVIER
SAUNDERS
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AN ATLAS OF HEAD AND NECK SURGERY, FOURTH EDITION ISBN 0·7216-7319-8

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NOTICE

Surgery is an ever-changing field. Standard safety precautions must be followed, but as new
research and clinical experience broaden our knowledge, changes in treatment and drug therapy
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 CONTRIBUTORS
AHMED ABDEHALlM, M.D.
Clinical Assistant Professor of Diagnostic Radiology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Neuroradiologist, Roswell Park Cancer Institute;
Neuroradiologist, Women and Children's Hospital
of Buffalo (Kaleida Health System), Buffalo,
New York
Advanced Techniques for CT in the Head and Neck
(Chapter 1)
RONALD A. ALBERICO, M.D.
Associate Professor of Radiology and Assistant
Clinical Professor of Neurosurgery, State University
of New York at Buffalo School of Medicine and
Biomedical Sciences; Director of Neuroradiology
and Head and Neck Imaging, Roswell Park Cancer
Institute; Director of Pediatric Neuroradiology,
Women and Children's Hospital of Buffalo
(Kaleida Health System), Buffalo, New York
Advanced Techniques for CT in the Head and Neck
(Chapter 1)
JOSEPH M. ANAIN, M.D.
Assistant Clinical Professor, Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Chief,
Division of Vascular Surgery, Sisters of Charity
Hospital, Buffalo, New York
Vascular Procedures (Chapter 22)
SHIRLEY A. ANAIN, M.D.
Assistant Clinical Professor, State University
of New York at Buffalo School of Medicine
and Biomedical Sciences, Buffalo, New York
Facial Paralysis (Chapter 7)
JOHN E. ASIRWATHAM, M.D.
Clinical Associate Professor of Pathology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Department of Pathology, Sisters of Charity
Hospital, Buffalo, New York
Bone Imaging and Pathology (Chapter 3); Pathology
of the Parathyroid Glands (Chapter 18)
ANGELA BONTEMPO, F.A.C.H.E.
President and CEO, Saint Vincent Health System,
Erie, Pennsylvania
A Comprehensive, Interdisciplinary Head and Neck
Service (Chapter 3)
DANIEL BRODERICK, M.D.
Assistant Professor of Radiology, Mayo Clinic,
Jacksonville, Florida
Bone Imaging and Pathology (Chapter 3)
DANiEl SETTE CAMARA, M.D.
Clinical Associate Professor of Medicine,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Gastroenterology Service, Sisters of Charity Hospital,
Buffalo, New York
Percutaneous Endoscopic Gastrostomy (Chapter 21)
DAVID M. CASEY, D.D.S., M.S.
Clinical Professor, Department of Restorative Dentistry,
State University of New York at Buffalo School
of Dental Medicine; Head, Maxillofacial Prosthetic
Section, John M. Lore, Jr., M.D. Head and Neck
Center, Sisters of Charity Hospital; Maxillofacial
Prosthodontist, Department of Dentistry,
Maxillofacial Prosthetics, Roswell Park Cancer
Institute, Buffalo, New York
Dental and Prosthetic Considerations in Head and
Neck Surgery (Chapter 3); Maxillofacial Prostheses
(Chapter 3)
GREGORY J. CASTIGLIA, M.D.
Neurosurgeon, Buffalo Neurosurgical Group, Amherst,
New York
Supraorbital Approach to the Orbit and Paranasal
Sinuses (Chapter 23)
v
 CONTRIBUTORS
NIEVA B. CASTILLO, M.D.
Assistant Clinical Professor of Pathology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Associate
Chief of Pathology, Department of Pathology,
Sisters of Charity Hospital, Buffalo, New York
Malignant Mixed Tumor (Chapter 17); Endocrine
Surgery (Chapter 18); Vascular Procedures
(Chapter 22)
KANDALA CHARY, M.D.
Medical Oncology, Sisters of Charity Hospital,
Buffalo, New York
Preoperative Chemotherapy, Uncompromised Surgery,
and Selective Radiotherapy in the Management
of Advanced Squamous Cell Carcinoma of the
Head and Neck (Chapter 3)
SCOTT CHOLEWINSKI, M.D.
Director, Department of Magnetic Resonance Imaging,
Sisters of Charity Hospital, Buffalo, New York
CT and MRI (Chapter 1); Bone Imaging and Pathology
(Chapter 3)
KEITH F. CLARK, M.D., Ph.D.
Clinical Professor, Department of Otorhinolaryngology,
University of Oklahoma Health Sciences Center
College of Medicine, Oklahoma City, Oklahoma
Endoscopic Sinus Surgery (Chapter 5)
ERNESTO A. DIAZ-ORDAZ, M.D.
Assistant Professor of Otolaryngology and Assistant
Professor of Communicative and Speech Disorders,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Acting Chair,
Department of Otolaryngology, Sisters of Charity
Hospital, Buffalo, New York
Infratemporal Approach to the Skull Base (Chapter 23)
ROBERT W. DOLAN, M.D.
Surgeon, Department of Otolaryngology, Head and Neck
Surgery, Lahey Clinic, Burlington, Massachusetts
Microvascular Surgery (Chapter 24)
MEGAN FARRELL,M.D.
Endocrinologist, John M. Lore, Jr., M.D. Head and
Neck Center, Sisters of Charity Hospital, Buffalo,
New York
Endocrine Surgery (Chapter 18)
DAVID F. HAYES, M.D.
Assistant Clinical Professor of Radiology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Chair, Department of Diagnostic Imaging,
Sisters of Charity Hospital, Buffalo, New York
CT and MRI (Chapter 1); Ultrasound (Chapter 1)
l. NELSON HOPKINS, M.D.
Chief of Neurosurgery, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences, Buffalo, New York
Vascular Procedures (Chapter 22)
R. LEE JENNINGS, M.D.
Assistant Clinical Professor of Surgery,
University of Colorado Health Sciences Center
School of Medicine; Colorado Surgical Oncology
Associates, Denver, Colorado
Preoperative and Postoperative Care (Chapter 3)
CONSTANTINE P. KARAKOUSIS, M.D., PH.D.
Professor of Surgery, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences; Millard Fillmore Hospital
(Kaleida Health System), Buffalo, New York
Malignant Melanoma (Chapter 3); Soft Tissue
Sarcoma (Chapter 3)
SOL KAUFMAN, Ph.D.
Research Assistant Professor of Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Consultant,
Biostatistics, Buffalo, New York
Preoperative Chemotherapy, Uncompromised Surgery,
and Selective Radiotherapy in the Management
of Advanced Squamous Cell Carcinoma of the
Head and Neck (Chapter 3)
DOUGLAS W. KLOTCH, M.D.
Surgeon in Private Practice, Tampa, Florida
Fractures of Facial Bones (Chapter 13)
ASHOK KOUL, M.D.
Clinical Assistant Professor of Pathology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Director of Pathology and Laboratory Medicine,
Sisters of Charity Hospital, Buffalo, New York
Commonly Used Terminology for Squamous Epithelium
(Chapter 3)

JOHN LAURIA, M.D.
Professor and Chair Emeritus, Department of
Anesthesiology, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences and Sisters of Charity Hospital, Buffalo,
New York
Venous Air Embolism (Chapter 2); Malignant
Hyperthermia (Chapter 2)
KEUN Y. LEE, M.D.
Assistant Clinical Professor, Department of
Otolaryngology, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences; Attending in Otolaryngology-Head and
Neck Surgery, Sisters of Charity Hospital; Buffalo
Otolaryngology Group, Buffalo, New York
Posterior Neck Dissection (Chapter 16)
JOHN S. LEWIS, M.D.
Associate Clinical Professor Emeritus of Otolaryngology,
Columbia University College of Physicians and
Surgeons, New York, New York
Temporal Bone Resection (Chapter 23)
THOM R. LOREE, M.D.
Chief, Department of Head and Neck Surgery,
Roswell Park Cancer Institute, Buffalo, New York
Management of Salivary Gland Tumors (Chapter 17)
A. CHARLES MASSARO, M.D.
Senior Vice President, Medical Affairs,
Sisters Healthcare System, Buffalo,
New York
A Comprehensive, Interdisciplinary Head and Neck
Service (Chapter 3)
JESUS E. MEDINA, M.D.
Paul and Ruth Jonas Professor and Chair,
Department of Otorhinolaryngology,
University of Oklahoma Health Sciences Center
College of Medicine, Oklahoma City, Oklahoma
The Neck (Chapter 16)
ROBERT S. MILETICH, M.D., Ph.D.
Associate Professor of Clinical Nuclear Medicine,
Department of Nuclear Medicine,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Staff Physician,
Veterans Affairs Western New York Healthcare
System, Buffalo, New York; Staff Physician,
Dent Neurologic Institute, Amherst, New York
Positron Emission Tomography (Chapter 1)
CONTRIBUTORS
DOUGLAS B. MORELAND, M.D.
Director, Buffalo Neurosurgery Group;
Chief of Neurosurgery, Sisters of Charity Hospital;
Co-Director, Gamma Knife Center,
Roswell Park Cancer Institute, Buffalo, New York
Endoscopic Endonasal Transsphenoidal Approach to
the Pituitary Gland (Chapter 23)
WILLIAM M. MORRIS, M.D.
Buffalo, New York
Cardiopulmonary Resuscitation (Chapter2)
WILLIAM R. NElSON, M.D.
Clinical Professor Emeritus of Surgery,
University of Colorado Health Sciences Center
School of Medicine, Denver, Colorado
Preoperative and Postoperative Care (Chapter 3)
ROBERT J. PERRY, M.D.
Clinical Associate Professor of Surgery (Plastic),
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Chief, Division of Plastic Surgery, Women and
Children's Hospital of Buffalo (Kaleida Health
System), Buffalo, New York
Cleft Lip and Palate (Chapter 10)
JOACHIM PREIN, M.D., D.M.D.
Professor of Maxillofacial Surgery and Chair,
Clinic for Reconstructive Surgery,
Unit for Maxillofacial Surgery, University Clinics
of Basel; Chair, European Maxillofacial Education
Committee, Basel, Switzerland
Compression Plating for Ireatment of Mandibular
Fractures (Chapter 13)
ALLEN M. RICHMOND, PH.D.
Clinical Instructor, Department of Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; John M. Lore,
Jr., M.D. Head and Neck Center, Sisters of Charity
Hospital; Staff, Buffalo Hearing and Speech Center,
Inc., Buffalo, New York
Voice, Speech, and Swallowing Rehabilitation of the
Head and Neck Patient (Chapter 3)
ARTHUR J. SCHAEFER, M.D.t
Clinical Professor of Ophthalmology and Clinical
Assistant Professor of Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences, Buffalo,
New York
Blindness and Ophthalmic Complications of Surgery
of the Head and Neck (Chapter 2)
t Deceased.
 CONTRIBUTORS
DANIEL P. SCHAEFER, M.D.
Director of Oculoplastic, Facial, Orbital,
and Reconstructive Surgery; Clinical Professor
of Ophthalmology; Clinical Assistant Professor
of Otolaryngology, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences, Buffalo, New York
Blindness and Ophthalmic Complications of Surgery
of the Head and Neck (Chapter 2); Thyroid-Related
Orbitopathy (Chapter 3); Supraorbital Approach to
the Orbit and Paranasal Sinuses (Chapter 23)
DHIREN K. SHAH, M.D.
Medical Director, Cancer Treatment Services;
Assistant Clinical Professor, State University
of New York at Buffalo School of Medicine and
Biomedical Sciences, Buffalo, New York
Radiation Therapy for Laryngeal Cancer
(Chapter 20)
DONALD P. SHEDD, M.D.
Professor Emeritus, Department of Head and Neck
Surgery, Roswell Park Cancer Institute, Buffalo,
New York
Common Departures from Sound Management
(Chapter 3)
MONICA B. SPAULDING, M.D.
Associate Professor of Medicine and Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Chief,
Oncology Section, Veterans Affairs Western
New York Healthcare System, Buffalo, New York
The Place for Chemotherapy in Management
of Squamous Cell Carcinoma of the Head and Neck
(Chapter 3)
MAUREEN SULLIVAN, D.D.S.
Chief, Department of Dentistry and Maxillofacial
Prosthetics, Roswell Park Cancer Institute,
Buffalo, New York
Osseointegrated Implants in Head and Neck
Reconstruction (Chapter 3)
NAN SUNDQUIST, R.N.
Formerly Chief Nurse, Department of Otolaryngology,
State University of New YQrk at Buffalo School
of Medicine and Biomedical Sciences, Buffalo,
New York
Preoperative Chemotherapy, Uncompromised Surgery,
and Selective Radiotherapy in the Management
of Advanced Squamous Cell Carcinoma of the
Head and Neck (Chapter 3)
 IN MEMORIAM

Dr. John M. Lore, Jr., passed away on January 12,2004. He continued active medical
practice and cared for his patients until shortly before his death. Dr. Lore was world
renowned as a head and neck surgeon. After receiving his medical degree from New
YorkUniversity, he completed residencies in both otolaryngology and general surgery.
He was the Chairman of the Department of Otolaryngology-Head and Neck Surgery
at the State University of New York at Buffalo School of Medicine, 1966 to 1991. He
later joined the Department of Head and Neck Surgery at Roswell Park Cancer Institute.
Dr Lore was one of the founders of the American Society of Head and Neck Surgery.
He was a past president of that society as well as of the Society of Head and Neck
Surgeons. He contributed to the early efforts to combine the two Head and Neck
Societies. He was also a founding member, and former chairman of the Joint Council
for Advanced Training in Head and Neck Oncologic Surgery, which was instrumental
in establishing the fellowship programs in advanced Head and Neck Surgical Oncology,
accredited by the American Head and Neck Society. During his long and distinguished
career, Dr. Lore received many honors and awards recognizing his many contribu-
tions to the specialty of Head and Neck Oncology. He was passionate and tenacious
in the practice of his profession; he was an early pioneer and champion of the use
of adjuvant chemotherapy in the treatment of head and neck cancer.
Jack was equally passionate and tenacious in his many nonprofessional interests
and pursuits. He was an avid and accomplished skier, sailor, and photographer.
Professionally, his most enduring and cherished attribute was his compassion and
his dedication to his patients. When I first met Dr. Lore, he was one of the leading
members of our specialty. I then became one of his collaborators and colleagues.
Eventually, 1 came to know Jack as my friend. He will be greatly missed. An Atlas
of Head and Neck Surgery, 4th edition, serves as a legacy and tribute to his memory.

Thom R. Loree, M.D.

IX
 Recognition by
The Board of Managers of St. Vincent's Hospital, New York,
New York, at the time of his death.
 To My FATHER

JOHN M. LORE, M.D., F.A.C.S.

1892-1950

whose energy and devotion both in his chosen field in medicine-otolaryngology-

and in his dedicated aim in medical education-a new medical center for his
medical school, New York University-were and still are an inspiration.
His desire for cooperation in and plans for a consolidated surgical training program
in the field of head and neck surgery provided the impetus for this Atlas.

Dr Lore, Sr. was born in Caleane, Sicily, and came to the United States of
America at age 5. He was a naturalized citizen of the United States and served in
World War I as an officer in the United States Navy.

XI
 PREFACE
Over 40 years have passed since the publication of the
first edition of An Atlas of Head and Neck Surgery,
including three English editions and one Spanish
edition. This Fourth Edition has further broadened its
background-an increased scope of each chapter with
an additional number of contributors.
Jesus E. Medina, M.D., is welcomed as an associate
editor to this Fourth Edition. He has been instrumental
in a number of facets, namely in obtaining Robert W.
Dolan, M.D., Department of Otolaryngology, Head and
Neck Surgery, Lahey Clinic, to author the new chapter
on Microvascular Surgery, and Keith F. Clark, M.D.,
Ph.D., for the addition of Endoscopic Sinus Surgery to
Chapter 5. Dr. Medina also has contributed to a number
of other areas.
The additions, it is believed, cover items that hit the
highlights of a number of aspects of head and neck
surgery, which are available to the surgeon as up-to-
the-minute help. It is not a cookbook of surgery, how-
ever. This could be an inherent danger in an atlas. The
surgeon must be experienced with the various proce-
dures and modifications thereof. No dabblers.! The
choice of the surgical procedure must not be based on
the easiest and quickest minimum resection but rather
must be aggressive'> There is a danger of preserving
soft tissue and bone with disease-free minimum margins
and even no margins.
Reference is made to Dr. Murray F. Brennan's presi-
dential address to the Society of Surgical Oncologists
in 1996.3 There should be no such attitude as "leave
disease right up to the line of resection." It appears that
widespread use of radiotherapy as a routine postoper-
ative modality is fraught with the misconception for
the surgeon that if a little tumor is left behind it is
really no worry since routine radiotherapy is the catch-
all. Margins in this methodology mean little since ion-
izing radiation will handle all that the surgeon neglects.
Radiotherapy, as well as chemotherapy, plays an impor-
tant part in the management of head and neck squa-
mous cell carcinoma, Stage III and Stage IV, but is not
meant to give a false sense of security to the surgeon.
Hence, it is believed that radiotherapy should not be
routinely used postoperatively but rather selectively. This
spares the patient of the side effects of radiotherapy, as
well as making radiotherapy available during the entire
follow-up period if indicated. With the use of chemo-
therapy, the surgeon must not compromise the scope of
surgical resection when there is a favorable response to
the chemotherapy. Please confer preoperative chemo-
therapy in Chapter 3.
As more tissue and bone are removed, the reconstruc-
tive measures must be further improved and expanded
from a cosmetic and a functional point. A caveat that
must be emphasized is that wherever possible or prac-
tical the reconstructive measures should not mask early
or late recurrence of disease. At times this is not possible.
As an expansion of the reference to microvascular
surgery in the preface of the Third Edition, a new
Chapter 24 has been added. The indication for micro-
vascular surgery has broadened and has served well in
a number of reconstructive problems, especially free skin
flaps for major skin defects of the cheek, as well as muscle
and bone transfers. This new chapter by Dr. Dolan serves
two purposes: (1) to demonstrate to the head and neck
oncologic surgeon what can be achieved by microvas-
cular surgery and (2) to present the techniques involved.
These techniques are not for the dabblers-only for
experienced microvascular surgeons.
Take time to evaluate and record the extent of disease
utilizing tattoo, when possible, prior to any manage-
ment plan. Do not depend on the site evaluation at the
time of the initial surgical procedure. This admonition
is an absolute with the use of preoperative chemotherapy
or, for that matter, radiotherapy, especially if salvage
surgery becomes necessary following any recurrence
after the radiotherapy.
Regular careful and thorough follow-up of patients
must be carried out to the best possible degree. Follow-
up must be done by the surgeon and by those expert in
the field of head and neck examination and knowledge
of the natural history of the disease. The primary respon-
sibility is the surgeon's and not the primary care physi-
cian's. Keep records, which will be valuable as an eval-
uation of outcome-not only the physical examination,
but also the quality of life. When evaluating the quality
of life, take into account the family support or lack
of support.
It may be worthwhile at different times to have
different physicians in other allied disciplines involved
in the search for early recurrence. For example, the
XIII
 PREFACE
reconstructive surgeon, the prosthodontist, the radia-
tion oncologist and the medical oncologist, and the
specially trained nurse clinicians all should be involved
in evaluation. This approach is time consuming both
for the medical professionals as well as the patient,
and sometimes it's shattering for the HMOs. These
follow-up examinations should be based on a regular
schedule-usually one time per month for the first year
and then every two months for the second year and so
on up to five years. They continue every 5 to 6 months,
as enumerated later. There is some indication or recur-
rence following preoperative chemotherapy. New pri-
maries may appear between the seventh and the tenth
year. Follow-up should not be more than every 5 to
6 months; sooner if there appears to be a predisposing
factor to squamous cell carcinoma.
Follow-up is for life. A patient who continues to smoke
or who has an indication of field carcinogenesis is an
example. Frequencies may be increased or decreased,
depending on the anticipated natural history of the
disease. This is time consuming yet most important.
Review all images-not just reports. CT, MRl, MRA,
angiograms, and PET scans, when appropriate, must
be reviewed by the surgeon. It is not unusual to spend
upwards of one hour in this type of preoperative evalu-
ation. Postoperative examination, especially long-term,
likewise involves considerable time and effort. This is
another problem for those from the HMOs to compre-
hend even though they may be physician consultants.
One HMO recognized this "unique specialty practice"
involving training in both otolaryngology and general
surgery. All this is a significant and tremendous respon-
sibility for the surgeon and all those concerned.
In the Preface of the Third Edition, the concept of
centers of excellence was introduced in the manage-
ment of neoplasms of the head and neck. In 1993, this
concept was initiated at Sisters of Charity Hospital in
Buffalo, NY. The following is a description of such a
center. It has flourished well and its weekly tumor
conferences with surgery, medical oncology, radiation
oncology, and endocrinology, as well as with its special-
ized nurses and support personnel, has attracted local
physicians from other hospitals in the Buffalo area. Since
its inception, it has trained fellows with backgrounds
in otolaryngology, general surgery, and plastic surgery.
The center supports the concept of excellence in patient
care plus the important addition of academia and ecu-
menism. The academia in itself is desirable, and when
joined in a single service including all of the disciplines
involved becomes a sine qua non in the management
of head and neck neoplasms, including thyroid diseases.
A dedicated interest in academia produces interest
in newer concepts-for example, molecular biology
with gene therapy-which may well become the basis
of future treatment of head and neck squamous cell
carcinoma.
Description of Head and Neck Services
at Sisters Hospital4
Over the years, management of neoplastic disease as well
as other diseases has crossed time-honored established
disciplines. In head and neck neoplasia, including thy-
roid malignancy; surgical, medical, and radiation oncol-
ogy; and endocrinology, other supportive disciplines
and services are involved. The input from these disci-
plines is usually achieved by multidisciplinary confer-
ences. To further develop this ecumenical approach, to
avoid "turf battles," and to further enhance cooperative
and close exchange of ideas regarding diagnosis and
management of head and neck neoplasia, a Head and
Neck Oncology Service within the John M. Lore, Jr.,
M.D., Head and Neck Center at Sisters Hospital, Buffalo,
NY, was established 8 years ago. This service encom-
passes the aforementioned disciplines plus all other
germane disciplines and services, including General
Otolaryngology, Reconstructive Surgery, Vascular Sur-
gery, Microvascular Surgery, Neuro-otology, Skull Base
Surgery, Oncologic Ophthalmology, Diagnostic Imag-
ing, Head and Neck Pathology, Nuclear Medicine,
Psychiatry, Maxillofacial Prosthetics, Dental Pathology,
Swallowing and Speech Pathology, Nutrition and
Biostatistics.
The main purpose is to render the best possible
patient care, to attract the best qualified physicians and
other professionals (thus sifting out the dabblers), and
to promote an academic atmosphere. This oncology
service functions as an autonomous service with the
cooperation and support of the Chairman of the Depart-
ment of Surgery and the Chairman of the Department
of Internal Medicine. The Service is responsible for
its own quality review data, which is supplied to the
Quality Review hospital committee. Outpatient; in-
patient; speech and swallowing professionals with labo-
ratory staff, physicians, fellows, and nurse clinicians;
as well as oncologic dentistry, conference rooms, library
and nutritional offices are all contiguous and on the
same floor of the hospital.
On the same floor is the Pathology Department and
up one flight are the OR and ICU. Down one flight is
Diagnostic Imaging and Nuclear Medicine. On another
floor is the Microsurgical Laboratory.
It appears that this approach to head and neck neo-
plasia, including thyroid and parathyroid tumors, truly
improves patient care without the stigma of "treatment
by committee." We may agree or disagree yet each indi-
vidual is free to treat the patient as he or she sees fit.
This type of service avoids the wasted time involved in
turf conflicts. The Head and Neck Oncology Service is
a complete system where the sum of all the components
is much better for patient care than any independent
part. At the very beginning of this project was and still
is Robert E. Rich, the founder of Rich Products, who

gave me the impetus to go ahead with this idea. He
produced the wherewithal to start basically a "one-
step" facility, which minimizes "wasted time" in the
diagnosis and management of head and neck neo-
plastic disease.
There are four team players who helped in the inau-
guration of this multiple discipline service: Kenneth
Eckhert, M.D., Chief of Surgery; Nelson Torre, M.D.,
Chief of Medicine; Sister Angela Bontempo, Adminis-
trator at Sisters of Charity Hospital; and Charles Massaro,
M.D., Vice President of Medical Affairs at Sisters of
Charity Hospital. Without the cooperation of these indi-
viduals this service could never have been developed.
It had previously been proposed when I was Chairman
of the Department of Otolaryngology at the State
University of New York at Buffalo to the dean, and
twice he turned this concept down saying, "We are not
ready for anything like that just yet." Hence, the medical
school was bypassed in this endeavor.
The amalgamation of the Society of Head and Neck
Surgeons, founded by Hayes Martin and Grant Ward
in 1954, and the American Society for Head and Neck
Surgeons, established in 1958 by the hard work of George
Sisson, M.D., along with other dedicated head and neck
surgeons, was a great step forward. Among the other
dedicated surgeons as founders of the American Society
for Head and Neck Surgery was Edwin W Cocke, M.D.,
John S. Lewis, M.D., W. Franklin Keim, M.D., William
M. Trible, M.D., and John M. Lore, Jr., M.D. This amal-
gamation in 1999 united the two societies into one
society, now known as The American Head and Neck
Society. This joined the disciplines of otolaryngology,
general surgery, and plastic surgery into one endeavor.
There are many benefits to this amalgamation, not the
least of which, of course, is improvement of patient
care by the sharing of various ideas among the various
disciplines all present at the same meeting.
The main downside as I see it is the fact that the
larger the society is, the less discussion there is from
the floor and membership. I would strongly suggest
that adequate time be allowed in meetings for this type
of discussion, because this enhances the exchange of
different ideas and different methodologies of treatment.
There is an interesting and laudable result of this
amalgamation in that it should and will eliminate the
striving of one society to have more members than the
other. This inherent danger, which previously existed,
should be eliminated once and for all. This attempt at
getting more members led to the admission of surgeons
regardless of background who were not fully qualified
in the field of head and neck oncology. There is no need
for an unlimited supply of head and neck surgeons
since, to quote from the Third Edition, "There are only
about 50,000 new patients each year with head and neck
cancer, and only approximately 35 to 75 new, well-trained
head and neck oncologic surgeons are necessary each
PREFACE
year to maintain an adequate workforce of some 400
to 1,000 head and neck oncologic surgeons to manage
this number of patients. Thus, we must minimize the
number of 'dabblers.'] There is simply no reason to
accept physicians who are not well-trained in this field.
Quality and not quantity is the objective.
There is no doubt that, except in the rare case, the
residents interested in this field must be dedicated to it
and spend extra time in a fellowship, preferably approved
by the American Head and Neck Society. This would
help them reach near perfection in their chosen field as
best as possible. This concept in medicine has been
useful in the training of hand surgeons, since it involves
the disciplines of general surgery, orthopedic surgery,
and plastic surgery. In hand surgery, this has been recog-
nized by the three boards as an important facet in the
training of a hand surgeon. Unfortunately, in head and
neck surgery, the three boards involved, namely, otolaryn-
gology, general surgery, and plastic surgery, have not
seen fit to endorse this concept. Unless the individual
is a genius, there is simply no way to adequately train a
resident in the various facets of head and neck oncology
and endocrinology in a residency training program,
since the training in that particular specialty involves a
number of other aspects over and above head and neck
oncology. As Harvey Baker, M.A.,s discussed in his
presidential address to the Society of Head and Neck
Surgeons entitled Head and Neck Surgery: The Pursuit
of Excellence in 1971 and pointed out that to be active,
for example in general otolaryngology, simply does
not afford the time and effort needed to become a well-
trained and practicing and active head and neck onco-
logic surgeon.
Logical conclusion to these standards is the active
participation in one of the approved fellowships. Having
been the originator of this additional fellowship train-
ing plus having the position of president of both head
and neck societies, I have had, and I say this with
humility, experience in the endeavor. Changes in the
fellowship curriculum were made from time to time
and rightly so. The latest one of admitting graduates of
well-trained foreign programs is strongly commended.
Remember, American surgeons at the time of the late
1800s and early 1900s were afforded the benefits of
learning from their European counterparts. We have
the same obligation and advantage today to share all
our ideas and techniques with our European colleagues.
We learn from one another.
Some flexibility is worthy of implementation, namely,
possibly one or two types of fellowships. The one-year
fellowship would primarily focus on the clinical aspects
of head and neck oncology but would also include a
reasonable amount of clinical research. The two-year
fellowship would involve basic research along with
clinical exposure in a suitable institution where the
candidate's desires can be realized. Selected arrange-
 PREFACE
ments for rotation of fellows from one parent institu-
tion to one or two other institutions-for one month-
would afford the fellow an excellent exposure to other
methodologies in the overall management of head and
neck neoplasia.
Again, it is my strong admonition that two years
of basic surgical training in an approved general surgi-
cal training program is highly recommended for those
who wish to pursue a head and neck oncologic fellow-
ship. The exposure to basic surgical principles cannot
be achieved, I believe, in a single discipline-oriented
program. I can attest to this again by personal experi-
ence, having completed the approved residency in the
American Board of Otolaryngology and the American
Board of Surgery. I am not inferring that double boards
are necessary. But otolaryngology residents would cer-
tainly benefit from two years of general surgery. The
reverse, namely, dedicated training in otolaryngology,
is also true for the general surgery and plastic surgery
residents. Ideally, another year of plastic surgery would
be fortuitous.
The next step in the joint venture of all three disci-
plines, namely, general surgery, otolaryngology, and
plastic surgery, would be the recognition by the three
boards concerned relative to an approval of this fellow-
ship. To attempt to achieve this objective, plans were
modeled after the three boards of general surgery, plastic
surgery, and orthopedic surgery, agreeing on a post-
residency hand training program. Dr. George Omer,
from Albuquerque, New Mexico, was the driving force
in this venture. It appears that they have succeeded
with the cooperation of the three boards recognizing an
acceptable fellowship in hand surgery.
Following this concept that was developed in hand
surgery, an attempt was made to achieve the same type
of recognition by the three boards involved in training
of head and neck oncologic surgeons. The initial data-
gathering trip was made by Dr. William Nelson and me
going to Albuquerque to review with Dr. George Omer
how he achieved the cooperation of the three boards.
Following his ideas, Dr. Elliott Strong and I developed
a similar concept for the recognition of head and neck
oncologic surgery by the American Boards of Otolaryn-
gology, Surgery, and Plastic Surgery as "added qualifi-
cations." Unfortunately, we failed despite our efforts at
the board level and at the American College of Surgeons
level and it was then that we simply gave up the
endeavor. I decided then to take the next step and that
was to develop a center of excellence in our particular
field and, hence, the development of the Head and Neck
Oncologic Service at Sisters of Charity Hospital.
Another aspect that is most important in the develop-
ment of our field is the realization that we are a profes-
sion and not a business. This is aptly referred to in
Dr. Robert M. Beyers's presidential address to the Society
of Head and Neck Surgeons in 1996 entitled, Barberpoles,
Battlefields,and Wounds that Will Not Heal.6 I quote
him as follows: "If we act like a trade or business rather
than a profession, we shouldn't complain about words
used to describe us such as healthcare providers and
our patients as clients." Dr. Beyers goes on to quote
Simon H. Rifkind, a lawyer, who expressed his views
about how a profession loses its professionalism. It is
recommended that Dr. Beyers's presidential address be
read in its entirety.
And Now a Few Caveats
Insecurity is the main stumbling block for a joint venture.
For management with the best overall survival for
advanced squamous cell carcinoma of the head and
neck, aggressive surgery is the mainstay.2 Radiation
Oncology and Medical Oncology are ancillary and
required fine-tuning. Molecular Biology may alter this
sequence in years ahead.
For organ preservation in advanced squamous cell
carcinoma of the head and neck, chemotherapy and
radiotherapy are the primary modalities with salvage
surgery for failures and backup. Patients must be aware
of the complications and effect on survival and quality
of life, specifically the significant complications of sal-
vage surgery. These complications were experienced
some 40 to 50 years ago when radiation was the first
treatment modality followed by surgery. Because of
these complications, the sequence of treatment was
changed to surgery followed by radiotherapy.
Physicians must be the real leaders in medicine.
Unfortunately, from time to time, physicians have abro-
gated this responsibility and opportunity. Do not admit
physicians into the American Head and Neck Society
who are not adequately and completely trained. Quality
and not quantity is the objective. Our prime objective
is the best of care, the highest quality for patients, regard-
less of the pressures of paperwork and other limitations
by insurance companies and government. Closely related
to the prime objective is evaluation of each and every
service's end results, performance data, and quality of
life- "evaluate your track record." Just because a pro-
cedure can be done, that is not the reason to do it.
Develop the atmosphere of academia, which stimulates
intellectual curiosity and improves quality of patient
care.
Randomization-Is this always necessary? Does it
make any and every presentation valid? Review the pros
and cons of randomized study techniques when you
report your end results.8 (Suggest review of this refer-
ence by Drs. Fung and Lore.)
There are shadows that surround us. Namely, the
insurance companies, the paperwork, and the loss of
valuable time in the encountering and fighting of these
obstacles. In any event, we must not be complacent
and discouraged. We must not lose the main objective

of our calling in life. We must not be dabblers. I We
must assume our responsibilities.? We must return to
the philosophy of the founding fathers of our country
and Constitution when they saw fit to engrave on our
coins In God We Trust.
Recommendations
It is recommended that the head and neck surgeon,
especially the younger ones who are not aware of the
background of this entire field, review a number of
excellent resumes and books. They are as follows:
The Head and Neck Story, by George A. Sisson, M.D.,
1983, published by the American Society for Head
and Neck Surgery, produced by Kascot Media,
Chicago, IL.
The Making of a Specialty, Hayes Martin Lecture, by
Jatin P. Shah, M.D., American Journal of Surgery,
Vol. 176, Nov. 1998, pp 398-403.
History of Head and Neck Surgery,by Jerome C. Goldstein,
M.D., and George A. Sisson, M.D., Otolaryngology
Head and Neck Surgery, Vol. 1, US, #5, 1996.
PREFACE
Donald P. Shedd, Historical Landmarks in Head and
Neck Cancer Surgery, 2000, American Head and
Neck. Society.
REFERENCES
1. Lore, JM, Jr: Dabbling in head and neck oncology (a plea for
added qualifications). Arch Otolaryngology Head Neck Surg 1987;
113:1165-1168
2. Forastiere, A, Koch, W, Trotti, A, Sidransky, D: Head and neck
cancer. N Engl J Med 2001; 345:1890-1900.
3. Brennan. MF: The enigma of local recurrence. Ann Surg Oncol
1997; 4:1-12.
4. Lore, JM, Jr., Massaro, M: Description of Head and Neck Services
at Sisters Hospital Abstract submitted.
5. Baker, HW: Head and neck surgery: The pursuit of excellence. Am
J Surg 1971; 122:433-436.
6. Beyers. RM: Barber poles. battlefields and wounds that will not
heal. Am J Surg 1996; 172:613-617.
7. Lore. JM, Jr: Bill of responsibility. The Hayes Martin Lecture. Am
J Surg 1992; 164:556-562.
8. Fung E, Lore, JM, Jr: Randomized control studies for evaluating
surgical questions. Accepted for publication Arch Otolaryngol In
press.
 ACKNOWLEDGEMENTS
First, I wish to once again thank my wife, Chalis, for all
the ancillary work she did as well as her quiet support
despite the mess of "paper" that I managed to disperse
throughout our home during these more than five years
of work on this Fourth Edition.
Shortly after deciding to go ahead with the Fourth
Edition, Robert Wabnitz, our master illustrator, suffered
a stroke, which to everyone, especially his wife, Sue,
was a terrible shock. He could no longer continue on
with this venture. Fortunately, he had taught medical
illustration at the University of Rochester Medical Center.
Margaret Pence, one of his students, took over for Robert.
She uses the same style that her teacher taught her, and
she has done an excellent and professional job. Not only
for her expertise as an illustrator are we all grateful, but
also her pleasant cooperation in anything and every-
thing we asked of her in her chosen field. She is a
superb Medical Illustrator.
I wish to also thank Jesus E. Medina, our associate
editor, and all of our contributors-in the previous
editions and in this edition-for their time, interest,
and expertise. They are all detailed in the list of contri-
butors. Many, many thanks. The extent of their contribu-
tions is noted in the various chapters. These included
contributions for an entire chapter, for example, Chapter
24, to major portions, inserts, and commentaries.
To a very grateful patient, supporter, and sponsor of
the John M. Lore, Jr., M.D., Head and Neck Center at
Sisters Hospital-Robert E. Rich. He recognized the
importance of an ecumenical approach in the develop-
ment of a medical and surgical service to achieve quality
of patient care. The center is a byproduct of this atlas,
and I am deeply appreciative of Bob's involvement and
support.
The next expression of gratitude goes to the two
transcriptionists: Lauri L. Hess, of Dr. Medina's office,
who, in dedicated fashion, transcribed my illegible
inserts onto the disks, and Leslie Berry, a freelance
transcriber par excellence, who, under considerable
pressure, completed the final draft. Dottie Kane, who
did most of the transcribing for the Third Edition, helped
us with initial note-taking relative to this Edition of An
Atlas of Head and Neck Surgery.
Other acknowledgements go to the staff of our Head
and Neck Service at Sisters of Charity Hospital in Buffalo,
NY: Karen Stawiasz, MS, RN, NP, OCN (Oncology
Certified Nurse), an incredible person who is Jill-of-all-
trades and master of all and, specifically, our Oncology
Clinical Nurse Specialist and Nurse Practitioner. To all
our specially trained head nurses, who tolerated my
idiosyncrasies during this protracted period, to complete
this edition: Joyce Clemons, our patient coordinator,
Jennifer Feltz, Maureen Heatley and Nancy Wojtulski,
Kathleen Killion, RN, OCN, Tracy Trifilo, RN, Jean
Errington, RN, Elizabeth Gryzybowski, RN, and James
Sped ding, a key helper and patient. Thanks to Barbara
Lowe, MS, RD, our nutritionist. Thanks goes to a num-
ber of other transcribers: Becky Lonczak, Sandra Ochs,
and Linda Eick. To the office secretaries and adminis-
trative assistants over the years, I'm indebted to Dottie,
and Linda Runfola. My deepest appreciation goes to
Sharon Eagles who bridged the gap from one Hospital
to another, Sisters of Charity Hospital to Roswell Park
Cancer Institute.
Many thanks to Elsevier Saunders, especially to
Rebecca Schmidt Gaertner, Stephanie Smith-Donley,
Christian Elton, and Arlene Chappelle, who were of
exceptional help in manuscript review, as well as all
the previous medical editors and associates, for with-
out them this publication could not have existed.
Among these are John Dusseau, Robert Rowan, and
Sam Mink.
My condolences to the families of William Bukowski
and Paul Milley-both contributors who have passed
away since the Third Edition. Their contributions were
valued. Bill was my personal primary care physician.
Paul was an excellent head and neck pathologist. (I
remember when he examined 137 sections of a thyroid
gland for the primary tumor in a patient who had an
incidental finding of metastatic papillary carcinoma of
the thyroid in a radical neck dissection, which was
done for squamous cell carcinoma.)
Many thanks to all and to all Ave atque Vale.
JOHN M. LORE,JR.
XIX
 PREFACE
TO THE THIRD EDITION
Twenty-six years have elapsed since the first edition of
this atlas, and 15 years since the second edition. This
third edition has in some respects departed from the
original concept of being simply an atlas. It contains
much more information, with background material in a
number of subjects, such as endocrine surgery of the
head and neck and chemotherapy. This background
material is most important if the surgeon is not to be
relegated to the position of being solely a technician,
which, sad to say, is occurring in a number of surgical
disciplines. This is not to say that diagnosis and manage-
ment of problems such as endocrine diseases involving
the head and neck are to be performed solely and inde-
pendently by the head and neck surgeon. The endocri-
nologist, specialists in nuclear medicine, and imaging
and surgical pathologists are all necessary, integral mem-
bers of the management team. It does mean, however,
that the surgeon operating on, for example, the thyroid
gland and parathyroid glands must have more than just
a superficial knowledge of these endocrine organs.
The third edition has been expanded in a number of
facets. The number of chapters has been increased
from 21 to 23 with the addition and further clarification
of Emergency Procedures (Chapter 2) and Base of the
Skull Surgery (Chapter 23). Although both these new
chapters include some procedures that were covered in
the previous editions, this material has now been signifi-
cantly revised and relegated to these two new chapters.
Virtually every chapter has been enlarged with new
and other time-proven procedures, encompassing addi-
tional text and plates. The reader has simply to refer
to the table of contents to see the increased amount
of material. To emphasize these additions, examples
include the following: expanded listing of complications
following most procedures along with air embolism and
blindness and pitfalls; adjuvant chemotherapy; carbon
dioxide laser surgery; myocutaneous and myomucosal
flaps; updated management of cleft lip and palate;
compression plates in the management of facial frac-
tures; various types of neck dissections and their appli-
cations; expansion of thyroid and parathyroid surgery;
rehabilitation following laryngectomy; expansion of
various reconstructive procedures related to the pharynx
and esophagus; and updated vascular procedures and
tissue expanders that lead to interesting possibilities for
reconstruction. The number of contributors has also
increased.
The anatomic sectional x-ray plates in Chapter 1 have
been related to the newer techniques of imaging. These
reproductions can be of great aid in the correlation
with both CT scans and MRI.
The comments in the preface of the previous editions
are still valid for the most part. Progress has been made
in the training of head and neck oncologic surgeons by
the formation by the American Society for Head and
Neck Surgery and the Society of Head and Neck
Surgeons of a Joint Council for Approval of Advanced
Training in Head and Neck Oncologic Surgery. This was
accomplished during 1976 to 1977 with the result being
the formation of a carefully structured fellowship follow-
ing the completion of a residency in otolaryngology,
general surgery, or plastic surgery. This fellowship is the
only one of its kind in head and neck surgery having a
carefully structured evaluation system, site visits, and
review by the executive councils of both head and neck
surgical societies. A diploma is awarded by these two
societies to those candidates who follow the rigid criteria
and successfully complete the fellowship. The fellow-
ship encompasses three phases: Phase [-basic surgical
training involving 1 or 2 years; Phase II-residency in
one of the aforementioned disciplines; and Phase [[[-
the fellowship portion of 1 or 2 yeats. Details of this
fellowship have been previously reported (Lore, J.M.,
Jr.: Head and neck oncologic training: Where we have
been and where we are going. Am. J. Surg. 142:504-505,
1981). Sixteen programs are now approved for this type
of training-IS in the United States and one in Canada.
The term head and neck oncology might be the better
term applied to this fellowship, since it involves not
only surgical training but also a knowledge of radio-
therapy, chemotherapy, and, where applicable, the future
of immunotherapy. This facet of head and neck oncol-
ogy is only one of five categories involved in head and
neck surgery, with the others being congenitallesions,
cosmetic surgery, and infectious disease. Likewise
involved in head and neck surgery is reconstructive
surgery, which relates to both head and neck oncologic
surgery and cosmetic surgery.
xxi
 PREFACETO THE THIRD EDITION
Head and Neck Oncologic Surgery
The concept of regional surgery appears to be well
established. Stumbling blocks still remain, one of them
being the cliche "fragmentation" of the parent disci-
plines. Interestingly enough, it all depends on one's
biases as to whether the changes of a specific aspect of
a major discipline are termed "fragmentation" or "spe-
cialization." Regardless, it is the marketplace that sets
the pace-specifically, the number of patients available.
To borrow the words of James Humphreys, M.D., "sur-
gery was fragmented when the surgeon left the barber
shop." The bottom line, however, is the search for
excellence in patient care and physician training. These
two aspects must not be compromised.
The thrust of head and neck oncologic surgery is a
cooperative and joint venture encompassing all disci-
plines that can and should contribute to this endeavor.
The initial step has been made with the two head and
neck surgical societies setting up the guidelines, site
evaluations, approval, and awarding of a diploma. The
next step is the formal implementation and recognition
of these postresidency fellowships by the residency review
committees and the specialty boards involved, an exam-
ination, and board recognition. Currently, it appears that
this recognition could be achieved by "added qualifica-
tions" in head and neck oncology by the boards. These
"added qualifications" could then be affixed to the exist-
ing certificate of each board. It is hoped that this would
be accomplished by the three boards jointly agreeing
on the same guidelines and examination. An excellent
example of this type of joint venture is the solution of
education in hand surgery, which has been worked out
by the two hand societies and the three boards of ortho-
pedics, general surgery, and plastic surgery. George
Omer, after many years of dedicated work developing
articles of agreement, is to be congratulated on its fruition.
I hope that a similar modus operandi will be achieved
in head and neck oncology.
To date, this concept of added qualifications has
been stalled by the concern of the three boards and the
three residency review committees as well as a number
of practicing surgeons in the three disciplines. Their
fears surround the worry of fragmentation of their
disciplines as well as the misgivings that such added
qualifications will lead to "a special club" of head and
neck oncologic surgeons and thus restrict their prac-
tice. It must be remembered that there are only about
50,000 new patients each year with head and neck
cancer and that only approximately 35 to 75 new well-
trained head and neck oncologic surgeons are neces-
sary each year to maintain an adequate work force of
some 400 to 1000 head and neck oncologic surgeons to
manage this number of patients. Thus, we must mini-
mize the number of "dabblers." No one who requires
coronary artery bypass surgery would seek treatment
by a surgeon and team who perform only a few such
procedures a year. We as surgeons must seek the solu-
tion, rather than have nonmedical forces outline the
solution for us. Yet with all this protectionism, general
surgery has in fact been fragmented. Otolaryngologists
are going down the same course with the fear of frag-
mentation. Hence, it appears that this concern only
enhances fragmentation rather than alleviating it. The
basic problem is that the profession of medicine and
its physicians and specialty societies react to obvious
changes that are in the making, rather than acting.
Physicians must be the leaders in this change, rather
than the followers. They must shape these changes,
since they are the ones who know the problem and can
best suggest and initiate the changes best suited to
excellency in patient care and physician training.
Unless this is achieved, a number of legitimate con-
cerns that exist will become aggravated. Following is
a list of such concerns (from Lore, J.M., Jr.: Issues in
community hospital or cancer center care of head and
neck cancer patients. In Myers, E. N., Barofsky, I., and
Yates, J. W. [eds.]: Rehabilitation and Treatment of Head
and Neck Cancer. Washington, D.C., U.S. Department
of Health and Human Services, Public Health Service,
National Institutes of Health [NIH Publication No.
86-2762], 1986, pp. 155-165).
1. The occasional patient manager or "dabbler."
2. Loss of expertise and proficiency for even the well-
trained physician.
3. Marginal and then inadequate treatment for head
and neck cancer patients.
4. Loss of concentration of training clinical material.
5. Loss of any significant number of patients for evalu-
ation as to treatment methods, old and new.
6. Increased morbidity, mortality, and cost of medical
care.
To achieve the solution to these problems, it appears
that the three boards and the three residency review
committees should pursue the concept of added qualifi-
cations and recognize the additional training beyond
the residency years so necessary to achieve the desired
excellency. In other words, support the fellowship con-
cept and officially recognize the fellowship concept.
To aid in the solution to these problems in a recog-
nized manner, several additional steps are suggested.
Training
1. The American Board of Surgery should develop recog-
nized training in basic surgery that might encom-
pass 2 years, with examination and certification for
the trainee.
2. The trainee then completes the standard residency
in general surgery, otolaryngology, or plastic surgery.

3. The trainee enrolls in a fellowship approved by the
three boards. An alternate route could be a similarly
approved preceptorship.
Centers of Excellence
Centers of excellence in head and neck oncology can
either be achieved in a university or community hospital
center with adequate patient load, professional person-
nel, and support staff. The interested reader is referred
to the aforementioned NIH publication as well as the
author's Presidential Address at the annual meeting
of the American Society for Head and Neck Surgery
(Dabbling in head and neck oncology-A plea for
added qualifications. Arch. Otolaryngol. 113:1165-1168,
1987).
Controversial Items
There are a number of controversial items quite apart
from the preceding that this author wishes to enumerate.
Correct and Exact Terminology
In the evaluation of statistics relative to survival with
or without disease, a distinction should be made at the
onset of treatment as to whether a patient is "operable"
and whether the lesion is "resectable" for cure or
palliation. Operability refers to whether the patient can
safely undergo a major surgical procedure, whereas
resectability refers to whether a neoplasm can in fact
be totally removed by the surgeon. Nonresectability
distinctly implies advanced disease and actually further
implies a stage beyond stage IV, namely a stage V
disease. This concept has been previously suggested in
a publication entitled Head and Neck Cancer; Proceed-
ings of the First International Conference, The Society
of Head and Neck Surgeons (Chretien et aI., St. Louis,
C.V. Mosby, 1985, p. 434).
Another point of contention are the words partial,
subtotal, near total, and total in regard to the various
surgical procedures, especially thyroidectomy. Granted,
there are fine lines that separate these terms and defy
total exactness, but regardless a more accurate designa-
tion of the surgical procedure is warranted as well as a
close adherence to the exact implication of these terms.
The same goes for the terms referring to the various
types of neck dissections, e.g., radical neck dissection,
classical neck dissection, modified radical neck dissec-
tion, functional neck dissection, and conservation neck
dissection.
Indications for Surgical Procedure
As for indications for surgery, my bone of contention is
a fundamental philosophical and, for that matter,
PREFACETO THE THIRD EDITION
practical problem, which can best be summarized as
follows: Just because a procedure can be technically
performed, that is not the indication to perform the
procedure. Advances in medicine and surgery require
the development and trial elfnew procedures. Neverthe-
less, these trials must be tempered to a certain degree
by past as well as present experience. Again, there
is the "gray zone." Specifically, a number of techniques
and procedures come to mind, for example, microvas-
cular surgery. These procedures have a selected place
in head and neck surgery relative to the following
surgical problems:
1. Augmentation of soft tissue with microvascular anas-
tomosis, e.g., involving massive defects of the top of
the scalp that cannot easily be reached by a myocu-
taneous flap (tissue expanders may have a signifi-
cant application in closing such defects).
2. Certain congenital lesions in which a transposed flap
or myocutaneous flap is not indicated.
On the other hand, microvascular techniques do not
appear routinely warranted in, for example, the
following:
1. Reconstruction of the mandible (associated with
ablative surgery) with an iliac bone graft and over-
lying skin. The added time necessary to accomplish
these procedures must be taken into account when
ablative surgery has already consumed a significant
number of hours of operating time. These microvas-
cular techniques on the other hand are applicable to
massive defects resulting from trauma.
2. Reconstruction of the laryngopharynx with a free
jejunal graft or gastric pull-up. The latter procedure
or colon interposition is definitely indicated when a
total esophagectomy is necessary.
Often, a much simpler reconstructive procedure does
in fact achieve the same end results related to the
reconstructive surgery. For example:
1. Mandibular resection that is reconstructed with the
simple use of a bent Kirschner wire with tie wires.
2. Total laryngectomy with total hypopharyngeal, oro-
pharyngeal, and partial nasopharyngeal resection
reconstructed with a myomucosal tongue flap with
dermal graft or pectoralis major flap with dermal
graft. These simpler forms of reconstructive sur-
gery make total hypopharyngectomy a very feasible
and relatively easy procedure. These techniques are
believed to afford a much better chance of resecting
the entire structure, thus leading to improved survival
rates. Preserving a narrow strip of posterior hypo-
pharyngeal mucosa for reconstruction of the gullet
hardly seems justified.
 PREFACETO THE THIRD EDITION
Other Suggestions
1. TNM classification. It is suggested that in the initial
evaluation of the patient basic information should
be tabulated along with the appropriate drawings,
and, if possible, photographs, which at any time can
then be transferred into virtually any TNM classifi-
cation that may be developed in the future (Kaufman,
S., and Lore, J.M. Jr.: TNM classification and disease
description in head and neck cancer. Am. J. Surg.
136:469-473, 1978).
2. Prevention and treatment of premalignant lesions.
Head and neck oncologic surgeons must face the
fact that to help achieve improved survival rates for
patients with head and neck cancer they should be
actively involved and cognizant of the premalignant
lesion as well as the management of "condemned
mucosa." This concept applies to the high-risk patients
and those with mucosal atypism and dysplasia.
Obviously, the avoidance of tobacco and exposure to
carcinogens is foremost. Next in line is the use of the
retinoic acids-vitamin A-as a dietary supplement,
recognizing, of course, the possible toxic side effects,
particularly of overdosage of vitamin A. This leads
to the establishment of, or at least involvement by,
head and neck surgeons in basic research.
3. Adjuvant chemotherapy. Another consideration is the
admonition that adjuvant chemotherapy be relegated
to organized protocols rather than the haphazard
use of chemotherapeutic agents in the management
of head and neck cancer.
4. Violation of the "Virgin Neck." Many years ago Hayes
Martin emphasized that limited surgical procedures
should be avoided in the unoperated neck, since this
could very well mask future metastatic disease. This
admonition is still true for the most part. For exam-
pIe, I shudder when I see and hear about the use of
the sternocleidomastoid muscle for solely a recon-
structive procedure in a patient with a surgical defect
following ablative surgery for intraoral cancer.
5. Randomized studies evaluating treatment and end
results. Although randomized protocols certainly have
definite advantages, there are a number of draw-
backs. When multiple institutions are included, varia-
tions in technique among the surgeons involved
cause inevitable problems. In addition, these studies
may not be as valid as they are supposed to be if the
number of patients is small or if a study lacks ade-
quate stratification of the various factors involved.
In one recent study (Corey, J.P., et al.: Surgical com-
plications in patients with head and neck cancer
receiving chemotherapy. Arch. Otolaryngol. 112:
437-439, 1986) evaluating surgical complications in
patients receiving chemotherapy, the patients were,
I believe, incorrectly stratified as follows:
Patients Control Chemotherapy
Stage II 5 1
Stage 1Il 8 12
Stage IV 6 10
The control group is overweighted with stage II
disease, and underweighted for stage 1Iland IV disease,
a form of incorrect stratification that places the chemo-
therapy group at a disadvantage.
In short, when a trial is randomized, care should be
taken regarding possible imbalance of results.
In summary, it is hoped that the preceding philo-
sophical comments and suggestions as well as the
expansion of this third edition will be of interest to the
head and neck surgeon.
JOHNM. LORE,JR.
 ACKNOWLEDGEMENTS
IN THE THIRD EDITION
During the years taken to expand this atlas many
friends have contributed-some as formal contributors,
others in ways and at times unknown to them either
in the sharing or exchanging of knowledge, others in
technical help, and still others in the various phases of
patient care, which in effect has had significant bearing
on this revision and expansion.
My wife, Chalis, has tolerated this third episode with
exceptional calm and has also helped in selective typing.
For the third time, Bob Wabnitz has joined me as the
one and only medical artist and illustrator of all the
editions of this atlas, demonstrating his skill par excel-
lence. Working with Bob is actually a pleasure. His skill
in his chosen profession as well as his knowledge of
anatomy and surgical procedures is only surpassed by
his humor and cooperative attitude. I repeat, "without
him, the atlas would not be."
For the bulk of the stenographic labor, I am deeply
indebted to Dottie Kane, who like Bob Wabnitz simply
smiled when I asked that more had to be done, and of
course, done yesterday.
In the patient care arena, which is so important to
a surgeon and the success of patient management, I
extend gratitude in a special way to those primarily
associated with the Sisters of Charity Hospital of Buffalo.
This includes in administration Sister Mary Charles and
Sister Eileen, and more recently, Sister Angela and her
staff; in the operating room, Sister Thomasine, and after
her, Pat Archambault, R.N., and on the special head
and neck nursing unit, the head nurse, Diane Smeeding,
R.N., and her staff of devoted and skilled nurses, prac-
tical nurses, aides and our floor secretary, Beth Powalski.
Along with patient care and many of the facets related
to this endeavor, I am grateful to my office staff, espe-
cially Nan Sundquist, R.N. and Debbie Foschio, and
also to Joan Bilger, R.N., who is our nurse clinician at
the Erie County Medical Center.
I have picked the brains of many physicians, espe-
cially my former associate, Duck Kim, M.D., and my
current associate in practice, Keun Lee, M.D. They
filled in for me while I struggled along with this revi-
sion. Also in this aspect I am grateful to the Pathology
Department of Sisters Hospital. To Paul Milley, M.D., I
am deeply grateful for his contributions both in his
section and in the chapter on endocrine surgery and for
his time, which he afforded me in the numerous prob-
lems associated with surgical pathology. John Sheffer,
M.D., and Ashok Koul, M.D., likewise were helpful in
this phase of surgical pathology, which is reflected in
hidden ways in many of the surgical procedures. These
three surgical pathologists are placed among the best
in the field of head and neck surgical pathology, espe-
cially related to frozen section, cytology, and recuts and
searching through many surgical specimens. This is
specifically applicable not only to carcinoma hidden in
those specimens that had a complete clinical response
to chemotherapy but also in thyroid specimens where
there has been a search for primary tumors as well as
C-cell hyperplasia.
I am indebted to Martha Schmidt, M.D., the expert
in nuclear medicine, especially that related to thyroid
scanning, as well as to Joseph Prezio, M.D., who is
chairman of the Department of Nuclear Medicine at the
School of Medicine, State University of New York at
Buffalo and Kwang Joo, M.D., who covers Sisters
Hospital. Gratitude is also extended to their technicians,
who are most important in this particular phase of
diagnostic imaging.
In a similar vein, Monica Spaulding, M.D., and
Kandala Chary, M.D., our medical oncologists are a
great help in the management of patients with advanced
neoplastic disease.
Included on our team is William Bukowski, M.D.,
our internist, and David Casey, D.D.S., our maxillofacial
prosthodontist, who have contributed significantly to
the team approach in the management of our patients.
Without the expert contribution of the Department
of Diagnostic Radiology and Imaging under the direc-
tion of David Rowland, M.D., and the person who I
pester the most, David Hayes, M.D., many of the surgi-
cal procedures would not have been brought to a suc-
cessful conclusion.
When speaking of "brain picking," the participants
in our endocrine conferences contributed much to my
understanding of thyroid and parathyroid disease. The
"regulars," Robert LaMantia, M.D., Donald Rachow,
M.D., Jack Cukierman, M.D., and James Kanski, M.D.,
are the stalwarts. However, I must say if there are
differences of opinion in the endocrine chapter, these
are my responsibility, not theirs. Contributing in this
xxv
 ACKNOWLEDGEMENTS IN THE THIRD EDITION
same fashion is Richard Blanchard, M.D., who would
come to my office and spend hours reviewing cases of
patients with thyroid and parathyroid disease, thus
affording me a learning experience seldom available to
a surgeon.
I am deeply indebted to Paul J. Davis, M.D., Professor
of Medicine and Chief of Endocrinology at the State
University of New York at Buffalo, for his review, sugges-
tions and additions to the endocrinological aspects of
the chapter on Endocrine Surgery. His help was most
important.
Part of the learning experience is exemplified by
many of my residents and fellows who were involved
in the exchange of knowledge and ideas-so well stated
by John Henry Cardinal Newman in his treatise "The
Idea of a University."
Several general surgeons have been significant contri-
butors to this endeavor in many facets. Frank Marchetta,
M.D., a head and neck surgeon par excellence, is respon-
sible for many original contributions to head and neck
surgery, as is Alfred Luhr, M.D., who operated with me
on some two-team procedures. Joseph Anain, M.D., a
certified general vascular surgeon and co-author of
Chapter 22, was and is a significant collaborator in our
head and neck vascular procedures. He is not only
involved in the operating room but also in the work-up
of patients who are suspected of having vascular prob-
ems associated particularly with neoplasia.
In all of this, a chairman of a department at a medical
school needs the support of his chief, viz. Dean John
Naughton, M.D., who is also Vice President of Clinical
Affairs. This support is afforded in many ways-some
not immediately recognized, but always appreciated.
In the publishing of a medical book with all its
applications, decision making, changes, and additions,
the staff of the W.B. Saunders Company has been
understanding, helpful, and cooperative.
When I try to remember all who have been an inspi-
ration and at the same time contributed much to head
and neck surgery, George Sisson, M.D., Chairman,
Department of Otolaryngology, Northwestern Medical
School, comes often to my mind. Many thanks George.
Although my mother has passed away during the
period between the second and third edition, she was
and still is an inspiration, and once again I dedicated
this atlas to my Dad, who was the inspiration behind
this entire endeavor.
JOHN M. LORE,JR.
 PREFACE
TO THE SECOND EDITION
Eleven years have passed since the publication of the
first edition of this atlas. The convictions expressed
in the preface of the first edition are reiterated here
and, in addition to them, the grave importance of the
cooperation of the various disciplines involved in sur-
gery of the head and neck-both in the management of
patients and in the training of residents-is empha-
sized. The combined efforts, contributions, cooperation
and sharing of patient problems and management must
be part of every aim in medicine and surgery, especially
in head and neck surgery in which there is so much
overlap among the various disciplines.
Fortunately, during the past five years, a definite
cooperative trend among the prime disciplines of general
surgery, otolaryngology, plastic and reconstructive sur-
gery and oral surgery has been developing. A number
of various types of combined head and neck services at
universities known to the author are participants in this
trend-the State University of New York at Buffalo,
Northwestern University, the University of Virginia and
Yale University-and others are surely in existence.
However, even more important than these services is
the emergence of a spirit of cooperation which has been
spread as seeds throughout the surgical community.
Unfortunately, among the fruitful seeds are still the
weeds which attempt to choke out the wheat because
of inherent parochialism, insecurity, jealousy and greed
of power or whatever. Regardless of the type of arrange-
ment of a combined venture, its success or failure depends
not so much on signed documents as on a spirit of equal
cooperation, understanding and trustworthiness. To insist
that a combined head and neck service lies solely within
one discipline or is a subspecialty of general surgery is
to lead the entire endeavor to certain doom.
Flexibility should be tolerated. For example, if need
be, a multidiscipline head and neck service could be
established within one department and thus achieve an
objective similar to that of a head and neck service
which involves more than one department. It is interest-
ing to note that during the past decade otolaryngology
has made significant strides and at present is believed
by many to be the prime discipline in the complete train-
ing of the head and neck surgeon.
The problem does not appear to lie among the various
head and neck surgeons of different backgrounds but
rather with certain autocratic and political forces who
attempt to control a major portion of surgery-the so-
called "umbrella of general surgery," an antiquated and
obsolete concept. However, it is the conviction that
general surgery serves as the foundation and the special-
ties as the superstructure. Therefore it appears that the
concept of regional surgery of the head and neck will
be the end-result.
It was not so long ago that mutual scorn and distrust
between several disciplines were so intense that any
exchange of ideas was tantamount to proclaimed heresy.
Now, it is changing toward a mood of basic ecumeni-
calism. The two head and neck societies, the Society of
Head and Neck Surgeons and the American Society for
Head and Neck Surgery, have had a joint meeting in
1973-an event which might well have been unthink-
able a few years ago. Both societies have opened their
memberships to capable surgeons in the various disci-
plines with similar standards and requirements. It is
believed that this cooperation is leading to a more com-
plete exchange of ideas and that this can be achieved
without the destruction of some of the good points of a
competitive climate.
As we proceed along the common pathway, a num-
ber of questions are encountered. For example:
I. What does the field of head and neck surgery encom-
pass?
2. What is the need in quality and quantity of surgeons
well trained in this field?
3. Should all residents in general surgery, otolaryngology
and plastic and reconstructive surgery be trained as
head and neck surgeons?
4. What should this training entail?
5. Should there be a cooperative effort among the various
disciplines or boards, and if so, how best is this objec-
tive achieved?
6. Should there be a certificate of competency issued
by the various boards involved?
7. Is some type of basic framework for residency training
desirable, or rather, should there be an individual solu-
tion to the training problem at the various large centers?
These queries cannot be answered or solved over-
night, and yet a few responses are possible at present.
xxvii
 PREFACETO THE SECOND EDITION
The field and training in head and neck surgery
should have a broad base and be flexible. Individual
surgeons and groups of surgeons may have their own
specific interests; there is no criticism of this action.
Nevertheless, it is important that the trainee develop
a versatility in the changing world of medicine and
surgery, and hence it is believed that to have a lasting
and firm foundation head and neck surgery should
encompass four categories.
1. Malignant and benign tumors.
2. Reconstructive surgery.
3. Congenital lesions.
4. Infectious surgical diseases.
Thus it is quite obvious that such training crosses
and encompasses a number of specialties as we know
them today. The old boundaries are no longer valid nor
. practical, and the new boundaries are far more flexible.
It must be emphasized that the various surgical spe-
cialties, as well as general surgery, are not in existence
for their own benefit but rather for the promotion of
ultimate excellence in patient care.
Another point appears quite clear. There is not a need
for a large number of head and neck surgeons, but rather
a need for a moderate number (how many??) of well
trained head and neck surgeons. For example, many of
the procedures outlined in this atlas are not intended
for the occasional operator with limited background,
but are intended as a reminder or review for those
well educated in the overall field of head and neck
surgery. For the latter audience, this atlas may be a
source of material in the ever-continuing field of medical
education.
During the past six years as a program director, the
author has realized a number of problems. First of all,
not all residents in either otolaryngology, general sur-
gery or plastic surgery need be, nor should be, trained
as head and neck surgeons per se. Secondly, a solid
block of time in general surgery (two to four years)
followed by a solid block of time in otolaryngology
(three years) has certain drawbacks. There is a psycho-
logical problem of a candidate being a senior resident
in general surgery and then starting at the bottom in
otolaryngology. This is no small matter. Another prob-
lem is that of graded training in both fields. It would
seem much easier to train a resident in physical diag-
nosis in both specialties at an early stage in his career.
The same comparison goes for the senior levels in
which major surgery will be performed. It is at this
stage of one's training that senior responsibility in both
specialties should be achieved, almost side by side, and
certainly not separated by several years, as is the case
in the solid block concepts.
At any rate, it appears worthwhile to outline an inte-
grated step-wise plan for head and neck surgical train-
ing, which recently has been passed by both the
American Board of Otolaryngology and the Conference
Committee on Graduate Education in Surgery, repre-
senting the American Board of Surgery, the American
College of Surgeons and the Council of Medical
Education of the American Medical Association. This
experimental program, applicable to certain selected
candidates with approval on an individual basis, exists
at the State University of New York at Buffalo with
instruction in otolaryngology, general surgery and
plastic surgery.
This concept was originally planned with the coop-
eration of John R. Paine, then Chairman of Department
of Surgery. Glenn Leak played an integral part in the
original outline. With the untimely passing of both of
these friends, G. Worthington Schenk, Jr., now Chairman
of the Department of Surgery, gave his support and
effort to achieve the final approval of this plan. The
program entails a five-year residency which, in step-
wise fashion, integrates in graded responsibility the basic
aspects of otolaryngology and general surgery and the
principles of plastic surgery. The years in training would
alternate between general surgery and otolaryngology,
with plastic surgery training incorporated within general
surgery, and additional reconstructive surgery within
otolaryngology. Senior resident levels in both general
surgery and otolaryngology would be reached in the
final two years. Not all residents in either of these two
fields would be included in the program-only one or
two at the most in anyone year. Nor is this program
intended to be the only avenue of training in head and
neck surgery.
In summary, the second edition of this atlas is
directed to the ecumenical approach in both patient
care and resident training in the field of head and neck
surgery.
REFERENCES
Baker. H. w.: Head and neck surgery: The pursuit of excellence.
Amer. J. Surg., 122:433-436, 1971.
Beahrs, O.H.: The next plateau. Amer. J. Surg. 114:483-485, 1967.
Bordley, J.E.: Problems facing otolaryngology today. Ann. Otol.,
80:783,1971.
Chase, R.A.: I'm against a rigid core curriculum prior to specialty
training in plastic surgery. Plast. Reconslr. Surg., 46:384-388,
1970.
Chase, R.A.: The "core knowledge" principle and erosion of specialty
barriers in surgical training. Ann. Surg., 171:987-990, 1970.
Eckert, C. (panel member): Panel discussion: Head and neck surgical
training. Medical Society of the State of New York Convention,
February 1972.
Fitz-Hugh, G.S. (panel member): Panel discussion: Head and neck
surgical training. Medical Society of the State of New York Con-
vention, February 1972.
James A.G.: Board to Death. Amer. J. Surg., 116:477-481, 1968.
Klopp, C.T.: Presidential address. Tenth annual meeting of Society of
Head and Neck Surgeons. Amer. J. Surg., 108:451-455, 1964.
Lore J.M., Jr.: Editorial. Head and neck surgery. Surg. Gynec. Obstet.
118:117-118, 1964.
 PREFACE TO THE SECOND EDITION

Lore, J.M., Jr.: Future of head and neck surgery. A combined head and Sisson, G.A.: Otolaryngology, maxillofacial surgery embark on chal-
neck service: An ecumenical approach. Arch. Otolaryng. 87:659-664, lenging course. From the Department of Otolaryngology and Maxillo-
1968.
facial Surgery, Northwestern University, Evanstown, Illinois.
Lore, J.M., Jr.: Head and neck surgery: The problem. Arch Otolaryng. Southwick, H.W: Presidential address. Eleventh annual meeting of the
78.842-843, 1963. Society of Head and Neck Surgeons. Amer. J. Surg. 110:499-501,
Lore, J.M., Jr.: Head and neck surgery: Proposed head and neck 1965.
training program. Arch. Otolaryng. 79:112-113, 1964. Wullstein, H.L.: A concept for the future of otorhinolaryngology.
MacComb, WS.: Future of the head and neck cancer surgeon. Amer. Ann. 0101., 77:805-814, 1968.
J. Surg., 118:651-653, 1969.
McCormack, R.M. (panel member): Panel discussion: Head and neck
surgical training. Medical Society of the State of New York Con-
vention, February 1972.
 ACKNOWLEDGEMENTS
IN THE SECOND EDITION
As with the first edition, my prime indebtedness is to
my wife Chalis, who single-handedly transcribed the
changes in the first edition and all the new text for this
expanded second edition. In addition to the manuscript,
she typed the bibliography with some help in classifi-
cation from my daughters Margaret and Joan.
The medical artist and illustrator is the same skilled
and dedicated one-Robert Wabnitz. Without him, this
atlas simply would not be. His persistence in accuracy
and consistent drive for detail is obvious in the artwork.
To him, also, am I deeply indebted.
Again, I am thankful to my mother for her encour-
agement and prayers.
For his revisions and statistics relative to temporal
bone resection, I am thankful to John S. Lewis, M.D.
I wish to thank William R. Nelson, M.D., who has
contributed a new section on pre- and postoperative
care. He has been kind enough to condense a much
larger treatise of this aspect of head and neck surgery,
which he originally produced in booklet form.
Gratitude is extended to James Upson, M.D., for his
review of the section on surgery of degenerative vas-
cular lesions and to John Bozer, M.D., as a consultant
internist.
I also wish to thank a number of photographers at
the various hospitals affiliated with the Medical School
at the State University of New York at Buffalo. They are
Sheldon Dukoff and Charles Jackson, of the Edward J.
Meyer Memorial Hospital; Joseph A. Dommer and
Dough Hanes, of Buffalo General Hospital; and Harold
C. Baitz, Theodore A. Scott and their secretary, Mrs.
Alfred Davis, of the Medical Illustration Service of the
Veterans Administration Hospital, Buffalo, New York.
Although many of their photographs do not appear in
the atlas, they served as a guide for the artwork and the
text.
Thanks also go to Joan R. Bilger, R.N., of the Edward
J. Meyer Memorial Hospital, for help in preparing some
of the photographic arrangements and supplying other
technical data; and to Bette Stinchfield, my secretary at
the Buffalo General Hospital, for aid in obtaining some
of the reference material.
During the time between editions, many new tech-
niques and modifications have reached the surgical
arena, a significant number of changes have occurred
and friends have lent their ideas and methods; how-
ever, one bit of philosophical admonition comes to
mind-primum non nocere-first, do no harm. I know
not the originator of this phrase, but to Julius Pomerantz,
a senior fellow physician from Good Samaritan Hospital,
Suffern, New York, I am indebted. It is to my residents
who have also contributed unwittingly to this endeavor
that I often pass on this thought in management of our
patients.
A great debt of gratitude is due the entire staff of the
W.B. Saunders Company for their unparalleled aid in
publishing this atlas. Their continuing help both as
publisher and personal friends makes an otherwise
burdensome task possible; their skill in the art of
publication makes it all worthwhile.
JOHN M. LORE,JR.
xxxi
 PREFACE
TO THE FIRST EDITION
The purpose and intent of this atlas is to encompass in
one volume related regional procedures of the head
and neck. It is actually a plea for a broader training
program to reunite with basic general surgery the many
surgical specialties and subspecialies concerned in this
area. Surely, there will always be a need for such
specialty groups alone but there is an even greater need
for the amalgamation and dissemination of their skills
in the total treatment of problems of the head and
neck. The foundation upon which this concept is built
is the basic principle that general surgery is the mother
and nurturer of all major surgery. The specialties are
the fruits. Hence, general surgery as well as the special-
ties of otolaryngology, plastic and reconstructive sur-
gery, maxillofacial surgery, neurosurgery, oral surgery
and thoracic surgery are involved. Disease knows not
the man-made barriers that have been set up.
Each field can contribute to the others. One has only
to reflect on the importance of mirror laryngoscopy
before and after thyroid surgery. Adequate examination
of the larynx is felt to be a sine qua non for any sur-
geon who performs a thyroidectomy just as a sigmoi-
doscopy should be performed by the surgeon who
performs the abdominoperineal resection. For anyone
who does major surgery in the neck, extension of
resectability must not be hampered by a lack of famil-
iarity with thoracic surgery when the disease has
extended below the clavicles. This principle holds true
for both malignant disease and trauma. Major surgery
on the larynx sooner or later will involve the cervical
esophagus and basic knowledge of bowel surgery will
enhance the armamentarium of the surgeon and aid
in his decision when selecting the most suitable type
of esophageal reconstruction. Procedures on the nose,
except the very simplest, can be refined and well select-
ed only when the surgeon borrows from the orolaryn-
gologist, the plastic and reconstructive surgeon and the
general tumor surgeon.
The skills and tricks of one field are often applicable
to another field. In the definitive treatment of malignant
tumors the details of an elaborate reconstruction proce-
dure are of little avail unless the primary disease has
been handled correctly with full knowledge of the natural
history of the disease. By the same token, radical surgical
treatment is incomplete if a suitable and adaptable
reconstructive procedure or prosthesis has been omitted
purely through a lack of versatility. Obstructive vascular
disease affecting the intracranial circulation amenable to
surgical correction may have its center of trouble located
either in the chest or neck or in both regions. The selec-
tion of the best-suited vascular procedure is enhanced
by a working knowledge of general vascular surgery.
With anticipation of the criticism that such a con-
cept would lead to a Jack-of-all-trades, master of none,
one need but read the history of surgery. Many of the
great surgeons of yesterday were first primarily general
surgeons; with this basic knowledge they contributed
lasting ideas both in the specialty fields and in general
surgery. Billroth was the master of gastrectomy and at
the same time contributed to cleft palate repair by frac-
turing the hamulus of the pterygoid process, thus releas-
ing the tensor veli palatini muscle. King, a general sur-
geon, made a significant contribution in the treatment
of bilateral abductor cord paralysis of the larynx. Such
examples are not intended to detract from the innu-
merable contributions by the surgical specialists which
in their own fields outnumber these examples. Nor
is the concept that is portrayed in this atlas intended
to lessen or minimize in any way the need for the
specialist. Actually it supports the specialist and re-
emphasizes the natural evolution of surgery.
John Henry Cardinal Newman in his classic The ldea
of a University advocated a liberal education which
would serve as the background for future endeavors.
He pointed out that any student able "to think and to
reason and to compare and to discriminate and to ana-
lyze, who has refined his taste, and formed his judg-
ment will not indeed at once be a lawyer, or a pleader,
or an orator, or a statesman or a physician ... but he
will be placed in that state of intellect in which he can
take up anyone of the sciences or callings ... with an
ease, a grade, a versatility, and a success to which
another is a stranger." So in the art and science of
surgery, a liberal basic foundation is necessary. From
such a foundation and broad outlook, the field of head
and neck surgery seems to have drifted. Reunification
of all groups interested in the field of surgical problems
related to the head and neck is the intention, hope and
aim of this Atlas of surgical techniques.
JOHN M. LORE, JR.
xxxiii
 ACKNOWLEDGEMENTS
IN THE' FIRST EDITION
.-,.-
I am deeply grateful to my wife, Chalis, for her sacrifice,
patience and able skill as an executive secretary. She
has typed and retyped the manuscript under consid-
erable duress.
My children, John III, Peter, Margaret and Joan, have
all felt the pressures and sacrifices resulting from the
loss of many happy hours together which have been
missed because of the time consumed in the prepara-
tion of this work.
I am indebted to my mother for her encouragement
and prayers.
Professionally, my indebtedness extends from books,
journals and other collections of the surgical literature,
through various opinions voiced at surgical meetings
(the authors of which I regret to say have slipped my
memory), to my recent and past teachers and associates.
All education is a compendium, and even more so sur-
gical education. Hence many of the steps in this atlas
are the ideas, thoughts and work of surgeons under
whom I have trained or worked. I owe much to my father
and to John J. Conley who were my early teachers. A
great many of the surgical procedures and techniques
concerned with the treatment of tumors of the head
and neck either originated with or were developed by
Hayes Martin and other surgeons on the Head and Neck
Service of Memorial Hospital. In the basic background
of general surgery which forms an integral part of this
atlas, I owe a debt of great magnitude to John L. Madden,
Director of Surgery at Saint Clare's Hospital.
To make the decision after my father's death to con-
tinue surgical training in general surgery after comple-
tion of the first phase in otolaryngology presented a
crisis. Two men convinced me and gave me advice of
immeasurable value. They are Michael Deddish, M.D.,
and Alexander Conte, M.D. Without them I never would
have completed my surgical training and never would
have come to realize the benefits of a multifaceted
surgical background.
John S. Lewis, M.D., who is mainly responsible for
the present technique of temporal bone resection in
cancer of the middle ear, has kindly contributed to that
section of the atlas.
Edward Scanlon, M.D., has been kind in lending his
original experiences and thoughts in colon transplants
for reconstruction of the esophagus. These ideas have
been of considerable aid and have been a guide to
personal experiences in this problem. Again to Alexander
Conte my thanks for supplying original photographs of
his technique of cervical esophageal reconstruction.
During the two years of pressure to complete this
work, my surgical partner, Louis J. Wagner, M.D., has
unselfishly covered our practice to allow me the neces-
sary undisturbed time. From him, I have also learned a
number of operative steps which have been successful
in the solution of some technical problems.
When this atlas was in its infancy, it was only through
the cooperation of John L. Madden and the administra-
tion of Saint Clare's Hospital, specifically the late Mother
M. Alice, O.S.F, and her successor Sister M. Columcille,
O.S.F., that actual work began. At Saint Clare's Hospital
I met Robert Wabnitz, the sole illustrator of this volume,
who since then has spent many hours in the operating
room making sketches and at the drawing board com-
pleting the art work. Without his skills as an artist and
his knowledge of anatomy, the illustrations would have
been impossible. Both he and I are grateful to the Univer-
sity of Rochester where he now heads the Medical
Illustration Department for allowing him time to com-
plete this work. If it were not for the skill in its repro-
duction, the best of art work would be for naught. The
W.B. Saunders Company has excellently completed this
endeavor. I am deeply indebted to the staff of the
Company for their advice, suggestions and patience. I
am grateful to my colleague William J. McCann, M.D.,
for initiating this most fortunate association with the
Saunders Company.
I wish also to acknowledge the cooperation of the
Administrator and Assistant Administrator of Good
Samaritan Hospital, Sister Miriam Thomas and Sister
Joseph Rita, as well as the Operating Room Supervisor,
Miss Martha Henry, and the entire nursing staff for their
help and vision in the treatment and care of the patients
with many of these operative and postoperative problems.
I would be remiss if I did not add the aid of the admin-
istration and staff of Tuxedo Memorial Hospital.
My thanks to Anthony Paul for drawing many of the
lead lines and some of the labels and to David Hastings
for his care in photographing the x-rays in Chapter I.
JOHNM. LORE,JR.
xxxv
 CONTENTS

1 SECTIONAL RADIOGRAPHIC ANATOMY Contrast Medium-Enhanced High-Resolution CT 40

AND SCANNING 1 CT Angiography of the Neck: Venous Malformation
With Traumatic Arteriovenous Fistula 42
ANATOMIC RADIOGRAPHS .......•..•.......................•......... 1
john M. Lore, Sr., 1938 CT Venography of Facial Venous Malformation 44
Sagittal Section Through the Midportion of the CT Angiogram of ECAjICA Bypass 45
Maxillary Sinus and Orbit 2 Three-Dimensional CT of Vascular Tumor Relationship 46
Sagittal Section Through the Lateral Wall of the Endoluminal and Cut-Away View of the Trachea
Nose, Lateral Border of the Tongue, and Lamina With Medial Deviation of the Carotid Artery ........••.......... 47
of the Thyroid Cartilage Showing Its Superior
and Inferior Cornua .............................................•.............. 4 EXAMPLES OF MRI IN THE SUPERIOR
Sagittal Section Through the Floor of the Nose MEDIASTINUM .•...........•.............•..........•....••......•......... 48
john M. Lore, jr.
and the Body of the Tongue .................................•...•........ 6
Sagittal Section Through the Middle of the Skull 8 OTHER EXAMPLES OF CT AND MRI .............•............•.. 52
Frontal Coronal Section in the Region of the john M. Lore, jr.
Second Molar Teeth 10 Multinodular Goiter in the Mediastinum 52
Frontal Coronal Section Just Beyond the Paraganglioma (Second Primary Thoracic Chain,
Third Molar Teeth 12 T4 by CT Scan) 53
Frontal Coronal Section in the Region of the Metastatic Papillary Carcinoma of the Thyroid
Anterior Faucial Pillar and Tonsil 14 (Usual Type) .....................................................•............... 53

CT AND MRI ....•.............•.............••........•.•.•.......•..•....... 16 Magnetic Resonance Angiography ..........................•.•.••....... 54

David F. Hoyes and Scott Cholewinski
ULTRASOUND ............•..........•......................•............•... 54
Single-Plane CT Scans 16 David F. Hayes
Frontal Coronal Section in the Region of the Example Uses of Ultrasound 54
Second Molar Teeth .......................................•......... 16
Frontal Coronal Section Just Beyond the POSITRON EMISSION TOMOGRAPHy .......•.•..........•.... 56
Third Molar Teeth .............................................•....... 17 Rabert S. Miletich and john M. Lore, jr.

Frontal Coronal Section in the Region of the Role of PETin Oncology 57

Anterior Faucial Pillar and Tonsil 18 Role of FDG-PETin Head and Neck Cancer ......•................... 57
Three-Dimensional Reconstructed CT Scans 18 Conclusion 63
MR Images 26
Imaging in the Diagnosis and Treatment of
Head and Neck Disease 26 2 EMERGENCY PROCEDURES 65
Overview ................................................•..................... 26
Scott Cholewinski VENOUS AIR EMBOLISM ......•...........•.......•.•.....•....•...... 65
john Lauria
ADVANCED TECHNIQUES FOR CT IN THE
HEAD AND NECK ....•.•...........•.........••.•........•.•.........•..... 34 MALIGNANT HYPERTHERMIA ...•.•.......•.•....•.•.•..•......•.•. 65
Ronald A. Alberico and Ahmed Abdehalim john Lauria

The Role of Imaging in the Head and Neck 34 Other Untoward Events Associated With Endotracheal
Anesthesia 66
Detection of Perineural Disease at the Skull Base 35
Oblique Imaging of the Oral Pharynx to Avoid Dental BLINDNESS AND OPHTHALMIC COMPLICATIONS
Artifact 36 OF SURGERY OF THE HEAD AND NECK ....•................. 66
Multiplanar Techniques to Evaluate Tumor Location Daniel P. Schaefer and Arthur f. Schaefer
and Margins 37 Blindness ...............................................•..•.......................... 66
Three-Dimensional CT of the Inner Ear .............•.................. 39

xxxvii
 CONTENTS

CARDIOPU~MONARY RESUSCITATION 70 Common Departures From Sound Management

-"Pitfalls" 123
William M. Marris
Donald P. Shedd
Emergency Cardiac Care ........................................•............. 70
Open Biopsy of a Lump in the Neck
Sequence of BLS .................................................•.•.............. 70 Before Performing a Complete Head and Neck
Closed Cardiac Massage 72 General Examination 124
Open Cardiac Massage Resuscitation ...............•................... 72 Inadequate Incisional Biopsy of an Oral Cavity
Thoracentesis ............................................•.......•.................. 74 Lesion 124
Insertion of Intercostal Catheter 74 Inadequate Excisional Biopsy of a Suspicious Oral
Cavity Lesion 124
Open Thoracotomy for Empyema Drainage 78
Failure to Review Previous Histopathologic Slides 124
Intercostal Catheter Suction Drainage
With Underwater Seals ..........................•.......................... 80 Permitting a Single Histopathologic Benign
Diagnosis to Override a Clinical Diagnosis
Cricothyroidotomy 82 .. 125
of Carcinoma .
Management of Acute Respiratory Emergencies 84
Biopsies of the Laryhx, Hypopharynx,
Emergency Establishment of Airway 84 Nasopharynx, Esophagus, or Trachea
Before Radiologic Studies and Imaging
Techniques 125
3 BASIC CONSIDERATIONS 87 Lack of Multidisciplinary Approach
When Indicated 125
Needle Biopsy Techniques .......................................•........... 87
Tailoring the Scope of Surgical Resection
Ashok Koul to the Ability of the Surgeon Rather Than
Needle Aspiration Biopsy ................................•........ ··· .. 87 to the Objective Requirements Imposed
Core Needle Biopsy ·.········· · 87 by the Lesion 125
Large-Needle Aspiration Biopsy 89 A Compromise of the Ablative Phase of Surgery
to Accommodate Limited Reconstructive Skills 126
Commonly Used Terminology for Squamous
Epithelium 91 Compromise of Surgical Margins Because
Ashok Koul Radiation Therapy or Chemotherapy
Was or Is to Be Given 126
Commonly Used Special Stains for Head and
Neck Lesions 91 Performing the Right Operation on the
Wrong Patient 126
Mucosal Biopsy: Toluidine Blue Staining Technique 91
Assessing the Degree of Successor Failure of
Exfoliative Cytology Biopsy Technique , 91
Radiation Therapy on the Basisof the Response
Z-Plasty 91 of the Lesion During or Immediately
Definition ..................................•..........................••....... 91 on the Completion of Treatment 126
Technique of Basic Z-Plasty .................................•......... 92 Failure to Realize the Implication of the
"Condemned Mucosa" or Multiple Primary
Types and Modifications of Z-Plasty 98
Syndrome 127
Tissue Expansion ...................................................•............ 100
Failure to Perform a Complete General Physical
Effects of Tissue Expansion .......................•.................. 100 Examination as Well as a Complete Head
W-Plasty ..........................................................•.................. 102 and Neck Examination 127
Rhombic Flap .........................•........................••................. 104 Prolonged Watch-and-Wait Attitude in the Face
of an Asymptomatic Mass 127
Excision of Dog-Ears .....................................•.•.................. 106
Bone, Cartilage, and Nerve Grafts 107 Inadequate Search for an "Occult" Primary Tumor 127

Basic Principles Relative to Bone and Cartilage Abandonment of the Patient With Neck Metastasis
Grafts and Implants 107 From an Undetectable Primary Tumor 128

Rib, Iliac, and Costochondral Grafts 107 Enucleation of Tumors of the Major Salivary
Glands and Thyroid Gland 128
Iliac Bone Graft-"Trap Door Type" 110
Treating a Patient With Antibiotics for an
Auricular Cartilage Graft 110 Extended Period of Time Without a Biopsy 128
Sural Nerve Grafts ......................•..................•....•........ 112 The Place for Chemotherapy in Management
Skin Incision ...........................................................•.......... 112 of Squamous Cell Carcinoma of the Head and Neck 128
Nonabsorbable Sutures for Mucosal Repair 112 Monica B. Spaulding

Preoperative and Postoperative Care 114 Recurrent or Metastatic Head and Neck Cancer .. 129
William R. Nelson and R. Lee Jennings Preoperative Chemotherapy, Uncompromised Surgery,
Preoperative Care .....................................•.•............... 114 and Selective Radiotherapy in the Management
of Advanced Squamous Cell Carcinoma of the
Postoperative Care 116
Head and Neck 132
John M. Lore, Jr., Sol Kaufman, Nan Sundquist,
and Kandala Chary
 CONTENTS

A Comprehensive, Interdisciplinary Head and Neck Telescopic Endolaryngeal Surgery 204

Service 141
Nasopharyngoscopy 205
john M. Lore, jr., A. Charles Massaro, and Angela Bontempo
Rigid and Flexible Direct Optical Nasopharyngoscopy,
Bone Imaging and Pathology 142
Laryngoscopy, Cervical Esophagoscopy,
Scott Cholewinski, john Asirwatham, Daniel Broderick,
and Rhinoscopy 210,.
ond john M. Lore, jr.
Rigid Nasopharyngoscopes 210
Methods of Bone Involvement: Mandible 142
Flexible Nasopharyngoscopes 210
VOICE, SPEECH, AND SWALLOWING Rigid and Flexible Direct Optical Rhinoscopy 210
REHABILITATION OF THE HEAD AND NECK
Cervical Esophagoscopy 212
PATIENT ..................................................•..............•.... 143
Allen M. Richmond
Total Laryngectomy 143
5 THE SINUSES AND MAXILLA 214
Conservation Surgery: Cancer of the Larynx 144
Swallowing 144 Intranasal Antrostomy 214
Glossectomy 146 Rhinoscopy ........................................................•........ 214
Palatal Surgery 147 Caldwell-Luc Antrotomy 217
Voice 147 Intranasal Ethmoidal Surgery for Benign Disease 220
Hearing, Cochlear Implants, and Middle Ear Surgery 148 Uncapping of Anterior Ethmoidal Cells 220
Malignant Melanoma 149 Ethmoidectomy 220
Constantine P. Karakousis Endoscopic Diagnosis and Surgery for Sinusitis 222
Soft Tissue Sarcoma 152 External Ethmoidectomy 223
Constantine P. Karokousis
Sphenoidal Sinusotomy 226
Thyroid-Related Orbitopathy 154
Daniel P. Schaefer
Puncture of Anterior Wall of Sphenoidal Sinus 226
Enlargement of Natural Sphenoidal Ostium or
Pathogenesis 154
Anterior Wall Puncture Site 226
Epidemiology 154
Other Approaches to the Sphenoidal Sinus 228
Clinical Course 155
Frontal Sinusotomy (Trephination) 230
Differential Diagnosis 156
External Frontoethmoidectomy 232
Treatment Plan 160
Osteoplastic Approach to the Frontal Sinus 234
Dental and Prosthetic Considerations in Head
Anatomy of Frontonasal Duct 234
and Neck Surgery 161
David M. Casey Partial and Radical Maxillectomy ..............................•......... 236
Maxillofacial Prostheses ......................................•............... 166 Case 1: Esthesioneuroblastoma 237
Dovid M. Cosey Case 2: Esthesioneuroblastoma, Nonresectable,
Osseointegrated Implants in Head and Neck Stage C 238
Reconstruction 171 Case 3: Neuroendocrine Carcinoma,
Maureen Sullivan Nonresectable, Stage C 238
Removal or Saving Remainder of Soft Palate
After Partial Maxillectomy 238
4 DIAGNOSTIC ENDOSCOPy 179 Radical Resection of Maxilla With Orbital and Partial
Ethmoidal Exenteration 239
PERORAL ENDOSCOPY OF THE HEAD AND NECK ..... 179
Resection of Maxilla Including the Floor of the Orbit
Indirect Mirror Laryngoscopy and Nasopharyngoscopy With Preservation of the Globe ...............•....................... 246
and Cervical Esophagoscopy 179
En-Bloc Resection for Chondrosarcoma 246
Direct Optical Laryngoscopy and Nasopharyngoscopy 180
Limited Resection of the Maxilla 248
Cervical Esophagoscopy 181
Cysts of Maxilla ................................................•................ 250
Direct Rigid Laryngoscopy and Nasopharyngoscopy 181
Excision of Nasoalveolar Cyst 252
Direct Rigid Laryngoscopy and Hypopharyngoscopy 182
Excision of Nasopalatine Duct Cyst 254
Rigid Bronchoscopy 188
Closure of Oroantral Fistula 256
Flexible Bronchoscopy 192
Tracheal Lengths 192 ENDOSCOPIC SINUS SURGERy 258
Keith F. Clark
Esophagoscopy 194
Cervical Esophagoscopy After Total Laryngectomy
or Cervical Esophageal Surgery 194
Rigid Esophagoscopy 196 6 THE NOSE AND THE NASOPHARYNX 267
Microscopic Endolaryngoscopy 200 Anatomy of the Lateral Wall of the Right Nasal Cavity 267
 CONTENTS

Uncinate Process 267 Total Resection of Nose for Carcinoma 356

Bulla Ethmoidalis 267 Resection of Nasal Glioma-External Ethmoid Approach 358
Infundibulum Ethmoidalis 267 Excision of Rhinophyma 362
Anatomy of Epistaxis 270
Anterior and Posterior Packing for Epistaxis 272
7 THE FACE 367
Ligation of Ethmoidal Arteries 276
External Ethmoidectomy Approach to Epistaxis 279 Anatomy of Facial and Scalp Muscles 367
Septal Dermoplasty 280 Basic Technique for Facial Excisions 369
Ligation of Internal Maxillary Artery 282 Sebaceous Cysts 369
Removal of Nasal and Nasopharyngeal Polyps 286 Dermabrasion 371
Transpalatine Exposure of the Nasopharynx and the Excision of Tumors of Skin of Forehead 373
Sphenoidal Sinus 288 Excisions for Carcinoma of Skin of Temple 375
Transmaxillary Approach to Nasopharynx and Base Basal Cell Carcinoma 375
of the Skull 294
Squamous Cell Carcinoma 376
Posterior Choana I Atresia 295
Rotation Flaps 377
Newborn and Young Children ........•........................... 295
Temporal Scalp Flap 377
Older Children and Adults 296
Cheek Flap 378
Submucous Resection of Nasal Septum 300
Excision of Tumors of Cheek by Cheek Flap Rotation 379
Septoplasty Type I 304
Facial Paralysis 380
Septoplasty Type II 310 Shirley A. Anain and Jahn M. Lare, Jr.
Rhinoplasty 316 Management Possibilities 381
Alternate Techniques of Rhinoplasty 324 Facial Reanimation 381
Correction of Broad Nasal Tip 325 Cross-Face Nerve Grafts with Microvascular
Augmentation of Dorsum of Nose 326 Muscle Transfer 381
Additional Nasal Tip Procedures 326 Upper Lid Gold Weights 382
Columellar Graft for Collapsed Nasal Tip 328 Hypoglossal-Facial Nerve Anastomosis 384
Type I 328 Masseter Muscle Transposition-Intraoral 386
Type II 328 Fascial Slings for Facial Paralysis 388
Nares and Columella Procedures 330 Treatment of Paralysis of the Depressors of the
Nasofacial and Nasolabial Flaps 332 Lower Lip 390

Septal Flap for External Nasal Defect 334 Trigeminal Neuralgia (Tic Douloureux) 392

Nasolabial Flap 336 Incision and Drainage of Abscesses 394

Excision and Reconstruction of Ala Nasi 336

Excision and Reconstruction of Columella 336
8 GENERAL PURPOSE FLAPS
Resection of Tumor of Tip of Nose 338
Resection and Reconstruction of Tumor of the Introduction: Flap Selection and Design 399
Superior Dorsum of the Nose 340 Classification of Large Transposed Myocutaneous
Full-Thickness Graft to Nose 340 Flaps 400
Composite Graft From Ear to Nose 342 Limitations and Pitfalls with Major Standard
Regional Flaps 401
Type of Flap 342
Limitations and Pitfalls According to Specific Flaps 401
Reconstruction of Nose With Arm Flap 344
Blood Supply to Skin Flaps 402
Nasal Reconstruction With Lateral Forehead Flap 346
Pectoralis Major Myocutaneous Flap 404
Nasal Reconstruction With Combined Scalp
and Forehead Flaps 348 Reconstruction of the Entire Hypopharynx
and Portion of Cervical Esophagus, Oropharynx,
The Sickle Flap 348
and Nasopharynx 412
The "Scalping" Flap 348
Cross Section of Reconstructed Hypopharynx 412
Nasal Turn-in Flaps 350
Applications of the Pectoralis Major Flap 420
Nasal Reconstruction 352
Deltopectoral Flap 425
Transection of Forehead and Scalp Pedicle 352
Reconstruction of Oropharynx, Hypopharynx,
Revision of Nasolabial Fold and Ala Nasi 352 and Portion of Cervical Esophagus 425
Enlargement of Nares With Z-Plasty 352 Applications of Deltopectoral Flap 434
Resection of Nasal Septum for Carcinoma Apron Flap 436
(Lateral Rhinotomy Approach) 354
 CONTENTS

Laterally Based Chest Flap ...........................•...................... 438 Unilateral Cleft Lip Repair 494
Mutter (1842) Nape of Neck Flap 440 Triangular Flap Cleft Lip Repair: Tennison-Randall
Posterior Scapula Flap .........................................•.............. 442 Technique 496
Forehead Flap (Temporal Flap) ..............................•............ 444 Rotation Advancement Cleft Lip Repair 498
Reconstruction of Cheek with Forehead Flap .........•.•......... 446 Bilateral Cleft Lip Repair 500
Midline Forehead Flap ...........................................•.•.•....... 452 Basic Deformities of Cleft Lip (Bilateral Complete) 500
Fat Flip Flap ..............................•...........................•............ 454 Repair of Complete Bilateral Cleft Lip
(Straight-Line Closure) 502
Repair of Incomplete Bilateral Cleft Lip (Rotation-
• THE LIPS 458 Advancement Technique) 504
Cleft Palate ....................................................•................... 506
Lip Excision and Reconstruction 458
Types of Cleft Palate Deformities ...............•................. 506
Planing of Lip .................................•.•.......................... 458
Reconstructive Goals ................................•...•.............. 506
Shield Excision of Lower Lip .............•...•...................... 458
Optimal Age for Operation 506
Cupid's Bow 460
Repair of Complete Cleft of Secondary Palate 506
Elliptical Excision of Benign Lip Lesion 460
Repair of Incomplete Cleft of Secondary Palate 512
Distortion of Mouth Corrected by Z-Plasty 460
Repair of Complete Unilateral Cleft Palate 514
Excision of Large Benign Lesions of Upper Lip
Pharyngeal Flap in Cleft Palate Repair 516
with Nasolabial Flap 460
Pharyngeal Flap for Velopharyngeallnsufficiency 517
Repair of Large Vermilion Defects .............................•........ 462
Abbe-Estlander Lip Operation 464
Correction of Rounded Commissure of Lips 467
11 PERIORBITAL REGION 523
Plication of the Orbicularis Oris Muscle to Repair
Partial Paralysisof the Lower Lip 468 Anatomy 523
Modifications of Abbe-Estlander Lip Operation 469 Repair of Lids and Conjunctiva .........................•................ 523
Reconstruction of Center Lower Lip Defect 469 Wounds of the Conjunctiva ..........................•............. 524
Reconstruction of Upper Lip Defect 470 Repair of Lid Lacerations 524
Correction of Rounded Commissure of Lips 470 Management of Disruption of the Canaliculi 524
Reconstruction of Large Defects of Upper Lip 472 Reconstruction of Lids ................................................•....... 524
Reconstruction of Upper Lip with Cheek Flap 472 Reconstruction of Lower Lid 526
Fan Flap Reconstruction for Large Defects Resection of Large Basal Cell Carcinoma of Lower
of Upper Lip 474 Lid With Reconstruction Using Lateral Cheek
Excision and Repair of Large Lesions of Upper Lip 476 Flap 532

Burow's Technique 476 Reconstruction of Upper Lid 534

Gillies' Technique 476 Bridge Flap Repair of Large Upper Lid Defects,
Cutler-Beard Technique 542
Repair of Large Defects of Upper Lip 478
Resection of Large Basal Cell Carcinoma Involving
Bitemporal ("Visor") Flap for Large Upper Lip
Both Lids and Nose 544
and Cheek Defects 480
Excision of Superficial Basal Carcinoma in Region
Resection of Lower Lip with Bernard Reconstruction 482 of Lateral Canthus of Lower Lid 546
Reconstruction of the Lower Lip 484 Excision of Benign Lesion of Upper Lid 548
Reconstruction of the Lower Lip after the Reconstruction of Superficial Horizontal Defect
Extirpation of a Lip Cancer ..........................•........... 484 of Portion of Lower Lid 548
Reconstruction of the Upper Lip after an Eyelash Reconstruction ...........•.•.................................. 550
Operation of Lip Cancer 485
Eyebrow Reconstruction 550
Reconstruction of the Lower Lip from the Cheeks
after an Operation of a Lip 486 Excision of Lesions at the Medial Canthus 552
Cancer with the Resection of a Part of the Medial Canthoplasty and Repair of Related Injuries 554
Lower Jaw 486 Dacryocystorhinostomy 558
Correction of Scar Contracture of the Lids
and Ectropion 560
10 ClEFT LIP AND PALATE 493 Tarsorrhaphy 562
ROBERTJ. PERRYand JOHN M. LORE,JR. Lateral Permanent Tarsorrhaphy or Canthorrhaphy 562
Cleft Lip .................................................................•........... 493 Temporary Tarsorrhaphy 562
Types of Cleft Lip Deformities 493 Graft for Defect of Infraorbital Rim 564
Normal Anatomy 493 Decompression of the Orbit for Exophthalmos 566
 CONTENTS

Resection of Benign Tumor of Lacrimal Gland 569 Repair of Large Mandibular Defects Utilizing
the DBDB Plate 618
Resection of Adenoid Cystic Carcinoma of the
Lacrimal Gland 570 Open Reduction of Depressed Fracture of Zygomatic
Arch With or Without Fracture of Body of Zygoma
(Gillies' Technique) 620
Open Reduction of Depressed Fracture of Zygoma
12 THE EAR 573 and Portion of Maxilla 622
Otoplasty 573 Early Reduction ........................•.•................................ 622
Cartilage Incision Technique ............................••......... 573 Late Reduction 622
Mattress Suture Technique (Correction of Early Reduction of Depressed Comminuted
Prominent or Deformed Ears) 576 Fracture of Anterior Wall of Maxilla 624
Surgical Treatment of Hematoma of the Auricle: Intraosseous Wiring for Facial Fractures 626
"Cauliflower Ear" 580 "Tent Peg" Method of Reduction and Fixation
Z-Plasty for Stenosis of External Auditory Canal 582 of Facial Bone Fractures 628
Excision of Small Malignant Tumor of Cartilaginous Open Reduction of Complete Fracture of Upper
Portion of External Auditory Canal · 584 Dental Arch of Maxilla (Le Fort I or Guerin) 630
Excision of Malignant Tumors of the Auricle 586 Suspensory Wire Technique 630
Excision of Hemangioma of the Face Involving Lobule Direct Intraosseous Wiring Technique 630
of the Ear 586 Internal Fixation of Fracture Through Middle Third
En Bloc Resection of the External Auditory Bony Canal 588 of Maxilla (Le Fort II or Pyramidal Fracture) 632
Total Resection of the Auricle With a Portion of the Open Reduction of Fractures Through Glabella, Orbit,
External Auditory Canal, Parotidectomy, and Zygomatic Arch (Le Fort III or Craniofacial
and Radical Neck Dissection for Recurrent Dysjunction) 634
Malignant Melanoma 590 Techniques of the Use of Miniplates in Le Fort I, II,
Technique 590 and III Fractures 636
Posterior Approach to the 7th (Facial) Nerve 590 Le Fort I-Basic ..................................................•........ 636
Final Pathology Diagnosis 592 Le Fort I-Complicated ................................•.......•...... 636
Le Fort II ..................................................•.................. 636
Le Fort III 637
13 FRACTURES OF FACIAL BONES 595 Internal Fixation of Fractured Hard Palate 638
JOHN M. LORE,JR.and DOUGLASW. KLaTCH Fractures Involving the Frontal Sinus 638
Basic Principles 595
Fractures of Floor of Orbit 640
Reduction of Fractured Nose 596
External Traction for Depressed Facial Fracture 646
Depression of Right Nasal Bone with Lateral Management of Zygomatic (Malar) Fractures 648
Displacement of Left Nasal Bone 597
Douglas W. Klotch
Depression of Nasal (Frontal) Process of Right Repair of Simple Fractures 649
Maxilla 598
Repair of Complex Fractures 650
Fractures of Mandible-Outline ..............................•.......... 599
Fracture of Condylar Process-Outline ..............•................ 600

FRACTURES OF MANDIBLE 602 14 CYSTS AND TUMORS INVOLVING

Douglas W. Klotch THE MANDIBLE 653
Overview of Fracture Repair 602
Excision of Cysts of the Mandible 653
Open Reduction of Fractures of the Mandible 603
Radicular Cyst ................................•............................ 653
Technical Aspects of Fracture Repair 605
Dentigerous Cyst 656
Compression Plating for Treatment of Mandibular
Marginal Segmental Resection of Mandible 658
Fractures 610
Douglas W. Klotch and Joachim Prein Resection of Large Benign Tumors of Mandible 660
Outline of Procedures for Rigid Internal Fixation 612 Mandibular Reconstruction 664
Fracture in Row of Teeth 614 Reconstruction of Mandible Using Steinmann Pin
and Tie Wires 665
Fracture Posterior to Row of Teeth ..............•............... 614
Mandibular Reconstruction Using Steinmann Pin 666
Fractures at Angle of Mandible 616
Use of Eccentric Dynamic Compression Plate 616 Other Options Relative to Mandibular
Reconstruction 672
Use of Dynamic Mandible Defect-Bridging Plate 616
Results of Reconstruction With Kirschner Wire
Fracture in the Edentulous Mandible 618 and Steinmann Pin 672
Treatment of Oblique Fractures by Utilizing
the Lag Screw Principle 618
 CONTENTS

Reconstruction of the Mandible Using Plates Buccal Wall lesions: Benign, Premalignant,
With or Without Free Autogenous and Malignant Squamous Cell Carcinoma 742
Nonvascularized Bone Grafts 675
Plan for Resection of Premalignant and Malignant
Resection and Second-Stage Reconstruction lesions of the Buccal Wall 744
of Anterior Portion of Mandible Using Iliac
Radical Resection of Buccal Wall With
Bone Graft 678
Mandibulectomy Associated With
Resection and Reconstruction of Major Portion Oropha~ngeal and Retromolar Trigone
of Body of Mandible With Bent Steinmann Pin Invasion: Advanced Squamous Cell Carcinoma 745
and Tie Wires and Forehead Flap 682
Reconstruction of Buccal Wall lesions 746
~=~ ~ Resection of Carcinoma of the Retromolar
Marginal Resection of Mandible, Partial Trigone and the Buccal Wall 747
Glossectomy, and Radical Neck Dissection for
Excisions of lesions of Soft and Hard Palate 752
Carcinoma of the Floor of the Mouth 688
Resection of Extensive Benign Minor Saliva~
Gland Tumors of the Soft Palate 760
Resection of Carcinoma of Soft Palate 764
t5 ORAL CAVITY AND OROPHARYNX 698
Excision of Ranula 766
Excision of Dysplasia (leukoplakia) and/or
Resection of Hemangioma and Neurofibroma
E~throplasia (Erythroplakia) of Tongue and
of Tongue 768
Buccal Mucous Membrane 698
Tonsillectomy and Adenoidectomy 770
Excision of Carcinoma In Situ or Small limited
Carcinoma of Tongue 700 Adenoidectomy 770
Excision of Small Midline Cancer of Anterior Third Salivary Duct Calculi 773
of Tongue 702 Repair of laceration of the Stensen Duct (Parotid) 773
Median labiomandibular Glossotomy (Trotter Reconstruction and Reimplantation of Stensen's Duct
Approach to Base of Tongue, Pha~nx, in the Buccal Wall 774
and Baseof Skull) 704 Pierre Robin Syndrome 774
Resection of Stage T1 Carcinoma of the Midline
of the Floor of the Mouth 708
Inlay Graft to Floor of Mouth for Carcinoma 710 16 THE NECK 780
Resection of Malignant Tumors of the Oral Cavity JESUSE. MEDINA and JOHN M. LORE,JR.
and Oropha~nx With Extension Above Into the Cervical lymph Nodes 780
Nasopha~nx and Below to the Hypopha~nx
With Cervical Metastasis With or Without Spinal Accesso~ Nerve 781
Involvement of the Mandible Including the Cervical lymph Node Metastatic Guide 781
Parapha~ngeal Space 714 Classification 786
Approaches 714 Radical Neck Dissection 788
Bone Involvement: Mandible ...........................•..•....... 716 Evaluation of Cervical lymphadenopathy
Guidelines 716 on Computed Tomography and Magnetic
Resection for Carcinoma of Tonsil, Soft Palate, Resonance Imaging 797
or Baseof Tongue by Mandibulotomy and Modifications of Radical Neck Dissections 797
Reconstruction 720 Parotid Extension of Radical Neck Dissection
Resection of Hemimandible, lateral Oropharyngeal (High Exposure of Internal Jugular Vein
Wall, and Portion of Soft Palate and and Internal Carotid Artery) 798
Hemiglossectomy With Reconstruction Modified Radical Neck Dissection Preserving
Using a Forehead Flap Versus Pectoralis Major Flap 724 the Spinal Accesso~ Nerve (Type I) 802
Combined Radical Neck Dissection, Partial Incision Modifications of Radical Neck Dissection 804
Glossectomy or Hemiglossectomy, and
Modified Radical Neck Dissection Preserving
Hemimandibulectomy Including Retromolar
the Spinal Accesso~ Nerve, the Internal Jugular
Trigone 726
Vein, and the Sternocleidomastoid Muscle
Base of Tongue 732 (Type III) 808
Anatomy of the Tongue 732 Selective Neck Dissections 811
Resection of Baseof Tongue 732 Extended Neck Dissections 814
Approaches to Base of Tongue 733 Resection of lower Margin of Mandible Combined
Resection of Baseof Tongue via Midline with Radical Neck Dissection 814
Mandibulotomy (Mandibular Swing) 734 Posterior Neck Dissection ...........................................•....... 818
Midline Mandibulotomy (Mandibular Swing) 736 Keun Lee

Resection of Baseof Tongue and Total Glossectomy 738 Excision of Thyroglossal Cyst and Sinus 824
Resection of lesions of the Buccal Wall 742 Resection of Submandibular Saliva~ Gland for Benign
Disease 828
 CONTENTS

Phrenic Nerve Crush 832 18 ENDOCRINE SURGERy 892

JOHN M. LORE,JR.,MEGAN FARRELL
Scalene and Infraclavicular Internal Jugular Node
and NIEVAB. CASTILLO
Biopsy 832
Muscle Lengthening for Torticollis .............•....................... 834 THYROID GLAND 892
Branchial Cleft Cysts 836 Diagnostic Evaluation 892
First Branchial Cleft 836 History ...................................•.•.•.•.............................. 892
Second Branchial Cleft (Most Common) 838 Physical Examination 893
Third Branchial Cleft (Rare) 838 Fine-Needle Aspiration of the Thyroid Gland 893
Fourth Branchial Cleft ......................................•..•....... 838 Thyroid Scans ('231 and 99mTc) 895
Resection of Branchial Cleft Cysts ..........................•.•......... 840 Sonography ...................................................•............ 895
Second Branchial Cleft ................................•............... 840 Computed Tomography ..............................•.•............ 896
Excision of Branchial Fistula and Sinus Tract ..........•.•.......... B43 Magnetic Resonance Imaging 896
Excision of Cystic Hygroma (Lymphangioma) 845 Positron Emission Tomography ...........•.•..................... 896
Excision of Benign Lesions of the Submental Space 848 Anatomic Considerations 896
Resection of Ganglioneuroma of the Neck Posterior Suspensory Ligament .........•.•....................... 897
and Superior Mediastinum 850 Recurrent Laryngeal Nerve 897
Excision of Neuroma 852 Inferior Thyroid Artery 898
Incision and Drainage of Abscessesof the Neck 8S4 External Branch of the Superior Laryngeal Nerve 899
Abscess of Tongue and Floor of Mouth Presenting Parathyroid Glands 899
in Submental Space (Ludwig's Angina) 854
Access to the Superior Mediastinum 900
Lateral Cervical Abscess 854
Motor Nerve Supply to the Strap Muscles 901
Penetration Wounds of the Neck ...............................•....... 856
Thyroglossal Duct Tract 901
Diagnosis and Treatment ...................................•........ 856
Normal Ectopic Thyroid 901
Basic Surgical Technique 903

17 THE PAROTID SALIVARY GLAND Definition of Terms ............................................•.•............. 904

AND MANAGEMENT OF MALIGNANT Evaluation of Laryngeal Nerve Function 905
SALIVARY GLAND NEOPLASIA 861 Arytenoid Dislocation 906
Management of Thyroid Cancer 907
General Considerations 861
Total Thyroidectomy Versus Subtotal
Fine-Needle Aspiration Biopsy 861 Thyroidectomy or Lobectomy 907
Total Lateral Lobectomy of the Parotid Salivary Gland 862 Nerve Paralysis 908
Facial Nerve in Infants 866 Hypoparathyroidism 908
Deep Lobectomy of Parotid Salivary Gland 868 Potential Problems in Management 909
Mandibulotomy and Deep Lobe Lobectomy of the Hormonal Replacement 910
Parotid Salivary Gland with Dissection of
Parapharyngeal Space ..........................................•.•....... 872 Additional Evidence Supporting Total
Thyroidectomy 910
Free Facial Nerve Graft .......................................•..••........... 876
Management of Well-Differentiated Thyroid Cancer
Gustatory Sweating (Frey's Syndrome) 876 (Includes Papillary, Follicular, and HOrthle Cell
Excision of the Recurrent Benign Tumor of the Oncocytic Carcinoma) 914
Parotid Gland 878 Pathologic Classification 914
Management of Salivary Gland Tumors 880 Nieva B. Castillo
Thorn R. Loree Danger of Underestimating Malignancy 919
Additional Caveats Relative to Malignant Tumors Treatment 919
of the Parotid Salivary Gland 882
Imaging 922
lohn M. Lore, If.
Adenocarcinoma Not Otherwise Specified (NOS) 883 Medullary Carcinoma of the Thyroid 922

Malignant Mixed Tumor 884 Origin and Characteristics 922

Nievo B. Costilla Types 923
Parotid Extension of Radical Neck Dissection .......•............. 886 Classification of Multiple Endocrine Neoplasia 923
High Exposure of Internal jugular Vein Diagnosis 923
and Internal Carotid Artery .......................•.•............ 886 Familial MCT 924
Parotitis ...........................................................•.•............... 888 Suggested Follow-up Regimen .......................•.•.......... 924
Family Screening .......................................•................. 925
 CONTENTS

Management of Residual or Recurrent MCT 926 Overview of Surgical Principles 985

Scope of the Operation 926 Detailed Review of Surgical Principles ...........•.................... 986
Prognosis .......................................................•............ 927 Excision of Parathyroid Adenomas 990
Hurthle Cell Carcinoma 927 Excision of Mediastinal Parathyroid Adenomas
Papillary Tall Cell Carcinoma 927 and Cystadenoma 996
Undifferentiated or Anaplastic Carcinoma 928 Mediastinoscopy 997
Squamous Cell Carcinoma 928 Anatomy 997
Summary of Management of Thyroid Cancer 929 Discussion 997
Substernal Goiter (Median Sternotomy and Total Excision of Posterior Superior Mediastinal Parathyroid
Thyroidectomy With Superior Mediastinal Node Cystadenoma via Median Sternotomy 999
and Radical Neck Dissection) 929 Postoperative Care 1002
Graves' Disease ........................................•......................... 932 Osteoporosis 1002
Exophthalmic Graves' Disease 934 Hypocalcemia 1002
Toxic Multinodular Goiter 934
Total Thyroid Lobectomy 93S
Subtotal Thyroid Lobectomy 946 1 THE TRACHEA AND MEDIASTINUM 1015
Modified Radical Neck Dissection with Preservation
Tracheoscopy 1015
of the Sternocleidomastoid Muscle and the Spinal
Accessory Nerve 950 Tracheostomy 1015
Total Thyroidectomy Without or With Radical Neck Cervical Mediastinotomy and Tracheomediastinotomy 1024
Dissection 955 Tracheal Resection 1026
Autonomous Thyroid Nodule 960 Closure of Cutaneous Tracheal Fistula 1034
Endemic Goiter Not Due to Iodine Deficiency Closure of Cervical Tracheoesophageal Fistula 1036
(Beierwaltes) 960 Mediastinum Anatomy 1036
Hashimoto's Thyroiditis (1912}-Struma Lymphomatosa 960 Mediastinoscopy .....................•........................................ 1038
Lingual Thyroid 962 Mediastinal Dissection 1040
Complications of Thyroid Surgery 963 Suprasternal Approach via the Superior Thoracic
Suggested Postoperative Orders After Thyroid Surgery 966 Inlet (Limited Dissection) 1040
Resection of the Medial Third of the Clavicle
PARATHYROID GLANDS ...•...............•...............•......... 966 on One Side 1040
Pathology of the Parathyroid Glands 966
Median Sternotomy 1041
john E. Asirwatham
Resection of the Manubrium With or Without
Embryology 966 a Portion of the Sternum and Medial Portion
Anatomy ......................................................•.............. 966 of the Clavicle 1041
Diseasesof Parathyroid 966 Exposure of the Mediastinum by Resection of the
Intraoperative and Frozen Section Examination Medial Third of the Clavicle 1041
of Parathyroid 967 DiseasesAmenable to the Approach With Medial
Hypercellularity 968 Third Clavicle Resection 1041
Surgery of Parathyroid Glands 968 Median Sternotomy, Total Thyroidectomy,
With Superior Mediastinal Node and Radical Neck
Blood Supply of the Parathyroid Glands ...............•...... 968
Dissection 1046
Hyperparathyroidism 972
Mediastinal Dissection for Tracheostoma Recurrence
Hyperparathyroidism Associated With MEN (Sisson Procedure) 1056
Syndromes 975
Transcervical Total Thymectomy 1062
Preoperative and Intraoperative Techniques
for the Surgical Management of Sporadic
Hyperparathyroidism: Adenoma and Hyperplasia 976
john M. Lore, jr. 20 THE LARYNX 1069
Section 1: The Author's (JML) Experience Indirect Mirror Laryngoscopy 1069
and Suggestions Regarding Imaging 976
Anatomy of Superior Laryngeal Nerve 1069
Section 2: Summary Evaluations, Pros and Cons,
for Each Imaging and Nonimaging Modality 980 Punch Biopsy of Lesions of Larynx and Hypopharynx 1073

Section 3: Pearls and Pitfalls Regarding Stripping (De-Epithelialization) of a Vocal Cord 1074
Parathyroid Imaging 982 Endoscopic Removal of Congenital Cyst of Ventricle
Indications for Surgery in Primary in Newborn (Internal Laryngocele) 1076
Hyperparathyroidism 984 CO2 Laser in Laryngeal and Endobronchial Surgery 1077
Chemical Diagnosis of Hyperparathyroidism 984 Microlaryngoscopy Using the CO2 Laser 1077
 CONTENTS

Endoscopic Intracordallnjection of Teflon Paste 1078 Resection of Carcinoma at Posterior Wall

of Hypopharynx and Oropharynx and Radical Neck
Thyroplasty;Vocal Cord Mediallzation 1080
Dissection (Lateral Pharyngotomy Approach) 1181
Laryngofissure (Thyrotomy) 1082
Introduction to Reconstruction of Pharynx
Cordectomy and Arytenoidectomy for Bilateral and Esophagus 1186
Abductor Cord Paralysis 1084
Carcinoma of the Hypopharynx and Cervical
Laterallzation of Arytenoid Cartilage (Arytenoidopexy) Esophagus 1187
for Bilateral Abductor Vocal Cord Paralysis 1086
Myomucosal Tongue Flap and Dermal Graft for
Cancer of the Larynx 1089 Reconstruction of Entire Hypopharynx, Posterior
Treatment 1094 Wall of Oropharynx, and Nasopharynx Associated
With Total Laryngectomy and Total
Radiation Therapy for Laryngeal Cancer
Hypopharyngectomy 1188
Dhiren K. Shah
Cervical Esophagoscopy 1190
Partial Laryngectomy (Outline) 1100
Reconstruction of Hypopharynx and Cervical
Cordectomy for Small Carcinoma of True Vocal Cord 1105
Esophagus Using PMF With Dermal Graft 1190
Vertical or Frontolateral Laryngectomy 1106
Reconstruction After Partial "Cuff" Cervical
Omohyoid Muscle Laryngoplasty 1114 Esophagectomy, Hypopharyngectomy, and Total
Strap Muscle Laryngoplasty 1116 Laryngectomy Above the Thoracic Inlet Using
Horizontal or Supraglottic Laryngectomy 1118 Local Cervical Flaps 1192

Simultaneous Radical Neck Dissection 1120 Free Skin Graft Over Tantalum Gauze 1196

Laryngeal Suspension 1125 Thoracic Skin Flap 1196

Total Laryngectomy 1126 Resection for Cancer of the Cervical Esophagus 1199

Tracheostomal Problems 1134 Gastric Pull-Up 1200

Technique of Construction of Large Tracheal Stoma 1134 Gastric Pull-Up With Extrathoracic Esophagectomy 1200

Correction of Tracheal Stomal Stenosis 1135 Resection of Cancer of Cervical Esophagus

at the Thoracic Inlet 1206
Total Laryngectomy and Radical Neck Dissection 1136
Cervical Esophagocolostomy 1213
Tongue Flap (Myomucosal) for Reconstruction
of Portion of Hypopharynx Associated With Total Reconstruction of Esophagus Using Transverse
and Descending Colon 1216
Laryngectomy 1142
Stamm Gastrostomy ·..· 1222
Voice Prostheses: Post-Total Laryngectomy 1143
Tracheal Esophageal Puncture (TEP) .............•............ 1143 Janeway Gastrostomy · 1224

Singer-Blom Technique (Modified) 1144 Percutaneous Endoscopic Gastrostomy .................•.......... 1227

Daniel Sette Camara
panje Voice Button Prosthesis 1146
Total Laryngectomy and Radical Neck Dissection 1148
Resection of External Laryngocele 1152 22 VASCULAR PROCEDURES 1233
Laryngeal Trauma 1154 JOHN M. LORE,JR.,JOSEPHM. ANAIN,
Correction of Laryngeal Web ......................•.................... 1162 NIEVAB. CASTILLO,and L. NELSONHOPKINS
Technique of McNaught (1950) 1162 Vascular Surgery in Operations of Neck, Extracranial
Portions of Head, Face, and Thoracic Outlet 1233
Technique of Frazer (1968) 1162
Basic Principles 1233
Aspiration ....................................•............................ 1162
Degenerative Vascular Disease 1240
Carbon Dioxide Laser 1164
Extracranial Cerebrovascular Disease 1242
Exposure of Bifurcation of Carotid Arteries and
Endarterectomy 1244
21 THE HYPOPHARYNX AND
Endarterectomy With Patch Graft 1248
THE ESOPHAGUS 1171
Intraluminal Shunts Used in Endarterectomy 1248
Repair of Pharyngoesophageal Diverticulum 1171 Complications of Carotid Artery Surgery 1250
Exposure of the Superior Portion of the Thoracic Controversies of Carotid Artery Surgery 1252
Esophagus 1176
Carotid Artery Stenting: Indications, Technique,
Repair of Iatrogenic Injury to the Esophagus 1176 and Results 1254
Resection of Adenocarcinoma From the Cervical L. Nelson Hopkins
Esophagus 1176 Exposure of Cervical Portion of Subclavian Arteries
Cricopharyngeal Myotomy ............................••............ ·..· 1178 and Proximal Portion of Vertebral Arteries 1256
Transhyoid Pharyngotomy ............................••................. 1180 Vertebral Artery Reconstruction 1258
Anterior Pharyngotomy 1180 Surgical Treatment of Occlusion of Vertebral
Arteries 1258
 CONTENTS

Exposure of Distal Common Carotid Artery Thoracic Outlet Syndrome-Scalenotomy 1340

and Placement of Bypass Graft 1262
Subclavian Steal Syndrome 1262
Surgical Treatment of Occlusion of Common 23 BASE OF THE SKULL SURGERy 1348
Carotid and Subclavian Arteries and Subclavian
Steal 1264 Base of Skull and Parapharyngeal Space 1349
Atherosclerotic Aneurysm 1266 Parapharyngeal Space 1350
Anomalies of the Internal Carotid Artery 1266 Anatomy of the Parapharyngeal Space 1350
Exposure of Innominate Artery and Proximal CT versus MRI 1351
Portion of Right Subclavian and Common Approaches to the Parapharyngeal Space 1352
Carotid Arteries via Sternal-Splitting Incision 1268
Glossopharyngeal Neuralgia 1361
BypassGraft for Obstruction of Innominate Artery 1270
Infratemporal Approach to the Skull Base 1365
Resection of Kinked Obstruction in Internal Ernesto A. Diaz-Ordaz
Carotid Artery 1272
Surgery of the Parapharyngeal Space 1365
Alternate Method to Correct Kinked Internal
Advanced Radical Exposure 1368
Carotid Artery 1274
Mandibular Swing 1374
Fibromuscular Dysplasia 1274
Craniofacial Resection 1377
Vasculitis 1275
Bilateral Total Maxillectomy for Chondrosarcoma 1386
Radiation Arteritis 1275
Supraorbital Approach to the Orbit and Paranasal
Spontaneous Carotid Artery Intimal Dissection 1275
Sinuses 1391
Neoplastic Disease 1276
Cranial Portion 1391
Metastatic Squamous Cell Carcinoma 1276 Gregory /. Castiglia and Daniel P. Schaefer
Resection of Portion of Common and Internal Facial Portion 1394
Carotid Arteries Involved by Cancer 1277 john M. Lore /r. and Daniel P. Schaefer
Results of Resection and Reconstruction of the Reconstruction 1394
Internal Carotid Artery in Metastatic Carcinoma 1283
Transseptal Transsphenoidal Hypophysectomy
Paragangliomas-Head and Neck 1283 -Cryosurgical and Surgical 1395
Resection of Carotid Body Tumor 1294 Cryosurgical Hypophysectomy 1400
Resection of Intravagale Paraganglioma Surgical Ablative Hypophysectomy 1400
With Preservation of Major Vessel Continuity 1300
Endoscopic Endonasal Transsphenoidal Approach
Intravagale Paragangliomas and Bilateral Superior to the Pituitary Gland 1404
Sympathetic Ganglion Paragangliomas and Douglas B. Moreland
Unilateral Carotid Body Tumors 1302
Temporal Bone Resection 1408
Intravascular (Glomus) jugulare Paraganglioma fohn S. Lewis
Tumor 1307
Trauma to Vessels 1310
Vascular Trauma Outline 1310 24 MICROVASCULAR SURGERy 1417
Immediate Sequelae of Vessel Injuries 1310 ROBERTw. DOLAN
Late Sequelae of Vessel Injuries 1313 Microvascular Free Flaps 1417
Resection of Arteriovenous Aneurysm of the Face 1314 Historical Perspective and Introduction 1417
Resection of Aneurysm of Common or Internal Flap Classification 1418
Carotid Artery 1320 Typical Donor Flaps 1418
Transection of Internal Carotid Artery/Internal Recipient Defects and Microvascular Flap Selection 1420
jugular Vein Fistula With Resection of False
Microsurgery 1422
Aneurysm , 1320
Advantages and Disadvantages of Specific Flaps 1428
Lateral Venotomy for Foreign Body 1326
Radial Forearm 1429
Control of Hemorrhage 1328
Fibular Osteocutaneous 1436
Effects of Cancer: Carotid Artery Blowout 1328
Rectus Musculocutaneous 1441
Prevention and Management of Carotid Artery
Blowout 1328 Scapular Osteocutaneous 1448
Protection for Carotid Artery 1331 Latissimus 1456
Protection for Carotid Artery and Sources of Jejunal 1462
Muscle Bulk 1334 Iliac Crest Osteocutaneous 1464
Ligation of More Proximal Vessel 1336 Gracilis 1468
External Carotid Artery Ligation 1336
Harvesting Saphenous Vein for Graft 1338 INDEX 1471
 1 SECTIONAL
RADIOGRAPHIC
ANATOMY AND
SCANNING
ANATOMIC RADIOGRAPHS
John M. Lore, Sr., 1938
The following seven radiographic plates (see Figs. 1-1
to 1-7) are part of a series of sagittal and frontal
sections of the head and neck made in 1938 by John M.
Lore, Sr. Their purpose at that time was to study the
anatomy primarily in relation to deep infections of the
head and neck. Since then, such infections have become
almost a surgical curiosity, yet the basic anatomy por-
trayed by this technique is believed to be of consid-
erable value to both the surgeon and the radiologist.
Both the actual relationship of bony structures and that
of soft tissue are well depicted in the original radio-
graphs, with some interpretation in the facing color
illustration.
The technique of their preparation began with cadaver
sections, for the most part one-half-inch thick. The
sections were fixed in formaldehyde and allowed to dry
a little so that there would be some separation of the
various structures in the specimens. Radiographs were
then made of the sections. In the original presentation
of this material, read at the New York Academy of
Medicine, Section on Otolaryngology, December 21,
1938, and published in Laryngoscope, June 1939, Dr.
Lore, Sr. acknowledged assistance in. this work thus:
"For the material, the late Professor Senior and his suc-
cessor, Professor Sheehan, of the Anatomy Department
of the Medical School of New York University, have been
more than generous. For the X-ray work, Dr. Frederick
Law, of the Manhattan Eye, Ear, Nose and Throat Hos-
pital, and the X-ray Department of St. Vincent's Hospital
have been most helpful and unstinting in their aid."
More recently, the color illustrations have been devel-
oped with the aid of Robert Wabnitz. Each figure alone,
and all as a group, should aid in the understanding of
sinus surgery, both limited and radical, as well as frac-
tures of the facial bones, related skull fractures, and
neoplasm, especially of the base of the skull. In addition,
the fibrofatty tissue planes are clearly demonstrated,
thus relating these radiographic studies to computed
tomographic (eT) scans of the head and neck. These
fibrofatty tissue planes are of significant diagnostic help,
especially in relation to lesions of the pharyngomaxil-
lary space, as delineated by Peter Sam.
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Sagittal Section Through

b. Optic nerve
the Midportion of the Maxillary c. Anterior clinoid process
Sinus and Orbit (Fig. 1-1) d. Maxillary sinus
e. Lateral pterygoid plate of sphenoid bone
f. Pterygomaxillary fissure
The posterior relations of the maxillary sinus to the g. Carotid canal
floor of the middle cranial fossa are clearly depicted. h. Jugular foramen
The roof of the maxillary sinus forms the floor of the i. Foramen spinosum (for middle meningeal artery)
orbit, and the floor of the maxillary sinus forms the j. Petrous portion of temporal bone
roof of the alveolar ridge. Within this latter structure k. Upper and lower heads of external pterygoid
are seen the upper teeth protruding almost into the muscle
sinus cavity. This anatomy is important in minor opera- I. Deep and superficial head of internal pterygoid
tions on the maxillary sinus, in partial or total resec- muscle. The internal carotid artery is deep and
tions of the maxilla for carcinoma, and in operations lateral to the pterygoid muscles.
at the base of the sheath. The course of the internal m. First cervical vertebra or atlas
carotid artery and the carotid canal in the base of the n. Internal carotid artery
skull is seen,with the jugular foramen slightly posterior. o. External carotid artery
Temporal bone resection reaches almost this depth, p. Hyoid bone
being somewhat lateral to this. q. Portion of thyroid cartilage
r. Thyroid gland
a. Frontal sinus

FIGURE1-1
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

FIGURE 1-1 Continued

 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Sagittal Section Through the

c. Anterior clinoid process
Lateral Wall of the Nose, Lateral d. Ethmoidal sinus or labyrinth
Border of the Tongue, and Lamina e. Sphenoidal sinus, lateral wall
of the Thyroid Cartilage Showing f. Underlying maxillary sinus
Its Superior and Inferior Cornua g. Inferior turbinate
(Fig. 1-2) h. Carotid canal leading to foramen lacerum
i. Pterygopalatine fossa
j. Pterygoid canal
The relationship of the posterior ethmoidal sinus cells k. Medial pterygoid plate of sphenoid bone
to the lateral wall of the sphenoidal sinus is shown. The I. Hamulus of pterygoid
surgical approach to the sphenoidal sinus must be more m. Hard palate and floor of nose
medial. The section includes the medial wall of the n. Longus capitis muscle
orbit, which is the lateral wall of the ethmoidal sinus o. Internal auditory meatus
and, incidentally, very thin. With the major portion of p. Hypoglossal canal
the middle turbinate excluded, the underlying maxillary q. Jugular bulb
sinus is visible. The anatomy of the base of the skull is r. First cervical vertebra or atlas
clearly depicted. s. Second cervical vertebra or axis
The main extrinsic tongue muscle-the genioglos- t. Vertebral artery
sus-is easily seen with its attachment to the mandible. u. Lingual artery within genioglossus muscle
Also noteworthy are the relationships of the hyoid v. Geniohyoid muscle
bone, thyroid cartilage, and cricoid cartilage. w. Epiglottis
a. Frontal sinus x. Hyoid bone
b. Orbital plate of frontal bone forming floor of ante- y. Thyroid cartilage
rior cranial fossa z. Cricoid cartilage

FIGURE 1-2
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

FIGURE 1-2 Continued

 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Sagittal Section Through the Floor

b. Cribriform plate of ethmoid
of the Nose and the Body of the c. Ethmoidal sinus or labyrinth
Tongue (Fig. 1-3) d. Pituitary gland
e. Uncinate processof ethmoid bone
f. Sphenoidal sinus, septum
g. Middle turbinate
Except for the superior turbinate, the structures of the h. Inferior turbinate
lateral wall of the nose are well visualized. The prever- i. Pterygoid processof sphenoid bone
tebral space is seen extending from the base of the j. Lingual artery within genioglossus muscle and
skull inferiorly toward the thorax. Note the relation- hyoglossus muscle
ship of the ethmoidal sinus to the floor of the anterior k. Genioglossus muscle
cranial fossa and its continuity posteriorly with the I. Epiglottis
sphenoidal sinus. Within the sphenoidal sinus is the m. Hyoid bone
cradle for the pituitary gland, the sella turcica. Behind n. Geniohyoid muscle
the uncinate processof the ethmoid bone is the hiatus o. Thyroid cartilage
semilunaris and the bulla of the ethmoid. Slightly p. Trachea
superior IS the osteomeatal complex leading to the q. Foramen magnum
natural ostium of the antrum laterally and the frontal r. Longus capitis muscle
sinus duct recess.Seealso p. 267. s. Spinal cord
a. Frontal sinus t. Prevertebral space

FIGURE 1-3
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

FIGURE 1-3 Continued

 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Sagittal Section Through the

d. Perpendicular plate of ethmoid
Middle of the Skull (Fig. 1-4) e. Pituitary
f. Sphenoidal sinus
g. Vomer bone
The relationship of the nasal septum to the anterior h. Soft palate and uvula
wall of the sphenoid sinus is visualized, demonstrating I. Superior pharyngeal constrictor muscle
the route of the transseptal approach to the pituitary. j. Genioglossus muscle
Also shown is the approach to the sphenoidal sinus via k. Geniohyoid muscle
the ethmoid labyrinth. Staying as close as possible to I. Vallecula
the midline avoids injury to the internal carotid artery m. Hyoid bone
and optic nerve, which are more lateral. The surface n. Epiglottis
anatomy at the base of the tongue and the inte~ior o. Arytenoid
of the larynx is seen. At the entrance to the cervICal p. Ventricular band
esophagus, the lowermost fibers of the inferior pharyn- q. Thyroid cartilage
geal constrictor muscle-the cricopharyngeus-are r. Ventricle
hypertrophied with an S-type curve to the lumen. ThiS s. True vocal cord
explains some of the difficulty that may be encoun- t. Posterior aspect of cricoid cartilage
tered during the introduction of the esophagoscope. u. Cricopharyngeus portion of inferior constrictor
The tendency of the so-called postcricoid carcinoma of muscle of pharynx
the larynx to esophageal spread is explained by this v. Lumen of cervical esophagus
view. w. Trachea
a. Frontal sinus x. Thyroid isthmus
b. Cribriform plate of ethmoid y. Prevertebral space
c. Ethmoidal sinus or labyrinth z. Straight sinus

FIGURE 1--4
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

FIGURE1-4 Continued
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Frontal Coronal Section in the

a. Frontal sinus
Region of the Second Molar Teeth b. Anterior ethmoidal sinus
(Fig. 1-5) c. Perpendicular plate of ethmoid
d. Middle turbinate
e. Inferior turbinate
Note the thin wall forming the boundary between the f. Vomer bone
ethmoidal sinus and the orbit. The variable relation- g. Maxillary sinus
ship of the floor of the maxillary sinusto the floor of h. Infraorbital foramen
the nose is represented. Between the sublingual gland i. Masseter muscle
and the submaxillary gland is the mylohyoid muscle J. Buccalfat pad
originating from the mylohyoid line on the mandible. k. Mandible
Fracturesof the infraorbital rim usually occur through I. Submaxillary salivary gland
the thinned area of the infraorbital foramen, always m. Sublingual salivary gland
involving, to a greater or a lesserdegree, the maxillary n. Tongue
sinus itself. o. Orbit
p. Mylohyoid muscle

FIGURE 1-5
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

FIGURE 1-5 Continued

 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Frontal Coronal Section Just

a. Frontal sinus
Beyond the Third Molar Teeth b. Cribriform plate of ethmoid with frontoethmoid cells
(Fig. 1-6) c. Ethmoidal sinus
d. Medial wall of orbit formed by lacrimal bone and
lamina papyracea of ethmoid bone
As in the previous section, the thin bony boundary e. Superior turbinate
between the ethmoidal sinus and orbit is depicted. f. Middle turbinate
The conservative approach to the ethmoidal sinus for g. Inferior turbinate
drainage purposes and moderate exenteration is just h. Perpendicular plate of ethmoid
above and lateral to the attachment of the middle I. Vomer bone
turbinate. This is easily seen on the right side of the j. Maxillary sinus
section. Also visualized is the hamulus of the pterygoid k. Body of malar bone
process around which courses the tensor veli palatini. I. Temporalis muscle
It is this process that is fractured in cleft palate repair. m. Ascending ramus and coronoid process of
For extensive carcinoma of the maxillary sinus, inclu- mandible
sion of the ethmoidal sinus en bloc is clearly shown to n. Masseter muscle
be the aim of the radical resection including the orbital o. External pterygoid muscle
contents. The relationship of the floor of the maxillary p. Internal pterygoid muscle
sinus to the floor of the nose is demonstrated, as is the q. Hamulus of pterygoid process of sphenoid bone
roof of the maxillary sinus to the orbit in blowout r. Tongue
fractures. s. Submandibular salivary gland with external maxil-
lary artery

FIGURE 1-6
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

FIGURE 1-6 Continued

 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Frontal Coronal Section in the

c. Posterior ethmoidal cells
Region of the Anterior Faucial d. Rostrum of sphenoid bone
Pillar and Tonsil (Fig. 1-7) e. Lateral pterygoid plate of sphenoid bone
f. Medial pterygoid plate of sphenoid bone
g. Hamulus of pterygoid process
This section demonstrates the structures that are h. Upper and lower headsof external pterygoid muscle
encountered laterally and posteriorly in radical i. Internal pterygoid muscle
resection of the maxilla and ethmoidal sinus for j. Temporalis muscle
carcinoma. The zygomatic arch is vividly depicted as k. Zygomatic arch
vulnerable in fractures of the facial bones. Extensive I. Masseter muscle
carcinoma of the soft palate involving the tonsil usually m. Parotid gland
requires resection of the pterygoid process of the n. Internal maxillary artery
sphenoid with at least the internal pterygoid muscle. o. Soft palate
Hemimandibulectomy is also warranted when the p. Tongue
mandible is involved. The fibrofatty tissue planes are q. Mandibular canal
clearly demonstrated. r. Anterior faucial pillar and tonsil
s. Submandibular salivary gland
a. Orbital plate of frontal bone
b. Cribriform plate of ethmoid

FIGURE 1-7
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

FIGURE 1-7 Continued

 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

CT AND MRI Single-Plane CT Scans (See Figs. 1-8

David F Hayes and Scott Cholewinski to 1-10)

The single-plane CT scans in Figures 1-8 to 1-10 and the Frontal Coronal Section in the Region of
three-dimensional reconstructed CT scans in Figures 1-11 the Second Molar Teeth (Fig. 1-8)
to 1-17 were prepared by David F. Hayes, MD, chairman
of the Department of Diagnostic Imaging at Sisters of
Compare this CT scan with the radiograph in Figure 1-5.
Charity Hospital, Buffalo, New York.
The magnetic resonance (MR) images in Figures b. Anterior ethmoidal sinus
1-18 to 1-24 are courtesy of Buffalo MRI, Buffalo, New c. Perpendicular plate of ethmoid
York (J. E. Gardner, AAS, RT, MR, chief technologist). d. Middle turbinate
The MR images in Figures 1-25 to 1-40 were prepared e. Inferior turbinate
by Scott Cholewinski, MD, Director of Magnetic Reso- f. Vomer bone
nance Imaging at Sisters of Charity Hospital, Buffalo, g. Maxillary sinus
New York. k. Mandible
n. Tongue

FIGURE 1-8
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Frontal Coronal Section Just Beyond the

Third Molar Teeth (Fig. 1 -9) d. Medial wall of orbit formed by lacrimal bone and
lamina papyracea of ethmoid bone
f. Middle turbinate
Compare this CT scan with the radiograph in Figure 1.6. g. Inferior turbinate
b. Cribriform plate of ethmoid i. Vomer bone
c. Ethmoidal sinus j. Maxillary sinus
k. Body of malar bone
r. Tongue

FIGURE 1-9
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Frontal Coronal Section in the Region Three-Dimensional Reconstructed CT

of the Anterior Faucial Pillar and Tonsil Scans (See Figs. 1-11 to 1-1 7)
(Fig. 1-10)
Three-dimensional reconstruction of images is an
interesting CT application. Closely spaced transverse
Compare this CT scan with the radiograph in Figure 1-7. images are stacked upon each other, as in a layer cake,
and the edges are smoothed together (the icing) to pro-
a. Orbital plate of frontal bone duce the unified anatomic structure. It may then be
c. Posterior ethmoidal cells viewed from any projection.
j. Temporalis muscle
k. Zygomatic arch Frontal Projection (Fig. 1-11)
I. Masseter muscle
p. Tongue
Notice the orbital rim, zygomatic bone, infraorbital
foramen, supraorbital notch, canine eminence, and
superior orbital fissure.

FIGURE 1-10
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

a. Orbital rim i. Supraorbital notch

e. Infraorbital foramen j. Canine eminence
g. Superior orbital fissure m. Zygomatic bone

FIGURE 1-11
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Lateral Projection (Fig. 1-12)

b. Medial wall of orbit
c. Orbit floor
Notice the roof, floor, and medial wall of the orbit; d. Orbit roof
pterygoid plates, including hamulus of medial plate; k. Pterygoid plates
and mandibular foramen. I. Mandibular foramen

FIGURE 1-12
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Oblique Waters' Projection (Fig. 1-13)

d. Orbit roof
e. Infraorbital foramen
Notice the zygomatic bone, including zygomatic arch, m. Zygomatic bone
ramus of mandible with coronoid process,orbital rim, n. Zygomatic arch
roof of orbit, and infraorbital foramen. o. Mandible
a. Orbital rim p. Coronoid process of mandible

FIGURE 1-13
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Oblique Lateral Projection (Fig. 1-14)

e. Infraorbital foramen
i. Supraorbital notch
Notice the supraorbital notch, infraorbital foramen, m. Zygomatic bone
coronoid process of mandible, and perpendicular plate n. Zygomatic arch
of ethmoid bone. p. Coronoid process of mandible
q. Perpendicular plate of ethmoid bone

FIGURE 1-14
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Interior of Skull, Viewed From Posterior Oblique

Projection (Fig. 1-15) g. Superior orbital fissure
s. Petrous bone
t. Clivus
Notice the crista galli, superior orbital fissure, petrous u. Dorsum sellae
bone, clivus, dorsum sellae, and sella turcica. v. Sella turcica

FIGURE 1-15
 SECTIONAl RADIOGRAPHIC ANATOMY AND SCANNING

Interior of Skull, Viewed from Frontal Projection,

With Facial Bones Removed (Fig. 1-16) k. Pterygoid plates
n. Zygomatic arch
s. Petro us bone
Notice the sphenoidal sinus, sphenoid rostrum, petrous w. Sphenoidal sinus
bone, pterygoid plates, zygomatic arch, and internal x. Sphenoid rostrum
occipital protuberance. y. Sagittal sinus

FIGURE 1-16
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Interior of Skull, Viewed From Above Anteriorly

in Frontal Projection (Fig. 1-1 7) a. Orbital rim
d. Orbit roof
f. Infraorbital groove
Notice the crista galli, roof of orbit, zygoma, zygomatic h. Inferior orbital fissure
arch, mandible, infraorbital groove, and inferior orbital m. Zygomatic bone
fissure. n. Zygomatic arch
o. Mandible
r. Crista galli

FIGURE 1-17
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
MRlmages (Figs. 1-18 to 1-40)
Imaging in the Diagnosis and
Treatment of Head and Neck
Disease
The technologic advancement in diagnostic imaging has
virtually revolutionized the entire field of medicine.
Nevertheless, there is a serious problem developing in
medicine at this time: the reliance on imaging as the
"be all and end all" in determining the extent of disease
or even the presence of disease. Imaging technology is
a great help, but it must be evaluated in conjunction
with clinical examination. Most important, all images,
even those produced by highly advanced computerized
processes, must be reviewed by the examining physi-
cian and the radiologist.
Overview
Scott Cholewinski
CT and MRI are critical in the diagnosis and manage-
ment of head and neck tumors, with MRI playing an
increasingly important role. These modalities localize
lesions and demonstrate tissue characteristics, which
are important in determining prognosis. They are also
important in evaluating for adenopathy (Hudgins and
Gussack, 1992).
CT and MRI are best viewed as complementary in the
evaluation of head and neck pathology. Each modality
has unique, inherent strengths and weaknesses. MRI
provides better soft tissue contrast resolution and allows
for direct, multiplanar scanning. There is no ionizing
radiation, and non-iodine-based contrast material is
used. CT is relatively quick and inexpensive compared
with MRI and is very sensitive to calcification, making
it valuable in the evaluation of osseous destruction,
particularly in the skull base region. I have found MR
superior to CT in the evaluation of lesions involving the
salivary glands, nasopharynx, oropharynx, tongue, and
floor of the mouth.
A detailed discussion of MR physics is beyond the
scope of this chapter. However, understanding a few
key concepts and terms is essential. Spin-echo MR
images can be Tl weighted with short TR (repetition
time) and short TE (echo time); T2 weighted (long TR
and long TE); or intermediate weighted, also termed
proton density weighted; (long TR and short TE).
Tissues have inherent and unique Tl and T2 relaxation
times, which can be short or long. Water and cerebro-
spinal fluid have both long Tl and long T2 relax-
ation times; and both are low signal on Tl-weighted
images and high signal on T2-weighted images. Fat
has a short Tl relaxation time and an intermediate
to short T2 relaxation time and is high signal on
Tl-weighted images and intermediate signal on T2-
weighted images.
Standard MRI of the neck is performed using a head
and neck array coil. A typical examination includes Tl-
and T2-weighted images in the axial plane, followed by
Tl-weighted images in the axial and coronal planes
after the administration of gadolinium. Gadolinium is a
paramagnetic intravenous contrast material that shortens
Tl relaxation times. Tl-weighted images demonstrate
exceptional anatomic detail, whereas T2-weighted
images are helpful in the identification of abnormal
tissue. Neoplasms in the head and neck tend to be
hypointense to isointense relative to muscle on Tl-
weighted images and may be low or high signal on T2-
weighted images. Fat suppression techniques can also
be extremely valuable in the assessment of head and
neck lesions. Table 1-1 lists characteristic MR findings
in typical tumors of the parapharyngeal space and upper
neck (Som et al., 1987).
As previously mentioned, CT and MRI are important
in the evaluation of cervical lymphadenopathy. Cervical
lymph nodes are typically of intermediate signal on
Tl-weighted images relative to fat and hyperintense to
fat on T2-weighted sequences. CT and MR size criteria
allow level 1 and level 2 lymph nodes to measure up to
1.5 cm in maximal dimension and 1.0 cm elsewhere.
Nodes of larger size should be considered highly suspect
for metastatic involvement, particularly in patients with
a known primary lesion (Hudgins and Gussack, 1992).
The choice in cross-sectional imaging modalities
between MR and CT will vary with individual patients,
specific diagnostic concerns, clinical questions, avail-
able technology, and clinician acceptance. What remains
important is to exploit the inherent strengths of each
modality to best obtain the necessary diagnostic infor-
mation for the patient.
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

MRI Characteristics of Parapharyngeal Space 1\unors

Signal Intensity

Calcification,
Tl-Weighted T2-Weighted Overall Fibrosis, or Bone
Thmor Image Image Contour Appearance Fragments

Paraganglioma Intermediate Moderately high; Smooth Flow voids Sites of fibrosis

salt-and-pepper common
appearance
except when
< 1.5 cm
Metastatic Intermediate Moderately high; Irregular Flow voids Bone fragments
vascular salt-and-pepper "may not be as possible
tumor appearance numerous as in
paragangliomas"
Hemangioma Intermediate High Smooth, but Flow voids
irregular in
some cases
Salivary gland Intermediate High Usually smooth; Homogeneous Focal calcium,
tumor irregularity fibrosis
may indicate
high-grade
malignancy
Neurogenic Intermediate High; salt-and- Smooth Homogeneous Focal calcium,
tumor pepper in one fibrosis
case
Lymphoma Intermediate Moderately high Smooth Homogeneous
Soft tissue Intermediate Moderately high Irregular in Homogeneous Bone fragments
sarcoma some areas,
smooth in
others
Liposarcoma High Moderately high Irregular Homogeneous
Chordoma Variable High Smooth Homogeneous Focal calcium,
fibrosis, bone
fragments

FromSam PM, et al: Thmorsof the parapharyngeal space and upper neck: MRimagingcharacteristics.Radiologyt64:823, 1987.
 SECTIONAl RADIOGRAPHIC ANATOMY AND SCANNING

Masseter Submandibular Mandible Soft palate

muscle Mandible gland

Masseter
muscle

Medial
pterygoid
muscle

Facial vein

Submandibular Trachea Sternocleidomastoid

gland muscle
Oropharynx Trachea Sternocleidomastoid
muscle
FIGURE 1-19

FIGURE 1-18

Thyroarytenoideus Sternocleidomastoid
muscle muscle Hypopharynx

Anterior
commissure
Aryepiglottic
Vocal cord
fold
Posterior
Vertebral
commissure
artery

Levator
scapulae
Pyriform
muscle
sinus

Sternocleidomastoid Spinal cord

muscle Trapezius Internal Spinal
FIGURE 1-20 muscle jugular vein cord
FIGURE 1-21
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Tongue base Masseter

muscle Nasopharynx

Mandible

Lingual
tonsil Maxillary
sinus

Oropharynx
Torus
tubarius

Medulla
oblongata

Internal Internal
jugular carotid
vein artery
FIGURE 1-22 Lateral Internal
pterygoid carotid
muscle artery
FIGURE 1-23

Retropharyngeal Lateral
space Odontoid Inferior pterygoid
Nasopharynx turbinate muscle

Torus
Tongue Masseter
tubarius
muscle
Fossa of
Rosenmuller Mandible
Vallecula
Internal
carotid Mastoid
artery air cells
Mandible

Internal Medulla Left

Epiglottis
jugular vertebral
vein artery
Cricoid FIGURE 1-25
cartilage

Larynx

Subarachnoid Esophagus Spinal

space cord
FIGURE 1-24
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Masseter Hard Soft Para pharyngeal Medial pterygoid Lingual

muscle Maxilla palate palate space fat muscle Mandible septum

Tongue

Uvula
Parotid gland
Palatine
tonsil
Facial vein
Parotid gland
External
carotid
Internal
artery
jugular vein

Longus
capitis Facial Masseter Odontoid
Jugular Internal Faucial muscle vein muscle process
vein carotid artery tonsil FIGURE 1-27
FIGURE 1-26

Masseter Palatine Parotid Median

. Facial vein muscle Tongue tonsil gland tail Mandible Tongue glossoepiglottic fold

Vallecula

Submandibular
gland

Internal jugular
vein

Splenius Semispinalis Internal

capitis muscle cervicis muscle jugular vein Vertebral Epiglottis
FIGURE 1-28 artery
FIGURE 1-29
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Digastric Body of Median Hyoepiglottic Laryngeal Pyriform

muscle Epiglottis mandible glossoepiglottic fold ligament vestibule recess

Submandibular
gland

External
jugular vein
Internal
carotid artery

External Vertebral Internal Internal Common Aryepiglottic

jugular vein artery jugular vein jugular vein carotid artery fold
FIGURE 1-30 FIGURE 1-31

Anterior True
Sternocleidomastoid
commissure vocal cord
Thyroid gland Trachea muscle

Arytenoid
cartilage

Common
/-~

'fJI
.....
~.'~."
.
carotid artery
I ,.~.\..
' ..
Internal
"
•
. (. ", \-.~,':.-
.·~.....rr.;•.'. .
. jugular vein
" ....•
" '. '.''''''' ",' Esophagus
..... ~~. -- ".,.-'L .. _

Internal Sternocleidomastoid
Common Vertebral
jugular vein muscle
carotid artery artery
FIGURE 1-32
FIGURE 1-33
 SECTIONAl RADIOGRAPHIC ANATOMY AND SCANNING

Thyroid Frontal Sphenoidal Optic

Sternocleidomastoid
Trachea gland sinus Tongue sinus chiasm
muscle
Pituitary
gland
Internal jugular Pons
vein Cerebellum
Clivus
Cisterna
Esophagus
magna
Nasopharynx
Soft palate
Spinal cord
Epiglottis
Subarachnoid
space
Vallecula
Pulmonary Common Medial and posterior Body of Inferior nasal Trachea
apex carotid artery scalene muscles mandible concha
FIGURE 1-34 FIGURE 1-35

Maxillary Buccinator Lateral Lateral Superior Superior

sinus muscle pterygoid muscle rectus muscle rectus muscle oblique muscle

Ethmoidal
Medial sinus
pterygoid Optic nerve
muscle
Medial rectus
Internal muscle
carotid artery Maxillary sinus
Middle nasal
Levator
turbinate
scapulae
Inferior nasal
muscle
turbinate
Jugular vein

Inferior Tongue
Mandible Submandibular rectus muscle
gland FIGURE 1-37
FIGURE 1-36
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Torus Sphenoidal Lateral Lateral Optic Internal carotid artery,

tubarius sinus pterygoid muscle pterygoid muscle chiasm cavernous portion
Trigeminal
cistern
Foramen ovale
Masseter
Nasopharynx
muscle
Medial
Nasopharynx pterygoid
muscle
Medial Uvula
pterygoid Oropharynx
muscle Epiglottis
Tongue Submandibular
gland
Hypopharynx
Aryepiglottic
fold
Mandible Epiglottis Trachea Submandibular
Arytenoid Trachea Cricoid Thyroid
gland
cartilage cartilage cartilage
FIGURE 1-38 FIGURE 1-39

Internal Lateral mass Trigeminal

carotid artery of C1 nerve

Internal jugular
vein

Parotid gland

Odontoid
process

Longus capitis
muscle

C4 vertebral C4-5 intervertebral Sternocleidomastoid

body disc muscle
FIGURE 1-40
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
ADVANCED TECHNIQUES FOR CT
IN THE HEAD AND NECK
(See Figs. 1-41 to 1-50)
Ronald A. Alberico and Ahmed Abdehalim
Many aspects of modern medicine change rapidly over
time as we continually revise and relearn our special-
ties in an effort to improve patient care. Few areas have
changed as rapidly in recent years as diagnostic imag-
ing. This revolution in imaging technology has been
driven by faster more powerful computers and equip-
ment, enabling us to obtain more information faster
and more accurately than ever before. As a consequence
of this change, variations in practice techniques occur
regionally and even locally depending on the equip-
ment available to the radiologists and the skill of the
radiologists using that equipment. Controversy also
exists as to the preferred technique of imaging the head
and neck: MRI or CT. While we will leave those
arguments to the scientific literature, it should be
stated that the two modalities outperform each other in
certain specific areas and when appropriate we make
efforts to point out which study is preferred for a given
application.
The Role of Imaging in the
Head and Neck
Patients presenting for head and neck imaging studies
generally have a specific clinical symptom or finding
on examination requiring evaluation. Our goal as head
and neck radiologists is to allow the clinician to eval-
uate the source of findings on physical examination
and to define the extent of disease that is occult to the
examining physician so that more appropriate thera-
peutic planning and prognostic determination can be
obtained. We hope to obtain sufficient detail about the
specific location and imaging characteristics of the lesion
to make an educated guess as to the specific diagnosis.
It is very important to maximize the information obtained
from the scan by providing the radiologist with all per-
tinent physical examination findings and the clinical
impression. Any postoperative history is also very
useful for planning the best imaging technique.
As a general rule, suspected lesions of the salivary
glands should be evaluated with non enhanced CT
followed by enhanced CT. Patients with adenopathy or
known head and neck cancer require only enhanced
CT whereas thyroid cancer patients may require the
use of alternative contrast agents such as gadolinium to
avoid an unnecessary iodine load. Communication with
the radiologist is the key to getting the most appro-
priate imaging for your patient the first time. Standard
CT evaluation of adenopathy is obtained with section
thickness of 2 to 5 mm from the lower orbital rim to the
thoracic inlet with intravenous contrast. This approach
avoids unnecessary radiation to the lens. Evaluation for
head and neck cancer requires inclusion of the skull
base so that perineural spread of disease can be assessed
at the level of foramen ovale, the pterygopalatine fossa,
stylomastoid foramen, and superior jinferior orbital
fissure (see Fig. 1-41). Thin sections of 1 tD 2.5 mm will
enable detailed evaluation of these small structures
routinely as well as routine high-quality multiplanar
and three-dimensional reconstructions. We frequently
obtain reverse coronal angles through the patients' oro-
pharynx in those patients with dental related artifacts
to improve visualization of that area. Using that tech-
nique, we occasionally detect the primary tumor in
patients with tumors of unknown etiology (see Fig.
1-42). In the following plates we attempt to illustrate
the power of modern CT equipment and the details that
image reconstruction and post processing can bring to
the head and neck surgeon enabling maximum infor-
mation and planning preoperatively. All images are
derived from our daily clinical practice and are made
available for surgical planning.
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Detection of Perineural Disease
at the Skull Base (Fig. 1-41)
In head and neck cancer, malignant cells may spread
along the neural sheath. Perineural spread may be
asymptomatic, thus the importance of its detection.
The cranial nerves most often involved in perineural
tumor spread are the trigeminal and facial nerves.
The first division of the trigeminal nerve (oph-
thalmic) with potential tumor carrying from the lacrimal
gland, eyelid, and conjunctiva passes through the supe-
rior orbital fissure. The second division (maxillary) with
connections to the face, palate, and maxillary sinus
traverses the pterygopalatine fossa and the foramen
rotundum. The third division (mandibular), which can
carry tumor from the lower face, oral cavity, and sub-
mandibular and parotid glands passes through the fora-
men ovale. The facial nerve passes through the stylo-
mastoid foramen.
There are several findings on CT that suggest perineural
spread, including destruction of neural foramina, loss
of the normal fat pad adjacent to a foramen, excessive
enhancement within the neural foramina, and excessive
abnormal enhancement or widening of the cavernous
sinus, pterygopalatine fossa, or Meckel's cave.
A An axialcontrast medium-enhanced CT scan shows
tumor in the left pterygopalatine fossa (arrow). Note
the normal fat pad in the contralateral side (asterisk).
B Coronal contrast medium-enhanced CT shows
intracranial tumor extension into the left Meckel's cave
and cavernous sinus (arrows). Again note the normal
fat pad in the contralateral side (asterisk).

A B
FIGURE 1-41
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Oblique Imaging of the Oral

Pharynx to Avoid Dental Artifact
(Fig. 1-42)
All imaging of the head and neck requires thoughtful
input on the part of the radiologist to maximize avail-
able information.
A A standard CT scan of the neck for cancer evalu-
ation is shown. The lines are parallel to the scan plane.
B An artifact results from this patient's extensive
dental hardware.
C, D A simple adjustment of the scan angle reveals
the mass in the left oropharyngeal wall and soft palate
in this patient (arrows in D). This additional scan plane
is only needed if dental hardware severely limits views
of the oropharynx and soft palate.

A B

c D
FIGURE 1-42
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Multiplanar Techniques to
Evaluate Tumor Location and A Axial section shows a mass in the medial canthus
Margins (Fig. 1-43) region of the left eye (A) at the level of the inferior
rectus muscle (E). F, Inferior orbital fissure.
Thin sections and rapid helical scanning enable improved
B An enlarged left nasal lacrimal duct (arrow) is
localization of tumor margins and may give clues to
their origin. evident at the level of the petrous carotid arteries (G).

A B
FIGURE 1-43
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Multiplanar Techniques to C, D Same findings shown in sagittal (C) and coronal

Evaluate Tumor Location and (D) reformatted images. A, Lacrimal sac mass; B, nasal
Margins (Continued) (Fig. 1-43) lacrimal duct extension of the mass; C, sphenoidal
sinus; D, frontal sinus.

E The patient's surface anatomy and skin are seen in

this volume-rendered three-dimensional model (arrows).

E
FIGURE 1--43 Continued
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Three-Dimensional CT of the Inner

Ear (Fig. 1-44) A A base view of the left inner ear structure (mem-
branous labyrinth). A, Cochlea; B, internal auditory
To emphasize the detail possible with multidetector canal; C, lateral semicircular canal; D, posterior semi-
scanning, the following two images were created from circular canal; E, superior semicircular canal. Arrow
a standard multidetector scan of the temporal bone. indicates posterior ampullar nerve.
Note the ability to rotate the image and add or subtract
structures. Note also the posterior ampullar nerve B Lateral view of the left inner and middle ear with
(curved arrow), a structure measuring less than 1 mm ossicles and facial nerve. A, Cochlea; C, lateral semi-
in diameter! circular canal; D, posterior semicircular canal; E, supe-
rior semicircular canal; F, malleus; G, incus; h, stapes; I,
facial nerve.

B
FIGURE 1--44
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Contrast Medium-Enhanced Hlgh-
Resolution CT (Fig. 1-45)
The addition of contrast material to rapidly acquired
high-resolution CT can provide detailed views of vascu-
lar anatomy that rival conventional angiography.
A Presented is an axial section of a contrast
medium-enhanced high-resolution image of the tem-
poral bone and skull base. A, Petrous carotid artery;
B, foramen ovale (short arrow: accessory meningeal
artery); C, foramen spinosum (long arrow: middle
meningeal artery); D, temporal mandibular joint; E,
A
FIGURE 1-45
pyramidal eminence; F, common crus of the labyrinth;
G, facial recess.
B A three-dimensional lateral volume-rendered image
of the temporal and sphenoid bones is shown without
vessels. A, External auditory canal; B, mastoid process;
C, styloid process; D, pterygoid plate; E, pterygopala-.
tine fossa (arrow: stylomastoid foramen).
C A three-dimensional lateral volume-rendered image
of the temporal and sphenoid bones is shown with
vessels. A, Maxillary artery; B, superficial temporal
artery; C, occipital artery; D, middle meningeal artery.
Arrow indicates foramen spinosum.
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

B c
FIGURE 1--45 Continued
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

CT Angiography of the Neck:

mation enhances more slowly than the artery. A, Com-
Venous Malformation With mon carotid artery; B, internal jugular vein; C, enhancing
Traumatic Arteriovenous Fistula venous malformation (arrow: superior thyroidal artery);
(Fig. 1-46) D, external jugular vein; E, hyoid bone; F, unenhanced
portion of the'large venous malformation.
The usefulness of very rapid imaging with thin sections
reconstructed into three-dimensional volume-rendered B A sagittal reformatted image of the CT angiogram
images has been fully evaluated in the literature over in A is shown. A, Venous malformation; B, internal
the past decade. These techniques can assess vascular jugular vein; C, malformation draining into the jugular
structures directly to evaluate stenosis, aneurysms, mal- vein; D, common carotid artery.
formations, and injuries. Risk to the patient is negligible,
and information is comparable to that obtained from C Three-dimensional volume rendering of the CT
conventional angiography. CT angiography, although angiogram in B is presented with the veins removed.
requiring intravenous contrast material and some A, Common carotid artery; B, internal carotid artery;
radiation exposure, is less susceptible to artifacts than C, external carotid artery; D, lingual artery; E, facial
MR angiography and frequently provides more detailed artery; F,occipital artery; G, distal external carotid artery;
vascular images. It is our preferred choice for non- H, superior thyroidal artery; I, vertebral artery.
invasive vascular imaging in the head and neck.
D Three-dimensional volume-rendered CT angiogram
is presented with veins in place, A, Venous malforma-
tion (arrows: superior thyroidal artery runs in a ventral
A Axial CT angiographic image at the level of the groove in the malformation); B, internal jugular vein;
hyoid bone demonstrates that the venous malfor- C, connection between malformation and jugular vein.
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

A B

c D
FIGURE 1--46
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

CT Venography of Facial Venous

transparency to see the lesion while also providing
Malformation (Fig. 1-47) superficial landmarks

Venous malformations of the face are frequently treated B Three-dimensional volume-rendered CT venogram
with sclerotherapy and percutaneous embolization. CT has increased transparency allowing views of vascular
venography helps the interventionist target these lesions. detail and bony landmarks. A, Zygoma; B, facial vein;
C, superficial temporal artery; D, external jugular vein
A Three-dimensional volume rendering of the skin (thin arrows: embolic material from previous treatment;
helps target the lesion (arrows) by providing enough thick arrow: residual venous malformation).

A B
FIGURE 1-47
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

CT Angiogram of ECA/ICA Bypass

(Fig. 1-48)
CT angiography demonstrates the anastomosis between
the superficial temporal artery and the middle cerebral
artery in this patient with previous bypass. Simultaneous
display of bone and vessel as well as limitless possible
views provide sufficient detail to avoid repeated serial
conventional angiography and associated risks.
A Three-dimensional volume-rendered CT angiogram.
a, Superficial temporal artery; b, anastomosis between
superficial temporal artery and middle cerebral artery
(arrows: surgical craniectomy site); c, surgical microplate;
d, maxillary artery; e, infraorbital foramen.
B Three-dimensional volume-rendered CT angiogram
with upper cranium removed. a, Superficial temporal
artery; b, anastomosis between superficial temporal
artery and middle cerebral artery.

C Three-dimensional CT angiogram of intracranial

vessels including bypass, bone removed. a, Superficial
temporal artery; b, anastomosis between superficial
temporal artery and middle cerebral artery; f, vertebral
arteries; g, basilar artery; h, posterior cerebral arteries;
i, anterior cerebral arteries; j, middle cerebral artery.

B c
FIGURE 1--48
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Three-Dimensional CT Vascular
A This three-dimensional volume rendering of a large
Tumor Relationship (Fig. 1-49) squamous cell carcinoma shows neck vessels and bone.
A, Left common carotid artery; B, left internal carotid
Rapidly acquired contrast medium-enhanced CT can
artery; C, left external carotid artery; D, tumor; E,
be used for mapping tumor vessel relationships both in
innominate artery; F, right subclavian artery.
the neck and the brain. The following images show a
large neck mass with its relationship to the carotid
B A three-dimensional volume-rendered CT shows
arteries and other soft tissues. Any visible structure in
vessels and tumor on a soft tissue cut-away view. A,
the neck can be modeled in this way preoperatively,
Left common carotid artery; B, left internal carotid
from a single scan. artery; C, left external carotid artery' D tumor' G
thyroid gland; H, trachea. '" ,

A
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Endoluminal and Cut-Away View

of the Trachea With Medial A Endoscopic view is presented of a contrast
Deviation of the Carotid Artery medium-enhanced CT of the neck. a, Epiglottis; b,
vallecula. Arrows indicate retropharyngeal mass.
(Fig. 1-50)
B This cut-away view of the CT endoscopic image
The function of the head and neck radiologist is to
is at the same level as in A. a, Retropharyngeal
inform the surgeon of a pathologic process and its rela-
enhancing mass (carotid artery); b, contralateral
tionship to normal structures and to point out poten-
carotid artery; c, pyriform sinus.
tially dangerous variations from normal. The following
images demonstrate a fairly common finding-tortuous
C CT angiographic view is of the same scan as in A
carotid arteries and their relationship to the pharynx-
and B. Arrows indicate the midline position of the
using CT-derived endoscopic views. This patient has
proximal internal carotid artery.
known malignant adenopathy, but the endoscopic subcu-
taneous mass does not always represent extension of
the tumor.

A B

c
FIGURE 1-50
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

It is our hope that the detailed CT scans provided
here will begin to inform you of the potential that this
rapidly evolving technology has to offer the head and
neck surgeon. From detailed anatomic assessment to
three-dimensional modeling of tumor/vessel relation-
ships, advances in imaging technology will continue to
provide maximum preoperative and perhaps even intra-
operative information that will help the surgeon obtain
the best possible outcome for each patient.
EXAMPLES OF MRI IN THE
SUPERIOR MEDIASTINUM
______________ John M. Lore, Jr.
The following MR images (Figs. 1-51 to 1-57) of the
mediastinum demonstrate the importance of viewing
this area of anatomy with MRI performed at an up-to-
date facility. The sagittal views are extremely important
to localize the mediastinal thyroid as to whether it is
anterior or posterior and its specific relationship to the
great vessels. This latter relationship is likewise con-
firmed with the usual axial and coronal views.

FIGURE 1-51 Sagittal MRI views of large cervical thyroid goiter with extension to the aortic arch. However, the
extension into the mediastinum appears to be minimal because of the high location of the aortic arch. AA,aortic arch;
DA, descending aorta; T, trachea; LMB,left mainstream bronchus; G, goiter. (From Lore JM Jr, Martin PT,Koch R], et al:
Approaches to the superior mediastinum for the head and neck surgeon: Operative techniques. Otolaryngol Head Neck
Surg 5:73-83, 1994.)
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

FIGURE 1-52 MRI sagittal and axial views show residual mediastinal tissue after previous surgery. Patient's chief
complaint was pain. Residual mediastinal tissue was removed via the supraclavicular route with transection of the
intraclavicular ligament and sternocleidomastoid and strap muscles. G, residual thyroid tissue; T, trachea; E, esophagus.
(From Lore JM Jr, Martin PT, Koch R], et al: Approaches to the superior mediastinum for the head and neck surgeon:
Operative techniques. Otolaryngol Head Neck Surg 5:73-83, 1994.)

FIGURE 1-53 Axial (T scans showing complete encirclement of the trachea in a patient with a multinodular
adenomatous goiter with marked deviation of trachea by mediastinal extension. The goiter was removed by
transclavicular resection. (From Lore JM Jr, Martin PT, Koch Rj, et al: Approaches to the superior mediastinum for the
head and neck surgeon: Operative techniques. Otolaryngol Head Neck Surg 5:73-83, 1994.)
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

FIGURE 1-54 Coronal and axial MRI views showing massive cervical goiter extending into the mediastinum with
compression of the trachea. In the axial view, extension into the posterior mediastinum behind the aortic arch is well
visualized. The goiter was removed by transclavicular resection. G, goiter; T, trachea; lA, innominate artery; AA, arch of
aorta. (From Lore JM jr, Martin PT, Koch Rj, et al: Approaches to the superior mediastinum for the head and neck
surgeon: Operative techniques. Otolaryngol Head Neck Surg 5:73-83, 1994.)

FIGURE 1-55 Compression of trachea and extension into posterior mediastinum (same patient as in Fig. 1-54). Close
relationship to all of the major vessels is seen with goiter extending from hyoid bone inferior and posterior to aortic
arch. It was removed by left transclavicular resection. HB, hyoid bone; AA, arch of aorta; LMB, left mainstream
bronchus; CH, chamber of heart; T, trachea; lA, innominate artery; CC, common carotid artery; IJV,left internal jugular
vein. (From Lore JM Jr, Martin PT, Koch Rj, et al: Approaches to the superior mediastinum for the head and neck
surgeon: Operative techniques. Otolaryngol Head Neck Surg 5:73-83, 1994.)
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

FIGURE 1-56 Sagittal MRI view shows a right posterior mediastinal adenomatous goiter removed by transclavicular
resection. The trachea is displaced anteriorly. The inferior extension of the goiter is close to the azygos vein. The
recurrent laryngeal nerve and the inferior thyroid artery cross over the anterior aspect of the goiter (G). (From Lore JM
Jr, Martin PT, Koch Rj, et al: Approaches to the superior mediastinum for the head and neck surgeon: Operative
techniques. Otolaryngol Head Neck Surg 5:73-83, 1994.)

FIGURE 1-57 Axial MRI view of same patient as in Figure 1-56 shows posterior mediastinal goiter behind the trachea
and juxtaposed to the vertebral bodies. G, goiter; L, left side. (From Lore JM Jr, Martin PT, Koch R], et al: Approaches
to the superior mediastinum for the head and neck surgeon: Operative techniques. Otolaryngol Head Neck Surg 5:
73-83, 1994.)
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

OTHER EXAMPLES OF CT AND MRI

John M. Lore, Jr. The orthogonal projections afforded by MRI allow the
routine and accurate depiction of substernal extension
of a thyroid mass. a, Thyroid gland; b, clavicle; c, left
Multinodular Goiter in the innominate vein; d, aortic arch; e, internal jugular vein;
f, manubrium; g, trachea.
Mediastinum (Fig. 1-58)

FIGURE 1-58
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Paraganglioma (Second Primary Metastatic Papillary Carcinoma of

Thoracic Chain, T4 by CT Scan) the Thyroid (Usual Type) (Fig. 1-60)
(Fig. 1-59)

Pathologic lymph nodes (1) in the submandibular

Axial (transverse) CT scan of the upper thoracic region region are demonstrated on parasagittal image.
demonstrates a second primary lesion (1) in pedicle/
lamina/transverse process on the right.

FIGURE 1-59

FIGURE 1-60
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Magnetic Resonance Angiography
One problem with the MR "angiogram" is that there are
minimal to no landmarks of the exact relationship to
the other structures. On the other hand, there is no
concern, for example, in the diagnosis of a carotid body
paraganglioma, because there is typical splaying of the
internal and external carotid arteries.
ULTRASOUND
--------------- David F Hayes
Ultrasound may be the most artful tool in the medical
imaging armamentarium. While our quiver is resplen-
dent with elegant tools of electronic wizardry, ultra-
sound requires the imagination and intuition of the
imager like no other imaging modality. To wit, the
operator variable in the ultrasound imaging chain is
huge. The outcome, the value, and the meaning of an
ultrasound test are largely dependent on the skills of
the ultrasound technician and the radiologist. That
is, notwithstanding all the electronic gadgetry, the
importance of the human factor cannot be overstated.
This is why ultrasound has such a "bad rap" in some
locales and is held to be so valuable in other locales.
Stated differently, it simply depends on who is doing
the looking.
Example Uses of Ultrasound
I. Ultrasound as a diagnostic tool: characterizes texture
of a mass (cystic or solid); establishes relationship to
other organs, muscles, and vessels in the neck.
2. Ultrasound as an interventional tool: given state-of-
the-art equipment (machine, probes), the experienced
imager, with exquisite precision, can place a needle
into the neck, avoiding vessels, trachea, and esoph-
agus. The precise placement of the needle is valu-
able in:
a. Fine-needle aspiration. When the mass is palpable,
the needle may be positioned without imaging
assistance. If needle location is in doubt, or if the
lesion is not palpable, ultrasound-guided needle
positioning is the logical tool to objectively estab-
lish needle location at the time of sampling. Ultra-
sound can remove needle location issues from the
equation of tissue sample adequacy. The tissue
sample may be inadequate or misleading but not
because the needle was in the wrong place.
b. Diagnostic/therapeutic cyst aspiration. Needle tip
can be precisely positioned in the cyst.
c. Abscess drainage/sampling. Although percutaneous
drainage is not routine treatment, it is a spectac-
ular alternative to surgery for patients who are
too sick for exploration or who cannot have or do
not want to have surgical drainage.
d. Preoperative localization of nonpalpable lesion of
interest. Preoperatively with ultrasound, the lesion
can be identified and localized with placement of
a needle and hooked wire.
Figure 1-61 is an ultrasound image of the thyroid area.
The red area is the common carotid artery, and the
blue area is the internal jugular vein. Beneath the two
of these is a darkened area where the arrow indicates
a needle puncture was done, which resulted in 1.5 mL
of xanthochromic fluid. Histology was acellular. Just to
the left of the common carotid artery is a portion of
the left lobe of the thyroid, and slightly below this is
an area suggestive of a parathyroid adenoma. This
demonstrates the accuracy and safety of doing a fine-
needle aspiration in the vicinity of two major vessels
without any untoward sequelae. The probable origin
of the cyst is the thymus gland, which is juxtaposed to
the parathyroid adenoma.
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

FIGURE 1-61
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

POSITRON EMISSION TOMOGRAPHY nitrogen, oxygen, fluorine, or rubidium. These nuclides

Robert S. Miletich and John M. Lore, Jr.
Unlike CT or MRI, which mainly provide images of the
internal organs' structural anatomy, positron emission
tomography (PET) provides anatomic images of the
functional activity of the internal organs (Table 1-2).
This revolutionary imaging technique noninvasively
supplies an entirely new type of imaging information.
Any physiologic process in the body can potentially be
measured with PET.
Essentially what we are measuring with the PET
scanner is the rate, amount, distribution, and localiza-
tion of uptake in the body of a biologically compatible
drug, also called a radiotracer. This drug is usually
administered intravenously. It has no clinical effect
because the amounts administered are extremely low.
Because the radiotracer is similar, if not identical, to
endogenous molecules in the body or to therapeutic
drugs, its behavior in the body will be similar to the
endogenous molecules or drugs that it mimics. By
measuring this behavior with the PET scanner, we can
assay the physiologic processes that the endogenous
molecules or drugs are involved in. These physiologic
processes include sugar and oxygen utilization by cells,
drug metabolism, organ blood flow and receptor func-
tion, and interaction of drugs with their endogenous
chemical messengers. Even DNA/RNA metabolism and
gene mechanisms can potentially be measured noninva-
sively with PET. Single-photon emission CT (SPECT)
agents, on the other hand, are often bulky molecules that
cannot act as true tracers of endogenous compounds.
There are four sequential stages in the performance
of PET: radioisotope production, radiochemical syn-
thesis of radiotracer, PET scan acquisition, and scan
reconstruction/analysis. Unlike nuclear medicine, PET
uses radioactive nuclides of elements either endoge-
nous or analogous to those found in the body: carbon,
are extremely short lived. Oxygen-IS and nitrogen-B,
used for the measurement of brain or heart blood flow,
have half-lives of 2 and 10 minutes, respectively. Carbon-
11, used for measuring receptor or drug mechanisms,
has a half-life of 20 minutes. Fluorine-18, used for
measuring glucose utilization by cells, has a half-life of
110 minutes. A special device, usually a cyclotron, is
required to produce these radionuclides. Radiochemists
then incorporate them into radiotracers using special-
ized chemical synthetic methods. Once quality control
is performed by radiopharmacists, measuring the radio-
tracer's purity and amount, the radiotracer is shipped
to the imaging facility.
Although the outside of the PET device looks like a
conventional CT scanner, the inner workings are entirely
different. Inside are rings of many detectors, which
encircle the body. What we are measuring with PET is
the simultaneous triggering of detectors on opposite
sides of the body. After a positron is emitted from the
atom's nucleus, it travels a short distance until it collides
with an electron. The mass of both particles is con-
verted into energy. It is this energy, in the form of two
Sl1-keV gamma rays traveling 180 degrees opposite to
each other, that we are detecting with PET. This simul-
taneous detector triggering on opposite sides of the
body provides to PET better localizing ability and control
of the interfering effect from other parts of the body as
compared with standard nuclear medicine procedures,
such as SPECT. Improved spatial resolution and more
accurate quantitation of the radiotracer signal also result.
Ultimately, the sensitivity and specificity of PET as a
medical diagnostic tool is improved as well. Simultane-
ously, the radiation dose that a patient receives is of
the same order as that received for standard nuclear
medicine and radiology tests.
It is from the measurement of the radiotracer's
behavior in the body that PET can assay organ or

TABLE l-Z Comparison of PET with Other Imaging Modalities

PET SPECT MRI CT

Measures Function Function Structure Structure

Spatial Resolution 3.S-7 mm 8-14 mm 0.5-1.0 mm 1.0-1.5 mm
Physical Event Gamma rays from Gamma ray emission Nuclear magnetic Tissue x-ray
positron annihilation resonance absorption
Potential Radiation exposure Radiation exposure None Radiation exposure
Harmful Effects
Cost' $2000-3000 $500-800 $400-1000 $300-600

"These are typical costs. PETand SPECTare whole body imagingtechniques. The MRI and CT costs are per body region. Whole body MRI
or CT costs are comparable to those from whole body PET.

cellular function. Fluorine-18 incorporated into the
radiotracer, fluorodeoxyglucose (FOG), is used to
measure how much of the cellular fuel, glucose, is
used. This amount is altered by disease. FOG has
proved to be very useful in detecting and character-
izing cancer.
Role of PET in Oncology
FOG-PET is playing an increasingly important role in
oncology and is becoming a standard tool in the
management of cancer patients. This results from the
high diagnostic accuracy of PET in most neoplasms.
Warburg and colleagues, in 1930, first demonstrated
that cancer cells have higher utilization of glucose than
regular cells (Warburg et aI., 1930; Warburg, 1956). This
elevated glucose utilization increases with increasing
grade of tumor malignancy. As such, FOG-PET has
proven utility in the diagnosis, staging, and restaging
of cancer and in the evaluation of treatment effects
(Gambhir et aI., 2001; Glaspy et aI., 1993; Andrich and
Neumann, 1994; Ichiya et aI., 1991; Hoh et aI., 1993).
This is also evident in the wide array of indications that
have been approved and are under consideration for
approval, by the Center for Medicaid and Medicare
Services (CMS) and by third party payers for reimburse-
ment. In a comprehensive literature review on upwards
of 18,402 patient studies, the average FOG-PET sensi-
tivity and specificity across all oncology indications and
applications was 84% and 88%, respectively (Gambhir
et aI., 2001). This high diagnostic accuracy translated
into an average management change in 30% of patients.
FOG-PET not only can characterize the behavior of the
primary tumor but also has repeatedly been shown
efficacious in identifying unsuspected metastatic disease
(Gambhir et aI., 2001; Hoh et al., 1993). Changes of
staging from that derived by conventional methods,
both upstaging and downstaging, has also been demon-
strated. FOG-PET is proving invaluable to the assess-
ment of treatment effects, including surgery, radiation
therapy, and chemotherapy (Andrich and Neumann,
1994; Gambhir et aI., 2001; Ichiya et aI., 1991). Positive
therapeutic responses, reflected in improved clinical
outcomes, are associated with decreases of tumor
glucose utilization.
Role of FDG-PET in Head and Neck
Cancer
There are a number of potential indications for the use
of FOG-PET in head and neck cancer. These occur
principally in three clinical settings: initial or early
presentation; after tumor therapy; and evaluation for
possible tumor recurrence during follow-up, usually
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
associated with either clinical or structural imaging
abnormalities. These indications include diagnosis of
mass lesion, localization of tumor, tumor grading,
staging, evaluation of metastases of unknown origin,
assessment of tumor therapy efficacy, distinction of
tumor recurrence or necrosis, restaging, and prognos-
tication. Because the principles underlying these indi-
cations are similar for all tumors of the head and neck
region, further discussion focuses on the two most
common head and neck cancers: squamous cell
carcinomas and thyroid cancer.
The published literature has been somewhat incon-
sistent in the assessment of the utility of FOG-PET in
the management of patients with proven or suspected
head and neck cancer (Assar et aI., 1999; Chisin, 1999;
Keyes et aI., 1997; Myers et aI., 1998; Schechter et aI.,
2001). Reasons given for not using PET have included
that it has marginal benefit from a high-cost test, that
PET has poor anatomic localization as compared with
that from CT or MRI, and that it provides little addi-
tional information above physical examination and
endoscopy.
On the other hand, it is rare for patients to have CT
or MRI at a single anatomic position. Cost of PET
becomes comparable to CT and MRI during a patient's
staging work-up (see Table 1-2). Furthermore, in our
clinical practice we have witnessed potential diagnostic
problems related to questionable FOG uptake and exact
localization of uptake. Nevertheless, both of these PET
diagnostic conundrums can be corrected or minimized
with imaging methodologic changes. The significance
of questionable FOG uptake can be made more certain
by using two methods. First, much of the PET literature
is based on a measurement technique called the stan-
dard uptake value (SUV), which is regional activity
normalized to injected dose and body mass. In our
experience, a more reliable measurement method is one
in which lesional activity is normalized to the regional
activity of a reference tissue, called relative uptake
value (RUV). Second, we have found that measuring
the temporal behavior of the FOG uptake of lesions is
a helpful discriminator. Both methods facilitate distin-
guishing neoplasm from inflammatory or desmoplastic
changes, the principal differential diagnostic consider-
ation when foci of FOG activity are seen. In terms of
anatomic localization, a new generation of PET instru-
mentation allowing near-simultaneous PET with CT or
MRI and their spatial co-registration is appearing in
clinical practice. Even without this capability, however,
anatomic localization of FOG uptake is achievable by
cross-correlation of FOG uptake (from emission PET)
with tissue density images (from transmission PET).
Both sets of data are routinely obtained during a PET
scan session. These low-grade CTs (i.e., transmission
scan images) provide sufficient contrast to ascertain
compartmental and geometric position within the head
 SECTIONAl RADIOGRAPHIC ANATOMY AND SCANNING

TABLE1-3 FDG-PETin Head and Neck Cancer·

Sensitivity (%) Specificity (%) Accuracy (%)

Indication No. Patients PET CT PET CT PET CT

Diagnosis 298 93 66 70 56 87 58
Staging 591 87 62 89 73 88 67
Diagnosis/staging 360 88 69 83 85 88 73
Recurrence 511 93 54 83 74 87 65
Treatment response 169 84 60 95 39 96 54

'Key data extracted from Gambhir ss. Czernin J, Schwimmer J, et al: A tabulated summary of the FOG PET literature. J Nucl Med 42:
1S-93S, 2001.

and neck region, as well as elsewhere in the body.
These simple methods correct many of the problems
leveled at PET but unfortunately are currently
employed by few PET facilities.
The criticisms against the use of PET listed earlier
have been applied to the initial or early clinical presen-
tation. Most authors agree on the utility of FOG-PET in
the post-therapy setting. However, when the findings of
multiple publications are collated together, FOG-PET
appears to have applicability in each of the three
clinical settings listed earlier. Gambhir and associates
have published a landmark paper that provides a tabu-
lated summary of FOG-PET patient studies published
from 1993 to 2000 (Gambhir et a!., 2001). FOG-PET had
high sensitivity and specificity and resulting diagnostic
accuracy in all three clinical settings of diagnosis/
staging, treatment response, and recurrence/restaging
(Table 1-3). The utility of FOG-PET is reflected in the
impact PET had on patient management. Both for
diagnosis and staging and for recurrence or restaging,
FOG-PET had a 33% management change effect based
on IS patient studies.
Although it is true that physical examination with
endoscopic examination accompanied by CT/MRI is
likely to adequately diagnose and stage many patients
presenting with head and neck tumors, often these
findings may be equivocal or indeterminate. It is in this
situation that FOG-PET can be of benefit. The differ-
ential diagnosis of lesions identified by these diagnostic
methods can be narrowed by characterizing their meta-
bolic attributes. Inflammatory lesions, such as reactive
lymphadenopathy, can be distinguished from neoplasm
based on FOG uptake characteristics. Size and distri-
bution of the primary neoplasm and local nodal and
remote metastatic spread are the most important
staging, and thus prognostic, factors for head and neck
cancers. Nodal involvement is particularly important,
with the S-year survival of patients with node disease
less than half that of those without nodal tumor spread
(Myers et aI., 1998). The increased concentration of FOG
by cancer cells facilitates definitive diagnosis of sus-
pected nodal metastases and detection of unsuspected
nodal metastases (Fig. 1-62).
FOG-PET can dramatically alter patient management
by the detection of remote disease. Although metastatic
involvement of the thorax can be seen with squamous
cell carcinoma of head and neck origin, if metastases
are present it is typically local or regional disease. How-
ever, for other types of cancer involving the head and
neck, including lymph node metastases, lymphoma,
and more rare tumors, there often is disease in other
body regions. FOG-PET is particularly useful in staging
because imaging can easily be performed in the same
session not only of the head and neck region but
typically also of the thorax as well as more rostral and
caudal aspects of the body. Detection of remote
metastatic disease is particularly important in thyroid
carcinoma either in the neck or to the lungs or bone
(Fig. 1-63). With metastatic thyroid cancer, scans with
iodine-131 often show no or equivocal uptake. The
primary histologic types where this occurs is with tall
cell papillary carcinomas and Hiirthle cell carcinomas,
as well as with anaplastic carcinomas. FOG-PETcan be
particularly useful in these cases in identifying iodine
non-avid metastases.
Cancer often presents itself as metastases of unknown
origin (MUD). Asymptomatic cervical adenopathy in
patients older than 40 is often either lymphoma or
carcinoma. Controversy exists in the literature on the
utility of FOG-PET for head and neck MUD (Greven et
a!., 1999; Jungehulsing et a!., 2000; Keyes et a!., 1997;
Stokkel et a!., 1999), despite its documented ability to
identify the primary tumor (Bohuslavizki et a!., 2000).
Because FOG-PET is performed as a whole body scan,
its ability to find additional unknown and unsuspected
metastatic sites is important in the definition of the
total body tumor burden (Lonneux and Reffad, 2001)
(Fig. 1-64). Knowledge of the primary site and the total
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

FIGURE 1-62 A 54-year-old man presented with a history of left tonsil moderately differentiated squamous cell
carcinoma, status post tonsillectomy and recent left cervical lymphadenopathy. FOG-PET revealed multilobulated,
hypermetabolic lesion in left deep anterior cervical triangle (arrow). The FOG uptake characteristics were consistent
with high-grade malignancy in confluent jugulocarotid lymph nodes. No residual neoplasm was seen at the palatine
tonsil region, and no other metastatic lesions were identified either locally or remotely. PET images are three-
dimensional projection views of the body rotating in space to the right 68 degrees from the anterior projection to nearly
the left lateral projection.

FIGURE 1-63 A 69-year-old man presented with a history of thyroid cancer, status post thyroidectomy, and one
course of 30 mCi 1311 approximately 1.5 years before PET.The patient presented with new-onset seizure disorder. Whole
body FOG-PETreveals a metastatic lesion in the brain as the cause of the seizure (rostral arrow) but also reveals multiple,
unsuspected mediastinal and lung metastases (thoracic arrows). PETimage format is as in Figure 1-62.
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

P00831

FIGURE 1-64 A 59-year-old woman with a 1-week history of left face weakness and numbness with questionable left
skull base MRI signal changes. FDG-PETrevealed widely metastatic disease with over 50 lesions identified affecting soft
tissue and bony skeleton. Two metastases were identified by PETin the left skull base (bottom row, lateral projection
arrow) causing compressive cranial neuropathies. The primary lesion was identified by PETas a right upper lobe, non-
small cell lung cancer (top row: anterior projection arrow). PETimage format is as in Figure 1-62.

POO924
FIGURE 1-65 A 54-year-old man presented with squamous cell carcinoma of the left auditory meatus status post
radical mastoidectomy and fractionated radiation therapy that ended 3 months before PET.CT was unrevealing. PET
shows hypermetabolic focus in the petrous portion of the skull base, infra-auricularly and in the subjacent soft tissue,
consistent with poor radiotherapeutic response in residual/recurrent neoplasm (arrow). PET image format is as in
Figure 1-62. Whole body images have been cropped to zoom into the head and neck region.
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

body burden can add prognostic information. The
number of metastatic sites has been shown to be a
major prognostic variable (Le Chevalier et aI., 1988;
Nieder et aI., 2001). Given that conventional work-up
methods for MUO are often unsuccessful and costly,
PET may help target subgroups of patients for the most
appropriate treatment (Hainsworth and Greco, 1993;
Schapira and Jarrett, 1995).
1t is with treatment response evaluation that PET
may have its most unique impact. By measuring cellular
metabolism, PET is essentially measuring the biologic
behavior of the tumor. Effective therapy, manifested
with decreased tumor cell number or decreased cellular
activity, will be reflected in decreased FOG uptake.
These changes can occur in the total absence of any
structural changes within the tumor bed. Thus, the diag-
nostic accuracy for FOG-PET is near perfect, whereas
CT showed an accuracy little better than a flip of the
coin (see Treatment Response in Table 1-3). This ability
to accurately gauge treatment response is seen with
radiation therapy (Peng et aI., 2001; Stokkel et aI., 1998)
(Fig. 1-65), chemotherapy (Haberkorn et aI., 1993), or
combined radiochemotherapy (Gambhir et aI., 2001)
(Fig. 1-66).
Evaluation for the presence of recurrent disease is a
major element in the follow-up of patients who, at least
initially, have been successfully treated for head and neck
cancer. In this post-therapy setting, distortion of normal
architecture and scarring by surgery and radiation ther-
apy confounds physical examination and endoscopy
and limits the accuracy of structural imaging with CT
and MRI (Chisin, 1999). FOG-PET has a very high,
93 %, sensitivity for recurrence detection, in contrast to
54% for CT (see Table 1-3). 1t is in this setting that all
authors agree as to the utility of FOG-PET (Fig. 1-67).
The published results for the diagnosis and staging
of thyroid cancer have been slightly less impressive
than those for head and neck squamous cell carcinomas,
with an overall diagnostic accuracy of 84% (Gambhir
et aI., 2001). However, in the context of disease recur-
rence and restaging, FOG-PET is proving to be of con-
siderable value in thyroid cancer. Based on 601 patients,
FOG-PET had a sensitivity of 77%, specificity of 91%,
and an overall diagnostic accuracy of 86 %. This results
in a highly significant management change effect of
53 %. Thus, the indications for which FOG-PET can play
a key role in thyroid cancer are in assessment of recur-
rences, therapeutic effects, and staging, particularly of
tumors with low avidity for iodine-131, and in detect-
ing remote metastatic disease.
An inherent property of measuring the biologic
behavior of neoplasm is the ability to grade tumors, to

LAO

P01003

FIGURE 1-66 A 57-year-old man presented with squamous cell carcinoma of the tongue base, stage IV T4NOMO,
status post chemotherapy and high dose fractionated radiation therapy. Laryngoscopy reveals diffuse swelling consis-
tent with edema. CT shows diffuse ill-defined attenuation changes. PETreveals a bilobed hypermetabolic lesion in the
tongue base at the tumor site on the pretreatment CT. Patient was downstaged to stage III T3NOMObased on PET.
PET image format is as in Figure 1-65.
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING

Anterior

/
LAO

POl 046
A

Lateral

P0194l
B
FIGURE1-67 A 61-year-old woman presented with Hurthle cell thyroid carcinoma initially diagnosed 15 years before,
status post total thyroidectomy and then bilateral radical neck dissections with multiple metastatic nodes found. Two
ablative iodine-131 therapies were given before the first PETstudy (A) and one iodine-131 therapy before the second
PET study (B). Twenty months separate the two PETs. Physical examination and CT were unrevealing owing to
postoperative changes and scarring. A less than 1-cm focus is seen in the medial supraclavicular, anterior periscalene
region. This shows increased uptake from the first to the second PETand is consistent with a lymph node metastasis.
Supraglottic FDG localization on the first PET(A) was likely related to radiation-induced inflammation. PETimage format
is as in Figure 1-65.
 SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
determine their degree of malignancy and aggressivity
(Chisin, 1999). Although this capability has not been
used to any great extent in oncology for body cancers,
it has been known since the early 1980s for primary
brain tumors (Di Chiro et a!., 1982; Di Chiro and Fulham,
1993). This ability to grade tumors is used in our daily
clinical practice for assisting neuro-oncologists in the
management of their patients. The capability of grading
tumors and determining proliferative activity does exist
for head and neck tumors (Minn et aI., 1988). Prognos-
tication directly flows from grading and staging infor-
mation (Minn et al., 1997; Patronas et al., 1985). Patient
management must be rationally designed for each
individual patient based on the array of diagnostic and
prognostic information available.
Conclusion
FDG-PET is a functional imaging modality in which the
regional concentration of FDG provides an index of
glucose utilization. Because neoplasm has heightened
glucose utilization, FDG-PET has many uses in the
management of head and neck cancer patients. There
are indications for its use in three different clinical set-
tings: initial presentation/early work-up; after therapy
to assess treatment response; and during follow-up for
detection of disease recurrence. The indications for
FDG-PET include diagnosis of mass lesion, localization
of tumor, tumor grading, staging, evaluation of metas-
tases of unknown origin, assessment of tumor therapy
efficacy, distinction of tumor recurrence or necrosis,
restaging, and prognostication. The diagnostic accuracy
of FDG-PET has been recognized by the CMS and other
third party payers, with authorization for payment for
the diagnosis, staging, and restaging of head and neck
cancer. Thyroid cancer is currently in evaluation for
clinical reimbursement by the CMS. In the future, the
capability of FDG-PET of grading neoplasms and in
prognostication may play a greater role in the man-
agement of head and neck cancer patients.
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 2 EMERGENCY
PROCEDURES
VENOUS AIR EMBOLISM
---------------- John Lauria
Venous air embolism can occur whenever a vein is
opened and the pressure within the vein is negative
relative to atmospheric pressure. The presence of sub-
atmospheric pressure in the vein causes air to be
entrained and carried to the right atrium. The relative
negative pressure will be enhanced in the head-up
position, whenever the opened vein is elevated above
the level of the right atrium, and in conditions of low
central venous pressure, as in hypovolemia.
Although small quantities of air may be dissipated in
the lungs with no effect on the circulation, larger
quantities of air may prevent proper circulation to the
alveoli, causing an effective increase in the physiologic
dead space. This may manifest by decreasing end-tidal
carbon dioxide levels and hypoxia.
Larger quantities of air may accumulate in the
outflow tract of the right ventricle and effectively
block it, because of the heart's inability to pump a
compressible medium. When this occurs, severe
hypotension accompanied by a marked increase in
central venous pressure and hypoxemia will develop.
Unless immediate corrective measures are taken,
cardiac arrest will soon follow. A venous air embolism
is best avoided by eliminating positioning factors that
may contribute to it and using meticulous surgical
technique.
Diagnosis depends on a high index of suspicion and
attention to changes in the expired carbon dioxide
levels. In the case of massive air embolism a distinct
change in the heart sounds may be heard, the so-called
mill wheel murmur. A properly placed and calibrated
Doppler device may detect small quantities of air. The
early changes in carbon dioxide are probably most note-
worthy because the continuous monitoring of Doppler
sounds may be impractical. Transesophageal echocardio-
graphy can also detect air in the heart.
Highpoints
Treatment of massive embolism causing circulatory
failure must be rapidly instituted.
I. The patient must be returned to the level of slightly
head-down position, preferably left side down.
2. External cardiac massage must be started if extremely
low or no blood pressure is obtained.
3. The patient must be ventilated with 100% oxygen.
4. The circulation must be supported by the administration
of fluids and the appropriate vasopressors.
Although it is commonly taught that the patient
should be turned with the left side down while slightly
head down to allow the air to rise to the apex of the
right ventricle to relieve the outflow tract obstruction,
care should be taken that this maneuver does not
prevent effective external cardiac massage. Well-
managed external cardiac massage may be effective in
moving the air. If a central venous catheter is in place,
air may be aspirated from it.
Performance of head and neck surgery in which a
significant probability of air embolism exists should
warrant the preoperative placement of a central venous
catheter capable of being flow directed into the right
ventricle for use both diagnostically and therapeutically
(Yee et aI., 1983).
MALIGNANT HYPERTHERMIA
---------------- John Lauria
Malignant hyperthermia (MH) may present as an
emergency usually during or soon after the induction of
anesthesia. The anesthetics most commonly associated
with this condition are the halogenated hydrocar-
bons, such as halothane, and the muscle relaxant
succinylcholine. Although the incidence of MH is low,
if it is not treated properly the effects of it are so devas-
tating that every surgeon and every operating suite
should be prepared to prevent, diagnose, and treat this
condition.
Prevention depends on obtaining a reliable history
from the patient or the family. The basis of this
disorder is a genetically inherited trait that is auto-
somal dominant. In families in which it exists there
may be a high level of awareness and information
concerning successful treatment and prevention
protocols. In the absence of a positive family history,
any history of an untoward event occurring during an
operative procedure leading to cardiac arrest in a family
member should be investigated for the characteristic
signs of MH.
65
 EMERGENCY PROCEDURES
The diagnosis and successful treatment of MH require
that every patient be monitored to determine his or her
oxygen saturation, exhaled carbon dioxide levels, and
temperature. Because the characteristic feature of an MH
reaction is a hypermetabolic response to the offending
agent, tachycardia, increasing expired carbon dioxide, and
decreasing oxygen saturation occur early. The development
of an elevated temperature may be delayed until the
problem is well developed, and the absence of fever in
the presence of other signs should not delay treatment.
Spasm of the masseter muscles after administration
of succinylcholine should alert one immediately to the
possibility that the patient is susceptible to the
development of MH.
The surgical care of patients who are known to be
MH susceptible can be safely accomplished by avoiding
the known triggering agents: the halogenated inhalation
agents and succinylcholine. The prophylactic adminis-
tration of dantrolene may also be advised. A presurgical
consultation with an anesthesiologist familiar with MH
is certainly warranted.
Highpoints
1. When MH presents unexpectedly during a surgical
procedure the procedure should be terminated as
soon as possible.
2. The administration of any halogenated anesthetic
must be terminated immediately.
3. Intravenous access if not established previously
should be accomplished by whatever route is
immediately available.
4. Hyperventilation with 100% oxygen should be
started immediately.
5. Intravenous fluids including sodium bicarbonate
must be administered as soon as possible.
6. Measures to cool the patient must be instituted.
7. Dantrolene must be immediately available in the
operating suite along with all of the necessary items
to prepare it for administration. A large placard
displaying the treatment protocol should be present
in each operating room. Dantrolene must be
administered according to the protocol.
8. After resolution of the initial crisis, the patient must
be followed closely in a fully monitored setting for at
least 24 hours.
Other Untoward Events Associated
With Endotracheal Anesthesia
The following complications may also occur with
endotracheal anesthesia:
I. Dislocation of arytenoid cartilage may mimic vocal
cord paralysis (see Chapter 20).
2. An endotracheal tube inserted in the right mainstem
bronchus can have a fatal outcome if not recognized
and corrected.
3. Insertion of an esophageal cardiac monitor without
care may perforate Zenker's diverticulum.
BLINDNESS AND OPHTHALMIC
COMPLICATIONS OF SURGERY
OF THE HEAD AND NECK
Daniel P. Schaefer and Arthur J. Schaefer
Periocular, facial, sinus, and cranial surgeries are
commonly performed for the treatment of infections,
neoplasms, cosmesis, and other conditions. Generally
these procedures are relatively safe, but serious ocular
complications may and do occur. Comprehensive and
detailed knowledge of orbital, periorbital, nasal, and
sinus anatomy and of the pathophysiology of compli-
cations is mandatory for a complete understanding of
the mechanisms of injury, the significance of clinical
findings, and the main way to prevent and treat these
complications. In addition, meticulous surgical tech-
nique is essential to minimizing these potential surgical
complications. Combined teams of ophthalmology,
otolaryngology, and/or neurosurgery often facilitate
surgery.
Because of the proximity of the orbits to the nose
and paranasal sinus cavities, ophthalmic complica-
tions may occur in association with sinonasal surgery.
These include infection, hemorrhage, epiphora,
diplopia, ptosis, eyelid defects, nasolacrimal duct
obstruction, visual compromise, or even the devas-
tating ocular complication of a complete and perma-
nent loss of vision. The orbital structures at greatest
risk are those structures closest to the area that is being
operated on. The reported incidence of orbital compli-
cations secondary to sinus surgeries varies from 2.8 %
to 47%.
Blindness
Blindness, whenever it occurs, is an obvious calamity.
When it is iatrogenic it becomes such a serious sequela
of any surgical procedure that the axiom primum non
nocere is most pungent.
Therefore, care must be taken even while prepping
the patient. Accidental exposure to solutions such as
Hibiclens has resulted in a permanent decrease in
vision, owing to its corneal toxicity. Hibiclens will cause
corneal epithelial defects or corneal edema that may
take more than 6 months to resolve or may progress to
a bullous keratopathy, corneal opacification, vascu-
larization, thinning, or ectasia, which may require a
corneal transplant.

Operations that have been complicated by blindness
are too numerous to present a complete list here. Fortu-
nately, these are infrequent occurrences. Some of the
surgical procedures that may be associated with blind-
ness include the following:
1. Ethmoidal surgical procedures, especially those
injuring the lamina papyracea
2. Endoscopic sinus surgery
3. Reduction of fractures involving the periorbital region
4. Surgical procedures involving the contents of the orbit:
a. Lacrimal gland resection
b. Any intraorbital tumor resection
c. Release of entrapped intraocular muscles
5. Blepharoplasty
6. Ligation of ethmoidal vessels for epistaxis
7. Simultaneous or staged radical neck dissection (very
rare, but it can occur)
Table 2-1 lists numerous mechanisms that can lead
to blindness or a loss of vision as a result of surgery.
These causes are obviously overlapping, but the main
reason for blindness appears to be the interruption of
the blood supply to the optic nerve. Treatment is initi-
ated as soon as possible to lower the intraocular pres-
sure, and to restore the posterior ciliary artery circulation.
Mannitol, acetazolamide, topical antiglaucoma medica-
tions, and high-dose steroids are administered when
indicated. Hypotension, anemia, and other abnormal
systemic conditions must be corrected. If there is orbital
swelling, hemorrhage, or proptosis creating a "tight orbit,"
TABLE 2-1 Mechanisms Leading to Vision
Impairment After Surgery
--'-
1. Hemorrhage into the orbit
2. Compressionof the optic nerve and its vascular
supply from various causes
3. Stretchingor shearing forces to the optic nerve
4. Optic nerve ischemia
5. Packing the maxillaryantrum with oxidized
cellulose
6. Frontal sinus irrigation
7. Any sinus surgery that violates the orbital walls
(e.g., an antral trocar that is directed superiorly)
8. Inappropriate or no ocular protection for the patient
(and also the operating room personnel) when
using the various lasers
9. Sustained intraoperative or postoperative pressure
on the eye
10. Microembolism
11. Pulmonary venous gas emboli with the use of
neodymium:yttrium-aluminum-garnet(Nd:YAG)
laser for endobronchial lesion
12. Severeedema of face and neck
EMERGENCY PROCEDURES
a lateral canthotomy and cantholysis of the inferior crus
and, occasionally, the superior crus, and of the lateral
canthal tendon is performed.
Treatment is as follows, especially when there is prop-
tosis and a tight orbit, which is evident by a marked
increased resistance to retropulsion of the globe:
1. Remove sutures if present, open the wound, evacu-
late the clot, and obtain hemostasis.
2. If the first step is not successful, a lateral canthotomy
and then a cantholysis of the superior and inferior
crus of the lateral canthus is required.
3. If the second step is not successful, a decompression
of the bony orbit can be done.
4. For intermediate cases, treat as follows:
a. 500 mg of acetazolamide and/or I to 1.5 g/kg body
weight delivered at 3 to 5 mL/min of 20% mannitol
intravenously, or 1 to 1.5 g/kg body weight of
glycerol orally if not considering general anesthesia.
b. head elevation, steroids, and intermittent ice
applications.
Optic Nerve Injury
Direct injury or damage to the optic nerve has little in
the way of promising treatment. These complications
must be avoided through meticulous knowledge of the
anatomic variations in the relationship between the
optic nerves and ethmoidal sinus. Chronic infection
and inflammation makes recognition of the anatomy in
this area difficult, and thickened mucosa, polyps, scar
tissue, and hemorrhage add to the problem. Even
polypectomies can result in orbital injury.
Orbital Walls and Soft Tissue Damage
Frontal sinus surgery can lead to injury of the superior
oblique muscle, tendon, and trochlea or even to the
fourth cranial nerve. Even extensive manipulation of
the orbital fat around these structures can result in
postoperative scar tissue formation and restriction. When
the orbital wall is violated, this can result in entrap-
ment of muscle and orbital tissue. For the extraocular
muscle to be involved, orbital contents must be pulled,
cut, or torn, which will result in complications secondary
to the direct effect on the muscle, causing more scarring
and reaction than that seen with traumatic orbital frac-
tures. The creation of a larger defect of the orbital walls
can result in enophthalmos.
A most frustrating complication to the patient and
the physician is ocular motility problems. Persistent
diplopia can be extremely disabling, and treatment can
be very frustrating. Transient diplopia can result from
multiple causes, including orbital hemorrhage or orbital
fractures, or secondary to postoperative swelling and
infections. Permanent ocular motility problems may
 EMERGENCY PROCEDURES
result from direct muscle or nerve injury, orbital frac-
tures with entrapment, and postoperative scarring. It
may take up to 6 months for some transient motility
complications to resolve. It is important to determine if
there is significant restriction secondary to scarring by
performing forced adduction testing. When restriction
is significant, exploration of the muscle with possible
lysis of the cicatricial tissue is indicated.
When paralysis is significant, the correction should
be performed using the standard techniques. Injuries of
the orbital floor should be treated similar to traumatic
orbital floor fractures. Often these patients are not
referred to someone familiar with proper treatment
until weeks after the injury and the opportunity for an
early and possibly more successful repair may be lost.
If the patient is examined months after the injury, it
may be difficult to differentiate between the scarring,
entrapment, or injury secondary to muscle injury.
Direct laceration or damage to the extraocular muscle
itself may result in much more severe scar tissue
formation and restriction than entrapment does.
Orbital Hematoma
Another mechanism that can cause a loss of VISIOn
during ethmoidal surgery is orbital hematoma or
hemorrhage, which needs to be managed with urgent
control of the hemorrhage. Severe periocular and orbital
edema and hematomas may occur if adequate hemo-
stasis is not obtained during surgery, clotting mechanisms
are impaired, the patient has a severe coughing spell,
or the patient performs a Valsalva maneuver postopera-
tively. If the hematoma is localized in the lid, it can
often be drained through the incision or through a
small stab incision with a No. 11 Bard-Parker blade. If
the hematoma dissects into the orbit, intraorbital pres-
sure can be increased as a result of the edema or
hemorrhage, which may be sufficient to produce an
orbital compartment syndrome. The increased orbital
pressure extrinsic to the globe produces a compression
of the optic nerve and the vessels supplying the nerve
and globe. This can compromise vision from compres-
sion of the optic nerve and the vascular supply to the
globe. If an orbital hematoma occurs in a patient who
has had a tight pressure dressing applied, the risk of
loss of vision is greater owing to the increased orbital
pressure that is generated in this confined space.
Severe postoperative pain should alert the surgeon
to the possible development of an orbital hematoma or
hemorrhage, corneal abrasion, or a glaucoma attack.
Pressure bandages should be avoided, owing to the
possibility of masking and/or augmenting the effects of
orbital hemorrhage, because this can add to the intra-
orbital tissue pressure, obscure lid and conjunctival signs
of retrobulbar bleeding, and hinder the monitoring of
pupillary reactions.
As described previously, treatment is initiated as soon
as possible to lower the intraocular pressure and restore
the posterior ciliary artery circulation. The use of man-
nitol, acetazolamide, topical antiglaucoma medications,
and high doses of corticosteroids should be administered
when indicated. The correction of hypotension, anemia,
and other abnormal systemic conditions must be per-
formed. If orbital swelling, hemorrhage, or proptosis
creates a "tight orbit," which is evident by a marked
increased resistance to retropulsion of the globe, then
surgical intervention is indicated.
The optimal period of time in which to observe the
patients under treatment and the time window in which
successful surgical treatment may be performed are
unknown. No light perception vision is not necessarily
a contraindication but is actually an indication for
aggressive medical and surgical treatment. One must
never hesitate to take the appropriate steps to preserve
the sight of the affected eye.
Most orbital hemorrhages after blepharoplasty or
eyelid procedures are caused by bleeding from vessels
within the orbital fat or from diffuse bleeding of the
orbicularis muscle. Hemostasis must be achieved
intraoperatively but will not eliminate the possibility of
late hemorrhage. Traction on the orbital fat should be
avoided to decrease this complication from occurring.
Patients should be instructed to call immediately if they
develop pain, proptosis, or visual loss, especially in the
early postoperative period. Treatment of a post-
blepharoplasty orbital hemorrhage is an ophthalmologic
emergency. Decompression of the hemorrhage is the
most effective means of eliminating the orbital com-
partment syndrome (see Highpoints). Corticosteroids
and osmotic and ocular hypotensive agents are not
effective as primary therapy.
If the orbital pressure is not extremely severe, and
there are no signs of visual impairment (e.g., decreased
visual acuity or pupillary defects), temporizing measures
may be instituted (e.g., ice, prednisone, head elevation,
intermittent pressure). If the patient develops any signs
of visual compromise or progression of the hematoma
or hemorrhage, or when the increased orbital pressure
compromises the globe or optic nerve, then emergency
measures are required to reduce the orbital pressure
(see Highpoints). Heroic measures must be instituted
at the first sign of any progressive hematoma or hemor-
rhage, reduced vision, pupillary defects, or sign of a
central artery occlusion.
Highpoints
Table 2-2 describes surgical intervention.
Paracentesis of the eye has been advocated by some
as a treatment of visual loss secondary to an orbital
hematoma or hemorrhage, but we do not recommend
this because the pathogenic mechanism that must be

TABLE Z-Z SurgkallnterventioB for the
'D'eatment of Orbitallf;A IKI'hap .
1. Removesutures if present, open the wound,
evacuate the clot, and obtain hemostasis.
2. If not successful, then a lateral canthotomy and then
a cantholysis of the superior and inferior crus of the
lateral canthal tendon should be performed.
3. If not successful, then a decompression of the bony
orbit, through a combined lateral and inferior
approach, should be performed to preserve vision
(this treatment is rarely needed).
For intermediate cases:
a. 500 mg of acetazolamide and/or 1 to 1.5 g/kg
body weight delivered at 3 to 5 mL/min of 20%
mannitol intravenously,or 1 to 1.5 g/kg body
weight of glycerolorally if not considering
general anesthesia.
b. head elevation, steroids, and intermittent ice
applications.
corrected in these extreme situations is the elevated
orbital pressure not the intraocular pressure. If a globe
that is under intense orbital pressure is opened, or an
anterior chamber tap is performed, this may cause a
loss of the intraocular contents.
Ischemic Optic Neuropathy
Unilateral or bilateral blindness may occur secondary to
anterior or posterior ischemic optic neuropathy. This
devastating event can occur with ophthalmic, head and
neck, cardiothoracic, or even general surgical procedures.
Factors predisposing to it include anemia, hemorrhage,
hypotension, arteriosclerosis or small vessel disease,
carotid and/or vertebral stenosis or occlusion, and factors
that increase the intraocular pressure (see Table 2-1).
The posterior ciliary arteries, branches of the ophthalmic
artery, supply the optic nerve head in a "watershed fash-
ion." Circulation in the optic nerve head is dependent
on the difference between perfusion pressure of the
posterior ciliary arteries and the intraocular pressure.
Therefore, anything that causes a decrease in perfusion
pressure to the optic nerve head can be categorized into
local vascular factors, including stenosis, occlusion, or
spasm of the posterior ciliary, ophthalmic, or carotid
arteries. Systemic factors that influence the perfusion of
the optic nerve include atherosclerotic vascular disease,
temporal arteritis, hypertension, hypotension, diabetes,
migraine, collagen vascular disease, emboli, or hemorrhage.
The factors that can increase the intraocular pressure
include glaucoma and increased concentration of carbon
dioxide in expired lung gases, which also increase the
central venous pressure. Hypothermia decreases cerebral
blood flow and increases blood viscosity, which may
cause ischemia in the posterior ciliary arteries.
EMERGENCY PROCEDURES
Hypotension becomes more critical when combined
with factors such as anemia, excessive fluid replacement,
and individual variations in the neural microvascular
pattern, leading to a higher incidence of hypoperfusion
of the optic nerve's capillary bed.
An optic neuropathy may also result from tractional
stretching of the optic nerve, ischemia of the optic nerve
caused by torsion, traction, interruption of the small
nutrient vessels to the optic nerve, or repeated abrupt
elevations in intraocular pressure, as from excessive
retraction of the globe during surgery, vasospasm of the
central retinal artery and/or posterior ciliary artery, or
postoperative orbital edema or hemorrhage.
Close postoperative monitoring of visual acuity,
pupillary responses, color vision, intraocular pressure,
and retinal perfusion is imperative. A compromise of
the retinal perfusion can be evaluated on funduscopic
examination. If there are spontaneous pulsations of
the retinal arteries or these are easily induced with
minimal additional pressure on the globe, then there
is inadequate perfusion pressure to open vascular
channels during diastole. Transient perfusion occurs
only during systole. Perfusion compromise can arise
from elevated intraocular and/or intraorbital pres-
sure. Central retinal artery occlusion can be identified
by the characteristic narrowing or box-carring of vessels,
edematous whitening of the retina, and appearance
of a foveal cherry-red spot where the thin overlying
retina does not obscure the normal coloration of the
choroid to the extent that the edematous retina does
elsewhere.
Venous "Congestion"
Blindness is an infrequent but devastating complication
of simultaneous bilateral neck dissections. The
resection or ligation of both internal jugular veins
increases the risk factor for blindness, as does venous
congestion or ischemia caused by local compression or
central hypotension. The ligation of the internal jugular
vein may cause venous hypertension and increased
intracerebral and cerebrospinal fluid pressure, leading
to papilledema.
The increased intraorbital pressure may lead to a
reduced drainage of the orbital venous plexus into the
ophthalmic vein and a reduced flow in the pial venous
plexus in the optic nerve sheaths.
Orbital Injections
Perforation of the globe or injections into the optic
nerve or nerve sheath, during the administration of
local anesthesia, is a rare occurrence; but it is more
likely to occur when one uses a long (38-mm) sharp
needle, especially if a protective contact lens was not
placed. Improper insertion angle of the needle and
 EMERGENCY PROCEDURES
highly myopic eyes (anteroposterior axis greater than
24 mm) can increase the incidence of globe perforations
during orbital injections. Scleral perforations due to injec-
tion can manifest with immediate ocular pain, intraocular
hemorrhage, restlessness, or hypotony of the globe. The
planned surgery should be discontinued immediately
and the patient evaluated by a vitreoretinal surgeon.
In children, care should always be taken to avoid the
development of amblyopia (deprivational amblyopia).
Prolonged occlusion of the eye (secondary to patching
or swelling of the periocular structures and eyelids),
induced paralysis of one or more extraocular muscles,
or even the development of secondary cataracts may
lead to a severe amblyopia, especially in children younger
than 5 years of age.
Complications of orbital decompression surgery for
thyroid-related orbitopathy are infrequent but can be
serious. Postoperative hemorrhage, infection, exacerba-
tion of Graves' inflammatory reactions, and damage of
the infraorbital nerve and artery or the nasolacrimal
drainage system are generally avoided with good visuali-
zation and knowledge of the anatomy. Contraction scar-
ring or keloid formation may result from skin incisions,
and fistulas may develop with mucosal approaches.
Comprehensive and meticulous knowledge of
orbital, periorbital, nasal, and sinus anatomy and
the pathophysiology is mandatory for a complete
understanding of the mechanisms of injury, the
significance of clinical findings, and the main way to
prevent and manage complications.
CARDIOPULMONARY
RESUSCITATION
William M. Morris
Emergency Cardiac Care
Emergency cardiac care includes all responses neces-
sary to deal with sudden and frequently life-
threatening events affecting the cardiovascular and pul-
monary systems and often leading to cardiorespiratory
arrest. The most common events are malignant ven-
tricular arrhythmias, including ventricular fibrillation
caused by myocardial ischemia or infarction due to
underlying coronary artery disease. However, other
catastrophic events may be the cause. These events are
frequently initiated by respiratory arrest followed by
full cardiopulmonary arrest. In the surgical patient these
include upper airway obstruction, drug intoxication,
including sedative narcotics or anesthesia, chest trauma,
pneumothorax, or stroke. Prompt recognition of these
events and resuscitation frequently is life saving.
Emergency cardiac care involves both recognizing the
early warning signs, especially signs of hypoxemia, chest
pain, or electrocardiographic (ECG) changes including
ventricular arrhythmias, and the prompt initiation of
rhythm and oximetry monitoring.
The two components of emergency cardiac care are
basic life support (BLS)and advanced cardiac life support
(ACLS).Cardiopulmonary resuscitation (CPR) is an inte-
gral part of both. BLS is intended to prevent inadequate
or arrested circulation or respiration and to provide cardio-
respiratory support of the arrested patient through CPR.
ACLSincludes BLSplus the use of adjunctive equipment
to support ventilation (e.g., intubation, the establishment
of intravenous access), the administration of drugs, cardiac
monitoring, and arrhythmia control including defibril-
lation and the arrangement of care after resuscitation.
In a patient with cardiorespiratory arrest, if CPR is
initiated within 4 minutes, and ACLS including defib-
rillation where appropriate is initiated within 4 minutes
thereafter, the chances of full recovery are excellent. If
CPR is initiated after 6 minutes, brain damage will
almost always occur.
Sequence of BLS (Fig. 2-1)
When faced with an unresponsive patient an orderly
sequence of steps should be followed. CPR should not
be initiated until a proper assessment has been made and
the need for resuscitation established. Unresponsiveness
should first be established, followed by the determina-
tion of breathlessness, and pulselessness, the so-called
ABC sequence of BLS (Airway, Breathing, Circulation).
A Gently tap or shake the patient to determine unres-
ponsiveness and call for help if there is no response.
B Place the patient supine and open the airway
using the head tilt/chin lift maneuver. Assess for the
presence of spontaneous breathing by placing your
ear over the mouth and nose, to feel or hear the flow
of air while observing the chest for movement (3 to 5
seconds). If breathing is not detected, two breaths
should be given, mouth to mouth or mouth to mask.
Ifventilation is unsuccessful despite head repositioning,
airway obstruction is likely. The airway should be
cleared using a finger sweep maneuver or by direct
visualization and foreign body removal using a clamp
or forceps if available. Ventilation should then be
reinitiated at a rate of 10 to 12 breaths per minute.
C, C1 Palpate the carotid artery for a pulse (5 to 10
seconds). If pulse is present, continue ventilation.
D If pulse is absent, begin chest compressions. The
patient should be supine on a firm surface with a
backboard if necessary. The heel of one hand should
be placed over the lower one half of the sternum, with

the long axis of the heel parallel to the long axis of the
sternum. The other hand should be placed parallel over
the first. The shoulders should be positioned directly
over the sternum and the elbows locked and the finger
kept off the chest. The sternum should be depressed
1.5 to 2 inches with each compression. With two
rescuers, one breath should be administered for every
five compressions, and with one, two breaths after
each 15 compressions. Chest compressions should be
maintained at a rate of 80 to 100 per minute.
A. Determine Unresponsiveness
C. Determining Pulselessness
D. Chest Compression
FIGURE 2-1
EMERGENCY PROCEDURES
The rescuer providing ventilation should check the
carotid pulse periodically for adequacy of compression
and pause every 1 to 2 minutes for spontaneous return
of pulse. If pulse is restored, spontaneous ventilation
should be assessedand ventilatory support continued
if necessary.
ACLS measures should be initiated as soon as effective
CPR has been established and ACLS-trained personnel
arrive.
B. Determining Breathlessness
 EMERGENCY PROCEDURES

For a more detailed review, please refer to Basic Life

Support for Health Care Providers, published by the B The pleural cavity is immediately entered, expos-
American Heart Association. Formal BLS and ACLS ing the pericardium medially and the lung laterally.
training are strongly encouraged.
C If a suitable rib retractor is available, it is used to
open the thoracotomy incision farther. A triangular
Closed Cardiac Massage wedge of wood is satisfactory. Using fingers of both
hands, begin compression. The rate of massage is
There is little doubt that closed cardiac massage is just between 45 and 60 beats per minute. Pressure by the
as effective-maybe more so-as open cardiac thumb is to be avoided because rupture of the heart
massage. The exceptions in which open cardiac muscle may occur. Adequate time is allowed for the
massage may be indicated are outlined in the following filling phase of the heart. From time to time the
section. massage is interrupted to observe whether the
heartbeat has returned.

Open Cardiac Massage D If preferred, the pericardium may be opened

Resuscitation (Fig. 2-2) longitudinally and the massage continued from within
the pericardial sac. Injury to cardiac muscle and
The supportive measures for open cardiac massage are coronary vessels should be avoided.
the same as those for closed cardiac massage
resuscitation. E After resuscitation, the wound is inspected for
bleeding, especially from the internal mammary and
Indications intercostal vessels. A large catheter is inserted through
a dependent intercostal space near the anterior axillary
• Patient in operating room undergoing open line and connected to an underwater drainage bottle.
thoracotomy Pericostal sutures of 1-0 chromic catgut in double strands
• Patient with severe chest injury are inserted, avoiding the intercostal neurovascular
• Cardiac tamponade bundle, and the lung is expanded by positive pressure.
• Massive intrathoracic hemorrhage
• Possibly in postoperative patient having had an F If available, a rib approximator is used while the
open thoracotomy or median sternotomy intercostal sutures are tied. The intercostal muscles
may be approximated with either interrupted or
Technique continuous sutures. The remainder of the wound is
closed in layers. The catheter is secured with an
encircling suture of 2-0 silk.
A An inframammary incision is made. This will be in
the region of the fourth or fifth interspace. Clamping G The underwater drainage bottle is kept below the
vessels at this stage is unnecessary. level of the patient and on return to the recovery room
it is secured to the floor (see Fig. 2-5A).
 EMERGENCY PROCEDURES

FIGURE 2-2
 EMERGENCY PROCEDURES
Thoracentesis (Fig. 2-3A and B)
Indications
• Rapid decompression of a pneumothorax or tension
pneumothorax
• Aspiration of intrapleural fluid
• Diagnosis
Selected Etiologic Factors of Pneumothorax
Relative to Head and Neck Surgery
I. Puncture of the mediastinal pleura, for example:
a. Median sternotomy
b. Tracheostomy, particularly associated with severe
coughing during and after the procedure-this
complication may be minimized by use of a local
anesthetic (10% cocaine, 4% lidocaine, or 2%
tetracaine) injected into the tracheal lumen with
a SIB-inch 2S-gauge needle to facilitate topical anes-
thesia. Air is first withdrawn from the trachea to
be sure that the needle is in the tracheal lumen.
2. Puncture of the apical pleura:
a. Neck dissection
b. Any surgery in the vicinity of the clavicle
Highpoints
1. Insert needle at upper border of selected rib.
2. Use second anterior interspace for pneumothorax.
3. Use seventh or eighth interspace at posterior axillary
line for intrapleural fluid or place according to
radiographic localization.
4. In pneumothorax a single aspiration may suffice, but
it is usually safer to replace the needle with an inter-
costal catheter connected to underwater drainage.
This is mandatory in a tension pneumothorax
persistent air leak. If a large leak is present, as
evidenced by almost continual bubbling of air
through the underwater seal bottle, two or more
large catheters may be necessary, each connected to
a separate set of underwater drainage bottles.
5. When a tension pneumothorax associated
severe respiratory distress exists, it may be lifesaving
to insert any type of needle, knife, or sharp instru-
ment into the chest without syringe or any other
equipment.
A For pneumothorax or tension pneumothorax the
patient is preferably placed in a supine position. A 15-
to 18-gauge needle is inserted in the second anterior
interspace (X) along the midclavicular line. This
location will avoid the internal mammary vessels. If the
patient is in acute distress and sitting in an upright
position, it is better not to have the patient lie down.
The needle is guided along the superior edge of the
third rib to avoid the intercostal vessels. In an
emergency, no anesthesia is necessary; if time permits,
local anesthesia is used intradermally with infiltration
down to the parietal pleural level.
For aspiration of fluid, the sitting position at the side
of the bed resting over a bed stand elevated to breast
height is ideal. The site of insertion of the needle
depends on the radiographic findings; however, the
classic location is through the seventh or eighth
interspace at the posterior axillary line.
B A 20- or 50-mL syringe with an interposed three-
way stopcock is ideal. Rubber tubing or a catheter may
be connected to the stopcock if a hydrothorax is
present. This facilitates removal of the fluid. In a
tension pneumothorax, the barrel of the syringe may
be pushed out by the increased intrathoracic pressure.
When the proper depth of insertion is reached, a
straight hemostat immediately clamps the needle at
the skin surface, preventing the needle from going any
farther into the intrapleural space.
Insertion of Intercostal Catheter
(See Fig. 2-3C to J)
Indications
• Prolonged underwater drainage
• In an emergency tension pneumothorax when other
or equipment is not available
Highpoints
The high points of this procedure are similar to those
listed under Thoracentesis.
with
C A No. 11 blade knife is inserted in the selected
interspace hugging the superior edge of the rib to
avoid the neurovascular intercostal bundle.
D With a curved Kelly clamp, the incision is widened
both horizontally and vertically.
Continued
 EMERGENCY PROCEDURES

FIGURE 2-3
 EMERGENCY PROCEDURES
Insertion of Intercostal Catheter
(Continued) (See Fig. 2-3C to J)
E Using the Kelly clamp as a guide in the stab
wound, a multi-holed No. 26 to No. 30 French plain
rubber catheter is inserted in the thoracic cavity.
A straight hemostat is used to grasp the catheter and
passit in through the stab wound.
F Silk sutures are used to close the stab wound
tightly and are wound snugly around the catheter to
help hold it in place. A small dressing of petrolatum
and plain gauze with supporting adhesive completes
the dressing. The catheter is unclamped after it is
connected to the tubing from the underwater
drainage system (see Fig. 2-5).
G When a large-bore trocar with cannula is available,
an intercostal catheter is easily inserted. The technique
is similar to the method described in the previous
plate. The trocar is kept close to the superior border of
the rib. A clamp is placed on the catheter before
insertion.
FIGURE2-3 Continued
H As the cannula IS withdrawn, the catheter is
inserted.
I After a sufficient length of the catheter has been
inserted-at least until all the holes are within the
thoracic cavity-the trocar is gradually removed.
When the catheter is visible at the skin margin, a
clamp grasps the catheter to prevent it from being
withdrawn. After the trocar is completely removed,
the catheter is connected to the underwater drainage
system, as shown in Figure 2-5. In infants and children
similar results can be achieved by inserting plastic
tubing through the lumen of a large-bore needle that
has been inserted into the pleural space. The needle
can then be removed by withdrawing it along the
tubing. Such smaller tubing, however, may become
plugged.
J Minithoracentesis: Pictured is a simple self-
contained intercostal catheter with an attached needle
(after Algird, 1966).
 EMERGENCY PROCEDURES

J
FIGURE 2-3 Continued
 EMERGENCY PROCEDURES
Open Thoracotomy for Empyema
Drainage (Fig. 2-4)
Although thick, purulent empyema of the pleural space
is uncommon after head and neck surgery, when this
complication does occur, open thoracotomy is
necessary. Rarely, it may follow deep abscesses of the
neck that extend into the mediastinum and then
perforate into one or both pleural cavities. Perforation
of the esophagus causing mediastinitis may likewise
cause empyema and, in addition to drainage of the
mediastinum (see Fig. 21-4), open thoracotomy then
becomes necessary.
Highpoints
1. Local anesthesia can be used.
2. The most dependent point should be drained.
3. A section of rib is resected to make a large opening
in the pleura.
4. The neurovascular bundle is resected.
S. An underwater drainage system is not used.
A An incision is made over the selected rib,
removing about a 6-cm section of the rib (see
Fig. 21-12E to H). An elliptical incision is then made in
the posterior periosteum and pleura, removing a
portion of the periosteum and pleura and making an
opening that is larger than would seem necessary,
because there is a marked tendency for the wound to
close too rapidly. It is likewise recommended to excise
the dependent neurovascular bundle to minimize pain
and delayed hemorrhage resulting from pressure of
the drainage tubes.
B One or two large (1.0 to 1.5 cm in diameter)
rubber or plastic tubes with multiple holes are then
inserted into the empyemic cavity for drainage. Sutures
are either passed through or tied securely around the
tubes to prevent their loss in the pleural cavity.
Frequent changes of dressings are necessary. If the
pus is thick, the qlbes may be irrigated with saline and
changed as necessary. As the cavity becomes smaller,
the tubes are replaced by a catheter and drainage is
continued until the cavity has a volume capacity of less
than 5 mL. Prolonged drainage is usually the case and
premature removal is to be avoided.
 EMERGENCY PROCEDURES

A B

FIGURE 2-4
 EMERGENCY PROCEDURES
Intercostal Catheter Suction
Drainage With Underwater Seals
(Fig. 2-5)
To facilitate sealed chest drainage, a variety of devices
are available, which eliminates the cumbersome multiple
drainage bottles depicted. Yet, it is worthwhile to describe
the older multiple bottle technique if these devices are
not available and also to aid in the understanding of
the basic mechanical principles involved.
Highpoints
1. Be certain nursing personnel understand the
following:
a. Bottles are not elevated or removed from floor.
b. Bottle stoppers are not removed.
c. Fluid is not emptied.
d. Tubing is not disconnected.
e. All connections and stoppers are taped securely.
2. Tubing should be "milked" from time to time to
prevent plugging.
3. Kinks and loops in tubing and catheter should be
avoided.
A The intercostal catheter, No. 26 to No. 30 French
with multiple holes, is usually connected to a single
bottle, which acts as a water seal and drainage bottle.
The bottle is securely taped to the floor. This
arrangement usually suffices for the minor pleural leaks
complicating head and neck surgery. The long glass
tube extends 1 to 2 cm below the level of the water,
acting as a water seal so that air will not be sucked
back into the thoracic cavity. Bubbling of air out
through the tube into the water indicates that the
pleural leak is still present. The water column in the
glass tube should rise and fall with respirations
whether there is a pleural leak or not. If it does not, it
indicates that the tubing is plugged. The catheter is
removed 24 hours after there is no further evidence of
air leak or evidence of significant drainage. A large
curved clamp is kept in a conspicuous location for
emergency clamping of the catheter close to the chest
in the event of accidental break in the system.
B A three-bottle system connected to a source of
suction facilitates more rapid expansion of the lung
when there is a known or persistent air leak. In such
cases two intercostal tubes are used, one being placed
upward toward the apex, where it is secured to the
parietal pleura. Each tube is then connected to sepa-
rate underwater sealed bottles. Bottle 1 collects any
fluid draining from the thoracic cavity and serves as a
measure for this drainage. This bottle should be emptied
only by the physician and then only when the inter-
costal catheter is clamped. Bottle 2 serves as the under-
water seal and prevents the patient from sucking air
back into the pleural space if the suction fails. It also
indicates the presence or absence of a pleural leak by
the presence or absence of bubbling. The long glass
tube is 1 to 2 cm below water level. Bottle 3 is the
negative pressure control bottle. By adjusting the depth
of the long tube in the water, the amount of negative
pressure is controlled. Using 8 to 10 cm of water is
ideal. The normal intrapleural negative pressure is -8
to -15 cm of water, and if necessary, the negative pres-
sure in bottle 3 may be increased to -15 cm of water.
The source of suction can be any pump or apparatus
or wall suction that is able to make the air tube bubble
in bottle 3 even though the source of suction is much
more powerful. Bottle 3 adjusts it exactly.
C In the event a three-holed stopper is not available,
this arrangement using a Y connector duplicates the
physical principles of bottle 3. The only drawback is
the danger of kinking of the tubing.
The principles outlined under the use of a single
bottle system apply to the three-bottle system,
including the indications for discontinuance.
D Pictured is the Pleur-Evac device for self-contained
sealed underwater chest drainage, which replaces the
previously described bottle system. Note: It is
important to review the detailed description of the
Pleur-Evac on the package insert.
 EMERGENCY PROCEDURES

FROM
PATIENT

D
FIGURE 2-5
 EMERGENCY PROCEDURES

Cricothyroidotomy (Fig. 2-6) Complications

Highpoints • Hemorrhage
• Chondritis
1. Procedure is utilized in emergency glottic or • Subglottic and/or glottic stenosis
supraglottic airway obstruction or electively by
some thoracic surgeons after midline sternotomy,
when there may be an associated airway problem. A With the head and neck extended, palpation of
Next to intubation, this is one of the fastest methods the cricothyroid ligament is usually quite easy. It is at
of establishing an airway. this point that the airway is mos't superficial. A short
2. Obstruction must be ascertained to be above the horizontal skin incision is preferred. There is little to be
level of the cricoid cartilage. gained by a vertical incision, because vessels can be in
3. Either a horizontal or vertical skin incision is made, horizontal and/or vertical planes. In addition, a vertical
with the former preferred. incision carried too deeply may involve the cricoid
4. A midline separation of strap muscles is done. and/or thyroid cartilages.
5. A horizontal incision is made through the
cricothyroid membrane. B The anatomy of the cricothyroid membrane with
6. Bleeding may occur from the cricothyroid artery, blood vessels that may cause significant bleeding is
which is a branch of the superior thyroid artery. shown. The arteries are branches of the superior
7. Conversion to a standard tracheostomy is done as thyroid artery, while the veins drain into superficial
soon as possible except when the procedure is used thyroid veins and/or the median cervical veins. The
electively, in which case the tube should be removed exposure depicted is for anatomic purposes; the actual
as soon as possible, within a maximum of 5 to 7 surgical exposure is limited to the immediate area of
days. Antibiotics should accompany the cricothy- the cricothyroid membrane.
roidotomy during this period of time.
C The sternohyoid muscles may require retraction
Comment for additional exposure of the cricothyroid ligament. A
horizontal stab incision is made through the ligament
Although this procedure was condemned by Chevalier with cognizance of the blood vessels.
Jackson in the early 1900s because of related
complications of chondritis and glottic and subglottic D The stab wound is widened either with a clamp or
stenosis, the procedure is justifiable and very useful. with a tracheal dilator. The clamp may have to be
When reviewing Jackson's original articles, it becomes rotated 90 degrees to separate the cricoid cartilage
apparent that the procedure was often extended to farther from the thyroid cartilage. Care must be taken
include an incision through the cricoid and/or thyroid not to injure either cartilage or the vocal cords, located
cartilages. These extensions contributed significantly to superiorly. A standard tracheostomy tube is inserted.
the complications listed here. In addition, in the early The skin edges are loosely approximated. The
1900s there was a preponderance of infectious disease cricothyroidotomy should be converted as soon as
causing glottic obstruction. Antibiotics, of course, were possible to a standard tracheostomy.
not available at that time.
The immediate conversion to a standard tracheostomy
except in patients with laryngeal trauma has been Contraindication
challenged by some authors (Boyd et aI., 1979), who
emphasize that the complications of stenosis occur • Malignant neoplasm of larynx
when the tube is left in place for 1 week.
 EMERGENCY PROCEDURES

PYRAMIDAL LOBE

CRICOID CART.
,
~
(IRSTTRACHEAL CART.
c
" f

FIGURE 2-6
 EMERGENCY PROCEDURES
Management of Acute Respiratory
Emergencies
When medical management, including antibiotics with
or without corticosteroids, racemic epinephrine mist, and
ultrasonic aerosol therapy, fails in the management of
acute croup, epiglottitis, and laryngotracheobronchitis,
mechanical intervention to establish an emergency airway
is necessary. The indication for this kind of interven-
tion is progression of the symptoms characterized by
supraclavicular retraction, cyanosis, substernal retrac-
tion, and a general picture of increased air hunger.
The types of mechanical intervention for the
emergency establishment of an airway include:
1. Insertion of an endotracheal tube
2. Placement of a laryngeal-mask airway. The laryngeal
mask airway is recommended as the second most
desirable way to establish an airway under
emergency conditions because it can be successfully
inserted at times when endotracheal intubation fails
because of anatomically related difficult intubating
conditions or the presence of secretions or blood,
which make visualization of the glottis difficult.
Once it is properly placed it is an efficient means for
providing ventilation and may provide a passageway
for suctioning and placement of a smaller caliber
endotracheal tube (ASA Task Force, 1996).
3. Insertion of a bronchoscope
4. Percutaneous insertion of a large-bore needle into
the tracheal lumen
5. Nasotracheal intubation using virtually any type of
tubing available, for example, a portion of
stethoscope tubing
6. Tracheostomy (see Fig. 19-1)
7. Cricothyroidotomy (see Fig. 2-6)
8. Oropharyngeal airway
After the emergency establishment of an airway (if
tracheostomy has not already been carried out), a
tracheostomy is performed over the endotracheal tube,
bronchoscope, percutaneous needle, or nasotracheal
tube. If there is any doubt about the presence of any
significant amount of retained tracheobronchial secre-
tions or the possibility of a retained foreign body,
bronchoscopy is then performed under topical, basal,
or general anesthesia. At the same time a careful
evaluation of the larynx is done by direct fiberoptic or
rigid laryngoscopy.
A variation of this generally accepted method involves
the continuation of the use of the endotracheal tube
without tracheostomy for a number of days in conjunc-
tion with antibiotics, corticosteroids, and ultrasonic
aerosol therapy. When on a respirator the cuff on the
endotracheal tube should usually be adjusted to
"minimal leak," thus allowing a small amount of air to
leak by the cuff. This ensures that the cuff is not over-
inflated and can prevent damage to the tracheal mucosa
and possibly the tracheal cartilages. Such complication
leads to tracheal stricture and stenosis. It must be
emphasized that with this method there exists the
inherent possibility of temporary or permanent damage
to the vocal cords as well as subglottic stenosis.
Problems associated with the care of acute respira-
tory emergencies in which selective operative interven-
tion is necessary include the following:
1. Pneumothorax, tension and nontension, unilateral
and bilateral
2. Airway obstruction from any cause
3. Respiratory arrest and cardiac arrest
4. Tension pneumoperitoneum
5. Mediastinal emphysema
6. Perforated gastroduodenal ulcers in infants leading
to tension pneumoperitoneum associated with
aerophagia
7. Hemorrhage following neck surgery that compresses
the airway (e.g., thyroidectomy). The operative wound
must be immediately opened and the larynx examined.
8. Bilateral abductor vocal cord paralysis
Emergency Establishment of Airway
Airway obstruction and severe hemorrhage are two of
the most important and life-threatening emergencies
facing the head and neck surgeon. The important facet
in the emergency establishment of an airway is to
ascertain the location of the obstruction. This can have
any of the following locations:
1. Oral cavity
2. Oropharyngeal
3. Hypopharyngeal
4. Supraglottic-epiglottic or ventricular bands
5. Glottic
6. Subglottic
7. Tracheal
8. Bronchial
It is obvious that the location of the obstruction and
the etiology of the obstruction govern the methodology
of management. When appropriate, endotracheal
intubation through either the oral or the nasal route or
use of a nasal oropharyngeal airway is usually the
fastest. Nasal intubation can be achieved "blindly" with
any available tube having the correct diameter (e.g., a
relatively stiff section of stethoscope tube inserted with
the head and neck extended). The next method is the
placement of a laryngeal-mask airway for supraglottic
and glottic obstruction. Other methods are bronchoscopy
and the percutaneous insertion of a large-bore needle
into the trachea. To discuss this entire problem and

method of management would be a treatise in itself.
The previous figures depict cricothyroidotomy, which
is a very rapid and satisfactory method for establishing
an airway when the obstruction is located at the glottic
level or above. A number of instruments are available
that are useful for a cricothyroidotomy and can be
carried by any physician in the shirt or coat pocket.
"Anterior cricoid split" in infants and children to
avoid tracheostomy after extubation has been reported
by Holinger and colleagues (1987) as well as Cotton
and co-workers with a 77 % success rate (1980). An
anterior incision is made through the thyroid cartilage
commencing 2 mm distal to the thyroid notch and then
through the cricoid cartilage and the first and second
tracheal rings. A wedge of thyroid cartilage can then be
inserted at the site of the split in the cricoid cartilage.
When airway obstruction is associated with possible
cervical spine injury, either secondary to trauma or
congenital osseous defects (e.g., Hallermann-Streiff
syndrome), any procedure that involves hyperexten-
sion of the cervical spine must be avoided. Hence, the
types of mechanical intervention as listed earlier that
could be used are Nos. 3 to 8.
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 3 BASIC
CONSIDERATIONS
Needle Biopsy Techniques
There are two techniques of needle biopsy: needle aspi-
ration biopsy and core needle biopsy.
Needle Aspiration Biopsy
Needle aspiration biopsy is a special method of biopsy
that is not to be used indiscriminately and hence deserves
some clarification of its role. There are basically two
types of needle aspiration biopsy: fine-needle aspiration
biopsy and large-needle aspiration biopsy.
Fine-Needle Aspiration Biopsy
Fine-needle aspiration (used almost exclusively by this
author) requires a 22- to 25-gauge needle without a
stylet and a small syringe. No anesthetic is used. The
aspirant is usually not drawn or is minimally drawn into
the syringe unless the mass is cystic. Negative pressure
is applied only while the needle is working back and
forth at various angles in the mass, and then the needle
is withdrawn without negative pressure. Ideally, the
specimen is thus retained in the needle. The contents
of the needle are then spread on glass slides by first
removing the needle from the syringe and filling the
syringe with air. This prevents the aspirate from being
drawn into the syringe. The slides are fixed and/or air
dried, depending on the wishes of the pathologist. At
times some blood is aspirated into the syringe. When
spreading the material it may well be that the last amount
in the syringe has a concentration of the cells in ques-
tion. Hence, care should be taken when ejecting the
last amount of material from the syringe. To remove any
residual aspirant in the hub of the needle, use a dispos-
able interdental brush (Sunstar Butler GUM Proxabrush
Trav-Ler Model 1614) inserted in the hub and smear on
slides. Another technique (described by the French)
when the aspirate is blood is to insert the needle a
second time with the barrel of the syringe attached but
without the plunger. The material is then more likely to
be retained in the needle. After the needle and barrel of
the syringe are removed from the area aspirated, the
plunger is reinserted in the syringe and the material is
spread on glass slides. When spreading the materials,
spread as one would do a blood smear. The end of the
slide is used to spread rather than facing another slide
over the material, which may crush the cells and make
it very difficult for the cytologist to identify the charac-
teristic of the cells. When aspirating a thyroid nodule,
hyperextension is at times helpful; this is achieved by
placing a pillow under the patient's shoulders. Care must
be taken to avoid puncturing the great vessels and the
trachea.
Large-Needle Aspiration Biopsy (See Fig. 3-')
This technique is primarily of historical interest. Large-
needle aspiration uses an IS-gauge needle with a stylet
and a large syringe. A small amount of local anesthesia
is usually utilized, and a No. 11 blade knife is used to
puncture the skin, thereby avoiding withdrawal of any
squamous cells from the epidermis or dermis. Negative
pressure is applied when working the needle back and
forth in the mass. The negative pressure is usually con-
tinued as the needle is withdrawn, and the aspirate is
collected on the base of the plunger and barrel and then
removed with a small "rake" and smeared on the slides.
The specimen is primarily in the syringe and possibly
in the needle as well. This minimizes the question of
implant along the needle tract. Again, the fixation of
the slides depends on the wishes of the pathologist.
Core Needle Biopsy
Core needle biopsy requires, for example, a Silverman
needle or Tru-Cut needle. The core is then fixed in for-
malin and sectioned as a histologic specimen. Silverman
needle biopsies and Tru-Cut biopsies in the head and
neck are very seldom used and never in any vascular
structure, for example, a thyroid gland, unless the lesion
is extremely hard and avascular on a fine-needle aspi-
ration. Details of the utilization of the Tru-Cut biopsy
technique are supplied by the manufacturer, which is
Baxter Healthcare Corporation.
Discussion
Various types of needles have been devised as well as
various syringe devices. Close cooperation with the
concerned pathologist is most important. Some centers
have the pathologist present at the time or even have the
pathologist perform the actual biopsy. If at all possible,
the site of the needle puncture should be in a line of
87
 BASIC CONSIDERATIONS
possible surgical excision for the definitive surgery. At
times it is worthwhile to mark the needle site with India
ink to facilitate excision of the entire needle tract. This
is considered mainly when aspirating a lymph node in
the neck and not in thyroid aspiration. Success of needle
aspiration depends on both the surgeon's and the
pathologist's knowing its restrictions and limitations.
Only after a complete head and neck examination should
it be considered as an aid in determining the nature of
the mass in the neck, if its main use is for tumefactions
in the neck when metastatic squamous cell carcinoma is
suspected, or when a primary lesion cannot be found.
A fine-needle aspiration biopsy of the thyroid offers
the physician an opportunity to obtain a histologic diag-
nosis of thyroid pathology but has definite limitations.
It is performed with neither special equipment nor local
anesthesia and usually permits a prompt interpretation.
Its reliability depends on the expertise and competence
of the surgeon and cytopathologist. Fine-needle aspira-
tion of thyroid masses that may be difficult to palpate
but that appear on a radionuclide iodine thyroid scan
and/or a sonogram can be performed by using high-
resolution ultrasound. This is accomplished with a small
transducer placed laterally to the thyroid and directed
medially and is a great help not only in locating the mass
but also in directing the fine needle. The needle itself may
or may not be visible on the screen, but, for example,
its deflection of the anterior and posterior walls of a
cyst is clearly visible. Ultrasound thyroid imaging is also
useful in following the size of the thyroid mass when
the patient is on suppression therapy.
Limitations of cytologic diagnosis include difficulties
in interpretation of follicular lesions and Hiirthle cell
lesions and in trying to discriminate between benign and
malignant lymphocytic lesions. Fine-needle aspiration
of a follicular neoplasm cannot distinguish whether the
neoplasm is benign or malignant. The latter diagnosis
is based on histologic findings of vascular invasion and
capsular invasion. If the fine-needle aspiration of a thy-
roid mass reveals clear fluid or slightly xanthochromic-
colored fluid, then the diagnosis is almost certainly a
parathyroid cyst (see section on fine-needle aspiration
in Chapter 18). An example of fine-needle aspiration is
the difficulty, if not impossibility, of differentiating a tumor would significantly change the operative approach
micro follicular pattern cytology, whether benign or malig-
nant. Under these circumstances most surgeons would
recommend lobectomy, isthmectomy, and frozen section.
Well-documented studies indicate the reliability of posi-
tive interpretations to be about 95%, whereas negative
interpretations are only 75 %. In the final analysis, needle
aspiration, if it is utilized, must not be the sole method-
ology in making the diagnosis but most be correlated
with the other clinical and laboratory findings as well
as the important facets of the history. It is, however, of
distinct value when enlarged cervical lymph nodes
accompany a thyroid mass. When aspiration of such
nodes reveals thyroid tissue, the diagnosis of metastatic
cancer of the thyroid is virtually certain, realizing the
extremely low incidence of normal thyroid tissue in cer-
vicallymph nodes. When aspiration of a lateral cervical
lymph node reveals pinkish, dark, or yellowish cystic
fluid, or even frank, slightly thickened blood (be sure not
in vessel), the surgeon must first think of metastatic
carcinoma of the thyroid even though no thyroid mass
is palpable. Black or murky aspirants are suggestive of
a branchial cleft cyst or metastatic thyroid carcinoma.
Murky aspirant with slightly blood-tinged material is
suggestive of a necrotized metastatic squamous cell
carcinoma.
Some surgeons question whether a fine-needle aspi-
ration of the thyroid is indicated when the clinical diag-
nosis is very suspicious of carcinoma. The patient will
likewise question the rationale of fine-needle aspiration
under the circumstances. Nevertheless, fine-needle
aspiration does serve several purposes, if it is positive
for carcinoma:
I. Ability to discuss the various aspects of the diagnosis
and management of thyroid cancer with the patient
and the family and make plans accordingly. On the
other hand, some surgeons will say that if the fine-
needle aspiration fails to reveal malignant cells, then
the patient might defer surgery. If this is so, this may
be a serious calamity when the clinical diagnosis
points to malignant neoplasm.
2. If fine-needle aspiration is positive for malignant cells,
then computed tomographic (CT) scanning and/or
magnetic resonance imaging (MRI) of the neck and
mediastinum is indicated to further evaluate the pres-
ence of cervical lymphadenopathy, which may not
be clinically palpable.
It also can aid in the differentiation of a solid from a
cystic lesion.
In lymphoma, needle aspiration usually cannot facili-
tate a definitive diagnosis (only a suggestion) and open
biopsy is necessary. In tumors of the salivary glands,
needle aspiration is used only in very selective situations,
particularly when a positive diagnosis of a malignant
or if the mass is suspected to be a lymph node. If there
is diffuse swelling of a major salivary gland, fine-needle
aspiration may yield some diagnostic information (e.g.,
lymphoepithelial disease [Godwin's disease)). If a
chemodectoma is suspected, fine-needle aspiration using
a 22- or 25-gauge needle can usually be performed with
minimal morbidity. Either frank blood may be obtained
or, in fact, a smear with an adequate number of cells will
facilitate the diagnosis. Obviously, a pulsatile mass-to
be distinguished from transmitted pulsations-should
not be aspirated. Apart from needle aspiration, CT with
enhancement, magnetic resonance angiography (MRA),

or MRI can lead the clinician to the definitive impres-
sion that a paraganglioma is present. These are nonin-
vasive studies and offer a distinct advantage over the
arteriogram. However, once CT, MRA, or MRI is positive,
a bilateral arteriogram is usually indicated to obtain
more detailed anatomy of the vessels. Paraganglioma
can be bilateral (see Chapter 22).
An acellular or "negative" needle aspiration should
not be interpreted as a definitive diagnosis of a nonma-
lignant lesion. The limitation of fine-needle aspiration
biopsy cannot be overemphasized under such circum-
stances. On the other hand, when it is certain that the
aspiration needle is in fact inserted into a mass, and
clear material is obtained (not cystic fluid), a lipoma is
to be suspected. The cytology report usually states that
the material is acellular. A report of an acellular aspirate
in a very hard mass may also indicate a neurofibroma
or traumatic neuroma (e.g., a small, sometimes tender,
movable mass in the region of a transected cervical sen-
sory nerve following a radical neck dissection). These
are not to be construed as certain diagnoses but simply
suspicious impressions.
A not uncommon problem is the palpation of a
lymph node overlying and suspected to be fixed to the
bifurcation of the carotid artery or the internal carotid
artery. If the estimated thickness of the node is close to
or over 1 em, then insertion of the fine needle in a hori-
zontal or oblique plane is done to avoid the underlying
FIGURE 3-1
BASIC CONSIDERATIONS
vessel. Otherwise the aspiration can be done under
sonography because the needle can be seen and thus
avoid the vessel. In addition, clearance between the
node and the vessel may be visualized with a sonogram.
Another application of fine-needle aspiration is aspira-
tion of the lung in conjunction with CT.
Large-Needle Aspiration Biopsy
(After Martin, 1934) (Fig. 3-1)
A With a local anesthetic injected into the overlying
skin and using a No. 11 blade, a small stab wound is
made in the skin directly over the mass. Only the skin
is entered, not the mass itself. The stab wound should
be placed so that it can easily be included in the
standard neck dissection incision if operation becomes
necessary.
B A large-bore needle (No. 17 is ideal) with stylet is
inserted through the stab wound into the mass, with
the index finger holding the stylet in place. The
purpose of the stab wound and stylet is to facilitate
ease of insertion and to avoid picking up cells from the
skin and other overlying tissue.
Continued
 BASIC CONSIDERATIONS

Large-Needle Aspiration Biopsy

(Continued) (After Martin, 1934)
(Fig. 3-1)
C With the stylet in place, the needle is moved back
and forth in the mass a few millimeters, first in the same
plane as the original insertion and then a few degrees to
either side. This step is repeated with the stylet removed.
D Negative pressure is then applied with a specially
designed locking syringe with a metal plunger similar
to those used in the old direct transfusion sets. This is
known as a Hayes-Martin needle aspiration syringe and
is manufactured with a special locking device to hold
the barrel in position to facilitate negative pressure.
If this type syringe is not available, an ordinary glass
30-mL syringe can be used. The needle with syringe
under negative pressure is again moved back and forth
a few times, and then the needle and syringe are briskly
removed together. With this technique, the material in
the needle is deposited on the end of the barrel of the
syringe.
E The aspirate on the barrel of the syringe is spread
on one or more slides as a thin film. Any material left
in the needle is sprayed out over another slide. The
material on the slides is spread thinly, using the same
technique as that used in a blood smear. The slides
may be either immediately fixed in alcohol and ether
or air dried, according to the wishes of the pathologist.
If any sizable particles are adherent to the inner wall
of the syringe, these are removed with a "rake" or swab,
placed on filter paper, and fixed in formalin for block
paraffin section. If the pathologic process is malignant,
the needle tract and site of puncture (which were
marked with India ink) are excised at the time of
definitive surgery. If there is any question regarding an
inflammatory process, some of the material is sent for
culture.

o E

FIGURE 3-1 Continued


Commonly Used Terminology for
Squamous Epithelium
Ashok Koul
Metaplasia: Transformation of fully differentiated cells
of one kind into differentiated cells of another kind
in response to abnormal stimuli (e.g., columnar epithe-
limn changing to squamous epithelium due to irrita-
tion such as smoking).
Leukoplakia: White patch. There is no specific histologic
connotation. Causes of leukoplakia in oral cavity are
Candida infection, lichen planus (unknown etiology),
irritation by dentures, and chewing tobacco or betel
nuts.
Keratosis: Thickening of squamous epithelium. Three
types of keratosis include parakeratosis-thickened
keratinized layer with presence of nuclei in the cells;
hyperkeratosis-thickened keratinized layer without
nuclei with prominent stratum granulosum under-
neath; and dyskeratosis-distinct alteration of the
epidermal cells. Benign dyskeratosis is caused by
viral changes from molluscum contagiosum, herpes
simplex, and Oarier's disease. Malignant dyskeratosis
appears as enlarged nuclei, hyperchromasia, loss of
polarity, increased mitosis, and prominent nucleoli.
Dysplasia: Change affecting the size, shape, and orien-
tation of epithelial cells caused by chronic irritation of
any type. Dysplasia can be mild, moderate, or severe.
Atypia or atypism: Abnormal nuclei. They can be seen
in inflammatory disease, can be reactive, for example,
after repair following trauma or surgery, or can be
associated with neoplasms.
Commonly Used Special Stains for
Head and Neck Lesions
1. Cytokeratin: Used to stain epithelial cells and to dif-
ferentiate between epithelial and nonepithelial cells.
Also used to detect individual or small groups of
metastatic cells in a lymph node that cannot be seen
in routine hematoxylin and eosin stain. Helpful in
sentinel node of breast.
2. Thyroglobulin: Stains thyroid follicular epithelial cells
and can be used to differentiate between metastatic
thyroid and nonthyroid carcinoma.
3. Calcitonin: Used to stain for medullary carcinoma.
4. Congo red: Used to stain amyloid in medullary
carcinoma.
5. $-100: Used to stain neurogenic lesions and melanomas.
6. HMB-45: Used to stain melanoma.
7. LCA: Used to stain lymphoid cells, thus differentiating
lymphoma from undifferentiated carcinoma.
8. Mucin: Used to look for mucin production by a tumor,
thus helping in the diagnosis of mucoepidermoid
carcinoma.
BASIC CONSIDERATIONS
9. TTF-I: Used to differentiate thyroid and lung tumor
from other tumors.
Mucosal Biopsy: Toluidine Blue
Staining Technique
Although not specific for invasive squamous cell carci-
noma, toluidine blue staining may give some indication
relative to the ideal site for biopsy of a clinically dys-
plastic lesion. False-positive results are common relative
to an ulcerative inflammatory lesion. Any ulcerative
lesion could stain positive regardless of the etiology.
This technique consists of gently cleansing the sus-
pected areas with I % to 2 % acetic acid, staining with
topical application of the dye, and then gently cleaning
with water and I % or 2 % acetic acid. The suspicious
areas, for example, in erythroplasia or dysplasia may
stain a very deep blue, indicating the ideal sites to
biopsy. If there is negative uptake or minimal staining,
the clinical diagnosis overrides the lack of a deep stain.
Repeat biopsy or better yet total removal of the suspi-
cious area is indicated.
Exfoliative Cytology Biopsy
Technique
For the suspicious ulceration in an area where it may
be difficult or hazardous to obtain a sufficient excised
specimen (e.g., tracheoesophageal ulcerations overlying
a pulsating vessel), a small piece of Gelfoam can be used.
The Gelfoam is broken, and the broken edge is smeared
over the suspicious area. Cytologic slides are made, and
the Gelfoam itself can be sent for "cell block." This tech-
nique is also used during bronchoscopy (see Fig. 4-3).
Z-Plasty (Fig. 3-2)
Definition
A Z-plasty is the transposition of two opposing trian-
gular skin flaps, thereby reversing the initial "Z" incision.
The central arm of the initial Z is thus rotated, and the
distance between points I and 2 is increased (AI and
01). The most useful angle formed by each lateral arm
to the central arm is 60 degrees. The central arm corre-
sponds to the scar contracture, which is to be changed
in direction, lengthened, and tension released. The length
of each lateral arm equals the length of the central arm.
Variations in the angle will vary the direction of the
resulting central arm and the length gained. An extended
description of the Z-plasty follows, because it has wide
application in reconstruction procedures in head and
neck surgery.
 BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2)
Technique of Basic Z-Plasty
Highpoints
1. Optimal flap angle is 60 degrees. This will rotate scar
or incision 90 degrees (A and Al).
2. Be sure resultant rotated scar is in or in line with the
natural skin crease. The base ends of the lateral
arms should be in the line of the natural crease (A
and Al).
3. Realize effect of changes of flap angle to gain in length
of scar line and the degree of rotation of scar line.
The smaller the angle, the less the gain in length and
the smaller the amount of rotation (H and I).
4. The smaller the flap angle, the greater the danger of
tip necrosis (points X and Y of A); the larger the flap
angle, the more tension on surrounding tissue.
5. Carefully place sutures to avoid strangulation of
blood vessels.
6. Each lateral arm should be the same length as the
central arm in the classic Z-plasty.
7. As a check for correct planning of the classic Z-
plasty with 60-degree flap angles, an imaginary line
(natural skin crease) connecting the base ends (points
XI and yl of Al) of both lateral arms should pass
through the midpoint of the central arm.
8. It may be advantageous to have a set of dividers and
protractor in the sterile field.
Limitations and Complications
1. Dog-ears are likely to form near the base of the trans-
posed flaps. If these require excision, they cannot be
excised toward the base but rather away from the
base (see Fig. 3-4A to C).
2. When an angle formed by a scar with a natural skin
crease is progressively less than 50 degrees, the
angle of the tip of the transposed flap of the Z-plasty
becomes less than 30 degrees and hence reduces
practicability of the Z-plasty.
3. A word of caution regarding the use of an extensive
Z-plasty in the primary closure of a wound for a malig-
nant lesion: Margins must be free of disease for fear
of implantation of tumor cells along the transposed
flaps.
4. Tip necrosis may occur. Wilkinson and Rybka (1971)
have shown experimentally that glue or tapes prevent
tip necrosis.
5. Too much lateral tension occurs with larger flaps in
tight surrounding tissue.
6. Strangulation of blood supply with suture may
occur.
A The scar, web, or linear contracture extends along
the line X-V (central arm). An incision or excision of a
small amount of skin is made along the line X-YoFrom
points X and Y two other incisions (lateral arms), each
of equal length to the line X-Yare made to Xl and V',
respectively, at a 60-degree angle (flap angle) (range is
30 to 90 degrees). Points Xl and Y' are along the
natural skin crease.
B The flaps formed by X and Yare widely under-
mined with extreme care to preserve both arteries and
veins. Small skin hooks or fine nylon sutures are used
to handle the flaps. Trauma must be minimal. The
transposition is begun by rotation of Y to Y'.
C X is rotated to X'. Sutures of 5-0 or 6-0 nylon are
usually used. These sutures are placed slightly obliquely
to relieve tension along central arm after closure.
D, D1 Rotation is completed. The scar line (central
arm) has been rotated 90 degrees, and the distance
between points 1 and 2 has been increased 75%. These
geometric figures refer to a flap angle of 60 degrees.
Continued
 BASIC CONSIDERATIONS

y'_.

BASE END OF LATERAL ARM

- LATERAL ARM
y' .1
, x·
",6(1' CENTRAL ARM (SCAR)
,
~SKIN CREASE
60' ", BASE END OF
A A1 2
Y • -X' LATERAL ARM
LATERAL ARM
x'

FIGURE 3-2
 BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2)
E TO G If a parallelogram is outlined around the
corners of the Z-plasty, some interesting theoretical
measurements are obtained:
The short diagonal of the parallelogram before the
Z-plasty (which is the length of the scar contracture)
between points 1 and 2 in E becomes the long diagonal
of the parallelogram after the Z-plasty (points 11 and
2' in F). These diagonals approximately maintain their
respective lengths when rotated; hence the distance
gained in any classic Z-plasty between points 1 and 2
corresponds to the long diagonal minus the short
diagonal (G). Expressed in another way, the total length
desired between points 1 and 2 after the Z-plasty can
be easily achieved by constructing a parallelogram
before the Z-plasty whose long diagonal is equal to
the final desired length and the direction of the final or
resultant central arm.
The shaded triangle in E corresponds to one rotated
flap of a Z-plasty, the base being the dotted line, which
is shown transposed in F. The nons haded triangle is
the corresponding flap in the Z-plasty, the dotted line
being the base. Points A and B refer to the tips of the
respective triangular flaps, which are transposed.
The flap angle can be varied from a range of 20 to
90 degrees, with the most variable range around 60
degrees. The smaller the flap angle, the less percentage
rate of increase in the length of the release (McGregor,
1962):
• 30-Degree angle yields 25% increase in length.
• 45-Degree angle yields 50% increase in length.
• 60-Degree angle yields 75% increase in length.
H, I The smaller the flap angle, the lower the
number of degrees the central arm or "scar" line is
rotated. This is important in planning the resultant
arm to lie in a natural skin crease (dotted line).
Variations of flap angle end in various positions of the
resultant central arm, which is the long diagonal of the
parallelogram. This demonstrates how a Z-plasty is
varied so that the resultant central arm can rest along
a natural skin crease. This is further shown in the
following steps.
Continued
 BASIC CONSIDERATIONS

60'
E ,<
B
SCAR 2 NATURAL
TO BE EXCISED SKIN CREASE
LENGTH
TO BE INCREASED

SHORT DIAGONAL
(CENTRAL ~RM)
I LONG DIAGONALI
I
NATURAL INCREASED
SKIN CREASE l' LENGTH l'
\ I
I
\ I
I
I
GAIN I
I
I
I
I
I
LONG DIAGONAL

SHORT DIAGONAL

F
2' 2 2'

SCAR
LINE

I ...
FIGURE 3-2 Continued
 BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2)
J TO L First select the length of the central arm that
may equal the entire length of the scar or a part thereof.
If the scar is long, multiple Z-plasties are necessary (see
5 and T). The midpoint of the central arm should lie on
the natural skin crease (J), and the base end of each
lateral arm must be located on the natural skin crease
(K). Each lateral arm is equal in length to the central
arm. A protractor can be of aid in the determination of
these measurements. L demonstrates the final result.
(To achieve a more pleasing result, the lateral arms can
be slightly curved.)
FIGURE 3-2 Continued
The smaller the flap angle, especially less than 30
degrees, the greater the danger of tip necrosis. The larger
the flap angle (especially over 90 degrees), the greater
the tension on the surrounding tissue, with too much
borrowing from each side. These larger angles tend to
result in larger dog-ears at the base of the triangle.
Clinically, a GO-degree flap angle has been shown to
be the largest angle that will allow transposition of
triangular flaps while achieving the greatest increase of
length along the central arm or line of contracture. With
this angle the central arm is rotated 90 degrees. As the
central arm length is increased, the greater is the per-
centage increase in length. Depending on the relative
position of scar to natural skin crease, the two flap
angles may be of unequal size (Ql. This is also referred
to as half Z when one of the angles is 90 degrees.
 BASIC CONSIDERATIONS

FIGURE 3-2 Continued

M, N The direction of linear scars or webs or linear 0, P Scar across nasolabial fold is converted
contractu res is changed from vertical to horizontal in to lie in and along the natural skin crease of the
scars of the neck. The size of the Z-plasty is large for nasolabial fold.
clarity's sake. In actual practice multiple Z-plasties with Continued
a long scar are preferred (see Sand T) or a slight
curvature of the lateral arms.
 BASIC CONSIDERATIONS

Z-Plasty (Continued) (Fig. 3-2)
Q I ncrease the length between the ends of the
original scar contracture, for example, lengthening of
the contracted tissue causing upward distortion of the
upper lip.
R Release and redistribution of tension along linear
contracture breaks up unsightly scars of cheek and
thus returns some elasticity, aiding in normal facial
expression. This is accomplished either by multiple Z-
plasties (see Sand T), by opposing Z-plasties (see U
and V), or by W-plasty (see X and V).
Types and Modifications of
Z-Plasty
1. Single Z-plasty (M and N). The single or basic Z-
plasty has multiple applications as previously
described. By and large, however, it is limited to
relatively short scars. It can be useful in longer scars
only when the surrounding tissue is very loose, as,
for example, in the neck.
2. Half Z-plasty (Q and R). This is actually a variant of
the angles of a basic Z-plasty. It simply means that
an increase is made at right angles to a wound into
which is transposed one triangular flap (Q). This is
useful in the elongation of a wound, especially the
short side of a curved defect (R).
3. Multiple Z-plasties (5 and T, 51 and Tl) (Davis and
Kitlowski, 1939; Limberg, 1963; Morestin, 1914).
Multiple Z-plasties are two or more Z-plasties in
either a continuous series or interrupted series, with
a number of other modifications. Of necessity the
arms are usually short, as used in the face or neck.
This technique is useful for large scars of the cheek,
where, as in the latter case, the surrounding tissue is
tight or has lost its elasticity. A single Z-plasty in a long
scar would be impractical and almost devastating on
the cheek.
4. S-plasty (see W)
5. W-plasty (Borges, 1959) (see X and Y)
Continuous Types (Entire Scar Excised)
5 Depicted is a series of continuous Z-plasties in which
all the arms are equal, all the angles are 60 degrees,
and all the lateral arms are parallel. The entire scar con-
tracture is excised in a continuous line. The lengthening
of the scar contracture is obvious.
51 Depicted is a similar type of continuous Z-plasties,
except that the lateral arms are independent with a
space between each Z. '
Interrupted Types (Portions of Scar
Excised)
T Depicted is a series of multiple Z-plasties of equal
size similar to those in Sl except that intervening por-
tions of the linear scar between each Z are not excised.
The length of the remaining portion of the scar varies
according to the desired result.
T1 This series of interrupted multiple Z-plasties differs
from those in T in that two are opposite. These are the
so-called opposing Z-plasties.
Continued
 BASIC CONSIDERATIONS

T TI
FIGURE 3-2 Continued
 BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2)
U, V Depicted in steps U and V is an example of the
excision and reconstruction of a scar on the side of the
cheek. This technique is very useful in upsetting the
tension of contractu res, especially on the cheek (after
Converse, 1964).
W S-Plasty. The lateral arm of a basic Z-plasty may
curve in a convex arc. This aids in preserving the blood
supply, especially in burn scars in which the blood
supply is compromised. The full application of this
modification is in the neck, where a large S-plasty is
performed. This is possible because of the laxity of the
surrounding tissue.
Tissue Expansion (See Fig. 3-2Wl)
Versaci and Balkovich (1984) reviewed the history of
tissue expansion dating back to 1905. The technique
was revived by Neumann (1957), and important recent
contributions have been made by Radovan (1982,
1984), Austad and associates, (1982), Sasaki and Pans
(1984), Argenta and associates (1984), and Kabaker
and colleagues (1986).
Anatomic Physiology
The epidermis undergoes no significant decrease in
thickness during tissue expansion. There is usually a
U
FIGURE3-2 Continued
good match of color, texture, sensation, hair, and sweat
and sebaceous glands. The dermis becomes thinner but
may revert to normal after the prosthetic balloon is
removed. Collagen synthesis is increased in the papillary
dermis secondary to fibroblast formation. Myofibroblasts
develop. Hair follicles remain the same in structure and
number and become separated. Adipose tissue is decreased
in thickness, probably permanently. Muscle becomes
thinner, but there is no loss of function. Blood vessels
proliferate; increased vascularization of the skin with
distention of capillaries and an increase in the number
of arterioles becomes evident within several days. Because
of the dense vascular pattern, viability and survival of
expanded tissue is similar to that of delayed flaps.
Effects of Tissue Expansion (Cherry et aI.,
1983)
Tissue expansion permits an increase in the length of a
flap as compared with nondelayed random flaps (dermal
and subdermal plexus) and improves random flap
survival by increasing vascularity. Skin is not simply an
elastic membrane but has dynamic properties responding
to the tissue expander. This response allows many
applications in terms of modifications in flap design,
length, and overall size (Sasaki and Pans, 1984). After
implantation a dense fibrous capsule develops on the
implant due to elongated fibroblasts. This capsule
becomes thinner when the implant is removed.
 BASIC CONSIDERATIONS

FIGURE 3-2 Continued

 BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2)
Device (After Radovan)
A silicon balloon is inserted via a silicon tube to which
is attached an injection port. As shown in the photo-
graph (Wl), various sizes and shapes of balloons are
available.
Technique
Anesthesia is usually local plus basal. The incision is
made as small as possible, just large enough to insert
the empty balloon, alongside or near the tissue to be
expanded. Injection ports are kept away from the tissue
to be expanded and are buried under the skin by blunt
dissection so that they are easily accessible for injec-
tion of saline solution. For scalp expansion a 250-mL
balloon is inserted in the subgaleal plane.
The balloon is expanded using sterile saline with
gentamicin. The balloon is partially filled immediately
after the initial incision, and systemic antibiotics are given
for 5 to 7 days. After 10 to 14 days additional injections
of 10 to 30 mL, depending on the size of the balloon,
are given at 3- to 5-day intervals (some surgeons inject
every 7 to 10 days) usually over a period of 6 to 8 weeks.
If pain does not subside within 5 to 10 minutes, the
saline solution is withdrawn.
Another technique is rapid injection over a period of
24 to 48 hours to blanching of the skin and then with-
drawal of some of the sterile saline solution.
Careful monitoring for pain and skin necrosis is most
important. Avoid any dead space, and thus avoid the
use of drains. However, suction drains may be necessary
if dead space or significant dog-ears appear.
Occasionally two or three balloons can be used
simultaneously in two areas. If there is insufficient
expansion of the skin when the balloon is removed, the
process can be repeated.
The diseased area is resected when the balloon is
removed, and the defect is closed by advancement or
rotation flaps of the expanded skin. If the lesion is
malignant, the delay necessitated by the usual technique
of tissue expansion is obviously not possible. TWooptions
are available: (1) temporarily cover the defect with a
split-thickness skin graft and then use tissue expansion
at a second stage or (2) utilize short-term expansion
(Sasaki) intraoperatively by expanding tissue for
reconstruction for a period of 15 to 30 minutes. This
technique can facilitate closure of defects of up to 3 or
4 cm without long delay and can minimize the possible
complications of infection and prolonged deformity at
the donor site. Avoid resection of surplus skin over
dead space; these areas usually contract eventually.
Applications in Head and Neck Surgery
Tissue expansion can be used for defects secondary to
trauma, congenital lesions, and resection for carcinoma.
Sites include the scalp, forehead, and face. Tissue
expansion can be used before random flaps and free
flaps and in excision of cicatricial deformities with
closure by advancement or transposition flaps. Other
potential applications have been suggested by Argenta
and associates (1984).
Complications and Potential Problems
• Infection, avoided by strict sterile technique
• Skin necrosis
• Patient reluctance due to swelling of the expander.
Explain that this technique will usually result in a
smaller number of surgical procedures for large
defects that ordinarily would require several staged
operations.
W-Plasty (See Fig. 3-2X and Y)
x, Y The W-plasty is a method of excising a scar to
break up a straight line by removing small
interdigitating triangles on either side of the scar line.
It is useful in depressed linear scars of the cheek when
no lengthening of the line of contracture is necessary.
The W-plasty, unlike the Z-plasty, does not gain length.
A metal template or bent flap metal strip modeled to
correspond to small equal triangles is useful to mark
the area for the line of excision (X). McGregor (1962)
has demonstrated modification of the W-plasty for the
closure of an oval wound (Y).
 BASIC CONSIDERATIONS

~2

FIGURE 3-2 Continued

 BASIC CONSIDERATIONS
Rhombic Flap (After Limberg, 1963;
Modified After Gunter, 1983; Bray,
1983) (Fig. 3-3)
The rhombic flap is based on the mathematic shape of
a rhombus, which is an equilateral parallelogram in
which all sides are equal in length and the opposite sides
are parallel. There are two equal obtuse angles opposite
one another and two equal acute angles opposite one
another. The basic Limberg rhombus has two 120-degree
obtuse angles and two 60-degree acute angles. It is
important to understand this basic mathematic calcu-
lation to utilize this flap as well as minor modifications
of it. A rhomboid, on the other hand, is a parallelogram
in which the pairs of opposite sides are either longer or
shorter in length than the pairs of the other side.
Highpoints
Basic geometry of the perfect or ideal rhombic flap:
1. All sides are equal.
2. Opposing angles are equal.
3. The ideal acute angle is 60 degrees; the ideal obtuse
angle is 120 degrees.
4. The flap is exactly the same geometric size, shape,
and angles as the defect, including the length of the
short diagonal and the long diagonal of the
parallelogram.
5. The long diagonal (B, line A-El) of the flap forms a
60-degree angle with the long diagonal (B, line A-C)
of the defect in any of the four possible (A and B)
donor sites of the flap. Both long diagonals are the
same length and are represented as the line with
dashes in A.
6. The short diagonal (B, line D1.F) of the flap equals
the short diagonal (B to D) of the defect, and the two
are represented by the dotted lines.
7. The pivot point, the point on which the flap turns,
is A, whereas Dl, El, and F are the mobile or rotated
points (el.
Planning the Flap
1. The flap is outlined on the side of the defect that has
the most relaxed and available skin.
2. The flap site must avoid areas that, if mobilized, would
create additional defects; that is, avoid a donor site
that might distort the ala nasi or the lower eyelid.
3. The short diagonal of the flap should parallel as closely
as possible the lines of maximum extensibility (LME).
These lines are at right angles (perpendicular) to the
natural skin folds referred to by Borges (1959) as the
relaxed skin tension lines (RSTL). This principle is
demonstrated in Figure 6-21H and I, where the short
diagonal of the flap is at right angles to the naso-
labial fold.
4. Although the flap closes the defect, the donor site is
closed by undermining and mobilizing the skin that
forms the outer margin of the donor site, line E-F in
C. Hence, the flap must be planned so that transpo-
sition of line E-F will not cause distortion. Other-
wise, the vector of tension (VaT) (D) will be changed,
and distortion of other structures will occur. At times,
compromises may be necessary. This should all be
calculated before the flap is actually incised.
5. Exact geometry is not always necessary if there is
sufficient mobility of surrounding skin.
6. Modifications will be necessary if frozen sections
indicate inadequate margins in the resection of a
malignant lesion.
A The shaded area is the ideal defect, planned
primarily to resect all disease with adequate margins
and four possible juxtaposed donor sites. The choice of
the donor site should be such that the donor site short
diagonal is parallel to the LME.The long diagonal of
the defect equals the length of the long diagonal of
the donor site, both represented by the dashed lines;
the short diagonals are likewise equal, both repre-
sented by the dotted lines. Point A is the pivot point
with a 60-degree angle formed by both long diagonals.
The base of the flap is the line represented by dashes
and dots and obviously left intact. This is the space
between points A and F in Band C.
B The donor site has been chosen, again empha-
sizing that both defect and donor site are geomet-
rically identical. The short diagonal line B-D of the
defect equals the length of the short diagonal of the
donor flap as well as the side line Dl-E' of the flap. 0'-
E' is a straight line continuation of the short diagonal
line B-D.
 BASIC CONSIDERATIONS

B E

A F A

B C o
FIGURE 3-3

C Mobilization of the flap. Ideally, this is accom-
plished by rotating the flap on the fixed point A, with
point F mobilized and being moved to point D, which
is relatively fixed. This results in a vector of tension
(VaT), as depicted in D. If, on the other hand, point D
must be moved toward point F to effect closure of the
donor site, then the vaT changes toward point B. This
in turn lengthens the width of the defect B-D. This
then requires widening the flap along the line Dl_F,
which can be accomplished if the skin of the donor site
has sufficient elasticity, a factor that should be
evaluated before the choice of the donor site.
D The ideal closure demonstrates the ideal vaT.
Examples of this type of flap with modifications are
depicted in Figure 6-21 E to I.
 BASIC CONSIDERATIONS

Excision of Dog-Ears (Fig. 3-4)

Most dog-ears can be handled initially by flattening
and lengthening the ellipse of skin to be excised. If this
is impractical or dog-ears are present, one of the
following techniques can be used.
B A dog-ear is excised by resection of a longer and
flatter ellipse of skin.
C A dog-ear is excised using the V (step 1) to Y (step
2) principle (see Fig. 9-7J and K).

A The dog-ear has resulted from unequal lengths of Dog-ears can also be prevented by a modified W-
each side of the repair. plasty, as depicted on 3-2X and y.

1. The dotted line is the back cut.

2. A back cut has been performed and the excess
skin along the longer skin edge is excised on the
dotted line.
3. Completed closure.

A 3 c 2
FIGURE 3--4

Bone, Cartilage, and Nerve Grafts
(See Figs. 3-5 to 3-8)
Basic Principles Relative to Bone and
Cartilage Grafts and Implants
(After Schuller, 1980)
See also the discussion of osseous microvascular free
grafts in Chapter 24.
Bone Grafts
TYpesof bone grafts include autologous bone and homolo-
gous preserved bone (implant). Bone is a specialized
type of connective tissue covered by periosteum, which
in turn is a specialized form of connective tissue. The
bone is made up of (I) cortical bone, an outside firm
compact layer that provides rigidity, and (2) cancellous
bone, an inside layer coupled with marrow and a spongy
component that has the greatest osteogenic potential
for growth and thus prevents reabsorption of the bone
graft. Bone grafts in turn require two important items
for success: (I) a good blood supply in the recipient bed
and (2) mechanical stress (e.g., muscular contraction).
Hence, the ideal bone graft should, if feasible, include
both cortical and cancellous bone regardless of where'
and how the graft is utilized.
Donor Sites
The choice of the donor site depends on the type of
reconstruction intended and includes the following:
• Rib
• Iliac crest
• Septum-vomer and perpendicular plate of the
ethmoid
• Anterior wall of the maxilla
Cartilage Grafts
TYpes of cartilage grafts include autologous cartilage
and homologous preserved cartilage (implant).
Donor Sites
• Costochondral
• Nasal septum
• Auricular concha (see Fig. 6-26A to L)
The problem with cartilage grafts is that they tend to
curl with the concavity toward the perichondrium, if it
is preserved. Despite this problem the author prefers to
BASIC CONSIDERATIONS
preserve perichondrium when possible and when curling
is not a detriment.
In an animal experiment preserving the perichondrium
in free cartilage grafts Duncan and co-workers (1984)
concluded: "The results obtained strongly suggest that
perichondrium responds briskly to repair injury and
that the breaking load is greater in the presence of
perichondrium and increases with time. It is suggested
that perichondrium be included with free cartilage grafts
for optimal survival and intercartilaginous healing."
The question has been raised whether the experiments
should be repeated using costochondral cartilage, as this
experiment was done with ear cartilage. Tardy (1985),
however, does not believe that the perichondrium is
necessary for cartilage graft survival.
Gibson, in 1957, introduced the principle of "balanced
cross sections of cartilage." This concept stems from
the fact that the cartilage has a subperichondrial layer
of flattened chondrocytes that maintains the inner zone
of the cartilage taut. Interruption of the balance of
these peripheral cells on one side will make the carti-
lage warp toward the opposite side. Strict adherence to
the principles of balanced cartilage carving as stated by
Gibson will result in implanted cartilage grafts that will
not warp (e.g., Gibson selects cartilage and shapes the
cartilage graft by trimming equal portions on each
side). This, of course, means that the perichondrium will
be sacrificed. When utilizing thin strips of peripheral
cartilage, gentle morsulization or cross hatching of the
subperichondrium will break the spring effect and
prevent warping.
Implants
1. Alloplastic materials
a. Problem of rejection
b. Migration
c. Infection
2. Homologous bone and cartilage grafts
a. Problem of rejection
b. Questionable vascularization
c. Infection
Rib, Iliac, and Costochondral Grafts
(Fig. 3-5)
Highpoints
1. Preserve periosteum with cortical bone graft or peri-
chondrium on at least one surface. There is some
difference of opinion regarding this suggestion, with
more unanimity regarding the periosteum and the
perichondrium in children.
 BASIC CONSIDERATIONS
Bone, Cartilage, and Nerve Grafts
(see Figs. 3-5 to 3-8)
2. Excise a larger section of graft than is necessary.
This will allow sufficient latitude for choice of best
configuration of graft. The use of a template or model
made from plastic or stiff paper is a great aid in
shaping the graft.
3. Grafts must be firmly fixed and usually immobilized.
4. Recipient site should be free of contamination.
Infection must be avoided.
A Location of incisions for rib (1), iliac crest (2), and
costochondral cartilage (3) grafts.
Rib Graft
An inframammary incision (A [I)) is made extending
toward the posterior axillary line. The greater the curve
desired for the graft, the more posterior the incision.
The pectoralis major and minor muscles are transected.
Depending on the extent posteriorly, the latissimus dorsi
muscle may be sectioned. The attachments of the ser-
ratus anterior muscle are separated from the selected
rib, usually the sixth or seventh. The presenting perios-
teum is preserved intact. This graft is not used for
mandibular construction except possibly when combined
with other mandibular support.
B With the periosteum of the rib exposed, an inci-
sion is made through the periosteum along the supe-
rior margin and another incision along the inferior
margin of the rib. The periosteum is sectioned at
either end.
C Cross section of rib graft with intact periosteum on
anterior surface is shown.
D With the use of an Alexander rib periosteal ele-
vator, the periosteum along the superior and inferior
surfaces of the rib is separated. The neurovascular
bundle is included in the inferior periosteal flap and
preserved at the donor site.
E A Doyen elevator completes the periosteal sepa-
ration posteriorly. If this is carefully performed, the
pleural cavity is not entered. When the pleural cavity is
inadvertently opened, it is necessary to use underwater
drainage (see Fig. 2-5A to C) or to close the chest with
the lung fully expanded.
F With rib rongeurs, the rib is sectioned at either
end. The periosteum on the anterior surface of the rib
has been preserved intact with the rib graft. The
wound is closed in layers approximating the sectioned
muscles over the bed of the removed rib.
Iliac Graft
See Figure 3-6 for additional technique.
An incision (A [2)) is made inferior and posterior to
the iliac crest. The anterior attachments of the external
and internal oblique abdominal muscles are sectioned
close to the bone. A portion of the tensor fasciae latae
may also require transection. The periosteum is left
intact with the graft if the cortex is used.
G Depending on the length and width of the defect
to be grafted, a somewhat larger section of iliac crest
is removed with a Stryker saw. Suction type drainage
is used if indicated. Bone hemostasis is achieved with
electrocautery or bone wax. (A variation of this har-
vesting technique is depicted in Figure 3-6.) Refer to the
microvascular section in Chapter 24 for a discussion of
vascularized bone graft.
Costochondral Graft
An oblique incision (A [3)) is made over the broadest
expanse of the seventh, eighth, and ninth costochondral
cartilages. The anterior rectus sheath and the rectus
abdominis muscle are transected and separated,
exposing the underlying perichondrium, which is left
intact. The purpose of the retained perichondrium is to
facilitate an adequate "take." This, however, is contro-
versial. In addition, the perichondrium can cause
curvature of the cartilage graft. To avoid this, a central
core of cartilage is obtained.
H An area is outlined representing a much larger
graft than is required. This is cut to the desired depth,
avoiding a through-and-through incision of the
cartilage.
I A rectangular block is then excised with the aid of
a right-angle knife (Beaver Blade No. 64).
J The excised block of cartilage with anterior layer of
perichondrium intact is shown. The wound is closed in
layers.
 BASIC CONSIDERATIONS

Neurovascular
hundle
rletal pleura

FIGURE 3-5
 BASIC CONSIDERATIONS
Bone, Cartilage, and Nerve Grafts
(Continued)
Not depicted is the technique for obtaining cancel-
lous bone. This is procured from the iliac bone through
either bur holes or plugs or sections of cortical bone
first removed. The cancellous bone can then be obtained
either with a curet or in strips or blocks, depending on
its use. The use of curetted cancellous bone is shown
in the reconstruction of the mandible, using a metal
trough to hold the bone in place (see Fig. 14-lOH).
Iliac Bone Graft-"Trap Door Type"
(After Laurie et aI., 1984) (Fig. 3-6)
Highpoints
1. Avoid injury to the lateral femoral cutaneous nerve.
Hence, the incision is made lateral and oblique to
the iliac crest.
2. If the edge of the crest is not necessary for the
reconstruction, utilize a segment beneath the crest,
the so-called trap door technique.
3. Use a medial bone approach if possible.
4. Replace the crest.
Complications
• "Gluteal gate"
• Pain at donor site
A The skin incision is made lateral and oblique to the
iliac crest. The lateral femoral cutaneous nerve passes
deep to the lateral portion of the inguinal ligament
and should, if possible, not be transected. Likewise,
avoid trauma to the nerve by "over" retraction. If the
rim of the crest is not required, it is preserved, as
depicted, on a hinge of periosteum if possible.
B The hinged edge of the iliac crest is returned to its
original position and wired in place. The knots on the
wire suture are buried.
Auricular Cartilage Graft (Fig. 3-7)
The cavum-between the anthelix and the crus helicis
(see Fig. 12-2A)-is an ideal source of autogenous
cartilage for graft purposes. This cartilage graft, with
one side or both sides of perichondrium, can be used
to augment the dorsum and lateral portions of the
external nasal framework as well as to provide for
support in blowout fractures of the orbit (see p. 436,
Plastic Reconstructive Surgery, June 1982).
A Depicted is the incision for harvesting the auricular
cartilage. The incision is made along the inner edge of
the anthelix (see Fig. 6-26), maintaining a broad base
for the skin flap. The perichondrium is included (one
or both sides) in adults, but at least one layer of
perichondrium is left at the donor site in children. The
skin flap is returned and approximated with 6-0 nylon
sutures using cotton impregnated with antibiotics, or
povidone-iodine (Betadine) as a gentle compression
dressing over the donor site.
B The removed auricular cartilage demonstrates the
concave and convex contour of the cartilage. For nasal
reconstruction, it is best not to attempt to reshape the
configuration of the cartilage but rather to choose that
portion with its natural shape that best meets the
required shape and size. For orbital floor support, the
cartilage can be cross hatched and shaped and thinned
to 1 to 2 mm in thickness as required to close the
defect. The scar at the donor site is barely visible,
without any significant deformity.
 BASIC CONSIDERATIONS

FIGURE 3-6

B
FIGURE 3-7
 BASIC CONSIDERATIONS
Sural Nerve Grafts (Fig. 3-8)
The sural nerve, which is on the posterolateral aspect
of the lower extremity, accompanies the lesser saphe-
nous vein. It is formed by a junction of the medial
cutaneous sural nerve and the anastomotic ramus of
the common peroneal nerve. This is a sensory nerve
that supplies the skin of the posterior surface of the
lower leg and the region of the lateral malleolus.
Figure 3-8 depicts the anatomy of the sural nerve and
its formation from the two nerves, as just mentioned.
This nerve branches and may be used as a nerve graft
either in its branched form or in its single trunk form.
Its terminal portion, the lateral dorsal cutaneous
branches, is preferred for facial nerve reconstruction.
This nerve is distributed over the lateral portion of the
foot. It can be obtained by two or more short hori-
zontal incisions and can be carefully removed from its
bed alongside the lesser saphenous vein.
Skin Incision
All skin incisions in the neck, with few exceptions,
should follow the natural skin creases. This is important
from a functional as well as a cosmetic point of view.
Adequate exposure is accomplished by the development
of upper or lower skin flaps, which include the platysma
muscle. The superior-based cervical flap in neck dissec-
tion has the best blood supply, and the posterior flap
has the poorest. After adequate skin flaps are elevated,
the deeper fascial incision may be changed as the
exposure dictates.
Skin incisions for operations in the superior cervical
regions should be 3 to 5 cm below the horizontal ramus
of the mandible to avoid injury to the mandibular
branch of the facial nerve. For operations in the inferior
cervical region, the skin incision usually should be at
least 2 to 3 cm above the clavicle, because incisions
placed lower will tend to drop over the clavicle in time
and become unsightly. An exception is the upper inci-
sion for a deltopectoral flap, which lies close to the
level of the clavicle.
If a single horizontal incision following a natural skin
crease does not give adequate exposure as, for example,
in a thyroglossal cyst that lies at the level of the thyroid
gland or in a branchial fistula, multiple horizontal inci-
sions in stepladder fashion solve the problem admirably.
A skin incision made along the anterior border of the
sternocleidomastoid muscle is entirely unnecessary
except in an extreme emergency. Even in an emergency
tracheostomy, the horizontal incision is preferred.
There are exceptions to any rule of thumb. The expo-
sure for a radical neck dissection is the main exception.
Although multiple horizontal incisions (MacFee) can be
used in this operation, the exposure and time consumed
raise some questions (see Fig. 16-6A to F).
Another exception may be a total laryngectomy for
malignant disease in an individual with a long, thin
neck, in whom two horizontal incisions may extend too
far laterally and thus enter an area of later metastatic
spread. This exemplifies a basic principle in operations
for malignant disease: avoid skin incisions for cosmetic
purposes and the use of skin flaps for reconstructive
purposes in and from regions to which metastatic
disease may later spread. This dictum eliminates the
use of the so-called sternocleidomastoid muscle flap in
reconstructive procedures associated with neoplastic
disease except in the rarest circumstances. Scars in
such areas will delay an early detection of metastases
and often make later radical surgery difficult.
Nonabsorbable Sutures for
Mucosal Repair
Although nylon and Prolene suture materials have been
shown to result in minimal tissue reaction and are uti-
lized in repairs of mucous membranes of the oral cavity,
their use involving the mucosa in oropharyngeal, laryn-
geal, and hypo pharyngeal surgery has been found to be
not as satisfactory. The problem is that loose loops, ends,
and knots are sites for the collection of debris, mucus, and
food and are very difficult if not impossible to remove.
If the sutures are totally buried, nonabsorbable suture
materials (nylon, prolene, or silk) are ideal; otherwise an
absorbable material is recommended. Chromic gut is
preferable, rather than Vicryl; the Vicryl appears to have
a longer than necessary absorption rate on mucosal repair.
 BASIC CONSIDERATIONS

PERONEAL
ANASTOMOTIC N.

LESSER
SAPHENOUS V.

EDIAL SURAL CUTANEOUS N.

FIGURE 3-8
 BASIC CONSIDERATIONS
Preoperative and Postoperative
Care (See Figs. 3-9 to 3-12)
William R. Nelson and R. Lee Jennings
In this brief treatise, specific problems are mentioned
and procedures are described that are somewhat different
from those encountered and used in routine general
surgical and ear, nose, and throat patient management.
Adequate preoperative evaluation and preparation are of
the utmost importance in these patients, who are often
afflicted with disabling medical disease. After surgery,
these individuals need unusual care. Wound healing
may well depend on the surgeon's detailed knowledge
of the complications that might arise and of specific
peculiarities of tissues in the head and neck region.
Preoperative Care
1. The sine qua non of preoperative preparation is
proper evaluation of the disease for which surgery
is planned. For a patient with a tumor, radiographic
and pathologic studies and a positive biopsy after
radiographic studies are mandatory. In the event
that an unusual neoplasm has been diagnosed
(e.g., a soft-part sarcoma, lymphoma, or uncommon
variety of salivary tumor), it is often wise to ask
the attending pathologist to seek consultation on
the tissue slides. Pathology consultation is certainly
needed when the original tissue diagnosis was made
in a hospital unfamiliar to the surgeon. A second
opinion from an experienced tumor pathologist may
alter the surgical approach. Chest radiographs are
essential in the search for metastatic disease or
concomitant bronchogenic carcinoma, the latter
being a frequent second neoplasm in any patient
with head and neck mucosal cancer. CT or MRI
aids in the evaluation of the extent of the primary
tumor and nodal status in conjunction with phys-
ical examination. Imaging at times may be mislead-
ing, especially of the oropharynx. Angiography is
essential in blood vessel problems and can be help-
ful in neoplasms such as carotid body tumors, juve-
nile nasopharyngeal angiofibromas, and, possibly,
secondary operations on parathyroid adenomas.
On occasion, false-positive findings will be reported
when there is marked edema and/or fibrosis around
the tumor margins. Treatment planning can proceed
when this staging process is completed.
2. The usual supportive and diagnostic measures must
be instituted preoperatively in patients with surgical
diseases of the head and neck. Careful medical
evaluation and therapy are important because car-
diovascular, pulmonary, or hepatic dysfunction
commonly accompanies the surgical problem, par-
ticularly in the case of mucosal cancer. It is the
responsibility of the surgeon to identify medical
problems and obtain medical consultation to reduce
perioperative complications.
3. Cultures of infected lesions should be made well in
advance of surgery, because these problems may
require both local and systemic control measures.
The irrigation or power spraying of the oral cavity
(with half hydrogen peroxide and half saline solu-
tion) will often clear up necrotic tissues and exudate
on the surface of a tumor. In patients with known
preoperative infections, specific antibiotic coverage
would be indicated before, during, and after the
operation. Obviously, presurgical infection control
is vital in these instances.
4. Stop cigarette smoking well ahead of scheduled
procedures. Often, dramatic clearing of excessive
secretions will occur and postoperative tracheo-
bronchial difficulties will be less severe. Positive-
pressure breathing (with or without added medica-
tions for bronchodilatation and mucous liquefac-
tion) and postural drainage may be a great aid to
those individuals with pulmonary and tracheo-
bronchial disease. Oral or transdermal nicotine
products are helpful during withdrawal. Continued
tobacco use is detrimental to flap success when
flap or microvascular free-flap repair is planned.
5. The alcoholic patient should abstain from alcohol
for at least a week before surgery because post-
operative delirium tremens yields a high mortality.
Most alcoholics will be evasive about their liquor
consumption. The families of suspected alcoholics
should be questioned before the final scheduling of
surgery so that plans for adequate preoperative
hospitalization can be made. High caloric feedings,
vitamin therapy, and tranquilization will be of help
during this "drying out" phase. Alcohol rehabili-
tation clinics are helpful and in some cases provide
the only method to ensure preoperative abstinence.
6. It is vitally important for the surgeon to discuss
frankly and honestly with patients the possibilities
of loss of any function during an operative proce-
dure. With total laryngectomy or extensive oropha-
ryngeal procedures, the patient should be enlight-
ened about the physiologic and anatomic changes
to be incurred and must be encouraged about speech
and swallowing therapy possibilities. In situations
where there is some doubt as to the extent of
surgery, the possibilities of postoperative functional
loss must be outlined. It is always best to give each
patient some hope that such losses will not be
incurred. Any person awaiting surgery should be
given a lucid description of planned tracheostomy,
feeding tube, and drainage tube utilization. Simple
explanations of planned procedures are helpful, but
too detailed a discussion of the surgical technique
 BASIC CONSIDERATIONS

may frighten an already apprehensive patient. 7. All apparently malnourished patients require
Preoperative visits by previously operated patients nutritional evaluation pretreatment by the hospital
mayor may not be wise, depending on the disfigure- nutrition team. Nasopharyngeal or nasogastric tube
ment or dysfunction present and the patient's own feedings may be advisable preoperatively in patients
personality and state of anxiety. After surgery plagued with severe nutritional deficiencies and
when the individual is recuperating, a visit by one swallowing problems; however, this method has
of these veteran patients may be extremely helpful. been replaced in many centers by percutaneous
The local chapter of the Lost Chord Club or the endoscopic gastrostomy (PEG) tube placement
International Association of Laryngectomees should (Fig. 3-9) (see also Chapter 21). This method is
be contacted about each new laryngectomy case so better tolerated, may be continued postoperatively
that a visit by one of these laryngectomees can be for as long as needed, and avoids having a tube
scheduled. Speech therapy must be arranged through across suture lines. Complication rates may be less
this organization or through a professional speech and survival rates improved when the nutritional
therapist. For those patients who are candidates for status is more nearly normal. Nutritional support is
a Blom-Singer procedure, such surgery can be provided to patients undergoing preoperative
planned when indicated. chemotherapy or radiation therapy.

Gastrostomy
tube

B
A

Moss type gastrostomy

tube with jejunal
extension for feeding
c placed at laparotomy

FIGURE 3-9 A, B, and D show the PEG tube; C is the Moss type placed at laparoscopy.
 BASIC CONSIDERATIONS
Total parenteral nutrition (TPN) is extremely help-
ful perioperatively in those few patients in whom
tube feedings are not possible. Open gastrostomy
or jejunostomy feedings are rarely necessary but
are indicated when nasogastric and TPN approaches
are impossible or when skull base procedures require
harvesting gastric or jejunal flaps to separate the
pharynx from central nervous system. Then place-
ment of a gastrostomy tube for suction with jejunal
extension for feeding is helpful.
8. Red cell transfusions may be required preoperatively,
and generous amounts of blood should be held in
readiness for any radical surgical procedure, even
though blood administration is less often utilized
today in the average major head and neck proce-
dure. In selected cases, the patient can donate their
own blood for autotransfusion or obtain directed
donations from compatible family members. Coagu-
lation studies should be ordered when bleeding
tendencies are suspected, usually in alcoholic patients
with hepatic dysfunction.
9. Consult with the anesthesiologist well in advance
when airway, cardiac, alcoholic, hepatic, and other
systemic problems are present. Also make detailed
plans regarding type of intubation (orotracheal
or nasotracheal), tracheostomy, cardiac monitor-
ing, and optimum positioning of anesthesia equip-
ment. In case of partial airway obstruction, a
careful attempt to intubate the patient may be
made transorally or transnasally by the anesthe-
siologist. If intubation is not immediately suc-
cessful, a fiberoptic laryngoscope is passed into
the trachea with the patient awake but sedated
and then the endotracheal tube is positioned over
the endoscope. Always prepare for emergency tra-
cheostomy even though the procedure is rarely
necessary.
10. Shave and prepare the skin with germicidal soap to
widely encompass the area of surgery. Germicidal
soap preparation in the operating room is suffi-
cient. Some patients, particularly senile individ-
uals, require careful skin cleaning daily for 3 to
4 days ahead of time. Cleanse the external ear canal
with soap and a cotton-tipped applicator on two or
more occasions before parotid surgery and other
procedures in the ear area. Consultation with the
microvascular plastic surgeon ensures adequate
preparation and exposure when microvascular flaps
are planned. Skin preparation in the operating room
is carried out with the effective povidone-iodine
(Betadine) scrub and paint or a similar product.
Take care to protect the eyes with ophthalmic oint-
ment and pads during skin preparation, draping,
and surgery.
Bowel Prep
In the rare instance where bowel preparation is necessary,
this method is both simple and effective:
1. The patient must be on a clear liquid diet for at least
1 to 2 days before the operation.
2. GoLYTELY (PEG-3350 plus electrolytes; Braintree
Laboratories), 4 L, is administered orally beginning
early in the afternoon I day before surgery.
3. Neomycin (1 g) and erythromycin base (1 g) are
given orally at 1 PM, 2 PM, and again at 10 PM for
surgery the next morning (adjust for later surgery).
4. Encourage clear liquid intake until midnight.
5. Give a cephalosporin, 1 g, and metronidazole (Flagyl),
500 mg, every 6 hours for 24 hours beginning
preoperatively.
Postoperative Care
The postoperative orders for typical, all-inclusive care
after head and neck surgery might be outlined as
follows:
1. Careful monitoring of vital signs. The head should
be elevated to 30 to 45 degrees when blood pressure
has stabilized. Among the rare exceptions is ligation
of the common or internal carotid artery. In this case,
a flat or slightly head-down position would be impera-
tive. The head-up position decreases postoperative
edema and seems to improve respiratory function
greatly. Ambulation is started when the erect position
is tolerated without dizziness or syncope.
2. Tracheostomy care (Fig. 3-10). Give 40% oxygen
through a loosely applied mist mask (not by catheter
into tracheostomy tube), to maintain oxygen satura-
tion above 90 %. Pulse oximetry is recommended.
Suction the tracheostomy frequently in the early
postoperative stage. Insert a sterile, open-ended
catheter well below the inner tip of the tracheostomy
tube. (The person performing this procedure must
use sterile gloves or a sterile hemostaL) Deeper
suctioning is occasionally necessary.
At times counterclockwise rotation of the tra-
cheostomy tube can facilitate the introduction of the
suction catheter into the left mainstem bronchus.
Ordinarily, with deep suctioning, the catheter passes
into the right mainstem bronchus, since the right
bronchus is in a more direct line with the trachea
than the left bronchus.
Use a V-tube attachment for brief, intermittent
spells of suctioning. Each should last a few seconds
(no longer than the person handling the catheter can
comfortably hold his or her breath). Gently twist the
 BASIC CONSIDERATIONS

TRACHEOSTOMY CARE

SEPARATE
STERILE
TRACHEAL
CATHETER
FOR
EACH
SUCTIONING

STOMA CLEANED
2x DAILY

-
NOTTHIS! BUTTHIS!

FIGURE 3-10
 BASIC CONSIDERATIONS
catheter during each insertion and withdrawal to
prevent trauma to anyone area of tracheal mucosa.
The thumb should be repeatedly placed over the
open end of the V-tube and removed during the pro-
cedure. Avoid prolonged and continuous suctioning
to prevent dangerous oxygen desaturation. An oxygen
saturation monitor should be in use during suctioning.
Hyperventilation with 100% oxygen is recommended
before suctioning, and brief oxygen inhalation while
suctioning is used as needed.
Instill sterile normal saline solution with an eye-
dropper or syringe without needle in 1- to 2-mL
amounts every 2 to 4 hours and remove by suctioning
to prevent dry tracheitis. Detergents or enzymes may
be helpful locally in cases of severe dry tracheitis
with crusting. Remove and clean the inner cannula
of the tracheostomy at least every 4 hours. Remove,
clean, and replace the entire tube every 1 or 2 days
after the tracheostomy is well established (usually in
5 to 6 days). Large crusts may require removal by
forceps (with the entire tube out if a solid tract is
present). If large crusts or obstructing crusts occur in
a laryngectomy tube and cannot quickly be removed
from the tube, then remove the entire tube stat. Use
extreme care when changing a tracheostomy tube in
an infant. Carry out the first change in the operating
room or intensive care unit with a bronchoscope and
an endotracheal tube available.
A cuffed tracheostomy tube allows positive-pressure
breathing when required. A low-leak technique will
minimize injury to the trachea, thus preventing tra-
cheal stenosis. Otherwise, the traditional noncuffed
metal tube with inner cannula is desirable. The dis-
posable, cuffed plastic tube (without inner cannula)
has become popular with many thoracic surgeons in
patients requiring very brief tracheostomies. This
tube has not been generally satisfactory in our hands
because of its large outer diameter and the lack of an
inner cannula for cleaning purposes. The Shiley
cuffed tube does have an inner cannula and is the
preferred product in our hands but is also difficult to
insert and prone to tearing of the cuff. Some sur-
geons (JML) prefer the Portex tubes with inner
cannula. The cuffed tube-if needed-is easier to
insert. The tube is made in various models, some of
which are flexible. The low-pressure cuff is relatively
atraumatic; and when it is inflated, only enough air
should be injected to prevent leakage between the
cuff and the wall of the trachea. When patients are
learning to swallow after extensive procedures with
preservation of the larynx, cuff inflation prevents
aspiration but is ordinarily contraindicated, because
this merely hides evidence of aspiration of swallowed
liquid and pureed foods. When the patient returns
from surgery to the recovery room and respiratory
assistance is no longer needed, the cuff of the endo-
tracheal tube inserted at the end of the operation is
normally deflated. Just before this, however, the
nurse must be prepared to suction the remarkable
quantity of secretion that gathers above the inflated
cuff. This mucous material usually drops quickly
into the trachea on deflation. Never discontinue a
tracheostomy until it is certain that the patient has a
satisfactory airway. Mirror or fiberoptic laryngoscopy
allows evaluation of the subglottic, glottic, and supra-
glottic airway. In spite of some criticism of this method,
half- and full-corking is a satisfactory technique of
"weaning" the patient from a tracheostomy. However,
one must be certain that the tracheostomy tube does
not fill the lumen of the trachea when corking is
attempted! By gradually decreasing the size of the
tracheostomy tube (from the standard NO.7 for men
to NO.6 or No.5), the surgeon can then cork with
ease and finally remove the tube. Examine the
larynx before corking or removing the tube. At times
tube removal aids in deglutition.
The patient must be able to pull the cork at any
time if breathing becomes difficult. Of course, the
corked, inner cannula must be removed and cleansed,
just as previously described, until final discontinuance
of the tracheostomy. When oral or laryngopharyngeal
surgery with tracheostomy has been performed,
remove the feeding tube when the patient is swal-
lowing with ease. The tracheostomy tube must be
left in place as a "safety valve" in case aspiration
occurs. The surgeon must then carefully test the
swallowing function to be certain that ingested liquid
is not being aspirated before final termination of the
tracheostomy. Here, food coloring added to liquid or
puree diet aids in evaluating aspiration.
After partial laryngostomy, removal of the tra-
cheostomy tube may be necessary to initiate the act
of swallowing. Close observation for aspiration is
necessary, and, if significant, the tracheostomy tube
should be reinserted.
3. Laryngectomy stomata need care similar to that for
tracheostomies (see Fig. 3-10). The entire laryngec-
tomy tube must be removed, carefully cleansed, and
replaced at least twice daily by the surgeon, a member
of the house staff, or other trained personnel. At this
time the suture line is meticulously cleared of crusts
with saline solution (if necessary with cautious appli-
cation of diluted peroxide to loosen any dried material).
Avoid the use of peroxide within the stoma. It can
cause obstruction in both the tracheostomy or laryn-
gectomy tube, as well as in the suction catheter.
Antibiotic ointment is then applied to the skin/mucosal
edge before tube reinsertion. If there is ulceration or
persistent erythema, tincture of benzoin may be
applied carefully to the edge of the stoma and to the
surrounding skin. Most patients are allowed to go
without the laryngectomy tubes for increasing periods

during the waking hours after the first 2 to 3 days.
The patient should be taught self care as convales-
cence continues, the goal being independence in care
on hospital discharge. Many surgeons prefer to keep
the tube in place at night until it is certain that a large
rigid stoma has developed. In dry climates, prolonged
laryngectomy tube use and home humidification are
necessary to avoid dry tracheitis. Plastic "buttons" or
stoma rings (especially the Helsper button) are help-
ful in preventing stenosis when stomata are small and
in treating stenosis (by dilatation with larger and larger
rings). A "bib" of porous gauze (without cotton filling),
moistened frequently with water, should be placed
loosely over the stoma at all times. If a plug becomes
lodged at the distal end of the laryngectomy tube, the
entire tube must be removed STAT by anyone! This is
a life-saving procedure, since the author (JML) knows
of one patient who died because of this incident.
4. Narcotic requirements are usually minimal after head
and neck procedures compared with after abdominal
and orthopedic procedures. Adequate pain control is
to be ensured in the immediate postoperative period
with intravenous narcotics provided via patient-
controlled analgesia (PCA) according to the protocol
used in each hospital. Patients who have had proce-
dures that require the harvest of microvascular flaps
involving muscle and bone require longer use of
PCA analgesia, whereas patients with neck dissection
require minimal narcotic analgesia. Nonsteroidal anti-
inflammatory analgesics, such as ibuprofen 600 to
800 mg via feeding tube or orally every 6 hours, are
usually adequate for minor pain as recovery con-
tinues. The use of tranquilizers for anxiety or rest-
1essness is important. Alcoholics who require large
doses of tranquilizers should be cared for in the inten-
sive care unit until stable. Oversedation with resultant
respiratory depression should be avoided in any
patient who might aspirate. Serious consequences
have been observed in patients with partial airway
obstruction, such as in a patient with a posterior
nasal pack placed for nasal hemorrhage control who
was oversedated. All postoperative head and neck
procedure patients should receive prophylactic med-
ication to avoid gastritis and gastric hemorrhage.
Effective medications for gastric hemorrhage preven-
tion include H2 receptor blockers such as ranitidine
(Zantac), 50 mg intravenously every 8 hours or
150 mg via feeding tube every 12 hours.
5. Perioperative antibiotic use along with improved sur-
gical techniques has resulted in very low postoperative
infection rates. In clean surgical procedures (major
salivary gland resection, thyroid and parathyroid
resection, cyst removal, and radical neck dissection)
there is no evidence that antibiotic administration
decreases the already low infection rate. In longer,
clean cases (free flap repair, combined parotidectomy
BASIC CONSIDERATIONS
and neck dissection, or operation through radiated
tissue), a cephalosporin is administered beginning
preoperatively for 24 hours.
Clean contaminated cases are those in which the
surgical field is exposed to mucosal secretions (com-
bined oral and neck procedures, pharyngeal, sinus,
and laryngeal procedures). Here, the wound is exposed
to both aerobic and anaerobic bacteria and higher
wound infection rates are expected. Some proce-
dures, such as skull base surgery, in which the
central nervous system is exposed to pharyngeal
secretions and in which abdominal flap harvest is
utilized, would be impossible without perioperative
antibiotic use. In these cases, antibiotic administra-
tion is started preoperatively in full dose and discon-
tinued 24 to 48 hours postoperatively. In simpler
clean-contaminated cases (radical neck dissection
with oral or pharyngeal resection and free flap repair
or laryngeal surgery), 24- to 48-hour cephalosporin
coverage is used. Other surgeons use ampicillin
sodium/sulbactam (Unasyn), 1.5 g, intramuscularly
or intravenously every 6 hours unless the patient is
allergic to penicillin. This is given as a single dose
preoperatively and continued postoperatively for 24
to 48 hours. Some surgeons use clindamycin 1% as
a mouthwash one to three rinses per day before the
operation and continued 24 to 48 hours postopera-
tively. Ototoxicity and nephrotoxicity may occur. In
more extensive procedures (skull base surgery or
mandibular resection cases in which hardware is
used), perioperative cephalosporin and aminogly-
coside antibiotics are used for 48 hours. Still, there
is little evidence to recommend anyone drug com-
bination over another as long as the antibiotics are
effective against oral gram-positive aerobic and
anaerobic bacteria. In any cases, antibiotics will not
prevent infection where poor surgical technique
allows continued postoperative salivary wound con-
tamination. Watertight closure of suture lines with-
out tension is mandatory.
6. Irrigate the oral cavity at least four times daily when
suture lines are present. (Tube feedings should
replace oral intake during the postoperative healing
phase in all except the smaller, intraoral resection
cases.) Hydrogen peroxide/saline solution adminis-
tered by power atomizer, Asepto syringe, or Water
Pik, is useful in keeping the operative site clean.
Aspiration of the irrigating solution is best managed
by a tonsil tip attached to a portable or wall suction
apparatus (Fig. 3-11A). The patient should be placed
in a sitting position for this treatment to prevent the
aspiration or the swallowing of the irrigating solution.
As recovery progresses, the patient can be a valuable
ally in wound care. Patients who become self suffi-
cient in their care also have less anxiety and seem to
have a more comfortable postdischarge recovery.
 BASIC CONSIDERATIONS
7. Frequent wound cleansing with peroxide is advisable
to reduce wound contamination by tracheal secre-
tions and serum crusting. Stents over skin grafts are
kept in place for periods varying from 4 to 5 days for
mucosal defect skin grafts and up to 6 to 7 days for
skin defect grafts. Pressure dressings are not required,
because fluid accumulation can be prevented and
skin flaps made to adhere nicely to deeper structures
with the use of properly managed vacuum wound
catheters. Some surgeons use pressure dressing over
the parotid salivary gland after radical neck dissec-
tion to prevent edema and swelling of the parotid
salivary gland, which can be permanent. Pressure
dressings are also occasionally utilized along with
CARE OF INTRAORAL SURGICAL WOUNDS
POSTOPERATive _ 1_
CARE
OWER SPRAY 0
SALINE & H202
(1/2 AND 1/2)
CONNECTIONS TO POWER SPRAY-SUCTION APPARATUS
ALWAYS
PROTECT
THE EAR!
FIGURE 3-11
the suction drains. Kling is the best material to secure
the pressure gauze (see Fig. 3-11B) but there should
be no pressure over any type of transposed flap.
Vacuum apparatus of Hemovac or Jackson-Pratt types
is generally satisfactory for wound drainage, the
latter being preferred by this author (WRN) because
less clotting is experienced. Avoid drainage sets with
hard catheters. Large-sized catheters (10 mm) are best
for larger cases and small (7 mm) for less extensive
cases. Clotting will occur in any tubes inserted into
wounds and must be evacuated. Tube stripping or
"milking" is helpful in removing clots. Again, the
patient can assist with this procedure. A word of
caution regarding these tubes needs to be made.
ASEPTO SYRINGE OF
SALINE & H202

They must not cross the carotid vessels nor be located
too closely to a microvascular anastomosis, because
there is danger of pressure necrosis or microvascular
anastomosis failure. One or two fine, absorbable,
loosely placed sutures are used to keep the tubes in
the desired location.
Antibiotic ointment may be applied over exposed
suture lines. Some physicians prefer a quick-drying
liquid dressing administered by spray to these skin
closures. It is acceptable to leave neck wounds uncov-
ered postoperatively. This allows frequent inspection
,
\,
Pectoralis
major rotation
A flap
FIGURE 3-12 Avoid dressings or tracheostomy ties around the neck that could compress rotation flap or
microvascular flap blood supply. (A modified from Ritchie WP Jr, Steele G Jr, Dean RH: General Surgery. Philadelphia, JB
Lippincott, 1995, Figure 2-15.)
BASIC CONSIDERATIONS
by care personnel. Bulky dressings can hide the rare
but dangerous postoperative hematoma and do little
to protect the operative site. With pectoralis major
flaps no pressure dressing is used. In microvascular
free flap cases wound exposure is mandatory for
observation and Doppler checks of vascular flow.
Here, any pressure over the site of vascular anasto-
mosis may result in flap loss (Fig. 3-12).
All tubes and drains are possible sources of
ascending infection, and appropriate precautions to
prevent this should be taken. The neck wound should
 BASIC CONSIDERATIONS
be carefully examined daily for any evidence of fluid
accumulation. Prompt evacuation is imperative. Late
accumulations often herald the development of pha-
ryngeal suture line disruptions. (Foul-smelling, mucus-
containing material is diagnostic of such a compli-
cation.) If Proteus infection is suspected clinically or
by laboratory tests, use the appropriate antibiotic. If
necessary, dilute solutions of acetic acid used locally
may resolve the problem. If infection persists, widely
open the overlying skin flaps and .start irrigation and
packing after adequate drainage of any pockets.
Loosely and temporarily applied saline/hydrogen
peroxide packs after each irrigation will clear up any
anaerobic infections and stimulate formation of granu-
lation tissue. These packs should be changed fre-
quently. Antibiotic coverage is restarted when culture
results are available.
Carotid artery exposure (which is usually pre-
vented during the operation by muscle flap coverage
or dermal graft; see Figs. 22-35 and 22-36) necessitates
extremely vigorous local wound care. Ligation may
become necessary if granulation does not quickly
cover the vessel. The appearance of a pale, avascular
area in the arterial wall indicates an impending rup-
ture. If the wound is clean proximally and distally an
elective arterial bypass graft could be performed
through clean surgical fields (see Chapter 22).
8. When needed, feeding tube placement can be by the
preoperative PEG tube method or by a large bore
nasogastric tube placed during surgery. The former
method is preferred except where tube feeding require-
ments are only a few days and preoperative nutrition
is adequate. If not placed preoperatively, the feeding
tube must be inserted by the anesthesiologist, espe-
cially when the procedure is a laryngectomy. Here,
the tube insertion must be completed before pharyn-
geal wall closure to prevent possible perforation of
the suture line. Some surgeons prefer the PEG tube
(see Fig. 3-10) in a laryngectomy in the hope of
decreasing the incidence of fistula formation. In any
event, do not reinsert an accidentally removed feed-
ing tube after pharyngeal or esophageal closure before
wound healing, because the reinserted tube can dis-
rupt the suture line. Postoperative chest radiography
confirms proper placement of the tube before use.
Postoperative consultation with the nutrition team
allows calculation of caloric requirements and method
of product administration. Administer high-caloric
liquid feedings by tube after nausea and gastric atony
have subsided. Clear surgical liquids or DsW may be
given by tube in the interim. Commercial products
for tube feeding are now numerous, and specific
recommendations are not possible because a hospital
will usually have one product line available. Choose
the appropriate product after consultation with the
dietitian.
Your hospital may have an enteral feeding protocol,
but a simple sample protocol follows:
1. Confirm accurate tube placement by radiography
or air injection and auscultation. Small-bore tubes
require radiographic confirmation of position.
2. Elevate the head of the bed or place the patient in
a chair at the bedside.
3. Check gastric residual. If it is greater than 100 mL,
withhold feeding and check hourly until less than
100mL.
4. Start feeding by pump with dilute (half-strength)
product at 50 mL/hr. Check residual every 4 hours.
Discontinue feeding if residual is more than 100 mL
and restart when residual is less than 100 mL.
5. Advance to full strength after 12 hours if residual is
less than 100 mL.
6. Advance rate of feeding 25 mL/hr every 12 hours
when full-strength formula is tolerated until the
desired rate is achieved (caloric requirement
calculated by the nutritional team).
7. Convert to interval feedings in five divided doses
when the desired rate is tolerated.
8. Discontinue feedings and check residual if patient
complains of nausea or gastric discomfort.
9. Flush the tube with 30 mL of water before medica-
tion administration and with 60 mL of water after
interval feedings.
10. Give supplemental water according to the osmolarity
of the feeding formula.
11. Check electrolyte levels frequently until stable.
12. Diarrhea may be treated by tube-feeding adjust-
ment or medication.
Complications
Complications in nutritional support are related to the
delivery method. Properly adjusted TPN solution seldom
causes electrolyte imbalance, but central venous line
infections are common, particularly when a tracheostomy
is present. Central venous line placement complications
should be rare and include pneumothorax and bleeding.
Nasogastric feeding tube complications include the
avoidable misadventures of lung placement, nasal
cartilage necrosis, and esophageal perforation on tube
placement, especially if a tube with wire stylet is used.
PEG tube complications tend to occur at the time of tube
placement and are rare. There have been two instances
of postoperative implantation of squamous cell carci-
noma at the PEG site reported. Any enteral feeding
method may cause reflux and aspiration (more common
with large-bore nasogastric tubes) and diarrhea due to
the osmotic effect of the product. All methods of nutri-
tional support can cause electrolyte imbalance and are
more difficult to manage in patients with diabetes,
congestive heart failure, and hepatic and renal failure.

These brief preoperative and postoperative sugges-
tions should serve as a guide in the management of
patients undergoing head and neck surgery. Meticulous
attention to details of patient care will help to decrease
morbidity and mortality in these surgical cases involv-
ing complex anatomic areas.
Nasoesophageal Feeding Tube (Fig. 3-13)
When and if this type of tube is indicated, extreme care
must be followed if performed, for example, before
surgery or if necessary postoperatively.
The patient's head should be flexed forward so that
the best opportunity to insert the tube in the esophagus
is achieved. Hyperextending the head and neck will
tend to place the tube in the larynx and trachea, which
can end up in a very serious aspiration and death.
After the tube is inserted, the end is placed in a cup
of water to be certain that there are no bubbles. If there
are bubbles, then the tube is most likely in the trachea.
Examination with a laryngoscopy is sometimes necessary
to confirm mislocation of the tube.
Common Departures From Sound
Management-"Pitfalls" (From Lore
and Shedd, 1979)*
Sound clinical management, as collectively developed
over years of accumulated experience, is sometimes
'From NIH publication #80-2037, September 1979.
PUTTING IN THE FEEDING TUBE
(NASOESOPHAGEAL CATHETER FOR FEEDING)
CLAMP OR CORK MUST BE USED!
CATHETER ~EL.:
BUT TEST TO BE SURE!
FIGURE 3-13
BASIC CONSIDERATIONS
better expressed in negative rather than posltlve
terms-what should not be done or pitfalls to avoid. It
would of course be impractical to attempt any kind of
exhaustive listing of departures from sound practice;
however, a few that stand out as perhaps too often seen
are itemized below for easy reference and discussed
more extensively in the following section.
Unsound Practices
• Open biopsy of a lump in the neck before performing
a complete head and neck and general physical
examinations
• Inadequate incisional biopsy of an oral cavity lesion
• Inadequate excisional biopsy of a suspicious oral
cavity lesion
• Failure to review previous histopathology slides
• Permitting a single histopathologic benign diagnosis
to override a clinical diagnosis of carcinoma
• Biopsy of the larynx, hypopharynx, nasopharynx,
esophagus, or trachea before radiologic studies and
imaging when such studies are indicated to aid in
the evaluation of the extent of disease
• Lack of multidisciplinary approach, when indicated
• Tailoring the scope of surgical resection to the ability
of the surgeon rather than to the objective requirements
imposed by the lesion
• Compromise of the ablative phase of surgery to
accommodate limited reconstructive skills
SOPHAGUS - NOTE CATHETER
WITH OPEN TIP!
 BASIC CONSIDERATIONS
• Compromise of surgical margins because radiation
therapy or chemotherapy was or is to be given and,
conversely, giving less than an adequate tumor dose
of radiation therapy with the intent of resorting to
surgical excision of any residual disease
• Performing the right operation on the wrong patient
• Assessing the degree of success or failure of radia-
tion therapy on the basis of the response of the lesion
during or immediately on completion of treatment
• Failure to realize the implications of the "condemned
mucosa" or multiple primary syndrome
• Failure to perform a complete general physical examina-
tion as well as a complete head and neck examination
• Prolonged watch-and-wait attitude in the face of an
asymptomatic mass
• Inadequate search for an occult primary tumor
• Abandonment of the patient with neck metastasis
from an undetectable primary tumor
• Enucleation of tumors of the major salivary glands
and thyroid gland
• Treating a patient with antibiotics for an extended
period of time without a biopsy
Open Biopsy of a lump in the Neck
Before Performing a Complete Head and
Neck General Examination
Discussion
An open biopsy will yield the histologic diagnosis but
in carcinoma will usually:
• Not indicate origin or extent of the primary tumor.
• Encourage spread of tumor in the neck.
• Make necessary the resection of a large area of
overlying skin.
• Interfere with the usual anatomic surgical planes
relative to definitive therapy.
Prevention. Complete an adequate head and neck
examination, including optical nasal laryngoscopy, as
indicated, direct endoscopy, plus x-ray and imaging
evaluation of the mandible, sinuses, nasopharynx, larynx,
and chest and a general physical examination. It is very
important then when examining the oral cavity and
oropharynx that palpation, especially of the base of the
tongue, be performed. Rectal and pelvic examination
should be done as indicated. When all of these fail to
reveal the source of the primary tumor, then needle
aspiration is recommended. For example, prostate, colon,
and breast cancer can metastasize to head and neck
(see pp. 780 to 787 for a discussion of metastasis to
lymph nodes of the head and neck). If the needle
aspiration fails, then open biopsy is justifiable and,
depending on circumstances, may preferably be
performed in the operating room with frozen section.
Inadequate Incisional Biopsy of an Oral
Cavity lesion
Discussion
Punch biopsy of areas of leukoplakia or erythroplakia
may well miss the site of carcinoma and lead the physi-
cian to a false sense of security.
Prevention. The localized area of the leukoplakia or
erythroplakia not responding to conservative manage-
ment within 2 to 3 weeks is usually best totally excised.
The specimen, properly marked as to orientation, is
then submitted for serial histologic sectioning. Staining
with toluidine blue may be of aid in selecting sites of
biopsy.
Inadequate Excisional Biopsy of a
Suspicious Oral Cavity lesion
Discussion
By and large, highly suspicious lesions are best evaluated
before excisional biopsy by the physician who will
eventually make the decision as to the best course of
management, whether it be surgery, radiation therapy,
chemotherapy, or some combination of these.
This evaluation is best achieved before any surgical
intervention, so as to ascertain the size of the lesion as
well as its local extension and the presence or absence
of metastatic disease. For example, inadequate excisional
biopsy of a lesion of the floor of the mouth may mask
the actual extent of the tumor as well as cause obstruc-
tion of Wharton's duct, inducing enlargement of both
submandibular salivary glands. This latter effect could
be confused with possible metastatic spread to sub-
mandibular lymph nodes.
Prevention. Initial evaluation before any type of sur-
gical excision is best performed by a physician who will
ultimately be responsible for the total management.
Failure to Review Previous
Histopathologic Slides
Discussion
At times, the physician responsible for the management
of the patient with a head and neck neoplasm, which
has been sampled elsewhere, will, in the face of expe-
diency, rely solely on a written histopathologic report
from an outside source. This occurs when a biopsy and
histologic diagnosis have been performed at the time of
original patient contact. Errors can occur when the
personnel at the primary care facility simply have not
had the exposure to some of the types of head and neck
neoplasms. Evaluation of the degree of malignancy is
most important; for example, in a mucoepidermoid carci-

noma of a salivary gland, it is crucial to know whether
it is low grade, intermediate grade, high grade, or very
high grade. This grading not only influences prognosis
but also is most important in the type of surgical
management.
Prevention. Request submission of all histologic slides
and, if necessary, blocks for further evaluation. The
results may even indicate that an additional biopsy
should be performed.
Permitting a Single Histopathologic
Benign Diagnosis to Override a Clinical
Diagnosis of Carcinoma
Discussion
At times, the clinical diagnosis of a malignant neoplasm
is not substantiated by biopsy and histologic evaluation.
The problem may lie with the choice of the location of
the biopsy site. For example, if the biopsy is taken in an
inflammatory area surrounding a neoplasm, in the
center of a necrotic area, or in the far periphery where
only epithelial dysplasia is present, the specimen will
lead to a histologic diagnosis of a nonmalignant lesion.
Another problem may result from the paucity of histo-
logic sections taken through the block of tissue, thus
causing the malignant cells to be missed.
An example of this pitfall is a single punch biopsy
of a whitish patch involving, for example, the major
portion of the vocal cord. It is better to strip the
entire vocal cord. The specimen thus would include
the entire suspicious area for serial histologic sections.
Staining with toluidine blue may be of help in select-
ing sites of biopsy, for example, in the oral cavity,
oropharynx, larynx, or hypopharynx. The whitish
patch (leukoplakia, a term best discarded by the
examining physician because it has implications of a
malignant lesion) can be due to atypism, dysplasia,
cancer in situ, invasive cancer, Candida, or lichen
planus and may be related to smoking, irritation by a
denture, or chewing tobacco or betel nuts with or
without slacked lime.
Prevention. A skilled clinician's impression on
physical examination is more often right than wrong.
The clinician, thus, must be wary of a benign diagnosis
in the histologic evaluation for the previously men-
tioned reasons. Repeat biopsy or total excision of the
lesion must be performed with explicit understanding
by the pathologist that, if necessary, many serial sections
should be performed. It may also be necessary to have
recourse to one or several repeat biopsies. Then, should
all biopsy specimens prove to be benign, such patients
should be followed at close intervals until the diag-
nostic discrepancy is adequately resolved. Additional
consultation may be advisable.
BASIC CONSIDERATIONS
Biopsies of the larynx, Hypopharynx,
Nasopharynx, Esophagus, or Trachea
Before Radiologic Studies and Imaging
Techniques
Discussion
Biopsies of these organ sites will often cause edema
and/or distortion of the neoplasm as far as its extent
and size are concerned. Hence, radiologic studies, either
in the form of plain soft tissue radiographs, CT, MRI, or
contrast studies, can be erroneously interpreted, if
performed after such biopsies.
Prevention. If at all anticipated and practical, radio-
logic studies and imaging techniques are best performed
before biopsy of the areas in question to avoid distortion
in the interpretation.
lack of Multidisciplinary Approach When
Indicated
Discussion
A primary care physician has the tremendous respon-
sibility of the initial referral for definitive care of the
patient with a head and neck neoplasm. At times these
referrals are to other physicians who, although quite
capable in their own disciplines, are not well versed in
the multidisciplinary aspects of the management of
head and neck malignant neoplasms.
Prevention. Obviously, lesions frequently present with
a choice of management that is clear cut, but in the
patient's best interest even the slightest reservation should
be subjected to a broader scrutiny. Use of multidiscipli-
nary consultations or conferences should be stressed. The
primary care physician must be cognizant of this multidis-
ciplinary aspect and be sure that the physician chosen to
manage the patient is also cognizant of this multidiscipli-
nary approach. This latter physician in basic training
may have sufficient knowledge of the disciplines involved
or may in fact wish for an additional consultation.
Tailoring the Scope of Surgical Resection
to the Ability of the Surgeon Rather
Than to the Objective Requirements
Imposed by the lesion
Discussion
When making a decision about the feasibility of surgical
management of an extensive neoplasm it is a serious
error to render a verdict of nonresectability because the
physician or surgeon making the decision does not have
the expertise or background to carry out the necessary
operation.
 BASIC CONSIDERATIONS
Furthermore, in surgery; tailoring the scope of excision
to the ability of the surgeon, rather than to the objective
requirements imposed by the character, location, and
extent of the lesion, is inexcusable.
Prevention. Although there is often a wide divergence
of opinion regarding resectability, the physician making
the decision must be well versed in the various options
and fully aware of what can and cannot be resected with
reasonably satisfactory results. Clear-cut knowledge of
the natural history of the disease is as important as
knowledge of the surgical technique in making this
decision.
A Compromise of the Ablative Phase of
Surgery to Accommodate Limited
Reconstructive Skills
Discussion
When the ablative surgery is modified to such an extent
that adequate resection with reasonable free margins
is jeopardized to accommodate wound closure, a sur-
gical error is committed. The surgeon must be well
versed in both the ablative phase and the reconstruc-
tive phase of surgical management. Otherwise, the
likelihood of cure is compromised or the patient is
disabled. The reconstructive phase must at times take
somewhat of a "back seat" to the ablative phase but
never vice versa.
Prevention. Complete training of the head and neck
surgeon in all phases of ablative and reconstructive
surgery is necessary.
Compromise of Surgical Margins Because
Radiation Therapy or Chemotherapy Was
or Is to Be Given
Discussion
It is a sore temptation to limit the area of surgical
resection because of a false sense of security deriving
from a favorable radiation therapy and/or chemotherapy
result that has either already occurred preoperatively or
is anticipated postoperatively.
Prevention. If radiation therapy and/or chemother-
apy are utilized in combination with surgery, it is
important that the surgery encompass the same area
that would have been resected had it been the sole
treatment modality. Careful record keeping of the size
and extent of the primary neoplasm (at times with
the use of tattoo and photographs) as well as the
metastatic disease is most important to prevent this
error.
Performing the Right Operation on the
Wrong Patient
Discussion
This pitfall is closely allied with earlier items men-
tioned in certain respects but primarily concerns itself
with the definition of resectability versus operability. A
neoplasm may be technically resectable utilizing a spe-
cific surgical technique, yet the operation is not suited
to the patient or the patient may not be in such physical
condition to tolerate the operation or the consequences
of the operation (e.g., cardiac and pulmonary diseases).
Actually, in head and neck surgery, there are very few
general medical or general surgical problems that totally
interdict surgical management, yet there are contingen-
cies that influence the selection of a surgical procedure;
for example, a supraglottic laryngectomy may well be
suited to the carcinoma of the larynx but not suited to
the patient who is elderly with chronic pulmonary insuf-
ficiency. The same principle may also well apply to the
use of a nondelayed flap in a patient with diabetes and
severe arteriosclerosis.
Prevention. Careful evaluation of the total patient in
regard to all vital functions being certain that the
patient can tolerate not only the operation but also the
anesthesia as well as the sequelae of both is essential.
Assessing the Degree of Success or
Failure of Radiation Therapy on the Basis
of the Response of the lesion During or
Immediately on the Completion of
Treatment
Discussion
There is a tendency among some physicians to decide
prematurely that radiation therapy has failed when
disease is still present on completion of this modality.
Along the same line is the error of deciding that the
neoplasm under treatment will not eventually have a
successful outcome when, early or midway through the
treatment, the response has been slow. Conversely, a
rapid response during radiation therapy is sometimes
improperly used as a justification to reduce total dosage.
A high rate of response of a neoplasm does not have
implications for the dose needed to sterilize the tumors.
Prevention. The physician must realize that response
to radiation therapy is varied during the course of
treatment and that this may not necessarily indicate the
final outcome. On completion of the planned full course
of treatment, a 4- to 6-week interval should lapse
before biopsy is performed again.

On completion of the planned full course of radio-
therapy treatment, continued response may extend up
to 3 months and even possibly 4 months. Early re-biopsy
is indicated if there is clinical evidence of changes
indicating either a regrowth of the tumor or increase of
the size of the original mass.
After radiation therapy or chemotherapy, the over·
lying mucosa may be intact, giving a false impression
of a complete response (see section on chemotherapy).
There may be viable tumor cells deep to the intact mucosa.
Deep biopsy through edematous mucosa after radiation
therapy is challenging and may not be productive.
Failure to Realize the Implication of the
"Condemned Mucosa" or Multiple
Primary Syndrome
Discussion
Especially in patients with multiple areas of leukoplakia
and/or erythroplakia, multiple primary tumors are not
only a possibility but are also actually a probability. Even
in the absence of these possible precancerous lesions,
multiple primary tumors are a distinct possibility in a
patient who already has one squamous cell carcinoma of
the head and neck. This clinical entity is more common
in the heavy tobacco and/or alcohol user. These are the
patients who demonstrate the condemned mucosa. A
tendency to "zero in" on the site of the first or original
lesion in follow-up examination is only natural, and
often a follow-up and repeat complete head and neck
examination is bypassed, thus causing other lesions to
be all too frequently overlooked.
Prevention. A complete head and neck examination
must be performed at frequent intervals in all patients who
have demonstrated a primary squamous cell carcinoma
of the head and neck. A recommended regimen for
follow-up is reexamination every month for the first
year, every second month for the second year, and so
on, up to 6 years. Beyond 6 years, follow-up is suggested
every 6 months. Cell type and extent of the original
lesion could modify this regimen.
Failure to Perform a Complete General
Physical Examination as Well as a
Complete Head and Neck Examination
Discussion
Unfortunately, the division of human anatomy into
various regions, for example, head and neck, chest,
abdomen, and pelvis, is not respected by neoplastic
disease or, for that matter, by infectious disease or trauma.
A mass in the neck may not necessarily represent pri-
mary disease above the clavicle. The primary disease
BASIC CONSIDERATIONS
may be in the chest, breast, abdomen, pelvis, ovaries,
urinary bladder, or elsewhere.
Prevention. In addition to a complete head and neck
examination, a complete physical examination is a sine
qua non for diagnosis and must be performed before
commencement of definitive management of a head
and neck neoplasm. This examination should include
digital rectal and pelvic examination as indicated.
Prolonged Watch-and-Wait Attitude in
the Face of an Asymptomatic Mass
Discussion
All too often either the patient or the primary care
physician may delay the evaluation of a mass in the
head and neck that is causing no pain or interference
with the patient's normal function. This delay could
well be a disaster.
Prevention. Any abnormal mass must be promptly
and completely evaluated, and it is then usually
removed, depending on the findings and diagnosis.
Inadequate Search for an "Occult"
Primary Tumor
Discussion
There are patients seen who have histologically proven
involvement of cervical lymph nodes by squamous cell
carcinoma without an apparent primary lesion. Such a
patient should not be placed in this unknown primary
category until after a completely adequate diagnostic
work-up has been done.
Prevention. The only admonition for this problem is
to repeat complete head and neck and general physical
examinations with diagnostic studies including
radiographs of the paranasal sinuses, nasopharynx,
esophagus, and chest. Depending on the histologic
findings on aspiration of the metastasis, other radiologic
studies should be performed as indicated. Areas to scru-
tinize extremely carefully if the metastases are squamous
cell carcinoma are the nasopharynx (vault, lateral walls,
and posterior choanae, including posterior edge of
septum), tonsils, base of the tongue, pyriform sinuses,
and inferior portion of the laryngeal surface of the
epiglottis. If open biopsy is necessary after all else has
failed, it may well be performed in the operating room
with frozen sections, so that, depending on the
circumstances and histologic diagnosis, a radical neck
dissection can then be performed without delay.
At times, the location of the cervical metastasis may
give an indication of the location of the primary tumor
(e.g., posterior triangle node, nasopharynx [vault], sub-
digastric node; floor of the mouth, tongue, oropharynx,
 BASIC CONSIDERATIONS
hypopharynx, larynx, maxillary sinus, sphenoidal sinus,
and posterior portion of nasal septum). Nevertheless,
remember the possibility of skipped metastasis.
Abandonment of the Patient With Neck
Metastasis From an Undetectable
Primary Tumor
Such a patient should not be abandoned but should be
given the benefit of definitive treatment. If the cancer
in the neck node is well differentiated and if the node
is situated in the midportion of the lateral neck, it may
possibly represent a so-called bronchogenic carcinoma,
although there has been uncertainty about the exis-
tence of this entity. In such an instance, radical neck
dissection is indicated, with careful subsequent follow-
up in a continued search for a hidden primary tumor.
In some patients, the long-term repeat examinations
will eventually disclose the primary tumor, it is hoped,
at a treatable stage. If the node shows undifferentiated
squamous carcinoma and if the node is at the periphery
of the usual neck dissection, the management is more
controversial. Some clinicians would advise neck dis-
sections, whereas others would advocate radiation
therapy. When the neck is irradiated in such circum-
stances, a judgment is necessary as to whether the ports
should encompass the sites of a possible undisclosed
primary tumor, for example, nasopharynx or base of
the tongue (refer to the earlier discussion Failure to
Perform a Complete General Physical Examination as
Well as a Complete Head and Neck Examination for
additional suggestions). Despite the ominous situation
of the undiscovered primary tumor, a significant number
of such patients do achieve cure by a combination of
surgical and radiotherapeutic approaches.
Enucleation of Tumors of the Major
Salivary Glands and Thyroid Gland
Discussion
The practice of enucleation of circumscribed tumors of
the major salivary glands (usually the parotid) and of the
thyroid gland existed in the past and continues in the
present. This procedure is inadequate, can spread
disease, and makes subsequent surgery difficult. After
enucleation of a benign mixed tumor from a salivary
gland, the tumor will most likely recur; and as it recurs,
transformation to a malignant form can take place.
Enucleation of a thyroid nodule can lead to several
problems: (1) Although frozen sections may appear
benign, final sections could be malignant. The secondary
operation thereby necessitated is quite hazardous because
of the possibilities of injury to the recurrent laryngeal
nerve and/or external branch of the superior laryngeal
nerve and/or loss of the parathyroid glands. (2) A
second nodule, which was not perceptible, may be left
behind. This latter nodule has on occasion proved to be
the carcinoma.
Prevention. With all tumors of the salivary glands
and thyroid gland, the operation of choice is total
lobectomy. With the parotid salivary glands, exposure of
the seventh nerve is important. With the thyroid gland,
exposure and preservation of the recurrent laryngeal
nerve and preservation of the parathyroid glands and
external branch of the superior laryngeal nerve are
important.
In relation to thyroid lobectomy, the word "total" is
stressed, because it is suspected that all too often the
surgeon calls an operation a total lobectomy when in
fact a subtotal lobectomy has been performed. A portion
of the thyroid lobe is likely to be left behind the pos-
terior suspensory ligament (Gruber, Henle, Berry) of
the thyroid, if meticulous care is not exercised.
Treating a Patient With Antibiotics for an
Extended Period of Time Without a
Biopsy
Discussion
It is not at all uncommon to see patients with tumors
of the head and neck in whom the initial physician
assumed an inflammatory lesion was present and
prescribed antibiotics for extended periods of time.
Prevention. Often, in such circumstances, after a
reasonable period of no response to antibiotics, a more
careful examination of the lesion would mandate a
biopsy and thereby avoid an unwarranted delay in
beginning definitive treatment of cancer.
The Place for Chemotherapy in
Management of Squamous Cell
Carcinoma of the Head and Neck
Monica B. Spaulding
Until about 20 years ago, chemotherapy was used in
head and neck cancer as a last resort in those patients
who had either presented with metastatic disease or
failed other treatment modalities. Many of these patients
were of poor performance status, had lost weight and
had tumor-related problems with nutrition, suffered from
obstructive pulmonary disease, and had other medical
problems. In spite of these factors and in spite of having
a limited choice of drugs, head and neck cancer was
one of the first solid tumors found to be responsive to
chemotherapy. The number of drugs with activity in
head and neck cancer is now quite long.

More recently, there has been a great deal of interest
in utilizing chemotherapy as part of the initial treat-
ment plan in patients who present with advanced stage
III and IV disease. The rationale for chemotherapy use
is to improve the overall treatment results of standard
therapy. Chemotherapy can be given as a neoadjuvant
treatment, to shrink the tumor before surgery and/or
radiation therapy. Concurrent chemotherapy can be given
with radiation therapy, so that the patient receives
chemotherapy daily, weekly, or less often while receiving
daily radiation. Chemotherapy can be administered as
an adjuvant, after completion of standard treatment, or
"sandwiched" as a treatment between surgery and
irradiation. Finally, the utilization of chemotherapy as
an initial treatment modality has led to a proliferation
of "organ preservation" trials in which the standard
surgical treatment is eliminated or modified in the face
of a good response to chemotherapy.
Recurrent or Metastatic Head and Neck
Cancer
Single-Agent Therapy
The goal of chemotherapy in patients with locally
recurrent disease or metastatic disease is palliation.
Head and neck cancer may recur locally in the head
and neck area and be associated with pain, bleeding,
difficulty swallowing, or obstruction of the respiratory
tract or may be widely disseminated involving lung,
bone, and liver. The first chemotherapy demonstrated
to have significant activity against head and neck cancer
was the folate analogue methotrexate. Methotrexate
remains the standard against which all other drugs need
to be tested. It has a response rate varying between
10% and 30%, is relatively inexpensive, can be given
in the outpatient department by a bolus injection, and
has predictable toxicity consisting of mucositis and
myelosuppression. The mucositis is self-limited, lasting
only 2 to 3 days, and is dose dependent. Reducing the
dose reduces the degree of mucositis so that even its
toxicity is easy to manage.
Methotrexate can be given in higher doses followed
24 hours later with leucovorin, a folate analogue, which
protects normal cells from toxicity. In spite of the
leucovorin rescue, the risk of toxicity is greater with the
higher dose regimens, but there is no significant increase
in the response rates or the duration of response with
any of these studies. Other drugs shown to have signifi-
cant activity in head and neck cancer over the next
decade were bleomycin and S-fluorouracil (S-FU).
Bleomycin, although having a measurable response rate
of approximately 20 %, was limited by its toxicity. It is
not myelosuppressive but does cause mucositis and
BASIC CONSIDERATIONS
has a predictable dose-limiting side effect of irreversible
pulmonary fibrosis. S-FU has been known to have
activity in head and neck cancer since early studies as
well. Both drugs (S-FU given by continuous infusion)
have been utilized primarily in locally advanced disease
as part of drug combination and combined modality
programs.
The biggest breakthrough in the management of
head and neck cancer was the development of cisplatin
(formerly cis-platinum) as a chemotherapeutic agent.
The recognition that cisplatin was active in head and
neck cancer has had a major impact on therapy of this
tumor. As a single agent, it has higher response rates
than methotrexate; however, it does require careful atten-
tion to hydration and has more side effects. Because its
toxicity profile is different than other available chemo-
therapy, it is an ideal drug to include in drug combi-
nations for treating head and neck cancer. Most active
drugs cause myelosuppression and stomatitis, but the
dose-limiting toxicity of cisplatin is renal impairment, a
problem that can be overcome by administering large
volumes of fluid and, if necessary, diuretics, to ensure
good renal output. Carboplatin, a platinum analogue,
also has activity in head and neck cancer and does not
cause renal impairment, but dosing is limited by myelo-
toxicity, particularly a reduction in the platelet count.
There are new drugs undergoing phase II trials that
offer significant promise in head and neck cancer.
Paclitaxel (Taxo!) was developed from the bark of the
yew tree and has proved to be active in a variety of
solid tumors. Its has a unique mechanism of action that
also makes it a logical drug to include with others in
combination. As a single agent, its response rate is as
high as 40% in patients with recurrent or metastatic
head and neck cancer, making it one of the most active
drugs available for head and neck cancer (Cortes-Funes
and Aisner, 1997). Its use can be limited by neurotox-
icity, which can be severe and unpredictable, although
also quickly reversible. Docetaxel has the same mecha-
nism of drug action and seems to have the same degree
of activity in head and neck cancer, although the studies
are more limited. Both drugs can cause significant
myelosuppression with neutropenia; however, the use
of growth factors appears to ameliorate this problem.
Sepsis and other forms of infection are uncommon.
Mucositis has not been noted. Gemcitabine, an
antimetabolite, has undergone evaluation in a number
of tumors including head and neck cancer. The drug
has a relatively low response rate but is well tolerated
and may be useful in combination therapy. Like many
of the other agents, it appears to have synergistic
activity when used with radiation therapy, and studies
of its use with radiation therapy are ongoing. Other
drugs with significant activity in head and neck cancer
are cyclophosphamide, hydroxyurea, and vinorelbine.
 BASIC CONSIDERATIONS
Combination Chemotherapy
In attempts to improve response rates, active drugs
have been combined in a variety of ways. The active
combinations invariably include cisplatin. When the
combinations have been compared to a single agent such
as methotrexate or cisplatin, the combinations have
higher response rates, but frequently with more toxicity.
Methotrexate, as a single agent, has been compared
with the combination of cisplatin and 5-FU and of carbo-
platin and 5-FU. The response rate to methotrexate
alone was only 10%, whereas the response rate to the
combination was 32 %. There was no improvement in
survival. In another trial, cisplatin as a single agent was
compared with 5-FU as a single agent and to a combi-
nation of the two agents. Again, the combination resulted
in a response rate of 32 % whereas the single agents,
cisplatin and 5-FU, had response rates of 17% and 13%,
respectively. Again, in spite of the higher response rate,
there was no improvement in survival. Toxicity rates
were higher in the combination of two drugs as well.
Browman and Cronin (1994) did a meta-analysis of
randomized trials in head and neck cancer and pointed
out that the proportion of patients suffering severe
nausea and vomiting can be far greater when patients
are treated with a combination of drugs. Because new
drugs are being developed, and because drug combina-
tions are usually more effective in terms of response
rates, there will always be an incentive to find an effec-
tive but well-tolerated combination of chemotherapeutic
agents for patients with head and neck cancer. The
treatment goal for patients with recurrent or metastatic
head and neck cancer is palliation, and the toxicity of
combination treatments is very important.
Combined Modality Therapy
For patients with local/regionally advanced but non-
metastatic disease, chemotherapy has been used to
improve the results of surgery and radiation therapy.
Patients with advanced but resectable disease have
traditionally been treated by surgery with radiation
therapy. The goal of induction chemotherapy, given
before surgery, is to shrink the tumor so that it is more
likely that it can be completely eradicated by the standard
therapy that follows. Tumor responses during induction
chemotherapy are much more impressive than the
response seen when the same chemotherapy is given
when there is metastatic disease. Overall response rates
exceeding 85 % are common, and complete response
rates (no clinical evidence of residual tumor) as high as
66% have been reported. The reason for the difference
is probably better drug delivery to the tumor before there
are surgical and radiation therapy effects on the blood
supply. It is unclear, however, that such a high response
rate, even when followed by the same surgery, translates
into improved survival. A large number of single arm,
phase Tl trials have been reported, and most cite better
disease control and improved survival in patients receiving
chemotherapy when compared with a historical control.
The few randomized phase III trials that have been
reported have failed to show a survival benefit to the
induction chemotherapy. Although one can object to the
randomized trials as having inadequate chemotherapy
regimens, modified surgical approaches when there
has been a response to chemotherapy, or inappropriate
selection of patients, no new large-scale trial designed
to correct those deficiencies is even contemplated. The
number of patients required for such a study, the need
for quality controls, and enormous fiscal and manpower
cost make such an endeavor unlikely in the future. Lore
and colleagues (1995) have published a single-institution
study in which a single surgeon performed all procedures,
patients were carefully selected to have advanced but
resectable disease, and effective chemotherapy with high
response rates was given. Their results were compared
with a matched control of patients included in the
Head and Neck Contracts Program and clearly showed
improved survival and disease control.
Adjuvant Chemotherapy
In many tumors, such as breast and colon cancer,
chemotherapy is administered after surgery. This has
the advantage of using pathology to select patients with
bad prognostic features who are likely to relapse after
the surgical procedure. Johnson and colleagues (1996)
reported a lO-year study in which all patients undergoing
head and neck surgery at the University of Pittsburgh,
who were found to have extracapsular spread in their
resected specimen, were offered postoperative
chemotherapy in addition to radiation treatment. Of the
371 patients eligible for the chemotherapy, only 131
(35%) consented to receive it; however, their survival
was significantly better than those who had refused the
recommended chemotherapy.
A randomized adjuvant trial has been done in patients
with advanced head and neck cancer by the Radiation
Therapy Oncology Group. In this large trial, patients
with stage III and IV resectable head and neck cancer
were randomized to receive immediate radiation therapy
after surgery or three courses of chemotherapy with
cisplatin and 5-FU followed by radiation therapy after
surgery. There were 448 patients enrolled in the trial,
and after 5 years of follow-up there was no significant
difference in survival between those receiving
chemotherapy and those not receiving it. Although this
trial, like other randomized trials, showed no significant
survival benefit to receiving chemotherapy, there was a
decreased risk of metastatic disease. This suggests that
there is some benefit to utilizing chemotherapy as part of
the initial approach to advanced head and neck cancer.

Organ Preservation
When induction chemotherapy trials were first initiated,
there were some patients who had "fantastic" responses
to the chemotherapy and no visible tumor after two or
three courses. In most cases, the patients still under-
went standard surgery and radiation therapy. In some
patients, there was no residual tumor identified in the
resected specimen. In other cases, the patients refused
the recommended surgical procedure and accepted
radiation therapy only, and the tumor did not recur. These
observations gave a justification for a trial comparing
standard surgical and radiation treatment to chemotherapy
followed by radiation therapy to responders. In 1984,
the Veterans Administration Cooperative Trials Program
began a study comparing those two treatment approaches
in patients with advanced resectable, laryngeal cancer.
The goal was to see if a laryngectomy could be avoided
without compromising survival. Quality of life should
be improved in patients who retained their own larynx
and preserved intelligible speech. All patients were
followed closely, and a salvage laryngectomy was offered
for patients who did not respond to chemotherapy and
for those whose cancer recurred after chemotherapy
and radiation therapy. The end results were that the
survival was the same in both study arms, and two thirds
of the patients in the chemotherapy arm had laryngeal
preservation. Distant metastases were also reduced in
those receiving chemotherapy. A similar study has been
done by the European Organization for Research in the
Treatment of Cancer (EORTC) with identical result. A
three-arm study comparing induction chemotherapy
followed by radiation therapy, radiation therapy alone,
and concurrent chemotherapy and radiation therapy is
now in progress under the auspices of the Radiation
Therapy Oncology Group (RTOG).
Concurrent Chemotherapy and Radiation
Therapy
Chemotherapy and radiotherapy can be administered
concurrently to enhance the local effect of the radiation
and to simultaneously treat distant metastases. Early
studies looked at adding single agents, such as methotrex-
ate, bleomycin, and 5-FU, to standard doses of radiation
therapy, 200 cGy/day for 5 days per week, to a total dose
of 6500 to 7000 cGy. Each of these chemotherapeutic
agents has mucositis as a toxic side effect; and, not
surprisingly, mucosal toxicity was enhanced in patients
receiving the concurrent treatments. This sometimes
led to frequent treatment interruptions or even noncom-
pletion of the total treatment. To reduce the severity of
the mucosal toxicity, drug doses were reduced to the
point that there was unlikely to be a systemic effect.
Nevertheless, there were several randomized trials that
did show a benefit to the combined therapy.
BASIC CONSIDERATIONS
Radiation therapy works best in well-oxygenated
tissue. Some patients present with tumor that is massive,
fixed, and unresectable. Frequently, such a patient is
referred for palliative radiation therapy. CT may even
show areas of central necrosis, suggesting poorly oxy-
genated tissue and implying the radiation therapy is
unlikely to sterilize the area. Investigators at Yale
University have shown that mitomycin, an alkylating
agent that is more effective in the absence of oxygen,
does improve the results of radiation therapy. In a study
of 117 patients with advanced head and neck cancer
randomized to standard radiation therapy or the same
radiation therapy plus mitomycin, those patients
receiving the chemotherapy had a longer disease-free
and overall survival. With this agent there was not an
increased incidence of acute mucosal toxicity during
the radiation treatment.
Cisplatin also appears to be a radiosensitizing agent
and is an active single agent for head and neck cancer.
In a study of patients with advanced nasopharyngeal
cancer, Al-Sarraf and co-workers (1998) reported a
significant benefit to concomitant chemoradiotherapy.
All patients received 7000 cGy doses of radiation therapy
given over 6 to 7 weeks. Those patients randomized to
the chemoradiotherapy arm also received cisplat in
(100 mg/m2) on days 1, 22, and 43 of the radiation
therapy. They were also to receive three courses of
adjuvant cisplatin and 5-FU after completing the irra-
diation. Recurrence-free survival was 69% for those
receiving the combined treatment and only 24% for
those treated with radiation. The 3-year survival was
76% in those receiving the combined treatment,
whereas only 46% of the patients treated by radiation
alone were altve at 3 years.
Other studies of combined chemoradiotherapy are in
process. Vokes and associates from the University of
Chicago (1992) reported beneficial effects of induction
chemotherapy followed by concurrent chemoradiother-
apy, particularly for organ preservation in patients with
advanced head and neck cancer.
Conclusion
The role of chemotherapy in the management of advanced
head and neck cancer has been studied extensively. In
those patients with recurrent or metastatic disease,
newer drugs have been shown to have exciting activity
with manageable toxicity. The interest in combined
modality therapy as a first approach to advanced head
and neck cancer is expanding, and there are a number
of new drugs, new combinations, and new ways in
which treatments can be integrated to improve the
management of these tumors. The area of research
is changing rapidly, and one would anticipate even
more advances as investigators continue their clinical
studies.
 BASIC CONSIDERATIONS

Preoperative Chemotherapy, After Chemotherapy

Uncompromised Surgery, and
1. The primary tumor site is resected with classic radical
Selective Radiotherapy in the neck dissection with adequate margins regardless of
Management of Advanced any favorable response to chemotherapy. With
Squamous Cell Carcinoma of the classic radical neck dissection and after response to
Head and Neck chemotherapy, functional or selected neck dissection
should be modified only in relation to preservation
John M. Lore, Jr., Sol Kaufman, of the 11th cranial nerve when commensurable with
Nan Sundquist, and Kandala Chary adequate ablative surgical procedure.
2. Frozen sections of margins: re-resect if margins are
In the management of advanced squamous cell car- positive or deemed too close.
cinoma of the head and neck, there are a number of 3. Perform selective radiotherapy.
management possibilities:
This choice is based on an evaluation of a prospective
I. Surgery plus radiotherapy protocol, originally reported in .1995 (Lore et aI., 1995),
2. Radiotherapy alone and a 5- to 20-year follow-up presented in 2000 involving
3. Surgery alone 93 consecutive patients, 82 of whom have completed
4. Chemotherapy plus radiotherapy-sequential or the protocol. There were two preoperative chemothera-
concurrent (organ sparing) -7 "salvage" surgery peutic regimens: regimen A-cisplatinjbleomycin, 45
5. Brachytherapy patients; regimen B-cisplatinj5-FU, 37 patients. The
6. Preoperative chemotherapy, limited surgery, and extent of the aggressive surgery was carefully docu-
radiotherapy mented before chemotherapy with tattoo, drawings,
7. Preoperative chemotherapy, uncompromised ag- and anatomic stamps. This was the strict guide for the
gressive surgery, and selective radiotherapy uncompromised surgery after the chemotherapy. The
8. Post-treatment chemotherapy-palliation selective postoperative radiotherapy was based on pre-
9. Intra-arterial chemotherapy viously published criteria (National Institutes of Health,
10. lntratumoral chemotherapy 1979), with modifications.

Of the 10 options, 6 include various forms of
chemotherapy used in various techniques.
The preference of one of us (JML) is. preoperative
chemotherapy, uncompromised aggressive surgery, and
selective radiotherapy.
Highpoints
I. Preoperative chemotherapy: Two to three courses as
tolerated are suggested based on response and tolera-
tion. Advance from two courses to three courses
2. Surgery un compromised by any response to the
chemotherapy
3. Selective radiotherapy
Treatment Criteria
Before Chemotherapy
1. A careful and complete evaluation of disease is
based on clinical, CT, MRI, and, at times, PET
examinations.
2. The extent of the disease is documented using tattoo,
drawings, photographs, and description.
3. The planned operation is outlined in detail.
1. Highest superior and lowest inferior neck dissection
nodes positive
2. Margins positive on permanent section
3. Tumor extending through the lymph node capsule
(extracapsular spread)
4. Extension of disease beyond the fascial planes of the
neck
5. Invasion of the deep cervical musculature
6. Recurrence within 6 weeks
7. Inclusion of patients who had multiple cervicallym-
phadenopathy. This was later modified according to
the extent and location of the multiple cervical
lymphadenopathy. That is, all patients with multiple
positive nodes did not receive postoperative
radiotherapy.
The protocol commenced in 1979, and the latest
evaluation was done in 1999. The protocol is still used
with modifications of the chemotherapy plan, increasing
the number of courses to three whenever there was a
favorable response and the first two courses were well
tolerated. Also, other chemotherapeutic agents were used,
mainly paclitaxel (Taxo!), when the response to the
original protocol was not as favorable. The 5- to 20-year
follow-up results of this protocol were presented at the
 BASIC CONSIDERATIONS

5th International Conference on Head and Neck Cancer ~

in August 2000. They were also presented in November TABLE 3-1 Distribution by Site, Stage, and "
2000 at the Great Lakes Head and Neck Conference in 'Ireatment Regimen (N - 82) ,~
Buffalo, New York, and in September 2001 at the 2nd
World Congress of the World Federation of Surgical Stage Regimen
Oncology Societies in Naples, Italy.
The latest data on this protocol have been reported Site No. m IV A B
in the Annals of Surgical Oncology (Lore et a!., 2003).
The following is taken in part from that publication, Larynx 21 6 15 12 9
with permission of the publisher. Hypopharynx 10 2 8 8 2
Oropharynx 36 9 27 20 16
This protocol is not randomized, although random-
Oral cavity 15 7 8 5 10
ized controlled trials have been in the medical/surgical
Total 82 24 58 45 37
literature. Nevertheless, lack of randomization in this
current study and many other surgical studies is not From Lore JM Jr, Kaufman S, Sundquist N, Chary KK: Carcinoma of
necessarily an obstacle for validity. As said in the con- the head and neck: A 5- to 20-year experience with preoperative
clusion of an article by Fung and Lore (2002), "The chemotherapy, uncompromised surgery, and selective
nature of the RCTs is that they are difficult to use to radiotherapy. Ann Surg Oncol 10:645-653, 2003, with permission.
evaluate the surgical techniques." Ideally, a randomized
controlled trial of this current study would include one
surgical oncologist, one medical oncologist, one radia- these areas were included in the wide resection of the
tion oncologist, and one pathologist. Together these primary lesion but did not alter the T classification.
physicians would either be native or move for 2 to 4 years The latest evaluation (1999) was based on a minimum
to India, Egypt, or Puerto Rico. They would only see follow-up of 5 years, extending to 20 years when possible.
and treat patients with squamous cell carcinoma of the The survival data are given in Table 3-2. Figures 3-14 to
head and neck. This still would not lessen the problem 3-17 present the data in graphic form. Absolute
of uniform surgical technique, which can change from survival is based on death from any cause, whereas
time to time even with the same surgeon. relative survival is based on adjustments for normal
These patients were untreated, consecutive, operable, age/gender mortality based on the National Center for
and resectable for cure, with stage III to IV squamous Health Statistics 1997 Life Table (Anderson, 1999).
cell carcinoma of the head and neck, including the sites The recurrence data and analysis for the primary
listed in Table 3-1. The surgery was performed by a sites are in Table 3-3. Data for distant metastases are in
single surgeon (JML), including all the ablative surgery Table 3-4. Regimen A was 10/45 (22 %), and regimen B
and 95 % of the reconstructive surgery (no significant was 2/37 (5%), which yields a significant P value of
portion was done by a resident, fellow, or any other .03, indicating improved outcome of regimen B.
attending surgeon). Patients with carcinoma of the hypopharynx had the
The T classification was based on ulceration and extent highest incidence of distant metastases, 4/10 patients
of the firm submucosal indurated mass. When there was (40%). The P value, comparing the hypopharynx with
significant edema and fullness surrounding the tumor all other sites, is .015.

TABLE3-2 Selected Survival Probabilities

5 Years 10 Years

Group No. Absolute (%) Relative (%) Absolute (%) Relative (%)

Totalgroup 82 60 66 45 58
RegimenA (bleomycin) 45 46 50 36 44
RegimenB (5-fluorouracil) 37 77 83 46 64
Comparison of regimens A and B (P value) .004 .003 .5 .3

From Lore JM Jr, Kaufman S, Sundquist N, Chary KK: Carcinoma of the head and neck: A 5- to 20-year experience with preoperative
chemotherapy, uncompromised surgery, and selective radiotherapy. Ann Surg Oncol 10:645-653, 2003, with permission.
 BASICCONSIDERATIONS

....J 100
~
>
a:
:::>
(f)
UJ
Percent fo-
Absolute :::>
....J
Survival 40 o
(f)
ell
«
f0-
20
rD 20
()

o a:
UJ
o 5 10 15 c.. 0
TIMEFROMENTRY(YEARS) o 5 10 15
FIGURE 3-14 Estimated absolute survival for total TIME FROM ENTRY (YEARS)
study group (N = 82) with 95% confidence bounds. FIGURE3-15 Estimated absolute survival in regimens A
(Reprinted from Lore JM Jr, Kaufman S, Sundquist N, and B. (Reprinted from Lore JM Jr, Kaufman S, Sundquist
Chary KK: Carcinoma of the head and neck: A 5- to 20- N, Chary KK: Carcinoma of the head and neck: A 5- to
year experience with preoperative chemotherapy, 20-year experience with preoperative chemotherapy,
uncompromised surgery, and selective radiotherapy. Ann uncompromised surgery, and selective radiotherapy. Ann
Surg Oncol1 0:645-653, 2003, with permission.) Surg Oncol 10:645-653, 2003, with permission.)

Estimated Survival ....J

....J
« Confidence Bands ~
2: 80
>
:>
a:
a: :::>
:::> (/)
(f) w
UJ 60 >
> ~
....J
~ W
uJ 40 a:
f-
a: z
f0- w
rD 20 ~ 20
w
() c..
a:
UJ
c.. 0 o
o 5 10 15 o 5 10 15
TIMEFROMENTRY(YEARS)
TIME FROM ENTRY (YEARS)
FIGURE 3-17 Estimated relative survival in regimens A
FIGURE 3-16 Estimated relative survival for total study
and B. (Figures 3-15 and 3-1 7 tend to show that survival
group (N = 82) with 95% confidence bounds. (Reprinted
rates in regimen A approach those of regimen B after 5
from Lore JM Jr, Kaufman S, Sundquist N, Chary KK:
years. This may not be statistically significant, because
Carcinoma of the head and neck: A 5- to 20-year
after 5 years the number of patients in that group is not
experience with preoperative chemotherapy, uncom-
representative inasmuch as they have not been able to be
promised surgery, and selective radiotherapy. Ann Surg
followed long enough into the 5- to 10-year bracket.)
Oncol1 0:645-653, 2003, with permission.)
(Reprinted from Lore JM Jr, Kaufman S, Sundquist N,
Chary KK: Carcinoma of the head and neck: A 5- to 20-
year experience with preoperative chemotherapy,
uncompromised surgery, and selective radiotherapy. Ann
Surg Oncol 10:645-653, 2003, with permission.)
 BASIC CONSIDERATIONS

TABLE 3-3 Primary Site Recurrences (N - 9)

Regimen

Site No. A (N ~ 45) B (N ~ 37) Total

Oropharynx 36 6 (15, 20, 27, 35, 50, 93) * 1 (10)* 7 (19%)

Larynx 21 I (alive at 150 mol 0 1 (5%)
Hypopharynx 10 I (52)* 0 1 (10%)
Oral cavity 15 0 0 0(0%) v
Total 8 (18%) 1 (2%)

*Duration of survival in months.

From Lore JM Jr, Kaufman S, Sundquist N, Chary KK: Carcinoma of the head and neck: A 5- to 20-year experience with preoperative
chemotherapy, uncompromised surgery, and selective radiotherapy. Ann Surg Oncol 10:645-653, 2003, with permission.

TABLE 3-4 Distant Metastasis (N - 12) TABLE 3-5 Comparison of Clinical and
(15%) Histologic Data Relative to Neck Metastasis

No. in Metastasis Clinical

Origin Site No. Protocol Rate (%)
Histologic Positive Negative Total
Hypopharynx 4 10 40%*
Larynx 2 21 10% Positive 36 5 41
Oropharynx 5 36 14% Negative 24 12 36
Oral cavity 1 15 7% Total 60 17 77
Total 12 82 15%
From Lore JM Jr, Kaufman S, Sundquist N, Chary KK: Carcinoma of
Regimen A: 10/45 (22 %). the head and neck: A 5- to 20-year experience with preoperative
Regimen B: 2/37 (5%). chemotherapy, uncompromised surgery. and selective
P ~ .03. radiotherapy. Ann Surg Oncol 10:645-653, 2003, with permission.
*Comparison of hypopharynx with all other sites (P ~ .015).
From Lore JM Jr, Kaufman S, Sundquist N, Chary KK: Carcinoma of
the head and neck: A 5- to 20-year experience with preoperative
chemotherapy, uncompromised surgery, and selective (P = .03). In regimen A, the overall incidence of neck
radiotherapy. Ann Surg Oncol 10:645-653,2003, with permission. recurrence in the patients with radical neck dissection
is 7.8%. All of the six patients died of disease with
survival ranging from 13 to 71 months, which empha-
Note: Positive nodes are based on histologic exami- sizes the seriousness of neck recurrence (Table 3-8).
nation of neck dissection specimens after response to Five of these patients received radiotherapy; one refused.
chemotherapy. Hence, actual positive nodes would be A hypopharyngeal primary tumor is more likely than
high in number, because some nodes will not demon- other primary sites to lead to neck recurrence: 2/10
strate malignant cells after chemotherapy. (20%) in regimen A.
Of 17 necks judged clinically negative, 5 (29%) were Seven of the 10 patients with hypopharyngeal carci-
found to be histologically positive (as shown in Table noma with T3 and T4 lesions had total hypopharyn-
3-5, which further evaluates the comparison of clinical gectomies with total laryngectomies whenever there
and histologic data). A similarly calculated error in was any significant involvement of the hypopharynx.
clinical versus histologic evaluation of lymphadenopathy With carcinoma of the larynx, which required a total
was reported as 21 % by Sako and colleagues (1964). laryngectomy, a total hypopharyngectomy was also
Myers and associates (1998) evaluated PET scans in NO performed when there was any significant involvement
necks, in 14 patients having radical neck dissections of the hypopharynx. Reconstruction was usually per-
without any preoperative chemotherapy or radiotherapy, formed with a pectoralis major flap or a posterior tongue
and in 7 patients (50%) having positive nodes histo- flap, each combined with a posterior dermal graft (see
logically. Five of these patients had positive PET scans. Figs. 8-2G and 21-7). Preservation of a narrow strip of
Six recurrences in the neck occurred in regimen A posterior mucosa to facilitate a conduit for swelling
(13 %) (Tables 3-6 and 3-7). The difference is significant was not done.
 BASIC CONSIDERATIONS

TABLE3-6 Neck Recurrences in Regimen A· TABLE3-7 Neck Dissection and Recurrence in

(N - 6) According to Site Neck (N - 6)

Duration of No. of Positive

Survival Neck Dissection Patients Nodes Recurrences
Sitet No. Recurrences (mo)
Radical neck 77 41 6 (7.8%)
Oropharynx 20 2 (10%) 16,36 dissection"
Larynx 12 2 (17%) 13, 71 Regimen A 43 27 6 (13%)
Hypopharynx 8 2 (25%) 16, 16 Regimen B 34 14 0(0%)
Total 45t 6 (13%) Suprahyoid (all 2 0 0
regimen A)
-There were no neck recurrences in regimen B. No node 3 0
tThere were no neck recurrences for oral cavity primary tumors. dissection
Hotal comprises43 radical neck dissections and 2 suprahyoid neck
dissections. No functional neck dissection.
From LoreJM Jr, KaufmanS, Sundquist N, Chary KK:Carcinomaof All six patients dead of disease.
the head and neck: A 5- 10 20-yearexperience with preoperative RegimenA, 6; RegimenB, 0; P ~ .03.
chemotherapy,uncompromised surgery,and selective "Includes three simultaneous contralateral suprahyoid dissections.
radiotherapy.Ann Surg Oncol 10:645-653,2003, with permission. Reprintedfrom LoreJM Jr, KaufmanS, Sundquist N, Chary KK:
Carcinomaof the head and neck: A 5- to 20-yearexperiencewith
preoperative chemotherapy,uncompromisedsurgery,and
A total of 19 patients received the selective postopera- selective radiotherapy.Ann Surg Oncol 1O:645-6S3, 2003,
tive radiotherapy; 8 patients received it early (within 6 with permission.
weeks post operation) (Table 3-9). Twelve patients
received late postoperative radiotherapy (1 patient
received early and late irradiation) (Table 3-10). All of Only two patients had significant adhesions of the
these patients that received late postoperative radiotherapy metastatic disease to the internal and common carotid
died of the disease, although 3 patients survived more arteries, which precluded safe dissection. The carotid
than 5 years. artery's resection and reconstitution with a graft was not
Major complications, which were life threatening, feasible because the area involved was not resectable.
occurred as follows: one intraoperative death due to a Resection of the carotid artery (common or internal
myocardial infarction occurring shortly after the inci- carotids) was not necessary except for the 2 patients
sions were made; one carotid artery blowout, which listed earlier. This indicated a favorable effect of the
occurred 7 months after completion of late postoperative chemotherapy relative to clear surgical planes surrounding
radiotherapy after a contralateral neck dissection; one these vessels despite the proximity of tumor.
perforated gastric ulcer (outcome was good); and one Five hundred frozen sections were performed on all
respiratory failure (this patient had a long history of but 2 patients. Analysis of data on the frozen sections
respiratory problems and died). Other non-life-threatening at the primary site suggested frozen section aided in the
surgical complications are listed in Table 3-11. reduction of positive margins on permanent section.

TABLE3-8 Recurrences in the Neck (N - 6) (All in Ann A)

Primary Site Details of Recurrence Survival (mo) Outcome

Oropharynx Supraclavicular, infraclavicular, and mediastinal disease 16 000

Oropharynx" Recurrence at levels II, III, and IV 36 000
Hypopharynx Extracapsular spread 16 000
Larynx Soft tissue involvement 71 000
Larynx Recurrence at levels II and III 13 000
Hypopharynx Invasion of muscle (extracapsular spread) 16 000

·Patient refused radiotherapy.

ODD,dead of disease.
Reprintedfrom LoreJM Jr, KaufmanS, Sundquist N, Chary KK:Carcinomaof the head and neck: A S- to 20-yearexperiencewith
preoperativechemotherapy,uncompromisedsurgery, and selective radiotherapy.Ann Surg Oncol 10:645-653,2003, with pennission.
 BASIC CONSIDERATIONS

TABLE 3-9 Early Selective Postoperative Radiotherapy (N - 8)

Regimen A Primary Site Regimen B Primary Site

Oropharynx Hypopharynx Oropharynx Larynx Hypopharynx

Indication (N = 20) (N = 8) (N = 16) (N = 9) (N = 2)

Highest node LFU at 3 mo

positive
Margins positive DOC at 26 mo DOC at 11 mo
(on permanent
section)
Extracapsular DOD at 16 mo DOD at 4 mo
spread
Invasion of Alive at 82 IDO
cervical
musculature
Early recurrence DOD at 10 mo
at primary site
Highest node and DOD at 8 mo
margins
positive

DOD, dead of disease; DOC, dead of other causes; LFU, lost to follow-up.
Reprinted from Lore JM Jr, Kaufman S, Sundquist N, Chary KK: Carcinoma of the head and neck: A 5- to 20-year experience with
preoperative chemotherapy, uncompromised surgery, and selective radiotherapy. Ann Surg Oncol 10:645-653, 2003, with permission.

Four patients had positive margins on frozen section at
the primary site and underwent resection. Of these 4,
only 1 had positive frozen sections on permanent section
and only I patient died of disease.
In a previous clinical trial (Lore et aI., 1989) evaluating
the surgical complications after preoperative chemotherapy
using a regimen similar to regimen A, it was reported
that the surgical complications were no greater and
actually less when compared with historical data of
surgery alone than when combined with preoperative
chemotherapy and selective radiotherapy. Evaluation of
surgical complications were as follows:

TABLE 3-10 Late Postoperative Radiotherapy (N = 12)

Regimen A Primary Site Regimen B Primary Site

Oropharynx Larynx Hypopharynx Oropharynx Larynx

Indication (N = 20) (N = 12) (N = 8) (N = 16) (N = 9)

Recurrence at 3 DOD at 6, 15, 27 mo DOD at 50 mo

primary site
Recurrence in DOD at 35 mo DOD at 71 mo DOD at 16*,
neck 16, 100 mo
Second primary DOD at 18 mo DOD at 75 mo
Metastasis to DOD at 45 mo
contralateral
neck

"'This patient also received early postoperative radiotherapy.

DOD, dead of disease.
Reprinted from Lore JM Jr, Kaufman S, Sundquist N, Chary KK: Carcinoma of the head and neck: A 5- to 20-year experience with
preoperative chemotherapy, un compromised surgery, and selective radiotherapy. Ann Surg OncollO:645-653, 2003, with permission.
 BASIC CONSIDERATIONS

Chemotherapy and radiotherapy are the adjuncts that

TABLE3-11 Non-ute- Threatening Surgk:al require fine tuning. No compromise of the ablative
Complications
surgery should be allowed, regardless of the response
to the preoperative chemotherapy (Fig. 3-18). Regimen
Complication No. (%] B is preferred.
When preoperative chemotherapy is substituted for
Pharyngoesophageal stricture 6 (7) routine, postoperative radiotherapy, this allows the irra-
Dysphagia (functional] 5 (6)
diation to be available for any recalcitrant recurrence.
Prolonged dysphagia 2 (2)
Once a complete therapeutic dose (e.g., 7000 cGy) is
Infection 4 (5]
used as a routine, irradiation no longer should be used
Fistula 3 (4)
Tongue (tethered; limited mobility; 3 (4) with the same ports or overlying ports. One recent
anterior one third slough] report indicates that an overriding port is feasible.
Dehiscence (flap) 1 (1) Radical neck dissection is preferred because specu-
Aspiration pleural effusion 1 (1) lation regarding the extent of the neck disease is thus
Poor wound healing I (I) no longer a worry or possibility. Remember neck recur-
Edema (left upper extremity] I (I) rences are a serious event. Patients in regimen B had no
Intractable pain I (1) neck recurrences. Functional neck dissection is not used
Narrowed cervical esophagus (beyond I (I)
in squamous cell carcinoma of the neck. A supraomohyoid
area of surgery] neck dissection is not even considered. A suprahyoid
Exacerbation of cardiopulmonary problem 1 (I)
neck dissection is used only in selected circumstances.
Total patients 24' (29)
The 11th cranial nerve is preserved if there is no
'Some patients with multiple complications. disease at levels II or IV.
Reprinted from Lore JM Jr, Kaufman S, Sundquist N, Chary KK: As time goes by, modification of regimen B has been
Carcinoma of the head and neck: A S- to 20-year experience with extended to three courses if the chemotherapy is well
preoperative chemotherapy, uncompromised surgery, and tolerated. Other agents, for example, paclitaxel, are
selective radiotherapy. Ann Surg Oncol 1O:64S-6S3,2003, included if the response has been poor to 5-FU. Pre-
with permission.
operative chemotherapy may lessen the requirement
for routine postoperative radiotherapy. Liberal use of
frozen section with immediate re-resection could well
• Minimal to no flap necrosis be a contributing factor in the overall improved sur-
• Minimal incidence of oral cutaneous fistula vival rate.
• Excellent wound healing Another important finding was the area in the clinical
• Absence of carotid artery blowout after surgery (one appraisal of the neck disease relative to both positive
blowout was following late postoperative radiotherapy) and negative lymph node evaluation. There was an error
• Good to excellent surgical anatomic planes especially of 29% relative to clinical negative necks being histo-
around major vessels, thus aiding in preserving the logically positive after neck dissection (see Table 3-5).
major blood vessels This observation is similar to that (27%) reported by
• Improved deglutition and hence improved nutritional Sako and colleagues (1964) in an evaluation of neck
status metastases. There should be a reduction in this clinical
• Improved airway when this has been compromised error as imaging techniques improve with CT, MRI, and
by the neoplasm PET.
• Reduction in the necessity for pretreatment With chemotherapy and radiotherapy, either alone
tracheostomy relative to airway compromise or combined, one never really knows whether the node
was positive or negative, unless a pretreatment fine-needle
Discussion aspiration or open biopsy was performed-the latter,
one hopes, not done unless absolutely necessary. Fine-
Although there were no controls, per se, in the proto- needle aspiration, if negative for malignant cells, may
col, the use of two different regimens, A and B, demon- have missed the malignant cells. The same applies to the
strated regimen B with 5-FU to be better. Regimen A, problem of preoperative chemotherapy as to whether a
then, serves as an internal control, providing evidence cervical node was negative or positive before treatment.
that preoperative chemotherapy can make a difference Unless the pathologist is extremely adept, he or she may
since there is a significant difference between the two not recognize that a positive node favorably responded
regimens (P = .004). to the pretreatment chemotherapy. A finding in the lymph
Aggressive surgery is a sine qua non in the man- node with foreign body granulation reaction, keratin,
agement of advanced head and neck squamous cell but no true keratinization and fibrosis is an indication
carcinoma. All else is complementary to the surgery. that a node was positive before the chemotherapy.

FIGURE 3-18 Photomicrograph of viable tumor cells
(arrow) deep to regenerated mueous membrane in a
patient who had 90% response to chemotherapy
(hematoxylin and eosin, low power). This demonstrates
the importance of tattoo so that the resection includes
the area of the neoplasm before the response to
chemotherapy; otherwise viable tumor cells would be left
behind, leading to recurrence. (Reprinted from Lore JM Jr,
Kaufman S, Sundquist N, Chary KK: Carcinoma of the
head and neck: A 5- to 20-year experience with
preoperative chemotherapy, uncompromised surgery,
and selective radiotherapy. Ann Surg Oneol1 0:645-653,
2003, with permission.)
Another factor in the evaluation of metastasis, which
could be a problem, is a small positive node in a neck
dissection, which may be missed in the evaluation of the
gross specimen. Tracheostomy for obstructing lesions
of the airway is seldom necessary with preoperative
chemotherapy. Local recurrence at the primary site,
neck, and distant metastasis is less. This same finding
of viable tumor cells beneath healed, intact, normal
mucosa has been reported in evaluation of preoperative
chemotherapy in the treatment of rectal carcinoma.
Hiotis and colleagues (2002) said, "A significant per-
BASIC CONSIDERATIONS
centage of complete responders have persistent deep
tumors or nodal involvement." (See Fig. 3-18.)
Additional Comments
As a corollary to the discussion, it appears that wide-
spread use of radiotherapy as a routine postoperative
modality is fraught with the misconception for the
surgeon that margins are of little concern because the
routine use of postoperative radiotherapy will adequately
treat any residual disease. Although radiotherapy plays
an important part in the management of head and neck
squamous cell carcinoma, it is not to be used as a false
sense of security for the surgeon; hence it is believed
that it should not be routine. Another reason for sub-
stituting preoperative chemotherapy for the routine use
of postoperative radiotherapy at the initial treatment
phase is that the radiotherapy would then be available
during the follow-up postoperative phase if indicated.
It is very interesting to note data that were reported
(January 2000) comparing mastectomyjlumpectomy in
younger women and older women. The researcher on
this article, Dr. Frank Vicini of the William Beaumont
Hospital in Royal Oak, Michigan, states, "You have to do
bigger surgeries to make sure you have all the cancer
cells." Vicini concluded by saying, "The postsurgical
radiation cannot compensate for a too-small cut."
Other supports from the literature regarding surgery
as the mainstay are:
1. Beauvillian and co-workers (1997) said, "This study
indicates that a routine conservative approach should
not be performed in patients with advanced squamous
cell hypo pharyngeal carcinoma after neoadjuvant
chemotherapy because surgery offers better results
in terms of local control and survival."
2. Jones and associates (1996) stated, "The most satisfac-
tory treatment is, of course, to completely excise the
tumor at the first operation, and intraoperative frozen
section histologic examination is helpful in achieving
this end." This article was in reference to the manage-
ment of head and neck squamous cell carcinoma.
3. The routine use of postoperative radiotherapy in the
management of lung cancer has been in question, as
reported by the PORT Meta-analysis Trialists Group
(1998) .
4. Forastiere and co-workers (2002) stated, "Aggressive
surgical resection is the cornerstone of therapy, with
increasing roles for both radiation and chemotherapy,
especially for organ preservation."
5. Bruce W. Pearson, of the Mayo Clinic at Jacksonville,
Florida, said of one of the 82 patients in the proto-
col, "Mary is now 11.5 years post-right oropharyn-
gectomy, partial mandibulectomy and right pectoral
myocutaneous flap for squamous cell carcinoma of
the right oropharynx. She had preoperative chemo-
 BASIC CONSIDERATIONS
therapy but no radiation. In summary, Mary is an
outstanding-outcome patient who has achieved, I
am sure, a cure without the long-term indignities of
radiotherapy effect."
All these data, even though some are anecdotal, indicate
that surgery, uncompromised, carefully planned, and all
encompassing, is the important modality in the manage-
ment of not all but most malignant lesions. Chemotherapy
and radiotherapy require fine tuning, and each has a
significant part in the overall planning of the treatment
of squamous cell carcinoma of the head and neck.
Organ Preservation
Most of the data regarding organ preservation are related
to the larynx, with 5-year survival figures scarce. Failure
of that treatment and the surgical salvage with its com-
plications in the report of recurrent disease, which can
be advanced, must be taken into account both in calcu-
lation of survival data, and in explanation to the patient,
regarding this option. The focus of this alternative is on
organ preservation to enhance quality of life while
attempting minimal degradation along with survival.
Whether the latter objective is realistic remains to be
clarified. Review of a sampling from the recent litera-
ture (including sequential and concurrent modalities
and covering the four major primary sites treated in the
present paper) demonstrates three 5-year survivals in
the range from 28% to 47%, a 4-year survival of 60%
(larynx), and a 3-year survival of 51%. Direct com-
parison of these numbers with the present study out-
comes would, of course, not be valid because of non-
comparability in the distributions of patient and disease
characteristics. On the other hand, the authors of the
reviewed studies generally assert the need for signifi-
cant improvements in control of the disease.
One surgeon's (JML) experience indicates the more
serious side effects relative to quality of life perspective
is not from voice loss, which can be handled with
tracheoesophageal device, electric larynx, or, in some
patients, with true esophageal speech, but rather dys-
phagia, which all too often becomes a chronic disability
and extremely difficult to manage long term.
The following references provide valuable data on
organ-preservation survival: Department of Veterans
Affairs Laryngeal Cancer Study Group (1991); Urba and
colleagues (2000); Kim and associates (2001);
Suntharalingam and associates (2001); and Calais and
co-workers (2000).
Summary of Methodology
A summary of the methods that are favorable factors
potentially contributing to improved survival are as
follows:
1. Careful and complete evaluation of the extent of
disease
a. Primary tumor
b. Neck metastasis
c. Distant metastasis
2. Recording of the extent of disease (recording
modalities: tattoo, written description, diagram,
photographs)
a. Primary tumor
i. Size
ii. Ulceration
ili. Mass
iv. Induration
v. Edema
b. Neck metastasis
I. Levels/zones
11. Size
lll. Multiplicity
IV. Bilateral
v. "Fixation"-presence and degree
c. Outline of the planned surgical procedure
3. Chemotherapy-two courses/three courses
a. Modification of dosages based on toxicity using
standard criteria
b. Regimen A is cisplatin and bleomycin
c. Regimen B is cisplatin and 5-FU
d. Addition of paclitaxel and possibility of other
agents as per molecular biology
4. Surgery
a. Area resected based on the pre-chemotherapy
recorded extent of disease, not on any favorable
response to chemotherapy
b. Free use of frozen sections to assess possible
involvement of margins (500 frozen sections on
80 of the 82 patients with 285 at the primary
site and 215 of the neck-58 positive in 26
patients)
c. Review of gross surgical specimen with
pathologist at the time of surgery
5. Postoperative radiotherapy: selective, not routine;
based on criteria published in National Institutes
of Health report (1979)
6. Follow-up-for the lifetime of the patient
a. First year: every month
b. Second year: every second month
c. Third year: every third month
d. Fourth year: every fourth month
e. Fifth year: every fifth month
f. Sixth year and after: two times per year, or
sooner depending on the postoperative course
and histology; for example, sooner at any time
there is recurrence, whether at the primary site,
or the neck, or distant metastasis, or a second
primary tumor
7. Extent of follow-up
a. Complete head and neck examination

b. Annual chest radiograph-preferably CT with
mediastinum in search for metastasis and a
second primary tumor
c. Images-CT and/or MRI of the head and neck;
frequency depends on the clinical history, find-
ings, and final pathology, specifically in relation
to number of nodes positive in the neck
d. Complete head and neck examination to search
for possible second primary tumors, even after
8 to 10 years' survival following first primary
tumor
Comments on the Previous Data by a Reviewer
(Reviewer Unknown to the Authors)
"This is a very thorough and complete study of the
management of advanced stage III and IV squamous
cell carcinoma of the head and neck. It has eliminated
many of the criticisms of studies being at a single insti-
tution by a single surgeon with very standardized surgery
including a standard management of the neck and
primary site performed over a period of 20 years. The
study is nonrandomized between the two arms with the
majority of the cis-platinum/bleomycin patients being
treated earlier in the study and the majority of the cis-
platinum/5-FU patients who had a statistically definitely
better survival, fewer distant metastases in the latter
part of the study.
"The major point of the paper is that preoperative
chemotherapy does not change in any way the need for
the previously-planned surgery. Radiotherapy is given
for specific reasons. The conclusions reached by the
author are far reaching: (1) that preoperative chemotherapy
does not predict the need for less surgery or a potential
better outcome (This, of course, is the mainstay for many
of the current organ preservation regimens that believe
that response to chemotherapy may predict patients
with a potential improved survival or at least an option
to preserve the larynx.); (2) that a standard neck dissec-
tion with preservation of the 11th nerve is required in
all patients who initially had positive adenopathy in
fear that residual malignancy may be missed in the
neck; (3) that preoperative chemotherapy may lessen
the requirement for postoperative radiotherapy; (4)
that preoperative chemotherapy in select patients may
reduce the incidence of distant metastases; and (5) that
it is essential to document the initial extent of the pri-
mary and regardless of the response to the preoperative
chemotherapy: the original area with a large margin
must be resected.
"It is for the reason above that I recommend publica-
tion of this article because of its value in substantiating
the role of surgery as a primary modality not influenced
by the effect of the chemotherapy. It provides specific
survival information when the standard regimen is
used consistently without any variation. It also reflects
BASIC CONSIDERATIONS
the vast experience of a senior surgeon with expertise
in the field of head and neck surgery."
Conclusions
• Improved survival: regimen B: absolute 76.7%, relative
83.4%
• Low incidence of distant metastasis: 5 % regimen B
• No neck recurrence: regimen B
• Recurrence at the primary site: 5% regimen B
• Surgery is a mainstay in the treatment of advanced
squamous cell carcinoma of the head and neck.
Chemotherapy and radiotherapy are important
adjuncts that require fine tuning.
Acknowledgments
The authors thank Ernesto Oiaz-Ordaz, MO, for his
dedicated work in the review of the 93 patients relative
to the initial review in the publication of the 1995 article
(Lore et aI., 1995). We also thank the following Fellows
in Advanced Oncologic Head and Neck Surgery: Frank
Goldzer, Lawrence Teruel, Stoyan Kokocharov, Michael
Medina, Robert Fowler, and Elbastar Mahmoud.
A Comprehensive, Interdisciplinary
Head and Neck Service
-------------- John M. Lore, ir.,
A. Charles Massaro, and Angela Bontempo
One solution to the problem of a joint cooperative effort
in the complete management of the patient with carci-
noma involving the head and neck can be achieved by
the development of a head and neck oncology service.
This service was formed at Sisters of Charity Hospital
in Buffalo, New York, in the early 1990s. This endeavor
requires the dedication and support from administration.
When this latter aspect fails, then this concept of a
patient care, academic, and educational facility no longer
exists. In any event, below is the outline. This was
successful for a period of approximately 8 years.
Over the years, management of neoplastic disease,
as well as other diseases, crosses time-honored estab-
lished disciplines. In head and neck neoplasia, surgical,
medical, and radiation oncology, as well as other sup-
portive disciplines and services are involved. The input
from these disciplines is usually achieved by multidis-
cipline conferences. To further develop this ecumenical
approach, to avoid "turf battles," and to further enhance
cooperative and closer exchange of ideas regarding diag-
nosis and management of head and neck neoplasia, a
Head and Neck Oncology Service within the Head and
Neck Center at Sisters Hospital, Buffalo, New York, was
established in 1993. This service encompasses the above
 BASIC CONSIDERATIONS
disciplines plus all other germane disciplines and services
numbering over 20. The main purpose is to render the
best possible patient care, to attract the best-qualified
physicians and other professionals, thus sifting out the
dabblers, and to promote an academic atmosphere. This
oncology service functions as an autonomous service
with the cooperation and support of the chairman of
Surgery and Internal Medicine. The service, however, is
not a separate department and has no representative on
the executive committee of the hospital. The service is
responsible for its own quality review data, which is sup-
plied to the Continuous Quality Improvement Hospital
Committee. Outpatient, inpatient, speech and swallowing
clinic, and laboratory, physician's, fellow's, nurse clini-
cian's offices, as well as oncologic dentistry and oral
facial medicine, conference rooms, library and nutri-
tionist's office and microsurgical laboratory are all con-
tiguous on the same floor of the hospital. Also on the
same floor is the pathology laboratory, where fine-
needle aspirations can be analyzed and reported within
30 minutes to 1 hour. One floor above is the operating
rooms and intensive care unit. One floor below is diag-
nostic and nuclear medicine. It appears that this
approach to head and neck neoplasia, including thyroid
and parathyroid tumors, truly improves patient care
without the stigma of "treatment by committee" and
avoiding the wasted time involved in "turf" conflicts.
The Head and Neck Oncology Service is a complex
system in which the sum of all the components is much
greater for patient care than is any independent part.
Bone Imaging and Pathology
Scott Cholewinski, John Asinvatham,
Daniel Broderick, and John M. Lore, Jr.
Methods of Bone Involvement: Mandible
1. Direct gross extension of a juxtaposed malignant
neoplasm through intact periosteum and cortex into
the marrow cavity is not very common.
2. More often, the extension is through the site of a
tooth socket, or the periodontal region, or retromolar
trigone or related to an alveolar ridge with absent
dentition. It is very important to have the patient
remove all dentures and to scrutinize areas hidden
by a denture.
3. Another route of bone invasion can be metastatic,
usually the bloodstream. The concept of lymphatic
spread has not been substantiated, although lym-
phatics may be demonstrated in periosteum accom-
panying the small arteries.
4. When periosteum is involved by tumor, the tumor
cells can enter the cortical bone through Volkmann's
canals and into the haversian system and then into
the marrow (medulla).
5. Involvement may occur through neurovascular
foramina.
There is paramount concern regarding the mandible
in the absence of direct gross invasion of the perios-
teum and cortex when there is a malignant juxtaposed
neoplasm. This is an increased concern when there are
varying degrees of fixation and extent of fixation to the
mandible.
Decisions regarding mandibular resection are based
on the following:
1. Juxtaposed neoplasm fixed to the bone
2. Imaging
a. Routine standard radiographs, as well as CT, will
only demonstrate a grossly ulcerative lesion of
the cortex.
b. MRI, in the absence of grossly ulcerative cortical
lesion, can be of help to the surgeon regarding a
decision of mandibular resection-segmental or
marginal with preservation of the mandible.
An MRI can indicate a pathologic process if there is
a change in the marrow. Normal marrow has a whitish
color comparable to adipose tissue on Tl-weighted image
due to marrow fat content. Abnormal marrow has a grayish
discoloration. This could be caused by edema, neoplasia,
inflammation, or other diseases. Thus, when there is a
neoplasm juxtaposed to the mandible and there is abnor-
mal marrow on MRI, mandibular resection is indicated.
Fixation of the neoplasm lends further support to the
decision to resect. Fixation alone is a judgment call: it is
better to err on resection of a portion or margin of the
mandible than assume the attitude of wait and see or use
postoperative radiation therapy. Intraoperative smears
of the marrow at the ends of a marginal resected area
may be worthwhile to histologically evaluate the presence
or absence of abnormal marrow cells.
Figure 3-19 is a schematic sketch of an MRI cross
section of mandible, demonstrating (I) juxtaposed neo-
plasm involving muscle; (2) periosteum (black line);
(3) cortex (black line); (4) marrow; (5) cortex (black
line); (6) periosteum (black line); and (7) juxtaposed
neoplastic process.
This drawing illustrates a muscle with evidence of
invasion by neoplasm that is adherent to the periosteum
(the narrow black line). The cortex appears intact, yet
the marrow is grayish rather than its typical white appear-
ance. This is a suggestion of infection or neoplasia or
some other disease within the marrow when using a
Tl-weighted image. This finding, plus the muscle with
neoplasia adherent to the periosteum, is an indication
to resect bone. In addition, an abnormality of the perios-
teum is suggested with a high signal on the T2-weighted
image. The heavy black lines in the schematic repre-
sent the cortex along with the periosteum seen on the

~
Periosteum ~ '\ }
@ Cortex
® Cortex } _
Periosteum ~
FIGURE 3-19
MRI. The smaller axial image with the two heavy black
lines equates once again the cortex and the surrounding
periosteum. Note that the marrow is not white but
grayish. (Drawing courtesy of Daniel Broderick, MD.)
Involvement of periosteum is an indication to remove
the underlying cortex, because if adjacent cortex remains,
the margin would then be a to 1.0 mm and hardly ade-
quate. This would be the error if involved periosteum
were stripped from the cortex with a periosteal elevator.
One answer to this dilemma is treatment with ionizing
radiation postoperatively. Some surgeons (e.g., JML) do
not agree: it is better to remove the adjacent bone and
the margin if possible or perform segmental resection
of the mandible with reconstruction. This appears to be
more valid in the younger patient, because the long-
term effect of radiotherapy is questionable. Imaging
evaluation with MRI is very valuable, because involve-
ment of periosteum can at times be readily ascertained.
Actual erosion of the cortex can occur but is not very
common. The periosteum, which is juxtaposed to the
tumor, may well be involved with the neoplasia. CT
(using bone windows) is the basic imaging for cortical
involvement, whereas MRI is ideal for evaluating marrow
and periosteum.
Dr. Broderick writes, "On routine Tl-weighted mag-
netic resonance (MR) images, the cortex and the marrow
of the bone are easily distinguished with the decreased
Tl signal intensity of the dense cortical bone and the
increased Tl signal intensity of the fatty marrow. The
periosteum is rarely evident as separate from the adja-
cent cortex. The increased Tl signal intensity of normal
fat adjacent to the cortex/periosteum is readily visual-
ized. When tumor extends to the cortex and obliterates
the adjacent fat, invasion of the periosteum and bony
cortex cannot be excluded. Altered signal intensity of
the marrow (namely, decreased Tl and increased T2
signal intensity) may reflect marrow edema and/or
neoplastic invasion."
BASIC CONSIDERATIONS
----
Voice, Speech, and Swallowing
Rehabilitation of the Head and
Neck Patient
Allen M. Richmond
The speech pathologist's role in working with the head
and neck patient appears to grow out of real day-to-day
clinical concerns. The head and neck surgeon may meet
situations that demand time-consuming and compre-
hensive solutions. The problems that develop may need
a model based on crisis intervention for solution, as
proposed by Salazar-Sanchez and Stark (1972) for the
laryngectomy patient. Other types of problems, even
those involving extensive head and neck surgery, may
involve less complicated, but appropriately timed inter-
vention to maximize rehabilitation potential.
Total Laryngectomy
Evaluation, treatment, and rehabilitation of the laryn-
gectomized patient involve a comprehensive approach
that takes into account the psychosocial concerns as well
as the physical limitations of the patient. Significant
depressive reactions can occur as a result of surgery for
cancer. Sutherland and Orbach (1953) relate postopera-
tive depression to a sense of injury and often to impor-
tant changes in the patient's functioning in the life
situation. Conley (1985), in discussing the changes that
occur as a result of surgical intervention in head and neck
cancer, states that "It automatically generates fear, depres-
sion, and possible annihilation mixed with hope for cure,
palliation programs, experiments, philosophies, calcu-
lations, emotions, and fantasies which the doctor and
the patient can have regarding this confrontation." He
further states that "regardless of the amount and quality
of external support, [the patient] is singular and alone."
Preoperative visitation by the speech pathologist
with a focus on the method and timing of the visit may
 BASIC CONSIDERATIONS
be helpful (Richmond, 1982). In addition, a visit by a
laryngectomized patient can be arranged by the speech
pathologist, who should find a suitable visitor that may
share some common connection with the patient.
Information on a wide variety of areas facilitates the
informed consent of the patient. Discussion and descrip-
tion of types of alaryngeal communication, such as the
artificial larynx and other augmentative communication
devices, esophageal speech and the tracheoesophageal
puncture (TEP), may be helpful. The AIdes and Lowry-
Romero protocol (1982) includes a review of physical
and lifestyle changes such as taste, smell, bathing,
showering, coughing, throat clearing, lifting, dry nasal
passages, hygiene, sex, smoking, drinking, first aid,
humidity, cold air, and care of the stoma.
Methods of Communication
Artificial Larynx and Other Augmentative
Communication Devices
Initial communication efforts can be facilitated through
the use of an artificial larynx, either intraoral or trans-
cervical, communication charts, and writing materials,
such as a dry erase board and marker. Excellent low-
cost word processing units are of help to some patients.
Patients who are unable to acquire skills necessary to use
the telephone can use e-mail, fax, prerecorded messages,
answering machines, and special automated emergency
call systems to provide some help. Illiterate patients
may experience considerable frustration until they can
be evaluated and fitted for an artificial larynx. Interpreters
can assist patients whose primary language is different
from that of the speech pathologist or physician. Bilingual
family members can frequently be an asset in bridging
the linguistic gap. They may be helpful throughout the
therapy process in explaining therapy techniques,
describing options, and defining therapy goals.
Esophageal Speech
Esophageal speech continues to form a part of the com-
munication rehabilitation process for some patients,
although it is no longer the method of choice in the
United States. Webster and Duguay (1990) reported on
1003 laryngectomy operations performed across the
nation: the most prevalent type of post-laryngectomy
speech used was "tracheoesophageal shunt speech," now
commonly referred to as tracheoesophageal puncture
(TEP), at 38.1%. Weinberg (1981) estimated that 25%
to 50% of patients do not learn serviceable esophageal
speech. Patients are not able to learn serviceable
esophageal speech because of such factors as cranial
nerve involvement, strictures, flaccid pharyngoesophageal
segment, hiatal hernia, achalasia, poor diaphragmatic
movement, stomach ulcers, and emphysema (Duguay,
1979). In a similar context Damste (1979) reports pos-
sible factors limiting the learning of esophageal speech,
which include wound healing, diverticula, fistula, and
amount of tissue in the pharyngeal wall.
Tracheoesophageal Puncture
The TEP is a primary consideration for voice restora-
tion with the post-laryngectomy patient. Considerable
improvement and development of TEP methods have
been effected, dating back to the early innovation of
the externally placed valve, which can produce finger-
free fluent speech. Blom and colleagues (1982), 810m
and Hamaker (1996), and Hilgers and associates (1995)
have improved the technology, with the first handmade
device introduced by Blom and Singer in 1978 to the
most recent designs and equipment innovations.
A preliminary insufflation test is effective to determine
potential for cricopharyngeal spasm before surgery.
This difficulty may preclude successful surgery unless
myotomy or neurectomy is carried out to facilitate air
flow through the neoglottis (see Chapter 20). Botox
injection is now a method of choice for reducing spasm
(BJom and Hamaker, 1996).
Conservation Surgery: Cancer of
the Larynx
Conservation surgery for cancer of the larynx may require
voice refinement procedures (Doyle, 1997), special
vocal treatment strategies focusing on specialized types
of tracheotomy tubes, and augmentative communicative
procedures (Mason, 1993) and/or special swallowing
diagnostic and therapy procedures (Richmond, 1997).
On occasion, patients may be placed on ventilators,
both preoperatively and postoperatively. Doyle (1997)
refers to improved diagnostic procedures for malignant
lesions and more accurate identification of histologic
character, loci, and spread of disease that result in an
altered conceptual framework for treatment. Important
goals of treatment can involve sphincteric and phonatory
functions that include safe swallowing, adequate nutrition,
and postoperative voice conservation (Bailey, 1985).
Swallowing
Swallowing Problems
Swallowing difficulties often accompany conservation
surgery procedures. These swallowing difficulties may
be amenable to special techniques of management.
Logemann (1993) stresses the importance of relating
the swallowing dysfunction to the exact extent of the
patient's surgical resection to account for variations in
surgical procedure. Richmond (1992) reviewed the swallow

status of patients who had oropharyngeal dysphagia.
He found that patients with posterior tongue and pha-
ryngeal surgery had the poorest swallow rehabilitation
results.
Problems that mayor may not result in aspiration
include delayed pharyngeal swallow reflex, delayed ele-
vation of the larynx, inability to protect the larynx by
vocal fold closure, cricopharyngeal dysfunction, incom-
plete or delayed velopharyngeal closure, limitations in
pharyngeal motility, pharyngeal and esophageal pressure
deviations, and general timing dysfunction. Pharyngeal
and esophageal pressure deviations are often minimized
in evaluation and treatment, but they are important facets
of swallow function. In a study of pressure function,
McConnel and co-workers (1988) report on manofluo-
rographic analysis of swallowing. They studied the
pharyngeal swallow with strain gauge pressure sensors
that recorded pressure, anatomic events, and bolus
transit on videotape, in coordination with lateral view
fluoroscopic swallow study recorded on the left side of
the video screen. They determined that an important
factor for the pharyngeal swallow is the establishment
of a pressure gradient for bolus passage. The oropharynx
generates a propulsive pressure and the hypopharynx
generates a negative pressure. The analysis of this two-
pump system facilitates a means for more precise quan-
tification of swallow function.
Multi-faceted swallowing difficulties are diagnosed
through instrumental assessment. Instrumental assess-
ments of swallow function include videofluoroscopy,
flexible fiberoptic endoscopy, ultrasound, electromy-
ography, electroglottography, and the measurement of
temporal association between respiration and swallowing
(Perlman, 1997). Additional instrumental imaging tech-
nologies may include scintigraphy, X-ray microbeam,
MRI, real-time assessment of lateral pharyngeal wall
movement, computer-assisted assessment of hyoid bone
movement, three-dimensional ultrasound, image seg-
mentation and volume determination, and quantifica-
tion of echogenicity of the tongue (Watkin and Miller
1997). Fiberoptic endoscopic video examination, com-
bined with a delivered air pulse, can aid in determining
laryngopharyngeal sensory discrimination thresholds
and provide a means for examining the sensory and
motor aspects of swallow function (Aviv et aI., 1998).
Some of the procedures are not used commonly for
clinic examinations and are applicable to research at this
time. Clinicians need to be aware of the scope of assess-
ments to assist in development of therapeutic protocols.
Medication Effects
Feinberg (1997) reviews medications that can have detri-
mental effects on swallowing function. The brain stem
for swallow reflexive function, cortex for voluntary oral
phase function, and sensory feedback mechanisms in
BASIC CONSIDERATIONS
the oropharyngeal area act in a coordinated way for
swallow function. Medications that affect these func-
tions can impede the swallow mechanism. Each patient's
medications should be reviewed because they may
involve mental status changes, confusion, and/or seda-
tion. Drugs may increase or decrease esophageal pres-
sure, such as antacids (produce pH-dependent increase
in lower esophageal pressure), alcohol (decreases lower
esophageal pressure), drugs that increase or decrease
skeletal muscle function (long-term use of corticosteroids
can cause skeletal muscle wasting), and drugs that
decrease food intake (antivirals or certain antibiotics
that cause stomatitis). Some diseases and problems
are treated with medications that cause or exacerbate
oropharyngeal dysphagia (e.g., Parkinson's disease,
hyper/hypothyroidism, steroid myopathy, alcoholic myo-
pathy, diabetic neuropathy, inflammatory myopathies,
and myasthenia gravis).
Gastroesophageal reflux disease (GERD) may relate
to excessive or prolonged or intermittent relaxation of
the lower esophageal sphincter (LES). The LESprovides
a barrier to the reflux of gastric contents. The elimina-
tion of irritating foods or drugs that lower LES pressure
may be helpful. Additionally, inability to clear refluxed
acid from the esophagus due to decreased esophageal
motility and diminution of saliva may be contributory
to GERD. Alcohol taken before lying down may also
contribute to reflux disease.
Odynophagia may be the result of esophageal injury,
but it can also be caused by a tablet or capsule lodging
in the mucosal wall of the esophagus. Xerostomia may
cause food to stick in the throat or difficulty chewing.
Videofluoroscopic swallow study (VFSS) is widely
used and considered the gold standard to define pharyn-
geal physiology (Logemann, 1983, 1986, 1993; Perlman,
1997). The study begins with presentation of 1 mL of
liquid barium and progresses to 3, S, and 10 mL. This
study has been shown to be a safe and effective way
of assessing oral and pharyngeal swallow function
(Logemann, 1993). It is important to reestablish swallow
function in as natural and timely a manner as possible
with proper diet and without unduly stressing the
patient. Dietary control is an important dimension of
swallowing treatment.
The rationale for dietary control appears to relate to
the body being able to make natural accommodations
or compensations for food intake, providing the food
intake is properly controlled. Involuntary and voluntary
compensatory movements are likely. The structures
"affected less by the disease process work harder to
avoid aspiration, excessive retention of bolus in the
pharyngeal cavity or nasal regurgitation" (Donner, 1988
[po 2]). Decompensation may occur if the disease pro-
gresses or, possibly, if the system is not used for long
periods of time and the musculature atrophies (Donner,
1988).
 BASIC CONSIDERATIONS
According to Logemann and colleagues (1992), head
and neck cancer patients accommodate small amounts
of aspiration with pureed foods. [n studying outcome
measures of swallowing rehabilitation in head and neck
cancer patients, these researchers state: "This tolerance
may result from good ciliary action or strong cough which
clears the aspirated material from the tracheobronchial
tree sometime later or may relate to the patient's
mobility and general good health" (p. 185).
The use of a staged diet, the Abbott Northwestern
Staged Diet (Felt and Anderson, 1989), was reviewed
for 36 head and neck surgical patients (Richmond,
1992). The diet controls for elasticity of, particulates in,
and viscosity of foods. The treatment of dysphagia
appeared most effective when specific dietary planning
was incorporated.
Temporary nonoral feeding may be particularly
important in the management of head and neck surgery
patients. Kirsch and Sanders (1988) report studies in
patients undergoing abdominal surgery that indicate a
IS % incidence of pneumonia as compared with a 1.5 %
incidence in patients without a nasogastric tube. They
further discuss a possible resultant incompetence of
the upper and lower gastroesophageal sphincters, with
regurgitation and aspiration of gastric and pharyngeal
contents. An associated 32 % incidence of edema is
reported with the nasogastric tube. The potential for
postcricoid inflammation and resultant chondritis and
laryngeal dysfunction is mentioned. The timely use of
PEG can measurably improve the speech pathologist's
ability to work with the dysphagia patient. Combined
oral and nonoral feeding may be an initial step, because
patients can have delayed pharyngeal onset owing to
postoperative pharyngeal edema. They may have more
difficulty in the controlled moving of very thin liquids
through the pharynx into the esophagus, owing to
delayed pharyngeal swallow onset. Thickening of liquids
is advised for some patients, whereas others may react
against "drinking" thickened liquids, which are changed
into a puree. The potential for dehydration must be con-
sidered. Quality of life can be improved with improved
swallow function, a byproduct of the combined oral
and PEG feeding approach.
A problem relative to swallowing management with
the nasogastric feeding tube may result from the use of
a tracheal cuff. Complications and hazards in use of a
tracheal cuff include total occlusion of the airway, her-
niation of the tracheal mucosa, tracheal stenosis, granu-
loma formation, tracheal erosion, tracheal malacia,
necrosis, erosion of the innominate artery, and tracheo-
esophageal fistula (Mason, 1993). Current tracheotomy
tubes are manufactured with low-pressure high-volume
devices that distribute the cuff seal over a larger area
with lower pressure. Tracheostomy tube cuffs should not
exceed pressures of 25 mm Hg against the tracheal wall,
and in some cases minimum pressures can be lower
depending on the patient's trachea size (Mason, 1993).
Glossectomy
Increased survival rates for glossectomy patients
(Lauciello et a\., 1980) have led to increased need for
speech-language intervention. Annually, 15,000 people
are diagnosed with oral cancer and carcinoma of the
tongue. This type of cancer is second only to lip cancer
as the most frequent type of oral cancer.
Recent advances in chemotherapy and irradiation
may have made preoperative speech consultation and
informed consent for total glossectomy more important
than previously. The patient may want and needs to
know the communicative implications involved after glos-
sectomy. Discussion of implications of speech therapy
and potential communication difficulties can facilitate
patient understanding.
Paulowski and colleagues (1993) emphasize the
importance of effectively counseling patients with oral
and oropharyngeal cancer before surgery as well as plan-
ning and assessing appropriate rehabilitation strategies.
Further data on functional outcomes for specific surgical
resections and reconstructions are needed. Sixteen
patients with anterior oral cavity lesions, resection of
the anterior tongue and mouth, distal flap reconstruc-
tion, and maintenance of the mandibular arch showed
no improvement by 3 months post healing. The lack of
improvement in speech and swallowing function in
these severely impaired patients suggests that speech-
language pathologists should be aggressive in the estab-
lishment and maintenance of a treatment program in the
immediate postoperative period. The aggressive program
is important or critical if the patient is receiving post-
operative radiation therapy.
Differences in prognosis for speech communication
recovery can relate to the portion and amount of the
tongue removed. Skelly (1972) described numerous com-
pensatory procedures for improving speech intelligi-
bility after glossectomy. When tongue tip, or a portion
of the tongue tip, can be retained, speech intelligibility
may be better. lmprovements in technology have facili-
tated communication through the use of fax machines,
speech synthesizers, and TOO devices. Implications for
swallowing post glossectomy also need to be discussed
with the patient. Special dietary adaptations such as
processing food in a blender or permanent nonoral
feeding may be indicated. Preoperative visitation by a
rehabilitated glossectomy patient may be helpful in pro-
viding a basis for improved or increased understanding
of the pending surgery and its implications.

Palatal Surgery
Velopharyngeal Function
Bzoch (1989) discusses an overall treatment protocol
for optimal standards of care for cleft palate, cleft lip,
and craniofacial anomalies:
1. Surgery to correct clefts of primary palate and lip,
usually at 2 to 3 months; continued involvement of
comprehensive evaluation team approach, in a com-
plete care center, that includes genetic counseling,
audiometric evaluation, language and speech stimu-
lation, and dental evaluation and care
2. Complete closure of hard and soft palate by 12 months,
if possible; assessment and monitoring of function
and comprehensive team monitoring
3. Focus on motor speech and expressive language skill
development and audiologic monitoring from 18 to
24 months
4. Continued team reevaluations; evaluation of velopha-
ryngeal function with video fluoroscopy and/or video
nasopharyngoscopy; possible referral to early educa-
tional setting (e.g., Head Start, pre-kindergarten, or
day care in third year); possible speech and language
therapy
5. In fourth year, if continued velopharyngeal insuffi-
ciency, for normal speech and language, considera-
tion of secondary surgical or prosthetic correction;
continued speech-language skill reevaluations and
therapy; continued team care
6. In fifth year, team visit and reevaluation at 6-month
intervals; pediatric health care review
7. In sixth year, necessary speech and language therapy;
continued pediatric health care review; orthodontic
and surgical treatment procedures necessary
8. In early adolescence, possibly lip revisions, rhino-
plasties, and alveoloplasties with bone grafts; continued
team care; psychosocial counseling recommended.
Palatal Ablation, Revision, or Velopharyngeal
Compromise
Surgical procedures that involve palatal ablation or
velopharyngeal compromise can predispose the patient
to hypernasality and significant limitations in speech
intelligibility. Additionally, intraoral pressure diminution
can result in diminished swallow function.
Videofluoroscopic examination of velopharyngeal
function can be approached in a comprehensive way,
as discussed by Witzel and Stringer (1989), with two or
three views: a lateral view, an oblique Towne view, or
a frontal Waters view. Video nasopharyngoscopy can
give information on the anatomy of the velopharyngeal
valve, closure patterns during speech, and the relative
BASIC CONSIDERATIONS
size and location of velopharyngeal gaps. Assessment of
consistency and specifics of movement and the function
of the dorsum and posterior tongue during speech can
be noted. Additionally, the anatomy and function of the
laryngeal structures can be observed. The videotape is
invaluable for further study and analysis. Aerodynamic
measurements can provide additional information
about velopharyngeaI function. Air pressure transducers
can measure relative nasal and oral pressures with flow
glottography. When questions of velopharyngeal function
arise before adenoidectomy or tonsillectomy, instrumental
procedures may be helpful in preoperative assessment
and the prevention of significant hypernasality. If there
are swallow problems, routine protocols are followed.
Recommendations are made on the basis of clinical and
instrumental findings.
Voice
Voice disorders are common not only in patients after
head and neck surgery but also in the general population.
Ramig and Verdolini (1998) refer to studies showing
estimates of voice disorders ranging from 3 % to 9 % of
the total population. According to the National Center
for Voice and Speech (1993), 24.49 % of the total
population (or 28,269,000 people) are reported to have
jobs that "critically require voice use"; 3.29% of the
population (or 3,840,000 individuals) have occupations
(e.g., air traffic controller, police, pilot) in which their
voice is necessary for public safety.
History taking and acoustic and perceptual assess-
ment are critical aspects of voice evaluation. Morrison
and Rammage (1994 [po 2]) state: "In our experience,
for the majority of cases it seems advisable to have the
otolaryngologist and speech pathologist see patients
together, from the outset, each bringing their own
professional skills to the evaluation process."
Another area of evaluation was examined by Jacobsen
and colleagues (1997 [po 69]). They studied the psychoso-
cial consequences of voice disorders and developed the
Voice Handicap Index (VHI). The test, according to the
authors, demonstrates "strong internal consistency,
reliability, and test retest stability."
Some voice disorders may lend themselves to surgical
intervention and careful preoperative and postoperative
assessment. These disorders include, but are not limited
to, laryngeal tumors (benign or malignant), papilloma,
vocal nodules, vocal polyps, contact ulcer, granuloma,
mucosal bridges, cysts, web, cricoarytenoid joint
problems, and vocal fold paralysis.
Preoperative and postoperative thyroidectomy voice
evaluation and electromyography are important (Cernea
et al., 1992). Women and professional singers are reported
to demonstrate impaired production of high tones and
 BASIC CONSIDERATIONS
altered speaking at fundamental frequency after thyroid
surgery (Hirano, 1988). Voice evaluations were per-
formed on patients who underwent thyroidectomy.
Measures were derived from laryngeal stroboscopy,
which included fundamental frequency, the lowest and
highest frequency, vocal range, and a number of phona-
tion time measurements. Deterioration in vocal perfor-
mance was noted in patients with complete lesions of
the external branch of the superior laryngeal nerve,
subsequent to thyroid surgery.
According to Morrison and Rammage (1994 [po 10]),
"The comprehensive acoustic evaluation includes
assessment of pitch, loudness, rate/duration and quality
parameters of phonation and speech." Popular exami-
nation includes history taking and analysis, videostro-
boscopy, electroglottography, flow glottography, and,
when vocal cord movement is of diagnostic importance,
electromyography.
Vocal Therapy and Vocal Management
Treatment efficacy in voice disorders is focused on data-
based research articles through group designs, single-
subject experimental designs, retrospective analyses,
case studies, and program evaluation data (Ramig and
Verdolini, 1998). Experimental and clinical data exist to
support the effectiveness of voice treatment for voice
disorders related to vocal misuse, hyperfunction, and
muscular imbalance. Voice disorders include those with
organic changes, special medical or physical conditions,
and psychological causes. Pannbacker (1998) reviewed
voice treatment techniques and outcomes and states that
voice treatment depends on diagnostic category, client
characteristics, and the preference of the clinician. Larson
and Mueller (1992) surveyed speech pathologists for
preferences in treatment approaches and ranked them
in the following order: counseling, vocal abuse elimina-
tion, hard glottal attack, relaxation, changing loudness,
pushing, yawn-sigh, ear training, establishment of new
pitch, and digital manipulation of the larynx.
Hearing, Cochlear Implants, and
Middle Ear Surgery
Cochlear Implants and Rehabilitation
Less than 1 % of 15 million people in the United States
with significant hearing impairment are candidates for
cochlear implant (National Institutes of Health, 1988).
Outcomes in children following cochlear implants are
varied (Carney and Moeller, 1998):
1. Children receiving implants before 5 years of age using
nucleus multielectrode cochlear aids and educated
in a total communication environment that encouraged
speech and signs to be used simultaneously had
more accurate production of vowels and consonants
than children who did not receive implants.
2. With single-electrode and multielectrode cochlear
implants, tactile aids, or hearing aids, better speech
intelligibility was associated with earlier implant fitting
(before adolescence) and better ability to perceive
speech.
3. Adult clients and patients who received various
types of multi electrode cochlear implants achieved
high levels of speech perception skill for sound and
word recognition.
4. Use of auditory information and feedback from a
multi electrode cochlear implant alone did not suffi-
ciently reduce deviant speech behaviors. Combined
behavioral treatment program with a sensory aid
was necessary to effect speech improvement.
5. A cochlear implant promoted language development
to a greater extent than would be predicted by
maturation alone.
6. Children using hearing aids who had severe to
profound hearing loss, in the range of 90 to 100 dB,
demonstrated speech perception and production skills
superior to the best performers with cochlear implants.
However, more recent research indicates the gap is
closing faster, because this group of children with
cochlear implants gain listening experience with
their devices.
Middle Ear Surgery: Medical, Audio/ogic, and
Speech Follow-up
Sullivan and Sullivan (1998) discussed surgical artifacts
and iatrogenic anomalies in the context of demonstrating
the utility of video otoscopy. They refer to postauricular
mastoid bowl defects and scar after mastoidectomy, seb-
orrheic residue, collapsing canal, extended and extruding
pharyngoesophageal tubes, extruding wire stapedectomy
prosthesis, fenestration cavity, and other problems.
An important part of management of postoperative ear
problems is a follow-up reassessment. The American
Speech-Language-Hearing Association Guidelines for
Identification Audiometry with children from 4 years of
age to grade 3 indicate that children who have had a
myringotomy and other surgical procedures involving
the ear should be followed with periodic hearing
examinations and communicative assessments.
"Once people have been identified by the program,
they should be followed regularly to ensure that their
communication and medical needs are met. It is point-
less to identify people who have hearing impairments
unless there is a concurrent follow-up program to
handle their habilitative educational and medical needs"
(American Speech-Language-Hearing Association,

1985 [po 50]). The audiologist and speech-language
pathologist can assist the otolaryngologist in this regard
with regular checkups and intervention as needed.
Psychosocial Support
The speech pathologist, in addition to providing com-
municative assistance, can offer support and encour-
agement when appropriate or needed. A person or family
in crisis becomes more susceptible to the influence of
"significant others" in the environment. Significant
depressive reactions can occur as a result of surgery for
cancer. Sutherland and Orbach (1953) relate the post-
operative depression to a sense of injury and often to
important changes in the patient's functioning in his or
her life situation.
A person or family in crisis becomes more susceptible
to the influence of "significant others" in the environ-
ment (Rapoport, 1971). Specific suggestions to assist
the cancer patient in discussing feelings and thoughts
appear applicable to patients with other types of disorders
as well. Suggestions to staff and caregivers include, but
are not limited to, the following:
• To develop a caring and understanding relationship
with the patient that can make communication easier
for both patient and staff
• To model expressive and open communication about
feelings in a considerate way
• To gently reflect some of the feelings that the patient
may be expressing indirectly
• To reinforce through words, gesture, and/or touch
any appropriate expressiveness manifested by the
patient
• To openly state that there are things the patient may
not be willing to discuss immediately and that the
staff members and caregivers recognize and respect
this need
Summary
The head and neck surgery patient can be helped before
and after surgery in many different ways, utilizing a
number of different support systems, specialists, and
methodologies. The author is familiar with the approaches
and means of helping that the speech pathologist may
offer these patients. It is hoped that the above discus-
sion will assist in the recognition and understanding of
these services. The review is not entirely inclusive but
may provide a basis for improved communication and
understanding between the physician, rehabilitation
personnel, and speech pathologist, resulting in improved
patient care.
BASIC CONSIDERATIONS
Malignant Melanoma
Constantine P Karakousis
There has been a considerable increase in the incidence
of malignant melanoma over the past 3 to 4 decades.
The lifetime incidence now is about 1 in 90. There are
about 38,300 new cases of invasive melanoma and
30,000 to 50,000 cases of in situ melanoma diagnosed
annually in the United States (Rigel, 1996). Therefore,
this is no longer a rare neoplasm. The only known
causal agent in the formation of malignant melanoma
is exposure to ultraviolet light (290 to 320 nm UVB
range) (Walter et aI., 1990). There is a higher incidence
of malignant melanoma in latitudes closer to the equator.
It is also more common in people with light skin color.
The four major growth patterns of melanoma are super-
ficially spreading melanoma (70% of cases), nodular
melanoma (15 % to 30 %), acrallentiginous melanoma
(2% to 8%), and lentigo maligna melanoma (4% to 10%).
Nodular melanoma is characterized by a rapid vertical
growth phase and has a high incidence of metastases
and a worse prognosis. Lentigo maligna has a better
prognosis, other factors being equal.
Microstaging of the Primary Melanoma
The previous morphologic description of the growth
pattern of malignant melanoma has been superseded
by the more accurate microstaging system provided by
new methods of classification of the primary lesion. The
method by Clark and colleagues (1969) classifies the pri-
mary melanoma according to the skin layer involved by
the malignant process: levell-melanomas confined to
the epidermis (in situ melanoma); level2-penetrating
through the basement membrane to the papillary dermis;
level 3-penetrating into the interphase between papillary
and reticular dermis; level4-penetrating into the reticular
dermis; level 5-penetrating into the subcutaneous fat.
Breslow's method (1970) relies on the direct measure-
ment of the thickest cross section of melanoma meas-
uring the depth of the lesion in millimeters from the
granular layer of the epidermis to the deepest extent of
the tumor. Melanomas less than 0.76 mm thick have a
5-year survival and an overall cure rate in the range of
approximately 98 %. Generally, melanomas are consid-
ered thin when they are less than 1 mm thick, of inter-
mediate thickness when 1 to 4 mm thick, and thick when
they are over 4 mrn in thickness (Balch et al., 1978). There
is a correlation between Clark's method and Breslow's
method of classification, and both of them correlate with
recurrence rates and survival. However, of the two
methods, Breslow's method correlates more closely with
survival than Clark's method does (Balch et aI., 1978).
 BASIC CONSIDERATIONS
5taging
The staging of malignant melanoma depends on the
micro staging of the primary lesion and the presence or
absence of metastases to regional lymph nodes or distant
sites. Thus, stage I melanoma (NO, MO) includes
melanomas less than 0.75 mm (IA) and those 0.76 to
1.5 mm (IB) in thickness; stage II (NO, MO) includes
melanomas 1.6 to 4 mm (IIA) and those thicker than
4 mm (lIB); stage III (any T, NI, MO) is that of any
thickness with limited regional node metastases or fewer
than five in-transit lesions; stage IV includes melanomas
of any thickness with advanced regional or distant
metastases (any T, N2, or M1) (Ketcham et aI., 1992).
Treatment of the Primary Lesion
The surgical treatment of malignant melanoma depends
on the microstaging of the primary lesion. Thus, for
melanomas less than 1 mm thick, a I-em lateral margin
is perfectly adequate in securing local control (Veronesi
and Cascinelli, 1991). In a large prospective randomized
study, comparing a 2-cm lateral margin with a 4-cm
lateral margin, the local recurrence rate was the same
in both groups (i.e., approximately 4%), and therefore
a 2-cm margin is preferable by virtue of improved
cosmesis and decreased morbidity (Karakousis et aI.,
1996). Melanomas thicker than 4 mm are treated with
2- to 3-cm margins, the concern for local recurrence in
these lesions being overshadowed by their high
propensity for regional and distant metastases.
In European reports, it has been recommended that
a I-em lateral margin is adequate for lesions up to 2 mm
(Veronesi and Cascinelli, 1991). Of course, in the head
and neck area, particularly in the area of the face,
traditionally narrower margins have been adopted.
Local Recurrence and In- Transit Lesions
Local recurrence is associated with a high rate of sub-
sequent metastatic disease and the death of the patient.
The mortality rate of local recurrence in one prospective
randomized series was 80% (Karakousis et aI., 1996).
However, there has been some evidence that the location
of the local recurrence might be of prognostic importance.
That is, recurrences occurring within the surgical scar
may have a much better survival (i.e., about 80% with
further wide excision) (Brown and Zetelli, 1995;
Drzewiecki and Andersson, 1995). Melanomas that recur
at a distance from the surgical scar of the first operation
have a higher rate of recurrence and mortality. Local
recurrence is considered a recurrence within 2 em from
the previous surgical scar. Lesions appearing beyond 2
em from the surgical scar are classified as in-transit
lesions when they occur between the primary lesion
and the regional nodal basin. In-transit lesions are not an
uncommon manifestation of recurrence from malignant
melanoma owing to trapping of melanocytes within the
subcutaneous lymphatics and growth of a melanoma
within this site. In-transit lesions are more common
after node dissection due to stasis in the lymphatic flow
occurring, with recurrences as high as 18 % in the same
extremity after groin dissection for positive inguinal
nodes. Local recurrence or satellite lesions around the
primary site and in-transit lesions should be treated
surgically whenever feasible (Karakousis et aI., 1980).
In the extremities, hyperthermic perfusion is also another
modality of treatment for the management of in-transit
lesions.
Regional Lymph Nodes
Elective Dissection
In the case of a clinically localized melanoma after con-
sidering the margin of resection according to thickness,
the other major consideration is the management of the
. regional lymph nodes. In the past it was believed that,
since about 20 % of the intermediate thickness melanomas
and a higher rate of the thicker lesions present later
with disease in the nodal basin, elective dissection
might improve survival for some of these patients. Two
prospective studies, however, failed to show any
improvement in survival comparing the patients who had
elective dissection with observation and lymphadenec-
tomy only for those patients who later developed
palpable nodes (Sim et aI., 1978; Veronesi et aI., 1977).
The problem with the elective node dissection is of
course that the majority (i.e., approximately 80% of the
patients) do not have microscopic disease in the regional
lymph nodes and, therefore, they have an unnecessary
operation. The largest and most recent prospective ran-
domized study showed no overall difference in survival
in patients who had elective resection and those submitted
to observation. However, there were some subgroups
that seemed to benefit from elective dissection. These
were patients with melanomas 1 to 2 mm thick and
patients younger than 60 years of age (Balch et aI.,
1996). A more recent update of this prospective ran-
domized study confirmed, and actually provided, a
significant difference in survival in favor of the elective
dissection group, for nonulcerated melanoma.
Intraoperative Lymphatic Mapping (5entinel Node
Biopsy)
The advent of a new method to identify the histologic
status of the regional lymph nodes short of a complete
lymphadenectomy has made largely irrelevant the issue
of elective node dissection. In this method, reported by
Morton and colleagues in 1992, it was shown that the
lymphatic drainage from each particular skin site drains

through the lymphatics to the regional nodal basin to a
single (and infrequently to two) node(s), which may be
called sentinel nodes. In this method of lymphatic map-
ping or sentinel node biopsy, one identifies and dissects
the first lymph node that receives lymphatic drainage
from the particular skin site involved by the melanoma
(Morton et aI., 1992). This node should contain a focus
of melanoma cells, if melanoma cells traveled through
the lymphatics to the sentinel node. The sentinel node
is identified by injection of a blue dye, isosulfan blue,
which is injected near the site of the previous biopsy of
the melanoma. Morton and colleagues initially suggested
injection of 0.5 to 1 mL intradermally on either side of
the biopsy incision. The site of injection is massaged
gently for approximately 5 minutes, and then an incision
is made over the nodal basin in the same direction that
would be done for an elective node dissection. Of course
the incision for sentinel node biopsy is shorter than
that for the elective procedure. Morton and colleagues
recommended the development of a flap at the nodal
basin toward the primary site and identification of a
blue-stained lymphatic channel within the subcutaneous
tissue, which then should be traced to the sentinel
node. If one cannot identify the blue-stained lymphatic
channel or the sentinel node, repeat injections of the
blue dye are performed at 20-minute intervals.
In the author's experience, one actually may inject a
larger amount of the dye, 2 to 3 mL, intradermally,
because if an inadequate amount of dye is injected ini-
tially and the dissection in the nodal basin fails to reveal
a blue-stained lymphatic channel and/or a sentinel
node, further intradermal injections at the primary site
may not help because the afferent lymphatics to the
nodal basin from the primary melanoma site may have
already been interrupted by the initial dissection. It
therefore may be best to inject a larger bolus of the dye
initially, hoping that there would be enough dye traveling
along the lymphatics so that the lymphatic channels may
be identified, as well as the sentinel node. The ability
to detect the sentinel node varies with the experience of
the surgeon in this procedure, and it tends to continually
improve as the surgeon acquires more experience with
this technique (Morton et aI., 1992). The success in
identifying the sentinel node varies also according to
the anatomic nodal basin, being highest in the groin
and somewhat lower in the axilla. In the head and neck
area, however, the identification of the sentinel node has
been problematic. In our initial experience with sentinel
node biopsy for melanomas draining to the cervical node
basin, the success rate in identifying the sentinel node
was only 56% (Karakousis and Grigoropoulos, 1999).
These difficulties have led some authors to suggest that
sentinel node biopsy is not applicable in the case of the
head and neck melanomas because of the high rate of
failure in identifying the sentinel node. Since the report
by Morton of his technique of intraoperative lymphatic
BASIC CONSIDERATIONS
mapping using the blue dye alone, identification of the
sentinel node through the intradermal injection near
the melanoma site of a radiocolloid has been reported
with a high rate of success in identifying the sentinel node
either by using this method alone or in combination
with blue dye. The radiocolloid, usually 99mTc-labeled
sulfur colloid, is injected intradermally on four sites
around the biopsy site of the melanoma and then the
scanning that is obtained serves to point out the nodal
basin(s) to which the melanoma may be draining, being
particularly useful for melanomas close to the midline
of the trunk or head and neck; it also helps significantly
in the localization of the sentinel node (exhibiting a
radioactivity two to four times higher than the rest of
the basin) through the use of an intraoperative probe.
If one uses the combination of the two methods at the
time of surgery, usually scheduled 3 hours after injection
of the radiocolloid, one scans with the probe over the
skin of the nodal basin, which has been shown to pick
up radioactivity with the scan and identifies percuta-
neously the hottest spot over the nodal basin, which
should be overlying the sentinel node. One can then
make an incision centered over the hottest skin spot in
the same direction as one would make for a cervical
node dissection. The incision is then deepened through
the subcutaneous tissue and platysma, and the probe is
used again to further direct the course of the dissection.
Scalpel or light cautery may be used in this process.
If a blue-stained lymphatic channel is found, one may
trace this channel with clamp and/or Metzenbaum
scissors dissection toward the actual sentinel node. The
sentinel node usually is stained blue in one pole at the
point of entry of the blue-stained lymphatic channel.
Occasionally, there are more than one lymphatic channels
leading to the sentinel node. Infrequently, there are two
sentinel nodes and, rarely, three sentinel nodes receiving
direct lymphatic drainage from the primary site. The
radioactivity of the sentinel node in vivo is recorded in
counts per minute (CPM) by using the probe covered
with a sterile sheath; and after the sentinel node is
removed, this is recorded ex vivo and the radioactivity
in the remaining nodal basin is also recorded. The last
should be less than half of the ex vivo radioactivity of
the sentinel node. If it is higher than that, this may
indicate that there may be additional sentinel node(s)
to be searched with the use of the probe because they
may not be stained with the blue dye. With the combi-
nation of the blue dye technique, as well as the use of a
radiocolloid with an intraoperative probe, the detection
of the sentinel node in the cervical area should be close
to 100% (Karakousis and Grigoropoulos, 1999). The
radioactivity counts recorded over the site of injection
around the primary lesion are about 30,000 CPM. In
the case of a melanoma arising in the skin of the neck,
the injection of the blue dye as well as radiocolloid near
the primary skin site may seriously interfere with the
 BASIC CONSIDERATIONS

identification of the sentinel node because of the close
proximity of the primary skin site to the underlying lymph
nodes. Therefore, for melanomas arising in the skin of
the neck, although one may try to apply the technique
just described, there may be serious interference from
the primary site in identifying the sentinel node. In such
cases, the decision can be made for elective node dis-
section on the basis of the prognostic parameters of the
primary lesion and the likelihood of there being micro-
scopic disease in the regional nodal basin (Balch et a!.,
1996). Generally, if one is unable to identify the sentinel
node, elective node dissection should be performed.
warrant attention regarding their prognostic factors and
management. The two most common histologic types
are liposarcomas and malignant fibrous histiocytomas
(Morton et a!., 1997). Sarcomas metastasize primarily
through the bloodstream but, infrequently, at an overall
rate of approximately 5% (2.6% to 10.8%) (Brennan et
a!., 1997) for all histologic subtypes, they may metas-
tasize through the regional lymph nodes. Some of the

Therapeutic Node Dissection

For patients who have palpable nodes in the cervical area,

therapeutic lymphadenectomy should be performed if
there is no evidence of metastatic disease at the distant
sites. A thorough node dissection should be performed
(usually a modified neck dissection) because one may
thus avoid the complications of local recurrence within
the nodal basin with its attendant risk also of further
dissemination of the disease (Karakousis, 1998). For
patients with positive nodes, interferon alfa-2b was
reported to provide significant improvement in disease-
free and overall survival in the range of about 12 % over
patients treated with surgery alone (Kirkwood et a!.,
1996). The interim analysis of a follow-up study, how-
ever, showed again an improvement in disease-free
survival but no significant difference in overall survival
between the treated and control groups. At the present
time, there is considerable interest in clinical research
using vaccine therapy for stage III malignant melanomas.

Distant Disease

For patients with hematogenous dissemination and a

limited number of lesions involving one body cavity,
resection of the metastases may improve survival par-
ticularly in patients with longer disease-free intervals
CKarakousis et a!., 1994). Vaccine therapy is also being
evaluated in patients who have resectable metastatic
disease as an adjuvant modality for stage IV melanoma.
Figure 3-20 shows a PET scan that confirms the presence
of melanoma metastasis.
Soft Tissue Sarcoma
Constantine P Karakousis
There are about 6,000 new cases of soft tissue sarcoma
diagnosed in the United States every year involving
various anatomic locations. A little over 50% of patients
ultimately die from progression of their disease (Brennan
et a!., 1997). They represent an uncommon group of
neoplasms; however, they occur frequently enough to
FIGURE 3-20 The whole body PET scan clearly
confirms the findings on CT of the mediastinal lymph
node in relation to the right innominate vein
(brachiocephalic) in a patient with malignant melanoma.
This verifies that the lesion seen on CT is most likely
metastatic melanoma, with the primary lesion in the skin
of the anterior chest wall. This patient also had a
metastatic node in the supraclavicular area laterally that
was removed by modified neck dissection. Remember
that lesions less than 5 mm in size usually do not show up
in a PET scan. 1, mediastinal lymph node; 2, cardiac
silhouette; 3, urinary bladder. (Courtesy of Hani Nabi,
MD.)

histologic subtypes, however, such as malignant fibrous
histiocytoma and synovial sarcoma, have a higher
frequency of metastasis through the lymphatic system
to the regional lymph nodes.
Presentation and Diagnosis
Sarcomas usually present as a mass associated with little
or no pain, and, thus, they are often diagnosed when
they are quite sizeable. The diagnosis is established via
biopsy. Aspiration cytology does not usually provide a
sufficient diagnosis. A core needle biopsy, such as with
a Tru-Cut needle, often provides enough tissue to make
a histologic diagnosis of soft tissue sarcoma and the
histologic subtype involved. To obtain a core needle
biopsy, the most prominent part of the skin around the
tumor area is infiltrated with local anesthesia down to
the surface of the tumor. A small nick with a No. 11
blade is made in the skin to allow passage of the rather
thick needle through the skin and into the subcuta-
neous tissue. Through this small opening in the skin,
three or four pieces from the tumor are obtained and
sent for pathologic evaluation. The other alternative is
open biopsy using an incision adequate enough to get
to the site of the tumor and obtain a piece. The incision
should be placed over the center of the tumor mass in
the direction of what might later be the definitive inci-
sion. A number of these tumor masses, of course, may
turn out to be lymphomas and be treated with means
other than surgical resection. During open biopsy, as
the tumor surface is approached and the incision is
made through what may be the pseudocapsule of the
tumor, a deeper cut into the tumor is done so as to have
a representative piece of tumor tissue.
Superficial biopsies are frequently not diagnostic
when they are derived from the capsule of the tumor
mass. If there is any doubt as to having a representative
piece of tissue, frozen section may be obtained at the
time of the incisional biopsy to ascertain that there is
indeed representative tissue. One should not rely on
frozen section to perform the definitive surgery unless
the latter is not expected to cause a significant functional
or cosmetic deficit. Frozen section is not as accurate as
permanent section in determining that one is dealing
with a soft tissue sarcoma or in defining the histologic
subtype. Exuberant granulation tissue can be confused
with malignant fibrous histiocytoma.
Treatment
Node dissections can be fairly formal in terms of their
extent, the incisions being used, and the dissection
involved owing to the fairly constant anatomic location
and the distribution of the regional lymph nodes. In
contrast, surgical resection of the primary sarcoma has
to be specifically designed for the anatomic location and
BASIC CONSIDERATIONS
extent of the primary tumor. This is true for the head
and neck area, as for other regions. In performing the
resection, an elliptical incision is made around any pre-
vious biopsy incision. A decision has to be made pre-
operatively as to whether any substantial amount of skin
should be removed, owing to close proximity to the
tumor. If one can avoid a large resection of skin, then
one may obviate the additional requirement of flap
reconstruction. The dissection is carried around the
tumor, trying to stay as far away from the tumor site as
local anatomy permits. In situations in which underlying
bone is in close proximity, one may have to remove a
partial or the full thickness of the underlying bone. In soft
tissue sarcomas of the supraclavicular area, because
some tend to extend underneath the clavicle, it may be
necessary to remove the clavicle to permit complete
resection of the tumor, with simultaneous provision of
adequate exposure of the brachial plexus and subclavian
vessels. Claviculectomy in itself does not produce any
significant morbidity or functional impairment for the
patients, although for 3 to 4 weeks after the operation
they may have to wear a sling until the healing is com-
pleted (Karakousis et aI., 1992). The objective is to obtain
as much margin as anatomically possible around the
palpable tumor mass. An adequate tumor margin of
normal tissue should be 2 em or greater, but that is not
always obtainable. However, in dissecting around the
tumor mass, one should be able to obtain an adequate
tumor margin in most directions around the mass and
limit the margin only in the vicinity of critical anatomic
structures that cannot be easily replaced or sacrificed.
The goal is to eliminate or at least minimize microscopic
residual tumor. It has been shown conclusively that
adjuvant radiation (i.e., radiation given for potential
microscopic disease) reduces significantly the rate of
local recurrence (Brennan et aI., 1991).
Radiation treatment may be given preoperatively, par-
ticularly in cases in which the tumor does not appear
to be resectable without first shrinking down its size.
More commonly, radiation is given postoperatively on the
basis of the clinical-pathologic assessment of surgical
margins and therefore the actual need for adjuvant radia-
tion when the margins are considered inadequate. In a
prospective randomized study, it was found that the
preoperative (neoadjuvant) radiation is associated with
a higher rate of wound complications compared with
postoperative radiation (O'Sullivan et aI., 1999).
Results and Prognostic Parameters
The rate of local recurrence with local excision alone
has been reported in the literature to be 65% to 95%
(Abbas et aI., 1981; Cadman et aI., 1965). When local
excision is supplemented with irradiation postopera-
tively, the rate of local recurrence is about 25 %, so it is
significantly decreased but still remains appreciable and
 BASIC CONSIDERATIONS
higher than the 10% rate observed after wide excision
alone (Karakousis et a!., 1995). Therefore, even when
one intends to use the adjuvant modality of irradiation,
it still is important to try to obtain as wide a margin as
possible around the tumor in all directions that is clini-
cally feasible. The 5-year disease-free survival depends
primarily on the grade of the tumor, being for grade 1
tumors about 90%; grade 2, 65%; and grade 3, 45%
(Karakousis et a!., 1995). The second prognostic
parameter significantly affecting survival is the size of
the tumor. Tumors less than 5 em in diameter have a
better prognosis than those larger than 5 em. The third
prognostic indicator is the location of the tumor: whether
deep or superficial to the fascia or covering a muscular
compartment. Sarcomas located in the subcutaneous
tissue have a better prognosis than those located within
muscle groups. Adjuvant chemotherapy of soft tissue
sarcomas is still investigational, although there is a trend
among medical oncologists to use adjuvant chemotherapy
for high-grade soft tissue sarcomas. This is in contrast
to sarcomas of childhood, especially rhabdomyosar-
comas and bone sarcomas, in which the use of adju-
vant chemotherapy is of proven efficacy in improving
survival.
Local Recurrence
Local recurrence should be resectable in the majority of
instances (95 %). The overall 5-year survival rate is
65 % after resection of a local recurrence similar to that
of primary sarcomas (Karakousis et a!., 1996).
Distant Recurrence
Soft tissue sarcomas spread hematogenously predomi-
nantly to the lungs. Resection of pulmonary metastases
is associated with a 5-year survival rate of about 20%
(Lawrence et a!., 1987), varying with the number of
metastases, the prior disease-free interval, the com-
pleteness of the resection, and control or lack of control
of the primary site.
Thyroid-Related Orbitopathy
Daniel P. Schaefer
Thyroid-related orbitopathy, also known as Graves'
ophthalmopathy, is the most common cause of both uni-
lateral and bilateral proptosis in adults. Synonymous
terms include Graves' orbitopathy, dysthyroid ophthal-
mopathy, thyroid eye disease, thyroid-associated orbitopa-
thy, infiltrative ophthalmopathy, congestive ophthal-
mopathy, endocrine exophthalmos, malignant exoph-
thalmos, and von Basedow's disease (Werner, 1977).
Graves' name can create confusion, because not all
patients with Graves' ophthalmopathy have systemic
Graves' disease (hyperthyroidism). The systemic thyroid
status may be hyperthyroid, hypothyroid, euthyroid, or
even involved in a neoplastic process (Morris, 1988).
Severity and duration of the disease are unpredictable.
The proptosis is usually accompanied by other orbital
signs, including eyelid retraction, orbital congestion, and
motility disturbances, in isolation or in various com-
binations. Although orbital manifestations typically
improve over several years, irreversible vision loss due
to corneal exposure or optic nerve compression does
occasionally occur (Grove, 1975, 1979). Careful obser-
vation and reassurance are helpful and often adequate,
but medical and surgical intervention may be required
and are beneficial when used judiciously.
The disease may cause disfigurement, which may be
psychologically devastating to the patient. Many patients
state that they don't look like themselves anymore. They
may have eyes that are protruding, with one eye looking
in the wrong direction, they are uncomfortable, and
they feel disfigured. Graves originally described a triad
of hyperthyroidism, dermopathy, and eyelid retraction.
Most patients with thyroid-related orbitopathy have pre-
existing or simultaneously diagnosed hyperthyroidism,
but not all of them do. In at least 20 %, the diagnosis of
a thyroid disorder follows (often by years) the initial
orbital manifestations. Furthermore, 3% never develop
a clinically apparent thyroid imbalance. Also, rather
than being characteristically hyperactive, the thyroid is
sometimes hypoactive.
Thyroid-related orbitopathy is primarily a clinical
diagnosis. The classic presentation is easily recognized.
Atypical presentations such as marked asymmetry or
purely unilateral disease, euthyroid status, acute severe
inflammation, myositis, pain, or subtle non inflamed
disease, unusual neurologic symptoms, unusual systemic
disease, trauma, or paranasal sinus disease are not
infrequent and may be difficult to differentiate, making
the diagnosis suspect or raising the question of a second
coexisting orbital process, especially if one fails to
consider the diagnosis of thyroid-related orbitopathy.
Orbital imaging studies will help in the diagnosis and
management of these patients.
Conversely, not all individuals with systemic Graves'
disease demonstrate orbital involvement. Only 60% to
90% possess at least subclinical orbital involvement,
such as enlargement of the extraocular muscles on CT.
The prevalence of symptomatic and clinically apparent
orbital involvement varies but is definitely less than
20 % of those with systemic thyroid disease.
Pathogenesis
The immune system is attacking the thyroid and the
orbital tissues. It is probably two different antigens that

cause thyroid disease and thyroid-related orbitopathy
but they are related and similar enough so that the
immune system can attack both or may just attack one
and not the other.
The pathogenesis between systemic thyroid disease
and orbitopathy remains a point of debate. Activation of
the thyroid gland, as a result of inflammation, trauma,
surgery, smoking, and irradiation, appears to prompt a
release of a thyroid antigen that stimulates both the
cellular and humoral cascades of the immune system.
This combination of cell-mediated and humoral activa-
tion promotes inflammatory cell migration and produc-
tion of edema in the orbit. Activated T lymphocytes
invade the orbital connective tissue at the same time a
local humoral immune reaction is initiated. Retrobulbar
fibroblasts proliferate, resulting in increased synthesis
and release of glycosaminoglycans. Locally produced
lymphokines amplify the cascade. The result is thickening
of the extraocular muscles and increase in orbital fat
volume. The specifics of each step have been the
subject of intense investigation (Volpe, 1974). A shared
orbit-thyroid antigen(s) is then presented and released
into the circulation (Heufelder, 1995). Therefore, the
thyroid gland and the orbital content are probably a
secondary responder to the immune system disorder
rather than a primary etiologic factor.
The histopathologic changes in thyroid-related
orbitopathy may cause the retrobulbar fat and con-
nective tissue stimulation with increased fibroblastic
activity, glycosaminoglycan deposition, and edema. The
extraocular myositis with edema, lymphocytic infiltration,
and muscle necrosis may occur. The pathophysiology
of thyroid-related orbitopathy is not well understood.
There appears to be stimulation of orbital fibroblasts to
produce hyaluronic acid. Doubling the hyaluronic acid
content in orbital tissue increases the osmotic load five-
fold. This may lead to passive swelling of orbital tissue
(Kroll and Kuwabara, 1966; Sergott and Glaser, 1981).
Epidemiology
Thyroid-related orbitopathy most commonly occurs
between the ages of 25 and 50. Graves' disease is five
times more likely to affect women than men. The peak
incidence is often earlier in women (fourth or fifth
decade) than in men (sixth or seventh decade). Men
have been reported to develop thyroid-related orbitopa-
thy more severely than women. All races are affected,
but whites are distinctly more commonly affected than
blacks or Asians. Predominant clinical signs may also
differ among races. Presentation in childhood is unusual
but not rare (Bartley et aI., 1995). Genetic factors appear
to have a role in the development of thyroid-related
orbitopathy, with 20% to 60% of those affected reported
to have a family history of thyroid disease. Human
BASIC CONSIDERATIONS
leukocyte antigen typing varies by race, and no single
marker has been shown to be universally common.
Environmental factors are also important. Although
the role of stress is disputed, cigarette smoking is clearly
capable of aggravating and prolonging thyroid-associated
orbital inflammation. Patients who have thyroid disease
are seven times more likely to develop a more severe
form of thyroid-related orbitopathy if they smoke. Surgical
manipulation of the thyroid gland and radioactive iodine
treatment have been reported to exacerbate preexisting
orbital signs and symptoms, but this connection has
not withstood careful scientific investigation.
Clinical Course
Thyroid-related orbitopathy is frequently a self-limited
disease, but each of its associated orbital signs varies in
prevalence and persistence. Soft tissue inflammation
and congestion are common and nonspecific signs and
typically resolve within 5 years. Eyelid retraction, either
unilateral or bilateral, is common (90% prevalence) and
the sign most likely to persist chronically. Extraocular
muscle dysfunction occurs in 40% of patients, and inter-
mittent diplopia will usually resolve over time. One
third of the patients who develop constant, noncomitant
diplopia will improve spontaneously. Unilateral or bilat-
eral proptosis occurs in 60% of patients. Improvement
is unusual in such cases, with fewer than 10% of patients
demonstrating significant improvement within 5 years.
Vision loss, the most feared complication, occurs in fewer
than 5 % of those with orbital involvement. Sequelae
that may cause irreversible vision loss if not managed
appropriately include compressive optic neuropathy,
corneal scarring, and secondary glaucoma. Corneal
ulceration is rare.
The clinical course of thyroid-related orbitopathy does
not follow a linear progression of severity. It can have
its onset over days to weeks. The acute phase may last
from 3 months to more than 2 years. This phase is charac-
terized clinically by inflammatory signs, including eyelid
erythema, chemosis, injection, and edema and also by
fluctuations that can occur daily or weekly. After reso-
lution of the acute phase, proptosis, diplopia, and eyelid
retraction may persist owing to the cicatricial changes
that occur in the extraocular muscles and orbital soft
tissue. The acute episodes may occur from one to three
times during the course of the disease.
The course of thyroid-related orbitopathy is unrelated
to treatment of systemic hyperthyroidism. The thyroid
and orbital manifestations act as two independent
clinical processes, the treatment of either of which does
not always affect the other. Many patients will have
spontaneous improvement of their symptoms. The
physician's goal is to prevent complications while we
are waiting for the disease to "burn out."
 BASIC CONSIDERATIONS
Ophthalmic signs and symptoms may worsen,
improve, or remain the same in patients who undergo
treatment of their hyperthyroidism with radioactive
iodine-131 (without concomitant systemic corticosteroid
treatment). Tallstadt reported in 1992 that thyroid-related
orbitopathy might worsen in hyperthyroid patients aged
35 to 55 treated with iodine-13l. Orbital disease in these
patients became worse compared with that in similar
patients treated with methimazole or subtotal thyroidec-
tomy. Mendlovic and Zafar suggested that this effect
was more likely in patients treated with multiple doses
of iodine-13l.
Another study revealed that 15% of patients who were
treated only with radioiodine developed or had worsening
of their thyroid-related orbitopathy. In contrast, none of
the patients who were treated with both radioiodine
and prednisone had progression and two thirds showed
an improvement. Only 3% of those treated with methi-
mazole had any worsening of the condition (Bartalena
et al., 1998). Patients should be maintained on cortico-
steroids throughout irradiation. Then the doses of the
corticosteroids should be slowly tapered. Levels of serum
and lymphatic thyroglobulin as well as of antithyroglobulin
antibodies increase in the 6 weeks to 6 months after
treatment with iodine-131 and also after thyroidectomy,
which may provide a clue to the clinically observable
flare-ups that sometimes occur after treatment.
Advocates of thyroidectomy believe that removal of
the inciting antigens in the thyroid gland with a total
thyroidectomy reduces the incidences of thyroid-related
orbitopathy. We have insufficient experience with this
treatment option to comment.
Differential Diagnosis
Severe cases of nonspecific orbital inflammation, orbital
infection, or cavernous sinus disease may cause conges-
tion and proptosis that resemble the features of thyroid-
related orbitopathy. In addition to high-flow fistula of
the cavernous sinus, infection and thrombosis may also
cause injection, chemosis, ophthalmoplegia, and prop-
tosis. Arterialization of conjunctival vessels and an orbital
bruit are characteristics of cavernous sinus fistulas and
do not occur in thyroid-related orbitopathy. Immuno-
compromise or signs of sepsis are typically present
with cavernous sinus infection or thrombosis.
Pseudo proptosis may be caused by an enlarged globe,
extraocular muscle weakness or paralysis, contralateral
enophthalmos, asymmetrical orbital size, or asymmet-
rical palpebral fissures (usually caused by ipsilateral lid
retraction, facial nerve paralysis, or contralateral ptosis).
Signs and Symptoms
There is no one universal answer as to how frequently
these patients should be monitored in the acute and
chronic phases of the disease. Treatment should be
individualized. Patients with active thyroid-related
orbitopathy in whom optic neuropathy is present, or
whose corneas are threatened by severe exophthalmos
or eyelid retraction, must be examined very frequently.
Patients who psychologically adapt poorly to the dis-
figurement that the disease may cause will require
much more time and possibly psychiatric counseling.
Symptoms and subtle signs of thyroid-related
orbitopathy are often present for many months to years
before diagnosis. A significant percentage of patients
experience at least mild inflammatory changes at some
point during the course of their disease. Common and
nonspecific symptoms include tearing, irritation, gritti-
ness, aching, and photophobia. Early signs include
conjunctival injection, periorbital puffiness, abnormal
tear break-up time, superficial punctate keratitis, and
elevation of intraocular pressure. Most commonly, the
conjunctiva is injected over the rectus muscle insertions.
This may be accompanied by interpalpebral chemosis.
The chemosis may appear hemorrhagic, and the con-
junctiva may prolapse over the lower lids. Corneal expo-
sure with keratitis, ulceration, or pannus formation may
occur secondarily to the combination of proptosis, eyelid
retraction and lagophthalmos, and restrictive myopathy
that reduces the Bell's protective phenomenon.
Periorbital skin may become puffy, and mild erythema
may be present. In severe cases, the skin becomes lax
and redundant with palpable subcutaneous edema. Eyelid
retraction (upper and/or lower eyelids), inflammation,
proptosis (unilateral or bilateral), lid lag, dry eyes, restric-
tive myopathy with diplopia, compressive optic neu-
ropathy, and disfigurements are the primary signs.
Increased orbital volume secondary to inflammation is
believed to impede venous outflow, which further aggra-
vates congestion and the resulting proptosis. Inflamma-
tion and congestion are two distinct processes, but they
are intimately related. There may be resistance to
retropulsion of the globe, but this is a nonspecific abnor-
mality that may also result from a retrobulbar tumor or
from diffuse inflammation. The signs may occur simul-
taneously or individually (Gorman et aI., 1984).
Allergic conjunctivitis and dry eye symptoms are
common misdiagnoses but eventually recognized to be
thyroid-related orbitopathy. Tears are produced in normal
quantity in this disease, at least as demonstrated by
Schirmer testing. These tears, however, have been found
to contain abnormal quantities of proteins and immuno-
globulins, which, in conjunction with increased evapora-
tion due to abnormal lid position, result in increased
osmolarity. The lacrimal gland is often mildly enlarged
and may be a target of immune interaction. The change
in tear stability may cause symptoms and corneal changes
identical to those seen in keratoconjunctivitis sicca.
Ocular hypertension may be the initial manifestation.
Orbital congestion and impaired venous outflow may

contribute to the increased frequency of ocular hyper-
tension. The examination should include a measurement
of the intraocular pressure in primary and upward
gaze, which may further elevate the pressure. Although
intraocular pressure may fluctuate between 25 and
30 mm Hg, development of glaucoma damage is occa-
sional. Patients with a preexisting diagnosis of glaucoma
or active thyroid-related orbitopathy of more than 5 years'
duration are at increased risk for glaucomatous optic
nerve damage. Secondary ocular hypertension usually
resolves as the orbitopathy improves, only rarely
progressing to true glaucoma.
Visual acuity and color vision are not affected until
very late in glaucoma. Glaucomatous field loss (e.g.,
arcuate or nasal step defects) differs from the pattern of
loss seen in compressive neuropathy or thyroid-related
orbitopathy (e.g., central or centro cecal defects). The
optic disc may initially be normal or edematous, but
diffuse pallor develops over time.
Tests Useful for Early Detection
The baseline examination includes assessment and
documentation of visual acuity, color vision, pupillary
function, intraocular pressure in primary and upward
gaze, lid position, globe position (as quantified by Hertel
exophthalmometer), motility (versions and ductions),
and dilated fundus examination. If intraocular pressure
is elevated or any component of afferent function is
abnormal, visual field examination is also performed.
Visual fields and color vision testing help in early
detection. Pseudoisochromatic plates and red desatu-
ration are complementary tests to establish the status
of color vision. Patients need to be alerted about the
possibility of a change in vision and need to arrange to
see an ophthalmologist if this happens (Henderson, 1958).
Examination of eyes with optic neuropathy includes
careful evaluation and documentation of visual acuity,
color vision, and pupil function at the initial examination
and each subsequent visit to highlight subtle changes that
will prompt further evaluation. Humphrey or Goldmann
visual field examinations are performed, as well as CT
(both axial and coronal views) to clarify optic nerve
position with respect to the enlarged muscles. Contrast
medium enhancement is not necessary.
Examination of the pupils should include the swing-
ing flashlight test to evaluate for an afferent pupillary
defect (Marcus Gunn pupil). In addition, anisocoria
should be documented and observation should be made
as to whether the difference is greater in the light
(parasympathetic defect) or dark (sympathetic defect).
Retrodisplace the globe gently in various directions.
Orbital tumors cause directional resistance to retrodis-
placement of the globe according to their location.
Thyroid-related orbitopathy causes a diffuse increase in
resistance to ocular retrodisplacement.
BASIC CONSIDERATIONS
Hertel exophthalmometry continues to be the standard
method of measurement, despite its limited accuracy. If
possible, the same practitioner should repeat the Hertel
measurements with a similar width setting on the exoph-
thalmometer at each evaluation. The Hertel exophthal-
mometer is useful to follow patients, but different
observers often arrive at different measurements, espe-
cially if the base dimensions are not kept constant.
However, careful measurements taken by a single
examiner over a period of time may accurately reflect
changes in globe position. More than 2 mm of asym-
metrical proptosis raises the possibility of an orbital
mass mimicking thyroid-related orbitopathy.
Orbital ultrasound is an effective method of demon-
strating increased muscle size but lacks specificity and
does not rule out other disorders.
Neuroimaging studies are often required when the
diagnosis is in doubt. CT will aid with the differential
diagnosis in atypical cases, help to evaluate the optic
nerve in cases of compressive optic neuropathy, serve as
a method to document progression in association with
clinical signs and symptoms, or serve as a planning tool
for possible orbital decompression surgery. Imaging
studies permit the surgeon to evaluate the sinus anatomy
and the degree of orbital congestion when orbital decom-
pression is being considered, especially in patients sus-
pected of having chronic sinusitis, because the finding of
sinus opacification allows for preoperative antibiotics or
sinus drainage. Nonenhanced CT (axial and coronal views
with thin sections) is the best method to define anatomy.
Contrast medium enhancement usually is not required
because the orbital fat provides intrinsic contrast for
many solid or cystic lesions and vascular anomalies
frequently manifest radiographically as asymmetrical
enlargement of the superior ophthalmic vein and a dilated
cavernous sinus. Another reason to avoid contrast mate-
rial is that iodine-containing agents preclude the imme-
diate use of radioactive iodine in the treatment of hyper-
thyroidism. CT with contrast enhancement is helpful in
patients who have more than the typical amount of pain
on extraocular movement. Scleral enhancement and
inflammatory infiltrates may differentiate an inflam-
matory pseudotumor from thyroid-related orbitopathy
in these patients.
CT is helpful in diagnosing and monitoring patients
with optic neuropathy. These patients have enlarged
extraocular muscles compressing the optic nerve at the
apex. This finding will differentiate between thyroid-
related orbitopathy and other causes of neuropathy,
such as anterior ischemic optic neuropathy.
Imaging studies will typical show fusiform expan-
sion of one or more of the extraocular muscles, gener-
ally with thin tendons. Large muscles, greater than 9 mm
in width, or a crowded orbital apex indicates patients
at risk for compressive optic neuropathy, as does
restrictive myopathy.
 BASIC CONSIDERATIONS
MRI is not necessary in evaluating thyroid-related
orbitopathy; it offers little additional information and is
more expensive than CT.
Eyelid Retraction
A common early finding of hyperthyroidism is eyelid
retraction. Like other findings in thyroid-related orbitopa-
thy, this can also be seen in euthyroid or hypothyroid
patients. The classic presentation is a bilaterally sym-
metrical retraction of the upper and lower eyelids, the
stare of thyroid-related orbitopathy. This generally
improves as the thyroid function stabilizes, but it rarely
resolves entirely. Involvement of Muller's muscle is
often found in these patients, and hypertrophy of the
levator palpebrae is not uncommon. Lagophthalmos
(retraction of the upper lid with passive eyelid closure
and in downgaze) and lid lag (a slowing of the descent
of the eyelid with downgaze) are a result of the infil-
tration of Muller's muscle and the levator palpebrae.
Forced ductions of the lid are usually positive in these
cases. The involvement of the lids is usually asym-
metrical, especially in chronic cases, but rarely may be
unilateral.
A number of patients develop an unacceptable
amount of retraction, which causes not only cosmetic
problems but also enhances tear evaporation and
aggravates dry eye symptoms. Topical eyedrops, such
as the a-adrenergic antagonists, have been used to
counteract the sympathetic tone of Muller's muscle,
but sustained improvement is rare, and topical toxicity
frequently develops. When the lid retraction has been
stable for at least 6 months in a noninflamed eye, then
surgical intervention can be entertained.
The differential diagnosis of eyelid retraction should
include lesions that involve the midbrain, such as
ischemia or tumors, hydrocephalus, or even contralateral
ptosis. Neurogenic lid retraction will have a limitation
of upward gaze, but lagophthalmos is absent; and
results of forced duction testing of the lid and globe are
normal. Other signs of neurogenic causes include
convergence-retraction nystagmus and light-near
dissociation of pupillary response.
Contralateral ptosis may result in lid retraction on
the intact side due to Hering's law of equal innervation.
To test for this, elevation of the ptotic lid will result in an
improvement of the contralateral lid retraction, demon-
strating that the excessive innervation, or Hering's law,
is the cause of the lid retraction. Also forced duction
testing is normal and lagophthalmos and lid lag are
absent.
The various surgical techniques for the correction of
lid retraction involve Muller's muscle and the levator
aponeurosis in the upper lid and the capsulopalpebral
fascia in the lower lid. Excising or recessing Muller's
muscle and/or the levator aponeurosis, performing a
myotomy of the levator muscle, or inserting a spacer
(fascia, donor sclera, or ear cartilage) between the distal
end of the aponeurosis and tarsus via a cutaneous or
conjunctival approach can lower the resting position of
the upper lid.
Lower eyelid retraction can be managed with recession
of the retractors of the lower eyelids. Severe retraction
requires grafting of spacer materials (fascia, donor sclera,
ear cartilage, and also hard palate mucosa) between the
lower eyelid retractors and the inferior tarsal border.
A lateral tarsorrhaphy is a useful technique for pro-
tecting the cornea, decreasing ocular exposure, but, aes-
thetically, the appearance of the horizontal shortened
palpebral fissure and the interference with the eyelashes
and peripheral vision is displeasing to many patients.
Upper and lower eyelid retractor repairs are much more
satisfactory.
A tarsorrhaphy may be a helpful adjunct to lower lid
retractor repair in some cases. In individuals who have
mild upper and lower eyelid retraction, particularly with
temporal flare of the upper lid, a conservative tarsorrhaphy
may be helpful in improving eyelid malposition, when
performed in combination with Muller muscle recession
in the upper lid and with recession of the retractors in
the lower lid.
When Hertel measurements are greater than 23 mm,
lower lid retractor recession is difficult, and an orbital
decompression should be considered before eyelid
retractor repair in these patients. Lateral tarsorrhaphy is
probably best reserved for patients with Hertel measure-
ments greater than 23 mm who are not candidates for
decompression surgery owing to their medical condi-
tion, a poor risk for anesthesia, or refusal to undergo
the procedure.
Proptosis
The orbital apex has no room for expansion. Muscle
enlargement posteriorly results in compression of the
optic nerve just anterior to the optic canal. Proptosis
serves as a protective function by expanding the total
orbital volume. Muscle enlargement in the absence of
significant proptosis is most likely to promote optic nerve
compression. It is essential to check for signs of afferent
dysfunction, (e.g., decreased visual acuity, abnormal color
vision, afferent pupillary defect, and abnormal visual
fields), even in apparently asymptomatic patients.
Proptosis is less prevalent than eyelid retraction. It is
caused by infiltration of the eye muscles with inflam-
matory cells and/or an increase in fat volume, resulting
in forward displacement of the globe. Proptosis is
usually axial and associated with increased resistance
to retropulsion of the globe. In general, bilateral and
asymmetrical proptosis is not uncommon.
Nonspecific orbital inflammatory syndrome, orbital
tumors (primary or secondary), orbital infections, and

cavernous sinus processes may cause proptosis. Orbital
inflammatory syndrome (orbital pseudotumor, myositis)
or rare cases of orbital amyloidosis with muscle involve-
ment are generally unilateral, accompanied by severe
pain. The inflammation of the muscles involves the
tendinous insertions and may simulate thyroid-related
orbitopathy. The fat will appear infiltrated, and scleral
thickening is not uncommon on CT. Orbital tumors (pri-
mary or secondary), on the other hand, cause unilateral
and often nonaxial proptosis, without significant pain
or inflammation. Orbital infections are also usually
unilateral, but they tend to be accompanied by mild to
moderate pain, inflammation, and sinus involvement.
The proptosis secondary to cavernous sinus fistulas or
dural fistulas is usually unilateral, accompanied by
conjunctival chemosis, arterialization of the conjunctival
vessels, and mild pain. There may be an orbital bruit or
a history of trauma, or the proptosis may be idiopathic.
Motility Abnormality
Transient or intermittent diplopia is common but can
progress gradually or rapidly to a constant diplopia.
Patients generally have difficulty with fusion in the
morning, owing to fluid accumulation in the muscles
that occurs with a prolonged prone position. Initially, the
extraocular muscles are infiltrated with inflammatory
cells and edema, which then progress to a fibrosis that
may create a permanent motility restriction. Ocular move-
ments may be limited in a specific direction of gaze by
the inflammation that involves a single or multiple
extraocular muscles. The inferior rectus and then the
medial rectus are the most commonly involved, which can
result in a noncomitant esotropia and/or hypotropia.
Thyroid-related orbitopathy most commonly involves
the inferior rectus muscle with fibrosis, which restricts
elevation of the affected eye and can even cause it to
be hypotropic in primary gaze. On attempted upward
gaze, the intraocular pressure may rise in the affected
eye. Forced duction testing is the simplest and fastest test
to evaluate restricted motility and is usually positive in
these patients owing to the restrictive myopathy. This
is important because approximately one third of the
time the ophthalmologist is the first to recognize the
diagnosis of thyroid disease. CT often reveals bilateral
involvement of all muscles but sparing of the tendons.
When orbital findings have remained stable for at
least 6 months, then strabismus surgery may be enter-
tained. Recession of the levator aponeurosis or inferior
retractor muscles will reduce corneal exposure. The
aim of extraocular motility surgery is to minimize
diplopia in the primary position and in downward gaze
but rarely will correct diplopia in all gazes. Adjustable
suture techniques may be helpful to achieve optimum
alignment, and optical prisms are a useful adjunct to
motility surgery.
BASIC CONSIDERATIONS
Botulinum toxin has been utilized in the treatment
of strabismus and can actually achieve a permanent
cure, obviating the need for surgery in approximately
30% of the patients in whom it is used. It is a great
temporizing measure in about another 30 % of patients.
Acquired diplopia may also be secondary to cranial
nerve paralyses, myasthenia gravis, trauma, tumors, and
orbital inflammatory syndromes. Cranial nerve paralysis
and myasthenia are not restrictive, and therefore the
forced duction test is normal. In myasthenia gravis, the
patient's symptoms will worsen with fatigue and at
the end of the day, with ptosis rather than an eyelid
retraction. If a patient with thyroid-related orbitbpathy
has motility disturbances and/or ptosis, he or she should
be evaluated for myasthenia, because 5 % of patients
with myasthenia gravis have thyroid disease and I % of
individuals with thyroid disease have myasthenia gravis.
Trauma to the floor or medial wall may result in a
restrictive myopathy, with positive forced ductions. CT
with coronal sections should be obtained in any patient
with a history of prior trauma. Orbital inflammatory
syndrome may mimic thyroid-related orbitopathy but is
usually unilateral and accompanied by pain. CT often
demonstrates the characteristic diagnostic tendon
involvement and changes in the orbital fat and sclera.
Optic Neuropathy
Compressive optic neuropathy is a vision-threatening
complication of thyroid-related orbitopathy that requires
very careful evaluation and management. It can occur
in inflamed orbits early in the course of the disease or
late, in the postinflammatory stage, and in proptotic or
nonproptotic orbits. CT or MRI of the orbit with coronal
sections is required to demonstrate the enlargement of
the muscles and their relations to the optic nerve.
Sometimes the orbits are congested and inflamed, and
sometimes they are not. The patients that have minimal
proptosis, but moderate to marked limitation of
extraocular motility and tight orbits show a warning
that they are at greater risk for the development of
thyroid optic neuropathy, owing to mechanical crowd-
ing phenomenon.
The risk of developing thyroid optic neuropathy and
loss of vision is relatively low (1 % to 5 %). Therefore,
these patients should be monitored and followed closely,
with evaluation of visual acuity, color vision, visual
fields, and optic nerve examinations. The absence of
disc edema or pallor does not exclude the diagnosis of
thyroid optic neuropathy.
Orbital decompression surgery is an effective treat-
ment for compressive optic neuropathy. The medial
orbital wall, especially the posterior ethmoids, along
with the orbital floor is removed to allow expansion of
the orbital contents into the ethmoidal and maxillary
sinuses. Preservation of the bony strut between the
 BASIC CONSIDERATIONS
ethmoidal and maxillary sinuses may reduce the adverse
effects on ocular motility caused by a medial and inferior
shift in the globe's position. Removal of the lateral wall
and orbital roof sometimes is needed as an adjunctive
decompressive measure.
Treatment Plan
Graves' disease is a complex, multisymptom disorder
with a chronic, unpredictable course. These patients
must be monitored and treated with a staged and com-
passionate approach that includes educational and
emotional support. The course of the thyroid-related
orbitopathy is generally independent of thyroid function.
The disorder in a hyperthyroid patient is not managed
differently ophthalmologically from that in a patient
who is hypothyroid or euthyroid. However, treatment
of the systemic thyroid condition often has a beneficial
effect on the thyroid-related orbitopathy.
Treatment may be divided into localized ophthalmic
protective measures, medical anti-inflammatory treat-
ment, surgical treatment, and radiation therapy. Cosmetic
surgery should be avoided during the active phase of
thyroid-related orbitopathy. Occasionally, low-dose irra-
diation (20 to 2S Gy) or surgical decompression is
required to preserve visual function. Corticosteroids
and irradiation are the most effective during the active
inflammation, whereas surgical decompression relieves
true congestion.
After identification of early symptoms and signs of
thyroid-related orbitopathy, observation and patient edu-
cation are indicated. It can be reassuring to the patient
to be given a description of the natural course of the
disease and suggestions on conservative measures that
help to control symptoms. When orbital inflammation is
mild to moderate, as in most cases, conservative treat-
ment, such as artificial tears and reassurance, is all that
is necessary. Artificial tears and the use of sunglasses
are helpful during the day, whereas elevating the head
of the bed and taping the lids for sleeping are useful at
night. In cases of mild to moderate proptosis and/or
eyelid retraction, topical lubrication with solutions or
ointment may suffice to provide adequate corneal pro-
tection. Moisture chambers or patching the eyes closed
at night may also be helpful. External treatment with
tears, humidifier, and topical nonsteroidal anti-
inflammatory drugs may be employed. These patients
have exposure because of eyelid retraction, and its
treatment is different than that for standard dry eye
syndrome.
Proptosis due to active inflammation may be improved
by oral corticosteroids, whereas proptosis due to chronic
inflammatory changes and fibrosis will not respond to
corticosteroids. During the active orbital inflammation,
and particularly during the acute phase of extraocular
myositis, systemic corticosteroids or immunosuppressive
agents may limit damage to the extraocular muscles,
decrease orbital edema, and decrease compressive optic
neuropathy. High doses in the range of 80 to 120 mg of
prednisone daily for adults usually are required for
suppression of orbital inflammation. I generally reserve
irradiation for the few patients who require additional
treatment after decompression.
One treatment plan is to initiate a 2-month tapering
course of corticosteroids, and if there is a rebound when
the corticosteroids are tapered, then radiotherapy, 20 Gy,
given in ten fractions, is offered along with another
course of corticosteroids. Care and judgment must be
used because long-term corticosteroid treatment may
be worse than the disease itself. It is better to defer sur-
gery until the disease stabilizes into the postinflammatory
or chronic phase. There can still be a waxing and
waning of the smoldering inflammation in the postin-
flammatory phase, which is generally characterized by
stability and lack of active inflammation. Staged recon-
structive surgery is often performed at this time. The
postinflammatory phase is often characterized by
considerable orbital congestion related to venous stasis
in a compressed orbit and manifested clinically by edema,
chemosis, and commonly a painful pressure sensation.
These congestive symptoms and findings must be dif-
ferentiated from frank inflammation, because congestive
disease in the postinflammatory stage responds poorly
to medications and irradiation but often responds well
to orbital apical decompression surgery, which restores
venous outflow.
Inflammation that is severe or associated with visual
loss is treated immediately with high-dose oral pred-
nisone; the doses are tapered slowly and tailored to the
patient's clinical response. Pulsed corticosteroid therapy
can be used in the more severe cases. High-dose cor-
ticosteroids are usually only temporarily effective in
treating optic neuropathy, and their significant side
effects preclude long-term use. Most of these patients
will require irradiation or surgery.
The role of radiation remains in dispute, and some
orbital surgeons proceed directly to surgical decom-
pression. Orbital radiotherapy (20 to 25 Gy) is believed
to reduce the acute inflammatory signs and symptoms
of thyroid-related orbitopathy. The chronic sequelae,
such as restrictive strabismus and eyelid retraction
from muscle and connective tissue fibrosis, are unlikely
to be relieved. Irradiation is also an adjunctive therapy
for patients with compressive optic neuropathy that does
not adequately resolve with surgical decompression
alone. It takes 1 or more months for maximal effect.
Surgical decompression is more effective than radiation
therapy for both correction of globe placement and relief
of compressive neuropathy. Only a few patients require
both treatments. Radiation therapy may be used in place
of decompression in patients who are poor anesthetic
risks or who refuse surgery.

In the presence of corneal compromise or optic nerve
compression, corticosteroids are used in a temporizing
fashion in conjunction with low-dose radiation therapy
(20 to 25 Gy). If vision deteriorates despite cortico-
steroid and radiation treatment, surgical decompression
is warranted. Removal of bone from the posterior medial
orbit is essential to decompress the optic nerve and can
be accomplished by direct or endoscopic techniques.
Contraindications to radiation therapy include con-
current chemotherapy or preexisting diabetes, because
these patients are at risk for postirradiation necrosis of
the retina and blindness. A relative contraindication to
radiation therapy are patients younger than the age of
40, owing to the increased risk of late-developing sar-
comas or other neoplasms of the orbital bones and soft
tissues.
Orbital decompression is indicated in patients with
significant exophthalmos, with severe cosmetic dis-
figurement, or visual loss or severe exposure of the
corneas. It is also indicated when corticosteroids are
ineffective or contraindicated or the patient is intolerant
or if irradiation fails or vision deteriorates rapidly.
Removal or restructuring of the orbital fat may be per-
formed in conjunction with the decompression. The
number of orbital walls removed should be proportionate
to the severity of the proptosis. In mild cases, the floor
and medial wall may be removed through an external
or endoscopic approach. When the operation is per-
formed because of optic neuropathy, it is necessary to
remove the bone in the region of the posterior medial
wall, the posterior ethmoids, to relieve tissue crowding
at the orbital apex. Lateral wall removal requires an
orbital approach, whereas the roof is best approached
intracranially.
Indications for Orbital Decompression
• Progressive proptosis
• Optic neuropathy
• Optic nerve compression
• Orbital inflammation or pain refractory to medical
management
• Exposure keratopathy
• Cosmetic deformity
Optic neuropathy at any time can change the order
of this plan, forcing orbital decompression earlier than
planned (Fatourechi, 1994).
The potential complications of orbital decompression
include diplopia, ocular dystopia, cerebrospinal fluid
leakage, meningitis, infraorbital nerve paresthesia, blind-
ness, nasal lacrimal duct obstruction, infections, and
death (Garrity et aI., 1993). In patients with muscle
enlargement and preexisting muscle restriction, post-
operative diplopia is common after decompression but
is rare in those who had normal motility before the
BASIC CONSIDERATIONS
surgery. Adequate exposure, especially of the ethmoidal
vessels and posterior medial wall of the orbit, and ade-
quate experience are required to avoid these serious
complications. The surgical assistants should be reminded
about the risk of excessive retraction of the globe and
orbital apex. The ethmoidal arteries must be isolated
before bony wall removal. These patients should be
advised that extraocular muscle and eyelid surgery will
often be required after decompression and is part of the
normal order of the treatment plan.
Any or all of the just discussed treatments may be
necessary in an individual patient with thyroid-related
orbitopathy. When multiple modalities are indicated,
the most commonly recommended order of therapy
is topical lubrication, trial of corticosteroids, radiation
therapy, orbital decompression, extraocular muscle
adjustment, and eyelid recession. This order of therapy
allows extraocular muscle surgery to be performed
after rather than before orbital decompression, because
decompression may alter the ocular motility alignment.
Eyelid recession is performed after extraocular muscle
surgery, which allows repositioning of the lower eyelid
retractors, which may be further retracted as a normal
sequela of the inferior rectus muscle recession (Wall
and How, 1990).
Endocrine co-management is essential in the treat-
ment of thyroid-related orbitopathy. Once this has been
established then orbital decompression, Botox (botulinum
toxin type A, Allergan) and prisms, strabismus surgery,
and finally lid repairs are administered and performed
in this order as needed. Overall, patients are psycho-
logically devastated by thyroid-related orbitopathy, and
counseling and support should be requested when
indicated.
Until we are able to identify the orbital target tissues
and their interactions with the thyroid, immunoregulator,
and so on, therapeutic intervention will remain reactive
and limited to palliation. In the future the treatment for
thyroid-related orbitopathy will involve selective immune
suppression that it is hoped will prevent many of the
ocular problems that we encounter.
Dental and Prosthetic
Considerations in Head and Neck
Surgery (Fig. 3-21)
David M. Casey
In the surgical management of cancer of the head and
neck, the patient's teeth cannot be disregarded. If ignored
or improperly managed, they may become sources of
acute or chronic complications for the patient, the head
and neck surgeon, and, ultimately, the dental oncologist
or maxillofacial prosthodontist who treats the patient's
dental and prosthetic needs.
 BASIC CONSIDERATIONS
The dental oncologist is a dentist with specialized
training and expertise in handling the dental needs of
the oncology patient. The maxillofacial prosthodontist
is a prosthodontist with additional training and expertise
in the oral and facial prosthetic needs of the postsurgical
patient. Both of these dental specialists are integral mem-
bers of the head and neck oncology team and should be
involved in virtually all head and neck cancer patients'
treatments, starting in the treatment plan stage. Their
own particular expertise makes them best able to pro-
vide input into what degree of involvement by them is
necessary and at what point in the patient's overall
treatment.
Highpoints
1. Preoperative consultation and examination of head
and neck cancer patients by a maxillofacial prostho-
dontist and dental oncologist contributes greatly to
total patient care.
2. Controversy exists whether to remove or save remain-
ing soft palatal segments after partial soft palatectomy,
included with or separate from partial maxillectomy.
A
FIGURE 3-21
A A preoperative consultation and examination of
the dental/oral needs of the patient and a close working
relationship between the head and neck surgeon can
only have a positive influence on the patient's overall
care by the head and neck team.
81, 82 Teeth that are foci of infection or unre-
storable or unusable should be removed before or at
the time of surgery to prevent acute dental crises post-
operatively. Preoperative (B1, arrow) and postoperative
(B2, arrow) radiographs are shown of strategic dental
extractions done before primary surgery.
C1, C2 Sectioning through a dentulous arch should
be through the center of the socket of an extracted
tooth (C1), except in instances when missing teeth, or
large spaces between teeth, already exist where the
surgeon plans to cut. (Dotted lines in C1 outline the
area to be resected.) This will prevent situations from
arising in which adjacent teeth are damaged or have
insufficient bony support to survive (C2, arrow
delineates damaged tooth).
Continued
 BASIC CONSIDERATIONS

FIGURE 3-21 Continued

 BASIC CONSIDERATIONS
Dental and Prosthetic
Considerations in Head and Neck
Surgery (Continued) (Fig. 3-21)
When a partial maxillectomy violates the integrity of
the soft palate, starting at the latter's anterior edge,
confusion often exists regarding whether to save the
remaining soft palatal segment. It is hoped that the fol-
lowing brief guideline will give direction when the
surgeon is faced with this conundrum.
Whether to remove the remainder of the soft palate
is based on the fact that the sling of the levator veli
palatini muscles occupy the bulk of the middle third of
the soft palate, moving the soft palate posterosuperiorly
during speech and swallowing to contribute to palatopha-
ryngeal closure. Thus, when only the anterior one third
of the soft palate is removed, the remaining two thirds
will be functional and should be retained. Conversely,
when the anterior two thirds is removed, the remaining
posterior third will be a useless, adynamic strand that
should be routinely removed.
The decision-making problem arises when the anterior
third is removed, along with part of the middle third.
How much of the middle third must be removed before
the remaining part becomes nonfunctional and is best
totally removed? The answer is probably somewhere in
the mid-middle third, keeping in mind that individual
variation is great, and this decision is totally in the
hands of the surgeon intraoperatively. The shorter the
soft palate is in overall length, the more difficult this
decision becomes. To err on the conservative side may
make prosthetic reconstruction with a speech-aid
prosthesis very difficult.
Dl, D2 When oncologically possible, the saving of
a tuberosity (D1, arrow) or premaxilla will greatly
improve stability of a maxillary prosthesis. D2 shows
the tissue surface of the resulting stable prosthesis,
with obturator part and tuberosity-supported section
(arrow).
E Small posterior strands of nonfunctional tissue after
partial soft palatectomy (arrows) are best removed at
the time of primary surgery. They prevent direct access
to the palatopharyngeal defect by the speech-aid
prosthesis and make insertion and removal difficult.
Removal of the uvula is also advised in these situations,
because a long uvula on an adynamic strand of soft
palate will give a foreign object sensation on the
posterior tongue.
F Rounding over of bone cuts may prevent delays in
healing, especially if radiation therapy is anticipated.
This bone remains exposed 2 years after orbital exen-
teration and removal of inferior orbital rim, followed
by radiation therapy.
 BASIC CONSIDERATIONS

E F
FIGURE 3-21 Continued
 BASIC CONSIDERATIONS
Maxillofacial Prostheses* (Fig. 3-22)
David M. Casey
Maxillofacial prosthetics is that subspecialty of prostho-
dontics that restores defects of the head and neck with
artificial materials. Those defects may be secondary to
oncologic surgery, trauma, or congenital defects. Prostho-
dontic rehabilitation is carried out when surgical recon-
struction is not the preferred option or in some cases in
conjunction with surgical reconstruction. Oral defects
most commonly treated are those of hard and soft palate
or of mandible or tongue or, more commonly, a combi-
nation of the above. Extraoral defects include orbital,
nasal, and auricular structures. To lend stability and
retention to prostheses, end osseous implants may be
placed in supporting bone, with attachments such as
magnets or clips to hold the prostheses in place.
* Endosseous implant cases presented here are courtesy of Norman
Schaaf, DDS.
For further reading, refer to Beumer J Ill, Curtis T, Marunick M:
Maxillofacial Rehabilitation: Prosthodontic and Surgical Considerations.
51. Louis, Ishiyaku EuroAmerica, 1996.
FIGURE 3-22
Highpoints
1. Surgical reconstruction, when possible, is nearly
always preferable to prosthetic reconstruction, when
comparable aesthetic and functional results can be
achieved.
2. Prostheses are sometimes used as interim treatment,
until a sufficient disease-free period has elapsed.
3. Prosthetic results can be enhanced by preoperative
planning and a close working relationship between
the maxillofacial prosthodontist and the surgeon.
A 1 TO A3 Surgical obturator. This prosthesis replaces
hard palate (A1) and alveolar ridges and is placed
during surgery (A2, arrow) being sutured or wired to
place for 5 to 7 days (A3). Its advantages include more
rapid return to oral feeding, helping to secure packing
in place, and psychological aspects.
81 TO 83 Definitive obturator. This prosthesis is
fabricated after healing is completed, usuallya minimum
of 3 months. It is made of more permanent materials
and rehabilitates the patient to near normal function,
in terms of speech, mastication, and swallowing.A partial
anterior maxillary resection is shown (B1) restored by
a definitive obturator (B2, B3, arrow).
Continued
 BASIC CONSIDERATIONS

FIGURE 3-22 Continued

 BASIC CONSIDERATIONS
Maxillofacial Prostheses (Continued)
(Fig. 3-22)
C Mandibular reconstruction with implants. After partial
segmental mandibulectomy, the ideal functional
reconstruction is the prosthetic replacement of teeth,
supported by endosseous dental implants, which are
placed in a vascularized bone graft. Preoperative plan-
ning for implant position is key to a successful recon-
struction. C shows such a case with implants (arrow)
and superstructure to which a dental prosthesis is
attached.
Dl TO D3 Orbital prosthesis. Because the orbit is not
amenable to surgical reconstruction, the ideal prosthetic
result is attained by an endosseous implant-retained
c
FIGURE 3-22 Continued
prosthesis (01, right orbit). The prosthesis shown here
is retained by magnets attached to the implants (02,
arrow), with "keepers" embedded in the back of the
prosthesis (03, arrow). "Reconstructing" the orbital
defect by obliterating it with a flap obscures detection
of early recurrence and eliminates the possibility of an
aesthetic prosthetic reconstruction.
El, E2 Nasal prosthesis. Adequate bone support for
endosseous implants is often not present for support of
nasal prostheses. The prosthesis (E1) is retained by
magnets attached to the superior surface of an obtu-
rator prosthesis that replaces the premaxilla (at arrows,
E2).
Continued
 BASIC CONSIDERATIONS

FIGURE 3-22 Continued

 BASIC CONSIDERATIONS

Maxillofacial Prostheses (Continued)

prosthesis (F2, arrow), and endosseous implants (F2,
(Fig. 3-22)
arrow) have served the aesthetic requirements of this
patient for 10 years as of this writing.
F1 TO F3 Auricular prosthesis. An ear prosthesis (Fl),
retained by magnets embedded in the back of the

FIGURE 3-22 Continued


Osseointegrated Implants in Head
and Neck Reconstruction
Maureen Sullivan
Mandibular reconstruction with fibula-free flap has
allowed for a more predictable outcome in replacing the
mandible. The use of osseointegrated implants in the
fibula is required as a means of replacing lost dentition.
Significant bulk of overlying soft tissue may prevent
adequate crown to root ratio for optimal restoration of
the implants. Because removable maxillofacial prosthetics
are not possible in the grafted bone without osseoin-
tegrated implants, close communication between the
surgeon and the prosthodontist is required to prevent
overbulking of the overlying tissue.
Maxillary reconstruction with free flaps in both the
hard and soft palate have significant advantages. The
ability for closure of the oroantral defects immediately
postsurgically is an advantage for the recovery of the
patient who is thus able to speak and eat. However,
the disadvantages that must be considered are (1) the
inability to inspect the surgical site for recurrent disease
and (2) the fact that the significant bulk of the flap may
prevent maxillofacial reconstruction with a removable
prosthetic appliance. If the flap has considerable bulk
overlying the surgical defect, there may be no means of
maxillofacial prosthetic reconstruction.
For maxillectomy patients who are edentulous, the
use of osseointegrated implants secured to the remain-
ing maxillary tuberosity should be considered at the
presurgical treatment-planning phase. If the defect is to
be left open, lining the defect with a keratinized skin
graft will provide a more stable surface to engage the
prosthesis.
Osseo integrated implants have provided a more reli-
able means of retention for extraoral maxillofacial pros-
thetics as well. Historically, the auricular, ocular, and
midface prostheses were retained by adhesive and soft
tissue undercuts. With the placement of implants at the
time of the initial surgery or at a subsequent procedure,
magnets, bars, and clips to help retain large prostheses
can be used. Close communication between the sur-
geon and the maxillofacial team during the presurgical
treatment phase enables implant placement during the
ablative surgery.
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 4 DIAGNOSTIC
ENDOSCOPY

PERORAL ENDOSCOPY OF THE

HEAD AND NECK may also not adequately allow for visualization of the
anterior commissure and the petiolus of the epiglottis
as well as portions of the wall of the pyriform sinus and
Indirect Mirror Laryngoscopy and ventricle and lateral border of tongue base.
Nasopharyngoscopy and Cervical
Esophagoscopy Highpoints

Probably the most important overall diagnostic measure,
indirect mirror laryngoscopy utilizes inexpensive
equipment, and, when able to be performed, it facili-
tates a wide view of most of the structures that need
examination. Its biggest drawback is a tendency to cause
gagging in some patients, despite topical anesthesia. It
1. Indirect mirror laryngoscopy (see Fig. 20-2) facili-
tates a view of the larynx, hypopharynx, base of the
tongue, and inferior tonsillar poles.
2. Indirect mirror nasopharyngoscopy (see Fig. 4-8A to
C) facilitates a view of the nasopharynx and nasal
surface of the palate.

179
 DIAGNOSTIC ENDOSCOPY
Direct Optical Laryngoscopy and
Nasopharyngoscopy (Fig. 4-')
A Nonflexible (rigid) Berci-Ward instrument
(manufactured by Karl Storz) utilizes the Hopkins rod
principle of optics and affords a complete magnified
view with a good depth of field of the structures
examined. In these respects, it is superior to the
indirect mirror technique and can be adapted to
photography, can be used as an observation tube, and
can be connected to closed circuit television, with
videotape recordings made, and used for stroboscopy.
It facilitates visualization of the larynx, hypopharynx,
D
FIGURE 4-1
base of tongue, inferior tonsillar poles, nasopharynx,
and the nasal surface of the palate.
B The Lore telescopic biopsy forceps (Karl Storz) is
another nonflexible optical instrument that can be
used to visualize and to biopsy lesions of the
nasopharynx and hypopharynx.
C, D The Lore rigid optical instrument (Karl Storz)
can be used for visualization, biopsy, and stripping of
a vocal cord. It is also excellent for mediastinoscopy
biopsy (see Fig. 19-8). D is a close-up view of the
forceps.

The flexible scope (see Fig. 4-9E) can be connected
to an observer's attachment (see Fig. 4-9G) for
photography as well as to closed circuit television. It
facilitates visualization of the entire nasal cavity,
nasopharynx (see Fig. 4-9F) , nasal surface of soft
palate, posterior and lateral walls of the oropharynx,
base of the tongue, hypopharynx, and larynx. Its main
drawback is the smaller, less magnified view of the
hypopharynx and larynx. Small lesions could be
missed. It is excellent for evaluating the motion of the
vocal cords in the recovery room, especially after
thyroidectomy. It is inserted through a naris, seldom
through the oral cavity. When passed through the oral
cavity, the nasal cavity cannot be visualized. The scope
can be passed through a tracheostoma or tracheostomy
tube for visualization of the trachea and bronchi
inferiorly and the larynx superiorly.
Cervical Esophagoscopy
The flexible scope with suction tract can be used to
examine the cervical esophagus and the reconstructed
pharyngoesophagus after total laryngectomy and total
hypopharyngectomy. Air can be fed through the injection
port with a hand-operated rubber bulb, which can dilate
the lumen of the esophagus and the reconstructed area.
Direct Rigid Laryngoscopy and
Nasopharyngoscopy
The Holinger hourglass anterior commissure speculum
is an excellent scope. Another instrument, interestingly
enough, is the Jesberg short adult esophagoscope. Both
of these can be inserted well into the intrinsic
structures of the larynx for careful visualization of the
walls of the ventricle as well as the pyriform sinus of
the hypopharynx and the petiolus of the epiglottis.
DIAGNOSTIC ENDOSCOPY
Evaluation of the medial wall of the pyriform sinus is
most important in all moderate and advanced carcinomas
of the larynx. Complete examination of the postcricoid
area and esophagus is likewise important.
All peroral direct rigid endoscopic procedures, that
is, laryngoscopy, hypopharyngoscopy, bronchoscopy,
and esophagoscopy, involve the same initial technique.
In each case the "scope" is introduced into the mouth
and hypopharynx using the same positioning of the
head and neck. Hence, the details of laryngoscopy,
which will be seen in detail (see Figs. 4-2 to 4-5), apply
to each phase of peroral endoscopy.
The supine position is routine; however, the sitting
and semi sitting positions (Rose) have merit, especially
in tense, unrelaxed patients and in those patients who
cannot tolerate a reclined position.
Some of the various types of rigid laryngoscopes
available are:
Abramson-Dedo: for Venturi type ventilation
Dedo: anterior commissure scope
Ossoff: posterior commissure scope
Jackson: anterior commissure scope
Holinger: "hour glass" anterior commissure scope
Dedo: double-action anterior commissure scope
Feder: single-action laser scope, bivalve scopes,
micro laryngoscopy scopes
Jako: laser scope
Zeitels: wide-angle scope
Kleinsasser: scope
While the patient is under general anesthesia it is a
good time to palpate the base of tongue, entire tongue,
floor of mouth, lateral oropharyngeal walls, and, if
feasible at times, the lower portion of the nasopharynx,
midline, and lateral walls plus perform a bimanual
examination with a finger inside the mouth and the
opposite hand on the neck.
 DIAGNOSTIC ENDOSCOPY
Direct Rigid Laryngoscopy and
Hypopharyngoscopy (Fig. 4-2)
Highpoints (for All Direct Rigid Peroral Endoscopy)
1. Proper positioning of patient is mandatory-flexion
of the neck with head in the neutral position in the
first stages and then extension. Shoulders are at the
free end of the operating table.
2. Head and neck must be in the midline and not
rotated to one side or other at the onset.
3. Do not insert the instrument in midline of mouth
over incisor teeth. A lateral approach in the region
of the premolars is ideal.
4. A contralateral approach is used when applicable
to known disease.
5. Never use the teeth as a fulcrum when exposing
the larynx; protect the teeth with a plastic guard.
6. Carefully examine teeth, both upper and lower,
beforehand for any "caps," defects, or loose teeth.
7. Expose and identify basic landmarks: (a) base of
tongue, (b) epiglottis, and (c) arytenoids.
8. The assistant holding the patient's head should be
on the left side, leaving the right side clear for
reception of instruments and suctioning.
9. When an instrument or suction tip is passed to
the operator for insertion into endoscope, the pass-
ing nurse places the tip of the instrument or suc-
tion tip into the lumen of the endoscope while the
operator grasps the handle or proximal end (see
Fig.4-3C).
10. The patient is assisted in relaxing all muscles and
reassured that no obstruction to the airway will
occur when using only topical anesthesia.
11. Instruments in immediate use are placed on the
"overhead" table (see Fig. 4-2A).
12. For teaching purposes-observation, a split field T
adaptor is used.
13. Instruments are reviewed with the nurse before the
procedure.
14. Any instrument that touches or passes by the vocal
cords can cause laryngospasm and cardiac
arrhythmias!
The exception to the lateral approach is microlaryn-
goscopy, during which the laryngoscope is usually but
not always inserted in the midline. An assistant to hold
the head is not utilized.
Anesthesia
Topical anesthesia is the anesthesia of choice for exami-
nation, evaluation, and simple biopsy for most adults,
children, and some infants. The agents of choice are
4 % lidocaine, 10% cocaine, or 2 % tetracaine, in varying
amounts (on cotton) in adults to correspondingly less
in children and infants. The application of the topical
anesthetic is started with the patient in the reclining
position. After the lips, oral cavity, and supraglottic
regions are anesthetized, the patient is seated upright.
The application of the agent to the vocal cords is first
performed with cotton on a laryngeal applicating cross
action forceps (Jackson) with teeth to secure the cotton
under vision using a laryngeal mirror. The agent is then
applied with a laryngeal syringe in drop fashion between
the vocal cords, also under mirror vision. The dosage
depends on the agent utilized as well as on the strength
of the agent. During this maneuver the vital signs-
blood pressure, pulse, and respiration-of the patient are
monitored and an electrocardiogram (ECG) is obtained.
Reaction to the topical anesthetic must always be
recognized early. Agitation and central nervous system
(CNS) excitement are the early signs, which proceed to
convulsions, after which follows marked CNS depres-
sion, apnea, hypotension, and cardiovascular collapse.
Treatment with oxygen, diazepam, or an intravenous
barbiturate is then urgent, with monitoring of the pulse
and blood pressure.
There are various opinions regarding the type of
topical anesthetic agent and dosage of each agent rela-
tive to safety and adequacy and purpose of anesthesia.
Topical anesthesia refers to the application of the anes-
thetic agent on the mucous membrane, whereas local
anesthesia refers to the injection of the anesthetic agent.
Nevertheless, several points should be emphasized in
the use of topical anesthetic agents:
1. Cotton is the preferred material in the method of
application. Cotton is just moistened; hence the
dose is minimal. A possible criticism of this method
is the fact that the exact amount of agent absorbed
by the patient is relatively unknown, because a
significant amount of the agent is still retained in the
cotton. Yet, it is emphasized that the dosage absorbed
is minimal, because, as mentioned, a significant
amount of the agent remains on the cotton. In some
48 years of experience (JML), this has proved very
satisfactory. For example, a total dose of 10% cocaine
would be only 1 mL if all were absorbed. Yet, by
using cotton in an unhurried manner, 3 mL has
proved safe. Anaphylactic reaction and idiosyncrasy
can occur; hence, time must be taken in applying
the agent along with monitoring vital signs.
2. Cocaine, rarely used today, is restricted to those
patients in whom vasoconstriction is desirable (e.g.,
in biopsy or endolaryngeal surgery). Cocaine crystals
are not utilized.
3. Cocaine colored red and tetracaine colored blue-
green are never injected. Hence the coloring is an
adequate warning sign.

4. Epinephrine is seldom utilized either with a topical
anesthetic agent or with a local (injected) anesthetic
agent. Epinephrine is not used, because it is believed
that many of the so-called reactions to these anes-
thetic agents are in fact caused by the epinephrine
itself. If vasoconstriction is required with topical anes-
thesia, oxymetazoline (Afrin) or phenylephrine hydro-
chloride (Neo-Synephrine 0.1 %) is utilized. The con-
comitant use of a vasoconstrictor allegedly decreases
the amount of the anesthetic agent absorbed. No
vasoconstrictor is used with local anesthesia.
S. As a standby precaution the patient is always moni-
tored by an anesthesiologist.
6. The application of the agent should not be hurried,
with several minutes given for each application to
take effect. This also allows time to evaluate the
patient's tolerance to the agent.
The total safe dosages of the agents vary. The rule of
thumb to calculate the amount administered is that a
1 % solution contains 1 g in 100 mL or 10 mg in 1.0 mL.
The estimated safe topical dosages absorbed vary from
agent to agent. For an average adult, the estimated
dosages (Snow, 1972) are as follows:
1. Lidocaine (Xylocaine) 2 % to 4 % -200 mg
2. Cocaine 4% to 10%-200 mg
3. Tetracaine (Pontocaine) 0.5 % to 2 %-80 mg
Other references indicate a wide dosage range, for
example, cocaine 10% (1 mL equals 100 mg). Fatal over-
dose is 1.2 g, yet severe toxic effects have been report-
ed with as little as 20 mg. Cocaine must be used with
caution in patients with severely traumatized mucosa
and sepsis.
General anesthesia plus topical anesthesia is used
for stripping of a vocal cord or other detailed endola-
ryngeal procedures. A small endotracheal tube can be
DIAGNOSTIC ENDOSCOPY
used, thus allowing for an unhurried procedure. This is
routine with all microlaryngeal procedures. Topical anes-
thesia is always used as a supplement to the superior
surface of the vocal cords. This is also routine with all
micro laryngeal procedures. This allows repeat, indirect
mirror laryngoscopy and reduces laryngospasm and the
amount of general anesthesia used. Muscle relaxants
should either not be used or used only in very small
doses when stripping a vocal cord; otherwise, a bowed
vocal cord will result. If a muscle relaxant is used, its
effect must be terminated before the stripping.
Discussion
If an examination of the larynx has not been performed
before the direct rigid laryngoscopy, an indirect mirror
laryngoscopy immediately preceding the direct exami-
nation in the operating room is performed. The patient
is now under preoperative medication and is more
relaxed than when he or she was examined in the
office. Indirect laryngoscopy affords a "bird's eye" view
as well as the evaluation of function, which is hardly
possible under general anesthesia. This same view is
better achieved with the optical instruments under
topical anesthesia.
Areas in which "hidden" primary tumors may occur
should be very carefully evaluated: base of tongue, wall
of vallecula, pyriform sinuses, base of epiglottis, and
ventricular and subglottic space.
While the patient is under general anesthesia, it is a
good time to palpate the base of the tongue, entire
tongue, floor of the mouth, and the lateral oropharyngeal
walls, and, if feasible, at times, the lower portion of the
nasopharynx, midline, and lateral walls. Bimanual
examination with the finger inside and the opposite
hand on the area on the neck should also be done.
Refer to Figures 20-2 and 20-3 for details of indirect
laryngoscopy.
 DIAGNOSTIC ENDOSCOPY
Direct Rigid Laryngoscopy and
Hypopharyngoscopy (Continued)
(Fig. 4-2)
Stage I (See Fig. 4-2A to D)
A Depicted is the "overhead" table used in all
peroral endoscopic procedures.
B This diagram outlines the operating room
arrangement utilizing the overhead table.
C, D The assistant who holds the head is located on
the left or right side of the patient, while the anesthe-
siologist (if general anesthesia is used) is located on the
left side alongside the overhead table. If required,
another instrument table is located on the right side
opposite the patient's head, with the instrument nurse
just above or slightly behind this table. In the recum-
bent position, the patient's shoulders are free of the
table with the neck flexed (i.e., above the level of the
shoulders). The head starts in the neutral position and
is then extended. The assistant sits on a stool with feet
on a raft or footstool. The assistant's knees are used as
support for his or her elbows. The head pad from the
operating table may be used between the kneesand the
elbows. Thus, the assistant does not tire when chang-
ing the position of the patient's head at the instruction
of the operator. The operator uses the left hand to
hold and insert the instrument and the right hand (D)
to steady the jaw and retract the lips. The instrument
is not inserted in the midline but off to one side. This
is most important because the angle of insertion is
greatest in the midline, owing to the longer and more
anteriorly located incisor teeth and the bulk of the
mid portion of the baseof the tongue. Injury is also more
likely to occur to the incisors than to the premolars.
Both upper and lower teeth are in jeopardy. A 4 x 4-inch
piece of gauze or a plastic tooth guard aids in the pro-
tection of teeth and lips. If surgery is to be performed
on the right vocal cord, the introduction of the gauze
is on the left side of the mouth, and vice versa.
Continued
 DIAGNOSTIC ENDOSCOPY

MAYO
OPERATING TABLE
TABLE
FOR TOPICAL
ANESTHESIA
I I
I OVERHEAD I
I TABLE I
I
I I
I I
ANESTHESIOLOGIS~

o
I I
I BASIC I
I INSTRUMENTS:
I
I I

EXTRA
INSTRUMENT
TABLE

U FOOT
STOOL
0 ~NURSE

ENDOSCOPISTD
B

FIGURE4-2
 DIAGNOSTIC ENDOSCOPY
Direct Rigid Laryngoscopy and
Hypopharyngoscopy (Continued)
(Fig. 4-2)
Stage /I (See Fig. 4-2E and F)
E, F The instrument, well lubricated, is advanced to
the base of the tongue exposing the epiglottis and
vallecula (the space between the base of the tongue
and the epiglottis). E shows the cross-sectional
anatomy, whereas F represents the view through the
laryngoscope. As the instrument is advanced, the head
is extended as depicted by the arrow. The laryngo-
scope tip is now in the midline, having eased into,this
position from the side of the posterior third of the
tongue while the body of the instrument still lies to the
side of the mouth. This is most important. (For clarity
the tooth guard is not depicted.)
' >.. \
.'"
FIGURE 4-2 Continued
Stage III (See Fig. 4-2G to I)
G The tip of the instrument is dipped slightly back-
ward to lift the tip of the epiglottis.
H This is termed engagement of the epiglottis. The
posterior commissure of the vocal cords, arytenoids,
aryepiglottic folds, hypopharynx, and medial portions
of both pyriform sinusesare visualized. If the instrument
is swung from side to side, complete visualization of
the pyriform fossae is achieved. G shows a cross section,_
whereas H depicts the view through the laryngoscope.
As the instrument is advanced, the head is further
extended. The neck, however, is still flexed so that the
occiput is 10 to 15 em above the shoulder level.
I With the head further extended, the tip of the
laryngoscope is advanced slightly farther to the base
Aryepiglottic fold
Cricoid cartilage
Arytenoid
Pyriform fossa
Esophageal lumen
H
 DIAGNOSTIC ENDOSCOPY 187

Ventricular
band

FIGURE4-2 Continued

or cushion of the epiglottis. Using the handle of the
laryngoscope as a lever, but not the teeth as a fulcrum,
the base of the epiglottis is raised and a full view of the
larynx is obtained. The base of the epiglottis is now
carefully scrutinized as well as the ventricle and
subglottic space.
Device to Hold Endotracheal Tube at Anterior
Commissure
the endotracheal tube can be displaced anteriorly and
held in position as follows:
1. The end of the plastic tooth guard is cut off the
guard.
2. This end is sutured with heavy silk to the anterior
portion of the laryngoscope.
3. The endotracheal tube fits into the concavity of the
tooth guard and is thus held at the anterior
commissure.

J When operating on lesions at the posterior Ossoff has designed a special scope for visualization
commissure or posterior one third of the vocal cords, of the anterior commissure (Weed et aI., 1994).
 DIAGNOSTIC ENDOSCOPY
Rigid Bronchoscopy (Fig. 4-3)
Highpoints
1. The right hand is used to introduce the bronchoscope;
this differs from introduction of the laryngoscope. Care
must be taken not to injure upper or lower teeth.
2. The total time of instrumentation usually should be
no longer than 20 minutes.
3. Avoid indiscriminate and blind punch biopsies, espe-
cially of any carina or a bulge with intact mucosa
and, of course, over pulsating areas.
4. Do not force the bronchoscope through the larynx.
The vocal cords must be abducted; otherwise,
damage may result. Gentle rotation of the tip may
aid insertion.
5. When a foreign body is suggested and granulation
tissue encountered, gently advance the broncho-
scope beyond the granulation tissue. Granulation
tissue may hide the foreign body.
6. Only the Holinger or similar type ventilation
bronchoscope should be used.
7. Indirect laryngoscopy (see Fig. 20-2) with topical
anesthesia is usually a routine done before broncho-
scopy. Direct laryngoscopy and hypopharyngoscopy
should also be performed. Lesions of the larynx and
hypopharynx have been missed by surgeons who
pass the bronchoscope (rigid or flexible or for that
matter an esophagoscope) immediately into the
trachea.
Anesthesia
Either general or topical anesthesia may be used in
adults and cooperative older children. General anesthesia
supplemented with topical anesthesia to the vocal
cords is used for foreign body removal in infants and
uncooperative children. After the bronchoscope is
inserted in the lumen of the trachea, the anesthetic gas
and oxygen are introduced through the anesthesia
adaptor on the Holinger ventilation bronchoscope. The
bronchoscopic lumen is then closed with a glass-capped
adaptor or glass cover on a pivot, thus providing a
semiclosed system. If tracheal toilet is the purpose,
topical anesthesia may be preferred.
Sanders (1967) has designed a ventilating attachment
for bronchoscopes utilizing the Venturi effect (Duvall et
a!., 1969).
A, B There are two methods of introduction of the
bronchoscope. One method relies on a laryngoscope
with a removable slide; the other method is direct
insertion of the bronchoscope. The direct insertion is
the usual procedure and follows the steps of
laryngoscopy exactly except that the bronchoscope is
held with the right hand. The method of using a
laryngoscope is depicted in A. After the vocal cords are
exposed, the' bronchoscope is passed through the
laryngoscope. Vision is then transferred from the
laryngoscope to the bronchoscope, which is passed
through the larynx into the lumen of the trachea. In
either method, the bronchoscope must not be forced
between the vocal cords. The vocal cords must be
abducted; otherwise, injury to the cords will ensue.
The slide of the laryngoscope is removed and the
laryngoscope is backed off and gently pulled out,
leaving the bronchoscope in place.
Bronchoscopy using the laryngoscope for introduction
should be familiar to all endoscopists. It is specifically
useful in infants and children because identification of
the laryngeal landmarks may be obscured through the
smaller-lumen bronchoscopes. In adults with short necks
and bulky tongues, the laryngoscopic introduction is
also advantageous. It affords a view of the larynx and
hypopharynx and protects the bronchoscope from oral
contamination, although granted this point may have
more theoretical than real value.
C The instrument nurse is shown placing the tip of
the suction cannula in the lumen of the bronchoscope
while the operator grasps the proximal end. The same
technique is employed in the introduction of any bron-
choscopic or esophagoscopic forceps or telescope.
In the background is a pegboard on which all the
endoscopic instruments are kept for easy selection by
the operator. These instruments should be kept sterile
in plastic transparent wrappers for immediate use.
Continued
 DIAGNOSTIC ENDOSCOPY

B c
FIGURE 4-3
 DIAGNOSTIC ENDOSCOPY
Rigid Bronchoscopy (Continued)
(Fig. 4-3)
D As the bronchoscope is advanced in the trachea,
the following routine checkpoints are noted: patency,
configuration, and deviation of the trachea and
position, axis, degree of sharpness, and transmitted
pulsation of the main carina. The orifices of the right
and left bronchi are then examined, and the bron-
choscope is inserted in the direction of the bronchus
to be examined with the head and neck deviated to
the opposite side.
The Right Bronchus. Just at or beyond the level of the
main carina, on the lateral wall of the rig\1t bronchus,
is the lumen of the right upper lobe bronchus. Its
carina is somewhat broader than the main carina. Only
about 0.5 em of this upper lobe bronchus can be seen.
A right-angled telescope usually enables visualization
of two or three of the segmental bronchi, that is, the
apical, posterior, and anterior segments. As the bron-
choscope is passed along, the lumen of the right middle
lobe is encountered on the anterior wall of the main
bronchus. Its carina is almost horizontal and usually
quite sharp. About 0.5 to 1 em of the middle lobe
bronchus is easily seen. This bronchus divides into
lateral and medial segments. This division is often
visualized. Just at or slightly below this level, the superior
segmental bronchus of the right lower lobe is encoun-
tered posteriorly. Beyond this point, the remaining ter-
minal divisions are identifiable as the medial, lateral,
anterior, and posterior basal segments.
The Left Bronchus. Several centimeters beyond the
main carina, on the lateral wall, the orifice of the upper
lobe bronchus is seen. Its carina is slightly off the
vertical and is usually sharp. With a right-angled or
retrograde telescope, the divisions into upper and
lower (lingual) branches are easily seen. Just at or
slightly below this level on the posterior wall of the left
mainstem bronchus is the superior segmental bronchus
of the left lower lobe. Beyond are the terminal divisions
identifiable as the anteromedial, lateral, and posterior
basal segments.
As the bronchoscope is withdrawn, careful retrograde
examination of all suspicious areas is made.
The previously described telescopes, although still
used by some endoscopists, have given way to the
flexible bronchoscope, which achieves more distal
visualization.
E In all bronchoscopies in which a malignant lesion
is suspected but no actual lesion is seen, Gelfoam
smears are made in the region of suspicion. A 12-mm
piece is broken off a sterile Gelfoam sponge (No.
7853-20 x 60 x 7 mm), folded, and grasped securely
in a forward grasping forceps with serrated and
slightly cupped jaws. "Peanut" foreign body forceps
are ideal. The slightly irregular end of the broken
Gelfoam is then rubbed over the area of suspicion and
withdrawn. The end of Gelfoam that was in contact
with the suspicious area is immediately rubbed on a
glass slide, which is plated in alcohol and ether for
fixation and Papanicolaou or hematoxylin and eosin
staining. This technique is used in addition to the
collection of aspiration specimens with or without
saline irri.gation. A Lukens collection tube is utilized
along with an open-ended suction tube. Extreme care
is taken not to lose a part or all of the Gelfoam. A firm
but not excessively firm grip on the alligator forceps is
utilized.
 DIAGNOSTIC ENDOSCOPY

E
Left lower lobe
superior
ant. medial basal Lower lobe
lateral basal superior
post. basal medial basal
ant. basal
lateral basal
post. basal

Middle lobe
carina
lateral
medial

Upper Division
apical post.
anterior Upper lobe
Lower Division (Lingular) apical
superior posterior
inferior anterior
Upper lobe
carina
FIGURE 4-3 Continued
 DIAGNOSTIC ENDOSCOPY
Flexible Bronchoscopy
The great advantage of flexible bronchoscopy over rigid
bronchoscopy is primarily in the visualization of the
sub segmental divisions of the bronchi. Coupled with
this advantage is the ability of the bronchoscopist to
obtain selective biopsy samples, including the brush
type from these subsegmental bronchi. Biplane fluo-
roscopy can also be combined with the flexible instru-
ment to obtain brush biopsy samples beyond the range
of the visualization of the scope. However, Gelfoam
smears cannot be obtained.
Flexible bronchoscopy can be performed under either
topical or general anesthesia. Under topical anesthesia
the instrument can be inserted either via the oral cavity
with a bite block or a pharyngeal airway with a mid-
line slot for the instrument or less commonly via the
nasal cavity. A slide-type laryngoscope (Jackson) can
be used to aid in the insertion of the flexible scope, if
needed. If the flexible scope is introduced via the nasal
cavity, the diameter of the scope may cause a problem,
possibly resulting in epistaxis, if there is any significant
nasal obstruction. Obviously, topical anesthesia must
likewise be applied to the nasal mucosa, and cocaine
can be used for this purpose because it is a vasocon-
strictor. Otherwise 4 % lidocaine is used with oxymeta-
zoline. Precautions in the use of cocaine are discussed
on page 182.
Under general anesthesia the flexible scope is intro-
duced through the lumen of an endotracheal tube. A
special adaptor to the endotracheal tube is utilized to
continue the anesthesia along with oxygen administra-
tion. The drawback of this method is that the hypo-
pharynx and larynx are not visualized unless they are
independently examined. This is most important. As a
matter of fact, too many times even without an endotra-
cheal tube, the endoscopist does not take enough time
to visualize the hypopharynx and larynx, thus possibly
missing a neoplastic lesion in one of these structures.
Thus, if an endotracheal tube is utilized, the hypophar-
ynx and larynx must be scrutinized by laryngoscopy.
Regardless of the method of insertion of the flexible
bronchoscope, it should be lubricated and introduced
so all structures can be visualized as it is moved along.
Additional topical anesthesia can be inserted through
the scope, and suction specimens can also be obtained
in the same manner.
The C-arm can be used for purpose of concomitant
bronchoscopy with fluoroscopy.
Complications
• Hemorrhage, especially from blind biopsies. This
can result in death when the biopsy is in either the
trachea or the bronchi.
• Hypoxia, anoxia, and respiratory arrest
• Laryngospasm. Always use topical anesthesia on the
larynx when general anesthesia is utilized.
• Cardiac arrhythmia
• Dental injury
Tracheal Lengths (Fig. 4-4)
The length of the trachea in both adults and children is
of importance in relation to the following:
1. Length of endotracheal tubes
2. Length of tracheostomy tubes
3. Feasibility of tracheal resection with end-to-end
anastomoses
4. Evaluation of dead space. The number of tracheal
rings will vary from 16 to 20.
It is interesting to compare tracheal lengths in the
cadaver (Table 4-1) with the living patient. The latter is
a dynamic measurement and somewhat longer. In
Figure 4-4 a comparison is made between measure-
ments in the living infant and cadaver. Although the
bases for measurements are not the same-Fearon and
Whalen (1967) measuring from the vocal cords to the
main carina and Hall (1955) from the lower edge of the
cricoid cartilage-there apparently is a longer length in
the living, and an indication of the dynamic nature of
the trachea is the possible influence by the action of the
diaphragm.
Another point of interest is that the trachea is not a
true cylinder but somewhat flattened posteriorly. This
is one of the reasons for the complication of tracheal
stenosis with the use of high-pressure cuffs on
tracheostomy tubes and endotracheal tubes.
Table 4-2 gives a guide for selection of appropriate
tracheotomy tubes and bronchoscopes for use in
children.
 DIAGNOSTIC ENDOSCOPY

TRACHEAL LENGTHS IN INFANTS TABLE4-1 Average Cadaveric Lengths of

10 1\'achea (After Jackson. 1950)
_ FEARON & WHALEN-(L1VING)
o HALL & ENGEL-(CADAVER)
8 Patient Length
7.2

6 Adult i2 cm (maie)
10 cm (female)
Child 6cm
4
infant 4cm
2

o 3 6 12 18
AGE IN MONTHS
FIGURE 4--4

TABLE4-2 Guide for Selection of Suitable 1\'acheotomy 1\1bes and Bronchoscopes

instrument Child's Age Size of Instrument

Holinger tracheotomy tube Premature No. 000 x 26 mm

( <4Ib)
Premature No. 00 x 26 to 33 mm
(>41b)
o to 6 mo No. 0 x 33 to 40 mm
6 to 12 mo NO.1 x 40 to 46 mm
12 to 18 mo No.1 x 46 mm
18 mo to 4 to 5 yr No.1 or NO.2 x 46 to 50 mm
4 to 5 yr to 10 yr No.2 or No.3 x 50 to 55 mm
10 yr+ NO.3 or NO.4 or No.5 x 50 to 68 mm
Bronchoscope < 5 lb 3 mm
o to 6 mo 3.5 mm
6 mo to 3 yr 4 mm
3 to 12 yr 5 mm
12 yr + 6mm

From Fearon B, Ellis 0: The management of the long-term airway problem in infants and children. Ann Otol Rhinal Laryngol 669:80, 1971.
 DIAGNOSTIC ENDOSCOPY
Esophagoscopy (Fig. 4-5)
Highpoints
1. Never advance the esophagoscope forcibly.
2. Advancement is made only when an actual lumen is
seen.
3. The Jesberg type of esophagoscope is preferred.
4. The danger area is at cricopharyngeus sphincter, at
the cardioesophageal region, or at any area of
constriction.
5. In removal of foreign bodies, the esophagoscope is
never passed to an assistant. Such manipulation
may lose the foreign body, which if sharp may cause
esophageal perforation.
6. If feasible, always perform mirror laryngoscopy first
under topical anesthesia. Pooling of saliva in the
pyriform sinus (Jackson sign) is an indication of
esophageal obstruction.
7. If unable to pass the esophagoscope, pass a red
rubber catheter into the lumen of the esophagus and
use this as a guide. If this fails, do not persist and
postpone until another day. Perforation is an
extremely serious complication. Primum non nocere
is the dictum.
Anesthesia
Virtually all esophagoscopies are performed under general
endotracheal anesthesia. This is usually preceded by
topical anesthesia (see p. 182) to the mucous mem-
brane of the oropharynx, hypopharynx, and larynx.
Careful scrutiny of these structures is always per-
formed. If there is filling of the pyriform sinuses, this is
an indication of a distal obstruction in the esophagus.
Usually, esophagoscopy is preceded by full-length
pharyngoesophagograms. An exception to these radio-
graphs is the presence of a radiopaque foreign body. A
suspected nonradiopaque foreign body may be visu-
alized with the ingestion of some cotton soaked with
the radiopaque material. Otherwise, the radiopaque
material may completely obscure the visualization of
the foreign body.
Cervical Esophagoscopy After Total
Laryngectomy or Cervical Esophageal
Surgery
Examination of the pharyngoesophageal area and the
cervical esophagus can be performed with the use of a
flexible nasopharyngoscope that has a suction port and
a second port for instillation of medication by attaching
a short section of tubing with a bulb for inflation to the
second port (similar to the bulb used on a sphyg-
momanometer) to inflate and distend the esophagus
(see Fig. 4-SB and C).
Flexible Esophagoscopy
In addition to the rigid esophagoscope, flexible fiber-
optic instruments are utilized. These are usually flexi-
ble gastroscopes and are the preferred instrument for
routine examination by gastroenterologists. The advan-
tage of these is that there is magnification and that the
esophageal lumen can be dilated with insufflation.
Endoscopic photographs are easily performed as well
as endoscopic excision of small areas of cancer in situ.
Using the flexible scope, the Japanese have reported
early detection of esophageal cancer in patients with
known head and neck cancer utilizing half-strength
glycerine-free Lugol's solution instilled into the
esophageal lumen. The Japanese have also reported
endoscopic resection of intraepithelial and intramucosal
early and superficial esophageal cancers, which do not
involve the muscularis mucosa. The disadvantages
include problems with performing dilatation, removal
of foreign bodies, and Gelfoam smears of suspicious
mucosal lesions.
Caution: Extreme care must be taken with both the
rigid and flexible esophagoscope not to perforate a
pharyngoesophageal diverticulum (Zenker) because
the scope may have a tendency to go into the diver-
ticulum rather than follow the lumen of the esophagus.
Although not encountered by the authors, there is the
possibility that the stiff plastic cardiac monitor tube
inserted by the anesthesiologist could likewise perforate
a diverticulum.
A A Jesberg esophagoscope is preferred because its
tip is so shaped that it acts as a blunt dilator. There are
no sharp angles at the tip, which might become engaged
with folds of mucous membrane. The esophagoscope,
lubricated with water-soluble jelly,is introduced exactly
the same as the laryngoscope or bronchoscope,
following steps E, F,G, and H in Figure 4-2, except that
the instrument is held in the right hand. The other
variant is that introduction is almost always through
the right side of the mouth, especially if a full-length
esophagoscopy is anticipated. When the posterior
commissure of the larynx and the arytenoid cartilages
are exposed, the tip of the esophagoscope is placed
exactly in the midline and the entire instrument is
brought into the same midline plane. This is achieved
by slightly rotating the head to the side opposite the
side of introduction through the mouth. The tip of the
esophagoscope is then gently advanced along the
space posterior to the bodies of the arytenoid cartilages
and the cricoid cartilage. This technique differs from
the pyriform sinus approach to the cricopharyngeus
sphincter in that the esophagoscope tip is in the
midline, stays in the midline, and never enters either
pyriform sinus. However, the pyriform sinuses are

FIGURE 4-5
carefully examined before the introduction of the
scope into the lumen of the esophagus. By staying in
the midline there is less danger of perforating either
the hypopharynx or the esophagus. The pyriform sinus
approach is through the pyriform sinus. With this
approach the instrument is introduced into the sinus
and when near the apex of the sinus it is carefully
displaced medially to the midline above the
cricopharyngeus muscle. The next structure encoun-
tered is the cricopharyngeus sphincter, which is the
most dangerous area in esophagoscopy. With waiting
and applying gentle pressure and sometimes with
gentle elevation of the tip of the esophagoscope, the
lumen is almost always perceptible. The esophagoscope
DIAGNOSTIC ENDOSCOPY
is never advanced unless the lumen through this
sphincter is seen. In difficult exposure problems,
switching to a smaller-lumen esophagoscope will help.
Another technique that provides aid is to pass a red
rubber catheter before instrumentation and follow the
tube through the cricopharyngeus sphincter. The red
rubber catheter is inserted through the nose and
enters the esophagus through the pyriform sinus. This
method has been found more suitable than using a
filiform bougie passed through the esophagoscope to
identify the lumen, and it is much safer. A bougie may
perforate the esophagus when there is significant
obstruction due to neoplasm.
Continued
 DIAGNOSTIC ENDOSCOPY
Rigid Esophagoscopy (Continued)
(Fig. 4-5)
As the esophagoscope is advanced through the
sphincter, the operator must not be so engrossed in the
instrumentation that he or she neglects to examine this
region carefully for any lesions, if the signs and
symptoms of the patient so indicate examination. This
area-especially the postcricoid region-can also be
evaluated during slow removal of the esophagoscope at
the close of the procedure.
Biopsy
Biopsy of neoplastic or suspicious neoplastic lesions of
the esophagus must be very carefully performed because
of the danger of perforation. If the lesion is small and
relatively nonprotruding, a cytologic smear is obtained
using Gelfoam, as described under Bronchoscopy (see
Fig. 4-3E). Avoid any deep biopsy of any lesion. Frozen
sections are often utilized to avoid repeat biopsies. If
the biopsy of the lesion is reported as benign on several
judicious attempts, consideration should be given to
open transcervical or transthoracic biopsy rather than
risk perforation.
The early signs and symptoms of perforation are
heart rate and temperature elevation and either cervical,
back, or epigastric pain. Hence, after all esophagoscopies,
the patient is kept NPO for several hours and is care-
fully observed.
Complications
• Esophageal perforation
• Mediastinitis
• Hemorrhage
Management of Perforated Esophagus
If the perforation is in the cervical area, the management
is intravenous administration of a broad-spectrum
antibiotic with maximum dosage. If symptoms persist
or worsen, then external drainage is indicated. Extreme
care must be taken not to injure any major vessel, for
example, the internal jugular vein or the common
carotid artery, nor the recurrent laryngeal nerve. Closure
of the perforation is not recommended nor is a proximal
diversion recommended. One patient was reconstructed
with an oblique end-to-side anastomosis after another
surgeon transected the esophagus at the thoracic inlet
with a proximal diversion of the esophagus and closure
of the distal segment of the esophagus. This was a very
difficult reconstruction performed through the cervical
area. Exposure was enhanced by resection of the medial
third of the clavicle to expose the posterior superior
mediastinum (see pp. 1041 to 1045). There was a tem-
porary left vocal cord paralysis, and reconstruction was
successful without leak.
If the perforation is in the thoracic esophagus, open
thoracotomy with closure is usually immediately indi-
cated. However, small perforations may be observed
from 8 to 12 hours while on antibiotics.
Note: These perforations may be the result of the
esophagoscope itself or the result of a deep biopsy of a
neoplastic lesion. Remember also there are diverticula
in the thoracic esophagus as well as in the pharyn-
goesophageal area.
8, C Depicted is the fiberoptic flexible nasolaryn-
goscope with an inflatable bulb attached to the
medicinal channel that can now be used as a cervical
esophagoscope. Air is gently insufflated into the
cervical esophagus for dilatation, which facilitates
inspection.
Continued
 DIAGNOSTIC ENDOSCOPY

c
FIGURE4-5 Continued
 DIAGNOSTIC ENDOSCOPY
Rigid Esophagoscopy (Continued)
(Fig. 4-5)
D, E After passage of the esophagoscope through
the cricopharyngeus sphincter, the lumen of the
cervical esophagus is exposed. Advancement is now
quite easy, but again the strict axiom applies that this
be done only when a clear lumen is seen. When the
thoracic esophagus is reached, the lumen will be seen
to open and close with respirations. As the instrument
is advanced past the landmarks of the arch of the aorta
and the point of crossing of the left bronchus, raising
and lowering the head, neck, and shoulders will be
necessary to keep the esophageal lumen exactly in the
center of the esophagoscope. As the cardioesophageal
junction is approached, the lumen will tend to become
obscure. This is the second danger site and indicates
the level of the diaphragm, and extreme care must
again be exercised to proceed only when the lumen is
fully exposed. The two leaves of the right crus of the
diaphragm form the hiatus, which may be quite
evident as a distinct site of sphincter-like action during
the phases of respiration. The esophagus usually bends
slightly to the left in this region, and this will
necessitate pointing the distal end of the esophagus
toward the left.
If the lumen does not become evident, gentle forward
pressure usually demonstrates it. The technique of
using the red rubber catheter is occasionally necessary.
Beyond the esophageal hiatus of the diaphragm, the
esophagus continues for about 2 cm as the abdominal
portion before it joins the stomach at the cardio-
esophageal junction. The stomach is easily entered and
is recognized (E) by the change of the whitish esophageal
mucous membrane to the reddish larger folds of gastric
mucosa. There may be a regurgitation of gastric juices
into the lumen.
The esophagoscopic distances from the upper incisors
are depicted along with the three constricted areas in
which foreign bodies are most likely to become lodged:
1. The cricoid cartilage, which marks the cricopharyn-
geus muscle and the beginning of the esophagus
2. The bifurcation of the trachea, which is at the level
of the descending portion of the arch of the aorta or
the crossing of the left bronchus
3. The level of the diaphragm, which is slightly above
the cardioesophageal junction
Just above the level of the diaphragm there may be
a slight dilatation, which is more noticeable on a
radiograph; that is the phrenic ampulla.
Another word of caution is needed about the danger
of esophageal perforation through the sac of an
esophageal diverticulum. A full-length esophagogram
is always performed except in the presence of a foreign
body. In the latter circumstance an esophagogram is
the choice of the surgeon, because the barium may
make subsequent esophagoscopy somewhat difficult
unless it is irrigated and removed by suction. Always
use blunt closed-tip suction in esophagoscopy.
 DIAGNOSTIC ENDOSCOPY

Distance from upper incisors ADULTS Female-Male

12 to 16 em.

Cricoid cartilage

22 to 29 em.

Bifurcation of trachea

32 to 50 em.

Cardioesophageal junction

FIGURE4-5 Continued
 200 DIAGNOSTIC ENDOSCOPY
Microscopic Endolaryngoscopy
(Fig. 4-6) (After Kleinsasser, 1961;
Jako and Kleinsasser, 1966)
The history of direct laryngoscopy dates back at least
to Kirstein (1894), with the first optical laryngoscopy
by Briinnings and the first binocular laryngoscopy by
Yankauer (1910). There are basically two methods of
obtaining magnified visualization of the larynx. One
uses the microscope, whereas the other uses rigid or
flexible telescopes.
At this point, only the microscope and rigid tele-
scopes are adaptable to endolaryngeal surgery. Although
the flexible scopes are useful in bronchoscopy for
biopsy purposes, this methodology has not been in
general use for the larynx. Kleinsasser (Karl Storz) has
designed rigid telescopes for use via his laryngoscope
mainly for visualization and photography. Lore and
Karl Storz have designed rigid telescopic laryngeal instru-
ments not only for visualization but also for biopsy
purposes and removal of benign lesions as well as of
carcinoma in situ of the larynx. These procedures are
performed using a standard type laryngoscope (e.g.,
the Holinger hourglass laryngoscope) and stripping
forceps incorporated with the rigid telescope (0, 30,
and 70 degrees).
Indications
• Diagnosis
• Surgery
• Teaching
Anesthesia
Topical plus general anesthesia, using a small (26 to 30
gauge) endotracheal tube with cuff, is used. One must
be careful to avoid overdose with muscle relaxants
when stripping of vocal cords is performed. The muscle
relaxant must be entirely worn off at the time of the
stripping otherwise bowing of the vocal cord may
occur. This complication is caused by the relaxation
and hence convexity of the vocal cord.
Topical anesthesia (see p. 182) is applied by the
operating surgeon, who then carefully inspects the
larynx by indirect laryngoscopy. This gives up-to-the-
minute information regarding any pathologic change,
including motility of the vocal cords. This is most
important, and this portion of the examination can be
more easily performed with a flexible nasopharyngoscope.
The cuff is inflated to prevent aspiration of blood
and air leak, which might cause fogging of the optical
system and mirror.
Some surgeons use intravenous analgesia combined
with a Lynch suspension apparatus with a naso-oral tube
to supply oxygen. No endotracheal tube is utilized.
There is a significant danger in utilizing this method
without control of the oxygen exchange because of
cardiac arrhythmia. The author prefers an endotracheal
tube, using topical plus general anesthesia.
In certain conditions in which an endotracheal tube
is impractical (e.g., evaluation of subglottic stenosis),
neuroleptanalgesia is utilized along with topical anes-
thesia. Neuroleptanalgesia is the combination of a narcotic
analgesic with a tranquilizer. A combination of meperidine
(Demerol) and promethazine (Phenergan) could be
considered in this category. More commonly, it is the
combination of fentanyl (narcotic analgesic) and droperidol
(tranquilizer) under the trade name of Innovar. Innovar
has a fixed amount of each of these drugs; some surgeons
prefer a different amount of each of these drugs.
Cardiac monitoring is advised, with the monitoring
continued during the postoperative period.
Innovar is not believed to be warranted as a preoper-
ative medication, because muscle rigidity and hypo-
tension are complications that could lead to death.
Succinylcholine is used to counteract the muscle rigidity.
Although the usual location of the endotracheal tube
is at the posterior commissure for operative procedures
on the vocal cords, the tube is placed anteriorly for
evaluation and biopsy posteriorly. This can be achieved
by using a portion of a plastic tooth guard.
An anesthetic device has been designed based on the
Venturi effect. The author has no personal experience
with this apparatus.
Instruments
1. Jako, Kleinsasser, Riecker, Lynch, or Dedo laryngo-
scope. All too often these wide proximal endoscopes
cannot be introduced safely. A Holinger hourglass or
Jackson anterior commissure speculum can be
utilized with the lateral oral approach. Monocular
vision is then necessary.
2. Operation microscope with 400-mm (if short instru-
ment used) or SOO-mm lens, x16 to x2S magnifi-
cation
3. Microsurgery instruments plus standard laryngeal
instruments
4. Lewy laryngoscope holder
S. A plastic guard for upper teeth
Diagnosis
Evaluation of small malignant lesions is possible with
staining by toluidine blue 1 % (Strong et al., 1968;
Shedd and Gaeta, 1971). Toluidine blue stain is picked
up by any ulcerative lesion and hence not diagnostic of
dysplasia, carcinoma in situ, or carcinoma, only sugges-
tive. It may be helpful in directing the biopsy to the

most suspicious area. With vocal cord lesions, for exam-
ple, in which virtually the entire cord is involved with
a whitish area, it is usually best to strip the entire vocal
cord and have the pathologist do serial sections. First,
gently cleanse mucous membranes with acetic acid 1 %,
apply the toluidine blue 1 % or 2 %, and then gently
wipe with acetic acid 1 % and water. Respiratory epithe-
lium and any benign ulcer yields a false-positive result.
The ventricles are lined with respiratory epithelium.
Multiple exacting biopsies with small forceps are
possible. Using the staining technique with the micro-
scope, biopsies are possible of areas that otherwise
might be missed. Hence, the unrecognized lesion on
mirror laryngoscopy and ordinary direct laryngoscopy
can be seen, and a biopsy sample can be taken, thus
often avoiding repeat examinations. Carcinoma in situ
is a specific example of a lesion that may go unrecog-
nized by the ordinary methods. A large diagram of the
larynx can be used to locate the sources of the biopsies.
Flexibility of the structures as well as subglottic space
and ventricles is evaluated. Transillumination of the
vocal cords and ventricular bands is possible but of
questionable value.
A telescope, Hopkins rod (Karl Storz), foreoblique or
retrograde, can be used through the laryngoscope to
yield additional information of the subglottic space.
When borderline lesions are present the technique is
especially helpful to evaluate the feasibility of partial
laryngectomy. In addition, hypo pharyngeal lesions can
be evaluated.
A photograph is taken through the standard beam
splitter and sidearm attachments. Videotapes are much
DIAGNOSTIC ENDOSCOPY
easier to make than still photographs. Television, for
teaching purposes, is also possible and yields an excellent
picture of the larynx and the surgical procedure.
Surgery
1. Removal of webs
2. Stripping of vocal cords (using adult- or child-sized
Lore, Sf. forceps) (see Figs. 4-7 and 20-5)
3. Selective biopsy
4. Intralaryngeal incision and/or excision of lesions
5. Cryosurgery
6. Transoral arytenoidectomy (Thornell)
7. Injection of vocal cords with Teflon or Gelfoam
(temporary) for adductor cord paralysis or bowing.
(General anesthesia is not used; rather Innovar is
given intravenously to evaluate amount of material
injected.)
8. Carbon dioxide laser
Complications
• Injury to teeth. A percentage of patients cannot be
examined by the laryngoscopes and holders now
available for micro laryngoscopy. A substitute for the
use of the microscope is the telescopic endola-
ryngeal instruments designed by Lore and Karl Storz.
• Cardiac arrhythmia
• Although both vocal cords can be operated on, there
is danger that web formation can occur if the
mucous membrane on both vocal cords is denuded
at the anterior commissure.
 DIAGNOSTIC ENDOSCOPY
Microscopic Endolaryngoscopy
(Continued) (Fig. 4-6) (After Kleinsasser,
1961; jako and Kleinsasser, 1966)
A The basic setup is depicted. A Mayo stand is used
to support the elbows of the operating surgeon, thus
steadying his or her hands. The laryngoscope is in the
midline. This is the main drawback of the technique,
because there can be undue pressure on the upper
incisors. At times a contralateral approach can be used
with a smaller-diameter laryngoscope.
B The location of the laryngoscope holder with the
cuffed endotracheal tube placed at the posterior
commissure of the larynx is depicted.
 DIAGNOSTIC ENDOSCOPY

FIGURE 4-6
 DIAGNOSTIC ENDOSCOPY
Telescopic Endolaryngeal Surgery
(Fig. 4-7)
Several modifications of the original vocal cord strip-
ping forceps designed by Lore, Sr. (after the Imperatori
Subglottic Forceps by Pilling) have been developed by
Lore, Jr. and Karl Storz. These instruments incorporate
a 0-, 30-, and 70-degree telescope with either a short or
a long right-angle forceps. Other types of microsurgical
forceps, for example those used with the microscope,
could be manufactured with the tube to carry the tele-
scope. This methodology is a substitute for the opera-
tion microscope.
These instruments are inserted through a Holinger
hourglass anterior commissure speculum with the use
of a Lewy holder under general endotracheal anesthesia.
These instruments do not require the large laryngoscopes
that are usually necessary when the microscope is
employed, so there is less danger of injury to the teeth.
The telescopes are first utilized without the forceps for
a careful inspection of all of the intrinsic structures of
the larynx, initially using the 0- and 30- degree telescope.
The 70-degree telescope is utilized primarily for
visualization of the subglottic area as well as the walls
of the ventricles. Fogging is eliminated by inserting the
scope in warm water. After careful scrutiny, the telescope
is then inserted into a tube within the forceps. Biopsy
or definitive stripping of a vocal cord is then performed
under magnification through the telescope. The exact
extent and depth of the excision are clearly visualized.
Lore-Storz LaryngealTelescopic Forceps
FIGURE4-7
Tracheoscopy
These instruments afford excellent magnified visuali-
zation of the cervical trachea when inserted through a
Holinger anterior commissure speculum. Although the
trachea can be examined using a rigid or flexible bron-
choscope, magnified visualization and biopsy of tracheal
lesions is better achieved with the instruments depicted
here. Tracheoscopy can be performed through an existing
tracheostomy site using the 70-degree Lore-Storz Hopkins
rod scope, which is used for endoscopic visualization
of the nasopharynx (see Fig. 4-1B; the scope is removed
from the biopsy forceps). This instrument can be rotated
180 degrees to examine the trachea both proximal and
distal to the tracheostomy. The vocal cords can also be
seen proximally. The instruments are also very adapt-
able during mediastinoscopy (see Chapter 19) for visual-
ization and biopsy.
A The 30-degree telescope.
B The 30-degree telescope inserted into the tube of
the forceps.
C Close-up view of long right-angle forceps for
stripping a vocal cord and for subglottic biopsy. This
instrument is also excellent for cervical tracheal biopsy
as well as mediastinoscopy and biopsy. (Allinstruments
shown are manufactured by Karl Storz.)

Nasopharyngoscopy (Figs. 4-8 and
4-9)
Nasopharyngoscopy can be divided into two forms,
based on the type of instruments utilized: (1) indirect
mirror, which offers a good overall view but is many
times quite difficult to perform, and (2) direct visuali-
zation, which is performed in two basic ways (see
Fig. 4-BA to E). The optical technique is done with a
non flexible scope, such as a Hopkins polished glass rod
via the nasal cavity or a Berci-Ward (Karl Storz) via the
oral cavity or a flexible nasopharyngoscope. The rigid
Yankauer nasopharyngoscope affords a limited view of
the posterior wall of the nasopharynx. It has no appli-
cation to ambulatory diagnostic nasopharyngoscopy.
Its main use is when the patient is under general anes-
thesia. At that time it does afford a reasonably good
view of the posterior wall of the nasopharynx.
Nasopharyngoscopy can also be divided according
to the route of examination: nasal route or oral route.
1. Nasal route
a. Flexible scope
b. Rigid scopes: 0, 30, and 70 degrees
2. Oral route
a. Mirror
b. 70- to 90-degree scopes
DIAGNOSTIC ENDOSCOPY
I. Small-lumen 70-degree scope with or without
incorporated biopsy forceps (with forceps-see
Figs. 4-7B and 4-9C) (Lore)
ii. Large-lumen 70- to 90-degree scopes
Indications
• Every head and neck examination
• Nasal obstruction
• After epistaxis
• For enlarged spinal accessory lymph nodes (posterior
cervical triangle), such as undifferentiated squamous
cell carcinoma (previously known as Schmincke
tumor or lymphoepithelioma) or lymphoma of the
nasopharynx
• Paralysis of any cranial nerves
• Any mass in neck or extracranial head
• Ear pain or persistent discomfort
Highpoints
1. Mirror technique, if feasible, affords a good overall
view.
2. Optical nasopharyngoscopes, rigid and flexible, are
used.
3. Topical anesthesia is necessary.
 DIAGNOSTIC ENDOSCOPY
Nasopharyngoscopy (Continued)
(Figs. 4-8 and 4-9)
A, B The tongue is depressed, and the patient is
asked to breathe through the nose. This usually throws
the soft palate forward. A suitable-sized warmed
mirror is then inserted, using a head mirror or
headlight for illumination. The angle of the mirror may
require adjustment, depending on the configuration
of the vault of the nasopharynx. Occasionally,
grasping the tongue as is done in mirror laryngoscopy
(see Fig. 20-2) is of aid.
C The area so visualized is depicted. To obtain
complete visualization, the mirror is simply rotated a
few degrees. The posterior wall of the vault is first
examined for any tumefaction, benign or malignant.
The ostia of the sphenoidal sinus may be seen. The
roof of the vault is likewise scrutinized and then the
posterior end of the nasal septum. The posterior tips of
all six turbinates should be visualized lying in the
posterior nares. Laterally, the eustachian tube orifices
in Waldeyer's ring are evaluated. The posterosuperior
aspect of the soft palate is checked.
D Another technique of nasopharyngoscopy is the
use of a rigid optical endoscope-O, 30, and 70 degrees
(e.g., scopes used for rhinoscopy via the nasal route).
Another instrument, preferred by many physicians, is
the flexible nasopharyngoscope (see Fig. 4-9E). After
topical anesthesia to the nasal cavity, the instrument is
inserted through the anterior naris. Rotation of the
scope at various depths is necessary to cover the
nasopharynx. Because only smaller visual fields are
available at each degree point, a composite picture is
more difficult. This technique is best reserved for
occasions when the mirror method fails or when a
specific area noted on mirror examination requires
more scrutiny. A biopsy forceps is combined with the
rigid endoscope (see Fig. 4-9A and B) and affords
good visualization of the suspected area with the jaws
of the biopsy forceps (Karl Storz) in full view.
An oral nasopharyngoscope, preferred by some
physicians, affords a larger field of vision similar to that
seen with a mirror. This instrument consists for the
most part of a rigid endoscope. The earlier models were
designed by and known as the Beck, Proud-Beck, and
Wolf. The more modern ones utilize the Hopkins rod
principle and include the Berci-Ward instrument manu-
factured by Karl Storz (see Fig. 4-90). This instrument
is also used to visualize the hypopharynx and larynx.
Digital examination is also performed to evaluate the
consistency of any abnormality visualized. The index
finger is inserted through the mouth and behind the
soft palate. The operator may find that standing to the
side of the patient facilitates this examination.
Retraction of Soft Palate
When the soft palate obstructs visualization of the
vault either during examination or biopsy or in minor
operations, it may be retracted in several ways.
E A specific soft palate retractor is available that has
its fixed point on the upper lip and alveolar ridge. The
drawbacks of the instrument are its size and the fact
that it tends to slip and is awkward.
Continued
 DIAGNOSTIC ENDOSCOPY

FIGURE 4-8
 DIAGNOSTIC ENDOSCOPY
Nasopharyngoscopy (Continued)
(See Fig. 4-8F to I)
Complications of Nasopharyngeal Biopsy
Hemorrhage
1. Never perform biopsy on an ambulatory basis of any
lesion suspected to be an angiofibroma. If biopsy is
necessary, perform it in the operating room with
endotracheal anesthesia and several units of blood
available. Be prepared to perform definitive surgery
following frozen section.
2. Never perform a biopsy of a pulsating mass (e.g.,
carotid-cavernous fistula) (Feuerman et al., 1984).
F A small curved retractor of the Cushing venous
type may be used. Usually, the tongue must also be
depressed, in which case an assistant is necessary.
G A small catheter may be inserted through one
naris and out through the mouth. Traction with a
clamp retracts the soft palate.
Biopsy of Nasopharynx
H Using the mirror method for visualization, a very
slender cup forceps is inserted through one naris. The
tip of the forceps and the tumor are visualized in the
mirror and the biopsy is performed.
I, P A transoral biopsy requires a curved forceps
(Karl Storz, Jl; Lawton). Visualization is in either a
mirror or a nasopharyngoscope or through the nasal
cavity. Visualization through the nasal cavity is seldom
possible and requires complete shrinkage of the nasal
mucosa. Only lesions in the visual range of the
posterior nares can be seen.
Random biopsies are also resorted to in the search
for an unknown primary tumor in the head and neck.
Caution: Do not perform a biopsy if any mass is
suspected to be an angiofibroma or pulsating mass. If
biopsy is necessary, this should be performed in the
operating room with blood replacement available.
One helpful way to detect an unsuspected primary
tumor of the nasopharynx is to apply cotton tamponades
in each nostril and extend them into the nasopharynx.
They will serve as a topical anesthetic; with their
removal, they may occasionally be spotted with blood
in the area in which the primary tumor is located. In
addition, all crusted mucus must be removed, because
this may well overlie the primary neoplasm.
Anatomically, the nasopharynx can be divided into
the following regions:
1. Vault-most superior portion
2. Posterior wall
3. Lateral walls and eustachian tube orifices
4. Nasopharyngeal side of the soft palate
S. Posterior edge of the nasal septum
6. Posterior choanae
The examiner should localize as accurately as
possible the region of the pathologic process. This is
most important from a therapeutic as well as a
prognostic point of view. For example, regions 3, 4, 5,
and 6 may be amenable to surgical resection when
involved by a malignant lesion. Resection of lesions in
regions 1 and 2 are usually relegated to chemotherapy
and radiation therapy for malignant lesions and surgery
for benign lesions. This designation, however, depends
on local invasion. Hard and fast rules are variable
depending on cell type and other factors; that is,
chemotherapy and radiation therapy may be the choice
for the treatment of malignant lesions in all or any of
these areas.
 DIAGNOSTIC ENDOSCOPY

F G

FIGURE 4-8 Continued

 DIAGNOSTIC ENDOSCOPY

Rigid and Flexible Direct Optical

Nasopharyngoscopy, Laryngoscopy,
Cervical Esophagoscopy, and
Rhinoscopy (See Fig. 4-9)
Rigid Nasopharyngoscopes
The rigid nasopharyngoscopes utilizing the Hopkins
rod principle are depicted on the accompanying photo-
graphs. These are the ones preferred by the author and
manufactured by the Karl Storz Company of Germany
and distributed by Karl Storz Endoscopy-America, Inc.
There are a number of types depending on the route of
introduction.
Nasal Route
A, B Depicted are two models each with a rigid
Hopkins rod optical telescope with biopsy forceps.
Each can be used with or without biopsy forceps. The
nasopharynx, eustachian tube orifices (patient at rest
and swallowing), and nasal cavity can be examined. It
can visualize not only the nasopharynx but also the
nasal cavity. In addition, any operative defect or any
antrum with a window can also be scrutinized. One
optical arrangement is categorized as 0 degrees (A) for
vision directly in front of the instrument; the other is
listed as 30 degrees (B) for angulated visualization.
Biopsy forceps are available through which the
telescope is inserted, affording exact visualization of
the area to be sampled.
Oral Route
hypopharynx are visualized. It is also used for
photography of these structures.
Flexible Nasopharyngoscopes
E Depicted is the flexible optical nasopharyngo-
scope. Although it is almost always introduced
through the nasal cavity, if there is severe bilateral
nasal obstruction, it can be introduced orally. The
nasopharynx, eustachian tube orifices (patient at rest
and swallowing), and nasal cavity can be examined
and any operative intranasal or sinus defects identified.
It is likewise used to visualize the hypopharynx and
larynx. Its only drawback is the smaller image as
compared with the rigid Berci-Ward instrument, which
yields a much larger image and more detail.
F Depicted is the flexible instrument within the
nasopharynx. This instrument is manufactured in two
sizes, one for the adult and the other for the infant and
child.
G This is a flexible observer's attachment for the
nasopharyngoscope. Karl Storz manufactures rigid and
jointed observation attachments that attach to the
eyepiece of its telescopes.
For the head and neck surgeon both rigid and flexible
scopes are a sine qua non for examination, biopsy pur-
poses, photography, and television recording. Often
when one instrument does not suffice, the other instru-
ment solves the problem.

Rigid and Flexible Direct Optical

C Depicted is the transoral 70-degree telescope and
Rhinoscopy
biopsy forceps (Lore-Storz). The advantage of this
instrument is it has a wider field of vision than that
These rigid instruments (A and B) utilize the Hopkins
obtainable with the transnasal instruments. The
rod principle, as incorporated in the scopes manu-
telescope can be utilized independently of the forceps.
factured by Karl Storz. They are 0 and 30 degree and of
With the combination of both forceps and telescope,
narrow diameter and are excellent optical instruments
the field of vision includes the biopsy forceps,
for scrutinizing selected areas in the nasal cavity and
affording exact visualization of the area to be sampled.
the sinuses. For examination, the telescopes are used
This instrument can also be utilized to visualize areas of
without the forceps. These instruments are not only
biopsy specimens of lesions of the hypopharynx by
utilized for primary diagnostic purposes but also for
simply rotating the instrument 180 degrees.
follow-up examination of any sinus surgery whether
for infectious disease or neoplastic disease. When com-
D The Berci-Ward telescope can also be utilized via
bined with the forceps, they are utilized for endoscopic
the oral route to visualize the nasopharynx as well as
biopsy and sinus surgery (see p. 220).
the larynx and hypopharynx. The advantage of this
The flexible nasopharyngoscope and laryngoscope
instrument is the wider field of vision and its
(E) are also suitable for rhinoscopy. However, for detailed
excellence for photography of the nasopharynx. Karl
examination, the previously described rigid scopes are
Storz manufactures the light source and the camera.
more suitable.
By rotating this instrument 180 degrees the larynx and
 DIAGNOSTIC ENDOSCOPY

A
o B oIf()
c

FIGURE4-9
 DIAGNOSTIC ENDOSCOPY
Cervical Esophagoscopy
(See Fig. 4-5B and C)
A bulb insufflator can be attached to a flexible optical
scope that has a channel for instillation of medication
and suctioning in the nasopharynx, hypopharynx, or
larynx. A bulb insufflator can be attached to the medicinal
channel for instillation of air. This will distend the
esophagus for insertion of the optical scope. The cervical
esophagus can thus be visualized and inspected as well
as suctioned.
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 5 THE SINUSES AND
MAXILLA
Intranasal Antrostomy (Fig. 5-1)
Rhinoscopy
In addition to the usual intranasal examination with
speculum, topical anesthetics, and decongestants uti-
lizing a head mirror or head light, telescopic examina-
tion yields considerably more information. The instru-
ments suggested are the Karl Storz Hopkins rods: the
O-degree, 30-degree, and, at times, the 70-degree tele-
scopes. The flexible scopes are also helpful, but the
rigid scopes can be directed in a more precise manner.
Following the technique described by Kennedy et al.
(1985), the 30-degree telescope is inserted in three
"passes": (1) along the floor of the nasal cavity; (2)
between the inferior and middle turbinates; and (3)
into the middle meatus. The third pass may be difficult
and is best achieved by inserting the telescope medial
to the middle turbinate to its posterior extent and then
rolling the scope into the middle meatus.
Expertise in this examination is the most important
step before the performance of any endoscopic sinus
surgery (see p. 220).
After rhinoscopy, transillumination of the antra and
ethmoidal and frontal sinuses still affords a screen-
ing evaluation, especially in the asymptomatic patient.
Routine sinus radiographs can also be used as a screen-
ing method, but for precise detail computed tomography
(CT) is recommended. CT serves as an excellent guide
during any type of sinus surgery, whether it be the
intranasal approach with or without endoscopes or the
external approach (see Chapter 4). Magnetic resonance
imaging (MRI) will afford more soft tissue detail whereas
CT provides more bone detail.
Highpoints
1. The site of opening must be behind the anterior wall
of the antrum.
2. The direction of the instrument must be either hori-
zontal or pointed slightly downward to avoid injury
to the floor of the orbit.
3. When irrigating, no air should be injected, to avoid
air embolism.
See Figures )-5 and )-6.
214
Anesthesia
• Local, topical 2 % tetracaine, 10 % cocaine, or 4 %
lidocaine
Postoperative Management and Additional
Follow-up
When an antral window is performed, inspection of the
antrum through the antral window is facilitated by the
use of a telescope. The telescope can be anyone of
various manufacturers and can be at various angles so
that the entire antrum is thus visualized (Karl Storz's
O-degree, 30-degree, and 70-degree telescopes; see Fig.
4-9). Biopsy specimens can then be obtained via the
endoscope.
Complications
• Injury to the orbit
• Air embolism
• Insertion of trocar anteriorly to anterior wall of
antrum and then into soft tissue of cheek could
result in subcutaneous emphysema.
A, A1 A small hollow antral trocar (Douglas) is
placed beneath the inferior turbinate. Occasionally,
the turbinate will hang and obstruct the approach. In
such casesit is fractured medially and elevated with a
blunt instrument. Its mucosa should not be injured.
With steady pressure,the trocar punctures the medial
wall of the antrum (the lateralwall of the inferior meatus).
The antrum is then gently irrigated with sterile normal
saline.The return flow is through the natural ostium. If
the bony wall is very thin, a spinal needle may be
substituted for the trocar.
8, 81 When the medial wall of the antrum is thick,
a Faulkner trocar chisel is used to perform the
antrostomy.
82, 83 If an antral window is desirable for
continuous drainage of the antrum, the instrument is
 THE SINUSES AND MAXILLA

c c'
FIGURE 5-1

rotated 180 degrees after the antral wall is punctured.
The undercut edge of the instrument then engages
the rim of the opening. As the instrument is with-
drawn, the opening is thus enlarged.
To enlarge the antrostomy farther, several techniques
are available.
C, C1 A curved rasp (Wiener) is inserted, and with to
and fro motion the opening is enlarged. Care must be
taken that the tip of the rasp is pointed downward.
This avoids injury to the floor of the orbit and removes
the bone at the base of the medial wall, allowing
adequate drainage. No ledge of bone should remain
at the base.
Continued
 116 THE SINUm ANDMAXIll~

Intranasal Antrostomy (Continued)

(Fig. 5-')
D A bone-cutting punch is also utilized to enlarge
the opening, as is a double-action cutting forceps if
the bone is thick. Again, the important direction is
downward, so that the nasoantral ridge is removed at
the antrostomy site. The floor of the nasal cavity is usu-
ally slightly lower than the antral floor, allowing free
flow of secretions from the antrum into the nose if the
nasoantral ridge is adequately removed. At times,
however, the floor of the antrum may be lower than
the floor of the nose.
E The antrum may be explored using Coakley curets.
Cysts and diseased mucous membrane can be removed
if so indicated. Any sizable polyp, however, should be
removed through a Caldwell-Luc approach or a medial
meatus anthrostomy created endoscopically.
A small drill hole is made in the same area in the
canine fossa as the Caldwell-Luc procedure. Various
endoscopes of 0 degrees, 30 degrees, and 70 degrees
can then be inserted into the antrum. Biopsies are also
feasible. The same precautions and complications apply
as with the Caldwell-Luc operation.

D1 A Kerrison forceps is used to enlarge the open-

ing.

FIGURE 5-1 Continued

 THE SINUSES AND MAXILLA

Caldwell-luc Antrotomy (Fig. 5-2) This procedure should be avoided when a malignant
lesion is suspected. Needle aspiration through the
Indications inferior meatus or the use of an intranasal antrostomy
with curettage using Coakley curets is preferred (see
• Benign tumors Fig. 5-1). If these methods fail, do not hesitate to explore
• Chronic empyema resistant to conservative treatment the antrum through this Caldwell-Luc antrotomy.
• Complicated fractures of maxilla Refer to Figure 6-10 for the trans maxillary approach
• Exploration to the nasopharynx and base of the skull.

Refer to Figures 1-1, 1-5, and 1-6.

A In the gingivobuccal sulcus (canine fossa), well
Complications above the tooth sockets, an incision is made through
mucosa and periosteum several centimeters from the
• Injury to infraorbital nerve midline. Sufficient mucosa is preserved inferiorly for
• Injury to roots of teeth ease of closure.
• Injury to the floor of the orbit
• Hypoesthesia or paresthesia of the cheek B The periosteum is elevated. The insertion of the
• Injury to the globes facial muscles may require sharp dissection to free
• Subcutaneous emphysema them from the anterior wall of the antrum.
• Injury to the superior alveolar nerve and tooth sockets Continued
• Prolonged edema

FIGURE 5-2
 THE SINUSES AND MAXILLA
Caldwell-luc Antrotomy (Continued)
(Fig. 5-2)
C The exposure is carried upward to a point just
below the infraorbital rim, where the infraorbital nerve
is identified and carefully preserved. With the use of an
osteotome or power-driven bur, the anterior wall of
the antrum is opened. This opening must be well above
the tooth sockets and above the floor of the antrum.
All the fractured fragments of bone are removed.
D With a Kerrison back-biting forceps, the opening is
enlarged to the desired size to permit exploration.
E Removal of benign tumors and cysts is then easily
accomplished by grasping forceps and scissors.Normal
mucosa should not be injured; however, all diseased
mucosa should be removed.
F Usually,an intranasal antrostomy beneath the inferior
turbinate is done to facilitate drainage (see Fig. 5-1).
FIGURE 5-2 Continued
G This intranasal antrostomy may be enlarged through
the original operative opening using forward bone-
cutting forceps, depending on the purpose of the
operation.
H Close-up of antrostomy in G is shown.
I Cross-sectional anatomy shows the dependent
intranasal opening. The arrow depicts the natural
ostium. Some surgeons have stressed the importance
of verifying the patency of this natural ostium and its
free communication with the middle meatus. The
natural ciliary motion is toward this ostium. Diseased
tissue should thus be removed to reestablish this com-
munication, otherwise antral disease is likely to recur.
Lining an enlarged ostium may require opening and
reflection of antral mucosa medially. Ethmoidal disease
may also require removal. This area on the nasal side is
termed the osteomeatal complex (see Figs. 1-2 to 1-4).
J The mucosal flap over the anterior wall opening is
approximated with interrupted or continuous 4-0
nylon or absorbable suture.
 THE SINUSES AND MAXilLA 219

Intranasal antrostomy

FIGURE 5-2 Continued

 220 THE SINUSES AND MAXilLA

Intranasal Ethmoidal Surgery for Uncapping of Anterior Ethmoidal Cells

Benign Disease (Fig. 5-3)
Indications
• Chronic ethmoidal sinusitis
• Ethmoidal polyposis
Highpoints
1. Avoid injury to thin lamina papyracea laterally.
2. Avoid injury to cribriform plate superiorly.
3. Never use a curet in an upward fashion, because
injury to the cribriform plate could occur; always
use a downward and slightly medial motion.
4. Be certain that disease is entirely intranasal, because
meningiomas may mask as polypoid disease.
5. Frequently monitor the eyes during and after the
operation for evidence of intraorbital hemorrhage.
6. Avoid too tight intranasal packing in the region of
the cribriform plate and the lamina papyracea.
A The point of entrance is just lateral to the attach-
ment of the middle turbinate. The middle turbinate
may require displacement medially. This is done with a
blunt instrument to minimize damage. The turbinate is
not removed. If the turbinate is cystic, it may be gently
crushed.
B Using an asymmetrical, oval, thin-beaked curet, the
anterior ethmoidal cells are opened with a downward
and inward motion. This involves removal of the unci-
nate process and leads to the hiatus semilunaris and
the infundibulum. The curve of the curet is turned
medially to avoid injury to the lacrimal plate.
C Further curettage is downward and backward. A
,- to 2-cm introduction often suffices for simple drain-
age. However, if there is evidence of extensive involve-
ment, further exenteration becomes necessary.

Various illustrations (Figs. 1-2 to 1-10 and 6-1) show Ethmoidectomy

the lateral view of the nasal cavity.
D, E With a Faulkner curved-ring curet, the ablation
Postoperative Care
of the more posterior cells is performed, always with a
downward and slightly medial motion. This will avoid
• Monitor vision and search for any proptosis or
injury to the cribriform plate. The lamina papyracea is
hemorrhage.
the lateral guide, whereas the middle turbinate is the
medial guide. Extreme care must be taken not to
Complications
injure the lamina papyracea; otherwise bleeding can
extend into the orbit, causing blindness. The eye is
• Hemorrhage either intranasally or into the orbit,
visualized during surgery.
usually from ethmoidal arteries arising from the
ophthalmic artery F As the operation progresses posteriorly, a smaller
• Injury to the orbit and optic nerve, with resulting
curved-ring curet is employed if the space narrows.
blindness. Do not drape eyes during surgery.
• Meningitis G The exenteration continues to the anterior wall of
• Cerebrospinal fluid rhinorrhea the sphenoidal sinus .
• Injury to the cribriform plate and frontal lobe lead-
ing to death H Ethmoidal-type blunt forceps are used to remove
any remaining diseased cells. The superior turbinates
If periorbital edema occurs, extreme care and may be removed with scissors if additional space supe-
evaluation of the globe are necessary. Immediate riorly is required. However, the less injury and removal
decompression of the orbit may be required to prevent of nasal-lining mucosa that are done, the better. In any
permanent damage to the optic nerve. The surgical case, atrophic rhinitis must be avoided.
approach is as depicted in Figure 5-6A. The incision is
carried through the orbital septum toward the lamina
papyracea. Some surgeons prefer an external ethmoidectomy
For details of immediate treatment of blindness refer for extensive disease. The approach is depicted in
to Chapter 2, page 66. Figure 5-4.
 THE SINUSES AND MAXilLA

FIGURE 5-3
 THE SINUSES AND MAXILLA
Intranasal Ethmoidal Surgery for
Benign Disease (Continued) (Fig. 5-3)
Endoscopic Diagnosis and Surgery for
Sinusitis
Another approach to inflammatory ethmoidal sinus
disease as well as antral and frontal sinus involvement
has been detailed by a number of authors. Messerklinger,
in Austria, and Kennedy, in the United States, as well
as others have described telescopic endoscopic diag-
nosis. These techniques are described in detail later in
this chapter. Instruments are shown in Figure 4-9A and
B, for anatomy see page 267, and the technique as out-
lined by Messerklinger (1985) is as follows (with per-
mission from Elsevier Science Publishers): Numerous
endoscopic investigations and examinations have indi-
cated the following relating to the pathophysiology of
chronic and recurring sinusitis: Most infections of the
paranasal sinuses are rhinogenic, spreading from the
nose into the sinuses.
If a sinusitis does not heal or is constantly recur-
ring, a focus of infection usually has remained in a
stenotic area, which keeps the infection ongoing, or
wherefrom the dependent larger sinuses are reinfected
time and again. This is true as well for primarily
dentogenic, traumatic, or blood-borne sinusitis that
is recurring after the primary source of infection has
been cured.
The narrow or stenotic areas involved are the
ethmoidal infundibulum at the entrance to the maxil-
lary sinus and the frontal recess at the entrance to the
frontal sinus. They build up a system of fissures and
folds in the middle nasal meatus, all of them being
parts of the anterior ethmoidal sinus.
Thus, the physiologic status and pathologic status of
the maxillary sinus and frontal sinus are dependent on
any disease process of the anterior ethmoidal sinus and
the osteomeatal complex.
Narrow space-like fissures and ostia under normal
conditions are very resistant to infections; as, for
instance, in a fissure the ciliary beat can transport a
pathologic mucus from two sides, in an ostium even
circularly. If, however, corresponding mucosal areas
are firmly pressed together, only the superficial secre-
tion around the contacting area can be transported
away. The mucus in between contacting or inflamed
mucosal areas is retained and provides ideal conditions
for bacterial growth. Depending on the duration and
intensity of an infection in such a place, mucosal hyper-
plasia occurs and thus results in a focus of permanent
infection. From areas like these, which can be free of
symptoms for quite a long time, infections can spread
time and again to the immediate vicinity and especially
into the dependent larger sinuses.
Nasal endoscopy combined with CT enables us to
localize exactly the diseased areas. Transnasal, endo-
scopic surgery is then carried out. The patient is sedated
and the medial wall of the ethmoidal infundibulum is
resected under local and surface anesthesia. This pro-
cedure opens the middle nasal meatus, and the view is
free into the ethmoidal bulla, the frontal recess, and the
sinus of the middle turbinate. Depending on the local-
ization and the extent of the disease, the ethmoidal
bulla is resected and the frontal recess, the conchal
sinus, and/or the ethmoidal infundibulum are cleared
of diseased mucosa. If the maxillary ostium is stenotic,
it is enlarged into the anterior nasal fontanel. This area
is the osteomeatal complex-a critical region.
If the posterior ethmoidal or the sphenoidal sinus is
diseased, it is cleared endoscopically after resection of
the ground lamella of the middle turbinate.
In the first 2 days after operation, wound secretion
is removed with an aspirator. For 8 to 10 days, an oral
antibiotic effective in the nasal mucosa is prescribed.
After this procedure even chronically recurring
infections of the dependent larger sinuses usually heal
within 5 to 6 weeks, even if their mucosal pathology
seemed almost irreversible. (See Figures 1-1 to 1-15 for
radiographic anatomy and imaging studies.)
Complications
• Perforation of cribriform plate and lamina papyracea
• Blindness (see Chapter 2): order stat ophthalmologic
consult; perform lateral canthotomy and external
ethmoidectomy.
• Injury to the lacrimal duct or sac
• Bleeding from the anterior or posterior ethmoidal
arteries
• Injury to internal carotid artery just lateral to posterior
ethmoidal and sphenoidal sinuses
Admonition
"Stop if you cannot see" (Kennedy).

External Ethmoidectomy (Fig. 5-4)
(Chiari, 1912) (After Kirchner et aI.,
1967; Montgomery, 1971)
Indications
• Extensive ethmoiditis refractory to conservative man-
agement as well as intranasal ethmoidectomy (see
Fig. 5-3). This indication is believed to be rare because
intranasal ethmoidectomy usually accomplishes the
desired results.
• Epistaxis high in the nasal cavity refractory to eth-
moidal artery and internal maxillary artery ligations
• Mucocele and benign tumors of the ethmoidal sinus;
malignant tumors of the ethmoidal sinus almost
always require a combined craniofacial resection of
the cribriform plate.
• Approach to the frontal sinus (Lynch, 1921; see
Fig. 5-70 and E)
• Approach to sphenoidal sinus and pituitary
• Repair of cerebrospinal fluid leak through the cribri-
form plate
• Approach to the anterior cavernous portion of the
internal carotid artery-possible application in carotid
cavernous fistula
• Approach to the optic foramen for decompression
and biopsy
The trans septal approach to the sphenoidal sinus
and pituitary (see Fig. 23-11) is preferred rather than an
external ethmoidectomy approach.
Anatomy (See Figs. 1-2 to 1-7.)
Refer to the alternate approach of Denker, page 294.
Highpoints
1. Important landmark: the foramina of the anterior
and posterior ethmoidal vessels as they perforate the
medial orbital wall mark the level of the cribriform
plate. This is the suture line between the frontal bone
above and the ethmoidal labyrinth below. Hence, do
not go above this line to avoid injury to the cribri-
form plate. The foramen of the posterior ethmoidal
artery indicates the plane of the most posterior
ethmoidal cells.
2. If necessary to transect the medial canthal ligament
for additional exposure, be certain to preserve a
medial stump of the ligament for approximation of
the ligament at the close of the operation.
THE SINUSES AND MAXILLA
3. Elevate the periosteum carefully from the lacrimal
bone, lacrimal sac, and lamina papyracea. Do not
injure the lacrimal sac, its proximal canaliculi, or its
distal outflow, the nasolacrimal duct (see Fig. H-12B).
4. Extreme care should be taken not to injure the globe
and orbital contents (tarsorrhaphy and gentle pressure
when retracting the periosteum and orbital contents).
5. Remove major portion of the lacrimal bone, portion
of the lamina papyracea, frontal process of the maxil-
lary bone, and, at times, varying portions of the nasal
bone, depending on the exposure necessary.
6. Remove at least the anterior portion of the middle
turbinate. If the purpose of the operation is to reach
the sella, the medial wall of the ethmoidal labyrinth
and thus the middle turbinate are not removed.
7. Take care to achieve good hemostasis to prevent
increased intraocular pressure as well as any pres-
sure on the optic nerve. Danger: blindness!
8. If there is any question regarding the patency of the
nasofrontal duct, insert a fine polyethylene tube.
Anesthesia
Although the operation can be performed under local
and topical anesthesia, this author (JML) prefers general
anesthesia for patient comfort as well as control of the
airway. However, topical anesthesia consisting of 10%
cocaine and oxymetazoline (Afrin) is used in the nasal
cavity to control mucosal bleeding. A tarsorrhaphy is
performed using 3-0 silk sutures, and the eyes are
protected with soft moist eye pads.
Surgical Technique
A curved incision is made similar to that depicted in
Figure 5-7A, except that the incision does not extend as
far medially as is shown for the external frontoeth-
moidectomy. Bovie cutting current is used to transect
the soft tissue down to the periosteum. Stay sutures are
utilized to retract the skin edges, with care taken not to
contact the globe. The angular vessels are clamped and
ligated.
Complications
• Hemorrhage-must have careful hemostasis
• Blindness (see Ophthalmic Complications III
Chapter 2)
• Diplopia
• Meningitis
 THE SINUSES AND MAXILLA
External Ethmoidectomy (Continued)
(Fig. 5-4) (Chiari, 1912) (After Kirchner
et aI., 1967; Montgomery, 1971)
A The periosteum is elevated over the frontal process
of the maxillary bone and lacrimal bone. The trochlea
(see Fig. 6-4B), the fibrocartilaginous pulley through
which the tendon of the upper oblique muscle passes,
may be elevated with the periosteum (Kirchner et aI.,
1967), depending on the exposure that is necessary.
The lacrimal sac is carefully mobilized from its fossa,
with care taken not to injure its proximal canaliculi and
distal nasolacrimal duct. As the periosteum is further
elevated from the lamina papyracea, the anterior and
posterior ethmoidal vessels are exposed as they pass
through their foramina along the frontoethmoidal suture
line. These vessels are clamped with House clips and
transected. Bipolar coagulation could be used on the
anterior ethmoidal vessels but should be used only if
absolutely necessary on the posterior ethmoidal vessels
because of the proximity to the optic nerve. Trans-
mitted heat could injure the optic nerve; therefore, use
a very low cu rrent.
The ethmoidal sinus is now entered just posterior to
the posterior lacrimal crest. This portion of the lacrimal
bone is thin and may be removed initially with a curet
or infractured with a chisel. The opening is further
expanded with Kerrison forceps and forward-biting
rongeurs. A major portion of the lacrimal bone is
removed with the lacrimal crest along with a portion of
the frontal process of the maxillary bone, portion of the
lamina papyracea, and, depending on the amount of
exposure, a portion of the nasal bone. Again, remember
that the frontoethmoidal suture line marks the cribri-
form plate level.
B The extent of possible osseous resection is depict-
ed. The stippled area includes the lacrimal bone and
the lamina papyracea, and the diagonally lined area
indicates the frontal process of the maxillary bone and
a portion of the nasal bone. The nasal bone area is only
removed if additional exposure is necessary anteriorly.
With the exposure now afforded, the anterior eth-
moidal cells are removed using small duckbill forceps
and Takahashi forceps. Care is taken once again not to
introduce the Takahashi forceps too close to the cribri-
form plate because of the danger of perforation. This
now exposes the anterior portion of the middle turbinate.
During this stage of the operation, the uncinate process
and bulla of the ethmoid are removed (see Fig. 6-1). If
purulent material is encountered, aerobic and anaerobic
cultures are obtained.
Depending on the purpose of the operation, the
entire middle turbinate is removed with scissors, one
blade in the ethmoidal sinus below and the other blade
just above the turbinate.
The attachment of the middle turbinate along with
ethmoidal cells is removed with an ethmoidal curet
and/or duckbill or Takahashi forceps. When the curet
is utilized, the motion must always be in a downward
direction to avoid injury to the cribriform plate (see
Fig. 5-3). The cribriform plate indicates the superior
extent of the resection, the lamina papyracea the lateral
extent, and the anterior wall of the sphenoidal sinus
the posterior extent. It is obvious at this point that, if
necessary, the sphenoidal sinus and the approach to
the sella can then be achieved. Small vessels-some
branches of the ethmoidal arteries and possibly
meningeal vessels-perforate the cribriform plate. It is
these vessels that may be the source of hemorrhage in
severe protracted epistaxis and may require clamping
with House clips and/or cautery.
The olfactory nerves are distributed to the mucous
membrane of the superior turbinate and the correspon-
ding portion of the nasal septum. This latter structure
is easily visualized in a more medial location in the
operative wound. If at all possible, these branches of
the olfactory nerves are best preserved.
If there is any question regarding the patency of the
nasofrontal duct (see Fig. 6-1), a fine polyethylene
catheter is inserted into the nasofrontal duct and
brought out through the naris. It is held in place with
a 4-0 silk suture secured to the floor of the naris. This
tubing is removed from 1 to 3 weeks postoperatively.
The operative site is gently packed with O.S-inch
strip gauze heavily impregnated with chlortetracycline
(iodoform) ointment. This packing must not impinge
on the globe, because a portion of the lamina papyracea
has been removed. The end of the gauze strip is brought
out through the anterior naris and secured externally,
so that if it becomes dislodged posteriorly, it can be
removed forthwith. Generally, it is removed in 3 to
4 days.
If the medial canthal ligament was transected, it is
approximated with two sutures of 4-0 nylon. The perios-
teum is returned to its normal position and reapprox-
imated wherever possible, and the skin is closed in
layers.
Antibiotics are utilized preoperatively and post-
operatively.
Careful evaluation of the patient's sight postopera-
tively is a sine qua non. If there is any question regard-
ing hemorrhage with increased ocular pressure, the
wound is rapidly opened and decompressed. This raises
the question whether the external wound should be
drained. The author (JML) by and large prefers the use
of a small section of rubber band drain that then can
be removed within 24 hours.
 THE SINUSES AND MAXilLA

T EDGE OF MEDIAL CANTHAL

I

FRONTOMAXILLOLACRIMAL
"SUTURE
, FRONTAL PROCESS
FRONTOETHMOID MAXILLARY BONE
SUTURE
(PLANE OF CRIBRI
PLATE) LACRIMAL FOSSA
ANGULAR A.

B
FIGURE 5-4
 THE SINUSES AND MAXilLA
Sphenoidal Sinusotomy (Fig. 5-5)
Highpoints
1. Check radiographs for possible ossification of sphe-
noidal sinus. CT scans are important.
2. Asymmetry of sphenoidal sinuses is the rule rather
than the exception.
3. Dividing partition is almost never in the midline.
4. Optical telescopes are very helpful. Refer to Figures
1-2, 1-3, 1-4, and 1-7.
S. Distance from anterior nasal spine to sphenoidal
ostium in adult is from 6.5 to 8 cm.
6. Using floor of nose as a baseline, the angle to reach
the sphenoidal ostium is between 20 and 30 degrees.
7. The ostium is usually located just behind and slightly
above the posterior end of the superior turbinate.
8. Use CT to be certain all walls of sinuses are intact.
9. Use MRI for additional soft tissue detail.
Indication
• For emergency irrigation of acute empyema of the
sphenoidal sinus
Complication
• Edema surrounding natural ostium may hinder egress
of irrigation solutions.
A, B With topical anesthesia and use of a vasocon-
strictor, a malleable cannula is inserted into the nasal
cavity closely hugging the septum. It is directed toward
the posterior ends of the middle and superior turbinates
at an angle of 20 to 30 degrees from the floor of the
nose. The anterior wall of the sphenoidal sinus is thus
reached, and by gentle manipulation the ostium is
located and entered. Optical telescopes-flexible or
rigid-aid in localization of the ostium. If necessary,
radiographs may be used to confirm the location of the
cannula. Gentle irrigation is then performed. Deviation
of the nasal septum and other anomalies may make
access to the ostium impossible.
The sphenoidal cannula pictured is the Van Alyea
instrument, which is 10 em in length and is equipped
with markers on the proximal end at 9 em. These
markers are placed at an angle of 23.5 degrees from
the shaft, thus simulating the angle of insertion using
the floor of the nose as the baseline. The distal end of
the cannula has a smooth 4-mm curve laterally.
Continued
Puncture of Anterior Wall of Sphenoidal
Sinus
Highpoints
1. Keep to midline-laterally are the internal carotid
artery and cavernous sinus.
2. Keep low and posterior-high and anterior are the
floor of the anterior cranial fossa and cribriform
plate of the ethmoid. The level of the inner canthus
of the eye corresponds to the level of the cribriform
plate.
3. Hook on instrument must face downward.
4. Check radiograph and other images for details of sphe-
noidal sinus and relationship to surrounding struc-
tures (e.g., internal carotid artery, cavernous sinus,
sella turcica). See Figures 1-2, 1-3, 1-4, and 1-7.
Indication
• Puncture of the anterior wall of the sphenoidal sinus
is performed if cannulation of the natural ostium is
not feasible.
Enlargement of Natural
Sphenoidal Ostium or Anterior
Wall Puncture Site
Highpoints
1. Avoid injury to or removal of posterior end of middle
turbinate.
2. Keep angle of biting forceps facing downward.
Indications
• Usually used for emergency sphenoidal sinus drainage
when irrigation through natural ostium or anterior
wall puncture appears inadequate.
• It is also used for exploration and biopsy of sphe-
noidal sinus.
Complication
• Injury to sella turcica, internal carotid artery, and
cavernous sinus
 THE SINUSES AND MAXILLA 227

Natural ostium of sphenoid sinus

B
FIGURE 5-5
 THE SINUSES AND MAXilLA

Sphenoidal Sinusotomy (Continued) Other Approaches to the Sphenoidal

(Fig. 5-5) Sinus

When the rare condition occurs that requires more ade-

C, D A sharp pointed instrument with hook facing
quate exposure of the sphenoidal sinus, for example,
downward (Sluder or Hajek sphenoidal hook, prefer-
removal of a "fungus ball," a more direct approach is
ably with a Tremble guard) is inserted into the nasal
the transpalatal (see pp. 288 to 293, Fig. 6-9). The
cavity, keeping close to the nasal septum. It is directed
exposure depicted is much larger than necessary, only
toward the plane of the posterior end of the middle
1.0 to 1.5 cm of hard palate is all that is required to be
turbinate. The anterior wall of the sphenoidal sinus is
resected. The patient with the "fungus ball" had exten-
thus reached, and the instrument is inserted through
sion into the sella turcica and erosion of the clivus and
a thin section of the wall (X). The point of entry is as
lateral walls of the sphenoidal sinus, with pressure on
close to the midline as possible and as low and poste-
the optic nerves, cavernous sinuses, and internal carotid
rior as possible. The lower and more posterior one
arteries. This approach was in the midline and anterior,
goes, however, the thicker the anterior wall of the
thus avoiding the clivus, sella turcica, internal carotid
sinus becomes. Puncture then becomes somewhat
arteries, and the cavernous sinuses. The "capsule,"
more difficult.
which enveloped the "fungus ball," was very thick and
this approach facilitates a very careful controlled inci-
E Using either the natural ostium or anterior wall
sion and excision of the portion of this capsule to
puncture site as the point of entry, a Hajek or Kerrison
evacuate the contents of the sphenoidal sinus. Currently,
biting forceps is employed to enlarge the opening. The
this procedure can be done trans nasally using endo-
enlargement is directed downward. It must be remem-
scopic techniques.
bered that the dividing septum of the sphenoid bone
Another approach to the sphenoidal sinus is
may not be in the midline, and hence the sinus entered
transseptal (see Fig. 23-11A to I).
may not be the one corresponding to the side of the
nasal approach. In such cases, careful breakdown of the
dividing partition is necessary. Confirmation is obtained
by radiographic examination when necessary.
 THE SINUSES AND MAXilLA

Point of entry

Mid. turbinate'

FIGURE5-5 Continued
 THE SINUSES AND MAXilLA
Frontal Sinusotomy (Trephination)
(Fig. 5-6)
Indications
• Purulent acute frontal sinusitis refractory to conser-
vative management (e.g., nasal decongestants and
10% cocaine applied on cotton tampon plus anti-
biotics in large doses)
• Persistent pain and tenderness with or without local
edema
• Exploration for chronic frontal sinusitis
• Biopsy
See Figures 1-2 through 1-7 for radiographic anatomy.
See Figure 6-1 for lateral view of the nose and frontal
sinus ostia.
If there is a bulge over the frontal sinus (usually just
below the supraorbital rim) immediate decompression
is achieved with needle aspiration.
Highpoints
1. Keep incision well above the medial canthal ligament.
2. Continue conservative management.
3. Careful radiographic evaluation preoperatively and
postoperatively, especially for any evidence of dehis-
cence of the inner wall, thus exposing dura. Remem-
ber plain Caldwell radiographic films of the frontal
sinus can be deceptive. This radiographic view is
obtained by placing the nose and the forehead on
the table top so that the orbital meatal line (join-
ing the outer canthus of the eye to the superior
margin of the external auditory canal) is perpen-
dicular to the film. The angulation of the x-ray beam
is 15 degrees craniocaudad. CT scans and/or tomo-
grams are necessary for complete evaluation of the
status of the inner and inferior wall of the frontal
sinus.
4. Avoid injury to the globe.
S. A trephine is used in or near the floor, not the ante-
rior wall, thus avoiding cancellous bone containing
marrow, which could be an excellent avenue for
osteomyelitis.
6. Do not irrigate if roof of orbit has a dehiscence; this
may cause blindness! (Thompson et aI., 1980.) (See
the discussion of blindness in Chapter 2.)
A A slightly curved incision is made just below the
eyebrow. It is carried through the periosteum, expos-
ing the bone.
B A small periosteal elevator exposes the underlying
bone just below the prominence of the frontal sinus.
The exact point of entrance is checked on the radio-
graphs. A small bur or curet is used to enter the sinus.
Cultures of any purulent material should be taken,
followed by gentle irrigation with normal saline.
Patency of the nasofrontal duct can be checked with
methylene blue inserted through the tubes (see C).
The duct usually should not be probed, because this
may result in stenosis.
An optical telescope can be inserted through the
trephine to inspect the inner lining of the sinus. One
must be certain that the inner bony wall is intact,
otherwise a more radical operation is indicated.
C Two small plastic tubes are inserted and held in
place with sutures. One tube can be used for daily
irrigations with a suitable antibiotic solution (e.g.,
neomycin, 1%) for 24 to 48 hours. The other tube acts
as the release for the irrigation fluid.
After the frontal sinusotomy, the cause of the sinusi-
tis must be ascertained, and treatment must be initiated
as soon as possible to prevent chronic frontal sinusitis.
The object is to reinstate intranasal drainage. Probing
and any attempt to recanalize or simply enlarge the
nasofrontal duct will only worsen the condition, because
such procedures will lead to complete stenosis of the
nasofrontal duct.
The steps to take are the following:
1. Meticulous and complete submucous resection of
the nasal septum
2. Removal of any nasal polyps
3. Resection of anterior portion of the middle turbinate,
if necessary
4. Anterior ethmoidectomy, as indicated
For details on fractures of the frontal sinus and
ethmoidal sinus, refer to the discussion on page 638.
 THE SINUSES AND MAXilLA 231

FIGURE 5-6
 THE SINUSES AND MAXilLA
External Frontoethmoidectomy
(Fig. 5-7) (After Lynch, 1921)
Indications
• Mucocele
• Externa] fistula
• Minor orbital complications
Recurrent frontoethmoidal sinusitis refractory to con-
servative management, including intranasal ethmoidec-
tomy, submucous resection of the nasal septum, and
frontal sinusotomy, is an indication for this procedure.
In this day and age, this operation is seldom indicated
for chronic sinusitis. If, in fact, chronic frontal sinusitis
exists, then serious consideration is given to endo-
scopic frontal sinus surgery and, if it is not possible, to
a bilateral or unilateral osteoplastic frontal sinus opera-
tion. If there is any doubt, it would be best to use the
osteoplastic approach (see Fig. s-8A to E): ]n the
absence of ethmoidal disease a frontoethmoidectomy is
not usually indicated but rather an osteoplastic frontal
operation. It is not suitable for malignant lesions.
Another consideration for use of this procedure is severe
polyposis and inverted papillomatosis. This approach
is also used by some surgeons (Bateman, 1961) for
hypophysectomy (see Chapter 23). Refer to Figures 1-2
through 1-7 for radiographic anatomy.
Highpoints
1. Use meticulous hemostasis.
2. Avoid injury to the eye and associated structures:
a. Medial palpebral ligament
b. Lacrimal sac and duct
3. Do not perforate the cribriform plate.
4. Preserve as much normal mucous membrane as com-
patible with a good drainage operation.
5. Problems with adequate and safe removal of frontal
sinus disease include:
a. Incomplete removal
b. Entrance into anterior cranial fossa through a bony
dehiscence in long-standing disease
6. Distance and depth between the anterior portion of
the resection and the posterior or deep portion of the
resection varies considerably.
7. Remove entire floor of frontal sinus and establish a
wide new frontonasa] communication. This is one of
the main objectives of the operation.
8. Any high (superior) deviation of the nasal septum
should be corrected; however, extreme caution must
be taken during this step not to injure the cribriform
plate.
Complications
• Orbital injuries
• Hemorrhage
• Stenosis of frontonasal communication
• Recurrent sinusitis, polyposis, or mucocele
• Perforation of cribriform plate or inner wall of frontal
sinus to dura
A The incision is 2.5 to 3.5 em long and extends
about 1 em below the level of the medial palpebral
(canthal) ligament. It lies midway between the attach-
ment of this ligament (see Figs. 11-1 and 11-12A to
B1) and the dorsum of the nose. A temporary tarsor-
rhaphy is performed to protect the globe.
The incision exposes the orbicularis oculi (orbicu-
laris palpebri) as well as the superior pa]pebral vessels
(branches of angular vessels), which are ligated. The
medial palpebra] ligament is exposed and preserved.
The periosteum is incised, elevated, and retracted
laterally, carefully freeing the superior portion of the
lacrimal sac. The periosteal dissection is continued
posteriorly exposing the entire lamina papyracea and
the floor of the frontal sinus. Avoid tearing the perios-
teum and the periorbital fascia, especially along the
frontoethmoidal suture, where the former is quite
adherent. Otherwise, periorbital fat will herniate through,
obstructing vision. Two smooth retractors or a Luongo
self-retaining retractor is inserted. The anterior and
posterior ethmoidal arteries are occluded, as shown in
Figure 6-4.
B At a point just posterior to the lacrimal fossa, the
medial orbital wall is entered with a sharp perforator.
With bone Kerrison forceps and curet, the bone pos-
teriorly (dotted line) is now removed, including the
posterior edge of the nasal process of the maxilla
(preserve the nasal mucous membrane) and thence
the lacrimal bone and the anterior portion of the lamina
papyracea. The preserved mucoperiosteum will be
used as a superior-based flap to line the new nasofrontal
communication. The anterior ethmoidal cells are then
removed.
The upper medial orbital bone is then removed, thus
entering the frontal sinus and removing the entire floor
of this sinus. As much as possible of the lining mucous
membrane is removed from the frontal sinus. Locu]a-
tions and septa can make this step difficult and frus-
trating. Care must be exercised that if dehiscence in the
posterior or roof of the frontal sinus exists, perforation
of dura lining the anterior cranial fossa does not occur.
If incomplete removal occurs, this could lead to recur-
rent frontal sinus problems, especially with marked poly-
posis-a failure for this procedure. An osteoplastic
 THE SINUSES AND MAXILLA

FLOOR FRONTAL SINUS

LACRIMAL SAC

MEDIAL CANTHAL

A B

FIGURE 5-7

frontal sinus operation may then be necessary at a later
stage (see Fig. S-8A to E).
As much of the middle turbinate is removed (by
punch, not tearing) as is necessary to provide a suitable
communication into the nasal cavity. This is accom-
plished both through the operation wound and through
the naris.
anteriorly the sphenopalatine vessels may be encoun-
tered, which then will require occlusion with silver
clips or electrocoagulation.
If the purpose of the operation is to perform a
hypophysectomy, the frontal sinus portion of the opera-
tion is deleted. From here on the reader is referred to
the section dealing with hypophysectomy in Chapter 23.

C The posterior cells are removed with punch forceps

both through the wound and through the naris, taking
care not to perforate the cribriform plate. This is most
important. The complete operation consists of removal
of the floor of the frontal sinus, portion of lacrimal
bone, lamina papyracea, ethmoidal cells, and portion
of middle turbinate.
If the sphenoidal sinus is to be entered, this is accom-
plished by either making an opening with a sharp curet
or enlarging the natural opening. Kerrison or Hajek
forceps are used to enlarge the opening. Inferiorly and
D The preserved superior-based mucoperiosteal
nasal flap is now used as lining for the new frontonasal
communication. Gauze impregnated with antibiotic
ointment is utilized to coapt this flap and extend into
the nasal cavity. The gauze is removed in 1 week. An
intranasal tube into the frontal sinus (fine polyethylene)
is left in place for up to 1 to 3 months, depending on
the patient's clinical progress. This intranasal tube is
best sutured to the floor of the naris to prevent dis-
lodgement. The short tube or drain through the external
incision is removed within 1 week.
 THE SINUSES AND MAXilLA
Osteoplastic Approach to the
Frontal Sinus (Fig. 5-8) (After Alford,
1964; Beck, 1908; Goodale and
Montgomery, 1964)
Highpoints
1. Perform a preoperative ophthalmologic evaluation.
2. Use template of frontal sinus cut from radiographs
showing Caldwell view (see B). Check the change
in size relative to x-ray tube distance from patient.
3. Cosmetic incision: choose eyebrows or coronal
hairline.
4. Leave periosteum attached to bone forming ante-
rior wall of frontal sinus. The periosteum acts as a
hinge, attaching the bone fragment inferiorly.
5. Bevel bone incision inward toward sinus and make
it slightly smaller than the x-ray template.
6. If mucous membrane is hopelessly diseased, it should
be removed completely and meticulously using a
power-driven bur. The mucosa of the nasa frontal
duct-if patent-is better left intact. If duct is
obstructed, then remove mucous membrane.
7. If the major portion of the mucous membrane is
normal (e.g., in an osteoma), the mucous mem-
brane of the sinus and nasa frontal duct should be
carefully preserved.
8. Do not shave the eyebrows, because they may not
regenerate.
9. Do not enter the anterior cranial fossa.
10. Preoperatively order culture and sensitivity testing
in the presence of infection.
11. Perform a temporary tarsorrhaphy-optional-during
pregnancy.
12. Bilateral approach is more common (see G and H).
Anatomy of Frontonasal Duct
The frontal sinus drains into the nasal cavity via the
nasa frontal duct, into the semilunar hiatus, and then
into a groove termed the infundibulum, which lies
between the bulla of the ethmoid bone and the uncinate
process. It then communicates with the middle meatus.
Variations can occur (see Hollinshead's Anatomy for
Surgeons, volume 1, page 262).
Details relative to the anatomy of the lateral wall of
the right nasal cavity along with the nasofrontal duct
are described and depicted in Figure 6-1.
A The incision may be just above or below the eye-
brows, as shown. The upper incision is slightly curved.
B A superior-based skin flap is developed consisting
of all layers of tissue down to the periosteum. The
periosteum is left attached to the underlying bone. A
template of the left frontal sinus containing an osteoma
has previously been cut, slightly smaller; from the Caldwell
view and has been gas sterilized. The template is placed
over the frontal sinus, and an incision is made through
the periosteum along the superior, medial, and lateral
edges. The inferior edge is left intact, forming the hinge
for the anterior frontal sinus bone window. Preser-
vation of the periosteum along the inferior edge is most
important, because this is the source of blood supply
to the periosteal bone flap.
C The line of incision through the periosteum is
slightly widened with a narrow elevator to allow free
access for the saw blade. With a Stryker sagittal plane
saw, a cut is made and beveled slightly inward and
downward. This protects the edges forming the bound-
aries of the sinus and later on supports the bone flap
when it is returned. The dotted line indicates the'hinge
of intact periosteum and the line of fracture of the
bone-periosteum flap. Additional bone is transected
on the edges of the dotted line for a distance of a few
millimeters inferiorly through the supraorbital rim.
D With the use of an osteotome along the cut edges,
the bone periosteum flap is elevated and fractured
along its inferior margin.
E The flap of bone and periosteum is reflected down-
ward, exposing the pathologic change in the frontal
sinus, which in this case is an osteoma. The osteoma is
removed, revealing the major portion of mucous mem-
brane to be intact and normal. The mucous membrane
is left undisturbed; the nasofrontal duct is left inviolate.
If the pathologic change consists of chronic sinusitis
with diseased mucous membrane, all mucous membrane
is meticulously removed. Small spurs of bone are
leveled off with a bur, destroying any minute infolding
of mucous membrane. The operation microscope can
be of help. Too much time spent at this stage cannot
be criticized. Preserve the mucous membrane of the
nasofrontal duct if the duct is patent. If the duct is
obstructed anywhere along its course from the frontal
sinus to the infundibulum, strip the mucosa very care-
fully and completely obliterate the duct. The other
approach is to stent the duct, removing obstructions.
The problem is the removal of all mucous membrane
from the sinus wall. This may not be possible. Any
remaining mucous membrane in the sinus will be the
nidus for future problems. At this point, place an

FIGURE 5-8
autogenous adipose tissue graft into the sinus cavity
and duct remnant to aid in the obliteration; otherwise,
perform a transfrontal ethmoidectomy. When the sinus
cavity is obliterated with adipose tissue (obtained from
the anterior abdominal wall), it is best to remove as
much cortical bone as possible from all areas, includ-
ing the bone flap. This aids in supplying blood to the
adipose graft.
Continued
THE SINUSES AND MAXILLA
Complications
• Fracture of the inner wall or table leading to a
possible cerebrospinal fluid leak
• Fracture of the roof of the orbit
• Injury to the inner wall or table during the initial
saw cut through the outer table
• Air leak into operative area during postoperative
period
• Recurrent disease
 THE SINUSES AND MAXILLA
Osteoplastic Approach to the
Frontal Sinus (Continued) (Fig. 5-8)
(After Alford, 1964; Beck, 1908;
Goodale and Montgomery, 1964)
F The flap of bone and the periosteum are returned,
and the periosteum is approximated with 4-0 catgut
sutures. The skin flap is closed in two layers. Debride
the edges of skin if there is thickened scar tissue from
chronic sinusitis. This will reduce the unsightly bulge
over the diseased frontal sinus. A cutaneous drain is
used only in those patients with active infection.
G An outline is shown of the extension of the brow
incision in bilateral frontal sinus disease. Occasionally,
the opposite sinus may be approached through the
original exposure by removing the sinus septum. This
depends on the extent of disease and the size of the
sinus. It is usually more beneficial to use a bilateral
approach.
H A coronal hairline incision may be preferred in the
female patient to avoid the brow incision. In the male
patient this may be disastrous if he is bald. Regardless
of the skin incision, in the bilateral approach the bone
across the nasal process of the frontal bone usually
requires transection with saw or chisel.
Occasionally, if the infectious disease is limited to
one side (e.g., mucocele of the frontal sinus), drainage
may be achieved by taking down the septum in the
frontal sinus, thus facilitating drainage to the uninvolved
side and its nasofrontal duct. There may be more than
FIGURE 5-8 Continued
one septum between the right and left sides of the
frontal sinus. Be sure all septa are removed as thoroughly
as possible with a large communicating fenestra. The
nasofrontal duct on the uninvolved side must be patent.
This can be verified with the instillation of methyl blue
dye. This maneuver is controversial, however, and yet
it has proved efficacious.
Partial and Radical Maxillectomy
Operations involving resection of the maxilla and con-
tiguous structures for carcinoma can be divided into
three main types: partial maxillary resection with pres-
ervation of the roof and superior portion of the pos-
terior wall of the antrum, total maxillary resection and
ethmoidal exenteration with preservation of the globe,
and total maxillary resection with ethmoidal exentera-
tion and orbital enucleation.
One of the perplexing problems in the surgical treat-
ment of carcinoma of the maxilla is the evaluation of
the extent of the neoplasm. This problem is aggravated
at times by late diagnosis as well as by concomitant
infection. Another problem is the extent of the malig-
nant changes in an inverted papilloma. Inverted papillo-
mata without malignant change can cause bone changes.
Hence, the question arises as to the extent of the sur-
gical resection and the frequency of combined therapy
with radiation (preferably postoperative). Evaluation of
the extent of the neoplasm is done both preoperatively
and operatively and follow-up is done for life.
The preoperative evaluation includes careful inspec-
tion of the nasal cavity, its floor and lateral wall, the nasal
septum, and the nasopharynx; the standard paranasal

sinus radiograph, tomograms, CT, and MRI; and radio-
graphic views of the base of the skull. Ophthalmologic
consultation may be helpful in ascertaining whether
the orbital contents have been invaded. The obvious
signs-proptosis and extraocular muscle impairment-
leave no doubt that orbital exenteration is necessary,
if indeed the lesion is resectable. Occasionally, the first
sign of maxillary sinus carcinoma is an enlarged metasta-
tic sub digastric cervical lymph node. A Caldwell-Luc
operation is a last resort for diagnosis and is best
avoided if an unequivocal histologic diagnosis can be
made through an intranasal antrostomy. Regardless,
errors have been made by confusing long-standing
inflammatory disease with neoplasm.
Difficulty can also be encountered in differentiating
anaplastic squamous cell carcinoma from large cell
lymphoma (formerly classified as reticulum cell sar-
coma). This differentiation can be aided by immuno-
staining. For example:
1. Leukocyte common antigen: positive-lymphoma;
negative-most likely not lymphoma
2. Cytokeratin: positive-anaplastic carcinoma
Historically, the electron microscope was of some
help in this differentiation. In all epidermal tumors there
are desmosomes between the outer cell membranes.
This feature is somewhat more obvious in squamous
cell carcinoma and is absent in large cell lymphoma.
Operative evaluation of the extent of disease is des-
cribed during the following discussion of surgical tech-
nique. In view of this additional information relative to
the extent of disease, permission for removal of the eye
must be obtained in all patients.
Another problem in maxillectomy for carcinoma is
the fact that when the disease has extended beyond the
confines of the antrum, many of the contiguous struc-
tures (e.g., the ethmoidal sinus, sphenoidal sinus, crib-
riform plate, posterior aspect of the maxilla with ptery-
goid plates, posterior portion of the orbit, and infratem-
poral fossa) defy uniform en bloc resection. Other exten-
sions that involve the nasal septum and nasal cavity,
palate, and skin of the cheek can usually be encom-
passed with maxillectomy with little difficulty. Exten-
sion to the base of the skull and resection is described
in Chapter 23. When the lesion is not resectable,
chemotherapy and radiation therapy combined with a
drainage procedure and removal of grossly involved
and necrotic tumor is the best that can be afforded the
patient for palliation.
At other times the extent of the surgical resection
can be more easily modified. For example, if there is
gross evidence of disease involving the bony wall at the
canine fossa, this area must be widely encompassed,
including a portion of the upper lip and possibly the
cheek. The same applies to extension into the mucosa
THE SINUSES AND MAXilLA
overlying the hard palate. Regardless, this mucosa IS
always resected with the hard palate.
In the following discussion the indications for radical
and partial maxillectomy are reviewed with each descrip-
tion of the surgical technique. Each patient must be
individually evaluated and consideration given to pallia-
tive resection-usually partial maxillectomy combined
with radiotherapy or preoperative induction chemother-
apy-to remove offensive necrotic tumor.
It is suggested that preoperative chemotherapy be
considered in advanced squamous cell carcinoma of
the paranasal sinuses following the regimen detailed
in Chapter 3. Although neoplasms of the paranasal
sinuses were not included in that review, owing to the
limited number of patients, nevertheless one would
expect similar favorable results.
Ohngren, in 1933, divided the maxilla into an ante-
rior inferior portion and a posterior superior portion by
drawing an imaginary line from the medial canthus of
the eye to the angle of the mandible. He pointed out
that lesions arising in the anterior inferior section carried
a better prognosis than those in the posterior superior
section because the extension of the disease in the latter
section "very soon encroached upon the meninges and
vascular stems, thereby eliminating every chance of
successful therapy." This thesis has withstood the test
of time and forms the basis for the decision whether to
perform a partial or radical maxillectomy. Yet it must
be emphasized that error in management rests with the
lesser resection because of the inherent difficulty in the
preoperative evaluation of the extent of the disease.
Three anecdotal examples are reported demonstrating
the place for chemotherapy in the treatment of esthe-
sioneuroblastoma, as well as neuroendocrine carcinoma.
Case 1: Esthesioneuroblastoma
A 39-year-old white man presented with a stage III
tumor primarily involving the right nasal cavity, eth-
moidal sinus, and cribriform plate confined to the
extradural space. The tumor was deemed to be resec-
table. Treatment consisted of two preoperative courses
of chemotherapy with cyclophosphamide, etoposide,
vincristine, and cisplatin. Craniofacial resection was
performed. Four years later metastasis was discovered
in the right submandibular area and a right radical
neck dissection was done. The pathologic report showed
four positive nodes (three level I, one level IV). One
year later the tumor recurred in the cribriform plate. A
secondary craniofacial resection was done that included
maxillectomy and orbital enucleation. Three years later
there was spread to the temporal lobe. One year later a
craniotomy was performed for recurrence followed with
gamma knife therapy. The patient received late radio-
therapy (5040 rads) but died 9 years after the initial
treatment.
 THE SINUSES AND MAXILLA
Case 2: Esthesioneuroblastoma,
Nonresectable, Stage C
A 51-year-old white man presented with a tumor involv-
ing the nasopharynx, right orbits, and sphenoidal sinus,
destruction of the clivus, and extension to the ethmoidal
sinus and nasal cavity and the middle cranial fossa.
Radiotherapy was instituted with cobalt 60 (5180 rads).
This was done concomitantly with administration of
doxorubicin, vincristine, and, subsequently, cyclophos-
phamide. The maximum dose of doxorubicin was
780 mg. This was followed with treatment with lomus-
tine. There was no evidence of disease after 22 years.
Staging followed the Kadish staging system for esthe-
sioneuroblastoma (olfactory neuroblastoma):
Stage A-tumor limited to the nasal cavity
Stage B-tumor within the nodes and paranasal sinuses
Stage C-extending beyond the paranasal sinuses
Case 3: Neuroendocrine Carcinoma,
Nonresectable, Stage C
A 31-year-old white woman initially presented with an
extensive mass in the nasal cavity involving the maxil-
lary sinus and ethmoidal sinus. This was designated
a stage IV lesion. There was a 6-cm mass in the right
side of the neck. Treatment initially was with surgery
following four courses of chemotherapy consisting of
cyclophosphamide, cisplatin, etoposide, and vincristine.
There was a 100% response of the neck metastasis,
as well as no residual disease in the nasal cavity. She
subsequently received an autologous stem cell trans-
plantation to the bone marrow and radiotherapy (6000
rads) to the paranasal sinuses and (5040 rads) to the
neck. After 7 years there was no evidence of disease.
It is interesting to note that in Case 1 the basic
principle that was used in the treatment of squamous
cell carcinoma (as discussed under preoperative chemo-
therapy in Chapter 3) was followed with surgery plus
radiation. In Case 2 there was control of the nonresec-
table esthesioneuroblastoma with chemotherapy and
radiotherapy and no surgery.
Although these examples are anecdotal, neverthe-
less they point to the importance of a careful evaluation
of patients and the treatment depending on stage and
resectability. In any event, this supports the importance
of chemotherapy and radiation in the treatment proto-
col. These data, relative to the long-term survival rates
as described, as well as the literature, support the con-
cept of chemotherapy and radiation in these nonre-
sectable tumors, as well as indicating the possibility,
especially in the neuroendocrine carcinomas and those
of squamous cell origin, of using preoperative chemo-
therapy followed by surgery and selective radiotherapy
(see Chapter 3). These suggestions, of course, deserve
much further evaluation as to end results, stretching
out beyond the usual 5-year survivals.
Removal or Saving Remainder
of Soft Palate After Partial
Maxillectomy
When a partial maxillectomy violates the integrity of
the soft palate, starting at the latter's anterior edge,
confusion often exists regarding whether to save the
remaining soft palatal segment. It is hoped that the
following guidelines will give direction when the sur-
geon is faced with this dilemma.
Whether to remove the remainder of the soft palate
is based on the fact that the sling of the levator veli
palatini muscles occupies the bulk of the middle third
of the soft palate, moving the soft palate posterosupe-
riorly during speech and swallowing, to contribute to
palatopharyngeal closure. Thus, when only the anterior
one third of the soft palate is removed, the remaining
two thirds will be functional and should be retained.
Conversely, when the anterior two thirds is removed,
the remaining posterior third will be a useless, adynamic
strand that should be routinely removed.
The decision-making problem arises when the ante-
rior third is removed, along with part of the middle third.
How much of the middle third must be removed before
the remaining part becomes nonfunctional and is best
being totally removed? The answer is probably some-
where in the mid middle third, keeping in mind that
individual variation is great. This decision is totally in
the hands of the surgeon intraoperatively. The shorter the
soft palate is in overall length, the more difficult this deci-
sion becomes. To err on the conservative side may make
prosthetic reconstruction with a speech-aid very difficult.
 THE SINUSES AND MAXILLA

Radical Resection of Maxilla With

Orbital and Partial Ethmoidal A A Weber-Dieffenbach (Fergusson) incision is made
with an extension into the floor of the nose. The upper
Exenteration (Fig. 5-9) lip incision is staggered to minimize postoperative con-
tracture. The vertical line is just medial to the philtrum,
Malignant tumors of the maxillary sinus (antrum of
and the horizontal line follows the vermilion border.
Highmore) amenable to surgical treatment, unless very
The eyelids are sutured together and are left attached
early and limited, are better handled by a more radical
to either the skin flaps or the eye. If an orbital pros-
operation than by a limited one because of the intimate
thesis is intended, it may be advantageous to remove
and complex relationship of the antrum to the ethmoidal
the lids with the skin flaps. Discuss this option with the
and sphenoidal sinuses as well as to the orbital contents.
maxillofacial prosthodontist (see Chapter 3, pages 161
Hence, the radical resection with orbital and ethmoidal
to 165, Dental and Prosthetic Considerations in Head
exenteration will be described first. Permission for orbital
and Neck Surgery). An incision in the floor of the naris
exenteration should be obtained in virtually all opera-
is optional, because the transection of the floor of the
tions for malignant tumors of the antrum. See Chapter
nose can be done without this incision. An acute angle
23 for block resections of the ethmoidal sinus with
of the skin incision is to be avoided near the medial
craniofacial resection.
canthus. Resect the skin of the cheek if it is involved.

Highpoints
B The bony area resected includes the entire antrum
with hard palate and floor of the orbit, lateral orbital
1. Antrum is not entered.
rim, body of the zygoma (malar bone), and portion of
2. Orbital contents should be resected with roof of
zygomatic arch (the double dotted lines on the arch
antrum in any extensive carcinoma of maxilla or
indicate the portion of arch excised to facilitate the appli-
with involvement of roof of antrum.
cation of silver clips to the internal maxillary artery per-
3. Resect as much of the ethmoidal sinuses en bloc as
formed early in the operation). The internal maxillary
possible. Remainder will require curettage.
artery may be superficial or deep to the external ptery-
4. Graft raw surfaces with split-thickness skin.
goid muscle or pass between the two heads of the
5. Leave orbital skin defect open to future inspection
muscle. The ethmoidal labyrinth, anterior wall of sphe-
for early detection of recurrences.
noidal sinus, and complete lateral wall of the nasal
6. Preserve soft palate if levator muscle is intact.
cavity with all three turbinates are included in the
7. Tracheostomy is indicated.
resection. The nasal septum ;s left intact unless the
septum is involved. If it is involved, the line of resection
Refer to Figures 1-1 through 1-6 for radiographic
through the floor of the nose is on the contralateral
anatomy.
side. It is preferred that the incision through the alveolar
ridge be made through the tooth socket to preserve
viability of the juxtaposed tooth.
Continued

Lamina papyr
Co.,
Maxillt.

Zygoma "'

:tub. of maxilla
B
-'Lat.pterygoid plate

FIGURE 5-9
 THE SINUSES AND MAXilLA
Radical Resection of Maxilla With
Orbital and Partial Ethmoidal
Exenteration (Continued) (Fig. 5-9)
C Skin flaps are dissected, preserving the orbicularis
oris and buccinator muscle in the lateral flap. The
remaining facial muscles are for the most part left
attached to the anterior wall of the antrum. The inci-
sion from the lip is carried along the gingivobuccal
sulcusposterolaterally to beyond the maxillary tuberosity.
Attachments of the buccinator muscle to the lower
edge of the maxilla, extending back to the tuberosity,
are transected. The nasal (frontal) process of the maxilla
is then sectioned with a chisel or a sagittal plane saw
up to the level of the medial canthus of the eye. This
area corresponds to the suture line of the maxilla with
the frontal bone and serves as a marker for the level of
the cribriform plate of the ethmoid-the floor of the
anterior cranial fossa. This is the superior level of resec-
tion med_ially.
D The upper incisor tooth on the side of the resec-
tion is removed. A stab wound is made into the nasal
cavity at the posterior edge of the hard palate. Through
the stab wound a curved clamp is inserted into the
nasal cavity, grasping the end of the Gigli saw (Cocke,
1956), which is passed into the nares. If any tooth
fragments remain on the edge of the saw cut, these
should be removed.
FIGURE 5-9 Continued
E The hard palate is transected longitudinally through
the floor of the right nasal cavity with the Gigli saw. An
incision is then carried across the posterior edge of the
hard palate (dotted line), separating it from the soft
palate. The soft palate is left intact.
F The anterior attachment of the masseter muscle
has been cleared from the anterior portion of the
zygomatic arch. A 2-cm section of the zygomatic arch
is excised with a Gigli saw. This opening affords access
to the pterygomaxillary fossa and exposure of a portion
of the internal maxillary artery, which is then transected
between silver clips (see L).
G The periosteum is incised around the entire supe-
rior, medial, and lateral circumference of the orbit (the
inferior segment will be excised with the en bloc resec-
tion). Periosteal elevators then elevate the periorbita to
the apex of the orbit. With the globe retracted down-
ward and medially, a curved clamp is passed through
the inferior orbital fissure to grasp the Gigli saw. Occa-
sionally, a fracture of some thin bone will be required
to introduce the clamp. If it is not possible to pass the
clamp, the lateral orbital rim is sectioned using a
sagittal plane saw.
 THE SINUSES AND MAXILLA

FIGURE5-9 Continued

H Directing the Gigli saw upward and forward tran-
sects the lateral orbital rim. The optic nerve is severed
midway between the globe and the optic foramen
(dotted line) or as far posterior as indicated. Avoid
excessive traction on the optic nerve because it may
produce damage to the optic chiasm and subsequent
visual field defects in the opposite eye. The ophthalmic
artery, which is medial to the optic nerve, is ligated.
Within the fat pad are small vesselsthat should likewise
be ligated.
Continued
 THE SINUSES AND MAXilLA

Radical Resection of Maxilla With rence of disease would be obscured. The argument for
Orbital and Partial Ethmoidal vascularized flaps is the adequate coverage of the
operative defect.
Exenteration (Continued) (Fig. 5-9)

The posterolateral attachment of the maxilla is freed

I A cut is made with a chisel or sagittal plane saw
in one of two ways. The pterygoid process is tran-
starting at the upper extent of the osteotomy per-
sected near its origin from the body and the great
formed in step C. This separates the maxilla from the
wing of the sphenoid bone (Jl). This is accomplished
frontal bone. The chisel is directed slightly downward
by first sectioning the external and internal pterygoid
and inward, hugging the inner aspect of the cribriform
muscles from the lateral and medial pterygoid plates
plate. This must be performed slowly and carefully to
and then transecting the pterygoid process with angu-
prevent injury to the cribriform plate. The cut extends
lated rongeurs. The lateral and medial pterygoid plates
across the superior margin of the lacrimal bone and
are prolongations of the pterygoid process. The two
through the upper third of the lamina papyracea of the
plates are joined anterior and superior and open pos-
ethmoid to the anterior lateral extent of the sphenoidal
terior and inferior. Overlying the pterygoid muscle is
sinus. In this manner as much of the ethmoidal labyrinth
the main trunk and some branches of the internal
as possible is removed en bloc with the maxilla.
maxillary artery. This artery is variable and may pass
deep to the external pterygoid muscle or between the
If gross disease has invaded the superior ethmoidal two heads of the muscles. These vessels are the source
cells or frontal sinus, extension of the operation to of significant hemorrhage if not individually ligated or
include these areas is performed by exposing the dura occluded with silver clips. This is performed early in
and anterior cranial fossa. This will require a combined the operation by removing a small section of the zygo-
craniofacial resection (see Chapter 23). The use of fore- matic arch (see B), remembering the variable location
head flaps or free vascularized flaps to close the orbital of the artery.
defect completely is believed unwise, because recur-

Pterygomaxillary fissue

Lateral Plate of Upper head ext. pterygoid m.

Pterygoid process of sphenoid .
Maxilla

FIGURE 5-9 Continued

 THE SINUSES AND MAXILLA'

Deep Temporal a.

Pterygomaxillary fissure

Upper head ext. pteryg. m.

Lower head ext. pteryg. m.
-Maxilla

Internal Maxillary a.

K L

FIGURE 5-9 Continued

The internal carotid artery is vulnerable at the time

of sectioning of the pterygoid process. The distance
between the internal carotid artery and the posterior
edge of the lateral pterygoid plate is approximately
1. 5 em or less. The styloid process overlies the internal
carotid artery. The foramen lacerum is located at the
base of the medial pterygoid plate. The inferior aspect
of the foramen lacerum is filled with a fibrocartilaginous
plate, above which passes the internal carotid artery,
after it passes through the orifice of the carotid canal.
This orifice is posterior to the foramen lacerum.
Complications
• Hemorrhage
• Cerebrospinal fluid leak
• Airway obstruction unless a tracheostomy is per-
formed
• Separation of wound between cheek and nose unless
a two-layer closure is used
K An alternate method of freeing the posterolateral
attachment of the maxilla is by directing a chisel
between the pterygoid process and the maxilla. This
cut extends into the pterygomaxillary fissure. Again,
branches of the internal maxillary artery require liga-
tion. This method is not recommended if there is any
suspicion of bone erosion in the posterior wall of the
antrum.
L The entire specimen is now usually free enough so
that the remaining weak attachments of the maxilla
deep in the medial aspect of the orbit are broken by
rocking the specimen back and forth. If necessary, a
chisel may be used gently to cut these attachments.
The line of transection extends across the posterior
reaches of the posterior ethmoidal air cells, usually
removing the anterior wall of the sphenoidal sinus.
Continued
 THE SINUSES AND MAXILLA
Radical Resection of Maxilla With
Orbital and Partial Ethmoidal
Exenteration (Continued) (Fig. 5-9)
Proximity of this line to the base of the skull and carotid
canal is well shown in Figure 1-1. The internal maxil-
lary artery and its branches are shown in this step. Silver
clips are utilized to occlude the vessel. This artery is
depicted superficial to the external pterygoid muscle
but may be deep or pass between the two heads of the
muscle (see Fig. 6-7A). The head is tilted backward and
sideward in the drawing, thus throwing the zygomatic
arch somewhat upward. Exposure of the vessels is facili-
tated by Langenbeck long retractors. Occasionally, this
maneuver fails. This approach also affords evaluation
of the extent of disease in the pterygomaxillary space.
Additional exposure of this area can be obtained by
transecting the base of the coronoid process of the
mandible, but this is rarely necessary.
M Any remaining cells of the anterior and posterior
ethmoidal sinuses are removed with curettage. The
curet is used in a downward motion rather than upward
to avoid injury to the cribriform plate of the ethmoid.
The anterior wall of the sphenoidal sinus, if still intact,
is removed with a forward grasping forceps (Jansen-
Middleton) or back-biting forceps (Hajek or Kerrison)
(see Fig. 23-" C to M). Ifthere is a question regarding
identity of the sinus-posterior ethmoidal or sphenoidal
sinus-place a metal probe in the area and check with
an intraoperative radiograph. A large posterior ethmoidal
cell can mimic the sphenoidal sinus. The internal carotid
artery is located just lateral to the posterior ethmoidal
and sphenoidal sinuses.
N After bleeding has been controlled, all bare sur-
faces both deep in the bony defect and on the under-
surface of the skin flap are covered with split-thickness
skin.Where possiblethe graft issutured with 4-0 chromic
catgut. The remaining opposition is achieved with a pack
of absorbent cotton saturated with liquid povidone-
iodine (Betadine) or chlortetracycline (Aureomycin)oint-
ment. The cotton must be squeezed almost dry to
avoid the Betadine dripping into the larynx and thence
into the lungs. Betadine pneumonia can occur.
o The orbital defect is filled with this type of
packing.
P Sutures of 3-0 nylon are used across the palate
defect, acting as slings to hold this pack in place. The
skin flaps are approximated in two layers throughout.
As soon as the skin graft has taken, and certainly
within 2 weeks, the first temporary impression is made
for the prosthesis. If this is delayed, contractures of the
anterior skin flap will occur and hamper proper fitting
for the final upper denture. Some prefer the use of an
immediate although temporary prosthesis for the palate
defect that is made before the surgery. The packing is
thus held in place by the prosthesis.
 THE SINUSES AND MAXILLA

M N

o p

FIGURE 5-9 Continued

 THE SINUSES AND MAXilLA
Resection of Maxilla Including
the Floor of the Orbit With
Preservation of the Globe
(Fig. 5-10)
This procedure is indicated when there is no erosion of
the orbital floor (hence the importance of CT for bone
detail and MRI for soft tissue/tumor detail) but the
tumor involves somewhat more than half of the contents
of the antrum. Permission for orbital exenteration should
be obtained, because intraoperative evaluation may dis-
close extension into the orbit.
The technique combines the initial steps of resection
of the maxilla with orbital exenteration except that the
globe is preserved. The globe is then supported by a
temporal muscle flap across the inferior aspect of the
globe (Wise and Baker, 1968). The orbicularis oculi
muscle is preserved.
Steps are shown that modify the basic operation
depicted in Figures 5-8F to Hand 5-9. The globe is
protected by a temporary tarsorrhaphy or contact lens.
The skin has been elevated superiorly to the orbicularis
oculi muscle, which is preserved and carefully retracted
upward with a Cushing vein retractor.
En-Bloc Resection for Chondrosarcoma
A patient with extensive chondrosarcoma of both maxil-
lary antra, both ethmoidal sinuses, and the entire nasal
cavity and entire framework had these structures removed
en bloc with the cribriform plate (Craniofacial Resection,
see Chapter 23). The exposure consisted primarily of a
degloving procedure of the skin overlying the maxilla
and the nasal framework, thus preserving the overlying
skin and also both eyes. A unilateral Weber-Dieffenbach
(Fergusson) incision (see Fig. 5-11) was made to facili-
tate the exposure. All margins were histologically free
of disease. Immediate reconstruction consisted of sus-
pending the medial canthal ligaments with stainless
steel wire to the frontal bone, and a temporary Steinmann
pin (see Fig. 13-29) (panje) was inserted through both
malar bones to support the immediate postoperative
prosthesis. Dermal grafts were placed to line the bare
areas of the flaps. The prosthesis was thus made in an
upper and lower portion, the upper portion to fill out
the face and skin of the nose, and the lower portion for
the lower maxilla and upper teeth (follow-up at 14 years
showed no evidence of disease).
Complications
• Minimal diplopia and some slight collapse of the nasal
bridge, partially corrected with padding over the
prosthesis
• Partial incision dehiscence under one eye. This serves
as an excellent port for inspection and insertion of
padding.
A Exploration of the floor of the orbit is performed
with an incision (dotted line) along the superior aspect
of the infraorbital rim. By careful elevation of the
periosteum at this point, palpation of the orbital
contents is possible. If there is no gross evidence of
disease in the orbit, if the floor of the orbit is intact,
and if preoperative (T reveals no bone erosion, the
floor of the orbit (roof of the antrum) is resected,
preserving the globe.
B The frontal process and arch of the zygoma are
transected with a Gigli saw. The medial attachment of
the infraorbital rim is transected with a sagittal plane
saw just inferior to the medial canthal ligament. The
dotted lines depict the extent of the osseous resection.
The central incisor tooth on the involved side is extract-
ed. The osseous transection is through the tooth socket.
C With a small malleable or curved retractor, the
globe with the orbicularis oculi muscle and periosteum
is gently retracted upward. Posteriorly and inferiorly
the orbital floor is transected with a curved osteotome.
The bony incision can be carried far posteriorly approxi-
mately 4 cm from the inferior orbital rim with care not
to injure the optic nerve and without entering the
antrum. The danger to the optic nerve is greater medially
when dissecting the lamina papyracea.
D The remaining steps in the procedure are similar
to the more radical operation except that the globe is
preserved. A temporal muscle flap (X) is then mobi-
lized by separating a 1-cm strip of the muscle from its
insertion and attaching this free distal end near the
inner canthus of the eye. This attachment can be made
to the fascia in the area or through a small hole drilled
in the remaining bone on the medial aspect of the
orbit. The temporal muscle flap thus forms a sling to
support the globe. The medial canthal ligament requires
resection when the osseous resection is higher. Then
the lateral portion of the medial canthal ligament is
later secured to drill holes in the nasal bone. These drill
holes are the same site where the temporal is muscle
sling is attached. (See Fig. 14-3D to F.) Care is taken
not to disrupt the lacrimal sac deep to the medial
canthal ligament.
 THE SINUSES AND MAXILLA

Superior
orbital fissure
,-cr'

Inferior Infraorbitai groove

orbital fissure Infraorbital foramen

FIGURE 5-10
 THE SINUSES AND MAXILLA
Limited Resection of the Maxilla
(Fig. 5-")
The technique of this procedure follows the basic prin-
ciples of the radical maxillary resection except that the
orbit is left intact and the ethmoidal labyrinth is not
removed en bloc but cleared by curettage. Permission
for orbital exenteration should be obtained, although
the need for this procedure would be unlikely.
Highpoints
1. This procedure is indicated mainly in carcinomas
involving only the floor of the antrum.
2. A portion, or all, of the floor of the orbit is preserved
as well as all the orbital contents.
3. The skin incision is made as close as possible to
lower eyelashes-otherwise troublesome edema of
lower lid will result.
4. Ethmoidal air cells are removed by curettage.
5. Preserve the soft palate.
6. All raw areas are covered with split-thickness skin.
A After the eyelids are approximated (temporary
tarsorrhaphy, see Fig. 11-15), a Weber-Dieffenbach
(Fergusson) skin incision is started across the mid-
portion of the upper lip in stepladder fashion to mini-
mize scar contracture. The incision is carried upward in
the nasolabial sulcus to the level of the inner canthus
and thence horizontally just beneath the eyelashes of
the lower lid and beyond the outer canthus. The
orbicularis oculi muscle is left intact and preserved at
its orbital location.
An incision is made in the gingivobuccal fold, and
the cheek flap, including the buccinator muscle, is
reflected back to the tuberosity of the maxilla.
B The area resected is schematically represented. This
includes the lower two thirds of the maxilla including
the juxtaposed hard palate. A Gigli saw is used to
transect the hard palate as in Figure 5-9D and E. The
nasal process of the maxilla is sectioned with a chisel
for a distance of 1.0 to 1.5 cm to the level of the
infraorbital rim.
The inferior turbinate (a separate bone) is thus includ-
ed in the resected specimen, whereas the superior and
middle turbinates, which are part of the ethmoid, are
excised as separate fragments after the main specimen
is removed.
If the t~mor grossly involves the medial wall of the
antrum, the middle turbinate and the superior turbinate
are removed en bloc with the main specimen. When
the tumor involves the septum, the floor of the nose is
transected on the contralateral side. The septum is thus
removed with the main specimen. If possible, the
columella is preserved; otherwise, an anterior strut
graft is inserted for support.
C The orbicularis oculi muscle is retracted upward. A
Stryker saw transects the upper third of the maxilla,
preserving most of the infraorbital rim and floor of the
orbit. This cut is' extended laterally across the body of
the zygoma. The posterolateral attachment of the maxilla
is separated from the pterygoid process of the sphe-
noid bone with a chisel as depicted in Figure 5-9K. The
posterior wall of the maxilla is then usually free enough
for removal of the specimen by rocking the maxilla.
The branches of the internal maxillary artery, especially
those in the pterygomaxillary fissure, will require ligation.
The anterior and posterior ethmoidal sinuses are
curetted as in Figure 5-9M, with the same precautions
as in an ethmoidectomy (see Fig. 5-3). A split-thickness
skin graft is used to line all bare areas (see Fig. 5-9N).
D Povidone-iodine (Betadine)- or iodoform-impreg-
nated cotton is used as packing (see Fig. 5-9P).
The packing is removed in 7 to 10 days, and a
temporary prosthesis is inserted. In 2 weeks the tem-
porary tarsorrhaphy is released.
A more extensive resection of the maxilla can be
performed in which the entire maxilla is resected as in
Figures 5-8F to H, 5-9, and 5-10, with preservation of
the eye. In such procedures, a portion or slip of the
temporalis muscle is detached from the coronoid process
of the mandible and swung as a sling under the eye for
support. The distal end of the muscle is sutured in the
region of the inner canthus of the eye.
 THE SINUSES AND MAXILLA 249

c D
FIGURE 5-11
 250 THE SINUSES AND MAXILLA
Cysts of Maxilla (Fig. 5-12)
A TO E Odontogenic and developmental fissural or
inclusion cysts of the maxilla are shown: radicular-
dental root or dentoperiosteal; follicular-dentigerous
(contains a tooth); nasoalveolar; nasopalatine; and
globulomaxillary.
Highpoints
1. Preoperative radiographs should be taken to eval-
uate the extent of bone encroachment.
2. The entire cyst wall must be removed, including a
juxtaposed portion of nasal or antral mucous mem-
brane, if necessary.
3. Teeth are retained if this is compatible with adequate
cyst wall removal. Devitalized teeth require root
canal treatment.
4. Frozen section should be performed if there is any
question regarding a possibility of neoplasm.
Resection of odontogenic cysts follows much of the
same technique and approach as with the basic
Caldwell-Luc operation (see Fig. 5-2). When possible,
the juxtaposed, normally located teeth are preserved by
dental care. The oroantral communication is closed, and
drainage is obtained with an intranasal antrostomy.
 THE SINUSES AND MAXILLA

ODONTOGENIC

DEVELOPMENTAL

FIGURE 5-12
 THE SINUSES AND MAXILLA
Excision of Nasoalveolar Cyst
(Fig. 5-13)
A Cystic swelling is shown at lateral base of right ala
nasi and vestibule with partial obstruction of anterior
naris. Cavitation of the bone is not present and rarely
occurs in these cysts.
B An incision is made along a portion of the nasolabial
fold forming the lateral base of the ala nasi. If the
presenting portion of the cyst were lower, an approach
in the alveolar labial gutter could be used.
C With blunt and sharp dissection, the presenting
wall of the cyst is exposed. If the cyst is extremely large,
aspiration will facilitate easier enucleation without
extension of the incision.
D A small, curved, blunt-nosed scissors is used to
enucleate the cyst, keeping the wall intact. In this
patient there was a line of cleavage between the cyst
wall and the nasal mucous membrane. The nasal cavity
was not entered. If there were no Iine of cleavage, the
adherent nasal mucosa would require excision.
The wound is closed with 5-0 nylon sutures without
drainage. Nasal packing impregnated with an antibiotic
ointment may be placed in the vestibule to coapt the
elevated nasal mucous membrane to the concavity of
the defect.
 THE SINUSES AND MAXILLA

A B

FIGURE 5-13
 THE SINUSES AND MAXILLA
Excision of Nasopalatine Duct Cyst
(Fig. 5-14)
A Depicted is a form of nasopalatine duct cyst pre-
senting as a sinus tract through the hard palate just
behind the right medial incisor tooth. This would
correspond to the right incisive canal. The cyst presents
in the right nasal cavity, displacing the inferior turbinate
superiorly, reaching the nasal septum, and causing
severe nasal destruction.
A 1 An incision is made in the gingivolabial sulcus
slightly acrossthe midline transecting the superior labial
frenulum. The incision is so placed that sufficient mucous
membrane remains on the gingival side to facilitate
placement of sutures for closure. The dotted line around
the sinus tract indicates the incision to remove the
lining of the sinus tract.
B With blunt and sharp dissection, the labial flap
is elevated, exposing the anterior wall of the cyst. A
small probe can be passed through the sinus tract to
demonstrate the communication with the cystic
cavity.
C Cross section shows the location of the sinus tract
and cyst with a small blunt curet attempting to sepa-
rate the mucous membrane of the floor of the nose
from the cyst wall. This is not possible posteriorly, and
thus juxtaposed nasal mucous membrane and cyst
wall are removed together. It is most important that all
portions of the cyst wall be excised; otherwise, recur-
rence will most likely take place. Any bone projecting
into the nasal cavity is removed with rongeur forceps.
D The entire lining of the sinus tract must likewise be
removed. This requires an elliptical incision around the
sinus tract in the hard palate, with careful curettage
along the walls of the defect in the bone. Considerable
bleeding may occur from terminal branches of the
greater palatine artery or the nasopalatine artery in the
tract. Electrocautery is used to control this bleeding.
Cautery is also utilized to destroy any possible remain-
ing epithelial elements of cysts and duct. A single suture
of 4-0 nylon is placed through the mucous membrane
of the hard palate to close the defect, whereas a con-
tinuous 4-0 nylon suture closes the gingivolabial inci-
sion. Packing of 0.5-inch strip gauze impregnated with
antibiotic ointment or nitrofurazone (Furacin) is
inserted in the defect in the floor of the nose and
brought out through this defect. Additional nasal pack-
ing may be required to control any oozing blood.
E Shown here is another type of nasopalatine cyst
that presents in the roof of the mouth rather than in
the nasal cavity.
F A palatal flap based posteriorly is elevated with an
incision just behind the gingiva, thus preserving the
greater palatine vessels.The cyst and wall are resected
using much the same technique as for the previous
nasopalatine cyst. Closure is with 4-0 nylon and a
drain brought out anteriorly, if necessary.
 THE SINUSES AND MAXilLA

FIGURE 5-14
 THE SINUSES AND MAXilLA
Closure of Oroantral Fistula
(Fig. 5-15)
Highpoints
1. Small oroantra! fistulae, 1 to 2 mm, usually close
spontaneously. Those from 3 to 4 mm are usually
successfully closed with a buccal flap (see F).
2. Fistulae 5 mm and larger as well as those of long-
standing duration associated with severe sinus disease
require a more extensive surgical procedure using a
large palatal flap.
3. Adequate sinus surgery with antrostomy is neces-
sary in this latter group.
4. Flaps must be rotated and sutured without tension.
5. The suture line must be well away from the bony
defect.
6. All diseased bone must be removed. In large fistulae,
the tooth on either side of the fistula is extracted.
7. If an active purulent sinusitis exists, antral washings
through an antrostomy with systemic antibiotics are
indicated preoperatively.
8. Any projecting bone should be leveled off so that no
undue pressure is exerted on the flap.
A The dotted line depicts the diseased edematous
mucous membrane to be excised. Because the ante-
riorly located tooth is close to the fistula, it will be
extracted. The solid line on the palate outlines the
mucoperiosteal palatal flap based on the greater pala-
tine artery (dotted line). A broad-based buccal flap is
also elevated to expose the canine fossa through which
a Caldwell-luc operation (see Fig. 5-2) can be per-
formed as indicated. large fistulae over 5 mm usually
require this antral surgery, depending, of course, on
the antral pathologic change.
B Frontal section through the fistula shows the diseased
mucous membrane extending into the fistula. All this
diseased tissue, as well as surrounding osteomyelitis in
adjacent bone, is excised. If the bone disease is exten-
sive, adjacent teeth or alveolar ridge is to be removed.
The arrow indicates the position of the Caldwell-luc
approach to the antrum through which diseased mucous
membrane is removed. If the oroantral defect is
extremely large, a Caldwell-Luc exposure may not be
necessary, because access to the antrum may be
through the fistula defect. An intranasal antrostomy
(see Fig. 5-1) is performed into the inferior meatus.
This is enlarged if considerable sinus disease is present.
C The palatal flap is elevated, preserving the greater
palatine artery. The buccal flap is turned upward to
expose the canine fossa when the Caldwell-Luc proce-
dure is deemed necessary. The tooth anterior to the
fistula has been extracted, and diseased bone and
mucous membrane have been excised.
Cl Following the technique of Proctor (1969), a
bone plug may be fitted into the bony defect when it
is large (0.5 to 2.5 em). The bone plug is taken from
the iliac crest and consists only of cancellous bone, the
hard cortical bone having been discarded. The bone
plug is tapered and shaped to fit the defect. It is
tapped into the fistula. Any protruding portion of the
bone plug is removed so that it is flush with the
surrounding bone.
D The palatal flap is rotated across the defect with-
out tension. The suture line must rest on sound bone
and not cross the fistula. If tension occurs posteriorly at
the second molar tooth, this unfortunately is removed.
The donor site on the palate may be allowed to gran-
ulate, or, if objectionably large, grafted with free dermis
or epidermis.
E The frontal section depicts the palatal flap closure
with suture lines well away from the fistula. The loca-
tions of the Caldwell-Luc operation and the intranasal
antrostomy are shown on the lateral and medial wall
of the antrum, respectively. A rubber drain is through
the intranasal antrostomy.
F With smaller fistulae (under 5 mm in diameter),
buccal flap is advanced to cover the fistula. Care must
be taken not to injure Stensen's duct in the mobiliza-
tion of the flap.
G The frontal section shows the buccal flap in posi-
tion. An intranasal antrostomy has been performed. A
disadvantage of the buccal flap is that it crosses the
buccogingival gutter and partially obliterates it-a
possible source of trouble with denture-wearing patients.
However, this flap will stretch in time. In the imme-
diate postoperative period, the patient must not wear
his or her denture because this would place undue
tension and pressure on the flap. Another disadvan-
tage is the possible tension placed on this flap with
motion of the lips and cheek.
Usually no dressing is used in either procedure;
however, with large palatal flaps, cotton soaked with
nitrofurazone and secured to surrounding teeth may
be used if the flap appears to buckle or separate from
the underlying bone. The intranasal antrostomy drain
is likewise optional. Antibiotics are used.
 THE SINUSES AND MAXILLA

FIGURE5-15
 25& TH£ ~INU~£~
AND MAXILLA
ENDOSCOPIC SINUS SURGERY
Keith F. Clark
Highlights
1. Safe and effective endoscopic sinus surgery requires
practice and a thorough knowledge of intranasal,
sinus, and perisinus anatomy that can only be gained
through study, cadaver dissection, and mentor-
supervised surgical training.
2. Thorough treatment with medications, including a
long course of a broad-spectrum antibiotic, cortico-
steroid sprays, decongestants, antihistamines, and
treatment of underlying conditions such as allergy,
elimination of smoking, and so on, should be attempt-
ed before sinus surgery is undertaken.
3. CT provides required detailed information about extent
of disease, anatomic relationships, distortions, and
abnormalities. Scans using I-mm cuts can be aligned
with the patient in the operating room using a com-
puter. Computerized, image-guided technology
provides the surgeon with the ability to accurately
locate any anatomic location touched in the patient
on the CT scan. lt can be particularly useful in revi-
sion cases when there is loss or distortion of anatomic
landmarks.
4. Endoscopic sinus surgery techniques have largely
replaced external approaches including the Caldwell-
Luc procedure. Today we have an understanding of
the physiology of the sinuses, particularly with respect
to patterns of ciliary flow, and a better understand-
ing of the anatomy through the availability of CT. In
addition, the endoscopic equipment and techniques
have allowed significant improvement in success rates
and the possibility of better healing through mucosal
preservation. Consider Figure 5-16, which illustrates
the results of a preoperative CT scan (A) demonstrating
maxillary disease and a postoperative CT scan (B)
taken after endoscopic middle meatus maxillary
antrostomy, showing resolution of maxillary disease
A B
FIGURE 5-16 A, Preoperative CT scan demonstrating maxillary disease. B, CT scan after endoscopic middle meatus
maxillary antrostomy showing resolution of maxillary disease without removal of the maxillary lining.
without removal of the maxillary lining. Prior to 15
to 20 years ago this patient would have been treated
by a Caldwell-Luc approach with removal of the
entire sinus lining and inferior meatus antrostomy.
However, it has been recognized more recently that
when the critical pathways are opened and decom-
pressed, the lining will heal and does not need to be
removed. The patient shown in Figure 5-16 was
treated by endoscopic partial ethmoidectomy and
middle meatus maxillary antrostomy with complete
resolution of the opacification and of the patient's
preoperative symptoms.
Indications
The indications for the endoscopic approach are similar
to those for other intranasal and external approaches
and in general include:
• Recurrent acute sinusitis
• Chronic sinusitis
• Allergic fungal sinusitis
• Chronic hypertrophic rhinosinusitis (polyps)
• Antrochoanal polyp
• Mucoceles in any sinus
As surgeons have become proficient with endoscopic
techniques many other procedures are being done
endoscopically, including:
• Septoplasty
• Drainage of periorbital abscess via ethmoidectomy
• Control of epistaxis including sphenopalatine artery
ligation
• Closure of cerebrospinal fluid leak
• Transsphenoidal hypophysectomy
• Orbital decompression
• Dacryocystorhinostomy
• Resection of intranasal tumors
• Repair of choanal atresia

Complications (Not Restricted to Endoscopic
Approaches)
• Intranasal bleeding
• Synechiae formation
• Stenosis and obstruction of sinus ostium with recur-
rence of disease
• Lateralization of middle turbinate
• Obliteration of frontal recess with persistent or de
novo frontal disease
• Mucocele formation, especially in the frontal sinus
• Orbital emphysema
• Epiphora
• Anosmia or hyposmia
• Persistent or recurrent sinus disease
• Severe arterial hemorrhage
• Orbital hematoma
• Diplopia
• Visual loss or blindness
• Cerebrospinal fluid leak
• Intracranial bleeding
• Stroke
• Death
Technique-General
Preoperative
Several preoperative considerations are important to
improve the intraoperative conditions, including treat-
ment with antibiotics, avoidance of topical deconges-
tant sprays, and treatment with topical or systemic corti-
costeroids, especially in the case of allergy, fungal
sinusitis, or the presence of polyps. Anticoagulants,
aspirin, and other nonsteroidal anti-inflammatory agents
should be discontinued well in advance of the surgical
procedure.
Surgical Planning
A thorough understanding of the operative technique,
identification of landmarks intraoperatively, and the
identification of anatomic variants (Table 5-1) seen on
endoscopic examination and/or a CT scan are critical.
Anesthesia
Endoscopic surgery can be performed under local or
general anesthesia. In the preoperative holding area, it
is helpful to decongest the nose with a topical decon-
gestant such as oxymetazoline. The face is draped with
the eyes exposed to enhance the surgeon's ability to
recognize intraoperative orbital hematoma. Local anes-
thetic is injected to the inferior turbinate, at the ante-
rior attachment of the middle turbinate, and at the region
of the uncinate process. During awake sedation, more
THE SINUSES AND MAXILLA
extensive injection may be necessary and can include
transpalatal sphenopalatine block. Recommended
anesthetic is 1% lidocaine with 1:100,000 epinephrine
to cause vasoconstriction and provide postoperative
comfort.
Holding Endoscopes
The endoscope should be held between the thumb and
forefinger and embraced with the other fingers while
resting the hand or fingertips on the patient's nose or
cheek. The scope is held as close to tlje lighted end as
possible, and the viewing end is supported by the
surgeon's periorbital structures. All light cords and
camera wiring are directed against the surgeon's chest
and then back to lie across the patient's chest. The
scope should be placed in the nasal vestibule first to
view the caudal septum. Then the dissecting instru-
ment held in the other hand is passed into view and the
scope and dissecting instrument advanced together
deeper into the nasal passage. Thus, the scope follows
the instrument into place. A gauze pad moistened with
antifogging solution is placed near the patient's nose to
wipe away blood and prevent fogging. The position of
the hand on the scope can serve as a depth gauge for
rapid cleaning of the endoscope tip and quick replace-
ment of the scope to the same depth each time. A
common mistake is to hold the scope near the viewing
TABLE 5-1 Surgically Important Anatomic
Variations
Frontal Sinus
Supraorbital ethmoidal cells
High frontal recess ethmoidal cells
Narrow frontal sinus ostium
Atelectaticfrontal sinuses
Ethmoidal Sinus
Concha bullosa
Paradoxicallybent middle turbinate
Infraorbital ethmoidal cells
Mediallydownsloping skull base with low medial lamella
of cribriform plate
Dehiscence of lamina papyracea or skull base
Maxillary Sinus
Lateralization of the uncinate process
Maxillaryatelectasis
Infraorbital ethmoidal cells
Accessoryostium
Sphenoidal Sinus
Onodi cells (sphenoethmoidal cells) overriding the
sphenoidal sinus
Projection of carotid artery and optic nerve into the
sphenoidal sinus
 THE SINUSES AND MAXilLA
end, which leaves the scope unstabilized against the
patient's nose.
Uncinectomy
There are several methods of performing the unci nec-
tomy, which is the first step before antrostomy and
ethmoidectomy. Some surgeons advocate minimal exci-
sion at the midpoint whereas others remove the entire
uncinate. The uncinate process can be viewed on the
lateral nasal wall under the middle turbinate. It has a
semilunar-shaped anterior attachment and posterior
free edge.
Its attachment superiorly is anterior and lies under
the leading edge of the middle turbinate attachment.
As one follows the attachment inferiorly, it curves and
moves posteriorly. The incision in the uncinate is made
at the concave region of the attachment approximately
4 mm anterior to its posterior leading edge. The poste-
Uncinate
Sickle
knife
Middle
turbinate
FIGURE5-17 Uncinectomy.
FIGURE 5-18 Backbiting forceps.
rior leading edge forms the hiatus semilunaris. The
uncinate can be removed by cutting its attachment with
a sickle knife beginning at the midpoint (Fig. 5-17). One
feels the cut through the mucosa, bone, and another
layer of mucosa into the free space lateral to the unci-
nate, which is the infundibulum. The knife pierces
through the three layers and is moved medially, and the
surgeon views the space of the infundibulum, confirm-
ing the proper position. The knife is then swept supe-
riorly and inferiorly in the semilunar direction described.
The remaining attachments superiorly and inferiorly
are then removed with a Takahashi or Wilde-Blakesley
forceps.
The back-biting instrument (Fig. 5-18) can also be
used to bite away the uncinate in a piecemeal fashion
with the remnants then removed using a suction-
debrider. Once the uncinate has been removed the
maxillary antrostomy and then ethmoidectomy can be
performed.
Accessory
ostium
Ethmoid
bulla
Middle
turbinate
FIGURE 5-19 Maxillary antrostomy.

Middle
meatus
antrostomy
FIGURE5-20 Maxillary antrostomy.
Maxillary Antrostomy (Figs. 5-19 and 5-20)
Use the 3D-degree endoscope. The natural ostium of the
maxillary sinus lies lateral to the uncinate process in an
anterior and medial location within the infundibulum.
It usually can be visualized after uncinectomy; if not, it
can be palpated with a curved suction. It should be
widened by removing anterior and inferior membranous
and bony fontanel with a back-biting forceps or debrider.
Occasionally, an accessory ostium is seen more poste-
riorly in the membranous fontanel, which can mislead
the surgeon into thinking antrostomy is unnecessary.
The natural ostium must be identified and opened
because ciliary flow is directed toward the ostium and
good function through the accessory ostium alone is
not likely. Care should be taken during palpation of an
obscured natural ostium to pass the curve suction just
above the attachment of the inferior turbinate directing
Sloped ethmoid roof
A
FIGURE 5-21
THE SINUSES AND MAXilLA
the curved suction through the membranous ostium
inferiorly to avoid penetrating the lamina papyracea
and entering the orbit. Another common mistake is to
pass the suction too superiorly between the bony orbital
floor and the sinus mucosa. Thus the sinus mucosa is
stripped from the roof without actually entering the
sinus cavity. The location of the lacrimal system duct
and sac is just anterior to the natural ostium. Overly
aggressive removal with the back-biting instrument can
lead to postoperative epiphora or other lacrimal system
complications.
Ethmoidectomy
Use the O-degreeendoscope. It is not necessary to remove
the middle turbinate. Avoid traumatizing the middle
turbinate during the ethmoidectomy (see Battered Middle
Turbinate Syndrome, later). Ethmoidectomy begins by
identifying the ethmoid bulla and opening it inferiorly
and medially. The ethmoidectomy can be done with
forceps, but there is a tendency to strip the mucosal
lining, causing delayed healing. It is preferred to use
the suction debrider device, which will more precisely
remove the septa and open into air cells without strip-
ping the lining. Aim for removal of all bony septa where
disease is present while sparing mucosa. The dissec-
tion begins inferiorly and medially and proceeds supe-
riorly and laterally using the middle turbinate and its
attachment, the ethmoidal fovea (roof) and the lamina
papyracea as limits of the dissection. The lamina
papyracea extends in the vertical plane from the mem-
branous fontanel at the level of the maxillary antrum.
The fovea is recognized by being denser, more yellow-
ish colored bone. It can be sloped or flat or a combi-
nation as shown in Figure 5-21. The fovea must not be
violated or a cerebrospinal fluid leak and likely meningitis
or other more serious central complications can occur.
A partial or anterior ethmoidectomy involves cleaning
the frontal recess area, exposing the anterior fovea of
Flat ethmoid roof
Ethmoidectomy.
 THE SINUSES AND MAXILLA
the ethmoidal sinus, and extending posteriorly to the
ground lamella of the middle turbinate. A total eth-
moidectomy includes removal of the ground lamella to
open into the posterior ethmoid cell. Pitfalls during
ethmoidectomy mainly relate to penetration of the
lamina papyracea, in which case a surgeon must recog-
nize the difference between mucosal thickening in the
sinuses and adipose tissue of the orbit. Bleeding usu-
ally occurs diffusely but can be profuse in the region of
the sphenopalatine arteries inferiorly and laterally near
the sphenoid natural ostium, as well as the anterior
ethmoidal artery in the posterosuperior aspect of the
frontal recess. The fovea is most likely to be injured in
the region of the anterior ethmoidal artery, at the junc-
tion between the posterior ethmoidal and the sphenoidal
sinus and along the attachment of the middle turbinate.
Anywhere along the fovea is at risk. The medial lamella
of the cribriform plate, which is medial to the middle
turbinate, should never be traumatized or anosmia or
cerebrospinal fluid leak will ensue.
Sphenoidotomy (Fig. 5-22)
Use the D-degree endoscope. The sphenoidal sinus can
be approached from the ethmoidal sinus once the total
ethmoidectomy is completed, by examining the region
in the inferomedial posterior ethmoidal sinus using the
point above the lower edge of the middle turbinate as
a landmark. The sphenoidal opening can be palpated
by placing a suction tip 7 em from the nasal sill at an
angle of 3D degrees. The posterior wall of the sphenoidal
sinus is 9 em from the nasal sill. Once the natural
ostium of the sphenoid is identified by palpation, the
suction tip can proceed from the posterior ethmoidal
sinus into the sphenoid ostium. The ostium should be
Sphenoid
ostium
Septum
FIGURE5-22 Sphenoidotomy.
widened by removing inferior and medial bone. Only
overhanging bone should be removed from the supe-
rior and lateral aspect, and this is done very carefully.
It is important to avoid sharp instrumentation of the
sphenoidal contents, because it is possible to injure the
carotid artery or the optic nerve. In addition, preopera-
tive CT should be evaluated for the presence of an
overriding posterior ethmoidal cell, which makes the
likelihood of an exposed optic nerve greater. It is not
necessary to perform ethmoidectomy to perform a sphe-
noidotomy. The sphenoidotomy can also be done directly
through the nose by gently fracturing the inferior
turbinate and the posteroinferior aspect of the middle
turbinate and then identifying the natural ostium by
palpation or direct visualization. The ostium can then
be widened as described.
Frontal Sinusotomy (Figs. 5-23 to 5-25)
Use the 3D-degree endoscope. The curved suction with
a large diameter curve is very useful for palpating the
frontal recess area. It can be used to gently displace
ethmoidal septa in the frontal recess, which then can
be removed with a suction ctebrider, curved curet, giraffe
forceps, or up-biting forceps. The 3D-degree sinus endo-
scope allows easy visualization of the frontal foramen,
which should be exposed without denuding mucosa
from bone. Various instruments are available, including
giraffe forceps, curved curets, and probes. The frontal
sinus and foramen anatomy can be evaluated pre-
operatively with C1. There are situations when a very
small opening could be made, in which case it is best
Frontal Foramen
Curved
Suction
FIGURE5-23 Frontal sinusotomy.

Narrow frontal foramen
A B
FIGURE 5-24
to avoid direct instrumentation of the area. On other
occasions, a very large frontal foramen can be iden-
tified, in which case a large opening can be made that
will remain patent. The frontal sinusotomy is one of the
more difficult techniques in endoscopic sinus surgery,
and it is the most likely site for postoperative stenosis
and persistent sinus disease after endoscopic surgery.
Transillumination of the frontal sinus is an excellent
method of determining that one has actually opened
the frontal sinus. Bright transillumination will only
occur when the frontal sinus is illuminated directly. If
there is a persistent high anterior ethmoidal cell, there
will be very minimal, if any, transillumination. This
high ethmoidal cell can be recognized on the CT scan
and certainly more easily identified using computer
image-guided technology.
Surgical Pitfalls
Battered Middle Turbinate Syndrome (Fig. 5-26)
Lateralization of the middle turbinate with associated
obstruction of the maxillary, ethmoidal, and frontal
sinuses is a common postoperative problem that can be
prevented by avoiding trauma to the turbinate mucosa
and/or fracture of the turbinate attachment. The middle
FIGURE5-25 Frontal sinusotomy.
THE SINUSES AND MAXilLA
Post-op frontal foramen
Frontal sinusotomy.
turbinate should be left undisturbed. It should not be
fractured. It is not usually necessary to trim it. There
are occasions when the inferior horizontal segment is
very large and the anterior portion can be removed. In
addition, a concha bullosa, or aerated middle turbinate,
should be treated by removal of the lateral wall. This is
done using scissors, but care should be taken to avoid
fracturing the attachment of the turbinate. If the turbinate
is removed because it has become diseased or is par-
tially removed for exposure, the attachment should be
left in place as a future landmark. The medial attach-
ment of the middle turbinate is the medial extent of the
ethmoidectomy. It is easy to injure the cribriform area,
and this can more likely occur if this landmark is lost.
Should the turbinate become fractured and flaccid, it
will undoubtedly lateralize and should be held medially
by a method that will allow at least 1 month of stabi-
lization against the septum. This can be done with a
transfixion suture through the septum, 3- to 4-week
stenting, or scarification of the turbinate to the septum.
Remember, middle turbinectomy does not guarantee
frontal recess patency.
Cerebrospinal Fluid Leak
Cerebrospinal fluid leak is a known complication of
ethmoidectomy and is best recognized and repaired at
the time it occurs.
FIGURE 5-26 Battered middle turbinate syndrome.
 264 THE SINUSES AND MAXILLA
Orbital Complications
Orbital complications include intraorbital hemorrhage,
injury to the extraocular muscles, visual disturbance,
and blindness. These are best avoided by recognizing
the lamina papyracea and avoiding lateral dissection in
the posterior ethmoidal and sphenoidal sinuses. Orbital
swelling after surgery with ecchymosis is suggestive of
orbital hemorrhage and possible hematoma. It should
be recognized early in the operating room or in the
recovery room and treated quickly with ophthalmologic
consultation and possible decompression with lateral
canthotomy. If orbital fat is exposed, it can be recog-
nized by its appearance as yellow soft fat. This can be
confirmed by feeling or seeing subtle eye movement
when the exposed fat is gently palpated with an instru-
ment. One can also see movement of the fat when the
eye is gently palpated. If fat should become exposed or
protrude into the ethmoidal cavity, simply leave it alone
and avoid this area. Postoperatively the patient may
experience mild eye pain or mild ecchymosis. He or she
should refrain from nose blowing for several days to
avoid orbital emphysema.
Bleeding
Preoperative treatment with corticosteroids is helpful
to decrease hemorrhage in cases of diffuse polyps.
Injection of 1 % lidocaine with 1:100,000 epinephrine
into mucosa, including polyps, is also helpful. The
suction debrider device is an excellent way of being
able to complete an extensive procedure that would
have been very difficult in the past using forceps alone.
Suction cautery can be used to control the occasional
bleeding that occurs from the sphenopalatine branches,
which will often bleed after sphenoidotomy and when
the dissection disturbs one of these vessels in the
inferolateral wall of the posterior ethmoidal sinus. Pack-
ing is usually unnecessary after endoscopic sinus sur-
gery. At the end of the procedure, cotto no ids moistened
with oxymetazoline can be placed in the ethmoidal
frontal recess and maxillary antral openings. Once the
patient is extubated and awake enough to cough,
swallow, and protect the airway from secretions, this
packing is removed and it is very unusual to see signifi-
cant further bleeding. Should additional packing be
necessary, it can be done with gauze or Merocel packs
made specifically for endoscopic sinus surgery.
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Applebaum EL, Desaum NM: Primary empty sella syndrome with
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 THE SINUSES AND MAXilLA

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 6 THE NOSE AND
THE NASOPHARYNX
Anatomy of the Lateral Wall
of the Right Nasal Cavity (Fig. 6-1)
The pathogenesis of sinusitis and its mechanism of
spread can best be understood if the anatomy of the
lateral wall of the nose is thoroughly reviewed. See
Figures 1-1 to 1-7, especially Figure 1-3. Pratt and Pratt's
description (1924) is excellent:
Uncinate Process
"The process (processus uncinatus) is a long, thin,
scimitar-shaped bone (accessory turbinate) attached
high up just under the anterior superior attachment
of the middle turbinate. It lies at an angle of about
45 degrees with the lateral wall, with the anterior edge
touching the lacrimal bone. At its upper beginning it
follows the contour of the nasal process of the maxil-
lary bone but soon curves backward, following and just
under the edge of the middle turbinate. It terminates
about in the middle of the hiatus maxillaris and gives
the bony hand-shaped frame that supports the mem-
brane, which covers the opening.
"Near the posterior end of the process and
partly covered by it, is located the ostium maxillaris.
It is from this point, which is the lower end of
the infundibulum ethmoidalis, that the antrum is
evaginated.
"The fingerlike projections at the end of the uncinate
process articulate with the ethmoid process of the
inferior turbinate and portions of the lateral wall.
These portions of membrane, which lie between the
fingers of the uncinate process, are known as the nasal
fontanelle, and when these membranous walls are
broken, form the accessory ostia of the maxillary sinuses.
The accessory ostia of the maxillary sinuses always
open into the middle meatus, while the true ostium
opens in the floor of the infundibulum ethmoidalis.
Any secretion from the antrum must pass through the
hiatus semilunaris to reach the middle meatus if it
passes through the natural ostium. The posterior supe-
rior surface of the uncinate process forms the anterior
inferior wall of the infundibulum ethmoidalis, while its
curved posteroinferior thin edge forms one margin of
the hiatus semilunaris, the bulla ethmoidalis forming
the other.
Bulla Ethmoidalis
"The bulla ethmoidalis is first noticed as a swelling just
posteriorly to the uncinate process which curves around
its anterior border by three furrows from which are
evaginated the cells which afterward occupy it. The
bleb-like protuberance projects medially, leaving an
under-shelving in its contact with the lateral wall. It is
this under-shelving space lying under the edge of both
the bulla and the uncinate process and follows the com-
plete contour of the bone that is known as the infundibu-
lum ethmoidalis.
"These bulla cells which compose the bulla eth-
moidalis open into the bulla recess which is one of the
bulla furrows and from there into the middle meatus.
The ostia, being in the superior part of the cells, do not
give gravity drainage and these cells are frequently
affected and often show polypoid degeneration.
Infundibulum Ethmoidalis
"Owing to the definition given the hiatus semilunaris
and the infundibulum ethmoidalis by the Basle Com-
mission in 1895, there has been great confusion in
describing these spaces. The infundibulum ethmoidalis
is the space on the bony lateral wall of the nose
extending from the lower end of the frontonasal duct to
the ostium of the maxillary sinus. It is bounded later-
ally by the lacrimal bone and the mesial wall of the
maxillary sinus, anteroinferiorly by the uncinate process,
and posterior-superiorly by the bulla. It communicates
with the middle meatus, by a semilunar-shaped open-
ing, formed by the sharp edge of the uncinate process
with the bulla ethmoidalis, which is known as the hiatus
semilunaris. At the lower end of the infundibulum
ethmoidalis is evaginated the sinus maxillaris, while its
upper end may terminate blindly or in an anterior
ethmoidal cell. This anterior ethmoidal cell may develop
into the frontal sinus and when this takes place, we
have direct communication from the frontal sinus to
the maxillary sinus. A number of anterior ethmoidal
cells empty in an indirect way, into the infundibulum
ethmoidalis which would allow any discharge from such
a cell to run down the infundibulum into the sinus
maxillaris. This 53 per cent explains some of the reasons
why the antrum acts as a reservoir for a suppurating
267
 THE NOSE AND THE NASOPHARYNX
Anatomy of the Lateral Wall
of the Right Nasal Cavity
(Continued) (Fig. 6-1)
ethmoidal or frontal sinusitis. In order for the antrum
to act as a reservoir, it is necessary that there be either
an extremely large ostium or an accessory ostium to
allow the air to escape as the discharge enters. An
accessory ostium of the maxillary sinus is present in
42 per cent of adult cases. The infundibulum ethmoidalis
acts as a draining trench, protected by bony walls, so
is not easily compressed, and thus keeps open many
cells, the ostia of which would otherwise be closed
during inflammations. The drainage by the infundibu-
lum may account for the absence of vacuum headache
when the nose is apparently completely closed by con-
gestion. At birth the lateral wall has all the markings
and cells of the adult but on a smaller scale."
A The dotted line and arrow demonstrate the course
of the frontal sinus duct (nasofrontal duct), one of the
more common types of the frontal sinus. This empties
into the middle meatus, medial to the hiatus semilu-
naris. Above this hiatus is the bulla of the ethmoid,
which contains the middle ethmoidal cells, which drain
through the bulla or near the bulla. The short solid
arrow depicts the location of the ostium of the maxil-
lary sinus into the middle meatus. The nasal lacrimal
duct opens into the anterior portion of the inferior
meatus. The sphenoidal sinus opening is usually near
the superior anterior wall of the sinus, depicted by the
long solid arrow.
B Another common type of drainage of the frontal
sinus is by an ostium that opens directly into the nasal
cavity. Disease of the anterior ethmoidal cells may
impinge on this ostium and may be the cause of
obstruction of the ostium, leading to frontal sinusitis as
well as blockage of the natural ostium of the antrum-
the ostial meatus complex.
 THE NOSE AND THE NASOPHARYNX

MIDDLE TURBINATE
BULLA ETHMOID
FRONTAL SINUS DUCT HIATUS SEMILUNARIS

SPHENOID SINUS OPENING

SUP. TURBINATE
NASAL LACRIMAL DUC

EUSTACHIAN TUBE

FIGURE 6-1
 THE NOSE AND THE NASOPHARYNX

Anatomy of Epistaxis (Fig. 6-2)
(After Koh et aI., 2000; Montgomery,
1971 )
Epistaxis can be either a very minor or a very major
problem. The most common area in children and young
adults is anteriorly on the septum (Kiesselbach or Little
area) and is the easiest controlled (see Fig. 6-3E and F).
The more complicated areas are posterior and superior,
both on the lateral wall of the nose and the septum in
older adults (see Fig. 6-3).
The important factors in the control of epistaxis are
etiology, location, and management.
Etiology
A. Local disease
1. Crusting and ulceration
2. Nose picking
3. Infection
4. Neoplasms
a. Malignant neoplasms
b. Juvenile nasopharyngeal fibromas
c. Angiomas
d. Metastatic renal cell carcinoma to the paranasal
sinuses and/or nasal cavity. Massive epistaxis
can occur. If feasible, resection of the meta-
static lesion may be the treatment of choice.
5. Trauma
6. Foreign body
will achieve control of the hemorrhage. Lateral rhinot-
omy may be necessary especially in familial telangiec-
tasia to insert a dermal graft for septal dermoplasty
(see Fig. 6-6) (Saunders, 1960).
1. Cauterization
2. Nasal packing-anterior, posterior, or both
3. Submucosa resection or septoplasty
4. Ligation of arteries
a. Ethmoid arteries, anterior and posterior
b. Internal maxillary and sphenopalatine arteries
c. External carotid artery rarely controls epistaxis.
5. Septal dermoplasty-removal of offending mucosa
and application of a dermal graft rather than split-
thickness epidermis .
6. Basic care of severe hemorrhage-frequency and
selection depends on degree of severity of blood loss.
a. Vital signs-every 1 to 2 hours
b. Hemoglobin and hematocrit determination, one
to three times per day
c. Blood transfusion
d. Central venous pressure
e. Blood volume
f. Venous cutdown or intracatheter in vein
g. Blood urea nitrogen determination-elevation is
result of swallowing and absorbing blood.
7. Embolization of branches of external carotid
artery-hazard of hemiplegia and facial palsy
Angiography-Digital Subtraction

B. Generalized disorders and disease This is seldom necessary but is of distinct use in per-
1. Arteriosclerosis-hypertension sistent and refractory epistaxis to determine feeding
2. Rheumatic heart disease vessels as well as recurrent epistaxis after unsuccessful
3. Blood dyscrasia and associated diseases arterial ligation. Obtain true lateral and anteroposterior
a. Anemia views (Koh et aI., 2000).
b. Polycythemia vera Angiography usually requires selective external
c. Thrombocytopenia purpura carotid artery with internal maxillary artery arterio-
d. Hemophilia gram and then an internal carotid artery arteriogram
4. Leukemia with visualization of the ophthalmic artery and its
5. Familialtelangiectasia (Rendu-Osler-Weberdisease) anterior and posterior ethmoidal branches. A bilateral .
6. Hepatic diseases angiogram is ideal but may have to be staged, depend-
7. Chronic nephritis ing on find-ings and patient tolerance. Complications
8. Vicarious menstruation of possible stroke and blindness must be explained to
9. Atmospheric pressure changes (e.g., scuba divers; the patient.
caisson disease)
10. Generalized infectious diseases Complications
11. "Stigmata"?
• Shock
Location • Aspiration of blood with airway obstruction causing
respiratory arrest and then cardiac arrest. Never have
Exact determination of the bleeding site must be made, patient keep the head back. 1f bleeding is to occur,
if at all possible, to facilitate direct attack. Occasionally, let it run out of the nose rather than down the pharynx
a submucous resection (see Fig. 6-12) or septoplasty and into the larynx. Oversedation can be the cause
(see Figs. 6-13 and 6-14) is necessary to visualize the of this complication.
site. Often under such circumstances these procedures • Death
 THE NOSE AND THE NASOPHARYNX 271

ANT
SUPERIOR ETHMOID ~ OPHTHALMIC _..•• _ INTCAROTID
POST

SEPTAL WALL (POSTNASAL)

(SPHENO-
NASOPALATINE _INT. MAX _ EXT..CAROTID
(POSTSEPTAL) - PALATINE)

ANT. ETHMOID __ OPHTHALMIC .•• INT.CAROTID

SPHENO-
NASOPALATINE - PALATINE - INTMAX. EXT..CAROTID
GREATER'" DESCENDING_INTMAX. - EXT..CAROTID
PALATINE PALATINE
(KIESSELBACHI
L1TILE AREA)

FACIAL
A SEPTAL BR. ..- SUP.LABIAL ~(EXT. MAX-) - EXT.CAROTID

ANT
• SUPERIOR ETHMOID _ OPHTHALMIC.~"'_----_ INT.CAROTID
POST

o POSTERIOR
SPHENOPALATINE
(POSTLATNASAL)
.•.• INT MAX. ••• EXT.CAROTID

B (I ANTERIOR NASAL SA.

• FACIAL
(EXT..MAX.)
'lI( EXT.CAROTID

FIGURE 6-2

Axiom There are numerous anastomoses of all these vessels,

Treat all cases of severe epistaxis as a serious problem.
A Anatomy of septal vessels.
B Anatomy of vessels on lateral wall of nose.
both intranasal and extranasal, as well as bilateral anas-
tomoses; other contributors to this are the occipital and
superficial temporal arteries. Hemorrhage from the internal
maxillary artery can steal blood from the intracranial cir-
culation via backflow from the middle meningeal artery.
Theoretically, a steal of blood could also occur via the
external carotid artery from the internal carotid artery.
 THE NOSE AND THE NASOPHARYNX
Anterior and Posterior Packing
for Epistaxis (Fig. 6-3)
Highpoints
I. Attempt to locate bleeding site by cleansing nasal
passages with cotton-tipped applicator dipped in
solution of cocaine 10%, or tetracaine 2 %, and a
vasoconstrictor.
2. Anterior septal vessels (Kiesselbach's plexus) are
the most common site.
3. In the absence of hypertension, bleeding at this
common site is usually controlled with a pledget of
cotton gauze soaked with cocaine or tetracaine and
a vasoconstrictor. If bleeding persists from this loca-
tion, cauterization with either a silver nitrate stick or
electrocautery is performed (see Fig. 6-3E). Ante-
rior packing (see Fig. 6-3F) may also be necessary.
4. Fatal hemorrhage is very rare, especially in hyper-
tension, if meticulous care is given.
5. Epistaxis in hypertension is looked on as a fortu-
nate safety valve mechanism, provided the patient's
vital signs are monitored carefully.
6. Aspiration and swallowing of blood should be
avoided. If oozing persists, allow blood to run from
anterior nares with head flexed forward. Overseda-
tion is strongly condemned because of the danger
of aspiration, respiratory obstruction, and death.
For the same reason the patient must not be
restrained.
7. Ligation of one or both external carotid arteries is
occasionally necessary.
8. Occlusion of anterior ethmoidal, posterior ethmoidal
(see Fig. 6-4), or internal maxillary arteries (see
Fig. 6-7) with silver locking clips may be necessary.
9. Ligation of the common carotid or internal carotid
artery is neither necessary nor justified.
10. Nasal packing of any type should be accompanied
by systemic antibiotics. Strip gauze one-half inch,
impregnated with an antibiotic ointment, is ideal.
n. Occasionally in persistent epistaxis (e.g., in familial
telangiectasia), an arteriogram may be helpful.
Collateral blood supply has been demonstrated via
the vertebral artery and the occipital artery into the
internal maxillary artery in a patient with external
carotid artery ligation.
12. A nasal mucous membrane dermoplasty (excision
of diseased mucous membrane and coverage with
dermal graft) may be required in familial telangiec-
tasia (see Fig. 6-6).
13. All packing should be impregnated with antibiotic
ointment plus systemic antibiotics for normal flora
and gram-negative bacilli.
Posterior Packing
A Topical anesthesia may be applied to the nasal
mucosa. A small rubber catheter (No. 10 French), to
which an l8-inch length of soft-bodied string is tied, is
inserted into one naris. The forward end is grasped
with a small sponge stick and pulled out through the
mouth, leaving the string in the nasal cavity and
mouth. This maneuver is repeated through the other
naris.
B The oral ends of the string are then secured to a
prearranged roll of gauze impregnated with antibiotic
ointment to which is tied a third section of string.
C Steady traction is then applied to the nasal ends of
the strings and, with the index finger of the opposite
hand, the roll of gauze is firmly directed into the
nasopharynx. The third string protrudes from the
corner of the mouth.
Continued
 THE NOSE AND THE NASOPHARYNX

FIGURE 6-3
 THE NOSE AND THE NASOPHARYNX
Anterior and Posterior Packing
for Epistaxis (Continued) (Fig. 6-3)
Complications
• Persistent hemorrhage leading to hypovolemic shock
and death
• Aspiration of blood passing down through nasophar-
ynx. Oversedation may well be a contributing factor
to this avoidable complication, which has caused
death.
• Elevation of blood urea nitrogen from absorption of
ingested blood
• Any other complication resulting from hypovolemic
shock (e.g., myocardial infarction, kidney shut-down)
• Decrease in arterial P02 and an increase in Pe02
• Decreased pulmonary compliance
• Synergistic effect of hypoxia and hypercarbia with
preexisting obstructive lung disease may well account
for sudden death in prolonged nasal packing
• Nasal septal mucosal excoriation
• Necrosis of the alar naris and columella and/or the
palate from sutures, tape, or "string" or tubing related
to the packing
• Infection secondary to gram-negative bacilli
• Toxic shock syndrome. Treatment is removal of the
nasal packing and culture and treatment with anti-
biotics. Suggested antibiotics are intravenous methi-
cillin sodium or cefazolin while awaiting the sensi-
tivities from the nasal culture of the nasal packing
and nasal cavity.
• Obstructive sleep apnea
D The two nasal ends of the string are tied securely
over a small cushion of gauze or dental roll across the
columella. The oral string is loosely taped to the cheek.
This latter string facilitates easy removal of the poste-
rior pack.
When this equipment is not available, a Foleycatheter
is inserted through one naris. When the tip has passed
the nasopharynx, the bag is inflated and pulled forward
into the posterior naris. The catheter is secured with
folded gauze tied at the anterior naris.
Dl The Stevens nasal balloon with or without a
built-in breathing tube can also be used. Its use is
similar to that of the Foley catheter. Other devices are
commercially available (e.g., "Epistat" manufactured
by Xomed, which accomplishes both posterior and
anterior tamponade). At times these various balloon
devices fail in severe bleeding, and the gauze packing
is able to control the bleeding.
Conuol of Anrerior Hemo"hage
E Cauterization of the anterior septal vessels is done
after initial control with topical application of cocaine
10%, or tetracaine 2%, and a vasoconstrictor. Either
silver nitrate (stick or 50% to 100% solution) or elec-
trocautery is used as the agent.
F When anterior nasal packing is necessary, one-half
inch gauze impregnated with antibiotic ointment is
placed in horizontal layers. In this manner more com-
plete and uniform pressure is obtained or selective
pressure at one level is obtained by simply raising or
lowering the packing. This latter technique leaves a
small air passage for respiration. Systemic antibiotics
are used with any type of nasal packing.
Nasal Endoscopy and Cauterization
Currently, most clinicians prefer endoscopic examina-
tion of the nasal cavity, under general anesthesia, direct
visualization of the bleeding vessel(s), and electrocau-
terization. This approach avoids the discomfort and
morbidity associated with nasal packing, particularly
posterior nasal packing, and considerably shortens
hospitalization time.
 THE NOSE AND THE NASOPHARYNX

FIGURE 6-3 Continued

 THE NOSE AND THE NASOPHARYNX

Ligation of Ethmoidal Arteries

as they arise from the ophthalmic artery, which is the
(Fig. 6-4) first branch of the internal carotid artery (see Figs. 1-1
to 1-6 for bony relationships). The excellent articles by
Indications
Weddell and colleagues (1946) and Kirchner and co-
workers (1961) refer to the details of the surgical
• Epistaxis superiorly (above the middle turbinate)
anatomy of these vessels. An important relationship is
(see Fig. 6-2)
the proximity of the posterior ethmoidal artery to the
• Perform concomitantly with internal maxillary artery
optic nerve, which "entering at a small angle with the
ligation if unable to ascertain region of bleeding.
medial orbital wall, lies only 1 or 2 mm from the point
at which the posterior ethmoid[al] artery leaves the
Highpoints
orbital soft tissue to enter the foramen" (Kirchner et aI.,
1961). The posterior ethmoidal artery usuallyapproaches
1. Avoid injury to the medial canthal ligament and the
its foramen at a 90-degree angle to the bone. The
lacrimal sac below and the trochlea of the superior
posterior ethmoidal foramen is between 4 to 7 mm in
oblique muscle above. If this ligament is sectioned,
84% of the skulls from the optic foramen. Hence, the
careful repair is necessary. The trochlea may be ele-
admonition of caution if electrocautery is used to
vated with the periosteum if additional exposure is
obliterate this vessel. It must be applied meticulously
necessary.
to the bony foramen with retraction of the orbital
2. Subperiosteal dissection is necessary.
contents. Silverlocking clips are preferred. The distance
3. Avoid injury to the globe and optic nerve.
relationships depicted on the illustration are from
4. Do not fracture the thin lamina papyracea of the
Kirchner, but he hastens to emphasize that there are
ethmoid bone.
such variations that these distances may be of little
5. Control all bleeding meticulously-postoperative intra-
help to the surgeon. The anterior ethmoidal artery is
orbital hemorrhage could damage the optic nerve by
usually the larger, but the reverse can be true. One or
pressure.
the other vessel may be absent. Occasionally, there
6. Ligate both anterior and posterior ethmoid arteries.
may be three ethmoidal arteries.
7. Use of the operating microscope facilitates improved
illumination and magnification.
B An anterolateral view of the anatomy of the medial
8. Digital subtraction angiography (arterial) or standard
bony wall of the orbit shows the more typical location
artertography may be of help, of the foramina of the anterior and posterior ethmoidal
arteries in the region of the frontoethmoidal suture
A Depicted is the anatomy of the origin and rela- line.
tionships of the anterior and posterior ethmoidal arteries Continued
 THE NOSE AND THE NASOPHARYNX 277

CRISTA GALLI
FRONTAL SINUS
FRONTOMAXILLOLACRIMAL SUTURE
SUP. OBLIQUE M.

13-18MM 1 CRIBRIFORM PLATE

ANT. ETHMOID A.
SUP. RECTUS M.

MEDIAL RECTUS M.
POST. ETHMOID A.
10-13MM!
OPTIC N.
LACRIMALA.
4-7MM
OPHTHALMIC A.

FRONTOMAXILLOLACRIMAL
SUTURE
OPTIC FORAMEN
FRONTAL PROCESS MAXILLARY
BONE

LACRIMAL FOSSA
ANGULAR A.

ORBITAL PLATE OF MAXILLARY BONE

WabniQ
B
FIGURE 6-4
 THE NOSE AND THE NASOPHARYNX
Ligation of Ethmoidal Arteries
(Continued) (Fig. 6-4)
The relationship of the medial canthal ligament and
the lacrimal sac to the region of the surgical approach
is depicted in Figure 11-12B.
The trochlea is a fibrocartilaginous pulley through
which the tendon of the superior oblique muscle passes.
The stippled area is a portion of the lacrimal bone
and the lamina papyracea whereas the diagonally lined
area is the frontal process of the maxillary bone and the
juxtaposed nasal bone. These are areas resected in an
external ethmoidectomy (Fig. 5-4B).
Complications
• Hematoma
• Optic nerve damage
C A temporary tarsorrhaphy may be performed. A
slightly curved incision about 3 cm in length is made
as depicted, extending more above the medial canthal
ligament than below it. Branches of the angular vessel
will require ligation. This artery anastomoses with the
dorsal nasal branch of the ophthalmic artery.
D The periosteum is incised and elevated above the
medial canthal ligament, avoiding the lacrimal sac
LACRIMAL SAC
c D
FIGURE 6-4 Continued
below and the trochlear above. This exposes the suture
line (vertical) between the frontal (nasal) process of
the maxilla and the lacrimal bone and the suture line
(horizontal) between the orbital plate of the frontal
bone and the lamina papyracea of the ethmoid bone.
Microsurgical spatulas are ideal for periosteal elevation
posteriorly. A suitable self-retaining retractor with inter-
changeable slatted and solid blades (Luongo) is inserted.
If necessary, a small malleable retractor can also be
used to retract the periosteum and the globe laterally.
Following the frontoethmoid suture line, the anterior
ethmoidal artery is identified. Silver clips using the
House hemostatic clip instrument (Storz) are placed
proximally and distally-if possible, two on each
side-and the vessel is transected. This is necessary to
facilitate deeper exposure of the posterior ethmoidal
artery, which is then simply occluded with one or two
silver clips. Care is taken not to dislodge the silver clips
on the ends of the transected anterior ethmoidal artery
during the maneuver.
At this point extreme care is exercised to avoid
injury to the optic nerve (see Fig. 6-4A).
When hemostasis is incomplete, bipolar electrocautery
can be used for small vessels if extreme care is taken
not to injure the optic nerve nor any other contents of
the orbit (best to avoid cautery of posterior artery); the
wound is closed with a drain (portion of rubber band).

External Ethmoidectomy Approach
to Epistaxis (Fig. 6-5)
In the unusual event that bilateral ligation of the ante-
rior and posterior ethmoidal vessels as well as internal
maxillary arteries fails to control hemorrhage high in
the nasal cavity, an external ethmoidectomy may be
necessary (see Fig. 5-4). The extent of the osseous
resection of the lacrimal bone to the frontal process of
the maxillary bone and the nasal bone for the approach
to the vessels perforating the cribriform plate depends
on whether the location of the bleeding site is anterior
or posterior. Preoperative digital subtraction angiogra-
FIGURE 6-5
THE NOSE AND THE NASOPHARYNX
phy (DSA) (arterial route) is necessary to evaluate the
presence of such vessels (Fig. 6-5). In one patient, an
angiomatous type lesion was seen on the DSA, and
the external ethmoidectomy was used to resect this
suspicious area as well as clip the feeding vessel that
existed through the cribriform plate (Sobie and Loft').
The accompanying anteroposterior left carotid angio-
gram (DSA, arterial route) demonstrates a concen-
tration of dye (circled) just inferior to the cribriform
plate in a patient with recurrent, severe, life-threatening
epistaxis. (Angiogram courtesy of Dr. David Rowland,
Director of Radiology, Sisters Hospital of Buffalo,
New York.)
 THE NOSE AND THE NASOPHARYNX
Septal Dermoplasty (Fig. 6-6)
(After Saunders, 1960)
Indication
• Repeated epistaxis is secondary to familial telangiec-
tasia (Rendu-Osler-Weber disease). This disease is
systemic with possible bleeding from any epithelial
or mucosal surface including the gastrointestinal
tract. Cardiac failure secondary to anemia must be
carefully evaluated and managed before any surgical
intervention.
Highpoints
I. Remove entire mucous membrane in area to be
treated, leaving intact the underlying perichondrium
or periosteum, which will serve as the source of
blood supply to the graft.
2. If there is any question regarding the viability of the
septal cartilage from use of electrocautery, it may be
wiser to stage a procedure on the opposite side to
avoid perforation.
3. Remove as much of diseased area as possible from
one side-this usually includes mucous membrane
not only on the septum but also on the lateral wall
of the nose, including turbinates.
4. Give adequate exposure.
5. Avoid aspiration of blood; if performed under general
anesthesia, pack hypopharynx in addition to using a
cuffed endotracheal tube, because the bleeding may
be profuse.
6. The nasal packing (packing impregnated with antibi-
otic ointment) must be carefully inserted so as not
to disrupt the graft. The use of a Teflon splint against
the graft and sutured in place accomplishes this
protection.
7. Blood transfusions may well require washed packed
red cells rather than whole blood and/or the use of
fresh-frozen plasma.
8. Provide therapy with systemic antibiotics for the
normal nasal flora as well as gram-negative bacilli.
Complications
• Recurrent epistaxis
• Cardiac failure: danger of overtransfusion during
surgery, postoperative tachycardia, and auricular
fibrillation
• Graft failure
• Septal perforation
• Atrophic rhinitis with varying degrees of crusting
A Depicted is a lateral rhinotomy (see Fig. 6-32),
which affords adequate exposure of the nasal septum
and a portion of the lateral wall of the nasal cavity. The
lateral rhinotomy usually does not require osteotomy.
The dotted line outlines area of mucous membrane
excised. Allthe mucous membrane must be excised so
that no islands remain under the skin graft. A sharp
ring curet can be used to remove inaccessible mucosa
and at the same time preserve the perichondrium. The
perichondrium is preserved. Bleeding is usually copious
and is controlled with electrocautery. Care must be
taken not to perforate the nasal septum.
A1 Because it is quite impractical to place sutures
completely around the edges of the mucosal defects
on the skin graft, the grafts are merely sutured ante-
riorly using 5-0 continuous nylon or absorbable suture
material. The grafts are then folded in over the defects
on the septum and lateral wall of the nose, leaving
excess graft posteriorly. This will slough off in due
time. One-half-inch gauze packing impregnated with
antibiotic ointment is carefully and loosely placed within
the nasal cavity separating the two grafts, medially
and laterally. Teflon splints are utilized alongside the
septum (see Fig. 6-131 to L).
B Frontal section through the nasal cavity shows the
location of the skin graft. Both split-thickness epider-
mal and dermal grafts have been utilized, more recently
the latter. Although not proven, it is believed that the
dermal grafts may possibly assume some of the mor-
phologic characteristics of mucosa in the nose as they
do in the oral cavity and pharynx. One caution would
be the possible adherence of the dermal grafts on the
septum and the turbinate to one another. Hence, pack-
ing or splint (see Fig. 6-131) should be maintained until
epithelialization of the dermis occurs. Another possible
criticismwould be the increased thickness of the dermal
graft over the epidermal graft, thus compromising the
nasal airway.
The nasolabial incision for the lateral rhinotomy is
closed in layers. There must be no bleeding at the close
of the operation.
Ligation of internal maxillary and/or ethmoidal arter-
ies may be necessary (see Figs. 6-4 and 6-7B to D).
 THE NOSE AND THE NASOPHARYNX

I. SPLIT THICKNESS
1 OR
I DERMAL
GRAFT

FIGURE 6-6
 THE NOSE AND THE NASOPHARYNX

Ligation of Internal Maxillary a. Sphenopalatine (posterior lateral nasal)

Artery (Fig. 6-7) b. Posterior nasal (nasopalatine; posterior septal)

Indications The branches of the third part are those involved

in the transantral ligation for the control of epistaxis,
• Epistaxis posteriorly (from the sphenopalatine artery specifically the terminal medial branch forming the
and its nasopalatine branch) (see Fig. 6-2) or any sphenopalatine and the posterior nasal arteries and the
epistaxis refractory to nasal packing, especially pro- descending palatine. There are anastomoses with the
longed packing internal carotid (via ethmoidals and ophthalmic), other
• Recurrent epistaxis external carotid branches (via facial), other branches
• Often performed concomitantly with ethmoidal artery of the maxillary artery (via buccinator), and crossed
ligation (see Fig. 6-4) anastomoses with vessels of contralateral side (via
sphenopalatine). Hence, there is the obvious difficulty
Part I of controlling persistent epistaxis and often the neces-
sity of performing bilateral multiple ligations of not

(Medial to mandible) only the maxHiary artery branches but also the bilateral
ethmoidal arteries. In one patient (with familial telan-
I. Deep auricular giectasia) who previously had bilateral external carotid
2. Anterior tympanic artery ligations as well as ethmoidal and sphenopala-
3. Middle meningeal (and accessory meningeal) tine artery ligations, an angiogram performed via the
4. Inferior alveolar superficial temporal artery revealed anastomoses of a
branch of the maxillary artery with the vertebral artery
Part II via the occipital artery. It is in such situations that an
angiogram is of help. A common carotid arteriogram
(Relationship deep or superficial to external pterygoid would also demonstrate any significant variant of the
muscle-all muscular branches) internal carotid, which is extremely rare, as shown by
Quain (1844), in which the branch to the foramen
1. Masseteric rotundum and the accessory meningeal arteries sub-
2. Deep temporal (2) stituted for the internal carotid artery.
3. Buccinator
4. External and internal pterygoid Highpoints

Part III 1. Check anatomy and size of antrum with radiographs.

A markedly small antrum will require removal of
Pterygopalatine part lies against posterolateral aspect lateral inferior wall of the antrum for exposure (see
of maxilla and passes in a plane lying between two Fig. 6-70). The average size of an antrum is 23 mm
heads of external pterygoid muscle to enter pterygopala- wide, 33 mm high, and 34 mm deep (Schaeffer, 1920).
tine fossa (lateral portion). 2. Be cognizant of proximity of internal carotid artery.
3. Related nerves lie in a deeper plane and should easily
A. Lateral be avoided.
1. Posterior superior alveolar 4. Take care not to dissect too high and enter the
orbit-this may occur with the smaller antrum.
B. Anterior 5. At least occlude the terminal medial branch forming
1. Infraorbital the sphenopalatine and posterior nasal arteries and
2. Descending palatine (somewhat medial and infe- the anterior branch forming the descending palatine.
rior) Ideally, at least three sites should be occluded, as
a. Greater palatine depicted in C, as well as the main trunk of part III of
b. Lesser palatine the maxillary artery.
6. A portion of the orbital process of the palatine bone
C. Posterior should be removed for access to the terminal branch
1. Pharyngeal of the maxillary artery forming the sphenopalatine
2. Branch to foramen rotundum and to the pterygoid and posterior nasal arteries.
canal 7. Use locking clips or multiple clips and transect vessels
3. Medial and superior when possible.
 THE NOSEAND THE NASOPHARYNX 283

PART I PART II PART III

POSTERIOR

PHARYNGEAL
PTERYGOID CANAL
{ FORAMEN
ROTUNDUM

EXT. PTERYGOID M.
SUP. HEAD
INF. HEAD
MEDIAL & SUPERIOR

SPHENOPALATINE
MIDDLE
POSTERIOR NASAL
MENINGEAL AND
ACCESSORY A.

LATERAL

A POST. SUP.
{
ALVEOLAR

FIGURE 6-7

8. Do not use oxidized cellulose or any other material

capable of expansion if packing the antrum. Expan-
sion of packing can cause pressure and result in
blindness and/or total ophthalmoplegia.
The approach to the antrum is a Caldwell-Luc opera-
tion (see Fig. 5-2) with a large opening. Take care not
to injure the infraorbital nerve and preserve as much of
the lining mucosa as possible to cover the surgical defect.
Cocaine 10%, oxymetazoline (Afrin), or phenylephrine
(Neo-Synephrine) (check with the anesthesiologist
regarding side effects of any general anesthetic agent,
e.g., halothane) is applied to the antral mucosa to
decrease bleeding. General endotracheal anesthesia is
provided with the patient in semi-Fowler's position so
that the direction to the posterior wall of the antrum is
toward the inferior aspect, thus avoiding any injury to
the orbit.
A Depicted is the basic anatomy of the internal
maxillary artery (now known as simply the maxillary
artery, whereas the external maxillary artery is known
as the facial artery) (see Figs. ,-, to '-7 for bony rela-
tionships). The maxillary artery may be either superior
(anterior) to the external pterygoid muscle or deep to
the muscle or pass between the superior and inferior
heads of the muscle. This main terminal branch of the
external carotid artery (along with the superficial tem-
poral artery) is of prime concern to the surgeon. It is
divided into three parts. There may be some confusion
regarding terminology, and alternate names are in
brackets.
Continued
 THE NOSE AND THE NASOPHARYNX
Ligation of Internal Maxillary
Artery (Continued) (Fig. 6-7)
Complications
• Facial numbness
• Intolerance to extremes of heat and cold over the
distribution of the infraorbital nerve
• Pain
• Blindness and ophthalmoplegia with the use
oxidized cellulose packing
• Infection extending into pterygomaxillary space
B An inferiorly or laterally based mucoperiosteal flap
is then elevated and reflected from the posterior wall
of the antrum. With the use of the operating micro-
scope with 300-mm lens, 0.6 magnification setting,
and angulated eyepiece the thin inferior posterior wall
of the antrum is removed with a bur or curet. This
opening is then enlarged superiorly with fine back-
biting Kerrison forceps and hooks. The bone removal
is continued upward to resect a portion of the orbital
process of the palatine bone (see Fig. 6-4D) (Pearson
et aI., 1969). This may require additional use of a bur,
and this exposes the region of the sphenopalatine
foramen. Take care with the patient's head and neck
hyperextended not to make the opening in the pos-
terior wall of the antrum too high. If it is too high and
medial, one can enter the ethmoidal sinus; if it is too
high and lateral, one can enter the orbit.
The vessels may be just beneath the periosteum and
are thus in jeopardy during the removal of the bony
posterior wall. Extreme care must be exercised to avoid
lacerating a vessel. If this does occur, the area must
be packed. The procedure may have to be terminated
if the vessel cannot be clipped. At times removal
portion of the lateral wall of the antrum to expose the
internal maxillary artery proximally may afford expo-
sure to place a clip proximally.
C The posterior layer of periosteum is then opened
using a fine instrument or electroscalpel. This exposes
adipose tissue, which is teased forward, exposing some
of the branches of the third part of the maxillary artery.
A small Mixter forceps as well as a nerve hook is of aid
in this dissection. Small forward grasping forceps are
advantageous for removing adipose tissue. Depicted is
a rather typical configuration (after Pearson et aI., 1969).
At times the main trunk of the internal maxillary artery
enters the operative area from the inferior aspect.
Minimally, three sites are occluded with clips and, if
possible, the intervening vessels are transected. It is
important to occlude the maxillary artery proximally
(1) as well as distally (2), where the vessel continues on
to divide into the sphenopalatine and posterior nasal
branches and the descending palatine artery (3), to
of prevent retrograde flow. If additional small vessels are
apparent, these, too, should be occluded because of
the crossed anastomoses. In other variants of the maxil-
lary artery, multiple clips are utilized again. It may not
be possible to identify each branch by name. It is ade-
quate to occlude them all. Avoid the sensory nerve to
the palate, which accompanies the descending pala-
tine artery.
If bleeding occurs during the procedure, the antrum
is packed and then re-explored. All related nerve struc-
tures are usually deep to the vessels and easily avoided.
D If the antrum is small or the patient is undergoing
secondary operations, a somewhat different dissection
of the antrum is performed:
1. Remove the lateral inferior wall of the antrum, and
if necessary, communicating this exposure with the
Caldwell-Luc opening, expose the upper and lower
heads of the external pterygoid muscle. The maxillary
artery may lie over the lower head or pass between
the two heads or may cross the muscles in a vertical
direction. All branches of the vessel are then occlud-
ed with clips. It may be possible to pass a silk liga-
ture around the main trunk of the maxillary artery
(part III) using a fine Mixter clamp.
2. Ligation of the maxillary artery will then be lateral
and posterior to the antrum.
of a
3. Be careful not to enter the orbit.
After hemostasis is ensured, the posterior muco-
periosteal flap is replaced. An antral window is usually
not required unless antral packing is necessary. The
packing should be strip gauze impregnated with antibi-
otic ointment and applied very loosely to avoid any
pressure that might be transmitted to the optic nerve.
Do not use oxidized cellulose or any material capable
of expansion. The Caldwell-Luc incision is closed with
continuous 4-0 nylon without drainage.
If there is difficulty in locating the maxillary artery,
the technique described in Figure 6-70 can be helpful.
 THE NOSE AND THE NASOPHARYNX 285

UPPER HEAD

LOWER HEAD

D INT. PTERYGOID M.
FIGURE 6-7 Continued
 THE NOSE AND THE NASOPHARYNX
Removal of Nasal and
Nasopharyngeal Polyps (Fig. 6-8)
Highpoints
1. Use topical tetracaine 2%, or cocaine 10%, with or
without a vasoconstrictor, for anesthesia.
2. Usually more polyps will become visualized after
removal of initial polyps.
3. Suspect polypoid disease in sinuses and some type
of allergic background.
4. Most polyps tend to recur.
5. Do not confuse a polypoid turbinate with a true
polyp. Do not remove part or all of middle turbinate.
6. In infants a nasal glioma may simulate an innocent
polyp (see Fig. 6-34).
7. Do not confuse an angiofibroma with a nasopharyn-
geal polyp.
8. Be cognizant of other lesions in the nasopharynx
and nasal cavity: glioma (infants, see Fig. 6-34),
meningiomas, chordomas, Thornwaldt's bursa, Rathke
pouch remnant with pituitary gland (see Craniofacial
Approach in Chapter 23). "In the median line of the
adenoid, especially in adults, you will often find an
opening leading upward and backward to a cavity
commonly known as the pharyngeal bursa, or
Thornwaldt's bursa. Mellinger, who has investigated
it extensively in adults, has found it frequently pres-
ent, deep and often in a state of chronic inflamma-
tion. In some instances pus pockets were found and
a chronic inflammation of the adenoid, even though
small, was clearly evident. Emerson has also report-
ed similar affections, which are commonly known as
Thornwaldt's Disease" (Barnhill, 1937).
9. Refer to nasopharyngoscopy, Chapter 4. Flexible and
rigid telescopes are a great aid in the evaluation of
lesions not only of the nasopharynx but also of the
nasal cavity.
Complications
• Hemorrhage
• Aspiration of blood or, conceivably, polyps, causing
respiratory embarrassment
• Septic shock syndrome following any nasal packing
• Disaster if lesion is other than nasal polyp that arises
intracranially
A A nasal polyp snare is slipped around the polyp
under direct vision through a nasal speculum.
B The snare is tightened only after it is worked up to
the base of the pedicle. If possible, the snare is not
completely closed, thus not completely transecting
the pedicle. At this point, the snare has a firm grip on
the pedicle; snare and polyp are removed together. If
the pedicle is completely transected, a bayonet forceps
or duckbill forceps (Watson-Williams) is used to remove
the free polyp. If it is inaccessible, the patient is asked
to blow the nose gently and this will expel the polyp.
C Some large posterior polyps presenting in the
nasopharynx cannot be encircled with a snare alone.
D A grasping forceps through the mouth is used to
introduce the dependent portion of the polyp into the
loop of the snare. Gentle traction on both instruments
works the snare upward to the pedicle.
E When the snare meets resistance, it is at the base
of the pedicle; it is then completely closed. This severs
the pedicle completely and the polyp is removed orally
using the grasping forceps.
Smaller polyps and remnants are removed with punch
forceps. Extension of polypoid disease into the sinuses
may require sinus surgery. Refer to uncapping of ethmoids,
ethmoidectomy, antral window, and Caldwell-Luc opera-
tions. All polyps and, for that matter, all tissue must be
submitted for histologic examination at all times.
 THE NOSE AND THE NASOPHARYNX 287

FIGURE 6-8
 THE NOSE AND THE NASOPHARYNX
Transpalatlne Exposure of the
Nasopharynx and the Sphenoidal
Sinus (Fig. 6-9)
Indications
• Removal of large benign and locally invasive lesions
(juvenile angiofibroma); nasopharyngeal chordoma
• Exposure for surgical correction of posterior choanal
atresia
• Diagnostic exploration when other methods have
failed
• If lesion extends beyond confine of nasopharynx,
another approach or combination of approaches is
necessary.
• An alternate approach to the sphenoidal sinus (see
p.228).
Alternate Techniques
1. Most benign pedunculated lesions in the nasopharynx
can be removed with nasal snare (see Fig. 6-8).
2. Posterior choanal atresia also can be surgically treated
via the nasal cavity with or without the operating
mIcroscope.
Highpoints
1. Never biopsy a lesion in the office that is suggestive
of being an angiofibroma.
2. A mucoperiosteal hard palate flap is used.
3. Remove and discard the major portion of the bone of
the hard palate.
4. Preserve the greater palatine arteries bilaterally. Elevate
the vessels and nerves with a mucoperiosteal hard
palate flap.
5. Safeguard as much mucous membrane as possible
(e.g., along floor of nose, septum, vomer, and palatal
crest). If the lesion is malignant, the mucous mem-
brane is removed with the lesion.
6. Additional exposure can be achieved by mobilization
of the greater palatine vessels by removing surround-
ing bone.
7. Flexible and rigid telescopes are a great aid in evalu-
ation of lesions in the nasopharynx.
Additional Criteria and Characteristics of
Juvenile Angiofibroma
1. External carotid arteriogram (digital subtraction)
is helpful in delineating feeder vessels that are
usually the internal maxillary and ascending
pharyngeal arteries. Although uncommon in this
invasive test, stroke is possible if the dye reaches
the intracranial circulation; the complications
must be explained to the patient. Do not perform
a selective vertebral arteriogram. It can result in
basilar artery syndrome and adds no useful
information.
2. Tumor can extend into the orbit, any paranasal
sinus, pterygomaxillary space, nasal cavity, or
temporal fossa and involve the foramen of the
skull and extend intracranially.
3. Bleeding is usually profuse-have up to 12 units
of blood available.
4. The use of hormones such as estrogens as
definitive treatment has not been proved to be
of value.
5. A computed tomographic scan with enhancement
is mandatory in the evaluation of the extent of
tumor.
6. Temporary occlusion of the external carotid
artery. The vessel should not be permanently
ligated, because subsequent arteriograms to
evaluate recurrence will then be quite difficult to
perform. However, such an arteriogram can be
performed with permanent ligation through a
catheter in the superficial temporal artery.
7. A transpalatine approach is usually preferred.
The pterygomaxillary space can be reached via
this approach. The combination of trans maxillary
and lateral rhinotomy approaches may be
necessary, depending on the extent of the tumor
behind the antrum (Pressman, 1962). Lateral
rhinotomy can be performed via an extended
Caldwell-Luc approach. This can be performed
without an external facial incision (see Fig. 6-10).
8. Cryosurgery has been utilized in conjunction with
this surgical procedure to reduce the size of the
tumor and to reduce the hemorrhage, but late
hemorrhage has occurred.
9. Radiation therapy is not advised unless absolutely
necessary because of the subsequent danger of
malignant change. Hypotensive anesthesia,
although used by some surgeons, carries too
great a risk.
10. Some of these tumors are very friable, others
are very firm. If at all possible, they should be
removed intact rather than piecemeal. This
requires careful blunt dissection.
11. If the tumor is large and bleeds profusely, external
carotid artery ligation can be attempted, but by
and large this has not proved useful. The better
approach would be to ligate the internal maxillary
artery via a transantral approach. In addition this
trans antral approach will give additional exposure

to the larger tumors that extend into the antrum,
behind the antrum into the lining of the antrum,
or further into the pharyngomaxillary space as
well as the sphenoidal sinus. The author's
technique is to perform a transantralligation of
the internal maxillary artery as the initial step,
depending on the findings of digital subtraction
angiography (arterial).
12. Infratemporal or infrazygomatic swelling indicates
further spread of the tumor. Intracranial spread
must also be evaluated before any surgical
approach. Chemotherapy has been reported for
nonresectable intracranial extension.
13. Consider the use of fresh-frozen plasma after 4
to 6 units of blood transfusion.
THE NOSE AND THE NASOPHARYNX
14. Magnetic resonance imaging may prove to be
of help in the evaluation of the extent of the
tumor.
Complications
• Naso-oral fistula, especially at the anterior portion
• Related specifically to angiofibroma: profuse hemor-
rhage during and following surgery
• Incomplete removal or recurrence; neurologic seque-
lae from vertebral arteriogram-possibly due to blood
flow stasis from catheter in vertebral artery or bolus
of the radiopaque material
• Rhinism
 THE NOSE AND THE NASOPHARYNX
Transpalatine Exposure of the
Nasopharynx and the Sphenoidal
Sinus (Continued) (Fig. 6-9)
A Anatomy of the palate and outline of the palatal
flap. The incision is made parallel to the gingival margin,
leaving enough mucous membrane on the gingival side
for placement of closure sutures. The anterior extent of
the incision should be within 1 cm of the bases of the
upper incisors. The important greater palatine arteries
are depicted. A vertical incision in the soft palate is of
no help for exposure.
Al Cross-sectional view depicting blood supply.
B The palatal flap, including the periosteum, is mobi-
lized with the aid of an elevator. The vesselsand nerves
are within the flap. The crucial point is at the site of
emergence from the greater palatine foramen, which
is juxtaposed to the third molar region. To facilitate
further retraction of the palatal flap, the posteromedial
wall of the greater palatine foramen and canal can be
removed to give more length to the greater palatine
artery. In addition, the tensor veli palatini muscle can
be sectioned or the hamulus of the pterygoid bone
fractured. The incision, extended behind the third molar
and along the anterior tonsillar pillar, is necessary.Care
must be taken not to injure the thin nasal mucous
membrane on the contralateral side, especially when a
Bovie cutting current is used.
C The palatal flap is retracted and the hard palate
removed with rongeur forceps. The hard palate found
directly under the incision should be left intact so that
the closure has underlying intact bone. The mucous
membrane along the floor of the nasal cavity is left
intact, if possible. In angiofibroma, the hard palate and
mucous membrane may be eroded. Occasionally, the
greater palatine artery can be sacrificed on one side if
the integrity of all the vesselson the contralateral side
is preserved. These include the lesser palatine artery
and branches of the ascending palatine artery (see A).
In these instances, on the contralateral side, extension
of the incision is not made nor the flap developed.
D A transverse incision through the mucous mem-
brane of the floor of the nose is made as far anterior as
the lesion extends. Laterally, this incision may be length-
ened to reach the anterior angle of the eustachian tube.
If the lesion is an angiofibroma, care should be taken
to avoid trauma to the tumor and its feeding vessels.
Continued
 THE NOSE AND THE NASOPHARYNX 291

LESSER PALATINE

ASCENDING PALATINE

,.j
D
FIGURE 6-9
 THE NOSE AND THE NASOPHARYNX

Transpalatine Exposure of the

F The lesion is resected by sharp and blunt dissec-
Nasopharynx and the Sphenoidal
tion. Depending on the histology, there may be profuse
Sinus (Continued) (Fig. 6-9) bleeding. If this is the case, pressure with gauze, suc-
tion, or cauterization may be necessary. Complete
If the angiofibroma extends into the pterygomaxillary
hemostasis is achieved after total removal of the tumor.
space with a presenting mass in the cheek, exposure
If necessary, the septum or the posterior portion of the
can be gained through an incision in the buccal sulcus
inferior turbinate can be excised.
(after Sardana, 1965). Profuse hemorrhage will likely
occur from the internal maxillary artery, which will
G The completed resection.
require occlusion with clips.
If the angiofibroma extends into or arises in the
H, I Anterior and posterior packing has been inserted
antrum, a Caldwell-Luc (see Fig. 5-2) approach is ideal
depending on the hemostasis necessary. Closure con-
both for removal of the antral tumor as well as ligation
sists of the best possible approximation of the mucous
of the internal maxillary artery. The latter is performed
membrane of the floor of the nose. The palatal flap is
first. With communication into the nasal cavity and the
sutured with 4-0 nylon to the gingival mucous mem-
nasopharynx and/or sphenoidal sinus the Denker (see
brane. Care in closure is important to avoid oronasal
Fig. 6-lD) type operation is the procedure of choice.
fistula formation.
The canine fossa incision is extended across the mid-
line, thus obviating the need for a Weber-Fergusson
J If pressure is required to maintain the palatal flap in
type incision.
position, this is achieved by securing gauze or cotton
soaked in liquid antibiotic or nitrofurazone (Furacin)
E Depicted is a tumor arising from the left posterior ointment with cross sutures of 3-0 nylon passed around
nasal cavity and the left side of the nasopharynx. The the teeth. When this is bulky and there is any question
septum is displaced to the right and the turbinate to of postoperative bleeding, an elective tracheostomy is
the left. indicated.

FIGURE 6-9 Continued

 THE NOSE AND THE NASOPHARYNX

FIGURE 6-9 Continued

 THE NOSE AND THE NASOPHARYNX
Transmaxillary Approach to
Nasopharynx and Base of the Skull
(Fig. 6-10) (Modified Denker)
Following the basic technique of a Caldwell-Luc an-
trotomy (see Fig. 5-2), the cheek flap is further elevated
to expose the lateral wall of the antrum and a portion
of the zygoma by extending the gingivobuccal incision
line and the midline. The vertical nasolabial portion of
the Weber-Dieffenbach incision (see Fig. 5-9A-F) may
very rarely be necessary for the additional exposure. The
major portion of the bony anterior wall and a portion
of the lateral wall of the antrum is removed depending
on the exposure necessary. The lateral bony transection
approximates the zygoma-maxillary suture line. The
infraorbital rim, infraorbital nerve, and floor of the orbit
are all preserved.
FIGURE 6-10
The medial wall of the antrum is removed, exposing
the middle turbinate above and the nasal septum farther
medially. The middle turbinate can be removed, thus
exenterating the ethmoidal sinus. Care is taken not to
enter the orbital floor or the medial wall of the orbit.
This exposure thus leads to the nasopharynx and to the
sella turcica via the sphenoidal sinus.
As the procedure is extended posteriorly, the poste-
rior ethmoidal sinus becomes narrower. Hence the
exenteration of any posterior ethmoidal cells must be
medial and not lateral to avoid injury to the internal
carotid artery and the optic nerve (see Figs. 1-2, 1-3,
and 1-7). The internal carotid artery may not be covered
with bone as it traverses the sphenoidal sinus; 20% to
30% of cases have bony dehiscence over the internal
carotid artery in the sphenoidal sinus. In addition, the
superior extent of the posterior ethmoidal sinus may be
above the level of the cribriform plate.
MIDDLE TURBINATE
NASAL SEPTUM

Posterior Choanal Atresia
(Fig. 6-11) (After Beinfield, 1961 and
1965)
Newborn and Young Children
Highpoints
1. Bilateral choanal atresia is usually an airway emer-
gency (the newborn usually breathes through the
nose). Use an oropharyngeal airway until the infant
is brought to the operating room.
2. Extreme care is needed not to injure the spinal cord
between the axis and the atlas.
3. Extreme care is needed not to injure the base of the
skull.
4. Mark instrument-curet and sound-from tip along
shank to a distance of 4.4 em. This will indicate the
distance of the posterior pharyngeal wall to the edge
of the anterior nares along the floor of the nose. A
safe distance more superiorly is reduced to 3.2 em.
THE NOSE AND THE NASOPHARYNX 29S
S. The atresia can be unilateral or bilateral; it can be
bony or simply membranous.
6. General oral endotracheal anesthesia is preferred,
supplemented with topical cocaine 10% and a
vasoconstrictor.
7. Postoperative care is important to keep indwelling
tubes patent.
8. Other congenital anomalies may be present.
Described is the technique for bony atresia. Mem-
branous atresia is treated in basically the same fashion,
eliminating the steps for removal of the bony portion.
Yet with membranous atresia, a certain degree of bony
stenosis can be present and this requires the steps
referable to bony atresia.
Diagnosis is made by the inability to pass a nasopha-
ryngeal catheter. Contrast material instilled in the nasal
cavity with radiographs can be used to confirm the diag-
nosis. This is especially useful in older children and
adults in whom the differential diagnosis may involve
benign and malignant neoplasms.
 THE NOSE AND THE NASOPHARYNX
Posterior Choanal Atresia
(Continued) (Fig. 6-11) (After Beinfield,
1961 and 1965)
A Using either a No. 8 urethral sound or a No. 2
Lempert type mastoid curet, an initial opening is made
through the nasal mucous membrane overlying the
bony wall itself. The shank of the instrument is marked
3.2 cm and 4.4 cm from the tip to avoid injury to the
posterior pharyngeal wall, spinal cord, or base of the
skull. Keep the instrument along the floor of the nose.
Depicted is the use of the urethral sound. This is
performed with the sense of touch. Direct vision is
virtually impossible during this maneuver.
A1 Technique of utilization of the mastoid curet. It
must only be made in a downward direction.
8 If the posterior mucous membrane flap cannot be
safely perforated as depicted with the urethral sound,
a cruciate incision with a No. 11 or suitable ear knife is
made (Bl).
81 Using an ear speculum and the operating micro-
scope, visualization can be obtained and the incision
made with a suitable microsurgery ear knife. After the
opening is established, its diameter is increased by
gradually using larger diameter urethral sounds up to
size No.16, No. 18, or No. 20 French.
Continued
Older Children and Adults
The technique used at the older ages usually is that
of a transpalatine approach (see Fig. 6-9). In addition
to the diagnostic measures described under infants,
nasopharyngoscopy is routine.
After exposure of the posterior choanal region via the
transpalatine approach, the bony wall forming the atresia
is excised. The posterior end of the nasal septum may
require resection. Depicted in this plate is the midline
incision; in Figure 6-9A to D is the palatal flap incision.
Highpoints
1. Avoid injury to the pterygopalatine and posterior
palatine canals.
2. Preserve as much nasal and juxtaposed mucous
membrane as possible, using this retained tissue to
line the raw edges of the resulting bone.
Complications
• Cerebrospinal fluid leak
• Meningitis
• Hydrocephalus
• Pressure necrosis of anterior nares rim or columella
• Postoperative plug of indwelling tubes
• Extrusion of tubes
• Late stenosis
• Regurgitation of feedings into nasopharynx-usually
transient
• Aspiration of feedings. If this persists, an associated
neuromuscular deficiency may exist-cricopharyngeus
myotomy has been tried in one patient without success.
 THE NOSE AND THE NASOPHARYNX

4.4cm
/

FIGURE 6-11
 THE NOSE AND THE NASOPHARYNX
Posterior Choanal Atresia
(Continued) (Fig. 6-11) (After Beinfield,
1961 and 1965)
C A rubber catheter is then passed through the nose
and retrieved through the mouth. A section of silicone
rubber tube (No. 16 French) measuring 4.0 to 4.5 cm
in length is then sutured to the distal end of the
catheter. The inferior aspect of the distal end (posterior
end) of the silicone rubber tube is transected obliquely
to increase the size of the lumen and also to prevent
the end of the tube from being obstructed by the
posterior nasopharyngeal wall. Then the tube is pulled
into place by withdrawing the catheter. Ideally, this
maneuver pulls the posterior mucous membrane
edges into the newly formed posterior nares.
D If bilateral, the same procedure is performed on
the opposite side. Both tubes are sutured together with
4-0 nylon across the anterior portion of the columella
with suitable padding of the columella to prevent pres-
sure necrosis. Neosporin (polymyxin B/neomycin/
bacitracin) or chlortetracycline (iodoform) ointment
is used liberally at this juncture and continued post-
operatively. The presenting end (anterior) of the tube
is lodged just within the alar rim to minimize necrosis
of the rim. This end of the tube must be carefully
observed so that it is not obstructed by the alar rim.
Postoperatively, ultrasonic mist and meticulous nurs-
ing care with suctioning of the tubes are mandatory.
Gavage feeding may be necessary for days or weeks.
The tubes are left in place from 3 to 8 weeks, depend-
ing on the healing progress.
E After the posterior portion of the hard palate has
been exposed and the soft palate mucosa incised and
a cleavage plane developed between the mucosa and
palatal muscles (see Fig. 6-9A to D), the bony portion
of the hard palate is removed, as depicted by the
dotted lines. The underlying mucoperiosteum should
be preserved to form flaps.
F The bony atresia has been excised and the
mucoperiosteal flaps formed. A Silastic tube is shown
on one side, with the flap on its inferior aspect. These
flaps are so placed to aid in lining the new choana,
which helps in the prevention of subsequent stenosis.
G The palatine incision is then closed. The tubes can
be secured anteriorly as in the infant or with through-
and-through sutures of nylon at the columella end
of the septum. The postoperative care of the tubes
should be meticulous. They are left in place for about
1 month's time.
 THE NOSE AND THE NASOPHARYNX

E G
FIGURE 6-11 Continued
 THE NOSE AND THE NASOPHARYNX

Submucous Resection of Nasal

A, AlAn incision using either a No. 15 blade or a
Septum (Fig. 6-12)
No. 66 Beaver blade is made 12 to 16 mm from the
distal end of the septum using the index finger in the
Highpoints
opposite naris as support. The incision extends through
mucosa and perichondrium but not through cartilage.
I. Subperichondrial plane of separation is necessary.
2. Leave adequate support dorsally and distally.
B, B1 With a small curet or curved elevator with the
3. Avoid fracture of cribriform plate of ethmoid.
concavity facing medially, the white glistening car-
4. Secondary procedures on septum are difficult; hence,
tilage is exposed. This marks the correct subperichon-
perform a complete operation at the first sitting.
drial plane of separation of the mucoperichondrium.
S. Be certain that there is no impingement of the orifice
Again, the index finger in the opposite naris lends
of the nasofrontal duct by the deviated septum.
support to initiate this step.
Anterior portion of middle turbinate may require
resection.
C, C1 Elevation of the mucoperichondrium and
mucoperiosteum is then completed by carefully hug-
Comment
ging the cartilage and bone. At times this blunt sepa-
ration fails at an old fracture site or ridge. Sharp dis-
Some surgeons are of the belief that this standard sub-
section may be necessary. Care must be taken not
mucous resection of the nasal septum should be replaced
to puncture or to tear the mucoperichondrium and
by septoplasty (see Figs. 6-13 and 6-14). It appears that
mucoperiosteum. This may occur owing to infolding
each procedure has its merits and indications and that
of the mucosa into a previous fracture of bone or
more often than not an operation combining both tech-
cartilage. Sharp dissection may be necessary at this
niques is ideal.
point (see Fig. 6-13Al). Take care when using suction,
because the suction tip can easily tear the mucosa. If a
Complications
tear does occur, satisfactory healing usually takes place
if the mucosa on the opposite side is intact.
• Saddleback deformity. This may occur many years
later.
D, D1 The cartilage is then incised through the
• Septal hematoma
original incision. Extreme caution is necessary to avoid
• Collapse of nasal tip and columella
a counter incision in the opposite perichondrium. The
• Nasal obstruction-incomplete resection
index finger is an excellent guard, for as soon as the
• Mucosal tear-if feasible repair with fine chromic
knife blade reaches the perichondrium it may be felt.
catgut. Teflon splints will likewise aid in coapting
If the mucoperichondrium is cut, the defect should be
mucosa.
sutured, along with the main incision on the opposite
• Toxic shock syndrome-following any nasal packing
side; otherwise, a perforation may persist.
(see p. 274)
• Septal perforation. If troublesome, a Silas tic button
E, E1 Using the small curet or curved elevator with
may be used.
the concavity facing the midline, the perichon-drium
• Cartilage and bone may have "memory" to return to
and periosteum are elevated in the same way as on the
original deformed position.
left side. Elevation of the mucoperichondrium and
mucoperiosteum should extend beyond the deviated
area to be resected.
Continued
 THE NOSE AND THE NASOPHARYNX

FIGURE 6-12
 THE NOSE AND THE NASOPHARYNX
Submucous Resection of Nasal
Septum (Continued) (Fig. 6-12)
F In preparation for the Ballenger swivel knife, a
small cut is made with scissors at the superior edge of
the incised cartilage.
G, G 1 The swivel knife is placed at this cut straddling
the cartilage. Before the knife is pushed backward and
upward, make certain that no portion of mucoperi-
chondrium or mucoperiosteum is caught on the edge
of the knife. The knife is then advanced to the bony
septum and follows this junction downward to the
vomer bone and then anteriorly. The freed cartilage is
removed with forceps.
H Cartilage-cutting forceps (McCoy) or duckbill
forceps (Watson-Williams) allow for the removal of any
remaining cartilage as well as portions of the per-
pendicular plate of the ethmoid and vomer. A portion
of septum 12 to 16 mm wide must be left dorsally to
support the bridge of the nose. When removing the
deviated portion of the perpendicular plate of the
ethmoid, the cribriform plate of the ethmoid must not
be injured. Proper use of the bone forceps is necessary.
Fragments are not avulsed; small complete bits are
taken carefully. When rotation of the forceps is utilized,
it is done gently around a single axis. It is often best
to remove such mobilized fragments with bayonet
. forceps, because the mucoperiosteum may be adher-
ent in several areas and require sharp separation. A
Jansen-Middleton spoon-shaped biting double-action
forceps is also excellent for this stage.
I Inferiorly, portions of a broadened vomer or ridge
are difficult to remove with forceps. Decussation of the
periosteum and perichondrium at this point is best
separated by sharp dissection (see Fig. 6-13Al). An open,
sharp, ring curet placed posteriorly and drawn forward
often removes this bone and cartilage. Again, one must
be certain that no mucoperiosteum is adherent.
J Occasionally, an osteotome is necessary to remove
a thick bony ridge along the base of the septum. A free
septal cartilage graft is then reinserted to support the
anterior portion of the septum so further support is
given the dorsum of the nose. Anterior to the dotted
line is the critical area for support; posterior to the dotted
line no support is necessary (Tardy et aI., 1985). A sep-
tal cartilage graft can be added to the anterior area.
The septal flaps are coapted and the incision approxi-
mated with 4-0 nylon. Two techniques are available:
K A specially designed (Lore, Sr.) septal hollow needle
with suture material already threaded is inserted as
depicted. The free posterior end is grasped with forceps,
and the needle is withdrawn.
L The knot is tied anteriorly.
M If such a needle is not available, the incision and
anterior portion of the septum are approximated with
one or two through-and-through sutures. In each case,
a portion of the anterior cartilage strut is included in
the suture. These sutures are removed in 3 to 7 days.
Teflon splints are now used routinely (see Fig. 6-131
and L) to coapt the flaps and to control bleeding. One-
half inch gauze impregnated with antibiotic ointment is
inserted in both nares to add support to approximate
the flaps. This packing is removed the following day.
If the flaps appear to separate-this will not occur if
the Teflon splints (see Fig. 6-13) or the septal needle has
been used-the packing may be reinserted. Johnson
(1971) reports the use of small suction catheters insert-
ed under the septal flaps. These are connected to suc-
tion, thus removing serum and approximating the flaps.
 THE NOSE AND THE NASOPHARYNX

wab~

FIGURE 6-12 Continued

 THE NOSE AND THE NASOPHARYNX

Septoplasty Type I (Fig. 6-13)

(After Gorney, 1962)
Highpoints
1. Prime indications are external nasal deformity due
to deviated septum and dislocated columella. Some
surgeons have substituted septoplasty for the classi-
cal submucous resection.
2. Complete mobilization of all deformed cartilage-do
not depend on stents and sutures to correct
deformity.
3. Precise realignment of mobilized cartilage. Cartilage
and bone have a memory to return to their original
deformed position!
4. Provide adequate cartilaginous support for tip and
bridge of the nose.
5. Wherever possible, leave a portion of mucoperichon-
drium attached to mobilized cartilage to ensure com-
plete viability of cartilage.
6. A rhinoplasty is necessary if part of the deformity is
caused by displacement of the bony framework.
7. Study Figure 6-13G because it is very important.
8. Suture the base of the caudal supporting strut of
cartilage to the anterior nasal spine with buried 5-0
nylon (see Fig. 6-13M and N).
A An incision is made along the dotted line at the
caudal end of the deviated septum.
A 1 If an inferior obstructing septal ridge is present,
it will often consist of both cartilage and bone. The
perichondrium and periosteum decussate at the point
where cartilage meets bone. This prevents the eleva-
tion of the mucoperichondrium and mucoperiosteum
by blunt dissection with the elevator (nasal freer).
Hence, sharp dissection is necessary, as depicted along
the dotted lines. The deviated bone is removed with
the osteotome at the site of the solid horizontal line.
B The deviated septum is shown, causing the external
nasal deformity. The dotted line depicts a portion of
the alar cartilage, which may require excision depend-
ing on an associated tip deformity. In similar fashion a
portion of the upper lateral nasal cartilage may require
excision (see Fig. 6-14M and N).
C The caudal end of the septum is exposed.
Unilateral or bilateral tunnels can be developed for
additional exposure.
Cl The incision commences on the left side of the
caudal end of the septum. The initial separation of the
soft tissue from the septum requires sharp dissection
and may be difficult. Take care not to fragment the
soft tissue. This may be made on the right side when
the deviation is to the right.
D The dotted lines depict the extent of the elevation
of the mucoperichondrium. It will be noted that the
mucoperichondrium is not elevated from the right side
of the most caudal portion (1) of the septum to ensure
viability of this most important section of the nasal
septum. The next section of cartilage (2) may be swung
into alignment with complete mobilization or be excised
or be used as a free graft. If it is swung into alignment,
a vertical strip of cartilage between section 1 and section
2 must be excised to prevent overriding of the two
sections of cartilage. If section 3 is deviated, this portion
is removed as in a standard submucous resection of
the nasal septum.
Another method of correcting a twisted septal carti-
lage is depicted in Figure 6-1 3pl and Pll.
E Lateral view depicting the comparable sections of
cartilage corresponding to D. The inferior and superior
incisions mobilizing the septal cartilage depend on
the type and extent of deviation. The solid line on the
superior portion of cartilage (section 1) refers to
the incisions between the lateral nasal cartilages and
the septum. Details of this are in G and H. These
incisions extend posteriorly only as far as is necessary
to free the caudal section 1 so that it will realign in the
midline. These incisions may be made with scissors as
depicted or with a No. 11 blade knife. If made with
scissors, the mucosa is elevated and preserved. If there
is any ques-tion of stability, a suture is placed as in H,
with reposi-tioning of the relationship of the septal
cartilage to the lateral nasal cartilage as depicted. It is
at this stage that a portion of the alar cartilage may
require excision as outlined in B. All sections of car-
tilage must be freely mobile for realignment. Adequate
support along the most caudal end (section 1 and
section 2) and the bridge of the nose must be ensured.
If a simultaneous or second-stage rhinoplasty is
performed, these dic-tums are most important. By and
large a one-stage septorhinoplasty rather than a two-
stage procedure is preferred (Tardy et aI., 1985).
F At the close of the operation, realignment of the
nasal septum must be independent of any packing or
splints or sutures. These supports are used mainly for
immobilization and prevention of hematomas, much
as a plaster cast is used in the treatment of Colles'
fracture (i.e., immobilization but not reduction).
Depicted is the use of Teflon splints to achieve this
 THE NOSE AND THE NASOPHARYNX

A CI

3, I !

D F

G H
FIGURE 6-13

immobilization. They are secured in position with degree of caudal external deformity; otherwise, the
through-and-through 4-0 nylon sutures. Details of the septal cartilage will most likely assume its original
use of these splints are shown in Figure 6-131 to L. deviated position days or weeks postoperatively.

G Incision is made between the lateral nasal cartilage H Suture supporting repositioned cartilages.
and the septum. This step is most important with any Continued
 THE NOSE AND THE NASOPHARYNX
Septoplasty Type I (Continued)
(Fig. 6-13) (Gorney, 1962)
Teflon Splint
I Outline of a typical Teflon splint cut to size of
patient's nasal cavity after the technique of Johnson.
The Teflon is from 0.022 (less than 1 mm) to 0.034
inch (about 1 mm) in thickness; the holes are made
with an ordinary leather or paper punch. The holes are
optional and are usually omitted. A smooth lateral
bend at the caudal inferior end of the splint is made
with a clamp. This prevents the base of the caudal end
from cutting into the soft tissue (see also Fig. 6-13L).
Pink dental wax as well as Silastic may also be used.
J To prevent overriding of the sections of cartilage,
especially when no splint is used, a 4-0 nylon suture
can be placed as depicted following the technique of
Wright.
K, L Details of placement of the Teflon splint. Also
shown is another variety of cartilaginous sutures that
help prevent overriding of sections of cartilage.
A ring curet can be used to set the knot when the
suture is placed deep in the nasal cavity (Johnson,
1971). Or, the tip of the needle can be inserted into the
turbinate after it passes through the septum to localize
the needle. The needle tip is then removed from the
turbinate.
Because there is usually no bleeding with the use of
splints, intranasal packing is not necessary. The splints
may be left in place for up to 2 weeks. Care must be
exercised to avoid any pressure points along the edges
of the splint. A suitable surgical ointment is applied to
the splints at the time of insertion and postoperatively
along the free presenting edges, especially at the infe-
rior (base) aspect of the columella.
These splints should protrude several millimeters
distally beyond the columella. This will prevent undue
pressure on the mucoperichondrium of the nasal
septum. The sutures should not be tight. They should
be relatively loose, and their purpose is mainly just to
hold the splints in position as far as dislodging them
posteriorly is concerned.
One surgeon has reported slough of the mucoperi-
chondrium following the use of splints. This may have
been the result of excess pressure due to tight sutures.
Correction of Septal Cartilage and Anterior
Nasal Spine Deformity
M When the inferior portion of the caudal end of the
septum is overriding the anterior nasal spine or maxil-
lary crest, fixation of the realigned septal cartilage is
necessary. This is achieved by drilling a hole using a
sturdy Keith needle through the spine or crest.
Exposure is either through an existing incision with a
tunnel at the base of the spine and the floor of the
node or through a sublabial incision.
N Fixation of the cartilage to the spine or crest is
then secured with a buried 4-0 or 5-0 nylon suture.
o When the septum is arched in its superior-inferior
axis at the caudal end, the mucoperichondrium being
elevated, a section of cartilage is removed. The septal
nasal spine relationship is corrected. If the normal
V-shaped approximation is absent and this becomes
necessary to maintain the position of the cartilage, the
spine is reconstructed in V fashion.
P A 4-0 or 5-0 nylon suture is buried beneath the
mucosa for fixation. A Teflon splint is usually necessary
to maintain the superior and inferior sections of the
nasal septum.
Pl Numerous types of deformities can occur at the
region of the anterior nasal spine. Depicted is a devi-
ated caudal end of the cartilage resting on a ridge of
the spine. This ridge (hatched area) can be removed
and the base of the caudal end of the septum then
sutured to the main portion of the nasal spine as
depicted in steps M and N. A wedge of cartilage is
excised from the nasal septum to facilitate its
realignment to the spine.
Continued
 THE NOSE AND THE NASOPHARYNX 307

TEFLON
SPLINT

J K

pili

!!

M N o p pi
FIGURE6-13 Continued
 THE NOSE AND THE NASOPHARYNX
Septoplasty Type I (Continued)
(Fig. 6-13) (Gorney, 1962)
Other deformities can occur where the anterior nasal
spine is not located in the midline. Several methods can
be used to correct this deformity. One is to take the
base of the caudal end of the septum and to suture it
to the medial side of the anterior nasal spine. This will
realign the caudal end of the septum in the midline.
Another method is to move the entire nasal spine in the
midline and to secure it in position with buried 5-0 or
4-0 nylon sutures, The correction of this deformity may
require a sublabial incision.
If the nasolabial angle is too obtuse, then an inferior
edge of the nasal spine along with the juxtaposed base
of the caudal end of the septum can be removed; this
will decrease the nasolabial angle.
Various other types of modifications may be neces-
sary at this area of the septoplasty. Detailed descrip-
tions of all the various types of modifications and
corrections are virtually impossible here, because they
can be so numerous. Ingenuity and use of the described
basic techniques can, for the most part, correct these
deformities.
Consideration must be given in realigning the base
of the caudal end of the supporting strut in that the
posterior aspect of this strut must likewise be very care-
fully realigned, because at a later date this portion of
the cartilage may assume its original deviated position.
P2 An alternate method for correction of septal
cartilage (Fry) involves removing wedges of cartilage
from the convex surface while interposing incisions are
made on the concave surface.
P3 The straightened cartilage. The problem with any
corrective surgery of cartilage is the "memory" of carti-
lage, which has a tendency to cause the cartilage to
return to its original deformed position. Intact mucoperi-
chondrium contributes to this "memory." Teflon splints
may be of aid in preventing this complication.
Composite Lateral View of Reconstructed Septum
Q Occasionally,the deviated caudal end of the septum
resists all the previously described techniques. In such
circumstances an incision through the cartilage bridge
at point X is made to straighten the caudal end of the
septum. This incision may be made through only the
cartilage or, if the mucoperichondrium is not elevated
in this area, the incision may be made through the
mucoperichondrium on one side. Ifthe cartilage edges
are very loose, a suture of buried 4-0 nylon is used to
prevent overriding as shown in the illustration. Shown
also isthe suture through the inferior edge of the caudal
strut and the anterior nasal spine. To lend additional
support, a cartilage graft from the removed or mobilized
septum is placed as depicted. Teflon splints are used to
maintain the position during the healing period.
Closure of the wounds is similar to that illustrated in
Figure 6-12F to M. It is important to excise any bulky
soft tissue at the columella (see Fig. 6-14C).
Another incision at point Y may be necessary to
further realign a deformed nasal septum. Suture is
usually not feasible, but if feasible it does have the
advantage of preventing misalignment of the dorsum of
the nose. With such cartilaginous incisions, a simulta-
neous rhinoplasty may not be advisable. A septal crush-
ing mold or clamp can also be utilized to re-form severely
deviated cartilage before the cartilage is reinserted as a
free graft.
R The stippled area depicts the bilateral tunnels that
are formed at the base of the nasal septum, elevating
the mucoperiosteum from the nasal spine as well as
the floor of the nose. This elevation can then be carried
along the cartilaginous septum. The approach to devel-
oping these tunnels can be either through the nares or
by exposing the floor of the nose and nasal spine via
an incision along the alveolar labial groove elevating
the lip.
 THE NOSE AND THE NASOPHARYNX

CARTILAGE
GRAFT

Q R
I
FIGURE 6-13 Continued
 THE NOSE AND THE NASOPHARYNX

Septoplasty Type II (Fig. 6-14)

Occasionally, external nasal deformity is due solely
or primarily to a severely deviated septum. Correction
depends on realignment of the septum. If there is asso-
ciated bony deformity in the adult, it is corrected by the
usual rhinoplasty (see Figs. 6-15 and 6-16).
Highpoints
A The external nasal deformity is due to a deviated
septum.
B, C The usual incision for a submucous resection is
made followed by elevation of mucoperichondrium on
the left side (see Fig. 6-12A to E). It is important to
excise any excess soft tissue (C, point X) to reduce
bulk.

1. Complete mobilization of the deviated septum is D A small right-angle knife is inserted under the
obtained. elevated mucoperichondrium to the point of angula-
2. Preservation of as much cartilage as possible is done. tion of the septum. The cartilage is then transected
3. If possible, mucoperichondrium is left at least par- along the dotted line leaving a narrow bridge of carti-
tially attached to one side of the mobilized septal lage intact along the upper border (X). Partial incision
cartilage. of the narrow ridge of cartilage may be required at a
later stage to permit the anterior portion of the septal
Complications cartilage to be swung and maintained in the midline.
The base of the cartilage must likewise be transected
• Saddleback deformity (may occur many years later) along the dotted line. If the nasal spine and/or base of
• Septal hematoma the vomer bone is significantly off center, this may
• Collapse of nasal tip and columella require correction with a chisel (see Fig. 6-14]). Fixation
• Nasal obstruction-incomplete resection of the anterior spine is then necessary.
• Mucosal tear-if feasible repair with fine chromic
catgut. Teflon splints will likewise aid in coapting E Through the incision in the cartilage, the muco-
mucosa. perichondrium is elevated posteriorly on the opposite
• Toxic shock syndrome-following any nasal packing side if there is a posterior deviation that is causing
(see p. 274) obstruction.
• Septal perforation-if troublesome, a Silas tic button Continued
may be used. Mucosal flaps are seldom successful.
The alternative is to widen the perforation posteriorly
if a "whistling" noise occurs.
• Cartilage and bone may have "memory" to return to
original deformed position.
 THE NOSE AND THE NASOPHARYNX

Bony septum

Mucoperichondrium

Medial crura of
alar cartilages
c D
FIGURE 6-14
 THE NOSE AND THE NASOPHARYNX
Septoplasty Type II (Continued)
(Fig. 6-14)
F, G For a posterior deviation, a Ballenger swivel knife
is used to remove the cartilaginous obstruction, whereas
a McCoy forceps is used to remove the thin bony
obstruction. Thicker bone requires the use of Jansen-
Middleton spoon-shaped forceps.
H, I Using sharp and blunt dissection, the anterior
portion of the septum and columella are mobilized at
the base down to the anterior nasal spine.
J This anterior section of cartilage is then transected
along its base. Tunnels are usually necessary for expo-
sure. Occasionally, a sublabial approach is used. If a
prominent bony ridge is present, this may require
mobilization with a small curved chisel.
The hinged anterior (lower) septal cartilage is then
swung into the midline. If sufficient mobilization at the
base has been done, the cartilage will stay in position.
More than likely, however, the mucoperichondrium on
the right side of the septum at the columella will pull
the hinged cartilage out of line. This will require fixa-
tion of the cartilage with buried 4-0 or 5-0 nylon, as
illustrated in Figure 6-13J to R.
 THE NOSE AND THE NASOPHARYNX

FIGURE 6-14 Continued

 THE NOSE AND THE NASOPHARYNX
Septoplasty Type II (Continued)
(Fig. 6-14)
K If this is the case, this mucoperichondrium will
require partial elevation through a separate incision on
the right side. This incision is made slightly more
distally than its counter incision on the opposite side.
An alternate step, which is preferred if the deviation
of the anterior portion of septal cartilage is very severe,
is the transfixion incision depicted in E and F of the
standard rhinoplasty (see Fig. 6-15). If the transfixion
incision is used, elevation of the mucoperichondrium
on the right side of the anterior deviated portion of
septum is performed through this incision. Hence, the
additional incision depicted in K is.not necessary.With
such severe deviation, additional elevation of the
mucous membrane along the floor of the nose on the
right side will be advantageous.
L The anterior septal cartilage is now swung into
position. If the deviation is severe, the attachments of
the lateral cartilages to the septum will require tran-
section (Ll) with the use of a No. 11 blade knife (see
Fig. 6-13G and H).
M, N A triangular section along the medial edge of
the left lateral nasal cartilage may require removal if it
overlaps the newly aligned septum.
o Transfixion sutures are placed anteriorly. The inci-
sions in the septum, if gaping, are approximated with
nylon. Packing of nitrofurazone-soaked or antibiotic-
soaked one-half inch gauze is inserted, and an external
molded aluminum splint with sponge rubber or dental
compound mold is used for support.
 THE NOSE AND THE NASOPHARYNX 315

FIGURE 6-14 Continued

 THE NOSE AND THE NASOPHARYNX
Rhinoplasty (Figs. 6-15 and 6-16)
H/ghpo/nts
1. Perform subperichondrial and subperiosteal elevation
for cartilage and bone to be either modified or excised.
Elevation of periosteum (or perichondrium) should be
minimal-limited to areas where bone (or cartilage)
is to be removed or transected (Tardy et aI., 1985).
2. Excise the osteocartilaginous hump. Plan a nasal
profile angle at the glabella (nasal dorsal profile)
between 25 and 36 degrees (30 degrees is ideal). Be
conservative in excising the hump. Removal of exces-
sive hump is very difficult to correct.
3. When shortening the septum, if this is necessary, be
certain that a careful estimate is made regarding the
amount of septum excised.
4. When changing the nasolabial angle, be certain that
the exact configuration of cartilage excised matches
the correction desired (usually 90 degrees but can be
up to 120 degrees).
5. Bilateral osteotomy of the nasal processes of the
maxillae is done as close as possible to their bases
or origins.
6. "Outfracture" the lateral bony walls before final
shaping.
7. Be conservative in excision of any cartilage forming
or supporting the nasal tip.
8. Preoperative photographs must be in the operating
room with a careful analysis of deformity and a
planned method of correction.
9. It is important to correct even a moderate deviation
of the septum as a one-stage procedure (Tardy et al.,
1985). This deviation of the septum may be a signifi-
cant contribution to the external nasal deformity.
The posterior portion of the septum can be removed;
the anterior portion should be preserved!
Basic Surgical Technique
At the present time there are a number of books solely
dedicated to rhinoplasty that are recommended for
"fine tuning" as well as other approaches.
A A schematic drawing shows the deformity of the
hump along the bridge of the nose with the anatomic
features of the osteocartilaginous framework superim-
posed. The dotted lines represent the lines of the saw
cuts through bone and the incisions through cartilage,
which also indicate Tardy and colleagues' (1985) modi-
fication of the osteotomies: "The majority of lateral
osteotomies are best initiated on the ascending (frontal)
process of the maxilla just at or above superior margin
of the inferior turbinate" (see Fig. 6-16B), using an
osteotome.
A1 Depicted are the relationships of the cartilages
forming the columella.
B An incision is made intranasally between the lateral
and alar cartilage bilaterally using a No. 11 blade knife.
The incision is carried upward to start the separation of
the lateral cartilage from its perichondrium.
C This separation of cartilage and perichondrium is
continued using a Joseph knife up to the nasal bone.
At this level the tip of the knife raises the periosteum
from the nasal bone. Minimal elevation of periosteum
should be done, because intact periosteum acts as a
splint (Tardy et aI., 1985).
D A periosteal elevator (McKenty) is then inserted in
the same plane, and the periosteum is elevated to the
upper suture line of the nasal bone and to the midline.
The only exception here might be in the case of an
exceptionally large hump in which the overlying perios-
teum is removed with the hump to prevent regener-
ation of excess bone.
Continued
 THE NOSE AND THE NASOPHARYNX

, ,( NASAL FRONTAL SUTURE LINE

" Nasal bone

Excised hump

" Alar cartilage

LATERAL CRUS

A ALAR CARTILAGE
MEDIAL CRUS ALAR CARTILAGE
LATERAL CRUS

SEPTUM

FIGURE 6-15
 THE NOSE AND THE NASOPHARYNX
Rhinoplasty (Continued)
(Figs. 6-15 and 6-16)
E After the preceding steps are repeated on the
opposite side, a button end knife initiates the so-called
transfixion incision, which runs along the dorsal and
distal borders of the septum. To commence this inci-
sion, a curved button end knife may be more adapt-
able. In either case, the knife is inserted in the original
intercartilaginous incision on one side reaching and
lying in the subperiosteal plane over the bony hump.
The knife is then brought downward over the dorsum
of the septum, thus transecting the attachment of the
septum along its dorsal margin. When the knife reaches
the level of the opposite intercartilaginous incision,
the instrument is advanced through this incision and
extended to the septal tip or angle. At this point the
direction changes almost at a right angle, hugging the
lower or distal margin of the septum. The apices of
both nares are not retracted upward as in F so that the
membranous distal end of the septum is placed on the
stretch. In this manner the knife can follow the plane
between the membranous and cartilaginous portions
of the septum, leaving the membranous septum caudad
with the columella.
F The lower portion of this transfixion incision is
completed with a No. 11 blade knife or scissors down
to the anterior nasal spine.
G A long narrow retractor (Aufricht) exposes the
subperiosteal plane for the bayonet saw, which will be
inserted through the intercartilaginous incision. Care
must be taken not to injure or dull the teeth on the
saw, at the same time avoiding entanglement with soft
tissue.
H The bony hump is then sawed through from one
side to another. This requires a saw cut from the oppo-
site side. Both nasal bones and the dorsum of the
septum are cut in this manner. The hump usually still
has lower attachments of the lateral and septal carti-
lages that are not cut with the saw. A small curve
button end knife is used to sever these attachments in
a manner similar to its use in F.An osteotome may also
be used to separate higher attachments. The hump is
then removed with a clamp. An alternate method of
removing the hump is with a chisel. Remember to be
conservative in the amount of hump removed. It is very
difficult to correct an overaggressive hump removal.
I A sharp rasp is used to smooth any rough areas
along the bony edges as well as to round the outer
(dotted) edges of the cut surfaces of the nasal bones
(11). The rasp must be used in single downward strokes
and after each stroke the rasp should be cleaned of all
bony fragments. Additional bone is removed at the
nasal dorsal angle (glabella). This step is very impor-
tant to avoid a "straight line" effect. At times this may
be overlooked because of soft tissue edema.
J The small curved button end knife is used to correct
any irregularities of the lower portion of the incision
that involves the septal and lateral cartilages. This may
require the use of scissors. It is important that follow-
ing the use of the rasp and the button end knife all
fragments of bone and cartilage are removed; other-
wise, they may serve as a nidus for regeneration of
bone and cartilage.
Continued
 THE NOSE AND THE NASOPHARYNX 319

J
H

FIGURE 6-15 Continued

 THE NOSE AND THE NASOPHARYNX
Rhinoplasty (Continued)
(Figs. 6-15 and 6-1 6)
K Any remaining attachments of the lateral cartilages
to the septum are transected with scissors close to the
septum.
L The distal or lower margin of the septum is now
delivered into one naris and a triangular section of
cartilage with overlying mucoperichondrium is excised
with scissors. The shape of this excised section depends
on the relationship of the nasolabial angle (90 degrees).
It is important to evaluate carefully the amount of
shortening necessary to correct the existing deformity.
This may be done by raising the tip along a fixed ruler
and measuring the distance between the two points.
Remember that excising an extra amount of the distal
margin of the septum is nO assurance of a properly
raised tip; it is catastrophic if too much is excised.
L1 The septal angle or tip of the septum is then
rounded with a No. 15 blade knife. A small section of
mucoperichondrium is also trimmed back from this
angle to prevent any untoward bulkiness at the tip.
M As the tip is raised and the nOse shortened, there
is usually a protrusion of the lower end of the lateral
cartilage through the intercartilaginous incision. This is
excised,
Ml A schematic drawing shows the portion of the
lateral cartilage excised in the previous step. Again do
not shorten this cartilage any more than is necessary.
It is usually necessary to excise two triangular wedges
of bone, one on either side of the septum at its junc-
ture with the nasal bones. This step may be done at
this stage of the operation or concomitantly with the
"outfracturing" of the lateral bony nasal wall (see
Fig. 6-15U).
N Using a narrow osteotome, a cut is made close to
the septum. A saw can likewise be used to prepare for
the fracture.
o With the same osteotome, another cut is made
close to the edge of the nasal bone. In such fashion, a
wedge of bone is, one hopes, outlined and freed. (This
wedge of bone is removed with a hemostat. The same
procedure is performed on the opposite side.)
P The two wedges of bone are removed.
Q To expose the nasal (anterior) process of the
maxilla for the lateral osteotomy, an incision is made in
the pyriform recess that lies at the inferior margin of
the nasal process. This incision is so directed that it
leads to the periosteum on the external surface of this
inferior bony margin.
Continued
 THE NOSE AND THE NASOPHARYNX

Q
FIGURE6-15 Continued
 THE NOSE AND THE NASOPHARYNX
Rhinoplasty (Continued)
(Figs. 6-15 and 6-16)
R First a Joseph knife and then a periosteal elevator
is inserted through the incision in the pyriform recess,
and the periosteum is elevated along the base of the
nasal (frontal) process of the maxilla up to its suture
line with the frontal bone at the region of the inner
canthus of the eye. This tunnel is as close to the base
or origin of the nasal process as possible except that
superiorly it is anterior enough so that the medial
palpebral ligament is not detached. This ligament is
attached to the nasal (frontal) process of the maxilla in
front of the lacrimal groove.
S Using a narrow retractor or curved saw protector,
the bayonet saw is inserted through the subperiosteal
tunnel. This is done with the same care as depicted in
G when the saw was inserted for excision of the hump.
T Keeping as close to the base or origin of the nasal
(frontal) process of the maxilla as possible, this bone
is sawed through at right angles to the body of the
maxilla. An attempt is made to remove the "sawdust"
Rhinoplasty Dressing
with small scoops. The entire procedure is now
repeated on the opposite side. An alternate method is
the use of an osteotome or small circular saw (see Fig.
6-16B to D).
U The next step consists of the "outfracturing" of
these two lateral bony frames, each consisting of the
nasal bone and nasal process of the maxilla. This
maneuver aids in the ultimate narrowing of the nasal
bridge, because it usually establishes a clean fracture
line along the region of the suture line between this
lateral frame and the frontal bone. The outfracturing is
accomplished by the insertion of an osteotome between
the septum and the nasal bone. Several slight taps on
the osteotome are made and then, using the septum
as a fulcrum, the osteotome is moved laterally, thus
pushing the nasal bones outward. Beware of a green-
stick fracture. Some surgeons do not outfracture.
V The lateral nasal frame on each side, which is now
quite mobile, is fractured inward by pressure with the
operator's thumbs. If mobility is incomplete on one
side or the other, a Walsham nasal forceps or heavy
needle holder is used to grasp this lateral nasal frame
and "outfracture" it again. The "infracturing" is repeat-
ed. The bridge of the nose is again evaluated for any
rough or sharp edges, which now may be rounded to
a pleasing contour.
W Before the transfixion sutures are placed, evalua-
tion of the hanging septum is made. This consists of an
excessively deep columella made up of folds of skin
and broad medial crura of the alar cartilages. An ellip-
tical section of both skin and cartilage is excised as
depicted by the dotted lines. The two transfixion sutures
of 3-0 nylon are then inserted, being certain that there
is good coaptation of the septal angle with the carti-
lages of the tip. These are through-and-through sutures
joining the septum with mucoperichondrium and
columella with skin. They are usually staggered so that
when they are tied they will tend to raise the columella
and thence the tip. A problem may arise with an even-
tually dropped tip after these sutures are removed. To
minimize this complication, buried sutures of 6-0 nylon
can be placed. These sutures are not removed.
X Nasal packing of one-half inch strip gauze impreg-
nated with an antibiotic ointment or liquid nitrofura-
zone is then gently and rather loosely inserted into the
nose. A small plastic tube can then be inserted along
the floor of the nose on each side for breathing pur-
poses. Some surgeons eliminate any intranasal packing.
The skin is cleansed with hydrogen peroxide and
water, dried, and then coated with tincture of benzoin
or povidone-iodine (Betadine). Narrow strips of adhe-
sive are then applied with one or two strips placed
around the tip and the superior portion of the columella
and then pinched at the tip (see Fig. 6-17D).
Y A thin layer of lint, cottonoid material, or Telfa is
placed over this adhesive dressing. Then a splint com-
posed of a dental mold compound or soft malleable
metal is used as an additional external protection. This
external splint is held in place with adhesive strips as
shown. Five to 7 days later, the splint is removed.
 THE NOSE AND THE NASOPHARYNX . 323

1/
/ 1

x y
FIGURE 6-15 Continued
 THE NOSE AND THE NASOPHARYNX

Rhinoplasty (Continued) (See Fig. 6-16)

perform the lateral osteotomy. As the osteotomy pro-
Complications ceeds upward to the lacrimal groove it is curved ante-
riorly (dotted line). No guard is used on the osteotome.
Thus, trauma and bleeding are reduced. The osteotome
• Dropped tip
• Broad nasal base is sharpened before each operation. He prefers
• Prominent nasal or dorsal frontal angle the 2-mm osteotome. Depicted is the relationship of
• Saddleback deformity the lacrimal groove (the site of the lacrimal sac) to the
osteotomy. Although the proximity is striking, evidence
Alternate Techniques of Rhinoplasty of any significant and lasting damage has not been
substantiated (Flowers and Anderson, 1968).

A Removal of the dorsal hump, especially if small,
can be performed entirely with an osteotome along the
dotted line. A Hilger guarded osteotome is ideal for
this purpose. Deepening of the nasofrontal angle at the
glabella can also be achieved by use of an osteotome
along the solid line.
B The lateral osteotomy can be accomplished with
a guarded osteotome inserted in the pyriform recess.
Tardy uses a micro-osteotome (2 to 3 mm wide) to
C Another technique for lateral osteotomy is the use
of a small power -d riven Seltzer saw.
D Close-up of Seltzer saw.
E Cross section of correct (1) and incorrect (2) planes
for the lateral osteotomy. The horizontal osteotomy
facilitates support for the transected bone. The arrow
shows the lack of support for the transected bone when
the osteotomy is oblique.

FIGURE 6-16

Correction of Broad Nasal Tip
(Conservative Method) (Fig. 6-' 7)
Highpoints
1. Elevate perichondrium on both surfaces of medial
portion of lateral crura of alar cartilage to be excised.
2. Excise cartilage along medial and upper edges of
lateral crura.
3. Be conservative in amount of cartilage excised.
4. The anterior or rim incision (1 in B) must be made
at the free margin of the lateral crus and not at the
margin of the nares.
A The dotted lines enclose the medial and upper
portion of the lateral crus to be excised.
B Three incisions are made in the roof of the vestibule.
The posterior incision (2) is the intercartilaginous inci-
sion between the lateral and alar cartilages as done in
FIGURE 6-17
THE NOSE AND THE NASOPHARYNX
the standard rhinoplasty. The anterior incision (1) is
along the lower margin of the alar cartilage and is
known as the rim incision. The cartilage between these
two incisions is separated subperichondrially on both
surfaces. The medial incision (3) is made close to the
septum and carried through the alar cartilage. External
finger pressure over the alar cartilage aids in exposure
and helps deliver the alar cartilage into the incision.
During this maneuver, the cartilage is "turned upside
down."
C The medial and upper edges of the lateral crus of
the alar cartilage are trimmed very conservatively. It is
much safer to excise too little rather than too much
cartilage; otherwise, a pinched tip will result. The same
procedure is repeated on the opposite side.
D Supportive narrow strip adhesive is utilized to coapt
the cartilages by pinching the adhesive with a clamp.
D
 THE NOSE AND THE NASOPHARYNX
Augmentation of Dorsum of Nose
(After Tardy et al., 1985)
Probably the best source of material to correct a "saddle-
back" nose and other deficiencies of the dorsum and
lateral portion of the nose is a section of the auricular
cartilage. This section is the cavum between the anti-
helix and the crus helicis (see Fig. 12-12A). The cavum
with perichondrium and some attached soft tissue can
be removed through either an anterior or posterior
approach (see Fig. 12-30, E, and G and Fig. 3-7). The
important point to remember in the harvest of the carti-
lage is to preserve the entire antihelix and its superior
and inferior support as well as the blood supply of the
mobilized skin flap. If the patient is a child, at least one
layer of perichondrium is left at the donor site.
The cartilage and perichondrium and soft tissue thus
removed are best not morselized. The appropriate shape
and size is chosen in its natural form to augment the
nasal deformity. A pocket is made in the nasal dorsum
or lateral portion of the nose just large enough to facili-
tate the cartilage graft. The patient should be informed
that the cartilage will be mobile and that this mobility
is of no concern. The resulting scar on the auricle will
barely be perceptible.
Additional Nasal Tip Procedures
(Fig. 6-18)
Highpoints
1. These are the same as under the conservative method
(see Figs. 6-17 and 6-18).
2. If the dome of the lateral crus or the underlying
perichondrium and skin of the vestibule are cut
through completely, extreme care must be taken to
prevent overriding of the cut edges of the cartilage.
Complications
• Pinched tip
• Narrowed nares causing airway obstruction
• Distortion and twisting of columella
A As in the previous conservative method, two initial
incisions (Safian, 1935) are made. The anterior or rim
incision (1) along the edge of the free margin of the
lateral crus extending to the medial crus must not be
along the extreme edge of the nares; otherwise, this
soft tissue will contract and form a pinched or notched
area. Another posterior incision (2) is the intercarti-
laginous incision (between the upper or posterior edge
of the lateral crus of the alar cartilage and the quadri-
lateral or upper lateral cartilage). This is the same inci-
sion made in the standard rhinoplasty.
B Using straight or angulated scissors, the soft tissue
is separated subperichondrially along the outside,
presenting portion of the dome of the lateral crus and
of the medial crus of the alar cartilage. The locations of
the initial incisions are shown and numbered as in A.
C The dome is exposed. This is the site of the inci-
sion for resection of a portion of the cartilage. Again,
it is emphasized that conservation of cartilage is recom-
mended, because if too much cartilage is excised, a
pinched tip will result, which is impossible to correct.
Several modifications can be performed.
D Depicted is a complete transection through the
dome and underlying perichondrium and vestibular
skin. The desired amount of cartilage and underlying
soft tissue is then excised along the dotted line. This
technique is indicated mainly in very broad and bulbous
tips. Care must be taken so that there is no subsequent
overriding of the cut ends of the cartilage or displace-
ment of either the medial or lateral crura. This error
may cause distortion of the columella.
E A less radical type of cartilage incision is made as
depicted. Here, the underlying soft tissue is neither
incised nor excised. It will be noted that the cartilage
excised is along the posterior or upper border of the
cartilage, with a small rim of cartilage left intact along
the anterior or lower border (rim) of the cartilage.
F Depicted is the amount of cartilage excised accord-
ing to Brown and McDowell (1958).
G Depicted is the amount of cartilage excised accord-
ing to Goldman (1952) and Fomon (1960).
 THE NOSE AND THE NASOPHARYNX 327

EXCISED CARTILAGE

WabritU
F G
FIGURE 6-18
 THE NOSE AND THE NASOPHARYNX
Columellar Graft for Collapsed
Nasal Tip (Fig. 6-19)
There are two main causes of a collapsed nasal tip .
Type I is entirely due to lack of septal support and is
associated with a retracted columella. The second type
is due to a congenitally shortened columella associated
with lack of septal support. In either case a columellar
cartilage graft is necessary.
Columellar grafts are also used in total and subtotal
nasal reconstruction.
The technique of obtaining a section of costochondral
cartilage is shown in Figure 3-5.
Type I
Highpoints
1. Graft is autogenous cartilage or bone. Autogenous
cartilage is preferred.
2. Place graft anterior to medial crura of alar cartilages.
3. Cartilage graft may have layer of perichondrium
attached. This, however, may cause warping. Gibson
shapes cartilage grafts by trimming equal portions
on each side of the graft.
Type II
Highpoints
1. Lengthen skin of columella.
2. The cartilage graft should have a layer of perichon-
drium attached. This is controversial.
A Through an incision made anterior to the medial
crura of the alar cartilages, a tunnel is developed down
to and anterior to the anterior nasal spine. The tunnel
is extended upward into the bulk of the nasal tip but
not so far that the end of the cartilage graft will be
noticed subcutaneously.
B A thin strut of cartilage with attached perichon-
drium is then inserted in this tunnel. An anchor mattress
suture of 4-0 nylon is placed through the base of the
graft and brought out through the skin of the columella.
This suture is tied over a small rubber or plastic bootie.
The lateral incision is approximated with fine sutures.
Complications
• Absorption and/or warping of cartilage or bone graft
• Rejection of Silastic graft
• Dislocation of any type of graft
• Pressure on skin causing skin necrosis
C Collapsed nasal tip due to congenitally short
columella. During previous surgery, the septum was
shortened in an attempt to correct the deformity.
There is an associated lack of cartilaginous support.
D Skin incisions to lengthen the skin of the columella
and expose the area for a cartilage graft.
E The soft tissue of the columella is freed and reflect-
ed upward. The medial crura of the alar cartilages are
included in this columellar flap. The distal end of the
septum is exposed if present.
F After a tunnel is opened down to and anterior to
the anterior nasal spine, a slit-like pocket is made in the
bulk of the nasal tip. An anchor suture of 4-0 chromic
catgut or 5-0 nylon secures the upper end of the carti-
lage graft. This suture is buried and remains.
G Additional sutures of 4-0 or 5-0 chromic catgut
are placed to support the graft. These sutures grasp a
portion of the perichondrium of the septal cartilage on
either side. They straddle the graft but are not placed
through the graft.
H Two or three of these straddling sutures are utilized.
They are entirely buried and remain.
I The lateral margins of the upper lip defect are first
approximated with deep sutures of 4-0 or 5-0 chromic
catgut. The skin is closed with 5-0 nylon. The usual
rhinoplasty splint and nasal packing with nitrofurazone
(Furacin) strip gauze are used. The upper lip is best
immobilized with adhesive, and the patient should be
kept on liquids until healing occurs.
After any graft, primary healing may be delayed. The
patient should be kept on antibiotics and liquids with
the upper lip immobilized. Secondary healing occurs
usually within 7 to 10 days.
 THE NOSE AND THE NASOPHARYNX

,
I
J

FIGURE 6-19
 THE NOSE AND THE NASOPHARYNX

Nares and Columella Procedures

G Approximation of the baseand side of the columella
(Fig. 6-20)
is shown. At times the entire lip may require revision.
Correction of Bulbous and Flattened Nasal Tip
Correction of Pinched Naris
A An ellipse of skin and subcutaneous tissue is excised.
H This deformity is corrected by a simple Z-plasty.
B Closure is done with fine nylon. The lower edge of the ala is freed while a flap is
developed in the nasolabial fold.

Lengthening of Skin of Columella

C Using the principle of conversion of a V incision
into a Y closure, the skin of the columella is length-
ened. The entire tip of the nose may require mobiliza-
Straightening
tion by a transfixion incision as in a rhinoplasty (see
Fig. 6-15E). Further support may necessitate the use of
a cartilage strut.
D The upper columella flap is raised, and all skin
edges are approximated with fine nylon.
Shortening of Columella
E The skin of the entire columella is mobilized by a
through-and-through incision. A small section of skin
is excised, and the skin margins are approximated.
I The ala exchanges places with the nasolabial flap.
One or two deep sutures help secure the ala. The skin
margins are then approximated.
a Slanted Columella
J This deformity is usually associated with the so-
called harelip nose, in which case a complete rhino-
plasty is necessary.The skin of the columella, however,
is corrected by utilization of a Z-plasty. The upper flap
is in line with the slanted columella, whereas the lower
flap is placed so that its right margin is to the right of
center. In this manner, when the flaps are exchanged,
there is a tendency toward slight overcorrection.
K The flaps are exchanged and skin margins
approximated.

Narrowing a Flared Naris For enlargement of nares with Z-plasty see Figure
6-31G to I.
F A flared naris often accompanies a complete cleft
lip and is corrected by the excision of a triangular piece
of skin along the floor of the nose. Only skin is excised,
because there is usually a deficiency of subcutaneous
tissue.
 THE NOSE AND THE NASOPHARYNX 331

G H

FIGURE 6-20
 THE NOSE AND THE NASOPHARYNX

Nasofacial and Nasolabial Flaps

(Fig. 6-21)
Highpoints (Also see Figs. 6-22 and 6-23)
1. Skin on the nose is so fixed and inelastic that simple
closure is virtually impossible. Rotating or advanced
flap or skin graft is necessary.
2. Rotating flaps include same adipose tissue.
D The skin is approximated with 5-0 nylon.
E A skin incision is made as outlined.
F The lesion has been excised, and the rotating flap
is swung toward the defect. The lateral border of the
donor site is mobilized. This facilitates closure of the
donor site. Any dog-ear (X) at the superior margin of
the donor site is excised.

G Several deep sutures of 5-0 white silk or catgut are

A For lesions in the nasofacial sulcus, advanced flaps
used. The skin is approximated with 5-0 nylon. A dog-
usually suffice. A wide elliptical incision is carried down
ear at Y may require excision.
to the periosteum or perichondrium, and the lesion is
excised. H If the lesion is somewhat larger and lower on the
nose, the reverse type of rotating flap is used. X and Y
B The angular artery and vein are separately ligated.
refer to dog-ears that may require excision.

C The lateral skin flap is widely undermined. If closure

I The technique is identical to the preceding proce-
is still difficult, the lower portion of the lateral flap is
dure. X and Y refer to dog-ears excised.
advanced upward, as depicted by the arrow. The dog-
ear at the superior margin is excised (dotted triangle).
Several deep sutures are placed as shown in the inset The reader is referred to geometry of the Rhombic
(e1). Flap, Chapter 3, page 104.
 THE NOSE AND THE NASOPHARYNX 333

FIGURE 6-21
 THE NOSE AND THE NASOPHARYNX
Septal Flap for External Nasal
Defect (Fig. 6-22)
Through-and-through defects, surgical or traumatic, of
the external nasal framework can be reconstructed in
a number of ways: forehead flaps (see Figs. 6-29 and
8-12), sickle or scalping flaps (see Fig. 6-29), local turn-
in flaps (see Fig. 6-30), and arm flaps (see Fig. 6-27).
The choice depends on a number of factors, such as
size and location of defect and age of patient. In the
older patient some type of forehead or scalp flap is pre-
ferred, whereas in the younger patient the use of a fore-
head flap is hardly justifiable because of the residual
cosmetic deformity of the forehead. In the elderly an
arm flap is contraindicated because of the danger of
deltoid bursitis (supraspinatus tendonitis).
Depicted is a septal flap that avoids both of the
previous criticisms. The septal flap, however, results in
a permanent septal perforation that is associated with
crusting, bleeding, and possible chronic ulcerations
along the margins of the perforation.
Highpoints
1. Use a full-thickness flap.
2. Leave adequate support along the bridge of nose
and at the columella.
3. A second stage utilizes a full-thickness skin graft or
local flap.
A Shown is a full-thickness defect of the external
nasal framework. The dotted lines represent the area
to be trimmed or excised.
B Superior-based septal cartilage flap, including both
sides of the mucoperichondrium.
C Cross-sectional view depicting the superior-based
septal flap. The edges of the defect are trimmed along
the dotted lines.
D The flap is swung into the defect and sutured into
position. The coapting edges of the flap are denuded
of mucous membrane to facilitate adequate approxi-
mation to the edges of the defect.
At a later stage the remaining portion of mucous
membrane externally (but not the perichondrium) is
excised and a full-thickness graft from the retroau-
ricular region is applied over the perichondrium (see
Fig. 6-25A to D).
External covering can also be achieved with a rota-
tion flap as described in E and F.
E Superior-based nasolabial flap is elevated and rota-
ted into defect. A cheek flap formed by an incision
along the nasolabial fold is mobilized to close the donor
site. Any resulting dog-ear (X) is excised. The distal
end of the nasolabial flap may require excision, depend-
ing on the extent of the deformity. If a lesion is to be
excised, a cotton-tipped applicator inserted into the
nasal cavity will aid in affording counter pressure during
the excision.
F The completed closure using 5-0 nylon interrupted
sutures.
This procedure is well suited for non-through-and-
through defects resulting from excision of basal cell
carcinoma of the skin. Through-and-through defects
can also be closed with a nasolabial flap. The inner
aspect of the flap can be lined with buccal mucosa or
septal cartilage flap. Other modifications of this flap
are depicted in Figure 6-21.
 THE NOSE AND THE NASOPHARYNX

PERPENDICULAR PLATE OF
THE ETHMOID

FIGURE 6-22
 THE NOSE AND THE NASOPHARYNX
Nasolabial Flap (Fig. 6-23)
Highpoints
1. Through-and-through excision is necessary of all
malignant lesions.
2. Nasolabial turn-in flap forms inner nasal lining and
skin covering.
3. If there is any question regarding adequate circu-
lation, the operation is performed in stages.
When the carcinoma of the columella is more exten-
sive, then there is concern regarding the covering and
masking of the resected area with a flap. The reconstruc-
tion can be achieved by a prosthetic replacement (see
the section of Chapter 3 on maxillofacial prostheses by
David Casey). The prosthesis can be easily removed
and the operation site examined for any early recur-
rence. For additional surgery relative to carcinoma of
nasal septum, see Figure 6-32.
Excision and Reconstruction of Ala Nasi
A Note outline of skin incision for resection of the
lateral portion of the ala nasi and nasolabial turn-in
flap. The complete thickness of the ala nasi is resected
along with a portion of the alar cartilage. The width of
the turn-in flap should be slightly wider than the defect,
especially at the site where it is folded on itself.
When the nasolabial flap is elevated and folded, if
there is any question regarding adequate circulation a
delay is effected by returning the flap to its own bed
for 10 to 14 days. The edges of the alar defect are
closed by approximation of the inner nasal lining to
the skin edges.
B The nasolabial flap is turned in and folded on itself
with the approximation of its raw surface. One or more
sutures are placed within the nares to secure the end
of the flap to its own base. Through-and-through
sutures or a two-layer closure is used to approximate
the edges.
C If the flap is large, a through-and-through mattress
suture is placed in the middle of the flap over a rubber
or plastic bootie. This type of suture, if the flap is made
sufficiently wide, will tend to roll the fold in, simulating
the natural roll of the ala nasi. The nasolabial donor site
is closed in two layers by advancement of the cheek.
Nitrofurazone-soaked cotton is firmly packed in the
naris for support and pressure. External pressure is
achieved with similar material.
Another modification is the splitting of the distal end
of the flap: one portion will form the ala nasi, and the
other portion will close a defect of the floor of the nose
or the upper lip (Krizek and Robson, 1973).
Excision and Reconstruction of Columella
D The columella has been resected for a small local-
ized squamous cell carcinoma. A long superior-based
nasolabial flap has been elevated similar to that depict-
ed in Figure 9-8 and partially rotated to replace the
resected columella. The skin of the flap has formed the
left side of the defect, whereas a split- or full-thickness
skin graft has covered the bare side of the flap. This is
the right side of the reconstructed columella. A carti-
lage strut placed either primarily or secondarily (see
Fig. 6-19) may be necessary, depending on the amount
of septum removed. The skin graft at the base of the
flap serves as a temporary dressing that is excised when
the flap is transected in several weeks' time.
E The completed reconstruction is shown. The unuti-
lized portion of the flap has been returned to the
donor site. The donor site can barely be visualized if
the flap has followed the natural skin folds comparable
to the contralateral side.
A large nasolabial flap based inferiorly can be brought
through a stab wound in the cheek to reconstruct portions
of the floor of the mouth. The problem in this type of
reconstruction is that if the patient has a full set of teeth,
the teeth in fact may impair the blood supply to the flap.
 THE NOSE AND THE NASOPHARYNX

o E

FIGURE 6-23
 THE NOSE AND THE NASOPHARYNX

Resection of Tumor of Tip of Nose

(Fig. 6-24) A No. 11 blade knife is inserted between the distal
end of the septum and the columella, thus making a
Most lesions in the region of the nasal tip can be excised, through-and-through incision that is extended down-
and the defect can be covered with a full-thickness skin ward to the base of the columella.
graft (see Fig. 6-25).
E The distal end of the septum is delivered into the
Highpoints left naris, and a triangular section of septal cartilage with
overlying mucoperichondrium is excised with scissors.
1. This technique is adaptable for moderately large This shortens the nose and raises the nasal tip, thus
lesions in patients with a drooping or elongated facilitating closure of the defect.
nasal tip.
2. Underlying cartilage can be excised. F As the tip is raised and the nose is shortened, there
3. Closure follows the technique of nasal tip elevation is usually a protrusion of the lower end of the lateral
and shortening of the nose as in rhinoplasty (see cartilage through the intercartilaginous incision. This is
Fig. 6-15A to Q). excised. If the attachment of the lateral cartilages to
the septum inhibits the raising of the tip, these attach-
ments are transected (see Fig. 6-15K).
A The area excised is depicted by the oval incision.
Underlying cartilage can be excised if necessary. G Two or three transfixion sutures of 3-0 or 4-0 nylon
are utilized to approximate the columella to the distal
B An incision is made intra nasally between the lateral end of the septum. These are placed in staggered
(upper) and alar cartilages bilaterally using a No. 11 fashion so as to raise the nasal tip.
blade knife. The incision is carried upward to start the
separation of the lateral cartilage from its perichon- H The skin incision is then closed with fine nylon
drium. sutures.

C The separation of the lateral cartilage from its peri- I If skin closure is under too much tension, a superior
chondrium is continued using a Joseph knife up to the nasal flap is elevated with the excision of a triangle
nasal bone. The lateral extent of the resected area is (Burow's triangle) of skin bilaterally.
shown by the dotted line.
J The completed closure is shown with the superior-
D After the previous steps are completed, on the based nasal flap pulled downward.
opposite side the so-called transfixion incision of a
rhinoplasty is performed. It is modified in that only the
distal portion of the transfixion incision is necessary.

A B
FIGURE 6-24
 THE NOSE AND THE NASOPHARYNX 339

\IIi
\uf
>

c D

FIGURE 6-24 Continued

 THE NOSE AND THE NASOPHARYNX

Resection and Reconstruction of

Tumor of the Superior Dorsum of The donor site defect is closed primarily by undermin-
the Nose ing the posterior skin border.

When the lesion is higher on the midportion of the
dorsum, the reconstruction can be accomplished by
using the rhombic geometric principles as depicted in
Chapter 3 under Rhombic Flap, page 140.
When the defect is large, an inferior-based midline
forehead flap can be utilized (see Fig. 8-12).
B The lesion is then excised. If it is thought to be
malignant, biopsy may be bypassed, with wide exci-
sion done as a primary procedure. In such cases deep
excision and frozen section are mandatory. A stay suture
rather than a forceps is used for traction. Absolute
hemostasis is necessary.

C The full-thickness graft is secured with 5-0 nylon

Full-Thickness Graft to Nose with moderate tension on the graft. At least four of
(Fig. 6-25) these sutures are left long to be used to hold the
dressing in place. No incisions are made in the graft.
Indications
D After all serum and blood are gently extruded
• Basal cell carcinoma of the nose from beneath the graft, a cotton pressure dressing is
• Large benign skin lesions applied. The long sutures are tied over the dressing.
• Skin loss from trauma The cotton has been previously soaked in liquid anti-
biotic or nitrofurazone ointment surgical dressing, the
Highpoints excess liquid having been pressed out and the cotton
molded to the appropriate size and shape. The first
1. Take graft first when lesion is basal cell carcinoma. dressing is done in 7 to 10 days.
2. Excise to perichondrium when lesion is basal cell
carcinoma. E TO G The same technique is used as the previous
3. Use a pressure dressing. procedure. The excision is carried down to the perios-
4. Avoid use of forceps on graft. teum when the lesion is basal cell carcinoma. If the
5. More radical excision is usually necessary in squa- tumor has reached the periosteum, then the perios-
mous cell carcinoma. teum is removed; If squamous cell carcinoma, then
wider resection with the periosteum; if squamous cell
carcinoma involves the periosteum, then the under-
A After determination of the size of the defect using lying bone is resected (see the section in Chapter 3 on
an outline of methylene blue (alcohol solution), a full- bone imaging and pathology).
thickness layer of skin is excised from the retroauricular
region. All adipose tissue is removed from the graft. For composite graft from ear to nose, see Figure 6-26.
 THE NOSE AND THE NASOPHARYNX

c D

FIGURE 6-25
 THE NOSE AND THE NASOPHARYNX
Composite Graft From Ear to Nose
(Fig. 6-26)
Highpoints
1. The graft consists of two layers of skin with a layer
of cartilage in between.
2. Good blood supply is available at recipient site.
3. Very delicate care for the graft is necessary. Do not
use forceps.
4. All edges of graft should be less than 1 cm from
blood supply of the recipient area.
Anesthesia
Either general or local anesthesia is used. If local anes-
thesia is used, no solution is injected into the graft or
recipient area.
Complications
• Partial or complete loss of graft
• Deformed donor site with larger grafts when primary
closure is attempted without a posterior auricular
skin flap
A A liberal incision is made along the alar defect to
a point at which there is a good blood supply and
adequate thickness. This is most important. A narrow
rim of scar tissue may even be excised if necessary.
B The donor site is chosen along the edge of the
helix of the ear at a site that corresponds to the normal
ala. A pattern of the defect is then cut out of a piece of
discarded sutUre or knife blade wrapper or sterile
chamois. Using 5% alcoholic solution of methylene
blue, the pattern is traced on the donor site.
C With a 6-0 silk suture through an edge of the graft,
a No. 11 blade knife is used to cut the helix. No
forceps is placed on the graft; the cut is clean and
deliberate.
D The recipient site is clean and the edges are sharp.
E With 6-0 silk sutures, the anterior edges of the skin
are first approximated with very delicate care.
F The graft is then gently everted using a cotton-
tipped applicator. The posterior skin edges are approx-
imated.
G The completed graft is supported internally with
cotton soaked with povidone-iodine or antibiotic oint-
ment liquid or impregnated with antibiotic ointment.
Externally, a cottonoid also impregnated with povidone-
iodine or antibiotic ointment is placed, over which loose
cotton is laid. A splint of dental molding compound is
then applied over this dressing to protect the graft. If
the defect cannot be completely corrected, a subse-
quent composite graft is "piggy-backed" on the initial
graft (Cosman, 1980) 6 months later.
H If the defect in the helix is long, a posterior
auricular skin flap is elevated, turned, and used to close
the defect.
I Several weeks later the flap is severed along the
dotted line. This flap should be as wide as the hairline
permits so that a rolled edge of skin may simulate the
removed helix.
J, K When the alar defect is narrower, a wedge of the
helix is removed. If the defect at the donor site is short
in length, it may also be converted into a wedge to
facilitate primary closure .
L The wedge defect is easily closed. The cosmetic
result is excellent.
The first dressing may be delayed to the fifth or
seventh day and then a similar dressing applied. Alter-
nate sutures are removed at the 10th to 14th day. The
remaining sutures are removed in 2 to 3 days.
If the defect is large, a two-stage composite graft is
used. A first graft is placed that is no wider than 1 cm
at anyone point. Three to 4 months later a second
composite graft is placed alongside the first graft.
Composite grafts may also be used for small defects of
the columella.
Type of Flap
The surgeon should recognize the fundamental differ-
ence relative to the etiology of a defect, for example,
trauma or secondary to ablative surgery for a malig-
nant neoplasm. Briefly, avoid the use of flaps for the
defects relative to ablative surgery where a prosthetic
device will serve the same purpose. Whether the flap
be a local transposition of tissue or a microvascular
free flap depends on a number of factors: availability
of microvascular technique; adequate artery and vein
for blood supply; donor site; whether previous radia-
tion therapy has exposed the recipient site or the donor
site, which might interfere with the viability of the
free flap; and cosmetic, functional, quality of life, and
other factors.
 THE NOSE AND THE NASOPHARYNX 343

G
\
\

J
\ K

FIGURE 6-26
 THE NOSE AND THE NASOPHARYNX
Reconstruction of Nose With Arm
Flap (Fig. 6-27)
Highpoints
1. In young persons, an arm flap is preferred over a
forehead flap, since it avoids a forehead scar.
2. Arm flaps should be avoided in the elderly and in
those with bursitis.
3. Allow for 30% shrinkage of graft.
4. Allow additional length for folding over to form
columella and ala nasi. This may eliminate the neces-
sity of a cartilage graft at the tip.
5. Remove all subcutaneous fat from the graft. See also
Figure 8-12.
Complications
• Bulky result
• Color match possibly poor in adults
Note: With any procedure involving reconstruction
of the distal end of the nose-nares and/or columella-
custom-made silicon or acrylic resin nasal stents may
be used to help form the nares and support the bridge
of the nose as well as the columella (see the section in
Chapter 3 on maxillofacial prostheses by David Casey).
A The nasal defect consists of the loss of the entire
right ala nasi, the nasal tip, and portions of the
columella and left ala nasi.
8, C With the nasal defect primarily on the right
side, the left arm is used as the donor site. A piece of
chamois or other suitable material is used as a form to
outline the size of the defect. An allowance is first made
for 30% shrinkage, and another allowance is made for
the length of the pedicle during transfer. The widest
portion of the graft is at its base, because that will be
used to form the ala nasi by turning in the edges. As a
rule of thumb, this should be 7.5 em wide, whereas
the free or distal end should be about 5 em wide. The
length is from 12 to 15 em. These measurements may
have to be modified depending on the defect, but
remember that it is better to err with too large a graft
than too small a one.
The arm is then placed in position as in D, and the
outline form is transferred to the donor site. The angle
of the flap is approximately 30 degrees from the
horizontal with the base toward the axilla. An area free
of hair is desirable in which the texture of the skin
simulates that of the remaining nose.
Full-thickness skin cleared of all subcutaneous adipose
tissue is then elevated as a bipedicle flap; a 2-week
delay ensues. Some surgeons will prefer a single pedicle
flap as the first delaying procedure, with complete
elevation of the distal or free end at this stage. If the
bipedicle technique is used, after 2 weeks the distal or
free end is severed. After another 2 weeks of delay-
now we have a single pedicle flap in either case-the
entire flap is elevated and returned to its bed and left
until most of the edema has regressed. This takes 2 to
4 weeks.
D The flap is now ready for transfer. The flap is ele-
vated and split-thickness or dermal graft (free of hair)
covers both the donor site and the raw surface of the
flap except for edges along the distal end, which will
be sutured to the nasal defect. It is well to use catgut
sutures on this distal end, because the grafted surface
will form the lining of the nose and be inaccessible for
suture removal. The edges of the nasal defect are
trimmed to expose normal healthy tissue. A gener-
ously bared area is important to receive and nurture
the flap. By the same token, any portion of the split-
thickness skin that lines the flap must be incised and
any section must be excised that comes in contact
with a bared area of the recipient site.
E The arm and forearm are immobilized in a plaster
posterior mold splint. Circular plaster then is used to
secure the forearm and arm to the head and shoulders
and anchor them to the thorax. All pressure points and
areas of contact should be previously well padded.
F Transection of the pedicle is begun at the end of
2 weeks. This is done in stages during the next week
by transecting one third at first, another third in 3 days,
and the final third in 3 or 4 more days. Sufficient length
is allowed for turn-in flaps to form the edges of the
nares and columella.
G The nares and columella are shaped after the
edema has completely subsided. Final tailoring of
these structures depends on defects. The columella
will probably require a strut of autogenous cartilage
for support.
H The extent of the defect along the bridge and
whether there is sufficient septal cartilage will govern
the need for another cartilage graft to support the
bridge. The nares will most likely require a Z-plasty at
the apices to shape both a functional airway and natural
external contour (see Fig. 6-31 G to I).
 THE NOSE AND THE NASOPHARYNX

FIGURE 6-27
 THE NOSE AND THE NASOPHARYNX
Nasal Reconstruction With Lateral
Forehead Flap (Fig. 6-28)
Highpoints
1. Plan forehead flap in such a manner that the returned
pedicle and other rotated scalp flaps will cover the
forehead donor site. Careful preoperative evaluation
of the hairline in men and hairdressing styles in
women will aid in this planning.
2. Delay flap three times and before transfer; wait until
there is minimal edema.
3. That part of the flap to form the nose should include
skin only, whereas the pedicle includes muscle and
galea.
4. Line the future new nose flap with split-thickness or
dermal skin graft or local turn-in flaps from remain-
ing nose or face (see Fig. 6-30).
S. A drawback is a scar on the forehead, which is unfa-
vorable in a young patient. See also Figure 8-12.
Complications
• Bulky and edematous at nares, causing airway
obstruction
• Kinking of flap, causing vascular obstruction
A The flap is outlined using the measurements depict-
ed as a rule of thumb. The extent of the defect will
change these measurements. Allow about 15% for
shrinkage. At this stage only the upper and lower skin
margins are incised, leaving both ends intact. Along
the pedicle portion, the incision is made down through
the galea while at the distal end, which will form the
future nosel on1r skin is incised, This permits a better
blood supply for the pedicle, and at the distal end there
is only full-thickness skin, thus avoiding a bulky future
nose. At the end of 2 weeks, the skin of the distal end
is shaped and incised with flares to form the nares and
a projection to form the columella. It is not necessary
to undermine the flap completely because there is no
significant blood supply from the periosteum.
B Two weeks later the entire flap is elevated, swung
into position, and evaluated regarding length. If addi-
tiona I length is needed, the upper or lower incision is
extended at the base of the pedicie. Possibly only the
galea need be incised, thus preserving the precious
blood vessels. If desired and if the color of the flap is
satisfactory, the lining for the future nose may now be
grafted using split-thickness skin only where necessary.
At the same time, the opposing donor site is grafted
with thick split-thickness skin. The entire flap is then
returned and sutured along its bed. The two skin grafts
are now face to face. The only drawback may be the
collection of some fluid at these graft sites.
C After the edema has subsided-this may take up
to 2 months-the flap is transferred. The columella is
formed by folding over the projecting end of the flap
and applying one or two mattress sutures with rubber
or plastic booties. Be sure the skin is cleaned of all
adipose tissue during this and the next step. The bare
forehead donor site is covered with split-thickness skin.
A relatively slender, strong strip of bone can act as a
bridge support secured at the glabella and as a can-
tilever attached to the tip (Millard, 1967). Custom-
made silicone or acrylic resin nasal stents may be used
to help form the nares.
D The alae nasi are formed by turning in the edges
and using mattress sutures with booties.
E If a skin graft lining was not used in B, a lining split-
thickness skin graft is now applied and held in place
with several fine catgut sutures. In any case, the flap
must have bare areas at its point of contact with the
recipient areas. In turn, these recipient areas should
be carefully freshened and broadened if necessary to
furnish adequate arterial supply and venous return for
the flap. This step is very important.
F After 3 to 4 weeks, the flap is divided in V fashion
(see Fig, 6·31A to C). If desired, this division may be
staged over a period of 1 week. The remaining portion
of the flap is then returned to the forehead, removing
the unwanted skin graft. The top wing of the V on the
returned flap may be rotated downward to meet the
lower wing.
 THE NOSE AND THE NASOPHARYNX 347

FIGURE 6-28
 THE NOSE AND THE NASOPHARYNX
Nasal Reconstruction With
Combined Scalp and Forehead
Flaps (Fig. 6-29)
The Sickle Flap
The technique of elevation, delay, shaping, and skin
grafting is similar to that for the forehead flap, illus-
trated in detail in Figure 6-28.
Stages
A, B Stages of the technique.
1. Elevate flap between the two ends.
2. Two weeks later the distal or forehead end is
transected.
3. Three weeks later the entire flap is elevated and
returned to its bed. At this stage a split-thickness
graft may be inserted as the lining of the future
nose.
4. Six to 9 weeks later-after the edema has sub-
sided-the flap is rotated into position over the
nasal defect.
5. Three to 4 weeks later the pedicle is transected in V
fashion. This may be staged over a I-week period.
6. Two to 4 weeks later refinement of the grafted nose
is begun (see Fig. 6-31).
7. Blood supply is from the superficial temporal and
posterior auricular arteries.
The "Scalping" Flap (Converse, 1959)
The main difference in technique with this type of flap
is that it can be swung either at the initial stage or with
only one delay. If used for reconstruction after subtotal
or total nasal resection for carcinoma, the flap is out-
lined and edges incised at the time of the resection.
Although immediate reconstruction with transfer of the
flap is more common, a delay of 1 or more weeks may
be preferred. This delay serves several purposes. Time
is allowed for permanent histologic sections to be eval-
uated regarding adequacy of the resection for the carci-
noma. This basic principle in the surgery of a malignant
tumor, especially when the nasal mucosa is involved,
is sound even though frozen section may have been
used. Delay also allows skin grafting for the lining of
the flap. Turn-in flaps at the site of the defect are not
recommended in the surgery for a malignant tumor,
because extension of disease at a later date may be
masked. During this delay, the raw areas at the site of
the nasal defect are covered with split-thickness skin.
C, C1 The flap is outlined and incised as depicted.
The details of size and shape are as shown in Figure
6-28A. The distal end does not include the frontalis
muscle, which is left in place, as is done in the other
forehead and scalp flaps (see Fig. 6-28B). This minimizes
the occurrence of a bulbous nose. The remainder of
the flap includes all layers down to the periosteum.
Hence, the frontalis muscle is split at the medial border
of the free distal end so that it can be included in the
base of the flap.
D The entire flap is elevated and folded on itself,
thus covering the major portion of the raw area of the
flap. If any raw area remains, especially in the region
where the flap crosses the brow and that portion of
nose which is intact, split-thickness skin is used for cover.
This is most important, because any raw area is sus-
ceptible to infection and troublesome drainage. The
donor site is likewise skin grafted.
E The flap in position. The distal end forming the
nose is shaped as in Figure 6-28C to E. Take care to
avoid crossing and touching the eyes.
F The pedicle is transected in V fashion in 3 to 4 weeks,
in stages, if necessary. The final shaping follows the
technique shown in Figure 6-31. When the flap is
returned to the scalp, an attempt is made to adjust it
so that a minimal forehead defect results.
Complications
• Problems in shaping the ala nasi
• Nasal obstruction
 THE NOSE AND THE NASOPHARYNX

FIGURE 6-29
 THE NOSE AND THE NASOPHARYNX
Nasal Turn-in Flaps (Fig. 6-30)
Indication
• In total or subtotal loss of the nose, local turn-in
serve as skin lining for the nasal cavity. The
covering is obtained from an arm, forehead, or
flap. Cartilage grafts are usually necessary for
defects.
Complications
• Absorption of cartilage grafts
• Contracture with nasal obstruction
A Four turn-in flaps are elevated and made as thin as
possible. One flap above is brought down from the
bridge. One flap below is turned up from the lip for
flaps the columella. Two lateral flaps are outlined and reflect-
outer ed from the nasolabial origins.
scalp
large B These flaps are then sutured to one another with
4-0 chromic catgut. If structural support is believed
necessary, cartilage grafts are placed on the flaps. One
strip is used for the bridge with or without a hinged
portion for columella support. Cartilage grafts can also
be placed for support of the ala nasi. A portion of the
nasolabial defect and lip defect may be closed by
advanced flaps. An arm, forehead, or scalp flap is now
used for external cover (see Figs. 6-27 to 6-29).
 THE NOSE AND THE NASOPHARYNX 351

FIGURE 6-30
 THE NOSE AND THE NASOPHARYNX

Nasal Reconstruction (Fig. 6-31)

F The superior portion of the nasolabial fold is
Transection of Forehead and Scalp reapproximated with everting mattress sutures while
Pedicle the lateral borders of the ala nasi are reapproximated
with simple sutures. If deepening of this lateral border
is necessary, these sutures grasp the underlying tissue
A The pedicle of the forehead or scalp flap used for or even the periosteum. This will tend to invert and
the reconstruction in subtotal or total loss of the nose deepen the lateral sulcus.
is transected in 3 to 4 weeks in one or two stages. The
method of Penn is ideal, because it acclimates the graft
Enlargement of Nares With Z-Plasty
to the remaining portion of the nose. A V type of
incision is used as depicted.
Proper shaping of the nares at the time of flap recon-
struction is not always satisfactory. Revision is done at
B The V incision is beveled on the undercut so that a
another stage using a modified Z-plasty. Such a defor-
smooth approximation is facilitated along the dorsum
mity may also be congenital and is corrected in the
(bridge) of the nose.
same fashion.

C The completed approximation results in a T

closure. G A triangular flap of skin is first elevated with its base
on the columella. Excess subcutaneous tissue is excised.

Revision of Nasolabial Fold and Ala Nasi

H The lower flap is freed by an incision along the
septum and then raised and sutured to the rim of the
D After subtotal or total nasal reconstruction, the ala nasi.
lateral borders of the new nose usually require revision.
The superior portion of the nasolabial fold may be I The first flap is now swung in against the septum
retracted and too deep. The ala nasi may be too bulky. and sutured in place. The same steps are repeated on
An incision is made as depicted. the opposite side. The nares are then firmly packed
with nitrofurazone-soaked cotton.
E Any excess subcutaneous tissue is excised at the
lateral border of the ala nasi.
For other nares and columella procedures, see
Figure 6-20.
 THE NOSE AND THE NASOPHARYNX

D E F

FIGURE 6-31
 THE NOSE AND THE NASOPHARYNX
Resection of Nasal Septum for
Carcinoma (Lateral Rhinotomy
Approach) (Fig. 6-32)
Highpoints
1. Wide resection is performed of septum with adjacent
floor of nose.
2. Electrosurgical cutting knife aids in control of hemor-
rhage when transecting mucous membrane.
3. Adequate visualization is mandatory. This usually
requires lateral rhinotomy to evaluate the gross extent
of tumor, especially in reference to the floor of the
nose. For small lesions centrally located, the septum
with both layers of mucoperichondrium can be
resected through intact nares.
4. If possible, leave the anterior and dorsal strut of the
septal cartilage for nasal support. This must not be
done if adequate resection of safe margins around
tumor would be jeopardized. Support then is
achieved with autogenous cartilage or bone grafts
(see Figs. 3-5 and 6-19) or a Silastic strut.
Note: With any procedure involving reconstruction
of the distal end of the nose-nares and/or columella-
custom-made silicone or acrylic resin nasal stents may
be used to help form the nares and support the bridge
of the nose as well as the columella.
A A lateral rhinotomy incision is made extending
along the nasofacial sulcus. When the lower edge of the
nasal (frontal) process of the maxilla is reached, the inci-
sion is extended into the nasal cavity. The lateral nasal
and angular vessels, branches of the external maxillary
artery and tributaries of the anterior facial vein, should
be identified above and below and be ligated. The
lateral attachment of the ala nasi is completely mobi-
lized by swinging the incision into the floor of the nose.
B The nasal flap is rotated upward and medially.
With the septal lesion located anteriorly or distally on
the septum, such a flap suffices for visualization. For
more posteriorly located tumors, however, a lateral
bone flap is developed. This is performed by transec-
tion of the base of the nasal process of the maxilla and
transection of its superior attachment along the same
plane as the horizontal suture line of the lateral nasal
bone.
C Additional exposure, if necessary, is gained by
transection of the columella at its base. An incision is
then made posterior to the columella, the exact location
depending on the anterior extent of the tumor. In the
tumor pictured, no septal cartilage remains anterior.
The only cartilages in the columella then are the two
medial crura of the alar cartilages. With an electro-
cautery knife, the incision is extended around the
septal angle at the tip of the nose and upward along
the dorsal aspect of the septum. This incision is through
and through, and, if possible, a strut of septal cartilage
is preserved along the bridge of the nose for support.
Preservation of any nasal supporting cartilage must not
be done at the expense of adequate resection of the
tumor. In situations in which no anterior or dorsal
cartilage strut is preserved, cartilage or bone grafts or
Silastic is used either at the time of the primary
operation or at a second stage (see Fig. 6-19).
D The septal incision has been carried across the
posterior aspect down to the floor of the nose. This will
entail removal of a portion of the perpendicular plate
of the ethmoid and the vomer bones. Care must be
exercised in high posterior resections that the cribri-
form plate of the ethmoid, which is continuous with the
perpendicular plate, is not inadvertently fractured, with
resultant opening into the anterior cranial fossa. Obvi-
ously, extension of disease in this region may require
elective removal of a portion of the cribriform plate.
The dural leak if small may be handled by the use of a
piece of Gelfoam held in place with nitrofurazone-
soaked gauze. Massive doses of antibiotics are used to
prevent meningitis. Local bacitracin may also be used.
Using an osteotome, the inferior portion of the
septum is now freed by transecting the crest of the
maxillae anteriorly and, if posterior resection is indi-
cated, the crest of the palatine bone. If the tumor has
extended farther along the floor of the nose, an entire
section of the midportion of the maxillae will require
resection (see Fig. 5-9A to F).
E The completed resection. An anterior cartilage graft
(see Fig. 3-5) with an attached piece of perichon-
drium is inserted in the columella. The inferior end is
placed near the anterior nasal spine. It is important
that the mucocutaneous edges be closed behind the
cartilage graft so that it becomes completely covered.
F All skin edges are approximated after the nasal
cavity is packed with antibiotic impregnated one-half
inch strip gauze. When the columella and/or caudal
end of the septum requires resection, this can be
reconstructed with a nasolabial flap based superiorly.
The bare contralateral side is covered with a full-thick-
ness or split-thickness skin graft (see Fig. 6-23D and E).
 THE NOSE AND THE NASOPHARYNX 355

FIGURE 6-32
 TW~Nm~ AND TH~NASOPHARYNX
Total Resection of Nose for
Carcinoma (Fig. 6-33) D After both lateral walls of the nose have been
sectioned, excision of the columella and nasal septum
Highpoints is begun. Liberal margins are resected. Stay sutures are
used on the specimen to avoid use of clamps or forceps,
1. Unusually wide resection of external framework is which might fragment the tumor and cause implants.
required.
2. Careful evaluation of internal extent of disease is E Whereas the cartilage is easily transected with a
mandatory. knife, the bony septum, nasal bones, and nasal processes
3. A wide resection is done of the nasal septum and of the maxillae, if encompassed in the resection, may
columella. require bone-cutting forceps.

F The nasal cavity is packed with nitrofurazone-soaked

A, B The skin incision is outlined. The entire columella or antibiotic-impregnated gauze strips.
is excised, and the incision encompasses the base of
the nasal septum to the floor of the nasal cavity. G Split-thickness skin is used to cover all bare areas;
sutures are used only along the skin margins. A pressure
( The excision is begun from the lateral edge of one dressing of nitrofurazone-soaked cotton is applied.
naris so that there is adequate visualization to determine Cosmetic appearance is provided for by a prosthesis or
the extent of the septal invasion by the neoplasm. forehead flaps (see Figs. 6-28 and 6-29).
 TH~Nm~ AND TH~N~OrHARYNX

Transected base
of columella

F G

FIGURE 6-33
 THE NOSE AND THE NASOPHARYNX

Resection of Nasal Glioma-

External Ethmoid Approach A Rhinoscopic view of the polypoid mass that is the
(Fig. 6-34) intranasal portion of the glioma is shown. The over-
lying covering is normal-appearing nasal mucosa that
Highpoints arises from the ethmoid region.

1. A nasal glioma is a space-occupying expansile lesion,
histologically usually benign, arising from congenital
central neural elements. It is an encephalocele and
not a neoplasm.
2. There may be a connection with the intracranial
cavity, and hence removal may cause a dural defect
with leakage of cerebrospinal fluid and danger of
meningitis unless recognized.
3. In view of the possibility of dural defect, any nasal
polypoid mass in the newborn must be considered a
glioma until proved otherwise.
4. Intracranial extent of glioma is evaluated by air
studies according to signs and symptoms. Computed
tomographic scan with enhancement may help in
the evaluation of the extent of the lesion.
5. If the intracranial portion is large and especially if a
large dural defect is anticipated, the initial surgical
approach is transcranial using a craniofacial tech-
nique. See Chapter 23 for details. However, dural
defects are usually handled easily through an ade-
quate transnasal approach. An important point is to
recognize them and treat them accordingly.
6. TWo-stage procedures may be necessary when the
initial diagnosis is obscure.
In addition to gliomas, meningiomas can extend into
the nasal cavity. These require a combined cranio-facial
approach. See Chapter 23. Death can occur when an
intracranial approach alone is utilized. Entry into the
anterior cranial fossa is the serious complication.
B The external appearance of a glioma is depicted in
this 4-month-old child that was present since birth. It
resembles a dermoid cyst. Nasal gliomas may be either
external or internal or both.
The dotted and solid lines represent the skin inci-
sion. The excess skin is left attached to the glioma. The
incision is that of an external ethmoid approach.
C Medial and lateral flaps are developed. A O.5-cm
diameter (external) pedicle of gliomatous tissue is seen
extending through a smooth, well-rounded defect in
the nasal bone and nasal (frontal) process of the
maxilla.
D The inferior margin of the nasal bone and nasal
process of the maxilla are exposed, and an incision is
made along this margin to elevate the periosteum.
E The external portion of the glioma has been removed
for simplicity of exposure and working space. Because
it is not a neoplasm, this technique is permissible. In a
staged procedure, this may conclude the first stage for
diagnostic purposes and further evaluation. With a
nasal freer, the periosteum is elevated over and under
the nasal process of the maxilla.
F A lateral osteotomy is performed with a small curved
chisel up to the bony defect. From this point, the
chisel is directed horizontally across the superior suture
line of the lateral nasal bone to the midline. This forms
a periosteal bone flap that is attached to the midline
along the dorsum of the nasal septum.
Continued
 THE NOSE AND THE NASOPHARYNX

FIGURE 6-34
 THE NOSE AND THE NASOPHARYNX
Resection of Nasal Glioma-
External Ethmoid Approach
(Continued) (Fig. 6-34)
G The periosteal bone flap is swung medially along
its hinged attachment to the septum. The intranasal
portion of the glioma is seen extending from the
ethmoid labyrinth covered with nasal mucosa and
attached to the septum. With sharp dissection along
the mucosal reflection on the septum and careful blunt
dissection in the ethmoid region, mobilization is begun.
H As the glioma is dissected, another (internal) pedicle
becomes exposed, extending through the roof of the
ethmoid labyrinth into the anterior cranial fossa. The
middle and inferior turbinates are not involved.
I The entire intranasal glioma and as much of its
pedicle as possible are removed. There is a small dural
defect through which cerebrospinal fluid leaks.A patch
of Gelfoam is placed over the dural defect.
J Antibiotic-impregnated one-fourth-inch strip gauze
is inserted through the nares and placed firmly against
the Gelfoam to keep the latter in place.
K The periosteal flap is turned back into position and
fixed with periosteal sutures of 4-0 chromic catgut.
L The skin is approximated with interrupted 5-0 nylon.
Massive doses of penicillin and a broad-spectrum anti-
biotic are used until all evidence of cerebrospinal fluid
leak has ceased. Bacitracin is used locally on the packing.
 THE NOSE AND THE NASOPHARYNX

Intranasal portion of glioma

K L
FIGURE 6-34 Continued
 THE NOSE AND THE NASOPHARYNX

Excision of Rhinophyma (Fig. 6-35)

Rhinophyma is thought to be the final stage of acne
rosacea. It is a benign nodular swelling consisting of
dilated blood vessels. Between the nodules are fissures
of varying depths containing greatly increased numbers
and sizes of sebaceous glands.
Highpoints
1. Do not expose cartilage.
2. Preserve the rim of nares.
3. Grafting usually speeds recovery, although the skin
will regenerate if remnants of the epidermis remain.
A The hyperplastic sebaceous glands, fibrous tissue,
and involved skin are planed down to the desired size
without injury to the perichondrium. Dermabrasion of
not only the grossly involved area but the entire nose
has been advocated.
B If the area to be grafted is large, split-thickness skin
is taken from the clavicular area and sewn tightly in
place once the bleeding has been controlled.

B
FIGURE 6-35

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 7 THE FACE

Anatomy of Facial and Scalp

Muscles (Fig. 7-1)
A Depicted are the primary muscles of facial expres-
sion and the major blood vessels.The reader is referred
to the publication by Walsh (1969) regarding the liga-
tion of the feeder vessels in the treatment of giant
strawberry nevi.
Continued

FRONTALIS M.
SUPRAORBITAL A.
FRONTAL A.
DEPRESSOR GLABELLAE M.

ANGULAR A.

ORBICULARIS OCULI M.
SUPERFICIAL ZYGOMATICUS MINOR M.
TEMPORAL
A.
LEVATOR LABII SUPERIORIS M.
ZYGOMATICO-
ZYGOMATICUS MAJOR M.
ORBITALIS
ORBICULARIS ORIS M.
A.
DEPRESSOR LABIlINFERIORIS M.
TRANSVERSE FACIAL
A. DEPRESSOR ANGULI ORIS M.
STERNOCLEIDOMASTOID M. MODIOLUS
RISORIUS M.
A

367
 368 THE FACE

Anatomy of Facial and Scalp

Muscles (Continued) (Fig. 7-1)
B Frontal section of the head shows the layers of the
scalp, skull, and meninges.
C Most of the variations of the facial nerve occur in
the face. There are numerous communications with
other branches, for example, with the maxillary nerve,
which is sensory. If at all possible, when the facial nerve
is sacrificed, preserve the most important division, which
is the zygomaticotemporal division. This supplies the
orbicularis oculi muscle.

SUPERFICIAL FASCIA
APONEUROSIS
SUBAPONEUROTIC
FIBROUS SEPTA TISSUE
OUTER COMPACT BONE i·~ PERICRANIUM
DIPLOE - BONE
INNER COMPACT BONE DURA MATER

B SUPERIOR LONGITUDINAL SINUS

Trunk and Branches of

Facial Nerve
FT - Trunk of Facial Nerve
ZT - Zygomaticotemporal
T - Temporal
Z - Zygomatic
B - Buccal
RM - Ramus Mandibularis
CF - Cervical Facial
C - Cervical
c PD
SH
- Posterior Digastric
- Stylohyoid
PA - Post-auricular

FIGURE 7-1 Continued

 THE FACE

Basic Technique for Facial

Excisions (Fig. 7-2)
Sebaceous Cysts
A The incision is outlined to include a wedge of
overlying skin with the sebaceous duct involved. Even
though the duct may not be apparent, the wedge of
skin is always included. Because local anesthesia may
obscure the extent of the cyst, its outline can be marked
with dye before the use of the anesthetic.
B The wedge of skin affords an excellent traction
point for the cyst while the capsule is dissected. The
cyst is thus easily removed intact, and the more viable
skin edges ensure primary healing with a minimum of
dimpling.
Continued
Although malignant change in sebaceous and epi-
dermoid cysts is rare, it does occur in 2.2 % of these
cysts as shown by Bauer and Lewis (1980) in a review
of 3300 cases reported in the literature.

B
FIGURE 7-2
 THE FACE
Basic Technique for Facial
Excisions (Continued) (Fig. 7-2)
C The ellipse of skin excised always follows a natural
skin crease.
D The skin and subcutaneous tissue are cut in a
plane at right angles to the skin. Forceps may be used
on the specimen but should be avoided on the skin
edges.
E At least one margin is undermined adequately to
prevent tension on the skin closure. This, plus the deep
sutures, tends to maintain a fine scar. In this case, in
the nasolabial fold only the lateral edge is mobilized to
prevent distortion of the corner of the lips and mouth.
F The deep or subcutaneous sutures of fine material,
either 5-0 white silk or 5-0 absorbable sutures, are
FIGURE 7-2 Continued
placed so that the knots are buried. These sutures may
grasp either the deep edge of the dermis or the
superficial fascia, as the case may be.
G Sutures of 5-0 or 6-0 nylon are used for the epi-
dermis. Mattress sutures are utilized only when inver-
sion occurs.
If only a one-layer closure is used, it is important to
place the skin sutures diagonal to facilitate eversion
(see Fig. 7-3C3).
For treatment of superficial erythroplasia and Bowen's
lesions, boric acid ointment applied daily for several
weeks often proves beneficial. However, if there is any
possibility of carcinoma the treatment is wide excision
with frozen section examination of the depth and
margins.
Details of Z-plasty, rhombic flap, excision of dog-
ears, and skin incisions are given in Chapter 3.

Dermabrasion (fig. 7-3)
Dermabrasion is a form of surgical planing of the skin
using abrasive devices that removes the epidermis and
the superficial layer of the dermis. A new epidermis
regenerates from the cutaneous adnexa consisting of
the sweat glands and pilosebaceous structures. It is
used to smooth irregularities of the skin sutface.
Indications
• Acne scars
• Traumatic scars
• Superficial tattoos
• Superficial nevi
• Burn scars when combined with split-thickness skin
grafting
• Small multiple irregular shallow epidermal lacerations
Anesthesia
Local or general infiltration is used. Epinephrine is not
injected in any form because of the danger of cardiac
arrhythmia.
Highpoints
1. Extensive areas should be treated in a hospital.
2. An Iverson high-speed dermabrader is preferred,
using the various-sized emery paper cylinders rather
than a wire brush.
3. Proceed slowly, especially over bony prominences.
4. Do not abrade eyelids or the lower anterior neck.
5. Provide preoperative skin care with germicidal soap.
Cleaning the skin with ether will remove sebaceous
material deep in acne scars. Be careful not to allow
the ether to reach the patient's eyes.
6. Saline is used copiously during the procedure and
afterward.
FIGURE 7-3
THE FACE 371
7. Keep loose gauze clear of revolving parts of
equipment.
8. Repeat abrasion usually should be spaced 10 to 12
months apart.
9. Surgical excision of deep scars is combined with
dermabrasion.
10. "Feather" the edges of the area to be abraded to
avoid sharp depression at the edges.
11. Deep pits are marked with methylene blue.
12. Avoid exposure to sunlight for 6 months postopera-
tively.
A Iverson dermabrader is shown with guard in posi-
tion. The inside of the cheek may be supported by
packing the buccal space with gauze to add support to
the soft tissues. The area to be abraded has been out-
lined with a suitable dye. The depth is gauged primarily
by experience. As the epidermis is removed and dermis
is exposed, small bleeding sites will appear, which are
the dermal papillae. Next will be seen parallel ridges of
collagen. It is wise to terminate the procedure at this
level. If one proceeds deeper, adipose tissue will be
detected. Ifdeep scars remain, they are best excised at
the conclusion of the abrasion. This is the purpose of
first marking with methylene blue. This is especially
necessary if local infiltrative anesthesia is used, because
the pockets of the scars may be partially obliterated. At
the margins the planing must be feathered so that
there is a gradual sloping area to normal skin; other-
wise, a sharp depressed edge will result. Immediate use
of dermabrasion for small multiple irregular shallow
epidermal lacerations may be advantageous.
Continued
 3'2 THE FACE
Dermabrasion (Continued) (Fig. 7-3)
B Close-up view of Iverson dermabrader shows small
cylinder covered with emery paper sleeve.
Postoperative dressing consists of antibiotic ointment
covered with Telfa or Adaptex and an outer fluffed gauze
pad held in place with a Kling bandage. This outer
pressure dressing may be removed in 24 to 48 hours,
whereas the inner dressing is left in place for 7 to
10 days. It is important that this inner dressing not be
forcibly removed earlier because this would injure the
regenerating epithelium.
Approximate regeneration periods include:
• 1 week-Complete epithelialization.
• 1 month-Pigment begins to reappear.
• 6 months-Epidermis approaches normal thickness
(dermis does not reach preoperative thickness).
Complications
• Hyperpigmentation. Patients should be told to avoid
excessive sunlight and use sunscreens, ascorbic acid,
and cortisone. Oral contraceptives can also induce this
complication. Patients should discontinue this medica-
tion several months before dermabrasion.
• Milia. These are small white cysts that arise from the
epidermal appendages as the epidermis regenerates
(i.e., pilosebaceous structure and sweat glands). If
these small cysts do not disappear spontaneously as
they usually do, they may require uncapping and
pressure to remove their contents.
2
FIGURE 7-3 Continued
• Erythema. This reddish hue always occurs immediately
after dermabrasion and usually gradually disappears.
Again, overexposure to sunlight is to be avoided.
• Hypertrophic scars. These result with too deep der-
mabrasion or with dermabrasion in which there is a
paucity of cutaneous adnexa, as in the lower ante-
rior neck.
• Hypopigmentation. This is usually due to deep abra-
sion into the dermis.
• Pain. This is rare.
• Infection. Although rare, it is usually due to Staphy-
lococcus aureus and should be treated vigorously to
prevent scarring. Use bacitracin ointment plus sys-
temic antibiotics, depending on results of culture
and sensitivity studies.
( Depicted are the steps associated with the
dermabrasion and then the excision of a deep scar.
1. The epidermis alongside the depressed scar is
feathered by dermabrasion down to the dotted
lines.
2. The remaining deep scar is excised along the
dotted lines.
3. The edges of the resected scar are approximated.
The skin sutures are placed diagonally as depicted
to evert the skin edges slightly.
In selected patients a dermal graft can be placed over
a deep dermabraded area.

,
Excision of Tumors of Skin of
Forehead (Fig. 7-4)
Highpoints
1. All layers of scalp are excised for malignant lesions.
2. Margins depend on the type of tumor: basal cell car-
cinoma requires 0.8 to 1 cm; squamous cell carci-
noma requires 1.5 to 2.0 cm beyond gross disease.
Use frozen section on margins and depth of resected
specimen.
3. Use full-thickness skin mobilization without muscle
for advanced flaps to cover defect.
4. Both basal cell and squamous cell carcinomas can
invade periosteum and bone, the latter metastasizing
to regional lymph nodes (basal cell carcinoma very
rarely metastasizes).
5. Basosquamous cell carcinoma, although rare, can occur
as two types: (1) pure basal cell and pure squamous
cell in the same tumor as separate entities lying side
by side and (2) an admixture of both basal and
squamous cell with the basal cells as a rim and the
squamous cells in the center of the neoplasm. Type
2 can be highly malignant.
6. Basal cell carcinoma can spread deep to the skin
without any evidence on the skin surface-the
FIGURE 7-4
THE FACE 373
"RODENT" spread or morphea type of spread in which
strands of tumor infiltrate the subdermis, sometimes
for a distance of several centimeters. Multiple frozen
sections are done with resection of the entire thick-
ness of the skin and muscle if positive. Basal cell car-
cinoma can be invasive at times, involving perios-
teum and bone, resulting in the necessity to do an
orbital enucleation or a transcranial approach to
metastatic disease intercranially (see Chapter 23).
A Smaller lesions off the midline are excised as out-
lined, including skin, superficial fascia, galea, and muscle.
The galea is the tendinous aponeurosis that connects
the occipitalis and frontalis muscles. The galea and
muscles together form the epicranial layer. The line of
cleavage is the subepicranial connective tissue space.
B A single, lateral, full-thickness skin flap is mobi-
lized. The underlying frontalis muscle and nerve are
left intact except in the area excised when the tumor
is malignant.
C The lateral flap is advanced and sutured in place
using several subcuticular sutures of 4-0 chromic or
5-0 white silk and 5-0 nylon sutures for the skin.
Continued
 THE FACE

Excision of Tumors of Skin of

E Bilateral full-thickness flaps are elevated, preserving
Forehead (Continued) (Fig. 7-4)
the frontalis muscle and nerve.

D When the lesion is larger or in the midline, a F Closure is in similar fashion as in C.

shield-shaped excision is used with bilateral advanced
flaps. Again the tissue is excised through the
subepicranial space.

FIGURE 7-4 Continued


Excisions for Carcinoma of Skin of
Temple (Fig. 7-5)
Basal Cell Carcinoma
Highpoints
1. Wide excision is done down to deep fascia.
2. Liberal mobilization of skin flaps is required.
Refer to Highpoints on page 373. Keep in mind that
the zygomaticotemporal branches of the facial nerve
are superficial to the temporal fascia, being in the same
anatomic plane as the superficial temporal artery and
vein. The auricular temporal nerve, although close to
the ear lobe, is also in this same plane.
A, Al The skin incision is made as outlined. The
upper edge is slightly concave, and the lower edge is
convex.
B If compatible with adequate excision, a branch of
the temporal division of the facial nerve is preserved at
the inner angle of the operative site. At other areas, the
FIGURE 7-5
THE FACE
excised tissue is carried down to the temporal fascia.
Branches of the superficial temporal artery are ligated.
Undermining is mainly carried out on the lower skin
flap. This plane (E) is through the subcutaneous tissue,
superficial to the fascia overlying the parotid gland.
The branches of the facial nerve cross the zygomatic
arch. The more medial is the zygomatic branch, which
can be further medial and cross the zygoma. The tem-
poral branch is lateral; the auricular temporal nerve is
still more lateral. The auriculotemporal nerve is a
branch of the mandibular division of the fifth cranial
nerve and is closely related to the superficial temporal
artery. The mandibular division is primarily sensory with
two other branches, namely, the lingual and the inferior
alveolar nerve. Parasympathetic nerve fibers leave the
otic ganglion and join the auriculotemporal nerve to
reach the parotid salivary gland. It is these parasympa-
thetic nerve fibers that are involved in Frey's syndrome
(see p. 876).
C A minimum of undermining is done on the upper
flap. Here, the plane (E) is superficial to the temporal
fascia. Care is taken not to injure branches of the facial
nerve as they cross the zygomatic arch.
Continued
 THE FACE

Excisions for Carcinoma of Skin of

Closure is then achieved by raising a more extensive
Temple (Continued) (Fig. 7-5)
face flap with a postauricular incision. As the flap is
rotated upward, the postauricular dog-ear is excised.
D Two-layer closure is used with 5-0 white silk With squamous cell carcinoma, careful evaluation of
buried and 5-0 nylon for the skin. lymphadenopathy within the parotid salivary gland or
in the preauricular lymph nodes is important.
E Depicted is the cross-sectional anatomy. Parotidectomy is then necessary and, possibly, radical
neck dissection.

Squamous Cell Carcinoma

If the lesion is malignant melanoma, then elective
parotidectomy with node dissection is indicated,
F When the tumor is bulkier or is a squamous cell depending on the Clark level or the Breslow depth of
carcinoma, the area excised must be wider and deeper. the tumor.

Temporalis m.
Auricularis m.
Temporal fascia

Zygomatic arch

Ant. parotid fascia

Parotid gland

FIGURE 7-5 Continued

 THE FACE

Rotation Flaps (Fig. 7-6)

Complications

Temporal Scalp Flap (After Mustarde,

• Facial nerve injury
1969)
• Edema of the lower lid
The design of the flap must take into account the shifting
Correct Method
of the hairline and traction on the eyebrow. Injury to
the facial nerve must be avoided by any flaps that are
used to cover the operative defect. The zygomatic branch A Depicted is a lesion with the area of resection and
to the orbicularis oculi muscle is the important one, large scalp flap. When this flap is rotated, there will be
and usually this will not be injured if the lines of inci- minimal upward pull on the eyebrow. The amount of
sion are above a horizontal line drawn from the lateral hairline advanced onto the forehead at the temple will
canthus of the eye. Above this level is the temporal be quite acceptable. Note the back cut, which adds to
branch to the forehead. the length of the flap.

Highpoints
Incorrect Method
I. Adequate deep and wide resection of lesion is neces-
sary if it is malignant -show no regard to facial nerve B This poorly devised flap is short and almost
if it is clearly involved by tumor, except to identify vertical.
and tag proximal and distal ends, if feasible, for a
sural nerve graft (see pp. Il2 and Il3). C The result is an objectionable upward distortion of
2. However, do not injure the zygomatic branch with a the eyebrow and noticeable drop in hairline on a
flap incision. conspicuous area of the forehead.
3. Avoid traction superiorly on the eyebrow-flap must Continued
be well mobilized and long.

;I
...
.'
I

....
,
1I:.z;
....~:.~ ...

-.-

'.
. :0-.,

fl.'

FIGURE 7-6
 THE FACE
Rotation Flaps (Continued) (Fig. 7-6)
Cheek Flap (After Mustarde, 1969)
D, E A lesion inferior to the lower lid on the cheek
has been excised, including a small triangle of skin-
stippled area below the resected area to facilitate a
FIGURE 7-6 Continued
closure without the formation of a dog-ear. Also pre-
vented is downward tension of the lower lid, averting
ectropion.
A cutback incision (dotted line) may be necessary to
afford greater length to the flap and to avoid tension.
The cheek flap involves only skin and subcutaneous
tissue, thus avoiding the branches of the facial nerve.
 THE FACE 379

Excision of Tumors of Cheek by

Cheek Flap Rotation (Fig. 7-7) B. The completed procedure. If directly in the
nasolabial fold, this lesion can be managed with a local
Highpoints flap or split-thickness epidermal graft (see Figs. 6-21 A
to D and 6-25E to G) or a midline forehead flap (see
1. Adequately mobilize and extend the cheek flap to Fig. 8-12D).
prevent ectropion.
2. When elevating the flap, preserve the branches of C, D Tumor is smaller and located more laterally. The
the facial nerve to the orbicularis oculi muscle. area of excision is outlined, with the stippled area
indicating a lateral cheek flap. If there is undue tension,
Complications the cheek flap is extended as in A and B.

• Injury to facial nerve

• Edema and/or ectropion of lower lid When the entire or major portion of the cheek is
involved and resected, reconstruction can be performed
with a free microvascular abdominal wall flap (see
A Tumor is located below the lower lid close to the Chapter 24). Another option is a forehead flap (see
nasolabial fold. An area of excision is outlined, with the Fig. 8-llA to G).
cheek flap elevation shown in the stippled area. The hori-
zontal portion of the flap incision is just above the level
of the lateral canthus. A back cut is shown if necessary
(dotted line).

c D
FIGURE 7-7
 THE FACE
Facial Paralysis
Shirley A. Anain and John M. Lore, Jr.
The problem of rehabilitation of the paralyzed face still
remains an enigma. Bell's palsy is one problem; the other
is facial paralysis due to trauma, surgery, or congenital
anomalies. The functional and psychological conse-
quences are often profound, and, to be treated as effec-
tively as possible, the etiology of the paralysis must be
determined. Idiopathic facial nerve paralysis (Bell's
palsy) is the most frequently diagnosed unilateral facial
paralysis, with up to 85 % of patients with spontaneous
recovery requiring no further treatment of their paralysis.
Up to 15% of patients will have some residual deficit.
Surgical resection of tumors of the facial nerve or near
the nerve with identified transection is best treated with
immediate end-to-end anastomosis of the facial nerve
under microscopic control. Large gaps are repaired with
interposition nerve grafts. If more than 7 cm of graft is
needed, the sural nerve has been recommended.
Hypoglossal-facial anastomosis has been recommended,
although it can create mass movement and dyskinesis.
Delayed identification of facial nerve injury, post-trau-
matic paralysis, and post-acoustic neuroma resection
problems are more complicated to treat. Because recovery
is common, by the time facial paralysis is deemed per-
manent, muscular loss is irreversible. As with congenital
anomalies, definitive treatment of the nerve and muscle
may be needed.
Immediate exploration and decompression or repair
are advocated by many in trauma. Facial lacerations
can often be repaired with primary neurorrhaphy (see
Fig. 7-8C) (microscopic end-to-end interfascicular group
repair) with 8-0, 9-0, or 10-0 nylon suture if the edges
are well approximated. Primary nerve grafting is needed
if the edges need to be debrided or if there is significant
soft tissue loss. Repair of individual branches distal to
the lateral canthus or nasolabial fold is not only techni-
cally difficult but also probably unnecessary, because
there appears to be neurotization (regeneration) of the
denervated fibers from the intact surrounding area.
There is certainly more controversy in blunt injury,
skull fracture, and facial nerve decompression. Patients
with acute paralysis after closed injury may benefit
from electromyography, as has been recommended in
patients with Bell's palsy. Angeli and Chiossone recom-
mend decompression and repair of the facial nerve
within the temporal bone if there is 90% degeneration
in electro neurography within 21 days of injury and no
voluntary facial motion is noted on electromyography.
High-resolution computed tomographic (CT) scanning
is recommended preoperatively. Brodsky and colleagues
(1983) and McCabe (1970) have reported recovery with
delayed surgery (Brodsky and colleagues at 2.5, 3, and
14 months and McCabe at 21 days). Even though many
recommend early surgical intervention, it may be worth
considering late surgical intervention.
In discussing management possibilities in patients
with facial paralysis, one must consider their deficits as
well as their goals. Many "cosmetic" procedures will
improve symmetry, especially in patients with some pre-
existing issues on the contralateral side. These include
brow ptosis correction (bilaterally, if needed, with asym-
metrical pull) and rhytidectomy.
All patients are counseled in eye care: copious use of
normal saline wetting solution, eye protection (sunglasses
when outdoors), night-time protection, and close evalua-
tion by an ophthalmologist. Gold implants have been
utilized with some success in paralysis of the orbicularis
oculi to aid in closure of the eye, often in combination
with lower lid procedures (see Fig. 7-9A and B).
The goal in many patients is to achieve symmetry.
Conley stated: "It is never possible to restore natural,
spontaneous expression, full motor power, and perfect
synchronous movement by any operation." In recent
years great strides have been made in re-creating spon-
taneous motion in the mid face area. It is beyond the
scope of this atlas to delve into all the possible tech-
niques to treat this problem or to describe even a major
number of the various surgical techniques involved.
The technique of nerve graft is depicted in Figure 17-4,
and that of facial reanimation with cross-face nerve
grafting and free muscle transfer in Figure 7-8. Fascial
slings are described in Figure 7-12. Some say that the
sling procedures are obsolete, although there are
indications:
1. As a temporary method to "relieve a sagging cheek
protruding into the mouth" (Rubin, 1980)
2. When dynamic procedures have failed
3. As a primary procedure in patients unwilling or unable
to undergo more complex procedures

Management Possibilities (Baker et aI.,
1980; Tolhurst and Bas, 1982)
Nerve
1. Immediate end-to-end anastomosis, if feasible
2. Interposed graft (e.g., greater auricular nerve or
sural nerve) (see Fig. 3-8)
3. Hypoglossal-facial nerve anastomosis (see Fig. 7-10)
4. Crossover facial nerve graft from the contralateral
facial nerve with sural nerve grafts (see Fig. 7-8A
and B)
Muscle
1. Masseter transposition (see Fig. 7-11)
2. Temporalis transposition
3. Free muscle transfer (gracilis, pectoralis minor, serratus
anterior) (see Fig. 7-8A to C)
Nerve and Muscle Combinations
1. Reanimation with cross-face nerve graft (see Fig. 7-8A)
followed by free neurovascular muscle transfer (see
Fig. 7-8B and C)
2. Nerve crossover
a. To facial muscles
b. To masticatory muscles
Slings
1. Fascial
2. Superficial musculoaponeurotic system (SMAS)
Another important consideration is that reported by
Martin and Helsper in 1960, in which they documented
spontaneous recovery of verified sectioning of the facial
nerve without any reconstruction. This phenomenon
has been described many times. They suggested the
possibility of cross re-innervation via the trigeminal
nerve. Conley (1974) had reported data relative to
another route of cross-innervation. Parnes and colleagues
(1982) have reported data that further suggest, in addi-
tion to the facial nerve, the facial muscles that have an
additional nerve supply, hence the difficulty in evalua-
tion of the various surgical procedures used in the
management of facial nerve paralysis.
THE FACE 381
Facial Reanimation
Cross-Face Nerve Grafts with
Microvascular Muscle Transfer (Fig. 7-8)
Spontaneous facial animation with the most natural-
appearing motion of the restorative procedures has been
championed by several authors (Harii et al., 1982). This
two-step procedure requires patient cooperation for the
most complete rehabilitation.
Indications
• Paralysis of the upper lip and commissure
Advantages
• Spontaneous muscle function
• Can be combined with other reanimation techniques
Disadvantages
• Complicated two-step procedure
• Asymmetrical smile
• Additional scars on calf and thigh
Highpoints
I. Identify several buccal nerve branches before sacri-
ficing one or two to anastomose to the sural nerve.
2. Mark the end of the sural graft on the zygoma of the
paralyzed side.
3. Follow Tinel's sign to follow nerve growth.
4. Frozen section identification of nerve tissue in the
nerve graft is helpful at the time of the second
procedure.
5. Carefully mark the relaxed gracilis muscle in situ
before dividing with silk sutures placed approximately
2 cm apart.
6. Identify and dissect the facial artery and vein and
the nerve graft.
7. Place nonabsorbable sutures in the zygoma and in
the desired locations in the upper lip and commissure
before muscle transfer. Pull to check proper angle of
contraction.
 THE FACE
Cross-Face Nerve Grafts with
Microvascular Muscle Transfer (Continued)
(Fig. 7-8)
8. Transfer the muscle and suture into place keeping
the silk sutures at 2 em distances to allow for maximal
contraction force.
9. Proceed with microscopic anastomosis of the vessels
followed by the nerve.
A The contralateral buccal branches are identified
surgically through a preauricular or nasolabial fold inci-
sion as they exit from the anterior portion of the parotid
fascia. A nerve stimulator (set at its minimum) is used
to identify three to five buccal branches. A sural nerve
graft is tunneled to the involved side with the end
marked and left high on the zygoma. Microscopic
anastomoses are undertaken with one or two of the
branches (to prevent weakness on the contralateral
side). The rate of regeneration is followed by Tinel's
sign (distal tingling on percussion) and takes 9 to 12
months to reach the zygoma.
B Once the nerve growth is complete, the patient is
taken to surgery for muscle transplantation. The
choice muscle is determined by the best re-creation of
the angle and pull of the normal side on animation, as
well as surgeon preference. The author prefers seg-
mental gracilis muscle with tailoring. A preauricular
incision is made on the affected side. The end of the
nerve is identified, as are the facial artery and vein. The
origin and insertion are prepared, and nonabsorbable
sutures are placed.
C An end-to-end neurorrhaphy of the nerve of the
gracilis to the prior sural nerve graft is completed
microscopically utilizing interrupted 8-0, 9-0, or 10-0
nylon sutures (six to eight sutures per fascicle). No
sutures are necessary in the epineurium.
Upper Lid Gold Weights (Fig. 7-9)
A Upper lid function in facial paralysis can be
improved by the use of gravity with a gold weight. To
assess the amount of weight required preoperatively, a
series of weights are taped to the eyelids until normal
closure is obtained but still with the ability to open
the lids.
B Under local anesthesia, an incision is made in the
upper lid crease. The appropriate weight is inserted
above the tarsus and sutured to the tarsus.
 THE FACE 383

c
cross-facial
nerve graft
Anastomosis to
facial A, V and N gracilis m.
FIGURE 7-8

Superior tarsus

Gold plate

Gold plate

Inferior tarsus

A B
FIGURE 7-9
 THE FACE
Hypoglossal-Facial Nerve
Anastomosis (Fig. 7-10) (After Conley
and Baker, 1983)
Although the author has no specific experience with
the anastomosis of the 12th to the 7th nerve for facial
nerve paralysis, this procedure nevertheless has been
accepted as one of the methods of treatment of facial
nerve paralysis when the proximal main trunk of the
facial nerve is not accessible and, thus, interposition
graft is not feasible.
The 12th cranial nerve is identified just anterior to the
internal carotid and external carotid arteries medial to
the vagus nerve and the internal jugular vein. It is
identified as it passes beneath the posterior belly of the
digastric muscle. The nerve is then followed upward
beneath the stylohyoid muscle and beneath the tendon
of the digastric muscle and is traced superiorly toward
the tongue. It is transected just deep to the mylohyoid
muscle. The proximal end of the hypoglossal nerve is
tunneled beneath the posterior belly of the digastric
muscle and anastomosed with the distal end of the
main trunk of the facial nerve. Problems may occur in
that the distal end of the main trunk of the facial nerve
may be lacking and there may be only the cervicofacial
and the zygomaticotemporal divisions available for
anastomosis. Whether the 12th nerve is then split and
independently anastomosed is a moot question. At any
rate, the anastomosis is performed using the operative
microscope or a four-power loupe utilizing several
epineural sutures of 10-0 nylon. The problems associated
with this type of anastomosis are basically twofold.
One is the hemiparalysis of the tongue, and the other
is the mass movement of the facial muscles basically
related to the act of chewing and swallowing and
speaking. The reader is referred to Conley and Baker's
article (1979).
 THE FACE

/
/

FIGURE 7-10
 THE FACE

Masseter Muscle Transposition- 2. Use antibiotics for prophylaxis.

Intraoral (Fig. 7-11) 3. Intraoral approach-this may be the source of con-
siderable bleeding from the facial artery. Thus, it
Indications might be well to ligate the inferior edge of the muscle
before transection.
• Paralysis of the upper lip and commissure 4. Split the masseter muscle only half the distance
superiorly, with the medial mobilized portion further
Advantages split-one fourth to the upper lip, one fourth to the
lower lip.
• Does not interfere with the seventh nerve-possible S. Exercise extreme care when splitting the muscle to
return of function avoid injury to the delicate branches of the motor
• Can be combined with other types of restoration of nerve to the muscle.
seventh nerve function

Disadvantages A Diagram of the masseter muscle shows its split

nerve supply and the mobilized medial half of the
• Infection muscle one fourth to the upper lip and one fourth to
• Bleeding the lower lip. This mobilization is performed through
• Difficulty of exposure of the muscle intra orally the intraoral approach. The nerve supply is from the
• Masseter muscle can never be a substitute for natural branch of the trigeminal nerve and reaches the under-
expressIOn surface of the masseter muscle superiorly between the
condylar process and the coronoid process of the
Highpoints mandible.
Continued
1. Plot the exact location of melolabial (cheek-to-lip)
line and compare with normal side.

FIGURE 7-11

Masseter Muscle Transposition-
Intraoral (Continued) (Fig. 7-11)
B The intraoral incision passesalong the anterolateral
surface of the mandible posteriorly from the region of
the ascending ramus anteriorly to just posterior to the
mental foramen. Exposure is important, and this is
achieved by the use of a single-side mouth gag with
the endotracheal tube secured to the contralateral side
of the operative field. The exact technique is taken
from the article by Sachs and Conley (1982): "The
masseter muscle is first freed medially by raising the
muscle off the mandible with the large broad-tipped
periosteal elevator, sweeping the dissection to the level
of the coronoid process superiorly and to the edge of
the mandible inferiorly. The anterior and medial por-
tion of the masseter muscle is thus exposed and is then
stabilized with a forceps, while a lateral tunnel is
sharply and bluntly raised with a scissorsin a plane just
above the masseteric fascia and medial to the soft
tissues of the face. Having freed the muscle medially
and laterally, it now must be detached from its
insertion at the inferolateral edge of the mandible. A
curved right-angled scissors is invaluable for this
maneuver in which first the muscle is cut inferiorly and
then an appropriate amount of the anterior portion
(usually half) is split from the remaining posterior seg-
ment. This anterior half is then split again, fashioning
two slips of muscle that ultimately will be tunneled to
the external incisions." Again, it must be emphasized
FIGURE 7-11 Continued
THE FACE
that the muscle is split only approximately halfway
superiorly to avoid injury to its motor supply. To help
avoid excess bleeding, the muscle is clamped along its
inferior edge before mobilization.
C This depicts the two skin incisions. The superior
one is located halfway between the melolabialline and
the lateral edge of the vermilion border of the upper
lip. The lower incision is placed along its vermilion edge.
These slips of muscle are brought through a common
tunnel, which is lateral to the buccinator and inferior
to the Stenson duct. The orbicularis oris muscle is pre-
served. These slips of muscle have been grasped by
inserting clamps through the external incision into the
intraoral incisions. The ends of the muscle are secured
with 4-0 white silk through the strong fascial segment
of the inferior masseter muscle and then to the deep
dermal layers of the skin. The tension on the muscle
slips is toward overcorrection. It is important that these
sutures be placed in the dermal layers of the skin rather
than in the subcutaneous tissues. If there is significant
atrophy of the orbicularis oris muscle,the massetermuscle
slips can be tunneled over the atrophic orbicularis oris,
thus achieving augmentation of the atrophied muscle.
The dressing is likewise important in that the upward
traction of the lips is reinforced with tape to further
stabilize the reconstruction. Feeding is with a naso-
esophageal tube, and the patient is kept NPO for 5 days.
 THE FACE
Fascial Slings for Facial Paralysis
(Fig. 7-12)
Facial nerve paralysis should be initially managed at
the source, whether it be Bell's palsy or traumatic or
surgical section of the nerve.
The etiology and pathologic anatomy of Bell's palsy
are disputed. However, edema with compression of the
facial nerve in its bony canal appears quite evident. A
discussion of whether an intratemporal bone decom-
pression of the facial canal should be performed and, if
so, when is beyond the scope of this atlas. However,
conservative management, consisting of corticosteroids,
antibiotics, and proteolytic enzymes, is begun imme-
diately. Frequent evaluation of the progress of the
impaired physiology is followed with electric stimulation.
Apparently, weak sinusoidal stimulation has been found
to be of some help in maintaining muscle tone. The same
can be said for a light massage of the facial muscles.
Both these forms of therapy should be delayed until
any local edema or tenderness, both of which are rare,
disappears. This same regimen is followed after parotid
surgery when temporary paresis occurs. After a nerve
graft, only the electrical stimulator is used. When wound
healing is complete, light massage and electrical stimu-
lation are employed. A Hilger stimulator may be used.
Galvanic stimulation of the muscles themselves has also
been utilized by the patient himself. Anyone utilizing a
muscle or nerve stimulator should be aware of the con-
troversial reports relative to DC stimulators (Hughes et
al. [1981], including reviewer's comments by May). A
suggested nerve stimulator is the Xomed-Treace Nerve
Integrity Monitor 2 (Xomed Surgical Products).
Occasionally, drooping of the side of the face occurs
after a radical maxillectomy when the major portion of
the malar (zygoma) bone is removed. The fascial sling
operation described is of distinct help. Stage I is not
necessary, the fascial sling being attached to the muscle
and the dermis (using a fine white nonabsorbable suture)
at the lowest point of the droop through a small skin
incision. The other end of the fascia is fixed in the tem-
poral region as in stage II. It is performed in one stage.
The drooping or sagging of the cheek under the eye is
also aided.
When the facial paralysis is ascertained to be
permanent-a waiting period of up to 9 to 12 months
is justified-a fascial sling procedure can be performed
to provide static support for the drooping face, espe-
cially for the corner of the mouth. The problem relative
to closing the eye, especially during sleep, to protect
the cornea is believed better helped by performing a
tarsorrhaphy (see Fig. 11-15) rather than by extension
of the sling procedure to include the orbicularis oculi
muscle.
Highpoints
1. Two basic features of the problem include:
a. Static suspension (In the operation described,
static suspension is involved.)
b. Dynamic action
2. Two stages:
a. Fascia implanted at orbital region
b. Sling from first stage to temporal region
An essentially similar procedure can be done in
one stage, which may be preferable.
3. Fascial support at oral cavity only on paralyzed side,
slightly crossing midline
4. Autogenous fascia
5. Slight overcorrection
6. No procedure is 100% perfect and may not be lasting.
Inform the patient of this.
Stage I (From Ragnell, 1968; After May, 1980)
A Depicted is one method of obtaining autogenous
fascia from fascia lata. A fascia stripper is used to obtain
a piece of fascia 0.6 em wide and 18 em long. Superiorly,
the fascia lata is in two layers; inferiorly,the two layers
fuse to form the iliotibial band.
B Three small incisions are made: (1) just lateral to
the philtrum column on the normal side; (2) opposite
No.1 on the lower lip; and (3) lateral to the commissure
on the paralyzed side in or close to the nasolabial fold.
Another approach is through a longer incision along
the nasolabial fold superiorly beyond the alae nasi.
This facilitates placement of another sling near the alae
nasi to correct any distortion of the nose, which in turn
can cause some nasal obstruction.
81, 82 With the use of a fascia carrier, one end of
the fascial strip is passed from the lateral incision (3 in
B) in a plane between the oral mucous membrane (do
not perforate it) and the paralyzed orbicularisoris muscle
of the upper lip out through the muscle of the normal
side at incision 1 in B. The fascia strip, locking the
normal muscle, is then passed back laterally between
the paralyzed muscle and the subcutaneous tissue to
the point of beginning (incision 3). The position of this
doubled-back fascia is depicted in sagittal section in
B2, including the same maneuver on the lower lip.
The four ends of the fascial strip are then tightened,
with care being taken not to make them too tight for
fear of stenosis. If the patient wears dentures, these
must be in place at this moment. These ends are then
tied together or sutured with 4-0 Tevdek. The wounds
are closed and sealed with collodion.
Continued
 THE FACE

82
FIGURE 7-12
 THE FACE
Fascial Slings for Facial Paralysis
(Continued) (Fig. 7-12)
Complications
• Disruption of sutures holding sling
• Wound infection. Because facial paralysis may be
associated with mastoid disease, be sure the ears are
"dry."
• Some sag may be expected over the years.
Ragnell (1968) performs a vastly different second
stage in that he affixes one end of a fascial sling to the
transected upper end of the coronoid process and the
other end to the zygomatic arch.
If warranted, as time goes by, excision of additional
skin along the nasolabial fold is performed.
Stage /I (Several Months Later)
C By direct exposure a wider (1 to 1.5 em) and
longer (15 em) piece of fascia lata is removed and used
as the sling. The previous lateral incision 3 in B is
opened, and the ends of the previously placed fascia
are localized. Another incision is made in the temporal
region with a preauricular extension if a rhytidectomy
(face-lift) is also planned. The temporal fascia is exposed.
A subcutaneous tunnel is then made connecting the
two incisions. A long slender clamp or fascia carrier
can be used for this purpose.
D The lower end of the fascia is then passed around
the loop formed by the fascia placed in stage I and
sutured with 4-0 nonabsorbable material. Redundant
skin may be excised, and then the dermis on the lateral
skin wound (rolled edge) is approximated to the fascia
with fine white non absorbable sutures. This wound is
left open until the operation is completed so as to view
the resulting effect with tension on the sling.
E The fascial sling is then drawn upward through the
temporal incision so that the deformity is slightly
overcorrected. The fascial end is then passed through
two incisions in the temporal fascia as depicted and
sutured securely in place with 4-0 Tevdek. The skin
incisions are closed with 5-0 nylon.
A collodion dressing is used as extensively as pos-
sible. A supportive Kling dressing is used for as long as
possible (1 month). The patient should avoid chewing
and excessive talking for at least 1 to 2 weeks.
F The completed operation schematically depicting
the location of the fascial strips. Also shown are modifi-
cations of fascial strips placed around the eye. These
latter strips can be secured around the medial canthal
ligament. An alternate approach to achieving narrowing
of the palpebral fissure is the performance of a lateral
canthoplasty (see Fig. 11-15).
Treatment of Paralysis of the
Depressors of the Lower Lip
This deformity, usually due to injury of the mandibular
branch of the facial nerve, as well as transection of the
platysma muscle, which at times extends over the
mandible and blends with other muscles (e.g., the riso-
rius muscle), often follows operations in the sub-
mandibular region and in the parotid salivary gland
and neck dissection (see Fig. 7-1). Often, it resolves with
time, especially when it is due solely to section of the
platysma muscle and when this muscle is carefully
approximated at the time of the wound closure. However,
if the deformity persists, several procedures are avail-
able for at least partial correction. These include the
following:
1. Z-plasty (see Fig. 9-2G and H).
2. Plication of the orbicularis oris muscle (see Fig. 9-6).
3. Transposition of the tendon of the subdigastric muscle
into the lower lip. This procedure, of course, would
have to be performed at the time of the definitive
surgery, and although the author (JML) has had no
personal experience with this technique, the fact
that the lip is fixed in a depressed position may be a
cause of additional deformity.
 THE FACE

E F
FIGURE 7-12 Continued
 THE FACE

Trigeminal Neuralgia 3. Decompression of the trigeminal nerve root. This com-

(Tic Douloureux) (Fig. 7-13) pression may be due to an arterial loop; however,
it is not certain that this arterial loop exists until the
Since the 1980s, the treatment of trigeminal neuralgia actual exploration, which requires a craniotomy
has developed to the point where most patients can be (Voorhies and Patterson, 1981).
reasonably relieved of their symptoms either perma-
nently or semipermanently (Dalessio, 1981). Complications
Medical and surgical management are a cooperative
endeavor, with most authorities agreeing that medical • Recurrence of symptoms
treatment is the initial treatment of choice. Response to • Anesthesia over nerve distribution
diethylcarbamazine (carbamazepine) usually occurs
within 24 to 48 hours; if not, the diagnosis is in doubt.
A Location and distribution of supraorbital (1),
Regardless of the response, evaluation of disease in the
frontalis (2), supratrochlear (3), infratrochlear (4), and
paranasal sinuses and nasopharynx, as well as glaucoma,
infraorbital (5) nerves. These are the sites for the
IS mandatory. Pain from trigeminal neuralgia should
injection of the local anesthetic and possibly the 90%
not be confused with pain from other sources, because
alcohol. Injection is directed into the bony orifice of
the pain of trigeminal neuralgia is usually extremely
the nerves, if possible. This may require probing with
severe and excruciating, at times causing the patient to
a needle until the excruciating pain is elicited, if not
throw himself or herself on the floor and roll around in
present at that time-an indication of exactly the correct
utter agony. The pain may well be cyclic. In these severe
site-followed by injection of a short-acting then a
episodes, patients simply cannot wait 24 to 48 hours for
long-acting anesthetic and then, ifdesirable, the alcohol.
medical relief. It is then that blockage of the peripheral
There should be a good response within 15 minutes.
nerves involved is indicated with a suitable local anes-
However, the patient may have a short breakthrough
thetic. At the same time, a long-acting anesthetic agent
of pain for 5 to 10 minutes during the next 24 hours.
can supplement the immediate action of a short-acting
It is at this time that the patient can be placed on the
agent. In addition, injection of 1 to 2 mL of 90% alcohol
carbamazepine.
can also be performed. At times, patients will have relief
for weeks and months after this management. This
B The surgical approach to those nerves is demon-
response has prompted the author to utilize peripheral
strated through three incisions. One or all nerves are
neurolysis in selected patients before the habitual use
exposed and sectioned depending on the clinicalpicture.
of carbamazepine, which can result, although rarely, in
The eyebrow is never shaved. The approach to the
severe blood dyscrasias (e.g., anaplastic anemia, agranu-
infraorbital nerve is depicted in detail in Figure 5-2A to
locytosis, thrombocytopenia, and leukopenia). Carba-
C.
mazepine can also cause ataxia and may act as a seda-
tive. Nevertheless, the relatively simple blockage of the
( Details of the technique of section and avulsion of
peripheral nerve is rarely used today. Other drugs can
the supraorbital and frontalis nerves are shown. The
be used (e.g., phenytoin sodium, baciofen, and chlor-
same technique applies to all the other nerves. The
phenesin carbamate). However, between 25% and 50%
orbicularis oculi muscle fibers are split.
of patients will eventually require some type of surgical
management. D The nerves are mobilized with nerve hooks.
Surgical management can be divided into the
following categories: E Clamps are placed proximally and distally, and the
nerve is transected.
1. Treatment of the peripheral nerves by either anes-
thetic blockage or neurolysis. This is seldom used at F By twisting the clamps, both proximal and distal
the present time. ends are avulsed.
2. Radiofrequency electrode insertion, producing a ther-
mal lesion in the sensory roots of the trigeminal
nerve. The recurrence rate is 10% to 25%. For pain distribution along the lateral side of the
tongue or lower lip, an intraoral block and injection of
 THE FACE

A B

FIGURE 7-13

the lingual nerve or inferior dental nerve is performed.
Various techniques to block the maxillary division of the
trigeminal nerve in the pterygopalatine (sphenomaxil-
lary] fossa as it leaves the skull through the foramen
rotunda have been used. The reader is referred to
Hollinshead (1954] for an anatomic description of the
problem.
Resection of portions of the lingual and inferior dental
nerves has been performed intraorally. The lingual nerve
is exposed at the posterior floor of the mouth, while the
inferior alveolar nerve is exposed on the lateral aspect
of the oropharynx, overlying the mandibular foramen
on the inner surface of the mandible and offering some
temporary relief.
 THE FACE

Incision and Drainage of Abscesses

(Fig. 7-14)
Highpoints
1. All intraoral and intranasal abscesses are simply
drained with no anesthesia or topical or local anes-
thesia. General anesthesia is contraindicated unless
an endotracheal tube is used.
2. Abscesses at or near cartilage should be drained early.
3. Massive amounts of systemic antibiotics are
administered.
Complications
• Cavernous sinus thrombosis
• Chondritis if cartilage is involved, with possible slough
of cartilage
Deep abscesses of either face or neck, especially the
latter, may be very difficult to locate. The use of a needle
often will aid in localizing the abscess. The needle is left
in the abscess and used as a guide while the incision
and drainage is performed.
A Septal abscess. A vertical incision is made to the
most dependent point. Postoperatively, vasoconstrictor
nose drops with or without sulfathiazole are used. A
drain is optional.
B, C Abscess of upper lip. A horizontal incision is
made in the presenting mass on the inner aspect of
the lip.
D A rubber tissue drain is sewn in place with nylon.
E Abscess of lower lip. An incision is made along the
vermilion border. If there are multiple abscesses, a
separate incision is made on the opposite side and
connected under the lip.
F A through-and-through drain is used with the two
incisions.
 THE FACE

E F

FIGURE 7-14
 396 THE ~ACE
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 8

Microvascular free flaps are depicted in Chapter 24.
Some of the areas require reconstruction, outlined in
this and other chapters. For example, large defects of
the buccal wall, face, and lips may be better recon-
structed with a microvascular free flap.
Introduction: Flap Selection and
Design (Tables 8-1 and 8-2)
Highpoints
1. Etiology of the primary defect: should a flap be
utilized or is a prosthetic device preferred?
2. Donor site consideration is a factor.
3. The simpler the flap, the better.
4. Is a local or distant flap necessary? Should it be
cutaneous or myocutaneous?
5. Age and general medical condition of the patient are
factors.
6. There should be a minimal number of stages.
7. There should be minimal disability.
8. Inform the patient that the flap may be hair bearing!
Three Basic Principles
Etiology of the Primary Defect
Should a flap be utilized or is a prosthetic device preferred?
Is the defect due to (1) surgical ablation for neoplasia,
(2) trauma, or (3) congenital deformity? Although many
flaps are interchangeable, the cause of the defect is impor-
tant in the decision regarding the use and selection of
flaps. The use of a flap developed from the potential
areas of spread of a malignant tumor is contraindicated
(e.g., the use of a sternocleidomastoid myocutaneous
flap if cervical metastasis is at all possible). The complete
coverage of the location of the primary tumor site
when such a tumor has a high rate of local recurrence
is likewise contraindicated (e.g., an orbital defect after
a maxillary resection and orbital enucleation). In this
case a split-thickness skin graft with prosthetic device
is preferred. Another example is a defect due to a recur-
rent adenoid cystic carcinoma of the palate or nose. A
prosthetic device is also preferred in this situation.
Regardless of the type of flap utilized, the adage of
avoiding coverage of areas of highly probable recurrent
carcinoma still applies. Most of the time this problem
cannot be avoided except for coverage as mentioned
earlier of an orbital defect or a defect after resection of
the ear. In these two latter areas, a full-thickness flap-
either free microvascular or full-thickness local rotated
flap-thwarts the use of a prosthetic eye or ear in
addition to masking recurrent disease.
As a basic principle, knowledge of the natural history
of a malignant neoplasm is paramount when deciding
whether a flap is preferred over a free skin graft and/or
a prosthetic device. Aside from the natural history of
the malignant neoplasm, the surgeon must determine
whether the defect site is such that a prosthetic device
is the simpler method of rehabilitation. Circumstances
that usually are more amenable to devices are (1) total

TABLE8-1 Examples of Defects and Choices of Flaps

DefectExample Choices

Totalor subtotal nasal loss Prosthesis-scalpingflap (see Fig. 6-29)

Portion of cheek
Floor of mouth, large portion of tongue
Major portion of buccal wall
Hypopharynxand oropharynx
Advanced lateral cheek flap/free groin flap (see Fig. 7-6)
Pectoralis major flap (see Fig. 8-2A)/apron flap (see Fig. 8-6)
Forehead flap (see Figs. 8-10and 8-U)/free groin flap
Pectoralis major flap with dermal graft (see Fig. 8-2A),deltopectoralis flap
(see Fig. 8-4Aand B), and posterior tongue flap and dermal graft (see
Fig. 21-7)

399
 G~N~RALPURPOS~FlAPS
Simplified Classification of Flaps
Blood Supply
Random Dermal and subdermal plexus
Axial Predominant artery and vein in flap
Free Microvascularanastomosis
ear replacement, (2) large palatal defects, and (3) large
nasal defects. This does not mean that flaps are not to
be utilized in the last two instances. In certain large nasal
defects, the patient's attitude, desires, and personality
may be the deciding factors. For example, an elderly
patient once flatly refused a necessary total resection of
the nose for squamous cell carcinoma unless he was
rehabilitated with living tissue. He refused a prosthetic
device (see Fig. 6-29).
Donor Site Consideration
Another consideration is the nature of the defect at the
donor site. For example, use of a forehead flap in a
young individual for reconstruction of a significant facial
defect secondary to trauma is usually contraindicated
because of scarring of the forehead, whereas in elderly
patients, scarring of the forehead is usually much less
noticeable. To minimize the apparent defect, the
incisions are best placed along the hairline above and
just above the eyebrows below. Gillies has described
various rotation flaps to minimize the defect of the
donor forehead site. Others have suggested not to apply
skin grafts to the donor site immediately but rather to
wait for granulation tissue to fill in the depression
along the edges and then to apply a skin graft. Others
have utilized full-thickness grafts from the clavicular
area after drilling the cortex of the frontal bone.
The dorsalis pedis free microsurgical flap is con-
traindicated because of the disability at the donor site.
If a free flap is preferred, the groin flap, with or without
iliac bone, by and large would be the one of choice.
The problem with this flap may be its color rendition
when it is utilized to replace large defects in the cheek.
Dermabrasion may aid in improved color rendition.
The groin flap may be ideal for a large buccal wall
replacement, or a forehead flap externally and a pectoralis
major flap for interior cover.
Another donor site problem could arise with use of
the deltopectoral flap in certain females in whom a
defect of the anterior chest wall is undesirable.
The Simpler the Flap, the Better
The use of local advanced skin or mucosa flaps, if fea-
sible, is often preferred. At times no flap is necessary at
all-using a skin graft or leaving a wound to granulate
may suffice.
With the introduction, or re-introduction, of "new
flaps," there often is an eagerness to try them out. This
is understandable in our attempt to further evaluate
something new and may be justified under certain
circumstances. Yet, constraint must be employed based
on experience and the final results to be achieved. It
must be emphasized that because a procedure is possible
and feasible does not mean it is an indication for the
procedure. All in all, most flaps are nonfunctional in
that they do not have muscular activity in relation to
the part that they are replacing. There are few excep-
tions. Flaps brought into the floor of the mouth and to
the tongue are simple space-occupying boluses of
tissue. They may reduce scar contracture and aid in the
preservation of the mandible-a very important
objective-but they do not have motor function.
The pectoralis myocutaneous flap supplies bulk and
probably has the potential for the best survival rate of
any distant flap. It can be combined with a deltopec-
toral flap on the ipsilateral side and can be brought
deep to or superficial to the cervical skin. Its length can
be increased by sectioning the muscle at the base of the
pedicle or resecting the medial third of the clavicle.
Classification of Large Transposed
Myocutaneous Flaps
1. Pectoralis major myocutaneous flap. This is able to
handle up to 90 % of virtually all defects that require
a significant amount of soft tissue.
2. 1l'apezius flap. This flap has a very questionable
blood supply that is often interrupted during a
radical neck dissection; however, some authors have
indicated that this flap can be utilized despite the
interruption of the transverse cervical artery. Never-
theless, because of its questionable blood supply, it
is seldom necessary and is rather awkward to use
because the patient has to be rotated or has to be
specially positioned with an inflatable thyroid
pillow. It is seldom utilized.
3. Latissimus dorsi flap. Usually, this flap has a good
blood supply and an adequate amount of tissue;
however, its drawback is that the surgeon must change
the position of the patient, which also becomes
awkward. A potential advantage is additional length.
The blood is from the thoracodorsal artery.
4. Sternocleidomastoid myocutaneous flap. There is
usually no application for this flap in major head
and neck oncologic surgery, because it violates the
neck. One exception is its use in the modified neck
dissection for thyroid cancer. If the lesion on the face
is of such a size that it requires a myocutaneous flap,
the possibility of nodal metastasis, present either at

the time of the initial surgery or later on, is so high
that the flap will obscure the clinical early detection
of metastatic cervical disease. This results in the so-
called violated neck. A pectoralis myocutaneous or
free vascularized flap is recommended.
S. Forehead flap. This is an excellent flap as far as blood
supply is concerned. The problem is in the defect in
the donor site, which can be minimized by placing
the incision along the hairline. Nevertheless, in a
younger individual the defect is not warranted if
some other flap can be utilized. A free vascularized
flap would be preferred.
Limitations and Pitfalls with Major
Standard Regional Flaps
1. Usual lack of function of a flap (e.g., a flap brought
into the floor of the mouth and/or tongue will not in
itself move with deglutition); dysphagia and pooling
of food may result.
2. Compromise of viability of the flap by ablative sur-
gery and/or radiotherapy relative to the donor site
3. Generalized arteriosclerosis
4. Severe diabetes mellitus
S. Severe malnutrition
6. Kinking or compromise of a flap by dressings, drains,
tubes, or tracheostomy tube tape
7. Flap must be in contact with the underlying structure
that is to be protected. This must be accomplished
without pressure on an underlying firm object,
whether it be a clavicle, a zygomatic arch, Kirschner
wire, Steinmann pin, or a mandibular bar or plate.
Limitations and Pitfalls According
to Specific Flaps
Deltopectoral Flap
1. A failure rate of 9% to 18% may occur, especially
with an extended deltopectoral flap. Although this
failure is usually not a disaster, if the flap is used to
cover the carotid vessels in the presence of a fistula
and/or previous radiotherapy, carotid artery blowout
is a possibility and has been reported.
2. When used to reconstruct defects of the hypopharynx,
oropharynx, cervical esophagus, or oral cavity, a
planned fistula is usually necessary. This then requires
at least one more operative stage and prolongs the
"wait to swallow period" up to 11/, to 3 months. At
times, de-epithelialization of a portion of a flap may
obviate the fistula. A simpler one-stage reconstruc-
tion utilizing a tongue flap and dermal graft is pos-
sible for hypopharyngeal defects up to 8 em in length.
A free jejunal or tubed radical forearm free flap is
ideal for this type of defect.
GENERAL PURPOSE FLAPS
3. Previous radiotherapy to the neck may result in scatter
radiation over the anterior chest wall. This could be
avoided by shielding during the radiotherapy; other-
wise, the upper incision of the flap should be moved
inferiorly 2 to 4 em below the level of the clavicle,
and delay may entail several stages, starting with
only skin incisions.
4. 1fthe deltopectoral flap is used to cover, for example,
a vascular anastomosis just above or deep to the
clavicle after a radical neck dissection, a dead space
can result with carotid artery blowout unless the
clavicle is resected.
S. Dependent traction of a deltopectoral flap by its mere
weight can cause deformity (e.g., reconstruction of a
large portion of the skin of the soft tissue of the chin
will pull the lower lip inferiorly). Suturing of the upper
and lower lips with a small opening in the middle
may minimize this problem. On the other hand,
bilateral advanced lateral cheek flaps (e.g., Bernard
[with Burow triangles] method) would prevent this
problem (see p. 482).
Forehead Flap
1. Donor site defects especially in the younger patient
are detrimental.
2. Compromise of blood supply is possible via the
superficial temporal artery if a simultaneous radical
neck dissection has sacrificed the external carotid
artery. Although McGregor and Reed (1970) minimize
this possibility, loss of a portion of the forehead flap
can occur. 11is most important to include the pos-
terior auricular artery with a portion of the scalp
above and behind the ear. Delay is advised.
3. In the reconstruction of the floor of the mouth and
portion of the tongue, do not drape the flap over a
bare Kirschner wire that is being utilized to stabilize
the mandibular ends when a section of the mandible
has been resected. Another problem that can occur
is pinching of the flap if it crosses opposing teeth to
reach the floor of the mouth or tongue.
4. There is danger of compromise of blood supply if
the flap is tunneled deep to the zygomatic arch. 1f
this is the approach to reach the oral cavity, it is best
to fracture the arch outward with two osteotomies.
The other approach is over the zygomatic arch.
S. Injury to the facial nerve may occur when performing
an access to the oral cavity.
Nape of the Neck Flap
1. This flap must be delayed.
2. Possible injury may occur to the spinal accessory
nerve.
3. This flap has limitations in regard to its length.
 GENERAl PURPOSE FlAPS
Apron Flap
1. Do not extend below the level of the clavicle, other-
wise the tip may necrose.
2. Unless an epithelial shave is utilized, a planned, yet
temporary, orocutaneous fistula will result when
this flap is utilized to reconstruct the floor of the
mouth.
Converse Scalping Flap for Total or Subtotal
Nasal Reconstrucuon
1. Take care to avoid pressure on the eye on the side of
the base of the flap.
2. There is a problem in shaping the ala nasi.
3. Nasal obstruction may occur.
Pectoralis Major Myocutaneous Flap
1. This flap appears to be one of the best myocuta-
neous flaps utilized in head and neck surgery.
2. Muscle bulk can be a problem in this flap. When
utilized for the reconstruction of the cervical
esophagus and/or hypopharynx, use a dermal graft
for the posterior wall of reconstructed gullet rather
than a flap (see Fig. 8-2G and G').
3. If muscle bulk is desirable, be certain that the nerve
supply is preserved.
4. There is some limitation as to the length and mobility
because of the vascular supply. Resection of medial
third of clavicle is of help (see p. 1041) but is rarely
used.
Trapezius Myocutaneous Flap
1. There will be a defect at the donor site with a
shoulder droop.
2. At times there are problems with blood supply,
usually from the transverse cervical artery. When the
blood supply is solely or primarily from the trans-
verse cervical artery, this flap can be mobilized on
its long vascular pedicle and utilized as an island flap.
Reports state that this can be combined with bone
from the spine of the scapula. Bulk may be a problem
if it is used to reconstruct cervical esophagus.
Free Flaps with Microvascular Anastomosis
1. These flaps require additional time.
2. They are not for the surgeon who performs the
isolated reconstruction; the operation is relegated to
larger services with two teams.
3. Skin and adipose tissue should be 10% to 15% larger
than is needed.
4. Bulk is good and bad-good for buccal wall defect,
bad for cheek defects.
5. Details are presented in Chapter 24.
Blood Supply to Skin Flaps (Fig. 8-1)
(After McGregor and Reed, 1970;
Ariyan, 1979; Baek et aI., 1981)
The blood supply to skin flaps has been described by
McGregor and Reed (1970) as being axial or random.
Actually, a combination of both types may exist in a
number of skin flaps, for example, the pectoralis major
myocutaneous flap (Ariyan, 1979), which is the most
versatile of all flaps for head and neck reconstruction.
The axial pattern has a distinct arteriovenous circula-
tion that follows the long axis of the flap, giving off
branches to the dermal-subdermal plexus of vessels.
The viability of the flap depends on the length of these
axial vessels (artery and veins) and not on the ratio of
length to width. The random flap, on the other hand,
has no axial vessels and derives its blood supply from
the communication vessels in the dermal-subdermal
plexus (the deltopectoral flap [Bakamjian, 1968]). Hence,
the length of the random flap has a significant relation
to the width of the flap. It should be stressed that the
axial-patterned flap can and does have random por-
tions, depending on the location of the flap, either at its
distal end or along its sides. For example, the distal end
of a pectoralis major myocutaneous flap can have a
random portion beyond the pectoral branch of the
thoracoacromial artery when the skin and underlying
rectus fascia are included. In addition, a random por-
tion of the pectoralis major myocutaneous flap can
have a medial random portion extending over the ster-
num (Baek et a!., 1982). Any of these random portions,
however, can be tenuous and not as reliable as the pure
axial component.
The myocutaneous axial flap is based on a dominant
axial arteriovenous circulation from segmental vessels
that lie beneath the transposed muscle. This axial cir-
culation in turn has branches (perforators) that supply
the muscle. Either directly from the axial vessel (myocu-
taneous) or from the perforators (direct cutaneous) are
cutaneous vessels that supply the skin.
Depicted (after Ariyan, 1979; Harii, 1983) are varia-
tions of the myocutaneous flap that involve flat muscles
(e.g., the pectoralis major, trapezius, and latissimus
dorsi muscles).
The pectoralis major muscle without skin can be
used for reconstruction of the pharynx. The fascia of
the flap is sutured to the esophagus and the pharynx.
This is ideal for reconstruction after partial resections
of the base of the tongue.
 GENERAL PURPOSE FLAPS

RANDOM PORTION

PERFORATOR
. CUTANEOUS-DIRECT

SEGMENTAL

A B

c
FIGURE 8-1

A In the intact myocutaneous flap, for example, the
pectoralis major flap, the axial vessels (the pectoral
branch and at times the lateral thoracic) are seen
arising from the thoracoacromial artery giving off the
perforating muscular branches, and these in turn give
off the two types of cutaneous vessels, the myocuta-
neous and direct cutaneous. The axial portion of the
flap is with the pectoralis major muscle and axial vessel.
The portion of the skin beyond the extent of the
muscle and the axial vessel is the random portion of
the flap. This random portion without the axial vessel
depends on its viability from small vessels in the dermal-
subdermal plexus. Not shown are the accompanying
veins, which are as important as the arteries.
This type of flap is utilized when the entire portion
of the overlying skin is required to cover the defect as
well as forming a tube flap pedicle (see Fig. 8-2 0).
B This is the so-called paddle myocutaneous flap in
which the arteriovenous circulation along with the
overlying muscle is transposed. The intervening skin
between the base of the flap and the paddle is not
utilized. The advantage of this flap is that the axial vessels
and the muscle can then be buried under skin. Numerous
examples are shown in the following figures.
C This modification, in which the muscle is tran-
sected, is primarily used to achieve additional length
and can be more easily rotated. The danger is in the
interruption of the vascular pedicle, especially the veins.
Additional length can be achieved with a pectoralis
major myocutaneous flap by resection of the clavicle
(see Fig. 8-2H). Another application is the use of these
flaps as free flaps with microvascular anastomosis. This
variation has many drawbacks and is usually not
utilized with the pectoralis major myocutaneous flap.
 GENERALPUR~SEFLAPS
Pectoralis Major Myocutaneous
Flap (Fig. 8-2) (After Ariyan, 1979)
Highpoints
1. Outline the course of the pectoral branch of the
thoracoacromial artery to the pectoralis major muscle
(see Fig. 8-2B). Sometimes the pectoral branch of
the thoracoacromial artery is not significantly
developed at all and the major blood supply to the
pectoralis major is from the lateral thoracic artery.
This could be a disaster and points out the impor-
tance of inspecting the underportion of the pec-
toralis major flap with an incision along its lateral
border, thereby verifying the usual position of the
pectoral branch of the thoracoacromial artery. A
sterile Doppler device may be of help in delineating
this at the time of surgery.
2. Outline the size and the configuration of skin and
muscle that are required to cover the defect. These
dimensions obviously will vary depending on the
size and the location of the defect. This flap can
reach the orbit and at times the forehead.
3. If there is any possibility of the need of a deltopec-
toral flap, this flap should first be elevated from its
distal portion, at least to the medial aspect of the
thoracoacromial artery. Both a pectoralis major
myocutaneous flap and a deltopectoral flap can be
utilized on the same side. Preserve the lateral
thoracic artery if possible, especially if double side-
by-side paddles are to be utilized (see Fig. 8-30)
(Freeman et al., 1981). This artery can be preserved
by dividing the humeral head of the pectoralis
major muscle and the lateral border of the pec-
toralis minor muscle (Krespi et aJ., 1983).
4. The initial incision for the flap is then along the
lateral border of the outlined skin for the pectoralis
major flap. The incision is carried down to the
pectoralis major muscle.
5. If this incision is close to the lateral margin of the
pectoralis major muscle, then this lateral margin is
elevated deep to a plane along the anterior surface
of the pectoralis minor muscle. Otherwise, the
pectoralis major muscle is split along its fibers,
with the certainty that the pectoral branch of the
thoracoacromial artery is medial to this line of
separation. If there is any question regarding loca-
tion of the vascular pedicle, it is safer to visualize
first the pedicle via the lateral border of the pec-
toralis major muscle. As this incision is made, the
edges of the skin are sutured to the underlying
muscle to prevent separation and retraction of these
two structures.
6. Be certain to establish by blunt dissection the plane
and the adventitia deep to the pectoralis major
muscle, which is along the pectoralis minor muscle,
and the ribs, being certain that the pectoral artery
and vein and the lateral pectoral nerve are attached
to the undersurface of the pectoralis major muscle.
Preserve the fascia surrounding the neurovascular
bundle.
7. Keep the vascular bundle in view during the entire
dissection to avoid injury to this bundle. The nerve
is necessary if muscle bulk is permanently desired.
On the other hand, the nerve is sacrificed if muscle
atrophy is desired.
8. Do not dissect the vascular bundle from its surround-
ing fascia. This is very important if the muscle is
freed from its clavicular attachment to gain more
length. The vascular bundle with its surrounding
fascia is then freed of the muscle.
9. The flap is placed anterior to the clavicle, or the
medial one half of the clavicle is resected.
10. Resect the medial half of the clavicle if additional
length is necessary. This maneuver also serves other
purposes: It allows filling in of the dead space just
above the level of the clavicle resulting from a
radical neck dissection, protects the vascular pedicle
from any compression over the clavicle, and elimi-
nates any bulk over the clavicle. It also protects the
subclavian vein.
n. Use a separate Hemovac suction drain for the donor
site on the chest.
12. The donor site can almost always be closed by
advancing the medial and lateral skin flaps. When
a very large portion of skin is utilized, a skin graft
may be necessary.
13. No circular dressing or tapes around the neck are
utilized that might compress the vascular pedicle;
especially vulnerable are the veins. This would
lead to a "wet gangrene."
14. A tracheostomy should be performed when the
flap is utilized to reconstruct the hypopharynx,
oropharynx, or oral cavity.
15. Avoid twisting or rotating the vessels on them-
selves, because this might primarily obstruct the
veins as well as the arteries.
16. Separate Hemovac drains are used in the cervical area.
17. Postoperative clindamycin coverage is preferred
rather than use of a cephalosporin because clin-
damycin binds to leukocytes and may reach the
actual area of demarcation of a flap.

PECTORALIS
MAJOR M.
SERRATUS ANTERIOR MJ
LATISSIMUS DORSI M.
EXTERNAL OBLIQUE M.
A
FIGURE 8-2
A Depicted is the muscular anatomy related to the
anterior and lateral chest wall. Of particular impor-
tance are the various directions of the fibers of the
pectoralis major muscle. The superior fibers are hori-
zontal, whereas the inferior fibers are oblique. Hence,
these inferior fibers can usually be split, whereas the
superior fibers, particularly those attached to the
humerus, require transection.
Continued
The thick fan-shaped pectoralis major muscle has
three origins: (1) clavicular from the medial half of the
clavicle, (2) sternocostal from the manubrium and
body of the sternum and the first or second to the sixth
costal cartilages, and (3) abdominal from the rectus
fascia. The muscle inserts into the crest of the greater
tuberosity of the humerus. The direction of the muscle
fibers ranges from horizontal to oblique. This must be
kept in mind when dissecting, transecting, and splitting
the muscle fibers during the development of the flap. It
is thus obvious that the horizontal fibers at the axilla
must be transected to mobilize the pectoralis major
muscle fully. It is in this location that the lateral
thoracic artery is identified and preserved, if feasible.
This is advisable if a longitudinal double paddle is to
be utilized (see Fig. 8-3D).
The nerve supply to the pectoralis major muscle is
GENERAL PURPOSE FLAPS
RECTUS FASCIA
from the lateral pectoral nerve (also known as the
anterior lateral thoracic nerve) and the medial pectoral
nerve (also known as the anterior medial thoracic
nerve). The lateral pectoral nerve arises from the lateral
cord of the brachial plexus, whereas the medial pec-
toral nerve arises from the medial cord of the brachial
plexus. It is interesting, however, that in their distribu-
tion to the pectoralis major muscle, the medial pectoral
nerve actually is located laterally, whereas the lateral
pectoral nerve is located medially. These nerves enter
the muscle near the axilla under the horizontal fibers
of the muscle and can be visualized between the
pectoralis minor and the pectoralis major muscles. The
lateral pectoral nerve is closely related to the pectoral
branch of the thoracoacromial artery and is contained
in the neurovascular bundle. The medial pectoral nerve
is somewhat more lateral and often pierces the
pectoralis minor muscle to reach the pectoralis major.
The medial pectoral nerve almost always has to be
sacrificed in the mobilization of the pectoralis major
myocutaneous flap. Their exact identification can be
easily confirmed with a nerve stimulator. There seems
to be some evidence that the preservation of these
nerves will aid in maintaining the muscle bulk, if this
is advantageous. The converse is also true; that is,
when using the flap with a dermal graft to reconstruct
the hypopharynx and cervical esophagus, the muscle
then tends to atrophy if these nerves are sacrificed.
 GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous
Flap (Continued) (Fig. 8-2)
(After Ariyan, 1979)
B Depicted are the dotted lines that indicate graphi-
cally the general course of the pectoral branch of the
thoracoacromial artery, which is the main axial artery
of the pectoralis major myocutaneous flap. This
pectoral branch may be displaced laterally on females
with large pendulous breasts.
The initial dotted line runs from the shoulder tip to
the xiphoid process. The second line runs from the
midportion of the clavicle at a right angle to the first
line.
Continued
The thoracoacromial artery is a short trunk arising
from either the first or second part of the axillary artery
several centimeters below the clavicle. The thora-
coacromial artery pierces the coracoclavicular fascia,
which runs from the subclavius muscle to the pectoralis
minor muscle. The axillary artery (Anson and McVay,
1971), which is a continuation of the subclavian artery,
extends from the outer margin of the first rib to the
lower border of the teres major muscle, where it becomes
the brachial artery. The subclavian artery is divided
into three divisions or sections. The first division lies
behind the clavicular pectoral fascia and the clavicular
head of the pectoralis major muscle, the second divi-
sion lies behind the pectoralis minor muscle, and the
third division lies partially behind the pectoralis major
muscle extending to the lower border of the teres major
muscle. Another more simplified description is that the
first division is above the upper border of the pectoralis
minor muscle, the second behind the pectoralis minor
muscle, and the third from the lower border of that
muscle to the teres minor muscle. The thoracoacromial
artery thus usually arises from the first division of the
axillary artery, although some authors state that it
arises from the second division beneath the medial edge
of the pectoralis minor muscle. Regardless, numerous
variations of the branches of the axillary artery occur.
The pectoral branch of the thoracoacromial artery
lies between the pectoralis major and the pectoralis
minor muscles, is enveloped in fascia that is contiguous
with the deep fascia of the pectoralis major muscle, and
runs inferiorly along the oblique fibers of that muscle
to about the fifth or sixth rib. This axial artery is thus
medial to the nipple. However, in two overweight female
patients with pendulous breasts, this vessel could not
be identified in this location. In one patient in whom
the distal one third to one half of the flap failed, there
was a major vessel more lateral. On venous digital
subtraction angiography performed postoperatively on
the contralateral side, no pectoral branch as such could
be identified. The more lateral vessel appeared to be
the lateral thoracic artery. In any event, in overweight
females with pendulous breasts, it appears worthwhile
to identify the blood supply to the pectoralis major
muscle with preoperative digital subtraction angiog-
raphy. It is possible that the pendulous breasts are a
factor in displacing the entire pectoralis major muscle
laterally. An intraoperative aid may be the first
perforator of the pectoral artery, as described by Kaplan
and Harwick (1983).
The thoracoacromial artery usually has four branches
(pectoral-the largest, acromial, clavicular, and deltoid),
although there may be a fifth branch, the lateral thoracic.
DeGares, in Gray's Anatomy, states that the lateral tho-
racic artery arises directly from the axillary artery (as
depicted) in 30% of patients, whereas in 60% of patients
it arises from the thoracoacromial artery or the sub-
scapular artery. In any event, the lateral thoracic artery
contributes to the blood supply of the pectoralis major
muscle as well as the pectoralis minor muscle, and this
author attempts to preserve this vessel whenever pos-
sible. It often lies behind the pectoralis minor muscle
and may run to the lateral border of the pectoralis minor
for 4 or 5 em and then reach the pectoralis major muscle.
In summary, the pectoralis major muscle derives its
blood supply in order of importance from (1) the pec-
toral branch of the thoracoacromial artery, (2) the lateral
thoracic artery from the axillary artery or from the
thoracoacromial artery, and (3) from the superior
thoracic artery to a lesser extent. The blood supply is
also obtained from the pectoral branches and perfo-
rators of the internal mammary artery. These vessels
are of course always sacrificed in the mobilization of
this flap. The reader is referred to the excellent anatomic
injection studies of Freeman and colleagues (1981).
These authors also review the historical background of
this flap.
 GENERAL PURPOSE FLAPS 407

l
ACROMIAL A.
DELTOID A.
THORACOACROMIAL A.
, SUPERIOR THORAC1IC A.
AXILLARY A.
'1
PECTORAL BRANCH I'
(THORACOACROMIAL A.) t
I f41.1
!

LATERAL THORACIC A.
1

I
I
}
/
(
,

FIGURE 8-2 Continued

 408 GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous
Flap (Continued) (Fig. 8-2)
(After Ariyan, 1979)
C The course of the pectoral artery has been scribed
with a 'marking pen, and the appropriate paddle of
skin has been outlined. The length and width of the
paddle should be carefully measured relative to the
defect to be reconstructed. In general, for large defects
it is somewhat better to make the paddle larger, both
in width and length, than initially calculated. The
lateral incision is first made superiorly. The skin edges
are tacked to the immediate underlying muscle to
prevent separation and retraction of the skin from the
muscle. These sutures must not be placed deep into
the muscle, thus avoiding injury to the pectoral artery
or any of its branches. The safest method of avoiding
injury to the pectoral artery is to identify the lateral
border of the pectoralis major muscle, which is retracted
medially, A plane is then developed between the pec-
toralis major and the pectoralis minor muscles, taking
care to keep the fascia on the deep side of the pectoralis
major muscle with the muscle. The pectoral artery lies
within this fascia. Another advantage to this approach
is the probability and possibility of the preservation of
the lateral thoracic artery.
D An alternate method is to split the pectoralis major
muscle 2 em medial to its lateral border and then enter
the plane between the pectoralis major and the
pectoralis minor muscle. In overweight females this is
not advised. Regardless, the surgeon must be certain
that the artery is medial to this muscle split. Using this
technique, it is more difficult to preserve the lateral
thoracic artery, if not impossible.
Continued
The superior extension of the skin incision toward
the clavicle is optional. If there is enough elasticity to
the skin beneath the clavicle, the flap can then be
tunneled under the skin. The main point is not to have
too much pressure on the pedicle as it is passed
through the tunnel.
 GENERAL PURPOSE FLAPS

LATERAL THORACIC
;;A,
A.

PECTORALIS MAJOR M.

PECTORALIS MINOR M.

D
FIGURE 8-2 Continued
 GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous
Flap (Continued) (Fig. 8-2)
(After Ariyan, 1979)
E Further mobilization of the flap is shown. Its
attachments to the rectus fascia and the costochondral
cartilages have been transected. Perforating vessels as
well as the pectoral vessels from the internal mammary
artery are ligated. Smaller vessels are cauterized. The
reflected flap demonstrates the pectoral artery and vein.
Somewhat laterally are the lateral and medial pectoral
nerves. The medial nerve is lateral, and the lateral nerve
is medial. The superior portion of the lateral skin incision
is optional. This incision can be turned medially and
reach the clavicle or the muscle flap brought under the
skin through a wide open tunnel. An alternate method
is to elevate the distal end of the deltopectoral flap, if
such a flap is to be used concomitantly or later on.
The horizontal fibers of the pectoralis major muscle,
those that are attached to the humerus and that form
the anterior fold of the axilla, are transected somewhat
laterally to preserve the lateral thoracic artery, if deemed
necessary. Care is taken not to injure the contents of
the axilla. The lateral thoracic artery is thus medial to
this incision and courses along the lateral border of the
pectoralis minor muscle, supplying both the pectoralis
major muscle and the pectoralis minor muscle. It anas-
tomoses with the pectoral branch of the thoracoacro-
mial artery. If the lateral thoracic artery is not to be
preserved, the muscle is transected somewhat more
medially closer to the pectoral artery. Another deciding
factor is the amount of muscle bulk that is desired, for
example, if the tissue mass resulting from a radical
neck dissection is to be matched, the width of the pec-
toralis major muscle should be somewhat wider than
the sternocleidomastoid muscle that has been resected.
If a double paddle-side by side-is to be used, preserva-
tion of the lateral thoracic artery is virtually necessary,
with the lateral paddle supplied by the lateral thoracic
artery and the medial paddle by the pectoral artery (see
Fig. 8-3D).
F The flap is mobilized farther and brought under a
skin tunnel to pass over the clavicle. An alternate method
is to transect the skin along the dotted line or to
develop a deltopectoral flap. The lateral thoracic artery
has been preserved in this stem, showing transection
of the lateral fibers of the pectoralis minor muscle.
Continued
 GENERAL PURPOSE FLAPS

NEUROVASCULAR BUNDLE A.V.& N.

(
\ CLAVICLE
, \
PECTORALIS MAJG{R

HORIZONTAL FIBERS OF
THE PECTORALIS MAJOR
TO THE HUMERUS
E

PECTORAL SR.

LATERAL THORACIC A.

FIGURE 8-2 Continued

 GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous
Flap (Continued) (Fig. 8-2)
(After Ariyan, 1979)
Reconstruction of the Entire
Hypopharynx and Portion of Cervical
Esophagus, Oropharynx, and
Nasopharynx (see p. 1188)
The pectoralis major myocutaneous flap can be used
for reconstruction of the pharynx following totallaryn-
gopharyngectomy in some patients, particularly thin
males, in whom other methods of reconstruction are
precluded or whose general medical condition calls for
an expeditious reconstruction. The difficulty of tubing
this flap 360 degrees can be overcome by combining it
with a dermal graft.
G Also depicted is an excellent method of recon-
struction of the entire hypopharynx after total laryn-
gectomy and total hypopharyngectomy as well as a
portion of the cervical esophagus when the defect is
too large for a tongue flap and dermal graft (see
Fig. 21-7). The pectoralis major flap is tubed 270
degrees (reducing the bulk of the flap if it were tubed
360 degrees), forming the anterior and lateral walls of
the reconstructed gullet, just as a tongue flap is used
(see Fig. 21-7). The dermal graft forms the posterior
wall of the hypopharynx and esophagus. It can be
extended superiorly to reconstruct the posterior wall
of the oropharynx and nasopharynx to just above the
level of the eustachian tube. It is important that the
flap and dermal graft be sutured to the prevertebral
fascia to prevent tension on the mucosal closure suture
lines. This method reduces the bulk of an entirely
tubed pectoralis major flap, which is detrimental to
adequate deglutition. (See p. 1188 for tongue flaps
and dermal graft.)
Cross Section of Reconstructed
Hypopharynx
Gl When the dissection includes the lateral wall of
the nasopharynx, the internal carotid artery can be
jeopardized because it may only be several millimeters
deep to the mucosa. Hence, take extreme care in this
dissection. When the vessel is exposed, it should be
protected with either a transposed muscle flap or a
turned-in flap of prevertebral fascia. The fascia is then
covered with a dermal graft, which likewise covers the
posterior wall of the nasopharynx. Preoperative evalu-
ation of intracranial blood flow may be indicated. Angi-
ography is also advisable as well as computed tomo-
graphic scans with enhancement to localize the internal
carotid artery. MR angiography and improved resolu-
tion MR images can also be helpful regarding evalua-
tion of the vascular structures. The advantage of the
improved resolution MR imaging is that it also demon-
strates soft tissue as well. Balloon occlusion of the
internal carotid artery can be utilized. However there is
a reported incidence of stroke of 1%. At the time of
operation, trial occlusion can be done with evaluation
of back flow from the distal internal carotid artery.
Continued
 GENERAL PURPOSE FLAPS 413

ESOPHAGUS

DERMAL GRAFT

FIGURE 8-2 Continued

 GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous
Flap (Continued) (Fig. 8-2)
(After Ariyan, 1979)
A word of caution is needed regarding covering of
the resected lateral wall of the nasopharynx especially
when disease has extended superiorly from the
oropharynx. Recurrent or persistent neoplastic disease
can be so located. Skin grafts and flaps can mask this
disease. Once out of control, spread can extend superiorly
to the skull base as well as laterally into the paraph a-
ryngeal space (see Chapter 23).
H Further development of the flap with the clavicle
removed is shown. This figure depicts the underlying
anatomy, which is usually not visualized this well
because of the overlying soft tissue and fascia. Awareness
of these structures, however, is important. The lateral
thoracic artery has not been preserved in this step. The
white dotted horizontal line indicates the line of
transection of the pectoralis major muscle from its
attachment to the clavicle to gain additional length.
This, of course, is optional. The flap is then attached only
by its neurovascular bundle and enveloping fascia. If
this is done, extreme care must be taken to avoid
injury to this neurovascular bundle. A modification can
be performed in which the muscle fibers only lateral
and medial to the neurovascular bundle are transected.
At times the pectoral nerves require transection to
obtain additional length and mobilization.
I A pectoralis major myocutaneous flap is shown in
the reconstruction after a hemiglossectomy with preser-
vation of the mandible. The mandible has been tran-
sected in the midline, and the so-called mandibular swing
operation (see Fig. 15-14) approach has been performed.
The major drawback in tongue reconstruction is the
fact that this flap, like all other transposed flaps, is
adynamic. It is a space-filling method and somewhat
minimizes the tethering effect that otherwise would
occur if the remaining tongue was sutured to the
mucosa on the inner side of the mandible. Conley has
attempted to achieve some motion to the flap by
anastomosing the 12th nerve to the medial and/or
lateral pectoral nerves supplying the muscle. He reports
only very slight motor function of very questionable
value. This flap is also utilized to cover a bent Kirschner
wire and tie wires (see Fig. 14-5) when a portion of the
mandible has been resected. It is important not to
drape the neurovascular bundle of the flap over the
Kirschner wire to prevent kinking and obstruction of
the vessels. The flap bulk will usually reduce in size as
time goes by, depending on the transection of the
medial and/or lateral pectoral nerves.
Continued
 GENERAL PURPOSE FLAPS

THYROCERVICAL
TRUNK

VERTEBRAL A.

COMMON CAROTID A.

SUBCLAVIAN A.

INTERNAL THORACIC A.

THORACOACROMIAL A.
FIRST RIB

FIGURE 8-2 Continued

 GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous
Flap (Continued) (Fig. 8-2)
(After Ariyan, 1979)
J An example is shown of a distal skin paddle of a
pectoralis major flap used to reconstruct skin and
parotid loss after resection of these structures involved
in previous surgical and radiation failure. An advanced
or rotated medial cheek flap would usually suffice.
However, because of the scatter radiation, such a flap
might not survive. The very distal end of one of these
flaps was randomized, and 1.5 cm of the skin was lost.
The irradiated recipient site or the fact that this patient
had leukemia may well have contributed to this failure.
The defect healed, yet it may be well to avoid random
extensions when there is an irradiated recipient area,
the patient has leukemia, or there is severe arterioscle-
rosis or diabetes.
K Virtually the entire mammary portion of the flap
has been utilized to cover a massive resection of cer-
vical skin that was devitalized after radiotherapy. This
is another reason we no longer use preoperative or
routine postoperative radiotherapy. The nipple is located
posterolaterally. This procedure is reasonably adopted
in the male; in a female with pendulous breasts it
might well be quite a cosmetic oddity. The donor site
in this particularly massive flap usually requires a skin
graft (see Fig. 8-3G).
FIGURE 8-2 Continued
A modification in the female is the utilization of the
pectoralis major muscle without the overlying skin and
breast. The bare area of the external portion of the muscle
can then be covered with a free-skin graft. This same
technique can be used in any pectoralis major flap (i.e.,
when lining an intraoral defect). The inner portion of
the muscle is then covered with a free-skin graft.
L A pectoralis major myocutaneous flap is ideally
suited to reconstruct and to serve as the placement of
the tracheostoma after a Sisson procedure for resec-
tion of stoma recurrence (see Fig. 19-11 A). A tempo-
rary problem that may be encountered is too much
bulk on the proximal side of the new tracheal stoma.
Care must be taken to trim bulk off the muscle so that
the axial artery is not injured. A temporary 6-cm piece
of endotracheal tube secured on two tongue depres-
sors taped to the tube serves as a temporary stent to
prevent rollover of the bulky flap, which might partially
occlude the stoma. The tongue depressors are applied
to the skin and help position the endotracheal tube.
M A paddle with a pectoralis major flap has been
utilized to reconstruct skin, soft tissue, and a portion of
the trachea associated with resection of carcinoma of
the cervical esophagus.
Continued
 GENERAL PURPOSE FLAPS 417

FIGURE 8-2 Continued

 GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous
Flap (Continued) (Fig. 8-2)
(After Ariyan, 1979)
Complications
• Loss of flap-usually only the distal portion. This
has been encountered in only two situations: in the
overweight female with pendulous breasts and when
side-by-side paddles were used without preservation
of the lateral thoracic artery. Even with loss, the skin
paddle serves as a dressing, permitting underlying
granulation tissue to develop. This has sufficiently
protected the carotid vessels to avoid blowout. If
there is a suspicion of flap loss at the time of surgery,
a possible precautionary measure would be to cover
the carotid vessels initially with a levator scapulae
muscle flap (see Fig. 22-36) and place this under the
pectoralis major flap. Total loss of the flap occurred
in one patient because the lateral thoracic artery was
not preserved. Fluorescein injected into the deep
vasculature and visualized under ultraviolet light
might have prevented this complication.
• Infection-to avoid a serious calamity when a fistula
develops, adequate cervical and chest wounds must
be appropriately drained (Hodgkinson, 1982).
• Large flaps-any type tends to obscure early
recurrent disease.
• Possible limited use of ipsilateral upper extremity,
especially when combined with a classical radical
neck dissection when the lIth nerve requires
sacrifice (Schuller, 1980)
• Bulk of flap possibly not desirable in some instances
• Fistula formation-if this is anticipated because of
difficulty and/or tension on suture lines, a suction
catheter is inserted into the reconstructed gullet for
decompression purposes. This catheter is brought
out via the cervical incision.
• Hematomas and seromas at the donor site (Biller et
al., 1981).
• Hair-bearing portion may be a nuisance; it is best to
inform the patient regarding this possibility before
the surgery .
• Necrosis of flap (especially tubed)-it is best to
immediately excise the necrotic portion and reap-
proximate if at all possible, because necrosis tends
to spread.
N Depicted is a recurrence of oral carcinoma pre-
viously treated by surgery and radiotherapy. Afistula is
present. The patient was then treated with chemotherapy
followed by wide surgical excision and resection of the
mandible.
o The resected area was reconstructed with a tubed
pectoralis major myocutaneous flap. Ifthe tube cannot
be completely encircled with chest wall skin from the
flap, a temporary split-thickness skin graft is used to
cover the bare area as a temporary dressing. This also
avoids any compression of the axial vessels. Because
the patient had had a previous radical neck dissection,
the flap was necessarily external to the skin of the neck.
A portion of the internal and common carotid arteries
was exposed, and these arteries were adequately
covered. by the muscular portion of the pectoralis
major flap. A double-type paddle flap (see Fig. 8-3B)
was used to close the defect; the distal paddle for the
inner mucosal lining and the proximal paddle for the
skin coverage. Because the recipient area was heavily
irradiated, the tubed pedicle was transected in stages:
the first stage in 10 weeks, the second stage in another
month. Ariyan has reported transection of these
pedicles in 2 weeks.
 GENERAL PURPOSE FLAPS

FIGURE8-2 Continued
 GENERAL PURPOSE FLAPS
Applications of the Pectoralis
Major Flap (Fig. 8-3)
Depicted in Figure 8-3A to G are the outlines of the
various applications of the pectoralis major myocu-
taneous flap. It is obvious that of all the flaps utilized
in head and neck reconstruction this flap is the most
versatile. The shapes and areas of the skin are numerous;
the muscle bulk can be minimal to maximal. The
deformity of the donor site is minimal and usually can
be closed by advanced localized chest flaps. The patient
does not require changes in position during the opera-
tion, and, if desirable, two teams can work simulta-
neously to reduce the operating time. From the author's
point of view, it is the first choice of all the major flaps
in head and neck reconstruction.
A A large paddle is useful to replace major skin losses
of the neck. This can be enlarged to include the entire
mammary region, as depicted in G.
PECTORALIS
MAJOR M.
LATISSIMUS DORSI M.
EXTERNAL OBLIQUE M.
FIGURE 8-3
B A double paddle is used when two separate areas
require coverage. This is ideal for replacement of an
intraoral or intraoropharyngeal defect and skin. The
distal paddle is used for the mucosal reconstruction,
and the proximal paddle is used for the skin. A fold is
then made between the two paddles, taking care not
to obstruct the vascular pedicle. An example of this
double paddle used to close a persistent fistula is
depicted in Figure 8-2N and O.
C A long skin paddle is used, for example, as a tubed
pedicle external to the skin of the neck. The distal end
may be random. When a random portion is utilized,
the ratio of length to width is important in the
randomized portion. This type is depicted in Figure 8-
2N and 0, in which types 2 and 3 are combined.
Continued
RECTUS
FASCIA
 GENERAL PURPOSE FLAPS

PECTORALIS
MAJOR M.

RECTUS
LATISSIMUS DORSI M.
,j FASCIA

EXTERNAL OBLIQUE M.

PECTORALIS
MAJOR M.

RECTUS
LATISSIMUS DORSI M. j FASCIA
1

EXTERNAL OBLIQUE M.

c
FIGURE 8-3 Continued
 GENERAL PURPOSE FLAPS
Applications of the Pectoralis
Major Flap (Continued) (Fig. 8-3)
D A side-by-side double paddle is useful for closing
two separate areas (Morain and Geurkink, 1980).
Preservation of both the pectoral branches and the
lateral thoracic arteries is usually necessary (Lore and
Zingapan, 1971). The pectoral branch is the axial
artery for the medial paddle, and the lateral thoracic
artery is the artery for the lateral paddle. This flap can
be utilized to reconstruct the base of the tongue or a
portion of the mouth with the medial paddle and the
lateral oropharyngeal wall with the lateral paddle.
Care must be taken to preserve the lateral thoracic
artery, which usually arises directly from the axillary
PECTORALIS
MAJOR M.
LATISSIMUS DORSI M.
EXTERNAL OBLIQUE M.
FIGURE 8-3 Continued
artery (see Fig. 8-2B). The lateral thoracic artery is
mobilized by transecting some of the lateral horizontal
fibers of the pectoralis minor muscle (lore and
Zingapan, 1971; Krespi et aI., 1983).
E The pectoralis major flap is combined with a del-
topectoral flap. This can be performed simultaneously
or at different stages, if required.
F Use of an inframammary paddle is an excellent
cosmetic procedure in the younger female (Ariyan and
Cuono, 1980). A tunnel is developed under the breast
for delivery of the flap.
Continued
(
,
~
RECTUS
I FASCIA
i
 GENERAL PURPOSE FLAPS

PECTORALIS
MAJOR M.

RECTUS
LATISSIMUS DORSI M. FASCIA

EXTERNAL OBLIQUE M.

E
4

PECTORALIS
MAJOR M.

RECTUS
LATISSIMUS DORSI M. / FASCIA

EXTERNAL OBLIQUE M.

F
FIGURE 8-3 Continued
 GENERAL PURPOSE FLAPS
Applications of the Pectoralis
Major Flap (Continued) (Fig. 8-3)
G Virtually the entire pectoralis major muscle,
overlying skin with the breast, has been utilized in a
male to cover a total defect on one side of the neck. In
the male there is little problem, but in a female with a
pendulous breast this could offer quite a cosmetic
problem at the recipient site. The donor site in this
type of flap is virtually the only place that a skin graft
has been necessary to close the defect.
PECTORALIS
MAJOR M.
LATISSIMUS DORSI M.
EXTERNAL OBLIQUE M.
G
FIGURE8-3 Continued
Another variation of the pectoralis major myocuta-
neous flap is the incorporation of a portion of the fifth
rib, which has been reported to be used for reconstruc-
tion of the mandible. The author has no experience with
this variation and would not use it. Kirschner wires
bent and secured with tie wires are preferred for stabi-
lization and reconstruction of the transected mandible
at the time of the ablative surgery. The Kirschner wire
is then covered with the pectoralis major flap. This
flap, or any other flap for that matter, must be placed
so that the flap and its axial vessels are not draped over
the Kirschner wire. Otherwise, the Kirschner wire may
act as a guillotine and devitalize the flap.
The muscle portion of the pectoralis major flap has
been used for protection of the carotid artery after
radiotherapy to the neck, by burying it in the cervical
flaps (Lee, 1980).
RECTUS
FASCIA

Deltopectoral Flap (Fig. 8-4)
(After Bakamjian, 1965)
Although there are now a large number of various flaps
for reconstruction after major tissue loss in head and
neck surgery, the deltopectoral flap (Bakamjian, 1965)
still has a useful place in our armamentarium. It is a
full-thickness (including the fascia of the pectoral mus-
cles) anterior chest wall skin flap medially based, with
its blood supply from the first through the fourth perfo-
rator vessels and branches of the internal mammary
artery.
Characteristics and Advantages
1. It is usually not delayed.
2. It can be unilateral or bilateral.
3. The bilateral procedure can be simultaneous.
4. Usual length of the flap reaches the tip of shoulder
but it can be extended behind the shoulder or
inferior to the deltoid prominence or superior to
the spine of the scapula.
5. The deltoid portion is usually not hair bearing.
6. The flap is usually outside radiotherapy fields;
however, it may be in the field of scatter radiation
unless the donor site is lowered below the clavicles.
7. Blood supply is excellent with dependent venous
drainage.
8. The donor site is hidden, thus cosmetically
acceptable.
9. Flap can be rotated deep or superficial to cervical
flaps, depending on purpose.
10. Flap can be split longitudinally and distally and de-
epithelialized proximally (Krizek and Robson,
1973).
Disadvantages
This flap requires a second stage to close an orocuta-
neous fistula unless an epithelial shave is performed.
An epithelial shave is the removal of the epithelium of
the flap where it comes in contact with the overlying
cervical flap. The failure rate is 9 % to 18 %. If the flap
is used to cover the carotid vessels, blowout of the
carotid artery is a hazard if the flap fails.
Highpoints
1. Ratio of base of flap to length of flap IS of little
concern.
GENERAL PURPOSE FLAPS
2. Exercise caution when elevating flap at base to avoid
injuring the perforator vessels. The flap includes the
fascia of the pectoral muscles, excluding the thin
musculature investing fascia.
3. Meticulous care should be taken in the handling of
the flap.
4. Provide postoperative care to avoid kinking or
compression of the flap by dressing, drains, tubes, or
tape of the tracheostomy tube.
S. If the flap is to be passed beneath cervical flaps, the
lower cervical incision must be horizontal and is
usually the same incision as the superior incision of
the flap.
6. Delay flap, if:
a. Tissue turgor is poor.
b. Systemic disease is present (e.g., severe arterio-
sclerosis, diabetes, or severe malnutrition).
c. Excessive length-however, Bakamjian does not
necessarily use this as a reason for delay.
d. Scatter radiation over donor site.
7. Usually incise distal esophagus in vertical plane for
1 to 2 em to enlarge the esophageal opening when
the flap is used to reconstruct the esophagus.
8. Do not drape flap over the hardware that is used to
stabilize the ends of resected mandible.
9. If there is a significant and objectionable dead space
above the clavicle, resect the medial one third of
clavicle to coapt flap to underlying soft tissue and
vessels.
Types of Delay
1. Complete skin incision without elevation (preserves
thoracoacromial vessels).
2. Complete skin incision with elevation and return
(transects thoracoacromial vessels).
3. Partial skin incision:
a. Leave small area along the axillary area for
dependent venous drainage.
b. Leave small area along superior margin near
thoracoacromial vessels.
Reconstruction of Oropharynx,
Hypopharynx, and Portion of Cervical
Esophagus
For a discussion of carcinoma of the hypopharynx and
cervical esophagus, see Chapter 21.
 GENERAL PURPOSE FLAPS
Deltopectoral Flap (Continued)
(Fig. 8-4) (After Bakamjian, 1965)
A, A 1 Skin incision is outlined for a total laryn-
gopharyngectomy, partial cervical esophagectomy,
and left radical neck dissection with immediate
reconstruction using a deltopectoral flap. The dotted
line at the distal end of the flap depicts an extension of
the flap below and behind the deltoid prominence. A'
depicts a more horizontal and posterior extension,
which is preferred. The distal end of the flap can be
extended superior to the spine of the scapula (dotted
line). This has the advantage of combining the cervical
incision with the superior flap incision throughout its
entire length. This eliminates the small posterior trian-
gular skin flap X in step A. The lower horizontal cervical
incision (McFee) is the same as the superior incision for
the flap at its medial end.
B The ablative surgery has been performed. The
deltopectoral flap is elevated without delay and gently
passed beneath the bipedicle cervical flap.
Continued
 GENERAL PURPOSE FLAPS

A
INT. MAMMARY AND PERFORATOR
ARTERIES
/

FIGURE 8-4
 GENERAL PURPOSE FlAPS

Deltopectoral Flap (Continued)

(Fig. 8-4) (After Bakamjian, 1965)
C The distal end of the flap is approximated to the
transected end of the pharynx with interrupted or
continuous nylon, chromic catgut, or Dexon sutures.
Although nylon causesthe least tissue reaction, it can
be troublesome, because it does not absorb. If the
distal end of the flap is curved superiorly, the posterior
cervical triangular skin flap X is eliminated. This
modification is more desirable. The knots should be
buried if nylon is utilized. A feeding tube is passed
along the inside of the flap.

BASE OF TONGUE

EDGE OF PHARYNX

FIGURE8--4 Continued

FIGURE 8-4 Continued
For defects of the hypopharynx, reconstruction can
be achieved by a one-stage operation utilizing a tongue
flap and a dermal graft (see Fig. 21-7).
D The anastomosis of the distal end of the flap to the
pharynx is completed, and the flap is tubed. Depicted
GENERAL PURPOSE FlAPS
\
\
is the vertical line of closure of the flap, thus forming
the tube with the skin surface as the lining of the new
gullet. The feeding tube has been passed into the
esophagus. The esophageal lumen is incised (along
the dotted line) for 1 or 2 cm to enlarge the opening.
Continued
 GENERAL PURPOSE FLAPS
Deltopectoral Flap (Continued)
(Fig. 8-4) (After Bakamjian, 1965)
E, F Anastomosis of the side of the tube flap to the
end of the esophagus is performed using interrupted
sutures. If nylon is used, the knots are buried.
G Completion of the anastomosis except for a most
inferior portion, which forms the fistula (arrow).
Conley has performed an epithelial shave-removal of
the epidermis-at this site and then has closed the
fistula at this initial stage. Usually,closure of the fistula
is performed some 4 to 6 weeks later.
Continued
Complications
• Nine percent of the deltopectoral flaps in the author's
hands have lost viability.
• A carotid artery blowout occurs if flap loses viability
when used to cover the vessel.
• Serious aspiration may occur when flap is used in
combined reconstruction. A laryngectomy could have
been performed; however, the problem was simply
solved by performing a permanent tracheostomy
and total stripping and suture approximation of both
vocal cords.
• Dysphagia and pooling of food may occur.
• Most flaps do not have any muscular function; hence,
there may be difficulty in swallowing and propelling
food.
• There may be infection and fistula formation.
• Stenosis of reconstructed gullet may occur.
 GENERAL PURPOSE FlAPS 431

ESOPHAGU

FIGURE8-4 Continued
 GENERAl PURPOSE FlAPS
Deltopectoral Flap (Continued)
(Fig. 8-4) (After Bakamjian, 1965)
H The first-stage reconstruction and the ablative sur-
gery are complete. The fistula (arrow) is lateral to the
tracheostoma. The tube flap esophageal anastomosis
with the feeding tube and the vertical closure of the
flap to form the new gullet are "ghosted in" for clarifi-
cation. A split-thickness skin graft covers the donor
site. Care must be taken that there is no compression
of the "neck" of the flap by a circular dressing or the
tracheostomy tube tape.
Four to 6 weeks later the second stage is performed
to revise the lower anastomosis and thus close the
fistula as well as transect the flap and return the
proximal unused portion of the flap to the chest wall.
The previous anastomosis is exposed and the flap
transected along the dotted line. The skin graft is
partially elevated off the flap and chest wall.
J Transection of the flap is completed along the
dotted line and returned to the chest wall.
K The original side-to-end anastomosis is now
converted to an end-to-end anastomosis. The skin is
then closed without wound drainage. A feeding tube
is inserted and kept in place for about 1 week.
 GENERAL PURPOSE FLAPS

TUBED FLAP

FIGURE 8--4 Continued

 GENERAL PURPOSE FLAPS
Applications of Deltopectoral Flap
(Figs. 8-5 and 8-6)
The deltopectoral flap can be used to reconstruct the
cervical esophagus (see Fig. 8-4), intraoral defects,
floor of mouth, tongue, skin of the neck, chin and face,
wall of hypopharynx, and oropharynx and can be used
as a covering for carotid artery and vascular grafts. It
can also be combined with other flaps (e.g., apron flap)
(Haar, 1970). Bilateral deltopectoral flaps can also be
utilized, with one flap forming the inner lining and the
other flap used as the outer skin covering. Several
examples are depicted. Reconstruction of the lower lip
can be done with Bernard flaps (see p. 482) or the
modified Dieffenbach technique (see p. 484).
A A deltopectoral flap is used to cover a large skin
defect in the region of the chin after resection of a
portion of the mandible and anterior floor of the
mouth. The inner lining can be covered with the
forehead flap brought intraorally under the detached
zygomatic arch (see Figs. 14-10 and 15-10). The lips
are sutured together to temporarily prevent the lower
lip from drooping. The portion of the flap lying beneath
the cervical flap can be de-epithelialized-an epithelial
shave (Krizek and Robson, 1973)-thus eliminating a
second procedure to return that portion of the
deltopectoral flap to the donor site.
B A long deltopectoral flap extending around the tip
of the shoulder was delayed and then used to recon-
struct a portion of the soft palate, lateral oropharyngeal
wall, and a portion of the base of the tongue. The flap
is to be rotated on its long axis. This flap lies beneath
the cervical flap of a radical neck dissection. After
assurance of the viability of the deltopectoral flap, the
overlying cervical bipedicle flap is resected and
discarded. The fistula associated with this flap is then
closed by using local turn-in flaps.
C A long deltopectoral flap is utilized to cover a large
defect in the region of the parotid gland, neck, and
face. The base of this flap is exterior to the cervical skin
and is either tubed or bare under the area dressed with
split-thickness skin. After viability is ensured, the unused
portion of the pedicle of the flap is returned to the
chest wall if the pedicle has been tubed.
Another application of the modification of the del-
topectoral flap is the splitting of the flap at its distal end
in such a fashion that a portion of the flap can then be
used for outside covering while the other portion of the
flap is used for inside covering. This is particularly
applicable for uses in the oral cavity with an external
defect.
 GENERAL PURPOSE FLAPS

FIGURE 8-5
 GENERAL PURPOSE FLAPS
Applications of Deltopectoral Flap
(Continued) (See Fig. 8-6)
Apron Flap
A Depicted is an apron flap (Edgerton, 1960;
Edgerton and Snyder, 1965; Farr et aI., 1969) elevated
with a concomitant resection of the floor of the mouth,
partial glossectomy, and radical neck dissection. The
mandible has been preserved according to the criteria
in some reports. Farr and colleagues (1969) extend the
inferior dip of the apron flap below the clavicles. Tip
necrosis can occur with such a long flap. The X repre-
sents a superior extended deltopectoral flap, which is
usually preferred.
B The apron flap has been brought into the floor of
the mouth and sutured to the remaining tongue and
gingiva, thus allowing reconstruction of the intraoral
defect after a resection of the floor of the mouth and
partial glossectomy, with preservation of the mandible.
The apron flap donor site is now covered with a
deltopectoral flap (Haar, 1970). This may be readily
combined with a radical neck dissection. The arrow
depicts the planned fistula, which is closed at a second
stage. An epithelial shave can prevent this fistula
during the first stage.
Although a deltopectoral flap can be used directly to
reconstruct the anterior portion of the floor of the mouth,
this combination with the apron flap has proved to be
very adaptable. The forehead flap is somewhat more
adaptable for reconstruction of the anterior floor of the
mouth, whereas the deltopectoral flap is more adapt-
able for reconstruction of the posterior regions.
 GENERAL PURPOSE FLAPS

FIGURE 8-6
 GENERAL PURPOSE FLAPS
Laterally Based Chest Flap (Fig. 8-7)
(After Conley, 1960)
Highpoints
1. It is usually not delayed.
2. The donor site is cosmetically acceptable in males
and not as adaptable in females because of the
breast.
3. The donor site is able to be covered with local
advancement flaps or skin graft.
A Pictured is a patient with two separate recurrences
after a right jaw and radical neck resection for carcinoma
of the floor of the mouth. One recurrence is in the
submandibular region; the other involves soft tissue
over the sternoclavicular area. Treatment consisted of
planned preoperative super-voltage radiation therapy
followed by surgical resection and immediate recon-
struction using a bipedicle cervical flap combined with
a laterally based chest flap. The areas of resection are
outlined in solid lines, which correspond to horizontal
cervical skin incisions. Between the two areas of resec-
tion is a bipedicle horizontal cervical flap. The laterally
based chest flap is outlined with the broken line. A
vertical incision below the nipple is made to facilitate
closure of the donor site. Both flaps are full thickness.
The chest flap includes all soft tissue down to the level
of the pectoral muscles.
The blood supply of this laterally based chest flap is
the following: (1) cutaneous branch, coracoid branch,
and transverse scapular artery; (2) cutaneous branch,
coracoid branch, thoracoacromial branch, and axillary
artery; (3 and 4) cutaneous branch, deltoid branch,
thoracoacromial branch, and axillary artery. The lateral
thoracic artery may likewise contribute to the flap.
In faint outline are the inverted Y- and H-type neck
dissection incisions from the original surgery. These are
well healed and offer no problem for new flaps as
planned.
B The areas of local recurrence have been resected.
The medial third of the clavicle can be removed if
necessary (see Fig. 8-2G). The upper bipedicle cervical
flap is elevated and advanced upward. This advance-
ment enlarges the lower defect, which, however, will
be easily closed by the laterally based chest flap.
C The laterally based flap is elevated, including all
soft tissue, to the level of the pectoral muscles. Its
blood supply, laterally based, is preserved. The perfo-
rating vesselsof the branches of the internal mammary
artery medially are necessarily sacrificed. The flap is
then rotated upward to close the lower cervical defect.
The donor site is closed by advancing the inferior skin
margins upward. A vertical incision is of some help in
this maneuver. Hemovac tubes are inserted as depicted.
If the donor site is too large, it is covered with a split-
thickness skin graft.
D The completed procedure.
 GENERAL PURPOSE FLAPS 439

(
/

FIGURE 8-7
 GENERAL PURPOSE FLAPS
Mutter (1842) Nape of Neck Flap
(Fig. 8-8) (After Corso et al., 1963)
This is a cutaneous flap, not to be confused with the
trapezium myocutaneous flap.
Highpoints
1. Delay is recommended.
2. The flap may be lined with split-thickness skin graft
or not lined, depending on the defect to be covered.
3. If a concomitant radical neck dissection is performed,
it is best to preserve posterior auricular and occipital
arteries.
4. This flap may be preferable to a deltopectoral flap in
females, because the latter type flap deforms the
breast.
S. It is useful in closing orocutaneous fistulas and
defects of the side of the face and neck as well as of
the palate and lateral oropharynx wall.
6. It preserves the 11th cranial nerve.
A The arterial supply is superior via the posterior
auricular and occipital arteries on the homolateral side.
If there has been an interruption of these vessels
during a radical neck dissection, the superior base of
the flap can be widened to include the same group of
vessels on the contralateral side. This, however, will
limit the mobility of the flap to some extent. One of
two types of delay is performed, depending on the
type of defect to be covered.
Two-Stage Delay
B If an extensively lined flap is necessary (e.g., with
an orocutaneous fistula), and time is of little concern,
a two-stage delay is performed by first making the two
lateral parallel incisions and then lining the flap and
the donor site with split-thickness skin.
C In 10 to 14 days, the inferior margin is transected.
The excess split thickness on the flap lining is removed,
leaving an island of skin corresponding to the size of
the orocutaneous fistula, as depicted. A portion of
split-thickness graft is left proximal to the dotted line
of the flap if not tubed. If the flap is tubed, all split-
thickness skin is removed from the proximal portion of
the flap. The edges of the fistula are cleared of granula-
tion tissue and possibly some skin to afford a good
base for the transposed flap. Occasionally, sufficient
skin can be mobilized around the edge of the fistula to
form a trap door-type turn-in flap to line the transposed
flap. Usually, this has not been successful and is not
recommended because of a poor blood supply to the
trap door flap. The flap is transected when blood
supply and healing around the fistula are secured. This
occurs 2 to 3 months later. The remaining portion of
the flap is returned to the donor site. A rubber-shod
intestinal clamp or Huffman-Iowa clamp can be placed
across the pedicle for 15 minutes to evaluate the
adequacy of blood supply.
One-Stage Delay
D A single-step delay is achieved by simply incising
around the entire flap, as depicted. The flap is elevated
to include the fascia of the underlying muscles and is
returned to the donor site. The area to be covered is a
large skin defect overlying the side of the cheek.
E In 10 to 14 days, the flap is swung into position
and sutured in place. The original defect may have
occurred along with a neck dissection. In such cases,
the delay is done before the neck dissection so that the
definitive surgery and the reconstruction are performed
concomitantly.
F After suitable healing has occurred, the flap is
transected and the remaining portion is returned to
the donor site. The time interval may be from 6 to 12
weeks, depending on the estimated blood supply.
Cross clamping the pedicle with a lightweight rubber-
covered clamp can be performed to evaluate this blood
supply as described under C. The histamine wheal test
can also be used to evaluate the competency of the
blood supply. This is performed by first occluding the
blood supply at the base of the pedicle with clamps, as
described previously (see C). Several areas just distal to
the clamp and a comparable area on the opposite side
of the body are scarified with a needle. A drop of
1:1000 histamine acid phosphate is then applied to
each scarified area. Ifthere is an adequate blood supply,
a wheal will occur in both areas at about the same
time, usually within 8 minutes (after Conway et aI.,
1951).
 GENERAL PURPOSE FLAPS I 441

\
F
\

FIGURE 8-8
 GENERAL PURPOSE FLAPS
Posterior Scapula Flap (Fig. 8-9)
Highpoints
1. This flap is indicated primarily in large basal cell or
smaller squamous cell carcinoma of the skin located
in a posterior lateral cervical region.
2. It may be combined with radical neck dissection by
utilizing a large cervical flap based anteriorly.
3. Wide and deep resection of lesion is possible.
4. It is a non-delayed flap.
5. It is a wide base to scapula flap.
A A triangular area with a lesion to be excised is
shown. The blood supply of the scapula flap is from
the superficial cervical and transverse cervical arteries
arising from the subclavian artery. The dotted line
depicts a superior extension that may be necessary to
mobilize a superior occipital flap to aid in the closure.
The blood supply of this flap is from the ascending
branch of the occipital artery. The other solid lines are
the incisions for the scapula flap and the cervical flap.
B Appearance after the lesion has been excised. It is
advisable to obtain frozen sections to check the ade-
quacy of the depth of resection if there is any question
regarding deep extension. If so, underlying muscle is
removed. The larger scapular flap and smaller cervical
flap are undermined and advanced.
C The completed closure should be made with
minimal tension. One drawback to this type of closure
is the three lines of closure at the apex. If the occipital
portion is elevated and advanced, there will be four
suture lines at the apex; this is a further drawback. A
pectoralis major myocutaneous flap may be preferred
(see Fig. 8-2A).
 GENERAL PURPOSE FLAPS

A
\ WabnTIt

\
FIGURE 8-9
 GENERAL PURPOSE FLAPS
Forehead Flap (Temporal Flap)
(Fig. 8-10) (After McGregor, 1963)
General Data
The forehead flap, a myocutaneous flap, and its modifi-
cations can be used for a large number of reconstruc-
tion procedures: cheek (inside and outside), floor of
the mouth, nose, upper eyelid, chin covering for recon-
structed mandible, portion of tongue, and alveolar
region. More often than not it can be nondelayed if both
the superficial and temporal and posterior auricular
arteries are included in its base and not extended beyond
the midline. It is best to delay the flap if it extends
beyond the midline of the forehead, especially if a radical
neck dissection is performed (Cramer and Cult, 1969).
The flap may be in jeopardy if a radical neck dissection
has been performed in which the feeding vessels of the
external carotid artery have been sacrificed, although
some surgeons report no difference at all (McGregor,
1963). Another problem is the cosmetic deformity. In
younger patients, it is much less desirable, especially in
reconstruction procedures for tissue loss after trauma.
Other flaps from the neck or pectoral region are much
preferred. When using the forehead flap, less deformity
is usually noted if the entire forehead is utilized. Follow
the hairline. There may be a problem in males with
subsequent receding hairlines. A split-thickness skin
graft taken from the anterior chest wall if practical is best
for covering the donor site of the forehead. Numerous
variations of forehead flaps are depicted in the follow-
ing figures. Other varieties are in Figures 6-28, 6-29,
8-llA to G, 8-12, 14-10, and 15-10. Remember not to
cause more deformity than what is being reconstructed.
For example, use of a forehead flap to reconstruct a
palate is hardly justified when a prosthesis will serve
the purpose.
Highpoints
1. The flap is usually not delayed if the posterior
auricular artery and the superficial temporal artery
are included in the base and the flap does not extend
beyond the midline of the forehead; otherwise, delay
the flap, especially with radical neck dissection.
2. A full-thickness flap is taken down to periosteum of
skull (pericranium) including the frontalis muscle.
3. Use only a non-hair-bearing portion of the forehead
for intraoral reconstruction. The base does include
hair at the temporal region, but this is later returned.
4. Some surgeons bring the flap through the cheek, via
a separate incision well below the zygomatic arch.
Care must be taken not to injure the facial nerve or
the ducts of the parotid salivary gland. Others prefer
to tunnel the flap through an incision either just above
or just below the arch. The superficial temporal artery
must not be injured.
5. The tunnel may be superficial or deep to the zygo-
matic arch. If deep, fracture the arch outward to avoid
pinching of the base of the flap between the arch
and the temporalis muscle or resect the coronoid
process of the mandible.
6. When teeth are present, the flap can be pinched as
it crosses the occlusion line.
7. Another serious point of jeopardy is the crossing of
the flap over a Kirschner wire if there is undue
tension or angulation.
8. The base or pedicle can be returned in 3 to 4 weeks
but should be limited to only hair-bearing areas.
A, A 1 The forehead flap is outlined. Note that the
contour follows the eyebrows and the forehead hair-
line. This is more pleasing cosmetically. The lower
incision of the flap must not extend beyond the level
of the lateral canthus to avoid injury to the facial nerve.
The incisions are beveled to minimize the cosmetic
deformity along the remaining edges of the forehead
and scalp.
The dotted horizontal line depicts the incision
through which the flap enters the oral cavity. A lower
point of entrance can also be utilized. If so, do not
injure the facial nerve or the parotid duct system.
B A tunnel is formed through an incision just below
the zygomatic arch. This can be performed with
Metzenbaum scissors or a large Kelly clamp. Effort
must be made to avoid injury to the facial nerve and
parotid salivarygland. The donor site and bare exposed
area of flap are covered with split-thickness skin. Skin
from the anterior chest wall, if not hairy, is a good
cosmetic cover. The dotted line indicates the intraoral
position of the flap. Tailor the intraoral portion to
avoid excess length and bulk.
C The distal end of the flap is brought into the
intraoral defect and sutured in place with 3-0 or 4-0
nylon. It can be used to cover cheek, alveolar region,
floor of mouth, tongue, and a somewhat posterior to
tonsil region if it is wide enough. The flap is not
sutured to the tongue if only the buccal wall is
reconstructed. Suturing it to the tongue would tether
the tongue and create a problem in mastication and
swallowing. On the other hand, it may be necessary to
approximate the tongue to the flap if the tongue is the
only soft tissue available medially. The arrow delineates
the tunnel and a temporary fistula. The pedicle is
sectioned along to the dotted line in 3 to 4 weeks, and
the base of the flap is withdrawn from the tunnel and
returned to the forehead or discarded.
 GENERAL PURPOSE FLAPS

SUPERIOR TEMPORAL A.

\ ,

\
/

c
FIGURE 8-10

The free vascularized flap would be the first choice there is pressure on the flap.) This method of intro-
for buccal wall reconstruction if the defect involves the duction is preferred by the author. The section of
skin. Jejunum (free graft vascularized) is a method to zygomatic arch is left attached to the overlying fascia
replace the mucosa and underlying soft tissue because and realigned after the base of the flap is returned.
it provides moist mucosa and may prevent scar con-
tracture. An alternate is dermal graft for inner lining.
Complications
D An alternate tunnel is deep to the zygomatic arch,
• Hemorrhage
which is fractured along the dotted line. (The coronoid
• Necrosis, especially at pressure points
process of the mandible may be likewise fractured if
• Facial nerve injury
 GENERAL PURPOSE FLAPS
Reconstruction of Cheek with
Forehead Flap (Fig. 8-11)
This type of forehead flap with a lined skin graft sur-
face is available for deep soft tissue and bony defects
of the maxillary region. However, most of these areas
are for the most part better reconstructed with a micro-
vascular free flap, especially large facial defects. Intra-
oral defects can be reconstructed either with a pectoralis
major myocutaneous flap (see pp. 404 and 420) or
microvascular free flap (see Chapter 24). On the buccal
wall if there is need for a skin graft, a dermal graft is
preferred. The flap must bridge the defect. A cavity
simulating the antrum is thus reconstructed with depend-
ent drainage, because otherwise a closed cavity could
result with fistula formation or repeated infections. The
problem in reconstruction is the ultimate viability of
the flap, because the only source of blood supply is at
the edges of the defect and the pedicle itself. The edges
of the defect may be further compromised if the patient
has received any radiation therapy. Hence, the pedicle
is preserved and not transected.
Highpoints
1. Preserve superficial temporal and posterior auricular
vessels.
2. A forehead flap can be used with or without delay.
Delay in this case is preferred.
3. Allow permanent drainage from antrum into oral
cavity.
4. The base of the defect is previously skin grafted.
5. Delay all forehead flaps if external carotid artery has
been ligated.
6. A full-thickness defect of the buccal wall and cheek
can be reconstructed by using a forehead flap for
the outer cover and a pectoralis major flap for inner
cover. Another alternative is a microvascular free
flap.
A The skin incision as outlined includes the super-
ficial temporal vessels. The dotted line indicates the
inclusion of the posterior auricular artery, which facili-
tates nondelay. In a male, hair-bearing scalp may be
included, but in a female it should be excluded.
The defect consists of a loss of the entire anterior
and lateral bony wall of the maxilla along with the
overlying skin and muscles.
B The flap is full thickness, encompassing all soft
tissue with muscle down to but not including the
pericranium (periosteum of the skull). The flap is
rotated nearly 180 degrees and swung over the defect.
The distal end of the flap should easily overlap the
farthest edge of the defect by 1 cm. The incisions
mobilizing the flap are thus extended as necessary,
with care taken not to injure the main trunks of the
superficial temporal vessels and posterior auricular
vessels. At times only the galea aponeurosis need be
released.
The posterior and medial walls of the defect have
previously been covered with split-thickness skin graft.
C After satisfactory mobilization, the flap is returned
and sutured with continuous 5-0 nylon. The flap is
delayed in this case because of the poor vascularity of
the defect, which was previously irradiated.
D In 2 to 3 weeks the flap is again elevated, rotated
180 degrees, and swung over the defect. If any shrink-
age has occurred, release incisions are again made
with the same precautions. Now, the inner side of the
flap and the donor site are grafted with split-thickness
skin, using slightly thicker skin for the forehead donor
site. Be sure the donor sites for the split-thickness skin
are hairless, because hair in the new antrum is a nui-
sance because occasionally some hair will grow.
E, F The edges of both defect and flap are trimmed
and freshened and very carefully approximated with
fine interrupted sutures. If the soft tissue is scant at any
edge on the defect, a wire suture through bone is used
and secured on the flap with a button or silicone disk
so the flap is not injured. Because the entire under-
surface of the flap has been previously covered with
grafted skin, the base of the pedicle need not be
tubed.
F1 After 2 to 3 months, the dependent edge may be
revised if it becomes rolled and edematous. This is
done by undercutting and overlapping the edges or
by using the fat flip flap of Millard (see Fig. 8-13).
G The drainage tunnel from the new antrum is
depicted in the gingivobuccal sulcus. The patient cares
for this with daily irrigations.
Continued
 GENERAL PURPOSE FLAPS

FIGURE 8-11
 GENERAL PURPOSE FLAPS

Reconstruction of Cheek with

I The inner layer of skin of the pedicle is dissected
Forehead Flap (Continued) (Fig. 8-11)
and discarded.

H After 4 to 6 months, the pedicle of the flap is J The skin on the side of the face under which the
denuded of skin and buried. In this fashion the vascular pedicle will be buried is now elevated with
superficial temporal vesselsare preserved, and viability upper and lower skin flaps.
of the flap is ensured. This is safer than transecting the Continued
pedicle, because the only other source of blood supply
is at the margin of the flap. These margins have a very
poor blood supply because of previous irradiation. The
outside layer of skin is elevated by sharp dissection
from the pedicle. It is preserved at both ends and
retracted with stay sutures.
 GENERAL PURPOSE FLAPS ~9

"'-- l" ,
j
I
j,'

FIGURE 8-11 Continued

 GENERAl PURPOSE FLAPS
Reconstruction of Cheek with
Forehead Flap (Continued) (Fig. 8-11)
K The full-thickness lower skin flap is elevated. The
same technique is used on the upper flap.
L The pedicle is covered with the upper and lower
flaps, using interrupted sutures of 5-0 nylon.
M The remaining defects are covered with portions
of skin from the pedicle, which are trimmed
accordingly.
N Subcutaneous adipose tissue is removed from the
distal portion as required to achieve a smooth surface.
This is a type of island flap with the vascularpedicle
buried.
 GENERAL PURPOSE FLAPS

FIGURE 8-11 Continued

 GENERAL PURPOSE FLAPS

Midline Forehead Flap (Fig. 8-12)

(After Kazanjian, 1946) A 1 The flap is turned down to the nasofrontal angle
with sharp dissection. From here down, meticulous
Highpoints blunt dissection is used to preserve the blood supply
via the supratrochlear and dorsal nasal vessels. Tardy
1. This flap is useful for full-thickness defects of the states that mobilization of the base of the flap can be
nose, including the ala and portions of the columella below the level of the eyebrows by careful dissection
and cheek, especially below the eye. so as not to injure the supratrochlear arteries. Interest-
2. It may be lined with split-thickness skin if necessary. ingly enough, there are redundant skin and soft tissue
3. No delay is required. in this area that facilitate rotation of the flap without
4. Blood supply is via both supratrochlear arteries with tension. A patch of split-thickness skin is sutured with
contribution from the dorsal nasal branches. 5-0 chromic catgut to the raw surface of the flap corre-
5. Extreme care must be exercised with incisions: The sponding with the deep through-and-through defect
upper portions of the incisions are carried down in the nose.
to the periosteum, whereas below the level of the
nasofrontal angle the incisions are through skin only, B Through-and-through defect of the nose.
and dissection at this area is blunt to avoid injury to
the supratrochlear vessels. C The major portion of the donor site is closed by
6. Be sure there is adequate length, keeping in mind mobilization of the lateral skin margins. This may
the fact that the flap must be rotated in loose fashion require rather extensive undermining of the skin.
so as not to compromise the vascular supply. Inferiorly, the donor defect is covered with a triangular
section of split-thickness skin; otherwise, mobilization
Depicted is a nasal defect resulting from resection of of skin at this point will bring the eyebrows too far
a tumor; this type of reconstruction is equally well medially. When the flap is severed in about 3 weeks,
suited to a defect due to trauma. the unused portion is returned to that portion of the
donor site that had been covered with the split-
thickness skin graft.
A Outline of the flap with associated blood supply
and tumor of the nose to be resected. The upper D Here this flap is utilized to close a defect of the
extent of the midline incisions reaches the hairline. cheek just below the lower lid. The advantage of this
This portion of the flap is carried by sharp dissection type of reconstruction is ease of coverage, with
down to the periosteum. From the nasofrontal angle, prevention of ectropion of the lower lid.
the incisions are carried only through the skin, as out-
lined by the dotted lines. There is minimal interference
with motor function of the forehead, because little if A modification of this flap is the island flap (Esser,
any significant portion of the frontalis muscles is 1917), in which the flap with its blood supply is
involved in the flap. tunneled under an intact bridge of skin at the glabella.
 GENERAL PURPOSE FLAPS

FIGURE 8-12
 GENERAL PURPOSE FLAPS

Fat Flip Flap (Fig. 8-13) (After Millard

et aI., 1969) A The skin scar is excised along one border of the
flap.
Indication
B The skin and some subcutaneous tissue elevated
• To reduce bulging edema of transposed flaps from the adjacent area are slightly thinner than their
counterparts from the flap. The fat flap is outlined with
Highpoints the dotted line. This includes the bulging edematous
adipose tissue from the original flap.
1. Stage the procedure with l-month interval (Le.,
operate one border of flap at a time). C The fat flap is flipped over 180 degrees and
2. Excise skin scar along one edge. sutured as far as possible across and under the
3. Elevate skin and subcutaneous tissue of half of flap. elevated skin of the adjacent area. In this manner the
4. Dissect edematous and bulging fat in retrograde bulging adipose tissue is transferred to the adjacent
fashion as a second flap. area, which is depressed and wanting of adipose
5. Elevate at a slightly more superficial plane surround- tissue.
ing adjacent skin juxtaposed to the flap.
6. Turn the fat flap back as far as possible and suture. D The final closure is shown in cross section. The skin
7. Perform skin closure in a straight line if the closure closure is in a straight line approximating a natural
follows a natural skin line; closure should be in crease. Where the skin closure crosses the natural lines,
multiple Z-plasties if it crosses a natural skin line. multiple Z-plasties are performed (see Fig. 3-2Q to V).
8. Repeat the same technique on the other side of the
flap about 1 month later.

TRANSPOSED FLAP

A c

B D

FIGURE 8-13

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J Surg 144:473-476, 1982.
Lore JM Jr, Zingapan EG: Oeltopectoral flap. Arch Otolaryngol 94:
13-18, 1971.
Macomber WB, Wang MH: Tubed neck flaps in facial reconstruction.
Plast Reconstr Surg 45:346, 1970.
Magee WP, McCraw JB, Horton CE, Mcinnis WO: Pectoralis "paddle"
myocutaneous flaps. Am J Surg 140:507-513, 1980.
Maisel RH. Liston SL: Combined pectoralis major myocutaneous flap
with medially based deltopectoral flap for closure of large pharyn-
gocutaneous fistulas. Ann Otol Rhinol Laryngol 91:98-100, 1982.
Mathes SJ, Nahai F: Classification of the vascular anatomy of muscles:
Experimental and clinical correlation. Plast Reconstr Surg 67:
177-187,1981.
Maves M, Phillippen LP: Surgical anatomy of the scapular spine in
the trapezius-osteomuscular flap. Arch Otolaryngol 112:173-175,
1986.
McGraw lB, Furlow LT:The dorsalis pedis arterialized flap: A clinical
study. Plast Reconstr Surg 55:177-185,1975.
McGraw lB, Magee WP, Kalwaic H: Uses of the trapezius and ster-
nomastoid myocutaneous flaps in head and neck reconstruction.
Plast Recomtr Surg 63:49-57,1979,
McGraw lB, Myers B, Shanklin KD: The value of fluorescein in
predicting the viability of arterialized flaps. Plast Reconstr Surg
60(5), November 1977.
McGregor IA: The temporal flap in facial cancer: A method of repair.
Presented before the Third International Congress of Plastic
Surgery, 1963.
McGregor lA, Reed WH: Simultaneous temporal and deltopectoral
flaps for full-thickness defects of the cheek. Plast Reconstr Surg
45:326, 1970.
Mehrhof AI, et al: The pectoralis major myocutaneous flap in head
and neck reconstruction. Am 1 Surg 146:478-482, 1983.
Mendelson BC: The pectoralis major island flap: An important new
flap for head and neck reconstruction. Br J Plast Surg 33:318-323,
1980.
Millard DR, Stokley PH, Campbell RC: The fat flip flap. Plast Reconstr
Surg 44:202-204, 1969.
Milton SH: Experimental studies on island flaps: 1. The surviving
length. Plast Reconstr Surg 48:574-578, 1971.
Moloy Pl, Gonzales FE: Vascular anatomy of the pectoralis major
myocutaneous flap. Arch Otolaryngol Head Neck Surg 112:66-69,
1986.
Morain WD, Geurkink NA: Split pectoralis major myocutaneous flap.
Ann Surg 5:358, 1980.
Mouly R: Le lambeau en "u" jugal pour la reparation des pertes de
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Mustarde lC: The use of flaps in the orbital region. Plast Reconstr
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Myers MB, Cherry G: Differences in the delay phenomenon in the
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Narayanan M: Immediate reconstruction with bipolar scalp flap after
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1970.
Nichter LS, Morgan RF, Harman OM, et al: The trapezius musculo-
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pectoralis major myocutaneous flaps. Am J Surg 147:273-279,
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bipedicled deltopectoral flap and a Ticonium prosthesis: Case
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Plast Surg 34:334-337, 1981.
Lip Excision and Reconstruction
(Fig. 9-1) A An incision is made through the mucosa 0.3 to
0.5 em beyond the extent of the leukoplakia.
Planing of lip
B Following the vermilion border, or even including
Highpoints a small amount of skin if the leukoplakia has reached
the cutaneous margin, a flap of mucosa is separated
1. The entire exposed vermilion of either the lower or from the underlying muscle and excised.
upper lip or both may be excised for leukoplakia or
erythroplakia with immediate coverage using mucous C The remaining normal mucosa on the inner aspect
membrane advanced from the inner aspect of the of the lip is extensively undermined.
lip.
2. Obtain frozen section for any area suggestive of DUsing 5-0 nylon, the advanced mucosa is approxi-
carcinoma-toluidine blue stain may be of help. mated to the skin margin.
3. This operation may be combined with the shield
type of excision (see later) or the Abbe-Estlander E A "shield" type of incision is outlined with meth-
operation (see Fig. 9-4A to 0). ylene blue. If the lesion is malignant, 1 em of grossly
4. Specimen must be labeled "right" and "left" for normal tissue must be included on each side. The ver-
proper orientation of serial histologic study to rule milion edges on both borders are marked by a needle
out carcinoma. dipped in the dye. This aids in an accurate approxima-
tion of the vermilion edges following the excision. The
Complication excision is made through and through skin, muscle,
and mucous membrane. Grasping the lip between index
• Some flattening of the natural contour of the lip finger and thumb aids in the excision by stabilizing the
lip and controlling hemorrhage. Only after the com-
Shield Excision of lower lip plete excision are the vessels clamped and tied.

Highpoints F Layer closure is commenced by first approximating

the mucosa with interrupted 4-0 or 5-0 nylon.
1. Early carcinoma of lip up to 0.5 em in diameter can
be excised with adequate margins. G The orbicularis oris muscle and other deep
2. Up to one third of lower or upper lip may be structures have been carefully approximated using
excised-1.5 to 2.3 em-and the defect closed with 4-0 chromic catgut. The first skin suture of 5-0 nylon is
simple approximation of edges. Larger defects placed through the dye marks on the vermilion
require some type of reconstruction flaps. borders.
3. A three-layer approximation is used: mucous mem-
brane, muscle, and skin. H 5-0 Nylon is used to complete the closure.

458
 THE UPS

f
It

H
FIGURE 9-1
 THE UPS

Lip Excision and Reconstruction

(Continued) (Fig. 9-2) E The lesion with skin, mucosa, and underlining
muscle is excised. The muscle is approximated with
Procedures relative to deformities of the lip as well as one or more buried sutures of fine chromic catgut. The
more extensive facial paralysis can be found in Chapter initial skin suture is placed at the vermilion border.
7, pages 384 to 391.
F The completed closure.
Cupid/s Bow
Distortion of Mouth Corrected by
Indication
Z-Plasty
• When the upper lip is so deformed that the initial
repair has resulted in a straight horizontal line that G A Z-type incision is made through and through
makes the reconstruction all the more obvious, restora- the skin, muscle, and mucous membrane (see
tion of a Cupid's bow is indicated (see Fig. lO-lA for Fig. 3-2A to D).
normal anatomy).
H The full-thickness cheek flaps are swung as
depicted. A three-layer closure is used. The reverse Z-
A Triangular skin areas are outlined. plasty can be used (Gerold, 1960) for a drooping
commissure after section of the buccal division of the
B These areas are excised down to muscle that is facial nerve.
superficially incised along the dotted lines at each side
of the center of the bow. The mucosa of the lip is
Excision of large Benign lesions of
elevated from the muscle except in its midportion.
Upper Lip with Nasolabial Flap
C The completed restoration.
Skin incisions are made as outlined.

Elliptical Excision of Benign Lip lesion J The flap is rotated and sutured in position.
Extension of the incision is made to allow for closure of
Indication the donor site. The lateral skin margin is liberally
undermined .
• Small premalignant lesions and benign lesions
K The completed closure. Buried sutures of fine
D An elliptical skin and mucosal incision is outlined. chromic catgut or white silk are used subcutaneously.
 THE UPS

A B c

J K

FIGURE 9-2
 THE UPS
Repair of Large Vermilion Defects
(Fig. 9-3)
Highpoints
1. Use mucous membrane and muscle pedicle flaps.
2. If donor site defect is large, dermal skin graft or free
buccal mucous membrane serves as an excellent
buccal inlay.
3. Flap and pedicles must be thick to preserve adequate
blood supply.
4. Barton bandage is necessary for cross oral pedicles.
A A traumatic defect involves the central portion of
the lower vermilion. With both commissures evenly
retracted a bipedicle mucous membrane/muscle flap is
outlined on the upper lip. The outer or upper incision
is made about 0.5 em from the vermilion cutaneous
border, splitting the entire lip and leaving enough
attached at either side for an adequate blood supply.
The incision is made 1 to 1.5 em into the orbicularis
oris muscle. Another inner parallel incision is made at
least 1 to 1.5 em from the first incision depending on
the breadth of the defect in the lower lip. This likewise
includes the muscle and is directed so that it meets the
first incision deep in the muscle. The bipedicle flap
thus mobilized contains the superior labial artery (Al).
B The donor site can usually be closed by simple
approximation. If this is not possible without distortion
to the upper lip, especially the Cupid's bow, a free
split-thickness graft is inserted as depicted. The ragged
edges of the defect are trimmed.
C The bipedicle flap is now rotated 90 degrees so
that the inner edge of the flap is sewn to the skin
margin of the defect, and the outer edge of the flap is
sewn to the gingivobuccal margin of the defect. The
pedicle is carefully tubed near its base and closed pos-
teriorly so that there are no bare areas. A Barton band-
age is applied. The pedicles are severed after 2 weeks.
D This defect is a partial loss of the lower vermilion.
Reconstruction consists of the formation of a bipedicle
tube of mucous membrane and muscle from the lower
gingivobuccal sulcus, the donor site being covered
with a dermal or free buccal mucous membrane graft.
E The bipedicle flap is elevated and tubed while the
donor site is grafted.
F The next stage consists of transposing one end of
the pedicle to the edge of the defect, as shown by the
direction of the arrow in E.
G At the following stage, the defect is bared and the
pedicle untubed. The tube edges are now sutured to
the edges of the defect. A final stage may be necessary
to correct any inequality with the opposite side of the
lower lip.
 THE LIPS

skin graft

A B

FIGURE 9-3
 THE LIPS
Abbe-Estlander Lip Operation
(Fig. 9-4)
Highpoints
1. One third to one half of the upper or lower lip
can be resected for carcinoma with immediate
reconstruction.
2. Upper or lower lip defects after unsatisfactory cleft
lip repair or trauma can be reconstructed.
3. A full-thickness flap is utilized: skin, muscle, mucous
membrane.
4. The labial artery is preserved in the flap pedicle.
S. Local anesthesia or general anesthesia can be used.
6. With general anesthesia, extreme care is necessary
during the postoperative recovery phase regarding
airway obstruction and disruption of suture lines.
7. The vermilion borders are approximated.
A A shield of incision is outlined in methylene blue
(alcohol solution) with a minimum of 1 em of grossly
normal tissue on either side of the tumor. The
vermilion border is marked at the point at which the
incisions cross with a needle dipped in the dye. This
aids the approximation of the vermilion borders when
suturing. Using calipers or another measuring device,
a similar triangular area is outlined on the opposite lip,
the length being equal to or slightly longer than that
of the resected defect while the base or width is one
half that of the defect. This achieves a proportionate
shortening of upper and lower lips. The pedicle of the
flap is usually medial and always contains the labial
artery, which must be carefully preserved. It is better to
leave a larger pedicle-usually 5 to 8 mm-beyond
the vermilion border than to risk injury to the artery. If
the lesion is so located that the safety margin allows
preservation of the natural commissure of the lips, this
is preferable. Otherwise, the commissure is resected
and reconstructed by a double Z-plasty or conversion
of V-type incision to a V (see Fig. 9-7H to K). The
commissure can also be reconstructed by using the
Gillies method (see Fig. 9-5A to D).
B The lesion with its borders is excised through and
through. Using a clean knife, the flap is mobilized
through and through except for the median pedicle.
C Using a stay suture, the flap is rotated.
D One suture of 5-0 nylon is placed through the
needle marks of dye at the vermilion edges. It is left
loose until a separate three-layer closure is done with
mucosa, muscle, and skin. This closure is best begun
along the medial margin of the pedicle. The muscle
sutures are 4-0 chromic catgut; the mucosa suture is
nylon or Dermalene.
E All the mucosal and muscle sutures are completed,
and the skin is approximated with 5-0 nylon.
F A crown-type suture approximates the lateral
edges of the lips with the pedicle so that the otherwise
exposed border of the pedicle is covered with mucosa
of the lips.
G Approximation is complete. Feeding through a
straw may be necessary. The pedicle is left intact for 3
to 5 weeks.
Continued
 THE LIPS 465

FIGURE 9-4
 THE LIPS

Abbe-Estlander Lip Operation

(Continued) (Fig. 9-4)
H In 3 to 5 weeksthe pedicle is transected (1-2), and
reapproximation of the vermilion border is accom-
plished by a modified Z-plasty. An incision (5-6) is
made along the previous scar for a distance of 1 to
1.5 cm equal to the width of the pedicle. A lateral
extension (3-4) is made that is slightly longer.
The completed incisions.
J Points 2 and 5 approximate one another, splitting
the distance along the line 3-4. The vermilion edge is
thus exactly realigned (1-6). The same procedure is
performed on the upper lip.
K The completed reconstruction.

FIGURE9--4 Continued
 THE LIPS 467

Correction of Rounded Commissure

of Lips (Fig. 9-5) (Gillies)
After major lip surgery in which the commissure has
been either resected or displaced, the rounded corner
may be corrected by the method of Gillies (Fig. 9-5) or
that of May (see Fig. 9-7H to K).
Highpoints
A A small triangle of skin is excised at the site of the
neW commissure. The vermilion of the lower lip is cut
at an angle along the solid line.
B The underlying muscle is cut slantwise at the site
of the new commissure. The inside layer of mucous
membrane is transected in a horizontal line leading to
the new commissure.

The Gillies technique is as follows: C The lower vermilion that was freed has been
rotated into the new commissure, forming a portion of
1. Excision of a small triangle of skin the upper lip. It is sutured inside and outside. The
2. Section of underlying muscle buccal layer of mucous membrane of the lower lip is
3. Advancement of mucous membrane now freed with scissors or knife.

D This mobilized mucous membrane is now

approximated to the cutaneous border of the lower lip
defect.

FIGURE 9-5
 THE LIPS

Plication of the Orbicularis Oris

A An incision is made along the vermilion of the
Muscle to Repair Partial Paralysis lower lip of the involved side.
of the Lower Lip (Fig. 9-6)
(Mahler et aI., 1982) B The vermilion is dissected from the orbicularis oris
muscle to the commissure and retracted with stay
Indication sutures. The muscle is then plicated upon itself, thus
shortening and thickening the muscle. Absorbable
• Paralysis or weakness of the depressors of the lower sutures are utilized.
lip, usually following sacrifice of the ramus
mandibularis of the facial nerve C This cross section depicts the plication. Glenn and
Goode (1987) have described another technique for
Highpoints correction of the deformity of the lower lip after either
trauma to the mandibular branch of the facial nerve or
1. Incision is along the vermilion of the lower lip. surgery in which that branch must be removed. Their
2. This procedure includes an overfolding of the orbicu- technique involves a shield-type excision of the lower
laris oris muscle of the lower lip. lip near the commissure, similar to that in Figure 9-1 E.

FIGURE 9-6

Modifications of Abbe-Estlander
Lip Operation (Fig. 9-7)
Reconstruction of Center Lower Lip
Defect
A Rotation of upper lip flap to close a center lower
lip defect.
B The commissure of the mouth is preserved.
Operative details are in Figures 9-4 and 9-5.
C When a crossed pedicle flap for center defects may
not be tolerated by the patient or when general anes-
thesia is necessary, this type of transfer flap is used.
During reaction from general anesthesia the patient
may not be controllable, and the usual crossed pedicle
flap (A and B) is endangered.
FIGURE 9-7
THE UPS
After the usual eXCISion of the lesion, a lateral
rectangular flap is advanced to close the center defect.
D The resulting medial defect is closed with an
upper lip flap that includes the commissure. The com-
missure is preserved by following the technique in
Figures 9-4 and 9-5. In any event, an attempt is made
to preserve the modiolus (hub) (modus muscularis),
which is the site at which the orbicularis oris is blended
with other muscles associated with the commissure.
The modiolus is located lateral to the commissure
along the nasolabial fold. It is important in the main-
tenance of a normal commissure (see Fig. 7-1).
E The completed closure.
Continued
i
i
 THE UPS

Modifications of Abbe-Estlander
H A double Z-plasty (after May, 1949) is utilized to
Lip Operation (Continued) (Fig. 9-7) elongate and to sharpen the commissure. This is done
at least 3 to 5 weeks after the initial operation. Excision
Reconstruction of Upper lip Defect
of a small triangle of skin may be required between
flaps 4 and 2.
F Defects in the upper lip are closed with a rotation
flap from the lower lip. I Flaps 1 and 3 are rotated outward, whereas flaps 2
and 4 are rotated inward; thus, 2 and 4 are exchanged
G A new commissure is formed by the pedicle from with 1 and 3.
the rotated lower lip.
J Another method of correction for commissure
deformity is conversion of a V-type incision to a V. A Y
Correction of Rounded Commissure of
incision is made as depicted. Some skin may require
lips
excision on the lateral borders.

Indication
K Point 5 is then advanced to point 5'.
For the Gillies method see Figure 9-5A to D.
When the pedicle of a rotated lip flap forms the new
commissure, the rounded corner is correctable when
the modiolus has been sacrificed (see Fig. 9-7D).
 THE LIPS
Reconstruction of Large Defects
of Upper Lip
In the Figures 9-8 to 9-12, different techniques are
depicted for reconstruction of large full-thickness
defects of the upper lip. The first procedure is the use
of the cheek flap (Paletta, 1954), with a tongue flap for
inside mucous membrane lining (Bakamjian, 1971).
The other flaps are the fan flaps, lateral flaps (Burow,
Gillies), and forehead flaps. Each has its own advan-
tages and disadvantages.
Burget and Menick (1986) have described a
modification of the Abbe-Estlander flap, at times
combined with a rotation flap similar to that shown in
Figures 9-9 and 9-11.
Reconstruction of Upper Lip with
Cheek Flap (Fig. 9-8) (After Paletta, 1954;
Bakamjian, 1971)
Highpoints
1. Wide resection of tumor is possible: this can include
a portion of the base of the columella and floor of
nose as well as full thickness of the upper lip.
2. Medial border of cheek flap follows nasolabial fold,
leaving underlying muscles intact.
3. New vermilion and mucous membrane of recon-
structed lip are formed by tongue flap.
A Malignant tumor involves a major portion of the
upper lip. The cheek flap is outlined, its medial border
following the nasolabial fold. Resection includes all
layers of the upper lip and a portion of columella and
floor of the nose.
B A horizontal fishmouth incision is dotted along the
tongue (Bakamjian, 1971). The cheek flap (Paletta,
1954) is already in position. The inferior tongue flap
(1) will form the vermilion and lower portion of the
reconstructed lip, whereas the upper tongue flap (2)
will form the inner mucous membrane lining.
C The cheek flap is fitted into the defect with the
tongue flap sutured in position. The cheek lateral to
the flap site and portion of skin of cheek are
undermined for closure of the donor site.
D Cross section depicts the position of tongue flaps.
E Close-up view of tongue flaps (1) and (2). A
diamond-shaped area of tongue muscle may be
excised at the time of the division of the tongue flaps
to facilitate approximation of the tongue mucous
membrane.
F, G The completed reconstruction.
The flap can be utilized to reconstruct the entire
columella. The base area near the base of the flap is
temporarily covered with split-thickness skin. This is
removed when the pedicle is transected and the base of
the flap is returned to the donor site. The bare area on
the contralateral side of the flap forming the columella
can be covered with a full-thickness or split skin graft
if necessary (see Fig. 6-230 and E).
 THE UPS

A B

CHEEK FLAP

c D

FIGURE 9-8
 THE LIPS

Fan Flap Reconstruction for Large

Defects of Upper Lip (Fig. 9-9) Al, A2 The mucous membrane is elevated from the
inner aspect of a portion (1-2) of the flap. This is
Highpoints advanced and sutured to the skin margin to form a
new vermilion for the rotated flap.
1. Main blood supply is through the labial artery using
same principle as an Abbe-Estlander flap (see Fig. 9-4A B The flap is rotated into position.
to OJ
2. All incisions are through and through into the oral C With the flap in position, the defect in the
cavity. nasolabial region is closed in two or three layers. As
this is done, the lateral incision (7-8) is made
Complications depending on the way the flap lies.

• Involved procedure D Suturing the flap begins at the most advanced

• Results in excess scars in cheek edge (2-3). A two- or three-layer approximation is
made. Point 8 along the lateral border of the cheek is
lost either by stretching or by trimming the corner.
A Two thirds of the upper lip is excised or has been
lost as a result of trauma. Skin incisions are made as E The completed reconstruction. The rounded
outlined by the solid lines extending through all layers commissure will require revision in 3 to 5 weeks (see
into the oral cavity. The distal extent of the incision (6) Figs. 9-5A to D and 9-7H to K).
is 0.5 to 1.0 cm from the cutaneous-vermilion border
to avoid injury to the labial artery. The lateral incision
(7 -8) is not made until the flap is rotated.
 THE UPS

\
I
I
,

A B

c D

~,
-----
FIGURE 9-9
 476 THE UPS
Excision and Repair of Large
Lesions of Upper Lip (Fig. 9-10)
In these drawings two types of operations are depicted.
In the first operation the reconstruction is based on
Burow's principle of excision of excess skin and muscle
with straight horizontal advancement. In the second
operation, reconstruction is achieved by a fan flap, as
in the Abbe-Estlander procedure, which utilizes the
labial artery as the source of blood supply. Gillies has
Gillies' Technique
a modification of the fan flap, which facilitates recon-
struction of the skin of the columella when this is
necessary. A significant drawback to both of these
procedures is narrowing of the oral orifice. Paletta's
technique may be preferred (see Fig. 9-8).
Burow's Technique
Highpoints
1. Full-thickness eXCISiOn of lesion and nasolabial
crescents is performed.
2. Adequate mobilization is possible along gingivobuccal
sulcus, with preservation of rim of mucous membrane
in gingiva.
A An incision is made through and through the
upper lip on both sides of the tumor with a horizontal
connection at the base of the columella. Crescent-
shaped arcs are outlined in the nasolabial areas to
permit straight horizontal advancement of the sides of
the defect.
B The full-thickness crescent-shaped areas and the
tumor are excised.
( Mobilization of the lateral flaps is achieved by
liberal incisions on both sides of the upper gin-
givobuccal sulcus. Sufficient mucous membrane is left
in the gingiva for suturing the advanced flap.
D Three-layer closure is performed: mucous mem-
brane, muscle, and skin.
E The mucous membrane closure is demonstrated.
The rounded commissures may be corrected by
following the technique of Gillies (see Fig. 9-5A to D)
or May (see Fig. 9-7H to K).
F The major portion of the upper lip and skin of
columella has been excised. Bilateral face flaps are
made as follows. A point X is marked on the vermilion
border at a distance from the commissure equal to
approximately half the length of the defect of the
upper lip. About 1.2 em below and slightly lateral to
this point, a through-and-through incision is made in
the same direction away from the vermilion for a
distance of about 2.0 em. The labial artery, vital to this
fan flap, is thus preserved. The incision is then carried
in an easy sweep along the nasolabial fold to the
lateral edge of the nose and then downward to the
upper edge of the defect. The entire incision is through
and through all layers. The gingivobuccal sulcus is also
incised as in C.
G The mobilized lip flaps are rotated. Above point 2
on the lateral border of the lip flap, an incision (3-4) is
made in the cheek flap to adapt the advanced cheek
flap to the lip flap. Thus, point 3 is approximated to
point 1 and point 4 is approximated to point 2. Point
5 is rounded or lost as the cheek is advanced. Point 6
is used to reconstruct the columella.
H The completed reconstruction.
 THE LIPS 477

H
FIGURE 9-10
 THE LIPS
Repair of Large Defects of Upper Lip
(Fig. 9-11)
Indications
In the rare situation in which the upper lip defect is
caused by patient neglect and poor or no treatment of
the lip margins, when the defect is not the result of tissue
loss but mostly the result of retraction of the lip margin,
an advancement with some of the fan flap principles is
suitable. The associated cheek defect in this patient was
covered with a forehead flap. The other complicating
circumstance was the absence of well-vascularized sur-
rounding soft tissue, as the result of radiation therapy.
The fact that the lip margins were retracted by cicatrix
formation permitted this type of reconstruction with
minimum narrowing of the oral orifice.
A A very liberal incision is made in the gingivobuccal
sulcus with mobilization of the lip and cheek beyond
the nasolabial fold. Another incision is made in the
nasolabial fold (1-2-3).
B The incision in the nasolabial fold is then extended
beneath the nares from point 4 to 5. This completely
mobilizes the upper lip and cheek. A small triangle of
tissue between '-2-4 may require excision.
C The upper lip flap is then advanced; the cheek is
likewise advanced to close the defect in the nasolabial
area. Three-layer closure is used if possible: mucosa,
muscle, and skin.
D The lower lip is mobilized with a through-and-
through incision following the fan flap technique (see
Fig. 9-9).
E The inferior gingivobuccal sulcus is incised deeply,
thus mobilizing the outer portion of the lower lip.
F After the opposing ends of each flap are trimmed,
a three-layer closure is mandatory.
G The first layer is the mucosa, using nylon.
H The second layer is muscle, using 3-0 chromic
catgut.
I The skin is approximated using fine nylon, the first
suture being placed in the cutaneous-vermilion line.
The remaining cheek defect is reconstructed using
a forehead flap (see Fig. 8-11) or a microvascular free
flap such as a radical forearm flap (see Chapter 24).
 THE LIPS

FIGURE 9-11
 THE LIPS
Bitemporal ("Visor") Flap for Large
Upper Lip and Cheek Defects (Fig. 9-12)
Highpoints
1. No delay is necessary.
2. If pedicles cannot be tubed, cover all bare areas with
split-thickness grafts.
3. Free microvascular flap would be ideal for recon-
struction of this type of defect (see Chapter 24).
A After the hair is shaved, a bipedicle temporal flap
is outlined, including the major branches of the super-
ficial temporal arteries in both pedicles. It is important
to include a non-hair-bearing area for the lip turn-in
portion of the flap. An alternate to this turn-in is a free
split-thickness skin or dermal graft. A tongue flap can
also be used as mucous membrane lining (see Fig. 9-8).
No delay is necessary, and the bipedicle full-thickness
flap, including the galea, is immediately swung into
position over the defect. This is particularly well suited
to resections for cancer, because the defect can be
covered at the same operation. Another distinct
advantage in resection of a malignant neoplasm is that
local flaps are not used; hence, spread of disease is
detected more easily and not confused with the scars
of local flaps.
Split-thickness skin grafts are used to cover the
donor site and the bare areas of the pedicles if tubing
of the latter is not possible.
B The underside of the central portion of the
biped ide flap is covered either with a non-hair-
bearing turn-in fold from the flap itself or with a split-
thickness, dermal, or buccal mucous membrane graft
or a tongue flap or a combination of both. A horizontal
row of sutures is placed along any remnant of the
gingivobuccal mucous membrane. The lateral edges
of the lip and cheek defect are approximated as well as
possible to the bare undersurface of the bipedicle flap.
This will require revision at a later stage.
C The bipedicle flap is in position with sutures along
the upper edge of the flap to the upper edge of the
cheek and lip defect. The dotted lines indicate the
location of the turn-in fold or split-thickness dermal
graft or tongue flap, which forms the inner covering of
the upper lip.
D The time of section of the pedicles will depend on
the blood supply gained from the edges of the defect.
Sectioning should be done in stages-one side at a
time-and each side may be staged if necessary. The
pedicles are then returned to the scalp, removing the
split-thickness grafts where necessary. The only scalp
defect is in the center, where it may be hidden by
proper hair styling.
At a later stage, the vermilion of the upper lip can
be restored by using cross-lip grafts of vermilion from
the lower lip. For restoration of a Cupid's bow see
Figure 9-2A to C. If a forehead defect exists caused by
the use of a non-hair-bearing turn-in portion, this can
be covered by rotation flaps from the scalp and fore-
head in place of split-thickness skin grafts.
 THE UPS

FIGURE 9-12
 482 THE LIPS
Resection of Lower Lip with
Bernard Reconstruction (Fig. 9-13)
Highpoints
1. Resect adequate margins, especially down to chin.
2. Preserve external maxillary arteries.
3. If neck dissection is necessary, perform as second
stage (Martin et a!., 1941).
4. Virtually entire lower lip can be excised.
5. Preserve mucous membrane in lateral triangular
cheek flaps-this forms vermilion for reconstructed
lower lip.
6. Preserve some mucous membrane in gingivobuccal
sulcus for suturing lateral cheek flaps.
7. Tailoring of excess skin and muscle is performed as
last stages of operation.
A A rectangular full-thickness excision of the lower
lip and entire chin is performed. A narrow rim of
gingivobuccal mucous membrane (shown at A in B) is
preserved on the alveolar ridge. This serves as suture
sites for the lateral cheek flaps. With a suitable dye,
two lateral nasolabial triangles are outlined. The base
of each triangle is slanted slightly upward, and each
base is equal to half of the length of the excised lower
lip. The median border of the triangle follows the
nasolabial fold as closely as possible, so that with its
closure a more natural fold will result. The skin and
muscle (1) of these nasolabial triangles are now excised
carefully, preserving the underlying mucous membrane
(2 in A, B, and C). This mucous membrane (2) is now
mobilized, preserving its base. A small triangle of skin
(X) is excised as the mucous membrane flap (2) is
tailored to form the new lower lip vermilion. The two
triangles (Y) below the chin margin are not outlined or
excised until cheek flaps are mobilized.
B It may be necessary to excise some muscle and
subcutaneous tissue from the lateral area of this
triangle where the cheek is thick. On the right side of
the patient, the mucous membrane flap is already
sutured.
C The cheek flap has been mobilized along the
mandible as far lateral as the masseter muscle, taking
care not to injure the facial artery (external maxillary
artery), which is the principal blood supply to the
cheek flap. The anterior margin of the masseter muscle
may be freed if additional mobilization is necessary.
The closure is begun by approximation of the mucous
membrane of the cheek flap to the mucous membrane
of the gingivobuccal sulcus left attached to the lower
alveolar ridge. These sutures are placed to facilitate the
median advancement of the cheek flap. Before all
these sutures are tied, the mucous membranes of the
edges of the nasolabial triangle are closed. As the
cheek flaps are advanced, the two triangles below the
chin (Y in A) are excised to adapt the midline closure
in a satisfactory manner. Three-layer closure is used
wherever possible.
 THE LIPS

A
,
l /'
Iv //
'/
Y

FIGURE 9-13
 THE LIPS
Reconstruction of the Lower Lip
(Fig. 9-14) (After Dieffenbach, 1834)
Although this atlas does not dwell in any detail on the
historical aspects of head and neck oncologic surgery,
a translation of Dieffenbach's original 1834 article
appears worthwhile and at least very interesting.
Reconstruction of the Lower Lip after
the Extirpation of a Lip Cancer
First Case
A 71-year-old man suffered for many years of a cancer
of the lower lip, which subsequently changed into a
large, growing, cauliflower-like tumor. The glands near
the lower jaw and neck were healthy. An extirpation of
the entire lower lip had to be made whereby the inci-
sions began at the corner of the mouth and led across
the chin, where they met in an acute angle. To close the
distance of the incisions it was necessary to remove the
internal organs up to the lower jaw. Then five inter-
twining stitches were done, which apparently com-
pletely closed every point of the incisions. Some days
later the upper part of the fissure was closed and the
needles were removed, but the lower part festered. The
appearing fissure was closed with strips of surgical
tape. In the meantime the general health of the patient
became worse. A starvation process set in with
diarrhea and the patient died in the fourth week after
the operation. With the dissection some tubercles in
the lungs were found, and the spleen was hardened
with its upper area covered with a thick cartilaginous-
type skin.
Second Case
A 45-year-old country man of huge build suffered for
many years from a lip cancer, which gradually
increased to such an extent that the largest part of the
lower lip to the chin was transformed into cancerous
tissue in the size of a fist. All adjacent glands were
healthy. After the patient was pretreated, I extirpated
the cancer by two crescent-shaped incisions, which
started at each corner of the mouth, continued at the
outer limit of the tumor, and came together at an acute
angle under the chin; then I separated it from the gums
and the lower jaw. The periosteum was damaged in
several places, and I therefore scraped it off. After that
I severed from the lower jaw the cheeks up to the front
edge of the masseter, and then put through the center
of the edge of the incision a long, strong needle, around
which I wound thread ("atraumatic"). After a connec-
tion was achieved at that point, the upper part of the
fissure was completely connected by three needles, and
the lower part by four needles wound with thread.
By using a cooling outer and inner treatment the
upper half of the incision healed at the first connection;
the lower one, however, started to fester. Saliva and a
part of the liquids frequently drained through this open-
ing. But after removal of the needles from the upper
part and after the lower incision was connected by firm
pulling together with long strips of surgical tape, the
incision closed by itself completely within 14 days.
After 3 weeks no disfigurement could be seen on the
man. Because of the half-circle type of incision on the
soft parts underneath the corners of the mouth, two
cones were formed, which, when united, helped the
appearance of the lower lip.
After a year's time the man again came to me. On
the area of the operation another cancer had appeared.
I gave the patient Zittmann's Decoct (a kind of brand
name internal remedy) to drink for 4 weeks and then
operated again as in the above described manner. This
time I was able to close the incision with five needles.
The last of the needles were already removed on the
fourth day, but I still taped with long, thin surgical tape
around the head and chin, as in a circle from chin to
head and back. After the healing process was assured I
again gave the patient the Zittmann's Decoct to drink
for 4 weeks. I assume that no further problems arose
because I have not heard from the man again.
Third Case
A strong 60-year-old woman from the country suffered
for years from a cancer of the lower lip that encom-
passed most of the lip. The tumor had a cauliflower
type of appearance with the colors of red and white.
Especially unfavorable for the operation or success of it
seemed to be the solid (firm) connection of the tumor
with the jaw, a sure sign of deterioration (degeneration)
of the periosteum.
By making two cuts in a wide circle around the
cancerous growth I gave the wound a shape on the
chin that ran to a point. Then I separated the cancerous
mass from the bone and removed the loosened thickened
periosteum by careful scraping. After this was done, I
separated the cheeks on both sides of the lower jaw to
facilitate the joining of the edges of the wounds and
proceeded to the joining. For that, six atraumatic sutures
were necessary. I attached three heavy and three fine
needles, one after the other, and was pleased to see this
tremendous wound completely joined. Then I ordered
an inner and outer cooling treatment; healing took
place so rapidly that on the second day already two of
the thin needles could be removed, on the third day the
uppermost thick needle, and on the fourth day all the
others, after which I supported the young scar by two
long narrow pieces of surgical tape, which went around
the back of the head for several days, and I also ordered
poultices of lead water. Only right over the chin

remained for a few weeks a small festering wound that,
however, closed completely shortly thereafter. A
recurrence of the cancer has not taken place during the
last 4 years, and there is no sign of disfiguration to be
seen on the patient.
Reconstruction of the Upper lip after
an Operation of lip Cancer
Fourth Case
Cancer of the lip appears chiefly on the lower lip; if it
appears on the upper lip it is usually fungus or a
chancre that turned into a cancer or possibly a true
cancer of the corner of the mouth stretching to include
the upper lip. It could also be cancer of the wing of the
nose that affected the upper lip. This was the case of
an 83-year-old weaver whose left side of his upper lip
was affected. Through careful observation it was quickly
determined that this was not a true lip cancer but a
skin cancer that began at the wing of the nose affecting
the upper lip. Partly because of the advanced age of the
patient and partly because of the dangerous nature of
the skin cancer I searched for a cure with mercuric
chloride and then with "Hellmund's" ointment. But no
cure came about and an extirpation of the affected
parts of the lip up to the nose had to be made. TWooval
incisions encircled the affected area, and after its
removal the corners of the wounds were united with
five atraumatic sutures.
Because of the age of the patient one did not expect
a healing process of the wound to occur and yet it
occurred. The needles could be removed on the fifth
and sixth days and caused no reaction on the
surrounding areas.
Fifth Case (Lower Lip)
An almost 60-year-old, skinny, but otherwise strong, man
suffered for some years with a very large lip cancer,
which turned all the lower lip from both corners into a
huge carcinoma. The healthy upper lip was so unusually
large that one could make two lips out of it. This
particular phenomenon was very welcome.
After the patient recuperated a little with the help of
the Zittmann cure, which took a few weeks, I operated
on him. I went with the knife from the left corner of the
mouth along the jaw and ended 2 inches below the
chin. The cut on the right side was the same and they
joined in an acute angle. Now I started to remove the
diseased mass; it was a handful of cauliflower type
substance. The periosteum of the lower jaw was very
large and soft.
The rest of the procedures were the following: I
loosened the cheek backward over the masseter and on
the bottom from the lower jaw. After the blood flow
THE UPS
was stopped I burned the diseased periosteum with a
glowing iron. Then I again took the knife and made a
diagonal cut from each corner of the mouth an inch
into the upper lip toward the direction of the septum
but not quite that far. With these incisions I formed two
flaps that were meant to form the lower lips.
It was to be assumed by the loss of so much sub-
stance that the wound would not heal without lateral
incisions. First I placed a needle (length of a finger)
through the edges of the center part of the wound and
with the entwining of the needle and a pulling of the
heavy thread I achieved a tension in the cheeks. But
there was still an inch between the edges; thus I made
a cut on both sides, two inches long, through the cheeks
right in the center between the wound edges and the
front edge of the masseter. Through each of these open-
ings I was able to place two fingers into the mouth cavity.
In this way the tensions were relieved, and I was
able, with the pulling of the thread around the needle,
to combine (close) the wound exactly. Then I placed a
row of needles (I believe about seven or eight) where-
upon I was able to close the huge hole.
The conclusion of the operation was done whereby
I pulled the diagonal flaps of the upper lip downward,
combined them, and fastened their outer edges onto
the wound edge of the cheek skin, which now has
become a lip, with an atraumatic suture. Thus, a lower
lip was made through the cheek skin with the red
substance of the upper lip.
As one now examined the patient one found his
appearance quite adequate. Only the two huge lateral
openings made the patient look ugly because one could
see the mouth cavity and the tongue. If one separated
the jaws, one was able to look through the face as if a
cannon ball had penetrated the face, because the lateral
cuts, through their tension, appeared almost round.
With a cool treatment followed, in a few days in most
places, a healing process of the various wounds so that
in the third, fourth, and fifth days the needles could be
removed. Only on two places a festering occurred: First,
densely over the chin and then a little higher where
the corners of the red substance of the upper lip came
together with the vertical wound. The corners them-
selves were healing properly, though.
The lateral wounds, already in 8 days, have shrunk
two thirds in size, and their edges were covered with
granulation. Saliva and phlegm still flowed through
them. The surgical dressing was made with dry lint and
over it, just as across the closed wound parts, long
strips of surgical tape. This was done until the two
openings in the center of the lower jaw and the lip were
healed. In the third week the opening on the left was
closed, and in the fourth week the one on the right
closed without complication. The appearance of the
man was normal; his mouth was a little small but
natural with the usual corners and a red lower lip.
 THE LIPS
Reconstruction of the Lower Lip
(Continued) (Fig. 9-14) (After
Dieffenbach, 1834)
Reconstruction of the Lower lip from
the Cheeks after an Operation of a lip
Cancer with the Resection of a Part
of the Lower Jaw
Sixth Case
A 60-year-old man has suffered many years with a
cancer of the lower lip. This cancer covered the free
parts of the lower lip and did not reach the chin. On
both corners of the lip one-quarter inch of the red lip
substance was still here. The operation was easily com-
pleted. With a knife I first cut the left side of the lip,
encircled elliptically the cancer, and enlarged the inci-
sion through the healthy lower soft areas to give the
wound a good appearance and help with the closure.
On the right side I did the same thing. After the cancer
was scraped off the bones I loosened the soft areas
from the jaw.
Now I proceeded with the closure. Even though a
tension built up with the entwining of the needle, the
edges still combined so completely that lateral incisions
were not necessary. The tension became less after I
inserted five additional needles. Then I cut the thread
very short and the wound was cold bathed.
These compresses were continued for some days
and I made sure the patient was not allowed to speak.
His nourishment was taken with a quill. The success of
this operation was excellent. After a few days the
needles were removed, whereupon I fastened tape over
the chin and lip and washed it with lead water
(Goulard). The appearance of the lower lip was
completely normal.
Seventh Case
A 44-year-old laborer was admitted to me with one of
the largest cancers of the lower lip I have ever seen.
The cancer had spread to almost all of the lower part
of the face. All of the lower lip, both sides of the upper
lip, the soft areas of the chin plus the front and lower
parts of the cheeks were affected. The growth was
many inches and had an uneven wart type appearance.
The color of this growth was various; some humps were
pale, others red, some smooth, others with scales. In
the areas between the humps a sticky, wet substance
was found. The growth had almost fastened itself to
the teeth of the lower jaw and the gums were thus
affected with this cancer. They were no longer what
one could call gums. The soft areas behind the teeth of
the lower jaw were healthy. Not one single gland was
swollen, and no effects were noticed on the parotid
gland and the submaxillary glands.
This last observation made the operation (one of the
most difficult) necessary. It was done in the following
ways: The patient was sat in a chair and an assistant
pulled his head a little toward the back. I placed the
knife on the right side of the upper lip, where the cancer
started, and cut first up into the upper lip, encircled the
growth with a circular cut, turned outward toward the
cheek skin, then immediately went down far away
from the ear and chin and ended underneath the chin
in the center between the chin and the larynx. The cut
on the other side started on the left corner of the
mouth, did not go into the upper lip as far as the other
one, but went as far outward, and then went along the
lower part of the lower jaw and met with the first cut
in an acute angle under the chin. These type of cuts
encircled the whole areas of the growth.
Now with my left hand I grabbed the growth and
separated it from the lower jaw. The periosteum was
affected just as I thought. It was very thick, hard, and
fused with the growth. That there was much blood with
such long incisions does not have to be mentioned. All
vessels in the areas were greatly enlarged because the
blood gushed not only from the larger arteries but also
the entire parenchyma spurted with blood.
As much as I was able to remove from the periosteum,
I did. Then with tweezers I grabbed the inner edge of
the wounds of the lips and cheek skin and cut every-
where one-quarter inch off because the affected area of
the mucous membrane reached farther than that of the
outer area of the face. Now I could find no more trace
of diseased spots in the soft areas.
The worst part was the lower edge of the chin. It
was curiously full of holes. It looked terrible. The upper
part of a human face with skin and meat and the lower
part was a skeleton. This diseased area, the lower edge
of the chin, I sawed off squarely across.
To unite the soft parts of the cheek skin, as done in
this type of operation, more skin was needed than was
available. To make the available skin more pliable I
loosened it completely toward the back, not only from
the lower jaw but also from the upper lip of the upper
jaw. These internal cuts reached beyond the masseter.
Now I pulled the facial skin from both sides. Under-
neath the chin somewhat of a unification was accom-
plished but from the chin edge to the mouth an area of
skin about three fingers wide was still missing. This
missing skin had to be gotten from lateral incisions and
thus decreasing the tension as well.
First of all the closure (unification) of the skin under-
neath the chin was necessary. This was done com-
pletely with five atraumatic needles; then it became
tight, and the skin allowed itself only to be pulled over
the outermost edge of the chin. Now it was time to cut
the cheek skin, first on the left side the length of a

finger and then on the right. The cuts started under the
body of the malar bone, went slightly lower toward the
inside until the lower edge of the lower jaw, and sepa-
rated not only the skin but also the "buccinator" and
the mucous membrane of the mouth. Through these
openings one could place three to four fingers into the
mouth cavity.
With these lateral cuts, 2 inches away from the
needed closure, I was now able, with the help of strong
mounting pins, to close this huge opening so that there
was again only one mouth opening. The lateral cuts
now really gaped open. They were, so as not to expose
such great wounds to the air, gently covered with lint
and tape.
After the patient was cleaned from the great amount
of blood, he was brought to bed and given the most
antiseptic treatment possible. On the lower part of the
face an ice pack was placed. So that the pressure was
not too great and would not cause harm, the pack was
hung on a wooden ring. This ring was above the
patient's face fastened on both sides of the bed.
On the day after the operation the patient was amaz-
ingly well. The soft parts were greatly swollen and red,
but nothing unusual was to be noticed. The wound
edges seemed to be closely glued together. Thirty
leeches were attached. Days afterward the swelling was
lower, and today I took out the five lowest needles.
Everything was closed so tightly that it was not necessary
to apply tape. The edges of the lateral openings were
hard with growth, and the wound area was still covered
with necrosis type of tissue. We again attached leeches.
On the eighth day of the operation the condition of
the patient was as follows: The general condition was
favorable, and no fever was there. The upper part of the
face, nose, and eyelids was not swollen. Two thirds of
the wound (the needles were removed on the third,
fourth, and sixth days) had healed with the first closure.
The upper edges of the incision were festering, and
with narrow, long surgical tape were kept close together.
The lateral incisions cleaned themselves and showed
large granulations. The right one did not go through the
cheek any longer, since it had filled almost completely.
From the left some mucus was still draining, and the
water that was sprayed into the mouth to clean pus and
mucous still flowed from this wound in thick streams.
Both bridges were still inflamed but not as bad as
before. To lessen this continuous inflammation and to
reduce the festering of the center wound tepid Goulard
extract as well as camomile tea was applied.
The condition of the patient was very favorable. His
strength suffered so little because of the operation that
he did not wish to remain in bed a few days after the
operation. The upper part of the center wound, at the
two lateral incisions, continued to fester strongly, and
a large granulation filled the wound more each day.
THE LIPS
Almost all openings were filled with this granulation,
and still mucus and phlegm flowed through when one
day this granulation turned brown and changed into a
cancer. The skin surrounding the area also turned brown
and everything looked very dim. I now applied the
glowing iron to this growth and destroyed it. Internally
I ordered the "littmann's Decoct" for the patient. His
condition improved somewhat and the same procedure
is now being used. I will later announce the success of
this operation, because this case is very interesting and
since it fits so well with these observations that I don't
wish to leave it out.
Indication
• A one-stage procedure for the reconstruction of the
entire lower lip. It is obvious that a malignant neo-
plasm of this size under most circumstances would
require at least a unilateral radical neck dissection
and contralateral suprahyoid neck dissection and
probably a bilateral radical neck dissection. The neck
dissection using this technique would require a second
stage because a simultaneous neck dissection would
sacrifice the external maxillary artery and thus inter-
fere with the major blood supply of the cheek flaps.
Depending on blood supply, a free microvascular
flap could be an option.
Highpoints
1. The entire lower lip and portion of the soft tissue of
the chin can be resected. The outer table of the
mandible, if not directly involved, can be resected.
If, on the other hand, the bone is directly involved,
then the entire bone must be resected and recon-
struction would thus require a distant transferred
flap (e.g., pectoralis major myocutaneous flap; see
Fig. 8-2) to cover Kirschner wire stabilization of the
mandible (see Fig. 14-5).
2. Preservation of both external maxillary arteries is
done.
3. Extended mucosal flaps superiorly to the cheek flaps
are used to reconstruct the vermilion.
4. A portion of the masseter muscle is used to fill in the
defect medial to the masseter muscle.
5. Patency of Stensen's ducts is maintained.
6. Outline the anterior border of the masseter muscles
before anesthesia by having patient contract the
muscles.
7. Preserve a small portion of lower lip at the
commissure.
8. Preserve an edge of mucosa on the gingival side
attached to the mandible to facilitate closure.
9. Preserve facial nerve divisions and main branches
wherever possible.
 THE UPS
Reconstruction of the Lower Lip
(Continued) (Fig. 9-14)
Complications
• Contracture of lower reconstructed lip
• Facial nerve and/or Stensen's duct injury
A The solid line depicts the skin incisions. The dotted
lines indicate the mucosal portion of the flap. The
dotted portion above the horizontal skin incision is
obtained from the underlying mucosa and left attached
to the skin flap. It is this mucosa that will form the new
vermilion. The commissures are preserved with the
upper lip.
The lateral superior incision is made obliquely to
about 3.8 em anterior to the tragus. The vertical limb
of the incision is extended to below the mandible,
forming an acute angle with the lateral superior
incision laterally.
B The skin flaps are mobilized with care taken not to
injure the divisions nor main branches of the facial
nerve lateral to the anterior border of the masseter
muscle and superior to the upper skin flap. Stensen's
ducts must likewise be preserved.
The skin flap medial and anterior to the masseter
muscle is full thickness, including the underlying buc-
cinator muscle and mucous membrane along with the
mucosa superior to the skin-muscle flap, as depicted
by the dotted lines. Lateral and posterior to the anterior
border of the masseter muscle only skin and subcu-
taneous tissue down to the parotid fascia is included in
the skin flap, thus avoiding the underlying facial nerve,
Stensen's duct, and parotid gland. The facial artery
and vein will require ligation and transection at the
superior margin of the cheek flap.
C The dotted line on the right cheek flap indicates
the l-cm portion of mucous membrane left attached
to the cheek flap, which when turned down
(arrow) forms the new vermilion of the reconstructed
lower lip. The underlying submucosal subcutaneous
tissue and muscle may require some trimming to
obtain a thin lateral portion of the new reconstructed
lower lip.
The solid line below the teeth is a rim of mucous
membrane that is left attached to the mandible and is
preserved to facilitate closure. This is the incision made
along the lower gingivobuccal sulcus.
The cheek flap on the left side of the patient demon-
strates the preserved mucous membrane. This flap is
completely mobilized to the submandibular area using
blunt dissection. This mobilization is important to permit
complete freedom of the flap from the mandible. The
mental nerves usually require transection. The external
maxillary artery and accompanying veins as they cross
the mandible must be preserved.
Continued
 THE UPS

FIGURE 9-14
 THE LIPS
Reconstruction of the Lower Lip
(Continued) (Fig. 9-14)
D On the left side of the patient an anterior portion
of the masseter muscle is mobilized along the dotted
lines and rotated anteromedially to fill in the defect
from that portion of the buccinator muscle which was
mobilized with the cheek flap. The superior end of the
masseter muscle flap is sutured to the lower edge of
the remaining portion of the buccinator muscle.
E Closure of the defects to be performed (after May,
1971):
1. Connection of the lateral edge of the new vermilion
to form the commissure along with the small flap
from the upper lip
2. Closure of the posterior mucous membrane defect
as far as possible by mobilization of the posterior
mucous membrane
3. Approximation of the mucous membrane of the
cheek flaps to the rim of mucosa still attached to
the mandible
4. Approximation of both cheek flaps in the midline
with three-layer closure
5. Approximation of the lateral portion of the cheek
flap to the skin edges without tension
6. Closure of the donor site commencing at the lateral
corner, which is an acute angle and thus easily
closed. Drains are placed at the lateral lower wound
angles.
7. An internal stent may be helpful to decrease the lip
and labial contractu res in the edentulous patient.
F The vermilion is formed by advancing the retained
mucous membrane downward and is sutured to the
superior edge of the flaps. The dotted line represents
some adjustment to correct any dog-ear or pointing of
the skin margins.
 THE UPS

FIGURE9-14 Continued
 THE LIPS
BIBLIOGRAPHY
Abbe R: A new plastic operation for the relief of deformity due to
double harelip: The classic reprint. Plast Reconstr Surg 42:
481-483, 1968.
Ashley FL, McConnell DV,Machida R, et al: Carcinoma of the lip: A
comparison of five year results after irradiation and surgical
therapy. Am J Surg 110:549-551, 1965.
Axhausen G: Technik und Ergebnisse der Lippenplastik. Leipzig,
Georg Thieme, 1941.
Bailey BJ: Management of carcinoma of the lip. Laryngoscope
87:250-260,1977.
Bakamjian VY: Personal communication, 1971.
Baker SR, Krause CJ: Carcinoma of the lip. Laryngoscope 90:19-27,
1980.
Bauer BS, Wilkes GH, Kernahan DA: Incorporation of the W-plasty in
repair of macrostomia. Plast Reconstr Surg 70:752-756, 1982.
Bernard C: Cancer de la levre inferieur opere par un procede nouveau.
Bull Soc Chir Paris 3:357, 1853.
Bowers DG Jr: Double cross-lip flaps for lower lip reconstruction.
Plast Reconstr Surg 47:209-214, 1971.
Burget GC, Menick FJ: Aesthetic restoration of one-half the upper lip.
Plast Reconstr Surg 78:583-593, 1986.
Byers RM, Boddie A, Luna MA: Malignant salivary gland neoplasms
of the lip. Am] Surg 134:528-530, 1977.
Clairmont AA: Versatile Karapandzic lip reconstruction. Arch
OtolaryngolI03:631-633,1977.
Conley]], Donovan B: New techniques for lower lip reconstruction
in a melanoma patient. Otolaryngol Head Neck Surg 94: No.3,
1986.
Conley], Baker DC, Selfe RW: Paralysis of the mandibular branch of
the facial nerve. Plast Reconstr Surg 70:569-577, 1982.
Dieffenbach Jf: Chirurgische Erfahrungen, Abb, 3, V4, Berlinl 15341
pp 96-110.
Earley M]: Peri-alar skin excision and lip advancement in the closure
of lip defects. Br] Plast Surg 37:50-51, 1984.
Ellis DAF, Miller RB: Rehabilitation of the paralyzed lower lip.
J Otolaryngol13:403-405, 1984.
Estlander JA: Methode d'autop!astic de la joue au d'une levre par un
lambeau emprunte a I'autre levre. Rev Mem Med Chir 1:344, 1877.
Filatoff W: Plastic a tige ronde. Westnik Oflalmol Avril-Mai, 1917.
Fujimori S: "Gate flap" for the total reconstruction of the lower lip.
Br] Plast Surg 33:340-345, 1980.
Gage AA, Koepf S, Wehrle D, Emmings F: Cryotherapy for cancer of
the lip and oral cavity. Cancer 18:1646-1651, 1965.
Gerold F: Personal communication, 1960.
Glenn MG, Goode RL: Surgical treatment of the "marginal mandibular
lip" deformity. Otolaryngol Head Neck Surg 97:462,1987.
Guerrero-Santos J: Use of a tongue flap in secondary correction of
cleft lips. Plast Reconstr Surg 44:368-371, 1969.
Jesse RH: Extensive cancer of the lip. Arch Surg 94:509-516, 1967.
Lore JM Jr, Kaufman A, Grabau JC, Popovic DN: Surgical manage-
ment and epidemiology of lip cancer. Otolaryngol Clin North Am
12:81-95,1979.
Luce EA: Carcinoma of the lower lip. Surg Clin North Am 66:3-12,
1986.
McGregor IA: Reconstruction of the lower lip. Br J Plast Surg 36:
40-47, 1983.
Mahler D, Ben-Yakar Y, Baruchin A: Plication of the orbicularis oris
muscle to repair partial paralysis of the lower lip. Ann Plast Surg
8:224-226, 1982.
Martin HE, MacComb WS, Blady JV: Cancer of the lip. Ann Surg
114:226, 1941.
May H: Plastic and Reconstructive Surgery, 3rd ed. Philadelphia, FA
Davis, 1971.
Meyer R. Failat AS: New concepts in lower lip reconstruction. Head
Neck Surg 4:240-245, 1982.
Musgrave RH, Garrett WS Jr: Dog bite avulsions of the lip. Plast
Reconstr Surg 99:294-296, 1972.
Nakajima T, Yoshimura Y, Kami T: Reconstruction of the lower lip
with a fan-shaped flap based on the facial artery. Br ] Plast Surg
37:52-54, 1984.
Paletta FX: Cancer of the lip. From symposium on cancer of the head
and neck. In Gaisford JC (ed): Total Treatment and Reconstructive
Rehabilitation, vol II. St. Louis, CV Mosby, 1969.
Paletta FX: Early and late repair of facial defects following treatment
of malignancy. Plast Reconstr Surg 13:95-108, 1954.
Pelly AD, Tan EP: Lower lip reconstruction. Br J Plast Surg 34:83-86,
1981
5aemann 0: Die Transplanlations-Methode der Herm, Prof. Dr.
Burow. Dtsch Klin 20:221, 1853.
Su CT, Manson PN, Hoopes JE: Electrical burns of the oral
commissure: Treatment results and principles of reconstruction.
Ann Plast Surg 5:251-259, 1980.
Van Dorpe EJ: Simultaneous repair of the upper lip and nostril floor
after tumor excisions. Plast Reconstr Surg 60:381-383, 1977.
Villoria JMF: A new method of elongation of the corner of the mouth.
Plast Reconstr Surg 49:52-55, 1972.
van Bruns V: Das Handbuch d. praktisch Chir. Tiibingen, Lauppsche
Buchhandlung, 1859.
Wilson JSP, Walker EP: Reconstruction of lower lip. Head Neck Surg
4:29-44, 1981.
 10 CLEFT LIP AND PALATE
ROBERT J. PERRY
JOHN M. LORE, JR.

Cleft Lip (see Figs. 10-1 to 10-7)
To understand the objectives in cleft lip repair one must
evaluate not only the deformity but also its relationship
to the normal anatomy.
Types of Cleft Lip Deformities
combined with a cleft palate is not performed for a
number of reasons: optimal age is different, and mor-
bidity and mortality are increased, owing to possible
airway obstruction and blood loss.
Normal Anatomy (After Millard, 1968)
(Fig. 10-1)

Several classifications of cleft lip with or without cleft
palate are popular. Generally, a cleft lip may be unilateral,
bilateral, or median (rare) and present as a complete
cleft or in varying degrees as an incomplete cleft. Clefts
of the alveolar process and primary and/or secondary
palate may also occur. Simultaneous repair of a cleft lip
A Anterior view. The labeled structures and their
relationships are the normal landmarks important in
cleft lip repair.
B Lateral view. An infant's upper lip is often full in its
lower two thirds, with a prominent "pout."

RIM

ALA

BASE

RIDGE}
PHILTRUM
NOSTRIL SILL . GROOVE

CUPID'sf APEX BASE OF ARCH }

CUPID'S
BOW TUBERCLE
. MUCOCUTANEOUS
RIDGE
BOW

A
FIGURE 10-1

493
 ClEfT LIPAND PAlATE
Unilateral Cleft lip Repair
(See Figs. 10-2 to 10-4)
Basic Deformities of Cleft Lip (Unilateral
Complete) (Fig. 10-2)
There are three main deformities:
1. Maxillary defonnity: anterior displacement with external
rotation of the premaxilla (the central portion of the
upper alveolar ridge and maxilla from which the
upper incisors arise).
2. Lip deformity: decreased vertical height on cleft side
with variable tissue deficiency medially, preserved
two thirds of Cupid's bow and non-cleft-side philtral
column· and groove, and abnormal orbicularis oris
muscular insertion.
3. Nasal deformity: shortened cleft-side columella with
attenuated and "slumped" lower lateral cartilage and
flared alar base and deviated nasal septum to the side
of the cleft with contralateral anterior dislocation.
Basic Objectives of Repair
1. Recognize, identify, and preserve normal landmarks
and as much tissue as possible.
2. Realign these normal landmarks into their normal
position both from the anterior aspect and the lateral
aspect:
a. Lengthen the lip on its deficient cleft side to the
dimensions of the normal side.
b. Preserve the philtrum, Cupid's bow, the "pout,"
and the mucocutaneous junction.
c. Reconstruct the orbicularis oris muscular sphincter.
d. Correct the distortion of the alar base and columella
with undermining and mobilization rather than
any cartilage incision.
e. Some surgeons favor concomitant nasal tip correc-
tion using cartilage repositioning techniques
(Salyer, 1986).
f. Widely separated maxillary elements may be
brought into optimum presurgical alignment with
extraoral traction using simple taping techniques.
Precautions
In general, do not do the following:
1. Damage or excise any nasal cartilage.
2. Perform simultaneous cleft palate repair.
3. Excise any normal landmarks.
There are exceptions to these dicta depending on
the procedure utilized as well as the skill and expe-
rience of the surgeon. As the child grows, the nasal tip,
alar cartilage, and nasal septal surgery can be performed
at a later time. More than ever is the surgeon's oath of
primum non nocere applicable. When not sure, seek
help.
Optimal Age for Operation
There is considerable difference of opinion regarding
the optimum time of operation. Although the repair
can technically be done on the first day of life, the
earliest age that is reasonable is 10 to 14 days after
birth, provided that the infant has started to gain
weight and has otherwise normal signs, especially the
hemoglobin and hematocrit. The rule of "over 10" is a
good guide: over 10 weeks old, 10 Ib in weight, and 10
g of hemoglobin. Three months of age is believed by
others as the most opportune time.
Although cleft lip with or without cleft palate most
often occurs in isolation, other anomalies may exist.
This incidence is 7% to 13% in isolated cleft lip and
2% to II % in cleft lip with cleft palate (Cohen, 1983).
It is estimated that 1% of cleft lip with or without cleft
palate occurs as part of a syndrome (Bixler, 1981). A
complete medical history, family history, and physical
examination is mandatory.
Anesthesia
General endotracheal anesthesia is preferred with the
endotracheal tube brought out through the mouth across
the midportion of the lower lip. Care must be taken that
no tension is placed on the upper lip or oral commissures.
If a local anesthetic containing epinephrine is employed
to facilitate a drier operative field and a lighter plane
of anesthesia, one must not risk exceeding the maxi-
mum recommended dosage of epinephrine for the anes-
thetic agent used. Recall that a 1:100,000 dilution equals
10 mg/mL.
Classification of Types of Repair of Unilateral
Cleft Lip
Techniques in cleft lip surgery have evolved slowly,
dependent on the analysis of long-term results in the
young and growing patient. Several methods of repair
are still employed for the correction of the unilateral cleft
lip deformity, and with the exception of the straight-line
closure, all introduce tissue from the lateral element to
fill a deficiency medially. The procedure of choice at
this writing for both complete and incomplete forms is
the rotation advancement method of Millard, which
best preserves the natural landmarks while concealing
the incisions within natural lines.
 CLEFT LIP AND PALATE 495

COLUMELLA

~tNON-CLEFT-SIDE R ID.G.?
E~
g:::::!
CLEFT-SIDE RIDGE
I
iE GROOVE /

/ REMAXILLA
~\

C/J
~ ~
:::>co
()
{
APEX
.#
i
-JT. ELEMENT

FIGURE 10-2
 CLEFTLIPANDPALATE
Triangular Flap Cleft Lip Repair:
Tennison-Randall Technique
(Randall, 1959) (Fig. 10-3)
Highpoints
1. A "Z" incision is made on the lateral border of the
cleft, which is unfolded.
2. An incision is made into the medial border of the
cleft, which is opened to receive the triangular flap
from the lateral lip element, lengthening the medial
lip element.
3. The orbicularis muscle fibers are reoriented into a
normal horizontal direction (Randall et aI., 1974).
A The landmarks are identified with methylene blue.
1. The following points are marked on the medial lip
element: Point 1 is the midpoint of Cupid's bow on
the vermilion border. Point 2 is the apex of Cupid's
bow on the non-cleft side. Point 3 is the apex of
Cupid's bow on the cleft side such that length 1-2
equals length 1-3 (poin~ 3 corresponds to point 13).
2. The medial lip element is pushed toward the cleft,
straightening the colurpella in the midline. Point 5
is on the vermilion border of the medial element at
the base of the columella. Point 4 is the correspon-
ding point at the base of the columella on the oppo-
site nostril sill. Point 6 is a point in the nostril floor
of the lateral element with the same relationship
to the cleft-side alar base as point 4 has to the
non-cleft-side alar base.
3. Line 5-3 is drawn.
4. Point 7 is generally found on the philtral midline such
that angle 5-3-7 is approximately a right angle.
5. Line 3-7 is drawn.
6. Point 8 is located on the vermilion border of the
lateral element at the point where the mucocuta-
neous ridge becomes attenuated. The distance
from point 8 to the ipsilateral oral commissure
equals the distance from point 2 to the non-c1eft-
side oral commissure.
7. Point 10 is approximately the midpoint of 7-13, and
point 11 is approximately the midpoint of 9-12.
8. The locations of points 9 and 12 vary according to
the size of the cleft and the amount of tissue avail-
able. Point 9 is chosen first on a trial basis and adjust-
ed so that the following relationships are true:
a. Length 6-9 is made equal to length 5-13.
b. Length 4-2 minus length 5-10 equals length 8-11,
the distance across the base of the flap or the
amount required to drop Cupid's bow into normal
position.
e. Length 8-12 equals length 9-12.
B Full-thickness incisions are now made on the medial
side of the cleft extending from point 5 to point 13.
Excess lip is trimmed as in the shaded area. The inci-
sion 7-1 3 is made, revealing a triangular defect as the
Cupid's bow remnant is rotated into normal position.
C The markings are rechecked before the construc-
tion of the lateral triangular flap: length 4-2 equals the
projected length 5-10-3 equals the projected length
6-11-8. Full-thickness incisions are then made on the
lateral side of the cleft. Mobilization of the alar base
and cheek is performed sufficiently to realign the naris
on the cleft side to match as closely as possible the
normal naris. The orbicularis oris muscle bundles are
carefully dissected from the cleft edges by undermin-
ing in both subcutaneous and submucosal planes and
releasing them from their abnormal insertions superiorly
along the cleft edges. Lip closure is in three layers:
muscle, skin, and mucosa with points 6 to 5, 9 to 13,
12 to 7, and 8 to 3.
D The completed repair.
 CLEFT LIP AND PALATE

\
\
\
\
\
\

'\

c D

FIGURE 10-3
 CLEFT LIP AND PALATE

Rotation Advancement Cleft lip Repair

(Millard, 1958, 1976) (Fig. 10-4) on the cleft side (point 3). From this point superiorly
the cleft-edge vermilion is trimmed. The full-thickness
Highpoints incision is then carried upward following the reciprocal
curvature and position of the philtrum on the normal
1. Downward rotation of Cupid's bow into normal side until it reaches the base of the columella. The inci-
position (flap A). sion is cut on the bias to preserve as much muscle as
2. Medial advancement of upper portion of lateral lip possible on the flap. Without crossing into the normal
element into rotation gap (flap B). philtrum, the incision curves under the base of the
3. Elongation of cleft-side columella (flap C). columella and extends toward the normal side as far as
4. Independent correction of cleft -side alar flare with is necessary to rotate the Cupid's bow (flap A) into a
alar base flap (flap D). normal horizontal plane. A small back-cut (point X)
S. Reconstruction of orbicularis oris muscular sphincter. directed obliquely downward facilitates this rotation.

B A fine hook exerts upward traction on the c1eft-

A An incision is made at right angles to the vermilion
borders into the medial edge of the cleft lip at a point
corresponding to the potential height of Cupid's bow
side alar rim. This results in a defect at the base of the
cleft-side columella to be filled with flap c. An incision
is made into the membranous septum following the
posterior border of flap c. This flap is subsequently
undermined and advanced into position to balance the
columella. The medial aspect of flap c is tailored and
sewn into the superior aspect of the defect created by
the downward rotation of flap A.

B
FIGURE 10--4

FIGURE 10-4 Continued
Complication
• The most common iatrogenic complication is under-
rotation of flap A.
C Flap B is now developed, again cutting on the bias
to preserve as much muscle on the flap as possible.
The vermilion is trimmed by making an incision at a
right angle to the vermilion border at a point (8) at
which the vermilion becomes attenuated and at which
the resultant preserved length of the lateral element
when sutured to the medial element (flap A) will result
in a normal balanced upper lip. The distance between
this point (8) and the ipsilateral oral commissure (7)
generally corresponds to the distance between the
apex of Cupid's bow (2) and the oral commissure on
the non-cleft side (6). The incision is carried up along
the vermilion border to include the most superomedial
usable lip tissue and then curved laterally around the
alar base. (The reference numbers refer to those shown
in A.)
CLEFT LIP AND PALATE 499
Through an incision in the upper gingivobuccal
sulcus, the lateral element is then dissected from the
maxilla. At the same time the cleft-side alar base (flap
D) is released from its pyriform aperture attachment.
Attention is now turned to a careful dissection of the
orbicularis oris muscle bundles, freeing them both
subcutaneously and submucosally so that when
approximated across the cleft the orientation of their
fibers will be changed from an abnormal near-vertical
direction to the normal horizontal direction. Flap B is
then advanced medially and sewn into the defect
created by the downward rotation of flap A, and the
lip is closed in three layers: muscle, skin, and mucosa.
Flap 0 is then advanced medially to close the nostril
floor. A portion of this flap may be de-epithelialized
and sewn to the base of the nasal septum anteriorly
with a permanent suture as a unilateral alar cinch.
D The completed repair.
 ClEfT LIP AND PALATE
Bilateral Cleft Lip Repair (See Figs. 10-5
to 10-7)
Results from the repair of the bilateral cleft lip are gener-
ally less satisfactory than those for repair of unilateral
cleft lip. Although bilateral cleft lips tend to demon-
strate less asymmetry, the greater tissue deficiency in
the central element contributes to a more difficult
reconstruction.
The approach to the bilateral cleft lip varies accord-
ing to the severity of the nasal deformity. In most com-
plete clefts and in some incomplete clefts, a staged repair
is indicated in which the prolabium is shared between
the severely short columella and the deficient central
lip element. One should become familiar with those
techniques in which prolabial tissue is stored or "banked"
at the time of the initial lip operation, facilitating later
columellar reconstruction without reentry into a healed
lip repair (Millard, 1977). The straight-line closure is
presented as a popular solution to the bilateral cleft lip;
however, because the entire prolabium is used in the
lip reconstruction, this method is better reserved for
those few cases with adequate columellar length.
Techniques derived from unilateral cleft lip repairs
have been applied to the bilateral cleft lip and are par-
ticularly applicable to the incomplete form. The rotation-
advancement technique (Millard, 1960, 1977) is shown
in Figure 10-7.
Highpoints
1. Restore and maintain the premaxilla in proper position
in the upper dental arch. This facilitates bilateral lip
repair with minimal tension. (See problem 1, later.)
2. Plan the lip repair with the appropriate nasal correc-
tion in mind. (See problem 2, later.)
3. Recognize, identify, and preserve normal landmarks
and as much tissue as possible.
4. Reconstruct the central portion of Cupid's bow with
vermilion from the lateral lip elements.
5. Restore the orbicularis oris muscular sphincter at the
appropriate stage.
Basic Deformities of Cleft Lip (Bilateral
Complete) (Fig. 10-5)
There are three main deformities:
1. Maxillary deformity: separation of the premaxillary
component from the lateral maxillary arches. The
premaxilla may be deflected or rotated to one side
and may project anteriorly to a variable degree.
2. Lip deformity: variably sized prolabium containing
no muscular elements and demonstrating no Cupid's
bow or philtrum and abnormal orbicularis oris mus-
cular insertion in the lateral lip elements.
3. Nasal deformity: very short columella and attenuated
and "slumped" lower lateral cartilages with flared
alar bases.
Precautions
In general, do not perform the following:
1. Excise prolabium or premaxilla.
2. Create more asymmetry by repairing right and left
sides in separate operations.
3. Jeopardize prolabial blood supply with simultaneous
lip and columella reconstruction.
4. Use the redder prolabial vermilion in the vermilion
of Cupid's bow.
Problems
1. Projecting premaxilla. Presurgical manipulation of the
premaxilla with extraoral traction using simple taping
techniques is performed to avoid the growth distur-
bances often associated with a surgical premaxillary
setback. When the premaxilla is in optimal position,
the lip closure will then facilitate additional molding
of the maxillary arch. For those rare patients refrac-
tory to this conservative approach, surgical setback
is best delayed to age 6 years.
2. Small prolabium. Because the prolabium is used in the
staged reconstruction of both the lip and columella,
a preliminary lip adhesion may be indicated. In this
procedure, the orbicularis oris muscle bundles from
the lateral elements are attached to the cleft edges
of the prolabium to expand the prolabial tissue as
necessary.
Optimal Age for Operation
Gavage feeding techniques and improved neonatal care
have reduced the urgency of surgery in the bilateral
complete cleft lip and palate patient. Timing for surgery
follows the guidelines for the unilateral cleft lip repair
recommended earlier in this chapter.
 CLEFT LIP AND PALATE 501

COLUMELLA

ALAR BASE

PROLABIUM

PROLABIUM
VERMILION

PREMAXILLA1
I

I
\\
" LATERAL
"ELEMENT

FIGURE 10-5
 CLEFT UP AND PALATE
Repair of Complete Bilateral Cleft Lip
(Straight-Line Closure) (After Veau)
(Fig. 10-6)
Highpoints
1. Reconstruct Cupid's bow with vermilion from lateral
lip elements.
2. Vermilion of prolabium is preserved and used as oral
lining for center portion of reconstruction.
3. Small relaxing incisions are used for the alae nasi.
A Incisions along the vermilion borders are made as
indicated by the dotted lines. Note that the flaps
indicated by X and Y include the mucocutaneous ridge
("white roll").
B Flaps X and Yare mobilized.
C The vermilion of prolabium Z is incised along its
exterior border. The interior border is preserved. The
vermilion of the prolabium is thus hinged and turned
downward to serve as mucosal lining. Relaxing inci-
sions are made at the base of the alae nasi along the
dotted lines.
D The lateral lip flaps are approximated to the central
portion of the lip in three layers. The orbicularis oris of
the lateral elements is approximated either at this stage
(C) or at a subsequent operation.
E The lateral flaps X and Yare trimmed and trans-
posed beneath the prolabium. The vermilion of the
prolabium Z is sutured to the posterior aspect of the
reconstructed upper lip forming an intraoral lining.
F The completed restoration.
 CLEFT LIP AND PALATE 503

FIGURE 10-6
 CLEFT LIP AND PALATE
Repair of Incomplete Bilateral Cleft Lip
(Rotation-Advancement Technique)
(Millard, 1960, 1977) (Fig. 10-7)
Highpoints
1. Reconstruct Cupid's bow with vermilion from lateral
lip elements.
2. Release prolabium from premaxilla.
3. Reconstruct orbicularis oris muscular sphincter.
4. Make incisions within natural lines.
A Incisions are made as indicated by t,he solid lines.
The incisions along the vermilion border of each lateral
element include the mucocutaneous ridge ("white
roll"). The incision around each alar base separates it
from the lateral lip element. The vermilion of the pro-
labium is divided into three flaps: one central flap based
superiorly on the subcutaneous tissue of the prolabium,
which when reflected forms the posterior wall of the
reconstructed lip vermilion, and two lateral flaps based
on the premaxilla, which serve as additional premaxil-
lary lining. Note that the rotation incisions in the
superior aspect of the prolabium are clearly separated.
B Lateral lip flaps are mobilized by incising into the
upper gingivobuccal sulci bilaterally, freeing them off
of the maxilla. The prolabium (together with the central
turn-down flap of vermilion) is dissected off of the
premaxilla, and the lateral prolabial vermilion flaps are
sewn to cover the raw anterior surface of the premaxilla.
Orbicularis oris muscle bundles are dissected from the
lateral elements to facilitate a careful three-layer closure.
The lateral lip elements are then advanced to the mid-
line and sewn in two layers: mucosa and muscle behind
the elevated prolabial flap.
C The prolabium is then sewn to the skin margins of
the lateral lip elements. The transposed vermilion flaps
from the lateral elements are sewn together in the
midline beneath the prolabium. The reflected prolabial
vermilion forms the posterior lining of the lip.
D The completed repair.
 CLEFT UP AND PALATE 505

FIGURE 10-7
 CLEFT LIP AND PALATE
Cleft Palate (See Figs. 10-8 to 10-12)
Clefts of the palate may occur alone or in association
with complete unilateral or bilateral clefts of the lip.
An isolated cleft palate has an incidence of associated
anomalies as high as 13% to 50% (Cohen, 1983), and
as many as 8 % of cleft palates occur as part of recog-
nized syndromes (Bixler, 1981). The need for a com-
plete medical history, family history, and physical exam-
ination cannot be overemphasized. In many craniofacial
centers, this is performed by a geneticist trained in dys-
morphology.
Types of Cleft Palate Deformities
The incisive foramen divides prepalatal clefts (or clefts
of the primary palate) from palatal clefts (or clefts of
the secondary palate). Although prepalatal and palatal
clefts are embryologically distinct and occur individ-
ually in complete and incomplete forms, they frequently
are found simultaneously in the same patient.
Reconstructive Goals
1. Closure of the oronasal fistula
2. Production of normal speech (normal nasality)
3. Ensure normal occlusion and facial growth
4. Production of normal eustachian tube function
Not only do the clefts vary significantly in width, but
often there is a shortage of soft tissue and at times
inadequate muscular movement as well as a wider
than normal bony nasopharynx.
Optimal Age for Operation
The timing and choice of operation for cleft palate repair
remain controversial because of difficulties in standard-
izing speech results, in assessing facia! growth over time,
and in comparing patients with clefts who have vary-
ing degrees of tissue deficiency. Important considera-
tions influencing timing of repair are as follows:
1. Speechdevelopment. From the viewpoint of the speech
pathologist, the palate should be closed early (I.e.,
8 months) to enable the child to develop a competent
velopharyngeal mechanism before the onset of speech
production.
2. Dental development. From the viewpoint of the ortho-
dontist, palatal closure should be delayed until an
optimal relationship is established in the upper dental
arch to ensure the development of normal dental
occlusion. In addition, hard palate closure before
age 6 years should involve minimal periosteal strip-
ping to reduce the possibility of midfacial growth
retardation.
At present, narrow to moderately wide palatal clefts
are closed at 10 to 14 months of age. For wide clefts
( > 1 cm at the hard/soft palate junction), early velar
(soft palate) closure with obturation of the hard palate
defect until age 6 years is practiced at our center. Still
larger clefts with significant tissue deficiency, such as
those found in the Pierre Robin sequence, may require
a primary pharyngeal flap to import regional tissue for
closure (Stark and DeHaan, 1960). For clefts with a two-
piece maxilla (associated with the unilateral cleft lip and
palate) or a three-piece maxilla (associated with the
bilateral cleft lip and palate), there is a growing interest
in presurgical orthopedic manipulation of the maxillary
arch. This is an attempt to obtain a favorable alignment
of the individual bony elements before palatal surgery.
Repair of Complete Cleft of Secondary
Palate (After von Langenbeck, 1861)
(Fig. 10-8)
Highpoints
1. Use oral endotracheal intubation.
2. Extend head and neck with folded sheet under
shoulders.
3. Inject lines of incision with local anesthesia (lidocaine
1% with 1:100,000 epinephrine) for hemostasis.
4. Use tension-free closure of nasal layer.
5. Preserve greater palatine arteries.
6. Adequately mobilize lateral flaps without excessive
mucoperiosteal stripping.
7. Reconstruct levator veli palatini sling.
8. Carefully approximate nasal and oral layers, eliminat-
ing dead space, which can lead to fistula formation.
Positioning of Patient
1. Position patient for oral endotracheal intubation.
2. Extend head and neck with folded towel beneath
shoulders. Recheck breath sounds for possible intu-
bation of right mainstem bronchus.
3. No head drape is used once patient is positioned.
4. If mouth gag is used, recheck breath sounds once gag
is opened for possible endotracheal tube compression.
5. Some surgeons prefer sitting at the head of the table
with the patient in Trendelenburg position; others
prefer standing at the side.
 CLEFT LIP AND PALATE 507

A B

Tensor veli
palatini m. Pterygoid bone

Hamulus of
I .
pterygoid , In!. pterygoid m.

FIGURE 10-8

A The bony anatomy is depicted, showing the origin
of the internal pterygoid muscle, which marks the
plane of mobilization of the soft palate. This muscle
also leads to the identification of the hamulus around
which the tensor veli palatini courses.
of incision are injected with local anesthesia (lidocaine
1% with 1:100,000 epinephrine) for hemostasis and
to facilitate a lighter plane of general anesthesia.
The incision through mucosa and periosteum starts
medial to the alveolar ridge. When the posterior end

of the alveolar ridge (maxillary tubero~ity) i~reached,

B Exposure is achieved with a Dingman or Jennings the incision curves laterally and then extends poste-
mouth gag or cheek retractors; the tongue is either riorly to a line drawn through the plane of the uvula.
depressed or pulled forward with a 2·0 silk suture. Lines Continued
 CLEFTLIP AND PALATE
Repair of Complete Cleft of Secondary
Palate (After von Langenbeck, 1861)
(Continued) (Fig. 10-8)
C With the use of a cleft palate elevator or a nasal
freer, a mucoperiosteal flap is elevated from the hard
palate. Anteriorly, this extends around the anterior
edge of the cleft and medially up to but not through
the cleft mucosa. Posteriorly, the mobilization is con-
tinued, exposing the tensor veli palatini muscle. The
greater palatine vessels are preserved.
D The posterior mobilization of the soft palate is
achieved by exposing the internal pterygoid muscle
and tendon and opening wide the space medial to it.
This maneuver displaces the tonsil and tonsillar pillars
medially. The attachment of the flap to the palatine
bone near the origin of the pterygoid muscle is then
separated, using blunt or sharp dissection.
D1 Using the internal pterygoid muscle as a guide,
the sharp point of the hamulus is felt and exposed.
With a small osteotome, the hamulus is infractured,
releasing tension on the tensor veli palatini muscle.
The attachments of the soft palate to the posterior
margin of the hard palate may then be separated by
sharp dissection. The lateral releasing incision is packed
with a one half-inch gauze strip to control bleeding
while surgery is performed on the opposite side.
E With a stay suture through the uvula, an incision is
made along the medial cleft margin with a No. 11
scalpel blade. Note that this incision is actually made
in the oral layer several millimeters lateral to the cleft
edge. The cleft-edge mucosa is then reflected with a
Cottle elevator or sharp freer, providing increased width
to the nasal lining and a tension-free closure of the
nasal layer.
F Along the edge of the hard palate, two layers are
developed: the oral mucosa and the nasal mucosa.
Along the edge of the soft palate, three layers are
developed: oral and nasal mucosa plus a middle
muscle layer.
Continued
 CLEFT LIP AND PALATE 509

Post. palatine
vessels
Tensor veli palatini m.
Hamulus
Palatopharyngeus m.

FIGURE 10-8 Continued

 CLEFT LIP AND PALATE
Repair of Complete Cleft of Secondary
Palate (After von Langenbeck, 1861)
(Continued) (Fig. 10-8)
Postoperative Routine
1. Use oral suction only with soft catheter.
2. Maintain intravenous fluids until patient is taking
adequate fluids by mouth (typically 48 hours).
3. Use open cup feeding for 6 weeks. Do not use bottles,
"sippy cups," pacifiers, or straws, which would gen-
erate suction across the wound closure. It is advis-
able for the patient to practice with open cup feed-
ing several weeks in advance of surgery.
4. Use arm restraints for 2 weeks. A variety of products
are available consisting of cylinders that fit over the
arms, limiting elbow flexion.
Complications
• Hemorrhage during surgery and postoperatively
• Postoperative airway obstruction
• Wound dehiscence
• Complete
• Incomplete: fistula, most common at the hard/soft
palate junction
• Velopharyngeal insufficiency. Despite speech therapy,
approximately 30 % of patients require additional
surgery for hypernasal speech.
G Sharp dissection is usually necessary to develop a
clean nasal mucosal layer. Extreme care must be taken
not to fragment this mucosa.
H The dissection is continued until all the layers are
distinctly developed. This extends from the anterior
cleft angle posteriorly to include the uvula. The muscle
bundles of the levator veri palatini are carefully delin-
eated and then freed sharply from their bony attach-
ments to the posterior palatal shelves. At this stage all
layers of the medial edges of the cleft should approxi-
mate one another easily without any tension. Indeed,
the packing in both lateral spaces should achieve approx-
imation of the soft palate. (To clarify the anatomy, the
packing is omitted on one side in the drawings.)
I Progressing anteriorly to posteriorly, interrupted
4-0 absorbable sutures with the knots buried are used
to approximate the nasal mucosa. Small tapered urology
needles (Ethicon J-434: 4-0 Vicryl TF) are less traumatic
to the tissue.
J The muscle layer is approximated with 3-0 absorbable
horizontal mattress sutures. Note that the reconstructed
levator sling now assumes a retrodisplaced position.
K The oral mucosa is approximated with 4-0 absorbable
interrupted or vertical mattress sutures again using a
tapered needle (Ethicon )-434: 4-0 Vicryl TF or the
larger Ethicon )-214: 4-0 Vicryl RB-1).
The lateral gauze packing is then removed to check
for any bleeding. A 2-0 silk tongue suture is placed for
emergency airway control. It is removed in the post-
anesthesia recovery room once the patient is awake.
L Anatomy of normal palate (after Hollinshead, 1954).
 CLEFT LIP AND PALATE 511

TENSOR APONEUROSIS

PTERYGOID HAMULUS

L PALATOPHARYNGEUS

GLOSSOPALATINUS
M. UVULAE

FIGURE 10-8 Continued

 CLEFT LIP AND PALATE
Repair of Incomplete Cleft of Secondary
Palate (After Veau, 1931; Wardill, 1937;
Kilner, 1937; Modified by Peet, 1961)
(Fig. 10-9)
The "three-flap technique" for closure of an incomplete
cleft of the secondary palate is described. For a descrip-
tion of the "four-flap technique" for closure of a com-
plete cleft of the secondary palate or a complete uni-
lateral cleft palate, refer to Peet (1961).
Highpoints
1. Perform tension-free closure of nasal layer.
2. Preserve greater palatine arteries.
3. Adequately mobilize lateral flaps.
4. Reconstruct levator veli palatini sling.
S. Lengthen palate with a V-to-Y advancement with
theoretical improvement in velopharyngeal closure.
Complications
• A higher incidence of maxillary growth retardation
has been implicated with this technique secondary
to greater periosteal stripping required in the
dissection.
A A lateral relaxing incision is made, and the soft
palate is mobilized toward the midline (see Fig. 10-8D).
An incision is then made into the mucosa along the
free edge of the cleft with a No. 11 scalpel. The ante-
rior ends of the two incisions are then connected with
an oblique incision, creating a posteriorly based muco-
periosteal flap.
B The flap is then dissected anteriorly to preserve the
greater palatine vessels. With the exposure thus provid-
ed, all muscular attachments are divided from the pos-
terior palatal shelves (posterior edges of the hard palate),
preserving the nasal mucoperiosteum.
The nasal mucoperiosteum from the floor of the nose
is then elevated from the palatal process (1) (edge of
the cleft), beginning with the posteromedial palatal
spine (2), to which it is firmly adherent. Using blunt
dissection this layer is freed anteriorly and medially.
The levator veli palatini is then carefully delineated
by sharp dissection from the nasal and oral lining (see
Fig. 10-8).
C The edges of the triangular mucoperiosteal flap
anterior to the cleft are undermined slightly to permit
introduction of sutures. The nasal layer is then approx-
imated with 4-0 interrupted absorbable sutures. The
sutures are introduced in sequence from anterior to
posterior and then tied in sequence from posterior to
anterior. The levator veli palatini is then approximated
with 3-0 absorbable mattress sutures (see Fig. 10-8).
D The lateral flaps are then advanced in a V-to-Y
fashion and approximated with 4-0 absorbable sutures
from posterior to anterior. At the level of the posterior
palatal shelf a 3-0 absorbable suture is introduced into
one lateral flap, across the nasal closure, and then out
of the opposite lateral flap. This suture is tied last to
obliterate dead space between the oral and nasal layers.
The lateral flaps are then sewn to the triangular flap to
complete the closure.
 CLEFT LIP AND PALATE

FIGURE 10-9
 CLEFT UP AND PALATE
Repair of Complete Unilateral Cleft
Palate (Fig. 10-10)
Highpoints
1. Repair hard palate with a vomer flap technique
(Veau, 1931).
2. Repair soft palate with von Langenbeck technique
(see Fig. 1O-8F).
3. Adequately mobilize palatal and septal mucosal
flaps.
4. Include periosteum in mucosal flaps.
5. Reconstruct levator veli palatini sling.
6. Carefully approximate nasal and oral layers to elimi-
nate dead space, which can lead to fistula formation.
Postoperative Routine
I. Use oral suction only with soft catheter.
2. Maintain intravenous fluids until patient is taking
adequate fluids by mouth (typically 48 hours).
3. Use open cup feeding for 6 weeks. Do not use bottles,
"sippy cups" pacifiers, or straws, which would gener-
ate suction across the wound closure. It is advisable
for the patient to practice with open cup feeding
several weeks in advance of surgery.
4. Use arm restraints for 2 weeks. A variety of products
are available consisting of cylinders that fit over the
arms, limiting elbow flexion.
Complications
• Hemorrhage during surgery and postoperatively
• Postoperative airway obstruction
• Wound dehiscence
• Complete
• Incomplete: fistula, most common at the hard/soft
palate junction
• Velopharyngeal insufficiency. Despite speech therapy,
approximately 30% of patients require additional
surgery for hypernasal speech.
A The lateral relaxing procedures of a cleft palate
repair are first performed (see Fig. 10-8A to L). These
lateral wounds may be packed with strip gauze.
Incisions are then made along the free edges of the
cleft of the lateral and medial palatal elements. The
mucosal flap from the lateral element is first developed
to estimate the amount of septal mucosa that will be
necessary for later closure of the defect of the hard
palate. The incision in the free border of the medial
element is then made along the junction of the pink
mucosa of the septum with the whitish mucosa of the
palate.
B With the use of sharp and blunt dissection, the
mucoperiosteal flap from the lateral element is mobi-
lized. The mucoperiosteum of the septum (vomer) is
elevated in a similar fashion. Once a plane is estab-
lished over the bone, blunt dissection with a nasal freer
is sufficient. There should be adequate mobilization of
the two flaps to permit overlapping contact. The ele-
vation of the mucoperiosteum is carried to the poste-
rior extent of the septum. At this point the soft palate
is handled as it is during a von Langenbeck repair (see
Fig. 10-8F).
C Cross-sectional view depicts the elevated mucoperios-
teum of the hard palate and septum.
D, E Absorbable 4-0 horizontal mattress sutures are
used to approximate the two mucoperiosteal flaps
over the hard palate defect. These sutures are placed
so that the flaps overlap, being sure that raw surface
faces raw surface.
F, F1 Final closure of the hard palate defect. Care
must be taken that proper approximation of raw
surfaces is achieved at the anterior end. If feasible and
necessary, a single mucosal suture is placed anteriorly.
Three-layer closure is used for the soft palate, includ-
ing reconstruction of the levator veli palatini muscular
sling (Fl) (see Fig. 10-8L).
G The completed operation. Note the bare surfaces
of the hard palate.
 CLEFT LIP AND PALATE

c
Septum

mucosa
Palatal mucosa
~,

, >

FIGURE 10-10
 CLEFT LIP AND PALATE

Pharyngeal Flap in Cleft Palate Repair

(Fig. 10-11 ) A A superiorly based pharyngeal flap containing
mucosa, submucosa, and superior pharyngeal constrictor
Indications muscle is elevated, exposing the prevertebral fascia.
Nasal mucosal incisions and palatal releasing incisions
Pharyngeal flap reconstruction of a cleft palate may be are outlined.
performed either at a second stage or rarely as part of
a primary palatoplasty (Stark and DeHann, 1960). It is B The pharyngeal flap donor site is closed with
useful when repeated unsuccessful procedures on a sutures anchored to the prevertebral fascia. Care is
cleft palate have resulted in scarring, loss of tissue, and taken not to constrict the base of the pharyngeal flap.
shortening. When there is significant tissue deficiency Nasal mucosal turn-over flaps are developed of suffi-
of the palate at the initial examination, it may be cient width to provide oral lining for closure. Lateral
employed to facilitate a primary repair. Depicted is a releasing incisions permit medial mobilization of the
Millard (1962) modification of a primary cleft palate soft palatal flaps.
repair using a superiorly based pharyngeal flap.
C The pharyngeal flap is sewn into the nasal lining
Highpoints defect with close attention not to sew it under tension
either along its length or along its width.
1. Single pedicle flap is made up of mucosa, submucosa,
and superior pharyngeal constrictor muscle. D The oral lining is closed, anchoring the closure to
2. Reflect nasal mucosal flaps orally to provide addi- the pharyngeal flap to complete the repair. The releasing
tional oral lining. incisions are left open.
3. Pharyngeal flap is attached to the nasal surface.
4. Pedicle is left attached permanently. Note: In large horseshoe-shaped clefts, such as one
finds in the Pierre Robin sequence, the soft palate is
closed with a primary pharyngeal flap and the hard
palate is obturated with a removable appliance (a
"roofy") until 6 years of age.

A B
FIGURE 1 0-11

c D
FIGURE 10-11
Pharyngeal Flap for Velopharyngeal
Insufficiency (Fig. 10-12)
The production of normal speech requires periodic
closure of the velopharyngeal mechanism, a dynamic
process influenced by the length, compliance, and
motion of the soft palate (velum) as well as by the
coordinated action of the posterior and lateral pharyn-
geal walls. Different procedures both static and dynamic
have been developed in an attempt to correct velopha-
ryngeal insufficiency in the cleft palate patient to reduce
both nasal regurgitation and hypernasal speech. The
pharyngeal flap (Schoenborn, 1876) remains the most
popular surgical correction and is presented here. With
improved diagnostic techniques such as nasopharyn-
goscopy (Pigott et a!., 1969) and multiview videofluo-
roscopy, the pharyngeal flap can be appropriately de-
signed to obturate many velopharyngeal closure defects.
Pharyngeal flaps may be either superiorly based or
inferiorly based. Ease of construction of the inferiorly
based flap makes it more suitable for patients in whom
visualization is difficult. The superiorly based flap can
bridge a larger gap and avoids friable adenoid tissue.
Recall that the normal action of the levator veli palatini
muscle is to elevate and retract the soft palate poste-
riorly. The inferiorly based flap tends to pull the palate
caudad out of the plane of velopharyngeal closure,
while the superiorly based flap maintains the palate in
a more physiologic position.
Pressure flow studies (Warren, 1964) have demon-
strated that the threshold for velopharyngeal insuffi-
CLEFT LIP AND PALATE 51 7
ciency is a port whose cross-sectional area is approxi-
mately 20 mm2• In 1973, Hogan introduced the concept
of lateral port control during the construction of a
pharyngeal flap, limiting the port opening on either
side of the flap to the size of a 4-mm (I2.6-mm2)
catheter. Port size can then be adjusted further depend-
ing on preoperative measurements of lateral pharyn-
geal wall motion.
Highpoints
1. Prophylactic antibiotics are recommended.
2. Develop a superiorly based flap from the posterior
pharyngeal wall and close the resultant defect.
3. Split the soft palate in the midline.
4. Create paired, distally based nasal lining flaps.
5. Sew the nasal lining flaps to the raw caudal surface
of the pharyngeal flap.
6. Adjust the lateral ports.
7. Insert a nasopharyngeal airway.
Postoperative Routine
1. Admit the patient to an intensive care unit or step-
down unit for the first 24 hours postoperatively to
monitor the airway.
2. A nasopharyngeal airway is placed at the end of sur-
gery and removed on the first postoperative day after
verifying airway competency. In children, an uncuffed
endotracheal tube is cut down, inserted, and secured to
the membranous nasal septum with a 2-0 silk suture.
 CLEFT LIP AND PALATE
Pharyngeal Flap for Velopharyngeal
Insufficiency (Continued) (Fig. 10-12)
Complications
• Acute airway obstruction postoperatively
• Partial loss or distortion of flap. If flap is sewn under
too much tension, partial necrosis will result in exces-
sive scarring. If flap is unlined (some techniques make
no attempt to line the raw caudal surface between
the posterior pharyngeal wall and the posterior aspect
of the soft palate), shrinkage and "tubing" can result
in a flap of inadequate size.
• Persistent velopharyngeal insufficiency (if lateral ports
are too large)
• Possible airway obstruction, impaired sinus drainage,
eustachian tube dysfunction, and sleep apnea (if
lateral ports are too small)
Cautions
1. Down syndrome: because of the increased risk of
atlantoaxial (CI-C2) instability, cervical radiographs
must be obtained before hyperextending the neck.
2. Velocardiofacial syndrome: because of increased risk
of medial displacement of the internal carotid arteries,
a magnetic resonance angiogram should be obtained
before making incisions into the posterior pharyn-
geal wall.
A, A 1 The superiorly based pharyngeal flap is
designed on the posterior pharyngeal wall with a base
slightly above the palatal plane. The length of the flap
is calculated to extend well over the soft palate, and its
width is determined by preoperative fluoroscopic or
endoscopic evaluations of velopharyngeal closure. Typical
is a moderately wide, centrally positioned pharyngeal
flap whose width is nearly that of the posterior pharyn-
geal wall.
The flap margins are incised through mucosa, sub-
mucosa, and superior pharyngeal constrictor. The flap
is elevated off of the prevertebral fascia from below
upward. After the distal end of the flap (3) is retracted
with a suture, the donor-site defect in the posterior
pharyngeal wall is closed with 4-0 absorbable mattress
sutures, anchoring the closure to the underlying
prevertebral fascia to obliterate dead space.
B The soft palate is split in the sagittal midline with
a No. 11 scalpel. Traction sutures are placed in each
posteromedial corner (1).
C, C1 Paired distally based flaps are then developed
from the nasal lining, which will be used to cover the
raw caudal surface of the pharyngeal flap. The width
of each flap is slightly more than half the width of the
pharyngeal flap. These flaps are cut thickly and ele-
vated from anterior to posterior.
The pharyngeal flap is then sewn to the nasal sur-
face of the soft palate. This may be accomplished with
4-0 horizontal mattress sutures passed through the
palate to the flap, then back through the palate and
tied on the oral side. Care is taken not to sew the flap
under too much tension either along its length or
along its width, which would compromise its circula-
tion. The right and left nasal lining flaps are then sewn
together in the midline and then onto the caudal
surface of the pharyngeal flap.
0, 01, 02 The midline soft palate incision is closed
with 4-0 mattress sutures. Lateral ports are then adjusted
around a 4-mm catheter (No. 12 French Robinson)
passed nasally. At the conclusion of surgery a naso-
pharyngeal airway is directed through one lateral port
and secured in position.
 CLEFT UP AND PAlATE 519

FIGURE 10-12
 ClEFT LIP AND PALATE
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Hoopes JE, Dellon AL, Fabrikant Jl, Soliman AH: The locus of levator
veli palatini function as a measure of velopharyngeal incompetence.
Plast Recontr Surg 44:155-160,1969.
Iregbulem LM: Median cleft of the lower lip: Case report. Plast Reconstr
Surg 61:787-789,1978.
Isshiki N, Koyama H: Palatoplasty without elevation of mucoperiosteal
flap on the cleft side. Ann Plast Surg 4:457-461,1980.
Isshiki N, Morimoto M: Anterior cleft palate closure by turnover flaps.
Plast Reconstr Surg 42:249-25],1968.
Jackson IT, Vandervord JG, Mclennan JG, et al: Bone grafting of the sec-
ondary cleft lip and palate defonnity. Br J Plast Surg 35:345-353,1982.
Jackson IT, Soutar OS: The sandwich Abbe flap in secondary cleft lip
deformity. Plast Reconstr Surg 66:38-44, 1980.
Jayapathy B, Huffman WC, Lierle OM: The Z-plastic procedure: Some
mathematic considerations and application to cleft lip. Plast Reconstr
Surg 26:203-208, 1960.
Kernahan DA: The striped Y3/4A symbolic classification for cleft lip
and palate. Plast Reconstr 5urg 47:469-470, 1971.
Kernahan DA, Bauer BS, Harris GO: Experience with the Tajima proce-
dure in primary and secondary repair in unilateral cleft lip nasal
deformity. Plast Reconstr Surg 66:46-53, 1980.
Kernahan DA, Dado DV,Bauer BS: The anatomy of the orbicularis oris
muscle in unilateral cleft lip based on a three-dimensional histologic
reconstruction. Plast Reconstr Surg 73:875-879, 1984.
Kiehn CL, DesPerez JD, Brown F: Maxillary osteotomy for late correc-
tion of occlusion and appearance in cleft lip and palate patients.
Plast Reconstr 5m3 42:203-207, 1968,
Kiehn CL, DesPerez JD, Maes JM, Kronheim L: Temporal muscle
transfers to the incompetent soft palate: A progress report. Plast
Reconstr Surg 48:335-338, 1971.
Kilner IP: Cleft lip and palate repair technique. 5t. Thomas Hasp Rep
25:117,1937.
Kluzak R: Thansplantation of rib growth cartilage: Experimental study
and possible use in primary cleft lip repairs. Plast Reconstr Surg
49:61-69,1972.
Kobus K: Extended vomer flaps in cleft palate repair: A preliminary
report. Plast Reconstr Surg 73:895-901,1984.
Langenbeck B: Operation on congenital total cleft of the hard palate
by a new method. Plast Reconstr Surg 49:323-324, ]972.
Le Mesurier AB: The treatment of complete unilateral harelips. Surg
Gynecol Obstet 95:17-27,1952.
McCabe PA: A coding procedure for classification of cleft lip and cleft
palate. Cleft Palate J 3:383-391, 1966.
McConnel FMS, Zellweger H, Lawrence RA: Labial pits-cleft lip
and/or palate syndrome. Arch OtolaryngoI91:407-411, 1970.
McCoy FJ, Zahorsky CL: A new approach to the elusive dynamic
pharyngeal flap: Preliminary report. Plast Reconstr Surg 49:
160-164,1972.
McEvitt WG: Conversion of an inferiorly based pharyngeal flap to a
superiorly based position. Plast Reconstr Surg 48:36-39, 1971.
McWilliams BJ: The role of otolaryngological problems in speech
disorders associated with cleft palate. Thans Am Acad Ophthalmol
Otolaryngol 73:720-723, 1969.
Maisels DO: Chronic lip fissures. Br J Dermatol 81:621-622,1969.
Manchester WM: How t do it/colloquium: Surgical management of
bilateral cleft lip. Ann Plast Surg 1:509-512, 1978.
Marcks KM, Trevaski AE, daCosta A: Further observations in cleft lip
repair. Plast Reconstr Surg 12:392, 1953.
Messengill R Jr, Pickrell K, Mladick R: Lingual flaps: Effect on speech
articulation and physiology. Ann Olo! Rhinol Laryngol 79:853,1970.
 CLEFT LIP AND PALATE 521

Massengill R Jr, Walker T, Pickrell KL: Characteristics of patients with Randall P: A triangular flap operation for the primary repair of unilat-
a Pass avant's pad. Plast Reconstr Surg 44:268-270,1969. eral clefts of the lip. Plast Reconstr Surg 23:331-347,1959.
Millard DR Jr: A radical rotation in single harelip. Am J Surg 95: Randall P, Whitaker LA, LaRossa D: The importance of muscle recon-
318-322, 1958. struction in primary and secondary cleft lip repair. Plast Reconstr
Millard DR Jr: Refinements in rotation-advancement cleft lip tech- Surg 54:316-323, 1974.
nique. Plast Reconstr Surg 33:26-38, 1964. Rosedale RS: Pharyngeal flaps. Eye Ear Nose Throat Monthly 46:470-
Millard DR Jr: Extensions of the rotation-advancement principle for 478, 1967.
wide unilateral cleft lips. Plast Reconstr Surg 42:535-544, 1968. Salyer KE: Primary correction of the unilateral cleft lip nose: A 15-
Millard DR Jr: Closure of bilateral cleft lip and elongation of columella year experience. Plast Reconstr Surg 77:558-566, 1986.
by two operations in infancy. Plast Reconstr Surg 47:324-331, 1971. Schoenborn K: On a new method of staphylorrhaphy. Plast Reconstr
Millard DR Jr: A primary camouflage of the unilateral harelook. Surg 49:558-562, 1972.
Transactions of the 1st International Congress on Plastic Surgery. Shirokov EP: Carcinoma of the palate. Am J Surg 100:530-533, 1960.
Baltimore, Williams & Wilkins, 1957, pp 160-166. Stark RB: Cleft Palate: A Multidiscipline Approach. New York, Harper
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in bilateral cleft lip. In Wallace AB (ed): Transactions of the Stark RE: Cleft lip-a timetable. Ann Plast Surg 8:107-117, 1982.
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Millard DR Jr: Wide and/or short cleft palate. Plast Reconstr Surg Steffensen WH: A method for repair of the unilateral cleft lip. Plas!
29:40-57, 1962. Reconstr Surg 4:144, 1949.
Millard DR Jr: Cleft Craft, vol !, The Unilateral Deformity. Boston, Steffensen WH: Further experience with the rectangular flap opera-
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Millard DR Jr: Cleft Craft, vol II, Bilateral and Rare Deformities. Tennison CW: The repair of unilateral cleft lip by the stencil method.
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Millard DR Jr: Cleft Craft, vol Ill, Alveolar and Palatal Deformities. Thompson JE: An artistic and mathematically accurate method of
Boston, Little, Brown & Co, 1980. repairing the defect in cases of harelip. Surg Gynecol Obstet
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the palatal island flap. Plast Reconstr Surg 46:540-547, 1970. Uchida J-J: A new approach to the correction of cleft lip nasal defor-
Mina MMF: Styloid, velar, and pharyngeal muscles in cleft palate. J. mities. Plast Reconstr Surg 47:454-458,1971.
Otolaryngol 8:179-190,1979. Veau V: Division Palatine. Paris, Masson, 1931.
Nishimura Y: Cleft lip repair. Chir Plastica 4:109-114, 1978. Veau V: Bec-de-Lievre. Paris, Masson, 1938.
Noordhoff MS: Reconstruction of vermilion in unilateral and bilateral von Langenbeck B: Operation der angeborenen totalen Spaltung des
cleft lips. Plast Reconstr Surg 73:52-60, 1984. harten Gaumens nach einer neuer Methode. Dtsch Klin 8:231,
Ogino Y, Ishida H: Secondary repair of the cleft-lip nose. Ann Plast 1861; also Plast Reconstr Surg 49:323-324, 1972.
Surg 4:469-480, 1980. Ward PH, Goldman R, Stoudt RJ Jr: Teflon injection to improve
Orticochea M: A review of 236 cleft palate patients treated with velopharyngeal insufficiency. J Speech Hearing Disord 31:267-273,
dynamic-muscle sphincter. Plast Reconstr Surg 71:180-186, 1983. 1966.
Paradise JL, Bluestone CD, Felder H: The universality of otitis media Wardill WEM: Technique of operation for cleft palate. Br J Surg
in 50 infants with cleft palate. Pediatrics 44:35-42, 1969. 25:117-130,1937.
Peet E: The Oxford technique of cleft palate repair. Plast Reconstr Warren DW: Velopharyngeal orifice size and upper pharyngeal
Surg 28:282-294, 1961. pressure-flow patterns in cleft palate speech: A preliminary study.
Pigott RW, Bensen JF, White FD: Nasoendoscopy in the diagnosis of Plast Reconstr Surg 34:15,1964.
velopharyngeal incompetence. Plast Reconstr Surg 43:141-147, Wynn SK: Primary nostril reconstruction in complete cleft lips. The
1969. round nostril technique. Plast Reconstr Surg 49:56-60, 1972.
Potter J: Cleft palate-fifty years on. Ann Plast Surg 10:12-14, 1983. Yules RB: Cinefluorography, speech, and dynamic respirometry in
Potter J: As I remember-William Wardhill. Ann Plast Surg 9:344- preoperative and postoperative pharyngeal flap patients. Trans Am
347, 1982. Acad Ophthalmol Otolaryngol 73:724-727, 1969.
 11 PERIORBITAL REGION

Many of the principles outlined are from Mustarde (1969). Additional anatomy is depicted in Figures 11-12B
and Bl and 11-12 D and G and Figure 6-4.
Anatomy (Fig. 11-1)

A, B The anatomy of the eye and its relationship to

the bony orbit are shown.

EXT. SECTION
MEDIAL CANTHAL
L1G.

lATERAL RECTUS M.

lACRIMAL GROOVE

ANT. LACRIMAL CREST

• RECTUS M.
A ""+ . 9MATIC BONE
. NlA'XILLARY BONE
INFRAORBITAL NERVE

APONEUROSIS OF
lEVATOR PALPEBRAE SUP M.

ORBITAL SUP. OPHTHALMIC V.

SEPTUM
SUP. RECTUS M.
OPHTHALMIC A.
FORNIX

TARSUS SUP.
ORBICULARIS M.

TARSUS INF.

ORBICULARIS M.
FORNIX
ORBITAL SEPTUM

FIGURE 11-1

523
 524 PERIORBITAL REGION
Repair of Lids and Conjunctiva
(Fig. 11-2)
Wounds of the Conjunctiva
A There are three main types of wounds:
1. laceration at right angle (1) to the fornix requires
repair. Meticulously placed 6-0 gut sutures are
used; otherwise, scar contractures will occur.
2. lacerations parallel (2) to the line of the fornix
usually require no suturing.
3. lacerations of the palpebral (lid) conjunctiva are
repaired with 6-0 nylon pull-out sutures (see [3] in
B and C). Such lacerations more often than not
involve the entire lid. No knots are permissible on
exposed conjunctiva to prevent corneal damage.
Replacement of missing conjunctiva can be accom-
plished with conjunctiva from the opposite eye or
from the fornices. This has drawbacks; hence, usually
a mucosal graft from the inner aspect of the lips,
cheek, or nasal septum is preferred. Never use split-
thickness skin. A free-foreskin graft (prepuce) can
be used to replace bulbar conjunctiva (over the
sclera) for large defects. Lip and cheek mucosa are
abundant but tend to contract 50% to 60%. Nasal
mucosa is best and is obtained ideally by dissecting
the mucous membrane from the underlying peri-
chondrium, a different plane from what is used in
the submucous resection operation (see Fig. 6-12).
If the perichondrium is removed, there is no harm
except that the graft is somewhat thick and tends
to contract. If only ~he mucous membrane is excised,
then the donor site re-epithelializes well by being
covered with antibiotic ointment. If the perichon-
drium is removed with the mucous membrane, it is
best to cover the bare cartilage with a split-thick-
ness epidermal or dermal graft.
Repair of Lid lacerations
B, C A three-layer closure is performed: conjunctiva
with continuous 6-0 nylon pullout sutures (3) that splint
the edges of the tarsus together (the ends of this pull-
out suture are secured with tape as shown)-a small
portion of the tarsal plate is included in this suture;
orbicularis oculi muscle with only one or two 5-0 catgut
sutures (5); and the skin with 5-0 or 6-0 silk or nylon.
If nylon is used, the ends should be either very short or
very long to avoid injuring the cornea. A small suture
(4) of 6-0 silk is utilized to approximate the lid margins
exactly at the gray line. This suture is left long (2.5 cm
or more) to prevent a turning-in, avoiding injury to the
cornea.
Scar contracture of the lower lid can be corrected by
a single or double Z-plasty.
Management of Disruption of the
Canaliculi
D Depicted is a "near-far, far-near" type of suture
(Smith) for approximation of lid margins. This aids in
the prevention of notching of the lid margins. See also
Figure 11-12G.
Reconstruction of Lids
(See Figs. 11-3 to "-'0)
Basic Principles
These principles can be applied to tissue loss and severe
scars resulting from trauma.
1. The upper lid is more important than the lower lid,
because significant defect in the upper lid, especially
in the midline, will eventually lead to a corneal ulcer-
ation and loss of vision. Hence, do not use the upper
lid to reconstruct the lower lid except possibly for
the use of a small amount of redundant skin of the
upper lid. The lower lid may be used to reconstruct
the upper lid. The upper lid must be reconstructed
immediately.
2. Twenty-five percent (up to 30% in the elderly) of
the vertical lid (full thickness) defect can be closed
by primarily approximating the edges if both canthal
areas are uninvolved. If the defect is greater, addi-
tional length can be achieved by a lateral cantholy-
sis. Hence, a 25 % defect requires no grafting tech-
nique. This is the principle of "quarters."
3. Horizontal lid defects are separate problems and, if
of any size, require transposed tissue or rotated flaps
(see Figs. 11-9D and E and 11-14E and F).
4. Use a three-layer closure, except in situations in
which the conjunctiva loss is small and less than the
skin and muscle loss. In such cases the conjunctival
layer can be omitted (see Fig. 11-3C2 and C3).
 PERIORBITAL REGION

FIGURE 11-2
 PERIORBITAL REGION
Reconstruction of Lids (Continued)
(See Figs. 11-3 to 11-10)
Alternate and Additional Concepts
1. Some surgeons believe that portions of the full-
thickness layers of the upper lid can be safely utilized
to reconstruct the lower lid using the rotated (switch)
or pedicle flap technique. This would be the reverse
situation as depicted in Figure 11-5L to OJ. With
larger flaps from the upper to the lower lid or vice
versa, a "sharing" procedure is utilized (Hughes, 1954;
Cutler and Beard, 1955; see Fig. 11-6). The impor-
tant principle in any modification of this technique
is that the lid margin of the donor lid is not tran-
sected or violated (see Fig. 11-6). This feature may
be the reason why Mustarde and other surgeons have
abandoned this method-it is actually a failure of
application of surgical technique rather than a failure
of the basic method itself.
2. When there is only skin loss of the lids, free graft
from the opposite lid (opposite side if necessary) or
from the postauricular region or a thick split -graft
(freehand) is used.
3. When utilizing the Fricke upper lid flap (see Fig.
11-90 and E), the entire length of the skin of the
upper lid should be used to avoid disparity when
closing the donor site.
4. Both these surgeons (McCoy and Smith) avoid the
Mustarde technique of a lateral cheek flap (see Fig.
11-4) to reconstruct the lower lid. The lateral cheek
flaps may result in a downward pull on the recon-
structed lower lid. To aid in the prevention of this
problem, refer to Figure 11-4, which demonstrates
that the lateral side of the excised parallelogram is
longer and more oblique than the medial side.
5. When excising skin of the lower lid, Smith empha-
sizes the importance of having patients open their
mouths widely to evaluate the downward traction
on the lower lid to prevent ectropion.
6. In repairing lid defects, the layer closure of the inner
and outer incisions should not be directly in the same
plane (halving technique). This is more theoretical
than practical.
Neoplastic lesions of the lower lid are basal cell car-
cinoma (90%), squamous cell carcinoma, and meibo-
mian gland carcinoma. The operating microscope helps
in delineating the extent of a tumor when normal
meibomian orifices are visualized. The latter two types
can metastasize, but basal cell carcinoma rarely does.
Reconstruction of Lower Lid (Fig. 11-3)
Figure 11-3depicts in outline fashion the basic principles
of lower lid reconstruction for vertical defects following
the "quarter" rule of Mustarde. Details of technique for
large lower lid defects are shown in Figure 11-4.
A Vertical lid defect and "shield-type" incision are
shown.
B This horizontal lid defect requires transposed
tissue or rotated flaps. See Figures 11-9D and E and
11-14E and F.
Reconstruction of Lower Lid With 25% Defect
For suturing details refer to Figure 11-2Bto D.
C, Cl Shown is primary closure of a 25% defect
when both canthal areas are intact. (In elderly patients
up to 30% of the lid may sometimes be resected and
a primary simple closure performed.)
Continued
 PERIORBITAL REGION 527

25% DEFECTI _

FIGURE 11-3
 PERIORBITAL REGION
Reconstruction of Lower Lid (Continued)
(Fig. 11-3)
(2 Depicted is a pentagon-shaped excision (leone)
that is similar in some respects to the shield-type exci-
sion in A. The gross margins are at least 1 to 2 mm for
basal cell carcinoma. Frozen sections are obtained on
all three margins of the surgically removed specimen
as well as from the margins of the surgical wound to
be certain that the resection is adequate. If any of these
frozen sections are positive, additional excisions are done
until frozen sections are free of tumor. If the lesion is
squamouscell carcinoma (rare), then up to 5-mm margins
are recommended. The use of stay sutures on the lid
margins is of great aid to stabilize the lid during the
excision.
(3 The completed closure is shown.
Reconstruction of Lower Lid With 25% Defect at
Lateral Canthus
D, D2 Shown is a 25% defect at the lateral canthal
region. This usually requires a lateral canthoplasty (D1).
Either the inferior or superior crus or both crura of the
lateral canthal ligaments are transected. A medial
canthoplasty is not used because of possible injury to
lacrimal apparatus.
Reconstruction of Lower Lid With 30% Defect
E Shown is a 30% defect.
El A lateral cantholysis is again usually necessary
except in the elderly, in whom there is more tissue
laxity.
Continued
 PERIORBITAL REGION 529

C2 C3

25% DEFECT AT LATERAL CANTHUS_I -------------

D2

FIGURE 11-3 Continued

 PERIORBITAL REGION
Reconstruction of lower lid (Continued)
(Fig. 11-3)
Reconstruction of Lower Lid With 30% to 50%
Defect
F Shown is a defect of 30% to 50%.
Fl A lateral cantholysis plus an advanced cheek flap
is required for closure. Lining of the flap can be obtained
from some redundant conjunctiva at the lateral canthal
region. Note that the lateral side of the excised parallel-
ogram is longer and more oblique than the medial
side to prevent inferior contracture of the reconstructed
lid. This principle is applicable to the procedure in
steps G and H. Details of the technique are presented
in Figure "-4.
Reconstruction of Lower Lid With 50% to 75%
Defect
G A defect of 50% to 75% is presented.
G1 A lateral cantholysis plus a larger rotated cheek
flap with cutback incision is required for closure. The
lining of this flap will require a free septal cartilage and
mucous membrane graft (X). Be sure the mucosal
surface is identified and distinguished from the raw
undersurface when suturing the graft in place. Pullout
sutures of 6-0 nylon are used. Details of this technique
are in Figure "-4.
Reconstruction of Lower Lid With 100% Defect
H There is a , 00% loss of the lower lid.
Hl A lateral cantholysis plus a somewhat larger rotated
cheek flap with cutback incision is required for closure.
The lining of this flap will require a free septal cartilage
and mucous membrane graft (X). Details of the tech-
nique are given in Figure "-4.
The use of an extended nasofacial flap, superiorly
based to reconstruct lower lid defects, is shown in
Figures 6-21 and 6-23.
 PERIORBITAL REGION 531

H1

FIGURE 11-3 Continued

 PERIORBITAL REGION
Resection of large Basal Cell Carcinoma
of lower Lid With Reconstruction Using
lateral Cheek Flap (Fig. 11-4) (After
Mustarde, 1969)
Highpoints
1. A full-thickness resection is used.
2. Immediate reconstruction is done with a lateral
cheek flap.
3. Total release of a cheek flap in front of the ear with
right angle back cut at distal end of incision of
cheek flap is done when two thirds or more of the
lower lid is resected.
4. Lower lid resection includes an elongated inverted
parallelogram or "shield" below the tumor to ensure
proper advancement of cheek flap.
5. The sides of this parallelogram or shield are unequal
in length and direction: the medial side is shorter
and vertical; the lateral side is longer and slanted
obliquely downward and medially. This is done
to prevent a downward pull of the reconstructed
lower lid.
6. The cheek flap is extended slightly upward at the
lateral canthus and the release extends 1 cm below
the apex of the excised parallelogram.
7. The deep portion of the cheek flap is sutured to the
orbital rim, especially at the lateral canthus to prevent
downward tension on the reconstructed lid.
8. Lining of the newly reconstructed lid is ideally
achieved by utilizing a free-mucosal chondral graft
from the nasal septum.
9. Do not injure the lacrimal punctum and canaliculus
if this is compatible with adequate resection of the
primary tumor; otherwise, resect these areas. Trouble-
some epiphora mayor may not occur, and this can
be corrected later if need be by the utilization of a
conjunctival flap (see Fig. ll-llC).
10. Margins of tumor must be adequately identified
with sutures or staining with silver nitrate for frozen
sections.
11. Refer to page 526 for alternate and additional
concepts.
Complications
• Nylon pullout sutures may break: take care in re-
moving them .
• Downward droop of new lid: perform lateral
canthoplasty.
• Fold and edema of rotated cheek flap
• Failure of nasal graft, especially the cartilage
A Depicted is a tumor requiring resection of almost
the entire lower lid, sparing the canaliculus. The area
of resection with a large cheek flap and back cut (1) is
outlined.
A 1 Schematic outline of procedure emphasizes five
important features of the incision for the cheek flap.
1. The medial incision of the excised triangle is almost
vertical; the lateral incision is longer and oblique.
2. Adequate undermining is done below and espe-
cially lateral to the apex of the excised triangle.
3. A cutback (1) incision is made just below the lobule
of the ear.
4. A vertical relaxing incision on the cheek flap may be
necessary with an excision of small triangles (2) to
increase the length of the cheek flap. The cheek flap
consists of skin and subcutaneous tissue but not the
parotid fascia. The facial nerve and its branches are
thus spared.
5. The portion of the incision forming the cheek flap is
curved slightly upward toward the level of the brow
(3).
B The tumor is excised with a full-thickness resection
and a free graft consisting of septal cartilage, and
attached mucosa is sutured in place as a replacement
for the tarsus and conjunctiva. One or two continuous
6-0 nylon pullout sutures (4) are utilized. No knots are
tied on the conjunctival surface. To increase support
inferiorly 5-0 or 6-0 catgut sutures may be necessary.
C The inner subcutaneous tissue of the rotated cheek
flap is sutured (5) to the periosteum of the infraorbital
portion of the maxilla to prevent a downward pull on
the newly reconstructed lower lid. Similar sutures (6)
are also used to support the flap at the lateral canthal
region by fixing the sutures superiorly along the lateral
orbital margin.
~ Long 5-0 silk sutures are used to approximate the
cheek flap to the mucocartilage graft. For the remain-
der of the skin closure 5-0 nylon is used. The pullout
sutures securing the septal graft are depicted (4) .
 PERIORBITAL REGION

75%-90% DEFECT -------------------

FIGURE 11-4
 PERIORBITAL REGION
Reconstruction of Upper Lid (Fig. 11-5)
(After Esser, 1919; Mustarde, 1969)
Highpoints
1. Upper lid reconstruction must encompass the follow-
ing characteristics:
a. Ability to cover and to protect the cornea during
sleep
b. Ability to elevate if at all possible; hence it must
have some neuromuscular function
c. Must be lined with smooth mucous membrane
to protect cornea
d. Must be rigid enough to maintain its shape and
curvature to protect the cornea
3. Lower lid or portion thereof is best suited for
reconstruction whenever possible.
4. Use all layers of lower lid.
5. Preserve vascular supply to rotated lower lid: pedicle
in smaller flaps should be 5 mm wide and in the
larger flaps 6 mm wide.
6. Suture tarsal plate of rotated lower lid to remaining
portion of levator palpebrae superioris muscle or
its aponeurosis (see L).
7. As with lower lid, the principle of quarters is appli-
cable (see p. 526).
a. Defect up to one quarter (25%) is accomplished
by direct closure (no rotated flap from lower lid
is necessary).
b. Defect greater than one quarter and up to two
quarters is reconstructed by up to one-quarter
lower lid flap, with direct closure of donor site
of lower lid.
c. Defect greater than two quarters and up to three
quarters is reconstructed by a lower lid flap up
to two quarters of its length, with a rotation of
the lateral cheek flap to close the donor site of
the lower lid.
d. Defect greater than three quarters to total loss
is reconstructed by a lower lid flap up to three
quarters of its length preserving the medial
quarter of the lower lid, thus avoiding any injury
to the punctum and lacrimal apparatus.
8. The vascular hinge for lower lid flaps a, b, and c
under No. 7 is placed laterally, whereas flap d
under NO.7 is placed medially.
9. Avoid kinking of vascular supply in pedicle when
flap is rotated.
10. Refer to basic principles of lid reconstruction (see
p.526).
Reconstruction of Upper Lid With 25% Defect
A A 25% defect repair is depicted. The lidsare divided
into quarters for clarity. Direct three-layer closure is
performed following the technique in Figure 11-2B to
D. Ifthe defect is only slightly greater than 25% of the
lid, several additional millimeters can be gained in the
elderly patient by a lateral cantholysis (canthotomy)
(see Fig.11-3Dl). In a younger patient, it is best to rotate
a flap from the lower lid.
Al The completed closure is shown. The 6-0 nylon
conjunctival suture (1) and the gray line fine silksuture
(2) are depicted.
Continued
Refer to Figure 11-6 for an alternate technique.
 PERIORBITAL REGION 535

25% DEFECT

A
FIGURE 11-5
 PERIORBITAL REGION
Reconstruction of Upper Lid (Continued)
(Fig. 11-5) (After Esser, 1919; Mustarde,
1969)
Reconstruction of Upper Lid With 30% to 50%
Defect
B Thirty to 50 percent defect repair is depicted by
rotation of the lower lid flap measuring in width one
half of the upper lid defect and equal in height (ver-
tical) to the upper lid defect. The excision should be a
parallelogram or shield shaped.
With the use of fine hooks, the upper lid defect is
reduced 25%. The original defect (dotted lines) is thus
reduced to the solid lines. The defect is equal to
distance X-V, which is equal to distance X'-Y' of the
lower lid flap. The midpoint of this defect then locates
the point (1) on the lower lid where the vascular
pedicle is planned. When the resulting upper lid defect
is less than 6 mm in width (using the fine hooks), the
lower lid flap width for practical purposes should not
be less than 6 mm, because a rotation of a lower lid
flap less than 6 mm is too minute.
C The lower flap is outlined and rotated from the
lateral portion of the lower lid by first using scissors
through the lid margin (along the solid line) and then
by using a knife (along dotted line, C1 and (2) up to
within 5 mm of the lid margin where the pedicle (1) is
located, thus carefully preserving the vascular arcade.
The knife cut is made away from the pedicle. This vas-
cular arcade is actually 3 mm from the free border of
the lid margin, and thus, if meticulous pains are taken,
some additional relaxation of the rotated flap can be
achieved by incising the skin and conjunctiva another
millimeter or so.
D The flap is rotated and sutured in place using a
standard three-layer closure. Depicted is placement of
the conjunctival 6-0 nylon pullout suture. One suture
(2) is placed in the gray line of the lid margin at the
medial border of the defect. When there is not more
than a 50% defect of the upper lid, it is not necessary
to suture the levator palpebrae superioris to the flap,
because there is sufficient attachment to the remain-
ing upper lid. However, if practical, such attachment
can be done with 5-0 chromic catgut.
If additional relaxation is deemed necessary, a lateral
cantholysis (see Fig. 11-3Dl) is performed.
Sutures are placed in such a fashion as not to kink
the vascular pedicle. These sutures are removed on the
fifth postoperative day, except for the margin gray line
suture (2), which is removed 2 days later.
E, El The vascular pedicle is transected in 2 to 3
weeks, and the lid margins are tailored by an excision
of small triangles to facilitate good realignment of the
lid margins. A near-far, far-near suture may be placed
along the gray line to prevent notching (see Fig.
11-2D). This suture is left long (3).
F, F1 If the defect is at the lateral canthus, the
procedure is modified in that a single triangle (X) from
the pedicle can be excised at the lateral canthus to
form a sharper lateral canthus and to lengthen the
palpebral fissure.
Continued
 PERIORBITAL REGION 537

FIGURE 11-5 Continued

 PERIORBITAL REGION
Reconstruction of Upper Lid (Continued)
(Fig. 11-5) (After Esser, 1919; Mustarde,
1969)
Reconstruction of Upper Lid with 50% to 60%
Defect (After Mustarde, 1969)
This group is divided into two techniques:
1. Fifty to 60 percent defect is closed with pedicle of
flap based and swung laterally.
2. Sixty to 75 percent defect is closed with pedicle of
flap based and swung medially.
Laterally Based Flap
G A defect somewhat greater than two quarters is
depicted. Fine hooks simply put normal tension on the
cut edges but do not attempt to decrease the defect
by a quarter. Therefore, quite a different mathematical
plan is used to calculate the position and width of the
flap from the lower lid as compared with the smaller
defects. This is first done by marking the correspond-
ing width of the defect on the edge of the lower lid
with a dye (points 1 and 2). Then this marked defect
is reduced by a distance equal to one quarter the entire
length of the lower lid, the subtraction being done on
the lateral side of the marked defect. This is the distance
between points 2 and 3. Point 3 then becomes the
location of the pedicle of the lower lid flap that is to be
rotated from the lateral portion of the lower lid. This
prevents injury to the lacrimal apparatus.
H The flap is outlined. Distance 3-4 is equal to dis-
tance 1-3 in G. Point 4 on the lateral portion of the
lower lid flap is to be transposed to point 4' on the
medial edge of the upper lid defect.
I To close the donor site, an advanced lateral cheek
flap will usually be necessary (except in the elderly
when more lax skin is present). Refer to Figures 11-3F
to Hand 11-4.
11 The closure is the standard three-layer approxima-
tion (see Fig. 11-2). Transection of the pedicle is per-
formed at 2 weeks (see Fig. 11-50 to E1). The nylon
pullout conjunctival sutures (5) are taped to the skin.
Reconstruction of Upper Lid With 60% to 75%
Defect
Medially Based Flap (Close to 75% Defect)
When the defect in the upper lid is close to 75% loss,
a medially based flap is necessary, because there is not
sufficient length laterally for a rotated lower lid flap.
J Defect and calculation of the flap are depicted. The
calculation is the same as in G, but it is obvious that
there is not sufficient length laterally; hence, it is rotated
from the medial side. Distance 3-4 is the width of the
flap after one-quarter length of the lid has been sub-
tracted (distance 2-3). Point 4 on the medial portion of
the lower lid flap is to be transposed to point 4' on the
lateral edge of the upper lid defect. Caution must be
taken not to involve that portion of the lower lid flap
with the canaliculus. At times the outline of the flap
must be shifted slightly laterally to preserve this vital
apparatus.
K The flap is outlined and elevated medially, and the
remaining portion of the lower lid with the vascular
pedicle is advanced medially by a zygomatic and cheek-
relaxing incision, as shown in Figures 11-3F to Hand
11-4. This closes the defect of the donor site.
In no case is the canaliculus included in the flap.
Kl The closure is depicted. A standard three-layer
closure is performed as described in Figure 11-2B to D.
The muscle layer closure must be carefully performed
to restore motor function to the transposed flap. It may
be necessary to suture the muscle or the connective
tissue of the flap to the aponeurosis of the palpebrae
superioris muscle (see Fig. 11-5L).
The conjunctival pullout sutures (5) are taped to
the skin.
Continued
Transection of the pedicle is performed at 2 V2 weeks
after the technique shown in Figure 11-50 to El.
 PERIORBITAL REGION 539

50%-60% DEFECT ,--~~-~ _

FIGURE 11-5 Continued

 PERIORBITAL REGION
Reconstruction of Upper lid (Continued)
(Fig. 11-5) (After Esser, 1919; Mustarde,
1969)
Reconstruction of Upper Lid With 75% to 100%
Defect (After Mustarde, 1969)
The lower lid flap in this size defect must always be
rotated from the medial side, preserving, however, the
medial quarter of the lower lid, thus preventing injury
to the canaliculus. Hence, no more than a maximum of
three quarters of the lower lid is utilized. No calculations
are necessary with a total defect, because the pedicle is
always located at the lateral edge of the lower lid.
Because the flap is large, the width of the pedicle
should be larger-6 mm rather than 5 mm, as in the
smaller flaps. The tarsus requires transection, and this
will carry the incision farther, leaving only about 4 mm
on the inner side of the pedicle.
The flap must be sutured to the levator palpebrae
superioris muscle.
L Depicted is total loss of the upper lid with an out-
line of the lower lid flap. Point 2 on the medial side of
the lower lid is transposed to point 2' on the lateral
side of the upper lid defect. The stippled area on the
cheek represents a triangle of skin to be excised to
facilitate the advancement and closure of the lower lid
defect. Note that the medial side of this triangle is
shorter than the lateral side of the triangle. This aids in
the prevention of scar contracture and drooping of the
reconstructed lower lid. Additional details of this phase
are in Figure 11-3F and G and Figure 11-4.
The cut edge (X) of the remaining portion of the
palpebrae superioris muscle is tagged with two or
three fine silk sutures for later approximation to the
rotated lower lid flap. A vertical relaxing incision (3) on
the cheek flap may be necessary, with excision of small
triangles (4) to increase the length of the cheek flap.
M The full-thickness flap is elevated, and the relax-
ing incision is made with an elevation of the cheek flap
down to but not including the underlying muscles.
Injury to the branches of the facial nerve is avoided.
The flap with pedicle is advanced and rotated into the
defect. Care is taken not to kink the vascular pedicle; it
is better to leave a bit of a gap on the edges sur-
rounding the pedicle. Any resulting small defect is cor-
rected at the second stage when the pedicle is divided
in 2 weeks. Septal cartilage with mucosa (Y) is utilized
to line the reconstructed donor site and sutured in
place using 6-0 nylon pullout sutures.
The rotated lower lid flap is first sutured byapproxi-
mation of conjunctiva of the lid flap to the stump of
conjunctiva of the upper fornix. If the sutures are clear
of the cornea, 6-0 chromic catgut is used; otherwise, a
6-0 nylon pullout suture is utilized to prevent ulcer-
ation of the cornea. The next layer is the approxima-
tion of the previously tagged stump of the palpebrae
superioris muscle to the connective tissue of the lower
lid flap using 6-0 chromic catgut. The third layer is the
skin closure, taking care to avoid injury to the vascular
pedicle.
N The completed closure is shown.
0, 01 The pedicle is sectioned in 2 weeks, excising
two small triangles of lid margin to produce a smooth
curved lid margin. This is performed with the patient
under local anesthesia. The lid margins are approxi-
mated with 6-0 silk sutures, the ends being left long. A
near-far, far-near suture can be used on the margins to
prevent notching (see Fig. 11-2D).
 PERIORBITAL REGION 541

FIGURE 11-5 Continued

 PERIORBITAL REGION
Bridge Flap Repair of Large Upper lid
Defects, Cutler-Beard Technique
(Fig. 11-6) (After Fox, 1958; Smith and
Obear, 1967)
There is a difference of opinion regarding the reconstruc-
tion of upper lid defects. Esser's (1919) technique (see
Figs. ll-SA to Kl) has some drawbacks in that the rota-
tion flaps from the lower lid for large defects necessitates
a rather formidable procedure to reconstruct the lower
lid, which may in turn cause drooping of the reconstruct-
ed lower lid and shortening of the length of both lids.
The various techniques are the following:
1. Composite grafts
2. Temporal and forehead pedicle flaps
3. Lower lid flaps
a. Bridge flap of Cutler-Beard technique
b. Tarsal sharing flap of Hughes technique
c. Rotation flap of Esser
Highpoints
1. Full-thickness flap is used from lower lid and portion
of cheek.
2. Keep lower lid margin with marginal artery intact: a
width of 3 to 4 mm.
3. The procedure requires two stages, with up to 2 months
between stages; the patient must be informed that
the eye will be sutured closed for this period of time.
4. Lash grafting may be performed as a third stage.
5. Protect the cornea with a scleral contact lens during
all but the final steps of stage 1.
6. The width of flap equals horizontal width of upper
lid defect before resection.
7. Suture transected edge of levator palpebrae superioris
muscle to orbicularis oculi muscle and orbital septum
at the superior edge of the flap.
A A scleral contact lens has been inserted to pro-
tect the cornea. The width of the area to be resected
is measured. This will determine the width of the
bridge flap.
Resection of full thickness of the upper lid is then
performed with adequate margins. Stay sutures are
used both on the corners of the resected specimen
and on the corners of the remaining lid. The area
resected includes the tarsus or a part thereof, depend-
ing on adequate ablative surgery.
B The lower lid flap is described, preserving 3 to
4 mm of the lower lid margin, which preserves the lid
contour with the marginal artery. The horizontal width
of the flap is determined from the pre-resection meas-
urements of the upper lid defect, because after resec-
tion the remaining edges of the upper lid retract.
B1 Cross section is shown at the same stage as B.
( The lower lid flap has been mobilized as a full-
thickness flap. The skin, orbicularis oculi muscle, and
orbital septum are cut with a knife, whereas the under-
lying conjunctiva is cut with a scissors. The skin extend-
ing down to the cheek is mobilized to prevent undue
tension on the final suture lines. The arrow depicts the
course of the flap under the lower lid margin (the
bridge flap). Stay sutures or fine skin hooks on the flap
facilitate this maneuver. The scleral contact lens is then
removed just before approximation of the flap, which
consists of the following:
1. Suturing the conjunctiva layers of the upper lid defect
and the conjunctiva of the flap with 6-0 chromic
catgut with knots buried (not contacting the cornea).
2. Suturing the remnant of the levator to the orbicu-
laris oculi muscle and orbital septum of the flap with
interrupted buried 6-0 silk. This facilitates relatively
normal function of the levator to the flap.
3. Suturing the medial and lateral borders of the remain-
ing upper lid to the flap with two 4-0 silk mattress
sutures without vertical tension.
4. Suturing the skin edges with interrupted or con-
tinuous 6-0 silk sutures
5. Suturing the lower lid vertical incision with 6-0 silk
after all tension is relieved by an additional release
incision, if necessary
No sutures are placed in the preserved lower lid
margin. Skin sutures are removed in 6 days. Mattress
sutures are removed in 10 days.
(1 Cross section is shown at the same stage as C.
D The flap is transected over a groove director as
depicted about 1 to 2 mm below the normal lid margin
to allow for some postoperative retraction of the trans-
posed flap. The conjunctiva of the flap is sutured to the
skin of the flap with interrupted 6-0 plain catgut sutures
or a 6-0 nylon pullout suture forming the upper lid
margin.
E The remaining stump of the base of the flap is
repositioned into the donor site. Its edge is then sutured
to the freshened inferior edge of the margin of the
Continued
 PERIORBITAL REGION 543

FIGURE 11-6

An eyelash graft to the upper lid margin (see Fig.

lower lid. The remaining skin edges and conjunctiva ll-lOA) can be performed 6 weeks after the first stage
are approximated in two layers after the excision of (2 weeks before transection of the flap) or after the
any redundant skin. second stage.
 PERIORBITAL REGION

Resection of Large Basal Cell Carcinoma

Involving Both Lids and Nose (Fig. 11-7) Al, A2 An alternate plan would be to rotate the
remaining lower lid (3) to replace the defect in the
Highpoints upper lid (see Fig. 11-5L to 01). Only 75% replace-
ment is necessary (Mustarde, 1969). Depicted is a Fricke
1. Retain as much of upper lid as possible (compatible supraorbital flap (2) to reconstruct the lateral portion
with good tumor surgery), because this structure is of total loss of the upper lid. This flap is lined with
most important to protect the cornea and subsequent septal mucosa. A rotated cheek flap is used for the
vision. The new upper lid must protect the cornea lower lid (see Figs. 11-3F to Hand 11-4).
during sleep and ideally be able to elevate while
awake. B A forehead-scalp flap with a back cut (4) is elevated
2. Protect the globe. to reconstruct the medial portion of the upper lid. This
3. Resect the entire lacrimal apparatus. is lined with septal mucosa. Cartilage is optional, because
4. Check flap high points. the flap is quite thick and stiff. The cheek flap is ele-
5. Use septal mucosa graft for upper lid and septal car- vated also with a back cut (5) in the fashion described
tilage and mucosal graft for lower lid. in Figure 11-4. The only modification is the mobilization
6. Use adequate forehead and scalp flap. of the conjunctiva on fhe lower lid, with an incision
7. Allow for adequate margins (at least 1.5 em) around laterally along the fornix to permit lateral advancement
tumor and resection of underlying periosteum and of the entire remnant of the lower lid.
perichondrium-check margins with frozen sections
with careful labeling. This is most important because C The lined area on the upper lid indicates the loca-
gross evaluation can be misleading. tion of the septal mucosal graft, whereas the lined area
8. Once bone is invaded with basal cell carcinoma, on the lower lid indicates the septal cartilage and mucosal
radical resection of the osseous structure is often graft. These grafts are secured in position by 6-0 nylon
necessary with enucleation. Locally invasive basal pullout sutures or 5-0 catgut sutures. Long 5-0 or 6-0 silk
cell carcinoma is extremely lethal. Gross extension of sutures are placed along the lid margins. A split-thickness
disease is no criterion for microscopic extension. epidermal graft (X) covers the nasal defect. This could
also be covered with further mobilization and a larger
scalp flap (see Fig. 6-29). If there is undue tension with
A Outline the incisions for resection and the fore- primary closure of the scalp defect, the defect can be
head, scalp, and cheek flaps for reconstruction. The closed with a split-thickness epidermis graft (Y).
basic principle is the retention of as much of the upper
lid as possible to protect the cornea without compro-
mising adequate resection. Reconstruction of a lacrimal apparatus may be neces-
sary if epiphora occurs. The basic principle of a dac-
ryocystorhinostomy by construction of an outlet into
the nasal cavity (see Fig. 11-13) or a conjunctival flap
(see Fig. ll-lle) can be used.
 PERIORBITAL REGION 545

FIGURE 11-7
 PERIORBITAL REGION

Excision of Superficial Basal Carcinoma in

Region of lateral Canthus of lower lid C The completed procedure is shown.
(Fig. 11-8)
D Depicted is a superficial basal carcinama belaw
Although the lesion depicted could be excised by the the lateral canthal regian. Excisian is perfarmed, includ-
method described in Figure 11-30, because the lesion is ing a partian 'Of the underlying muscle. The incisian for
superficial, full-thickness resection of the lid is not the small flap is at 'Or slightly abave the level 'Of the
necessary. lateral canthus.

E After the flap is advanced it is impartant that na

A Excisian 'Of lesian includes a partian 'Of the under- dawnward pull is placed an the lawer lid. If necessary,
lying 'Orbicularis 'Oculimuscle. Outline 'Of skin flap (Fricke, a subcutaneaus suture is placed thraugh the flap inta
1829) from upper lid is shawn. This is permissible the margin 'Of the 'Orbit ta prevent tensian an the
because the lid margin is nat disturbed, there is redun- lawer lid.
dant skin present, and na defarmity 'Of the upper lid
will result (see basic principles 'Of lid recanstructian, F The campleted pracedure is shawn.
earlier in this chapter).

B Ratation 'Offlap is dane and appraximatian com-

pleted with 5-0 silk 'Ornylan.
 PERIORBITAL REGION 547

B E

c F

FIGURE 11-8
 PERIORBITAL REGION
Excision of Benign lesion of Upper Lid
(Fig. 11-9)
When simple approximation of skin edges after resec-
tion of a lesion near the medial canthus would distort
the medial canthus, an advanced skin flap from the
more central portion of the lid may be indicated.
A The line of excIsion with lateral extension for
advanced flap is depicted.
B The skin flap is advanced. A relaxing incision (dotted
line) may be necessary to avoid a dog-ear.
C The completed closure is shown.
Reconstruction of Superficial Horizontal
Defect of Portion of Lower Lid (Fricke
[1829], Upper Lid Flap)
D Depicted is a long horizontal defect of the skin of
the lower lid. The dotted line outlines an upper lid skin
flap that is to be rotated nondelayed to close the defect.
Becausethere is usually considerable redundant skin of
the upper lid, this is quite feasible, especially in the
elderly. Some surgeons emphasize that the upper lid
skin flap should extend virtually the entire distance of
the upper lid to avoid any uneven contractu res that may
occur with only a 50%-length flap. Care must be taken
not to injure the deeper structures of the upper lid
(e.g., the underlying muscle and tarsus), nor the most
important lid margin. This must not be violated under
any circumstances.
E The flap is in place. Depending on the extent of
the defect at the lateral canthus, the base of the flap
"X" can be returned to the donor area at a second
stage. Sutures must be carefully placed to avoid injury
to the globe. Edema of the lower lid margin can occur
if this margin is too wide.
When there is a narrow horizontal defect of the free
margin of the lower lid, a bipedicle flap of skin from
the upper lid appears preferred, as is depicted in Figure
11-14E and F. The conjunctiva of the remaining portion
of the lower lid is freely mobilized to the lower fornix,
excised, and sutured to the inner portion of the bipedicle
flap to form the inner lining. Although this procedure
is simple, the surgeon must be aware that the skin flap
may curl on itself and later on droop after the pedicles
are returned to the upper lid. It might prove to be fortu-
itous to leave the pedicles attached for a prolonged
period of time. (Fricke's supraorbital flap is described
in Figure 11-7Al.)
 PERIORBITAL REGION 549

E
FIGURE 11-9
 PERIORBITAL REGION
Eyelash Reconstruction (Fig. 11-10)
There is some difference of opinion regarding the advis-
ability of eyelash replacement for the lower lid; yet,
there is less question as to the advisability of upper
eyelash replacement.
Several methods are described, especially regarding
the donor site (e.g., eyebrow, temporal region, or post-
auricular region).
Highpoints
1. Evaluate proper direction of hair and maintain this
direction in graft.
2. Do not injure hair follicles-these are upward obliquely
and hence an incision deep to skin must follow this
angle.
3. Trim excess adipose tissue from graft.
4. Avoid donor site that may become bald later.
Complications
• Failure of graft-repeat.
• ScarrIng with inturning of new lashes against the
cornea; such hair will require removal by electrolysis.
Eyebrow Reconstruction
Reconstruction of the absent eyebrow can be usually
achieved following a technique similar to that used for
the grafting of an eyelash, except that the graft is wider
and through-and-through sutures are not used. The
wider the graft, however, the greater the possibility of
failure. Thus, an island flap of hair-bearing scalp can
be used based on a branch of the superficial temporal
artery and vein. Avoid a donor site that may become
bald later.
A Depicted is the temporal region donor site with
the incision placed in a relatively horizontal plane. The
hairs thus will be in the same plane when transferred
to the lid margin. Two or three rows of hairs are excised.
B The hair folliclesextend upward in an oblique direc-
tion, and care must be taken that the incision (dotted
line) for the graft follows this same angle; otherwise,
the follicles will be injured.
C The free graft (about 2 mm in width) consists of
two or three rows of hairs with follicles.Although some
adipose tissue is necessarily excised when the graft is
removed, as much of this fat istrimmed with fine scissors
as is possible. The rounded black protuberances of the
follicles must be preserved.
D An incision parallel and slightly outside or distal
(1.0 to 2.0 mm) to the free lid margin is made deep
enough to accommodate the free graft. Care must be
taken that the direction of the hair is in the correct
plane. Sutures through both lid edges and the graft
are carefully placed without injury to the globe.
The original hairs may fall out with new growth
occurring in about 3 weeks. These hairs will require a
periodic trimming.
 PERIORBITAL REGION

B
 552 PERIORBITAL REGION
Excision of Lesions at the Medial
Canthus (Fig. 11-11)
When the loss of tissue is at the medial canthal region,
a lateral cantholysis usually will not afford enough
relaxation, and a free full-thickness graft, which is quite
simple without additional scars, or transposed flap will
be necessary. If the defect is superficial and the cana-
liculi are preserved, a free graft is utilized (see Fig. 6-25E
to G). However, if the defect is full thickness with loss
of the canaliculi but yet quite small, the defect is closed
in three layers, as depicted in Figure 11-2B and C. The
tarsus is sutured to the medial end of the stump of the
canthal ligament or to the periosteum. A lateral can tho-
plasty may be necessary to gain an additional length
for one or both lids (see Fig. 11-301). Either the supe-
rior or inferior crus or both crura of the lateral canthal
ligament are transected. When the defect is larger, a
transposed flap is necessary.
A For a moderate defect, the glabella flap is utilized
resorting to the V-Vprinciple. The flap is full thickness
and must not include the brow. Only a few
millimeters' defect of the lids can be reconstructed
with this flap.
A1 The Vflap is lowered, and the donor site is closed
in Y fashion. A three-layer closure is utilized in which
the lids approximate the flap, attempting to suture
conjunctiva to conjunctiva.
For a larger defect a midline forehead flap is neces-
sary (see Fig. 8-12).
8, 81 A modification of the forehead flap (see Fig.
8-12) with the base at the contralateral side of the
nose is depicted. The dotted line represents the dis-
carded tip of the flap. This flap is performed in one
stage, whereas the flap shown in Figure 8-12 requires
a second stage to transect and to return the pedicle.
The disadvantages of the contra laterally based flap are
the horizontal scars plus the fact that the brows may
well meet one another in the midline. Mucous mem-
brane lining is usually necessary, and this is obtained
from the nasal septum as described in Figures 11-3F to
Hand 11-4. Be sure to suture the inner side of the flap
to the periosteum, where it dips into the canthal region
to produce a concavity.
C A somewhat distressing problem may arise regard-
ing tearing associated with the loss of the canaliculi-
epiphora. To reconstruct a suitable duct at the initial
operation isa matter of judgment, because some patients
do not develop epiphora. Depicted is Mustarde's method
(1969) for construction of a new duct. A flap of con-
junctiva along the inferior fornix is rotated medially
and sutured to the remaining lacrimal sac if present or
into the nasal cavity utilizing principles of a dacryocys-
torhinostomy (see Fig. 11-1 3).
Other surgeons have indicated that skin defects in
this region may require no covering, allowing the defect
to close by granulations and secondary intention. This
entails a rather protracted course. Another method of
handling such lesions is by radiotherapy, with extreme
care to protect the globe, or by using the technique of
Mohs' paste.
Warning: In the treatment of basal and squamous cell
carcinoma in this area be certain all margins, edges, and
depths are free of disease. Squamous cell carcinoma will
require a more extensive radical operation, yet basal
cell carcinoma at times may be almost as invasive into
surrounding soft tissue as well as bone. This tendency
is primarily noted, however, in squamous cell car-
cinoma. If basal cell carcinoma recurs, the subsequent
resection usually requires a more radical resection.
Basal cell recurrences (operated on elsewhere) have led
to bone, orbital, and intracranial extensions requiring
orbital exenteration and including trans cranial resec-
tion of involved dural and frontal bone.
 PERIORBITAL REGION

FIGURE 11-11
 PERIORBITAL REGION
Medial Canthoplasty and Repair
of Related Injuries (Fig. 11-12)
Highpoints
1. Disruption of the medial canthal ligament may be
associated with other local deformities:
a. Naso-orbital fracture
b. Injury to the nasolacrimal apparatus: puncta, cana-
liculi, lacrimal sac, and nasolacrimal duct
c. May be bilateral
2. If such injuries are present, all should be corrected
concomitantly, including a dacryocystorhinostomy
(see Fig. 11-13), if indicated.
3. More seriously, intracranial injuries may be present,
and, if so, these take precedence over any repair in
the region of medial canthus.
4. Protect cornea during operation.
A Typical deformity in the left medial canthal region
characterized by displacement of the medial canthus
primarily laterally and slightly downward and forward.
The canthus itself is rounded and blunted and may
be partially obscured by redundant tissue of the lids.
Distances a and b are the normal relationships, whereas
distance b' is longer than b and a' is shorter than a.
Although this deformity may be entirely and solely due
to rupture of the medial canthal ligament, fracture of
the medial wall of the orbit can also contribute to this
clinical picture. Radiographs are performed and, if
indicated, laminograms.
If the trauma is some weeks or months old and asso-
ciated with persistent swelling at the medial canthal
region, especially below the level of the medial canthal
ligament, injury to the lacrimal apparatus has occurred
with the probable formation of a mucocele of the lacrimal
sac. A dacryocystorhinostomy (see Fig. 11-13) would be
indicated. In either event all such associated deformities
must be corrected concomitantly. The procedure described
in the following illustration depicts only repair of the
medial canthal ligament and reduction and fixation of
fresh naso-orbital fractures.
B, B1 Surgical anatomy of the medial canthal
(palpebral) ligament and associated lacrimal apparatus
is shown. Bl is a coronal section through the medial
canthal ligament. The medial canthal ligament splits
into a thicker anterior section and a much thinner pos-
terior section, thus enveloping the lacrimal sac. Horner's
muscle lies just deep to the posterior section of the
medial canthal ligament. The anterior section is attached
to the anterior lacrimal crest behind the plane of the
cornea; the posterior section along with Horner's muscle
is attached to the posterior lacrimal crest. In B, the
anterior section of the ligament has been ruptured in
its midportion. However, other variations of disruption
of the ligament can occur. The disruption may be more
laterally at a point just over the proximal portions of
the canaliculi. Here the ligament is thinner. Repair in
this situation must approximate the upper and lower
origins of the ligament from the upper and lower lids.
Another type of disruption of the ligament may involve
an avulsion of a portion of the underlying bone with
a small fragment of bone attached to the medial end
of the ligament. This affords an excellent point for the
through-and-through wire suture, to be described.
Laterally, the ligament is attached to the medial angles
of the two tarsal plates. Medially, it arises from the
frontal process of the maxilla in front of the lacrimal
groove.
Continued
 PERIORBITAL REGION

LEVATOR PALPEBRAE SUPERIORIS

MUSCLE AND APONEUROSIS

FIGURE 11-12
 PERIORBITAL REGION
Medial Canthoplasty and Repair
of Related Injuries (Continued)
(Fig. 11-12)
C A small curved incision is made on the side of the
nose anterior to the medial canthus, avoiding the skin
of the eyelid. Care must be taken not to injure the cornea
of each globe during the operation. The lids can be
temporarily sutured together. With a small periosteal
elevator, the bone is exposed at the selected site for
fixation of the ruptured ligament. A similar incision is
then made on the opposite side of the nose. Two drill
holes about 5 mm apart are made in the medial wall
of the orbit through the exposed bone bilaterally. A
small dental bur or drill is utilized. No. 32 wire attached
to the bur or drill is then pulled through the holes, first
above and then through the ligament and through the
holes below.
D Inset drawing depicts detail of wire suture through
ruptured ligament. The wire could also be secured with
a through-and-through suture to the contralateral nasal
bone or the frontal process of the maxilla with drill holes.
E The wire is tightened on the contralateral side and
carefully twisted. The cut twisted end is then buried in
one of the drill holes. When scarring prevents complete
approximation, the attachment of the orbital septum
(see Fig. "-') to the periosteum along the orbital rim
is incised. Section of the lateral canthal ligament (see
Fig. "-3Dl) and the tarso-orbital fascia may likewise
be necessary.
F If an associated deformed fracture of the naso-orbital
compound is present and no intracranial complications
exist, through-and-through wires similar to those used
to repair the medial canthal can be utilized, if neces-
sary. These are placed slightly more anteriorly, and they
pass through the skin and acrylic plates or Silastic guards
on either side of the nose. Care must be exercised so
that no excess pressure is applied on the acrylic plates
or Silastic guards that might cause skin necrosis.
G If there is injury to the canaliculi, repair should
be done immediately, because secondary repair is
extremely difficult. Basically, this entails passing a plastic
tube , mm in diameter through the lumen of the
canaliculus and approximating the ends with two or
three 6-0 or 7-0 catgut sutures. The tubing, acting as
a stent, is sutured to the lower lid with fine silk sutures
and left in place 2 weeks. Dilatations are usually neces-
sary after removal of the tubing. An operation micro-
scope may be necessary to locate the distal end of the
canaliculus. The microscope may also aid in the sutur-
ing of the severed ends. If the distal severed end can-
not be located with the microscope, methylene blue
can be instilled in the other canaliculus if intact. This
will usually extrude through the distal severed end of
the injured canaliculus.
An alternate technique for reconstruction of the medial
canthal ligament consists of using a triangular skin flap
as a substitute for the torn ligament. This technique has
specific use when sufficient length of the torn medial
canthal ligament is absent or cannot be identified.
If there is associated depressed fracture of the glabella
resulting from a previous injury, a concomitant bone
graft is performed.
When obstruction of the nasolacrimal duct is present,
a concomitant dacryocystorhinostomy is performed
(see Fig. ll-l3).
 PERIORBITAL REGION

F G

FIGURE 11-12 Continued

 PERIORBITAL REGION

Dacryocystorhinostomy (Fig. 11-13)

(Pang, 1971) B A vertical 2- to 2.5-cm-long skin incision has been
made beginning 2 to 3 mm superior to the medial
Indication canthal ligament and 3 mm medial to the medial
canthus. This tends to avoid the angular vessels. The
• Obstruction of the nasolacrimal sac with or without muscle fibers of the orbicularis oculi muscle are split.
dacryocystitis The medial canthal ligament is identified and preserved.
Retraction or at times transection of this ligament is
Highpoints necessary. It must be repaired in any event. Using
sharp dissection, the fascia attaching the lacrimal sac
1. Canaliculi must be patent; otherwise, they require to the anterior lacrimal crest is transected along the
reconstruction (see previous figures and Fig. ll-l1C). dotted line. Care must be taken not to tear the sac. It
2. Any nasal or ethmoidal sinus disease must be is then completely mobilized from its bed by removing
corrected. the periosteum with the sac.
3. Local (Pang) or general anesthesia can be used.
4. Place skin incision 3 mm medial to the medial canthus C Using a small trephine saw, an opening is made in
to avoid the angular vessels. the anteroinferior portion of the lacrimal fossa and
5. Do not transect the medial canthal ligament if anterior lacrimal crest. Care is taken not to injure the
feasible-if lacerated or torn this requires repair at underlying nasal mucosa. The opening is then enlarged
the same sitting. Refer to previous figures. with Kerrison forceps to the shape of an oval-up to
6. Place vertical incision in lacrimal sac between the 15 mm long and 12 mm wide.
middle and posterior thirds, thus forming a longer
(or wider) anterior mucosal flap (see D). D At this point a cotton-tipped nasal applicator (dot-
7. Do not injure the canaliculi-at times catheteriza- ted lines) is inserted into the nasal cavity up to the
tion may be helpful to identify canaliculi and the region of the trephine opening. If the nasal mucosa
lacrimal sac if severe scarring is present. bulges into the opening, all is clear; otherwise, some
8. Refer to Figures 11-1 and 11-12A' to B' for anatomic interposing ethmoidal cells will require removal. For the
relationships of lacrimal sac. sake of clarity, the medial canthal ligament is omitted.
A vertical incision is made in the lacrimal sac in a
Postoperative Care plane between the middle and posterior thirds. This
results in an anterior flap (1) that is longer (or wider)
1. Do not blow nose. in the horizontal plane than the posterior flap (2). This
2. Use decongestants. is most important since the distance between the pos-
3. Antibiotics are optional. terior flaps of the sac and nasal mucosa is shorter than
the distance between the anterior flaps. A similarly
Complications placed vertical incision is then made in the nasal mucosa
using the cotton-tipped applicator as support to steady
• Stenosis due to cicatrization requires revision. the nasal mucosa .
Short horizontal incisions are made at each end of the
An alternate technique is described by lliff (1971). vertical incisions. This aids in the reflection of the flaps.
If necessary, because of lacerations and severe scar-
ring, the flaps may be varied and even placed in a
A Lateral view is shown of the bony framework horizontal plane.
forming the lacrimal fossa. The lateral portion of the
maxilla has been omitted for clarity. Dotted lines indi- E The posterior flaps are then approximated with
cate bone removal to form a new drainage route from three 6-0 or 5-0 chromic catgut sutures. The anterior
the lacrimal sac into the nose. The bone removed flaps are then sutured in similar fashion. For the sake of
includes the entire lacrimal fossa and a portion of thick clarity, the medial canthal ligament is omitted. If repair
anterior lacrimal crest. If need be, the posterior extent of this ligament is performed, the drill holes are made
can be enlarged by reaching the posterior margin of and sutures are placed (see Fig. 11-12D and E) but not
the lacrimal bone and even up to the lamina papyracea secured until approximation of the flaps is completed.
of the ethmoid. Some surgeons insert a fine plastic tube through
the canaliculus and thence into the nose. If the recon-
struction has gone smoothly, this seems superfluous.
 PERIORBITAL REGION 559

FIGURE 11-13
 PERIORBITAL REGION
Correction of Scar Contracture of
the Lids and Ectropion (Fig. 11-14)
A Scar contracture of the lower lid. The entire scar
must be excised. A Z-plasty is outlined with wide under-
mining of the surrounding skin as in the stippled area.
B The Z-plasty is completed as shown. If the scar is
exceedingly large, a transposed flap may be necessary
from the mid forehead (see Fig. 8-12) or an advanced
lateral cheek flap (see Figs. 11-3F to Hand 11-4).
C Scar contracture of upper lid with ectropion is
shown. A Z-plasty is outlined with an additional area of
scar excised.
D The completed Z-plasty is shown with a full-thickness
graft (3) inserted in the large defect. If the defect is
small, a simple closure is feasible. Pullout 5-0 nylon
sutures through the tarsoconjunctivallayer can be used
to aid in the approximation of the flaps of the Z-plasty.
For severe ectropion of the lower lid secondary to
scarring and tissue loss, a bipedicle flap (Tripier) from
the upper lid may be of help.
E A section of skin from the upper lid with some
underlying fibers of the orbicularis oculi muscle is
mobilized. A bipedicle flap of skin and muscle is thus
developed. A temporary tarsorrhaphy is performed
(see Fig. 11-16F).
F The flap is swung into the defect and approximated
with 5-0 nylon sutures. Both pedicles are tubed. The
donor site is closed by simple approximation. Sponge
rubber roll is sutured over the flap to help prevent
curling or bulging of the flap. The pedicles may be left
intact for months to act as suspensory slings for the
lower lid, or they may be transected and returned to
the ends of the donor site.
 PERIORBITAL REGION

c D

FIGURE 11-14
 PERIORBITAL REGION
Tarsorrhaphy (Fig. 11-15)
Indication
• To protect the cornea
lateral Permanent Tarsorrhaphy or
Canthorrhaphy
This type of intermargin adhesion is particularly adapt-
able for paralytic ectropion and drooping of the lower
lid that is of a permanent nature. It is used in defor-
mities associated with facial nerve paralysis involving
the orbicularis oculi muscle and minor deformities sec-
ondary to lower lid surgery.
Highpoints
1. The upper lid is made to support the lower lid.
2. Preserve most of the upper tarsal plate.
Temporary Tarsorrhaphy (Weeks)
This procedure is utilized when there is facial nerve
paralysis after facial nerve surgery or parotid surgery
when return of function is expected.
A simple temporary method of corneal protection,
for example, during surgery, is the use of a contact lens.
Highpoints
1. This procedure is used to correct alignment of upper
and lower lids.
2. Excise a small longitudinal area (6 to 8 mm) of muco-
cutaneous intermarginal tissue to form a bare area.
3. Incise the base of each bare area to open wounds.
A The lids are drawn together to the desired posi-
tion, and the lid margins are marked with a suitable
dye. The point is usually 6 to 8 mm from the com-
missure of the lateral canthus.
B The lids are split along the gray line with a knife,
using fine hooks on the lids as traction points. An
incision is carried through the canthus for 2 mm (point
X). The lids are then separated into two layers for a
distance of 3 mm (point V), starting at the dye marks.
C On the lower lid the skin and underlying orbicu-
laris oculi muscle are excised, while on the upper lid
the conjunctiva and a small portion of the tarsus are
excised as per dotted lines.
D Using a 6-0 nylon mattress suture, the two bare
areas are approximated with a guard of Silastic or
cotton over the skin.
E A long 5-0 silk suture is placed at the point at
which the two lids meet. In 10 days the nylon suture
is removed, and in another 3 or 4 days the silk suture
is removed.
F After the lids have been approximated and the
exact opposing sites for the tarsorrhaphy have been
marked with the point of a knife, 6- to 8-mm mucocu-
taneous rectangular areas are excised, leaving a thin
strip of epithelium on both ciliary and conjunctival edges
of the lid margins. The cilia are thus not injured, and
the normal lid contour is preserved.
A longitudinal incision 2 mm deep is made in the
base of each bare area. When the lid edges are approx-
imated, this incision facilitates flaring of the wounds
with more surface area for healing. Through-and-through
horizontal mattress sutures of 4-0 silk guarded with
small polyethylene tube booties are inserted and tied
snugly. The tarsorrhaphy can be sutured above the
eyebrow.
G The completed tarsorrhaphy. The sutures are left
in place for 8 to 10 days, or longer. With return of
function, the lids are then separated by a simple inci-
sion of the scar tissue.
 PERIORBITAL REGION

c o E

FIGURE 11-15
 PERIORBITAL REGION
Graft for Defect of Infraorbital
Rim (Fig. 11-16)
Highpoints
I. Incision in lower lid is made as close as possible to
the eyelashes.
2. Cartilage graft should have some perichondrium left
attached. Silastic can also be utilized.
3. Avoid pressure on infraorbital nerve.
Complications
• Absorption of cartilage
• Ectropion
A An incision is made through the lower lid just
below the lashes. This location of the incision prevents
postoperative edema of the lower lid, which would
occur if the incision were lower; however, this incision
may result in ectropion.
B After a temporary tarsorrhaphy, the orbicularis oculi
muscle is exposed and split parallel to its fibers. The
defect in the infraorbital rim is exposed.
C Scar tissue around the infraorbital nerve is carefully
freed and excised. The edges of the bony defect are
cleaned and freshened. Using a small drill point, a hole
is placed at an angle in the edge of the defect for a
distance of 0.5 to 1.0 em. It does not pass through
the bone.
D, D1 Another drill hole is placed in the anterior
aspect of the zygoma at such an angle as to reach the
blind end of the first hole. This is achieved by inserting
a straight needle into the first hole to help locate the
blind end. The two holes are connected.
E With the same type of drill holes placed in the
medial edge of the defect in the maxilla, a section of
costal cartilage (see Fig. 3-5) previously shaped is now
sewn into position, using fine tantalum braided wire.
An adequate notch is cut to avoid pressure on the
infraorbital nerve. It is important to preserve a section
of perichondrium on the cartilage. This aids in its
"take." Silastic (silicone rubber) cut from a suitable
block can also be utilized.
F The cartilage graft is in place. The skin is approxi-
mated with fine silk, the ends being left long to avoid
injury to the cornea. The tarsorrhaphy may be opened
immediately or left until the skin sutures are removed.
 PERIORBITAL REGION

FIGURE 11-16
 PERIORBITAL REGION
Decompression of the Orbit
for Exophthalmos (Fig. 11-17)
(After Walsh and Ogura, 1957;
Ogura and Pratt, 1971)
Progressive exophthalmos ("malignant") is usually but
not necessarily associated with Graves' disease-toxic
goiter. After a subtotal thyroidectomy, the exophthalmos,
either unilateral or bilateral, may become stationary or
progress. In our experience true total thyroidectomy has
been effective in halting and usually correcting exoph-
thalmos in Graves' disease (see also Perzik, 1963, and
White, 1974). If the exophthalmos becomes progressive,
corneal ulceration, edema of the eyelid and of the con-
junctiva, epiphora, diplopia, and finally loss of vision
can occur. The cosmetic deformity alone is an indica-
tion for an operation to decompress the orbital contents.
Exophthalmic Graves' disease can occur, although
seldom, in patients in whom the usual clinical signs
and symptoms of toxic goiter are absent. 1f the T3 and
T4 thyroid hormone tests are normal, then obtain the
thyrotropin-releasing hormone level and/or a T3 sup-
pression test. These test results may be abnormal and
will aid in the diagnosis. Computed tomography (CT)
as well as coronal scans can be helpful in visualizing
abnormalities of the extraocular muscles and optic nerve.
We have seen one patient who falls into this clinical
category with positive CT scan depicting edema of the
inferior rectus muscles. Attempts by endocrinologists
to halt and to improve exophthalmos, diplopia, and peri-
orbital edema by thyroid suppression using desiccated
thyroid have for the most part failed. Because we have
very encouraging results regarding the management of
exophthalmos with true total thyroidectomy, one specu-
lates whether this operation may be of some help to
alleviate the ophthalmopathy. (See Spaeth's Ophthalmic
Surgery, 1982, pp. 435 and 439.)
To measure the degree of exophthalmos accurately,
a Hertel exophthalmometer is utilized. The first step is
to test the patient in the same position (sitting position
is ideal) and to keep an accurate record of the setting
between the two lateral orbital rims so that the follow-
up examination is performed at the same setting. The
reference measurement is made from the lateral orbital
rim to the corneal apex, using the exophthalmometer.
The average normal distance in the adult is from 16 mm
up to 21 mm beyond the orbital rim. 1f it is more than
21 mm, bilateral exophthalmos is suspected. A differ-
ence between the two globes of more than 2 mm is an
indication of unilateral exophthalmos.
Several procedures have been described:
1. Removal of lateral wall of orbit
2. Removal of roof of the orbit, allowing the orbital
contents to herniate into the anterior cranial fossa
3. Removal of floor of the orbit, allowing the orbital
contents to herniate into the antrum
4. Removal of medial wall of the orbit, allowing the
orbital contents to herniate into a cavity formed by
removal of the ethmoidal' sinus cells and floor of the
frontal sinus
5. Removal of floor and medial wall of orbit-a combi-
nation of Nos. 3 and 4
Highpoints
1. When the exophthalmos is severe, gently tease the
adipose tissue with forceps, being sure not to grasp
the muscle.
2. Do not open the periosteum until all the bone of the
ethmoid is resected; otherwise, the adipose tissue
herniates through the resected bone area and thus
obstructs clear evaluation in the surgical field.
Depending on the degree of exophthalmos, either
procedure 3 or 5 (above) appears to be the most adapt-
able.
Technique 5 is depicted.
Complications
Always alert the patient as to complications, especially
blindness or even partial interference with vision. Other
complications include the following:
• Intraorbital hemorrhage
• Damage to the optic nerve (see p. 66)
• Subcutaneous emphysema
• Diplopia
• Cerebrospinal fluid leak
• Sinusitis
• Enophthalmos

FIGURE 11-17
A The areas excised are shown via a Caldwell-Luc
operation (see Fig. 5-2). The opening into the antrum
is made as large as possible so that adequate visual-
ization of the ethmoidal labyrinth and roof of antrum
is possible.
B With the use of various types of forceps, a com-
plete ethmoidectomy is performed up to the anterior
wall of the sphenoidal sinus. (This approach is similar to
the transantral ethmoidal sphenoidal hypophysectomy.)
PERIORBITAL REGION
A mastoid curet or osteotome may be necessary to
excise thicker portions of bone. If possible, leave the
anterior and posterior ethmoidal arteries intact. The
lamina papyracea is thus also excised. Do not resect
bone above the ethmoidal vessels, which approximates
the level of the cribriform plate (see Fig. 6-4A and B),
or more posterior than the posterior ethmoidal artery,
because damage to the optic nerve may result.
Continued
 568 PERIORBITAL REGION
Decompression of the Orbit for
Exophthalmos (Continued) (Fig. 11-17)
(After Walsh and Ogura, 1957; Ogura
and Pratt, 1971)
C With the use of Kerrison forceps, the roof of the
antrum is removed, preserving at this stage the supe-
rior layer of periosteum; otherwise, premature hernia-
tion of orbital fat will obstruct vision. The infraorbital
nerve should likewise be saved as well as, if feasible, a
narrow strip of bone to support the nerve. The bone
FIGURE 11-17 Continued
lateral to the nerve is also excised as far as the heavier
bone of the zygoma. The foramina of the optic nerve
must not be violated.
D After all the bone is removed, the periosteum of
the floor of the orbit is incised in several locations to
allow the orbital contents to herniate into the antrum.
A large nasoantral window is then made. The antrum
may be packed for 24 hours with strip gauze impreg-
nated with an antibiotic ointment. The incision in the
canine fossa is closed with 4-0 continuous nylon.

Resection of Benign Tumor
of lacrimal Gland (Fig. 11-18)
(Spaeth's Ophthalmic Surgery, 1982)
Highpoints
1. Management is similar to treatment of benign mixed
tumor of the parotid salivary gland.
2. Avoid open biopsy.
3. Avoid transection of the lateral canthal ligament.
4. Tag the superior and lateral rectus muscles before
resection.
5. Remove and replace the lateral orbital rim if tumor
is large; if the tumor is small, the rim is left intact.
6. Resection includes the entire lacrimal gland, capsule,
and adjacent periosteum. This follows the same basic
surgical principles for resection of any mixed tumor;
namely, avoid violation of the capsule of the tumor
or any incision of the tumor, with implantation of
cells.
7. Differentiate from malignant tumor, especially the
adenoid cystic carcinoma.
Discussion
The problem facing the surgeon in the evaluation of
any intraorbital mass is diagnosis. Needle aspiration
may be of some help. The needle puncture site should,
if possible, be placed along the line of the anticipated
skin incision and marked with India ink. This area is
then excised at the time of the resection of the neoplasm.
If the mass is suspected to be malignant (e.g., adenoid
cystic carcinoma), the most malignant of all tumors of
the orbit, then an incision and biopsy via an anterior
FIGURE 11-18
PERIORBITAL REGION 569
approach awaiting permanent histologic diagnosis has
been recommended if frozen section is not absolutely
confirmative of the diagnosis. In this circumstance, the
orbital rim is not removed, because a more extensive
resection with orbital exenteration is indicated after
the confirmed diagnosis of adenoid cystic carcinoma.
Obviously, one must be absolutely certain of the diag-
nosis when orbital exenteration is proposed. Variations
of these steps depend on clinical impression as well as
findings of CT and magnetic resonance imaging.
The signs and symptoms of orbital tumors are ptosis,
mass in the lateral superior area of the orbit, proptosis,
and downward displacement of the globe.
Complications
• Blindness: immediate surgical intervention is neces-
sary to evacuate hematoma and control bleeding
(see p. 66).
• Recurrence of tumor: recurrent mixed tumor may
become malignant.
A Skin incision is made below the unshaven eyebrow
. extending laterally 1 cm above the lateral canthalliga-
ment along the zygomatic arch. Care is taken to avoid
the zygomatic branch of the seventh nerve. A small
cross-hatch is made across the skin incision for realign-
ment,Qf the skin edges at the time of skin closure.
B Tag sutures are placed on the superior and lateral
rectus muscle as an aid for identification during the
orbital exploration.
Continued
 PERIORBITAL REGION

Resection of Benign Tumor

of Lacrimal Gland (Continued)
(Fig. 11-18) (Spaeth's Ophthalmic
Surgery, 1982)
- D The entire lacrimal gland, benign mixed tumor,
C The incision exposes the underlying muscles and
fascia. The muscle fibers are separated when possible.
The periosteum is elevated from the orbital rim. The
underlying periosteum is to be removed with the
neoplasm. Drill holes are made before the sectioning
of the bone for placement of wire sutures at the close
of the resection to replace the resected bone. Care
must be taken when using the drill to avoid entering
the tumor or soft tissue. A thin metal guard can be
inserted between the inner periosteum and bone.
periosteum, and capsule are removed en bloc. The
wound is copiously irrigated with saline. Hemostasis
must be meticulous, because postoperative hemor-
rhage could cause blindness.
The excised orbital rim is replaced and secured with
wire. A small drain is preferred.

FIGURE 11-18 Continued

Resection of Adenoid Cystic Although local flaps (e.g., forehead [see Fig. 8-10])
Carcinoma of the Lacrimal Gland may be used to cover the surgical defect, the donor site
on the forehead may be a significant cosmetic defor-
(Fig. 11-19)
mity, especially in the young patient. The alternative is
the use of a split-thickness graft to cover the defect,
Highpoints
rather than the forehead flap.
1. Diagnosis is verified by permanent histologic sections
because of the magnitude of the surgery.
2. Resect the roof and lateral wall of the orbit.
3. Perform orbital exenteration.
4. Schedule postoperative radiotherapy.

An outline of the orbital bony resection is shown that

is to be combined with exenteration and removal of
the lids and all of the contiguous soft tissue and
periosteum. Adenoid cystic carcinoma spreads via the
nerves and periarterial routes. The dura is carefully
elevated and preserved from the imier portion of the
resected bone, which has wavy contour with ridges.
Preservation of the dura of course is based on evidence
that there is no extension of disease to the dura; other-
wise the dura would require resection.

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Martinez-Lage JL: Bony reconstruction in the orbital region. Ann
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Morain WD, Geurkink NA: Split pectoralis major myocutaneous flap.
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Musgrave RH, Smith B, Wang MK-H, et al: Panel Discussion. Surgical
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Mustard<' JC: Repair and Reconstruction in the Orbital Region.
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 12 THE EAR
Otoplasty (Fig. 12-1)
Types of Operation
There are a number of various techniques described to
correct the protruding auricle with the absence of the
antihelix. Two different techniques are described that
have a significant variation. The first method completely
incises the cartilage, whereas the second method rolls
the cartilage and to a large extent depends on suturing
for the correction. The criticism of this method is that
it often leaves a rather sharp edge to the antihelix; in
the second method, the sutures can fail. Occasionally,
this deformity is associated with extremely thin cartilage
that is so flexible that additional sutures are necessary
to correct the deformity.
See Figure 12-2A to H for an illustration of the
surface anatomy.
Cartilage Incision Technique
(After Luckett, 191 0)
Highpoints
1. This technique depends on single or multiple parallel
incisions of cartilage rather than sutures to correct a
deformity.
FIGURE 12-1
2. Exercise extreme care with dressings.
3. Do not operate on a patient younger than 3 years of
age.
4. Extend the incision superiorly and inferiorly.
5. The helix should be approximately 2 ern from the
head.
6. Symmetry of both auricles is important.
7. The helix should be visible behind the antihelix
when viewed from in front.
A The ear is pushed back against the mastoid to its
normal position. This forms a fold in the ear cartilage,
which becomes the new antihelix. A straight cutting
edge needle is then inserted from front to back at
multiple sites along this new antihelix. Depending on
the deformity, additional needle punctures are made
along both crura of the antihelix superiorly. As the
needle is withdrawn, its tip is colored with an alcohol
solution of suitable dye. This maneuver stains the
posterior surface of the ear cartilage, indicating the
line of incision to be made later in the cartilage (see
Fig. 12-2A to H for normal anatomy).
573
 THE EAR
B An ellipse of skin is excised in the posterior
auricular sulcus, the major portion of the excised skin
being from the auricle itself. Depending on the degree
of the deformity, the width of skin excised may be
from 0.5 to 1.5 cm.
C A posterior auricular skin flap has been developed,
leaving the perichondrium intact. This flap is freed 4 to
6 mm beyond the dye marks, thus allowing sufficient
space to place the cartilage sutures. The incision in the
cartilage is made along the dye marks, taking care that
the perichondrium and skin on the anterior surface are
not incised. This is most important, because both peri-
chondrium and skin act as a hinge. If the index finger
is placed opposite the knife while the cartilage incision
is made, and a watchful eye is kept for the white glis-
tening perichondrium on the anterior surface, all will
go well. This incision should be carried to the upper and
lower limits of the main body of the auricular cartilage;
otherwise, the procedure will fail, because even a small
FIGURE 12-1 Continued
area of intact cartilage in this area will interfere with
the formation of the new antihelix. A slight curve in
the incision is very desirable.
D The lateral leaf of the auricular cartilage must be
so mobilized that the final stages of everting the two
leaves forming the new antihelix are achieved virtually
without reliance on the mattress sutures. However, the
cartilage of the helix is not incised.
If the medial portion of the body of the auricular
cartilage appears too wide, a small ellipse may be
excised as shown by the dotted line. Again, it is desir-
able to have a slight wave in this incision so that the
new antihelix thus formed will have a more graceful
curve. To minimize a sharp edge in the antihelix, several
parallel incisions in the cartilage are made rather than
a single incision. These incisions are made only through
a portion of the cartilage not through the full thickness
of the cartilage.
Continued

Otoplasty (Continued) (Fig. 12-1)
Complications
• Sharp edge of antihelix. Unless the surgeon is skilled
in avoiding the sharp edge, this technique should be
avoided (see Fig. 12-2A to H) .
• Protrusion of upper or lower portion of auricular
cartilage
E, El The two leaves of auricular cartilage are now
approximated with inverting mattress sutures, using
4-0 white silk. A cross section of the position of the
sutures and the inverted edges of cartilage is shown in
El. All the sutures, usually five to seven, are placed
before any are tied. A fine, multi-toothed forceps may
be used on the anterior surface of the inverted cartilage
(the new antihelix) to maintain the desired position
while the sutures are tied.
FIGURE 12-1 Continued
THE EAR
F, G The skin is approximated with four interrupted
5-0 nylon sutures by including the tissue over the
mastoid bone deep in the cephaloauricular sulcus. This
prevents bridging of the skin closure across this sulcus .
A continuous suture may be used to approximate any
gaping skin edges.
H The dressing is important. Absorbent cotton
impregnated with antibiotic ointment is painstakingly
used to fill the concavities of the auricle. A small amount
is placed posteriorly. Across the auricle, two or three
strips of gauze soaked with flexible collodion are used
for immobilization. Over this, a 4-inch stockinette is
pulled as a protecting night cap. Small windows are
cut in the stockinette to visualize the color of the helix.
Ten days elapse before the collodion strips are removed.
Thereafter, the stockinette alone may be used for an
indeterminate period, especially during sleep.
Continued
 THE EAR
Otoplasty (Continued) (Fig. 12-2)
Mattress Suture Technique (Correction
of Prominent or Deformed Ears)
(After Mustarde, 1963)
One of the main criticisms of the Luckett technique, in
which an incision is made through the cartilage of the
new antihelix (see Fig. 12-1), is the tendency to form a
sharp edge along the new antihelix. A definite contraindi-
cation to this cartilage incision technique is a very soft
and thin cartilage. Mustarde avoids this undesirable
result by the use of horizontal mattress sutures without
a cartilage incision. On the other hand, this mattress
suture technique may result in too prominent a "roll"
of the new antihelix. Abrasion or shaving of the medial
aspect of the cartilage can be used to reduce this roll or
bulk of the folded cartilage. A similar result is achieved
by using multiple minute incisions ("fish scale"). In
addition, other associated or isolated deformities may
exist, such as prominence due to a deeply cupped concha
with or without normal antihelix. Both Mustarde and
Furnas (1968) have modifications of the mattress suture
technique to correct this latter deformity. Hence, com-
binations of procedures are sometimes necessary to
achieve a pleasing and satisfactory result.
Highpoints
1. Mattress sutures rather than cartilage incisions are
the mainstays of the correction.
2. These mattress sutures encompass both layers of
perichondrium.
3. A minimum of three sutures is used. The number
varies depending on the extent of the deformity;
however, a superior suture is almost always necessary
and an inferior suture is necessary if the lobule is
prominent.
4. The position and tension of the sutures may likewise
be varied depending on the deformity.
S. Distance between the sutures should not exceed
4.0mm.
6. Rarely does a portion of the antitragus or thickened
cartilage of the posterior surface of the lobule require
excision if too prominent.
A The cartilage anatomy composing a normal ear is
shown.
B Deformity is absence of antihelix. The ear is folded
back to form the new antihelix. This is now marked on
the skin with a sterile solution of methylene blue dye.
Following this curved line, both medially and laterally,
being at least 7 mm from the curved line, through-
and-through punctures are made by a hypodermic
needle stained with a similar dye. These marks indicate
the placement of the mattress sutures.
C An ellipse of skin 0.5 to 1.5 em wide is excised on
the posterior aspect of the auricle. Skin and subcu-
taneous flaps are elevated to expose the dye marks
through the perichondrium. Mattress sutures of 4-0
white silk are now placed along the dye marks. These
sutures pass through both posterior and anterior layers
of perichondrium as well as cartilage but, of course,
not through the skin. A non-cutting edge needle is
best used to avoid slashing the cartilage. Aseach suture
is placed, it is temporarily snugged down and the
effect on the antihelix is surveyed to be sure the result
is pleasing without any folds between the helix and
antihelix. If not correct, the suture is removed and
replaced. Spacing should not exceed 4.0 mm. The
number, position, and tension vary depending on the
deformity and the desired result. It is not necessary to
firmly approximate the posterior layers of the peri-
chondrium (see Fig. 12~2Fand G).
D A variation of the staining technique is depicted.
The puncture marks are made along the new antihelix.
E Similar mattress sutures are placed paralleling the
dye marks. The same precautions, trials, and placements
are performed as under C.
F Coronal section depicts the placement of sutures
through both layers of perichondrium and cartilage
but not the skin.
G Coronal section depicts the sutures tied. It is not
necessary to approximate the posterior layer of peri-
chondrium. Tension depends on the desired results.
H The completed mattress suture line. If the concha
is too cup shaped, it is sutured to the periosteum of
the mastoid bone (see Fig. 12-2 0).
 THE EAR

FOSSA TRIANGULARIS,

CRUS HELICIS

TRAGUS

EXT. AUDITORY CAN

A B

FIGURE 12-2
 THE EAR
Otoplasty (Continued) (Fig. 12-2)
I If the superior portion of the helix has a tendency
to fold out, a tacking suture is placed through the
perichondrium and cartilage into the periosteum of
the adjacent temporal bone as depicted.
J By the same token, if the lobule protrudes, a similar
type of suture is placed inferiorly.
K Prominence of the ear may be due to a deeply
cupped concha. Depicted is a relatively normal antihelix
with a deep concha.
L Mustarde corrects this by repositioning the anti-
helix with mattress sutures. Coronal section depicts
the deformity. The arrow indicates the existing anti-
helix. The suture is placed so that the concha cupping
is reduced and the antihelix repositioned medially.
M The completed correction in coronal section.
Again, the arrow depicts the original antihelix with the
new antihelix depicted by X.
N Furnas (1968) corrects this deeply cupped concha
with a normal antihelix by transecting the posterior
auricular muscle and then placing mattress sutures
through the auricular cartilage secured to the exposed
periosteum and fascia overlying the mastoid bone.
Two mattress-type sutures are used. Exact positioning
of these sutures may require "trial and error."
o Care must be used in the placement of these
postauricular sutures to avoid pulling the concha
forward. Depicted is the correct placement.
P Placement of sutures is incorrect, pulling the
concha forward and thus narrowing the external audi-
tory canal orifice. The dressing is similar to that shown
in Figure 12-2H.
 THE EAR

L M

FIGURE 12-2 Continued

 THE EAR

Surgical Treatment of Hematoma

of the Auricle: "Cauliflower Ear"
(Fig. 12-3)
Highpoints
1. After aspiration, a conforming pressure dressing is
necessary.
2. Careful follow-up is required to be sure hematoma
does not recur and progress to fibrous deposits and
chondritis.
3. Repeated aspirations are often necessary-ifrepeated
more than two or three times, one or two mattress
sutures over the dressing are placed.
4. In any dressing, keep the outside edge of the helix
exposed to check blood supply.
C If aspiration and antibiotic ointment-impregnated
cotton dressing fails, one or two mattress sutures
through the scapha and fluffed gauze with buttons or
Silastic guards fore and aft are used. This situation is
rare if the initial aspiration was complete and the
impregnated cotton dressing was firmly applied.
D If a hematoma or repeated hematomas are not
treated and proceed to fibrous deposits, aspiration is
worthless. A shaving procedure is then necessary.
Depicted is the line of incision of the skin flap.
E The flap is elevated and retracted with extreme
care. The skin can easily be fragmented. The excess
fibrous tissue and portion of thickened cartilage, if
present, are removed.

A A hematoma is aspirated. F If excess bleeding is present, a small polyethylene

tube can be inserted through the cartilage and this
B Absorbent cotton (genuine cotton, not rayon) is connected to gentle suction. An alternative is to follow
impregnated with antibiotic ointment and molded to the method depicted in C.
the contour of the auricle. It is held in place with strips
of plain one-half inch packing gauze soaked with G Closure with fine 6-0 nylon sutures. The tubing is
collodion. removed in several days when no additional drainage
is obtained.
 THE EAR

D E

FIGURE 12-3
 THE EAR

Z-Plasty for Stenosis of External

Auditory Canal (Fig. 12-4) E As the dissection proceeds, the outer presenting
skin surface is divided into quadrants; care is taken not
When possible, this procedure is preferred to the opera- to incise the inner or hidden layer of skin. These four
tion of excision and intermediate split skin graft over a flaps are elevated to the normal canal wall.
sten!. The operating microscope may be of aid. This
procedure is only indicated when the cartilaginous and F The inner or hidden layer of skin is now incised in
bony canal is of normal diameter. quadrants, with the incisions bisecting the bases of the
outer flaps. Again four flaps of skin are dissected to the
Complications normal canal wall. If any thick scar or subcutaneous
tissue remains between the two layers of skin, this is
• Friability of skin flaps excised.
• Recurrent cicatrix
G The inner and outer flaps are interposed; the inner
flaps Yare turned outward while the outer flaps X are
A, B The stenotic area of the external auditory canal turned inward. Sutures of 5-0 or 6-0 nylon are placed
may be congenital or the result of trauma or burn. where necessary. One-fourth inch gauze impregnated
with an antibiotic ointment is used as a dressing in the
C The edge of the stenotic opening is excised or canal.
incised. The presenting skin surface is marked into
quadrants. H A lateral view shows the interposed flaps of skin.

D Elevation of the presenting skin surface is begun

by inserting a small right-angled knife between the
inner and outer layers of skin at the stenotic site.
 THE EAR

FIGURE 12--4
 THE EAR
Excision of Small Malignant Tumor
of Cartilaginous Portion of
External Auditory Canal (Fig. 12-5)
Highpoints
1. This procedure is limited to small (less than 1.0 em)
tumors that have not reached the inner half of the
external auditory canal nor have involved bone or
the tympanic membrane. If the middle ear or signifi-
cant portion of the temporal bone is involved, a
temporal bone resection is usually indicated. If the
osseous external auditory canal is involved without
additional extension into the temporal bone, a "core"
type resection of the external auditory canal and
middle ear with radical mastoidectomy is usually
the operation of choice. Otherwise, a temporal bone
resection is indicated with osseous involvement beyond
the osseous external auditory canal. See page 588
for en bloc resection of external auditory canal.
2. A skin graft is used immediately.
3. Depending on the extent and spread of disease, a
parotidectomy, neck dissection, and/or resection of
the ascending ramus of the mandible may be necessary
as well as mastoidectomy.
Complications
• Recurrent disease in which too large a lesion is
resected by this limited procedure
• Cicatricial stenosis of reconstructed canal
For temporal bone resection, see pages 1408 to 1414.
A The area excised is depicted by the solid line for a
lesion located at (1). The periosteum of the adjacent
mastoid bone may be removed. The entire cartilagi-
nous canal is resected along with a portion of bony
canal. A radical mastoidectomy may be necessary, and,
if so, an attempt is made to preserve the facial nerve.
The drum membrane and ossicles may likewiserequire
resection. If the bone is involved, not only is the facial
nerve sacrificed but usually a temporal bone resection
is indicated (see Fig. 23-1 3).
B An incision is made surrounding the external
auditory canal. A postauricular approach may be
necessary to increase the exposure.
C The split-thickness skin graft in place.
D Around a section of polyethylene tubing, cotton
impregnated with nitrofurazone or antibiotic maintains
pressure on the graft. A custom stent may be helpful
to prevent postsurgical stenosis.
 THE EAR

FIGURE 12-5
 THE EAR
Excision of Malignant Tumors of
the Auricle (Fig. 12-6)
Highpoints
1. Resect with adequate margins.
2. Resection of all layers-through and through-is
preferred.
3. When using postauricular skin flaps for reconstruc-
tion, avoid hair-bearing skin.
A A simple 0/) full-thickness excision is ideal for small
tumors limited to the helix.
B Primary closure results in minimal deformity.
C When the tumor involves both the helix and the
crus of the antihelix, a large triangular, full-thickness
area must be excised.
D Immediate reconstruction is performed with the
use of a postauricular full-thickness skin flap. The flap
is severed along the dotted line in 3 to 4 weeks,
leaving sufficient length to roll the end on itself to
form a new helix and serve as cover for the posterior
aspect of the flap. The donor site is closed either by
advancing the edges or by split-thickness skin graft.
E With small tumors limited to the mid region of the
auricle (e.g., the antihelix), an island is resected through
and through in the shape of an ellipse.
F The defect.
G Primary closure follows the natural curve of the
antihelix. The helix will appear distorted and pinched.
H Large tumors in the region of the antihelix may
require a postauricular skin flap for a more acceptable
cosmetic result. A curved full-thickness skin flap one
fourth to one third wider than the defect is outlined
with the base inferiorly. The entire flap need not be
elevated at this initial stage. Elevation of the distal edge
and lateral margins for approximation to the corre-
sponding edges of the defect will usually suffice. This
technique is suggested because occasionally complete
elevation of the flap may require a delay of 2 weeks.
Extreme care should be taken when elevating the flap
so that the proper plane is followed. Curved scissors
with the point tipping outward may well injure the
feeding blood vessel. The plane is the same as on a
forehead flap, between the pericranium and the
subaponeurotic tissue (see Fig. 8-10).
The flap is turned in to the defect.
J The distal and lateral margins of the flap are
sutured to the edges of the defect. The inferior edge of
the defect is closed by approximation of the auricular
skin edges, or an epithelial shave of the flap can be
performed. This area will be opened later to receive
the skin flap when it is transected in 3 to 4 weeks. Any
postauricular bare areas are covered with split-
thickness skin.
Excision of Hemangioma of the
Face Involving Lobule of the Ear
K The skin with the hemangioma is excised from
the ear lobule and the preauricular region. Flap 1 is
eventually rotated to point 2.
L An infra- and postauricular skin flap is mobilized
and rotated to cover the bare area on the lobule. The
preauricular defect is closed by the technique of a face
lift in which the skin of the face is mobilized, staying
superficial to the parotid fascia.
M The closure.
 THE EAR

A B c D

L
FIGURE 12-6
 THE EAR
En Bloc Resection of the External
Auditory Bony Canal
(See Fig. 12-6N, 0, and P)
Keun Y. Lee
This procedure is reserved for carcinomas of the external
auditory canal that extend to the bony canal located at
point 2 in Figure 12-SA but do not involve the middle
ear and main portion of the temporal bone.
Highpoints
1. The procedure is indicated for tumor involving the
external bony canal.
2. The procedure is not indicated when extensive tumor
involves the middle ear and mastoid.
3. Entire external auditory meatus and tympanic mem-
brane with malleus are removed in continuity, as
depicted by solid and dotted lines in Figure 12-SA.
4. lYpe III tympanoplasty with skin graft is used for
immediate reconstruction.
S. Extended facial recess approach is preferred to avoid
facial nerve injury.
6. Bleeding is controlled with ties. If this is not feasible,
bipolar cautery is used to avoid facial nerve injury.
Operative Procedure
A V-shaped preauricular and postauricular skin incision
is made with the apex of the V incision inferiorly. The
auricle, if it is not involved, is transected from the external
auditory meatus and reflected superiorly, maintaining a
broad superior skin flap.
 THE EAR

Type I Type II

N o

FIGURE 12-6 Continued

 THE EAR
Cortical mastoidectomy with an extended facial recess
approach is performed. The chorda tympani nerve is
transect ed, and the entire vertical portion of the facial
nerve is identified and preserved. The facial nerve should
be clearly identified at the stylomastoid foramen to the
parotid gland. The incudostapedial joint is disarticu-
lated through the facial recess approach.
Inferiorly, the dissection is extended along the tym-
panomastoid suture line between the stylomastoid
foramen and the inferior aspect of the tympanic bone.
Superiorly, zygomatic air cells are removed, and the
entire epitympanum is visualized. Dissection extends
over the root of the zygoma to the petrotympanic
fissure.
Anteriorly, the cartilaginous portion of the external
auditory canal and the tympanic bone is exposed.
Multiple bur holes are made in the tympanic bone,
medial to the anterior bony annulus. Care is taken to
avoid injury to the carotid artery. The residual bony
attachment is fractured along the bur holes by gentle
pressure. In this manner, the resection can include the
entire external auditory canal (type I resection), the exter-
nal auditory canal, tympanic membrane, and malleus
(type II resection), or the former structures plus the
styloid process and stylomastoid region and the facial
nerve (type III resection) (Medina et aI., 1990).
Large temporalis fascia is placed over the eustachian
tube, stapes capitulum, and mastoid cavity. The
remainder of the cavity is covered with split-thickness
skin graft and packed with antibiotic-impregnated
packing gauze.
Complications
• Injury to the facial nerve
• Conductive deafness
Total Resection of the Auricle
With a Portion of the External
Auditory Canal, Parotidectomy,
and Radical Neck Dissection for
Recurrent Malignant Melanoma
(Fig. 12-7)
Depicted is an example of total resection of the auricle
for recurrent malignant amelanotic melanoma involving
the postauricular area. The patient presented with
preauricular and tail of parotid positive lymph nodes
(sentinel lymph nodes). After initial surgery (done else-
where) the patient was treated with low-dose inter-
feron for 3 years.
Technique
Highpoints
1. If palpable node-parotid or neck-use fine needle
aspiration of "sentinel node."
2. If nodal disease-perform radical neck dissection
(see pp. 798-801, Parotid Extension of Radical Neck
Dissection) .
3. Resect 2.5 margins of the scalp.
4. Totally resect the pinna.
5. If intraparotid node-perform total parotidectomy
with preservation of 7th nerve.
6. If facial paralysis-perform total parotidectomy
with sacrifice of the facial nerve and reconstruction
with sural nerve.
7. It is better to use a split-thickness skin graft for
scalp defect:
a. Local rotation flaps are contraindicated (possibly
spread disease).
b. Free vascularized flap
i. Could hide recurrence
ii. Bulk interferes with prosthesis
8. Postoperative treatment (see the section in Chapter
3 on melanoma).
9. Computed tomographic scans of the head, neck,
and chest are helpful.
10. Evaluate ipsilateral axillary nodes-perform node
biopsy if enlarged node.
Radical neck dissection is a classic radical neck dis-
section (see Fig. 16-3) with preservation of the spinal
accessory nerve up to the area where it was juxtaposed
to the internal jugular vein and lymph nodes. A portion
of the nerve is sacrificed and then repaired with
neurorrhaphy. There was good function 1 year post-
operatively. Minimal pain was noted in the shoulder
with extended motion of the arm that did not affect the
patient's quality of life.
Posterior Approach to the 7th (Facial)
Nerve (see Fig. 12-7)
A A 25-gauge needle is inserted into the posterior
wall of the external auditory canal from the anterior
direction to mark the site of transection of the posterior
wall. This is used as a guide for subsequent transection
of the posterior portion of the canal. The scalp flap
including the periosteum extends 7 to 10 cm posterior
to the pinna. At 6 cm from the grossly involved soft
tissue the flap is then reflected anteriorly. The posterior
external auditory canal is transected at the needle site.
 THE EAR

superficial temporal a.

internal maxillary a.

postauricular n.
sternomastoid m.

Trunk and Branches of

Facial Nerve B
FT - Trunk of facial nerve
ZT - Zygomaticotemporal
T - Temporal
Z - Zygomatic
B - Buccal
M - Mandibular
CF - Cervical facial
C - Cervical
PD - Posterior digastric
SH - Stylohyoid
c PA - Postauricular

FIGURE 12-7

tents of the submandibular triangle and the exposed

8, C Although the posterior wall of the auditory
canal is transected, the anterior wall is not transected
at this stage until the main trunk of the 7th nerve is
identified. This is performed from the posterior
approach exposing the mastoid process and then the
temporoparotid fascia.
The fascia that covers the main trunk of the facial nerve
is usually exposed and transected from an anteromedial
approach. The main trunk of the 7th nerve and its
divisions and branches are now exposed and preserved.
The cervicofacial division of the 7th nerve is exposed
and traced to the posterior facial vein and external
jugular vein. It is at this point that the superoanterior
portion of the neck dissection which included the con-
and preserved ramus mandibularis joins the superior
posterior portion of the neck dissection. The scalp flap,
entire auricle, and a portion of the external auditory
canal, the entire parotid salivary gland and its tail (pre-
operative sentinel node biopsy), and contents of the neck
are now mobilized and removed in continuity.
The specimen was reviewed by the surgeon with the
pathologist. In this case the node within the parotid and
the preauricular area on frozen section were positive
for malignant melanoma. Hence, a completion parotidec-
tomy was performed preserving the facial nerve. Metasta-
tic disease was not immediately close to the nerve and
thus the nerve was preserved.
Reconstruction was performed with a free split-
thickness skin graft over the bare area of the scalp. The
external auditory canal was reconstructed using a por-
 THE EAR

tion of the inferior cheek flap. This flap was split: the
upper portion for the anterosuperior defect and the lower
section for the posteroinferior defect. The skin graft that
is used to cover the scalp defect was sutured to the pos-
terior edge of the cheek flap. Jackson Pratt suction drains
were used for the neck dissection while a pressure dress-
ing consisting of Durafoam and antibiotic ointment
covered the skin graft, which was secured with a cling
bandage and Elastoplast.
Final Pathology Diagnosis
1. Lymph node negative for metastasis, clinically
supraclavicular
2. Fragment of muscle and fibroadipose tissue with
fibrosis and inflammation, negative for tumor, clini-
cally cranial portion of trapezius
3. Lymph node negative for metastasis, clinically
intraparotid
4. Lymph node negative for metastasis, clinically
retrovascular
5. Ear with surrounding skin, right excision, parotidec-
tomy, and neck dissection-1.7-cm subcutaneous
recurrent malignant melanoma with focal extension
into the ear cartilage, surgical margins free of tumor
and metastasis to four lymph nodes: one at the
posterior border of the mid portion of parotid gland
(at site of previous biopsy), the second posterior to
the first lymph node, the third in the preauricular
area, and the fourth in the intraparotid lymph node
(close to the preauricular area)
6. Twenty-seven lymph nodes from the neck dissection
were negative for metastasis.
There was no facial paralysis postoperatively. A
prosthetic ear was constructed by Dr. David Casey
(Fig. 12-8).
A Postoperative status.
B Pinna prosthesis in place.
C Normal pinna contralateral side.

A B

c
FIGURE 12-8

Radical neck dissection resulted in good function 1
year postoperatively with no evidence of disease. The
patient had minimal pain in the shoulder with
extended motion of the arm not affecting his quality of
life and continued on interferon.
Three years later, a positron emission tomographic
scan was negative for metastatic disease (see the section
on melanoma by Dr. Karakousis in Chapter 3).
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Brown lB, Fryer MP, Morgan LR: Problems in reconstruction of the
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1980.
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THE EAR
House WF, Hitselberger WE: Endolymphatic subarachnoid shunt for
Meniere's disease. Arch Otolaryngol 82:144-146,1965.
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GM (ed): Otolaryngology, vol 5. Philadelphia, Harper & Row,
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cancer of the ear. Cancer 7:995, 1954.
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 THE EAR

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Surg 1:154-162, 1978.
 13 FRACTURES OF FAE
BONES
JOHN M. LOR~,JR.
DOUGLAS W. KLOTCH
Basic Principles
1. Axial and coronal computed tomographic (CT) scans
and three-dimensional CT reconstructions may be
helpful.
2. Evaluation of the general status of the patient is
essential regarding other life-threatening injuries in
the following areas:
a. Central nervous system
b. Vascular
c. Chest
d. Abdomen
e. Urinary tract
3. Optic nerve injuries compose 5 % of all head injuries.
This applies primarily to midface fractures, especially
those of the nasal-frontal complex, with specific
reference to Le Fort III fractures involving the frontal
bone in which the canalicular segment of the optic
nerve is injured. Conservative management without
open reduction is the consensus, with some differ-
ences. The optic nerve may well be injured by stretch-
ing but is not necessarily compressed. Therefore,
decompression of the optic nerve itself is reserved
for very select patients with delayed or progressive
loss of vision. It appears that conservative treat-
ment with high doses of corticosteroids may be the
treatment of choice with delayed repair of facial frac-
tures when vision status is stable. If there is extreme
immobility of the fractured bone, extraskeletal fixa-
tion may be utilized for stabilization. If the orbital
hemorrhage or intraocular pressure are increasing,
orbital decompression may be required. With evi-
dence of intraorbital hemorrhage and/or air under
pressure, as for example in fracture of the lamina
papyracea, decompression of the orbital contents is
indicated. When there is evidence of fracture through
the orbital foramen without blindness, reduction does
not appear indicated. CT in coronal sections will aid
in the evaluation of the optic foramen and floor of
orbit. When there is evidence of optic foramen frac-
tures on CT with no loss of vision, careful open reduc-
tion of facial fractures may be achieved. Cribriform
plate fracture has been visualized in axial sections if
very thin sections are obtained.
Approaches to optic nerve decompression within the
optic canal (canalicular segment) include the following:
a. Transfrontal craniotomy
b. Transantral ethmoidal-sphenoidal (basically the
Hamberger technique as modified by Sofferman,
1981)
c. External ethmoid technique (see External Ethmoidec-
tomy, pp. 224 and 232).
Extreme care should be taken when packing an
antrum associated with floor of orbit fractures to
avoid any undue pressure on intraorbital contents,
especially the optic nerve and its blood supply,
both arterial and venous. The same care is advised
when packing the nasal cavity with fractures of
the ethmoid bone, especially the cribriform plate
and lamina papyracea.
4. Ophthalmologic examination is a sine qua non when
there is injury or suspected injury to the orbital con-
tents. Repeated examinations should be performed
as indicated.
5. Immediate repair of soft tissue injuries and fractures
of the facial bones is the procedure of choice. Delay
is associated with wound infection and loss of tissue
as well as difficulty in fracture reduction.
If there is any question regarding patency of the
airway, a tracheostomy is indicated.
Multiple life-threatening injuries (e.g., intracranial,
thoracic, abdominal, pelvic, or vascular) obviously take
precedence. Blindness is another symptom that must
be immediately evaluated and treated (see section on
blindness in Chapter 2). Yet, often, a team approach
operating simultaneously is not only feasible but ideal.
This has been the author's experience as well as others
(Manson, 1986).
In addition, delay is complicated by edema and need
for multiple surgical procedures. Fractures of the facial
bones are prone to become semi-fixed or significantly
fixed in malposition and then require extensive and
complicated surgical procedures involving refracturing
for proper alignment. A team approach in multiple
injuries requires excellent cooperation and skilled train-
ing as well as expertise in planning; it is not for the
uninitiated. Intermaxillary fixation may result in tem-
porary, prolonged, or permanent trismus in patients
with sub-condylar fractures.
Stainless steel plates should be removed after 1 or
2 years because stainless steel corrodes when in con-
595
 FRACTURES OF FACIAL BONES

tact with electrolytes containing hydrogen and oxygen
(thus leading to metallosis) and when damaged by fric-
tional forces (Muller et aI., 1963). Vitallium (a cobalt-
chromium-molybdenum-nickel alloy) is reportedly
resistant to corrosion and can remain in situ indefinitely
(Venable et aI., 1937).
The minifixation plate (Thorp-Synthes) has revolu-
tionized the fixation of facial fractures and has virtually
replaced wire fixation. However, in certain situations
when the variety of miniplates is not available, wire
fixation can be used. Figure 13-1 gives examples of the
various types of mini plate fixation. Later in this chapter
other applications of the miniplates are shown. More
details of this type of fixation can be obtained from the
Manual of Internal Fixation in the Crania-Facial Skeleton,
edited by J. Prein with contributions by D. W. Klatch,
P. N. Manson, B. A. Rahn, and W. Schilli.
Reduction of Fractured Nose
(Fig. 13-2)
Highpoints
1. Early reduction within 24 hours is done if feasible
despite edema (unless massive).
2. Clinical evaluation is far more important than radio-
graphs.
3. Topical or local anesthesia is used except in an
unmanageable child.
4. The simpler the method of reduction, the better.
5. Preoperative and postoperative photographs are
advised, as well as notation and evaluation of a
history of unconsciousness.

FIGURE 13-1 Examples of the various types of miniplate fixation. (Courtesy of Synthes Corporation, West Chester,
PA.)
 FRACTURES OF FACIAL BONES

Depression of Right Nasal Bone with

Anesthesia
lateral Displacement of left Nasal Bone
Topical anesthesia using four tampons of cotton with
4% lidocaine (Xylocaine) or 4 mL of 10% cocaine and
a vasoconstrictor (e.g., oxymetazoline [Afrin]) is used.
Two tampons inserted in each side of the nose for 10 to
15 minutes is usually sufficient. The patient should be
evaluated regarding any untoward reaction to cocaine
by applying a small amount to the mucosa with a
cotton swab and waiting 5 to 10 minutes. Vital signs
are monitored with resuscitation equipment available.
In the presence of marked or even moderate edema of
the mucosa, the superiorly located tampons are care-
fully inserted somewhat higher after 5 minutes. If neces-
sary, additional anesthesia is achieved by local injection
of a suitable agent (e.g., 1% lidocaine without epinephrine
into the tissue at the base of the columella, glabella, and
the infraorbital nerve at its foramen at the infraorbital
rim). In addition, intranasal blockage of the anterior
ethmoidal nerves is performed, if necessary, using
injection of the 1 % lidocaine. General anesthesia is
seldom necessary except in unmanageable children.
A The elevator is inserted in the right naris with the
narrow edge facing forward and the broad surface along-
side the nasal septum. This instrument must not have
any sharp edges. Ideally it measures 8 x 3 x 180 mm.
The distance of insertion is gauged externally by the
extent of the deformity superiorly.
B The narrow edge of the elevator is placed high in
the nasal pyramid. It must not be inserted so far as to
injure the cribriform plate of the ethmoid.
C With counter pressure on the laterally displaced left
nasal bone, the elevator is moved in an outward, forward,
and lateral direction. Prying with a fulcrum motion must
be avoided. Reduction will be accompanied by a snap-
ping sound. Nasal packing usually is not necessary.
The use of an external splint depends on the degree
of impaction after reduction. If the septum is severely
comminuted, packing impregnated with antibiotic oint-
ment or Teflon splints sutured through and through
the septum are used (see Fig. 6-13).
Continued

A c

FIGURE 13-2
 FRACTURES OF FACIAL BONES
Reduction of Fractured Nose
(Continued) (Fig. 13-2)
Depression of Nasal (Frontal) Process
of Right Maxilla
D The elevator is inserted in the right naris with the
broad surface against the lateral nasal wall.
E The elevator is low in the nasal pyramid. The thrust
is in an outward and lateral direction. Again, prying
is to be avoided; no counterpressure on the nose is
indicated.
The nasal septum is usually displaced in fractures of
the external bony framework. Maintenance of reduc-
tion is difficult, because the cartilage tends to snap out
of position like a piece of spring sheet metal. Packing
may be helpful. Eventually many of these patients require
submucous resection of the septum or septoplasty if
the nasal obstruction is severe. Internal splinting with
Teflon or Silastic can be helpful (see Fig. 6-13F). Although
some surgeons use an Asch forceps to realign the
septum, the author believes that this instrument can
cause mucosal damage to the septum.
F Reduction of the nasal septum is performed using
the elevator with the broad side against the convex
deformity. Medial pressure is exerted. Ash-type forceps
are not recommended.
G Nasal packing using a one-half inch gauze strip
impregnated with antibiotic ointment is placed in one
naris to overcorrect the deformity. Such packing is also
used in severely comminuted fractures of the external
bony vault.
H An aluminum, foam rubber-covered splint, plaster,
or dental molding compound is used when severe
comminution is present or when there is a possibility
of misalignment. External sheets of lead and silicone
with through-and-through sutures are rarely needed
(see Fig. 11-12F).
 FRACTURES OF FACIAL BONES

D E

FIGURE 13-2 Continued

Fractures of Mandible-Outline a form of interdental wires, if sufficient teeth are

(Fig. 13-3)
Highpoints
1. Evaluate the supraglottic airway; severely com-
minuted, multiple fractures may have extensive soft
tissue injury involving the floor of the mouth and
the tongue posteriorly. Such injuries require a tra-
cheostomy. Preoperative as well as postoperative
radiographs are always necessary along with radio-
graphs several weeks and/or several months later.
2. For uncomplicated fractures, the simplest method
of treatment is the use of Erich arch bars (see G) or
present.
3. Never wire upper and lower jaws together immediately
after injury. Aspiration of vomitus with obstruction
to airway from blood and edema is always a possi-
bility.
4. Proper occlusion of upper and lower jaws is the
keynote of treatment.
S. If reduction with arch bars or interdental wiring fails,
some type of internal fixation is necessary. This is
specifically required in the edentulous patient. Another
method, although rarely performed, is the use of
Gunning splints (see Fig. 14-9C). The compression
type plates are ideally suited for this particular prob-
lem (see Fig. 13-22).
 FRACTURES OF FACIAL BONES
Fracture of Condylar Process-
Outline (see Fig. 13-3)
By and large the consensus in fractures of the condylar
process is conservative closed manipulation under anal-
gesia or general anesthesia. This is followed by inter-
maxillary fixation, using arch bars connected with rubber
bands or interdental wires (see B, C, and G). This tech-
nique may lead to trismus. In children there may be a
question regarding interference with the growth center,
and some surgeons suggest open reduction. This is per-
formed through a preauricular incision (see Fig. 17-1),
taking extreme care not to injure the facial nerve.
Intraosseous wires through drill holes proximally and
distally are then inserted. These wires must be heavy
enough to avoid subsequent breaking of the wires.
Complications of Mandibular Fractures
• Infection
• Nonunion
• Malunion
• Malocclusion
• Ankylosis of temporomandibular joint
See Figures 14-9 and 14-lOA to C for additional
mandibular procedures.
A A Barton-type bandage is an excellent temporary
support. It allows oral suction to be done easily and
can be released quickly if necessary. Kling is an admirably
suited material for the bandage. A plaster Barton-type
bandage is also excellent (Bartkowski, 1982). The ante-
rior extension over the chin is avoided if there is danger
of posterior displacement.
B Interdental wire 25 em in length is used. The
material may be either Angle's standard brass ligature
wire (0.508 mm) or stainless steel wire size NO.4 or
No. 26.
With a single wire, multiple loops are formed around
four teeth starting with the first or second molar and
working forward. The wire is placed around the molar
with the shorter end lying along the outer surface of
the teeth. The longer end is passed below and then
above this outer wire, forming a small loop of sufficient
length to allow for final twisting and the formation of
a hook. The short outer end of the wire is raised forward
each time the long interdental end is first placed between
the teeth. This aids in the placement of the interdental
end in the under and over positions. This procedure is
repeated on the maxillary teeth and on the opposite side.
C Small pointed pliers or a heavy needle holder is
used to twist the loops. The loops are first pulled forward
and outward before twisting is begun. The loops on
the mandible are bent downward, and the loops on
the maxilla are bent upward to form hooks around
which rubber bands are placed (G).
D Intramedullary fixation is done with a Kirschner
wire. The neural canal is to be avoided when drilling
the holes. Exposure of the fracture site is similar to that
depicted in Figure 13-6B to F. See Figure 13-22 for the
use of compression-type plates.
E After the Kirschner wire is inserted, malleable silver
or stainless steel wire is inserted through drill holes to
maintain approximation. This type of internal fixation
is left in place permanently. If a Kirschner wire is not
used, the interosseous wire should be in the form of a
figure-eight pattern, or two wires should be used.
F Another method of fixation with a Kirschner wire is
to insert the wire through a small stab wound in the
chin and use a Kirschner wire drill to pierce the thick
cortical bone and thence through the medullary canal.
G The Kirschner wire is shown in position. It may be
used in conjunction with Erich arch bars when neces-
sary to maintain proper reduction and occlusion. The
Kirschner wire may be removed or left in situ when the
fracture heals. Straight Kirschner wire should not be
used for fixation of fractures or reconstruction of the
ascending ramus, because the wire may migrate supe-
riorly into the skull.
 FRAGURES OF FACIAL BONES

FIGURE 13-3
 FRACTURES OF FACIAL BONES
FRACTURES OF MANDIBLE
Douglas W Klatch
Overview of Fracture Repair
Highpoints
1. Evaluate the airway: Severe fractures may produce
significant swelling of the floor of mouth, tongue
base, pharynx, and supraglottic larynx. If fractures
are displaced posteriorly, reducing the fracture by
pulling the mandible anteriorly may relieve the air-
way problem. Examination of the larynx is beneficial
to rule out potential concomitant laryngeal injuries.
Significant airway compromise or extensive bleeding
may necessitate tracheotomy to establish a controlled
airway.
2. Radiographic evaluation: A Panorex view is a good
screening examination but may miss minimally dis-
placed condylar and symphyseal fractures. Standard
mandibular views with high oblique and Caldwell
views help to better define these regions. Full CT
views of the facial bones will also provide excellent
fracture information, although they are not mandated
for trauma involving only the mandible. Preopera-
tive and postoperative radiographs are required to
ensure adequate reduction and repair.
3. Fracture repair options include the following:
a. The goal of fracture repair is to establish a normal
return of functional occlusion for the patient.
b. Maxillomandibular fixation (MMF) utilizing arch
bars, wires (Ivy loops), or maxillomandibular fixa-
tion devices provides repair for simple fractures
with a stable dental arch. Figure 13-4 demonstrates
placement of arch bars to achieve MMF. Figure 13-5
demonstrates MMF with maxillary and mandibu-
FIGURE 13-4 Placement of arch bars to achieve maxillo-
mandibular fixation.
FIGURE 13-5 Placement of maxillary and mandibular
bone screws to achieve maxillomandibular fixation.
lar screws. Please note that although this may be
adequate for condylar or stable fractures of the
angle, it requires a stable mandibular and maxil-
lary arch with normal occlusion to achieve its
objective. When in doubt use traditional MMF.
(1) Immediate placement of a patient into MMF
should be avoided if there is intraoral bleed-
ing, massive edema, or emesis. Generally these
are not problems associated with simple frac-
tures. If there is concern, the patient's fixation
can be delayed or the patient can be placed in
elastics to facilitate rapid removal of MMF.
c. Open reduction and internal fixation (ORIF) of
mandibular fractures is always an option for frac-
ture repair. Although not mandated for simple
fractures, ORIF provides immediate return of func-
tion for the patient. This provides the best out-
come for the patient with severe injuries. Likewise,
ORIF is beneficial for complex mandibular injuries
(i.e., comminuted or bone loss injuries), segmen-
tal injuries, or complex condylar injuries in which
both height and width maintenance are mandated
to provide optimal repair.
Incisions
1. Fractures anterior to the attachment of the masseter
muscle can generally be approached via an intraoral
incision.
2. Posterior fractures are more difficult to approach intra-
orally if two plates are to be applied. Adequate assis-
tants and transbuccal approaches are needed to facil-
itate intraoral application.
3. Condylar fractures generally require extraoral
approaches. A variety of incisions are available, and
the location of the fracture and the expertise of the
physician determine choice. These include preauricu-
lar, retromandibular, submandibular, and transparotid.

Open Reduction of Fractures of the
Mandible (Fig. 13-6)
Extraoral skin incisions:
A Place incision in lines of relaxation.
B The skin incision is made through the platysma
muscle and its fascial envelope but not through the
layer of the cervical fascia, which invests the sub-
maxillary salivary gland.
C The upper skin flap is developed carefully to iden-
tify and to preserve the mandibular branch of the
facial nerve. This nerve may lie as much as 2 em or
more below the lower border of the horizontal ramus
of the mandible in a plane deep to the platysma muscle
and its investing fascia and superficial to the facial
artery and the anterior facial vein. Its course may be
FIGURE 13-6
FRAGURES OF FACIAL BONES
compared with a hammock hanging from the mandible.
The cervical branch innervates the platysma muscle,
and its injury may be a factor in causing some flatten-
ing of the lower lip when the patient attempts to purse
his or her lips postoperatively.
Continued
After the mandibular branch of the facial nerve has
been identified, the upper skin flap is further mobilized
to expose the fracture site. The upper platysma flap and
soft tissue is retracted superiorly. The facial artery and
vein may require ligation and division to provide ade-
quate exposure. The periosteum is incised at the infe-
rior border of the mandible to expose the fracture. When
the fractures are more posterior, the masseter fibers must
be incised at their inferior attachment and dissected
adequately with a periosteal elevator to provide adequate
exposure for the repair of the fracture.
 FRACTURES OF FACIAL BONES

Open Reduction of Fractures of the

Mandible (Continued) (Fig. 13-6)
D The fracture is reduced if not previously accom-
plished by closed reduction. (The patient must be
secured into a stable occlusion before fixation of the
fracture. Generally this is done before opening the
fracture site after a closed reduction.) If a tension band
stabilization plate repair is planned, the tension band
is applied first at the alveolar side of the mandible. The
inner screws are placed first with the outer screws posi-
tioned after the application of the stabilization plate. A
template may assist in contouring the stabilization or
reconstruction plate. After the plate is appropriately
contoured with slight lingual overbending, it is held
into position by means of a plate bone-holding clamp.
The inner screws are placed first to ensure accurate
fracture reduction. All other screws may then be placed.
E A wire may be used to help reduce a fracture but
is removed once the fracture is stabilized by the first
screws.
F Today wire ligatures are seldom used for fracture
repair. However, this technique may provide adequate
repair if plating systems are not available. Patients
need to have a 6-week period of MMF to ensure frac-
ture healing. Wire ligatures do not provide adequate
fixation for complex comminuted fractures or fractures
with bone loss.
After the fixation a suction drain is placed and the
wound is closed in layers. If the patient has a delay to
surgery, a complex open fracture, or poor dental care, a
therapeutic course of antibiotics to cover oral pathogens
is used.

FIGURE 13-6 Continued

 FRACTURES OF FACIAL BONES

Fracture Types

1. Simple: displaced or nondisplaced-simple fractures

are treatable by MMF or ORIF.
2. Oblique: displaced or nondisplaced
a. Oblique fractures are treatable by MMF or ORIF.
b. A special technique utilizing a lag screw principle FIGURE 13-8 lag screw placement through plate.
may be applied for these fractures.
(1) Lag screws may provide excellent fixation for
long oblique or butterfly fragments. The outer Fracture Location
hole is drilled to the screw diameter size (i.e.,
2.0 mm for a 2.0-mm screw). The outer hole 1. Symphysis or parasymphysis
is countersunk to prevent fracture of the cortex 2. Body
and shifting of the fragments. The inner hole 3. Angle
is drilled to the core diameter of the screw 4. Ascending ramus
(Le., 1.5 mm for the 2.0-mm screw). The screw 5. Condyle
length is measured with a depth gauge and the 6. Coronoid
appropriate-length screw is placed (Fig. 13-7).
(2) Placing a lag screw through a plate for short Technical Aspects of Fracture Repair
oblique fragments prevents overriding of frag-
ments. The holes are drilled the same way as Open Repair Options for Symphyseal and
in (1), but no countersinking is necessary. If Parasymphyseal Fractures
a compression plate is used, none of the other
screws can be placed in compression. All other 1. Tension band splint and stabilization plate (Fig. 13-9):
screws are in neutral position (Fig. 13-8). The patient should normally be placed into a secure
3. Comminuted: These fractures require ORIF. occlusion before fixation of the fracture.
4. Bone loss: Fractures with bone loss require ORIF. a. The stabilization plate may be between 2.0 and
2.4 mm depending on the complexity of the fracture.
(1) If there is comminution or bone loss or insta-
bility at the inferior mandible, 2A-mm mandibu-
lar plates are used. The use of larger plate
systems requires careful bending to avoid the
potential malocclusion secondary to deforming
the fracture to an imprecise plate bend. Slight
overbending to provide lingual cortical com-
pression is generally recommended.

FIGURE 13-7 Lag screw for oblique fractures. FIGURE13-9 Tension band splint and stabilization plate.
 FRAcruRES OF FACIAL BONES
b. The tension band is simply the mandibular arch
bar, which is kept in place for at least 4 weeks
postoperatively. There must be a minimum of
three stable teeth in each fractured segment to
allow the tension band to be effective. A thin coat-
ing of cold-cure acrylic may help to stabilize the
arch bar and to coat the sometimes uncomfortable
wires but is not mandated.
2. Tension band plate and stabilization plate (Fig. 13-10):
a. Both plates may be 2.0 mm because the torsional
load in these locations is small. The tension band
plate may be even smaller (1.3 to 1.5 mm) as long
as there is enough cortical thickness and bone
density to fix the smaller screws. If intraoral inci-
sions are placed appropriately and the plates are
not too superiorly positioned, they are generally
well tolerated. If exposure of the tension band plate
occurs and there is screw loosening, loose hard-
ware usually can be removed without interference
with healing. The smaller plate systems are usu-
ally required for the pediatric population (1.3 to
1.5 mm).
(1) Care to avoid the tooth roots and the inferior
alveolar nerve is essential. The use of mono-
cortical screws (4 to 6 mm depending on the
thickness of the mandible) serves to protect
these structures. Drilling holes with appro-
priate drill bits with stops is required to avoid
potential drilling injury to these structures.
b. Larger plates may be used for the stabilization
plate but are rarely required (i.e., the 2A-mm plate
systems). One might consider this option if there
is questionable stability of the fracture site or the
patient is of extremely large body stature.
FIGURE 13-10 Tension band plate and stabilization plate.
FIGURE 13-11 Lag screw repair of body fracture. The
screws must miss the tooth roots and be within both
cortices.
3. The lag screw repair (Fig. 13-11)
a. Two lag screws may provide excellent repair for
noncom minuted symphyseal or parasymphyseal
fractures.
(1) Care in placement is required to avoid the
mental nerves.
(2) The screw placement is bicortical, and appro-
priate direction of the screw is mandated to
ensure capture of the posterior cortex.
4. Reconstruction plate repair for comminuted fractures
(Figs. 13-12 and 13-13)
a. The reconstruction type plates are designed to bear
the mandibular load without bone contact.
(1) Plates must be precisely bent with correct
screw placement to avoid malposition of the
mandibular stumps.
(2) A variety of reconstruction plates are avail-
able. Designs either expand a flanged screw
head within the plate hole (Thorp) or lock a
threaded screw head within a threaded (or
nonthreaded) plate.
(a) Threaded plate systems function like a
nut and bolt. It is important to precisely
align the mandible position before locking
the screw within the plate because once
the position is locked it is not changeable
without removal of all screws, reposition-
ing of the plate, and replacing the screws
with the plate and mandible segments
correctly positioned.
(b) A minimum of three screws, preferably
four, are required on each side of the
fracture.
 FRACTURES OF FACIAL BONES it?

band screws is essential to avoid injury to

the tooth roots.
2. Oblique fractures may be treated with the following:
a. Three lag screws for long oblique fractures
b. Lag screw through a stabilization plate or with
stabilization plate for short oblique fractures
(Fig. 13-14)
3. Comminuted:
a. Large comminuted fracture fragments may be
consolidated with lag screws or small plates with

stabilization with a larser fracture plate.

b. Comminuted fractures with multiple small frag-

ments are best treated similarly to areas of bone
loss using reconstruction plates (Fig. 13-15).
(1) No compression is used to provide normal
mandibular and dental relationships.

FIGURE 13-12 Reconstruction plate (bridging plate) for Open Repair for Angle Fractures
comminuted fractures.
1. Noncomminuted: May be applied with intraoral
approaches but generally require transbuccal screw
Open Repair of Body Fractures application. When comminution and significant dis-
location occur, extraoral approaches are generally
1. Noncomminuted: advised. The less experienced surgeon with minimal
a. Nonoblique fractures may be treated with the assistance should gain experience with extraoral
following: approaches unless fractures are simple and can be
(1) Tension band splint and stabilization plate: repaired by the single linea obliqua plate placement
when no comminution and stable teeth in the described below.
mandibular arch
(2) Tension band plate and stabilization plate
(a) Monocortical placement of the tension

FIGURE 13-13 Locking reconstruction plate: Plate

designs with screws that lock within the plate provide for
the ability to lock fragments into precise alignment regard-
less of the plate position from the bone. This facilitates
anatomic reduction for comminuted fractures. Likewise, FIGURE 13-14 Repair of short oblique parasymphyseal
special plates designed for the angle (3 x 3 holes and fracture with tension band splint and stabilization plate.
4 x 4 holes) region make it possible to repair more easily The screw through the plate is a lag screw. All other
displaced unstable mandibular angle fractures. screws are neutral.
 FRACTURES OF FACIAL BONES

a. Single small plate (2.0 mm) along the linea obliqua

(Fig. 13-16)
(1) This technique has been described by Champy
and is reliable for stable fractures in patients
with good dentition and no delay to fracture
repair.
(2) Screws are placed mono cortically.
(3) No comminution can be present.
(4) Noinf~ctioncanb~pr~s~nt.
(5) It is preferable to protect the fracture with 2
to 4 weeks of MMF if stability of the repair is
questioned.
b. Tension band plate and stabilization plate (Fig.
13-17)
(1) A variety of configurations are possible. Plate
choices are made relative to the complexity of
the fracture.
(a) Simple fractures: 2.0-mm tension band
and compression plate
(2) Segmental fracture may require a longer ten-
sion band and a more rigid longer stabiliza-
tion plate to provide adequate stability for
immediate function.
2. Comminuted: Usually require extraoral approach to
control the fragments and allow adequate bending
of the plate.
a. The best approach is to utilize a reconstruction
plate to position the fragments and provide ade-
quate stability for fracture repair (Fig. 13-18). The
locking reconstruction plate designed for the angle
provides excellent stability yet requires little bend-
ing. Likewise the locking screw design allows for
precise positioning of fragments without exten-
FIGURE 13-15 Repair of comminuted body fracture
sive bending. making transoral application with
with 2.4-mm mandible plate and tension band plates.
transbuccal instrumentation feasible.

FIGURE 13-16 Miniplate repair of angle fracture FIGURE 1 3-1 7 Tension band plate and 2.0-mm
(Champy). mandible plate for angle fracture.

FIGURE 13-18 Tension band plate and 2.4-mm stabi-
lization plate for comminuted angle fracture.
Open Repair for Condylar Fractures
1. Fracture type: deviated, displaced (severe displace-
ment produces telescoped fracture), and dislocated
a. Indications for open repair:
(1) Deviation greater than 45 %
(2) Dislocation of the condylar head
(3) Displacement where there is no bone contact
or telescoping of the fracture segment. Tele-
scoping will result in an open bite deformity
if not corrected.
(4) Bilateral unstable condylar fractures
(5) Concomitant midface fractures increase need
for condylar repair to help position and support
the midface as well as to help establish the
length and width of the facial anatomy.
2. Fracture location: intracapsular, high condylar, mid
condylar, low condylar (base of condyle) (Fig. 13-19)
a. Intracapsular:
(1) Generally treat with rapid mobilization.
(2) There is no role for ORIF.
b. High condylar
(1) Preauricular incision
Zones of Condylar Fracture
_Condylar fracture
-High subcondylar fracture
----Low subcondylar fracture
'~Fracture at condylar base
Oblique subcondylar fracture
FIGURE 13-19 Fracture zones of condyle.
FRACTURES OF FACIAL BONES
FIGURE 13-20 Repair of low condylar (subcondylar) neck
fracture with 2.4-mm mandibular plate.
(2) Repair with single mandibular plate (2.0 mm).
Be careful not to use thinner 2.0-mm midface
plates because these may fracture.
c. Mid condylar
(1) Requires retromandibular, trans parotid, sub-
mandibular (Risdon), or combined approach
d. Low condylar (subcondylar) (Fig. 13-20)
(1) It frequently may be approached intraorally.
(2) When associated with ascending ramus frac-
ture, it may require a long fracture or recon-
struction plate.
(3) Comminuted fragments may be either linked
together with several smaller plates and united
with a stabilization plate or bridged with a
reconstruction plate.
Open Repair of Coronoid Fractures
1. Rare fractures occur without association with com-
minuted mandibular fractures.
a. If isolated and nondisplaced, no repair is required.
b. If dislocated and affecting occlusion, then fixation
with small plates is needed. Fragments may be
pulled into the maxillary tuberosity and cause
trismus or inability to obtain occlusion.
Open Repair of Atrophic Mandible
1. The fracture fixation is complicated by the quality
and thickness of the bone being repaired.
a. Diminished cortical height and thickness and
decreased bone density require more screws to
provide the same stability for normal bone.
b. Four screws are recommended to fix the bone on
each side of the fracture (Fig. 13-21).
2. The load requirements of the mandible are depend-
ent on the patient's normal diet and may be similar
to those of patients with normal mandibles.
 FRACTURES OF FACIAL BONES

Mechanical Principles

The dynamic compression plate is a special device that

has screw holes developed to provide interfragmentary
compression. The provision of interfragmentary com-
pression, with maintenance of rigid fixation by the plate,
allows for primary bone healing. Maintenance of rigid
internal fixation and interfragmentary compression are
prerequisites to allow for rapid healing without develop-
ing infected bone nonunion. The following steps des-
cribe the structural anatomic limitations and the mechan-
ical principles for achieving the best results.

A The limitations in the structure of the mandible

FIGURE 13-21 Repair of atrophic mandible with univer- and the masticatory forces acting on the mandible
sal fracture plate. req'uire special consideration for plate placement and
its design.

a. The use of bridging plates (2.4 mm) may be con-
sidered with at least four screws in each segment.
b. Very atrophic cases may be repaired with smaller
long plates such as the universal fracture plate
designs (2.0 mm) (see Fig. 13-21).
Compression Plating for
Treatment of Mandibular
Fractures (Fig. 13-22)
Douglas W Klatch and Joachim Prein
This is a historical description as in the previous edition
of this atlas. Refer to Fractures of the Mandible for
more current plating principles and systems.
Indication
• To establish absolute stability, providing anatomic
repositioning with restoration of occlusal and func-
tional relationships
Advantages
• Early mobilization of mandible, decreasing trismus
post stabilization
• Immediate return to normal route of alimentation
• Early return to work without limitations
• Normal access to airway without interference of inter-
maxillary fixation
• Rapid primary, not secondary, bone healing
Disadvantages
• Facial scar
• Surgical procedure requiring special instruments and
skills
• Removal of stainless steel plates after a year
1. Ideally, placement of the fixator at the tension side
will provide greatest stability (gap stability).
2. Tooth roots may not allow placement of the plate at
the tension (alveolar) side.
3. The inferior alveolar nerve canal should be avoided
(no man's land).
4. These limiting factors generally require plate place-
ment on the less ideal compression side (basilar or
inferior position) of the mandible.
B A special plate and screw design provide the neces-
sary interfragmentary compression, which enhances
stability and allows for primary bone healing.
1. The gliding screw principle is provided by the
development of a screw hole that is thicker on its
outer end; it functions as an inclined plane. The
spherically designed screw head can easily glide
along this hole to provide a compression force.
2. Screws closest to the fracture are placed eccentri-
cally by a specially designed drill guide that allows
for positioning of the screw hole 0.8 mm from the
thinner aspect of the screw hole. This eccentric place-
ment allows the spherical screw head to contact the
inclined wall of the hole and to provide a force in
the direction of travel of the screw.
3. The large arrow in the diagram (B and B1) indicates
the direction of the compression force developed
when tightening the screw placed in the eccentric
position.
4. All other screws placed by the thinner aspect of the
plate hole are in the neutral position. The screw head
does not contact the incline located at the thick
wall of the plate hole, and no compression force is
developed. Screws placed in the neutral position
provide stabilization of the plate without providing
compression.
 FRAaURES OF FACIAL BONES 611

MUSCLES OF MASTICATION

\
FORCE OF MASTICATION

TENSION SIDE j
~¢INCLINED PLANE
.. ~

A ~PRESSORS OF
MANDIBLE

FORCES ACTING ON MANDIBLE

ERNST LIGATURE
B
.
.. - We.bnT~

B1
FIGURE 13-22

81 The screw position is shown after correct fixa-
tion. The innermost screws (closest to the fracture) are
placed in the eccentric position. Note that the screw
head contacting the gliding screw hole produces inter-
fragmentary compression in the direction of the two
arrows. The outer screws are placed in the neutral
position. No contact of the screw head with the gliding
(inclined) portion of the screw hole occurs, and no
compression force is developed. It is important to place
the screwsclosest to the fracture eccentrically to provide
for the greatest interfragmentary compression. It is
essential to place all other screws neutrally to avoid
distraction of the compression force already developed.
C The objective of any method for repairing a
mandibular fracture is to restore the patient's occlu-
sion and mandibular function. Therefore, the patient
must be placed into correct occlusion before opening
the fracture and applying internal fixation. This may be
achieved by application of conventional arch bars or
by placement of Ernst ligatures. The choice of fixation
is dependent on the location of the fracture.
Continued
 FRACTURES OF FACIAL BONES
Compression Plating for
Treatment of Mandibular
Fractures (Continued) (Fig. 13-22)
A minimum of two Ernst ligatures is required, one
on each side of the mandible. Placement of cold-cure
acrylic around the twisted ends of wires helps to stabi-
lize them and to maintain normal occlusal relationships
during the procedure.
1. The Ernst ligature is a figure-eight self-tightening
ligature placed around two stable teeth-two in the
maxillary arch and two in the mandibular arch.
2. Ligatures are placed on corresponding maxillary and
mandibular teeth and then twisted together to place
the patient into intermaxillary fixation.
3. Ernst ligatures generally provide stable occlusion for
fractures posterior to the teeth. They are also ade-
quate for anterior fractures in which good occlusal
relationships existed preoperatively and in which
teeth are stable for maintaining fixation. For patients
with preexisting malocclusion or multiple unstable
teeth or for patients with concomitant midface frac-
tures, conventional arch bars stabilized with acrylic
provide for better fixation of occlusion.
D Special reduction forceps have been developed to
aid in precise application of internal fixation. These
forceps are placed at the inferior cortical rim.
1. Forceps allow for reduction of fractures.
2. Special compression rollers should be used for
fractures in which tension band splints or tension
band plates cannot be applied. They are especially
useful in the reduction of angle fractures and are
essential for the correct application of the eccentric
dynamic compression plate (EDCP, not pictured).
3. Forceps allow for establishment of a preload that
compresses the two ends of the fracture together.
This interfragmentary force is maintained by the
special dynamic compression plate design.
The addition of compression rollers allows for better
distribution of the interfragmentary force for fractures
occurring at the angle. They also are necessary to
provide for the correct distribution of the preload
before applying the EDCP.
Outline of Procedures for Rigid Internal
Fixation
1. Fractures occurring within the tooth row may be
repaired by one of the following:
a. A tension band splint (see F) may be used in
combination with a six-hole dynamic compression
plate (DCP). The tension band splint is an arch
bar that is fixed to at least two stable teeth at
either side of the fracture.
b. Lag screws may be utilized for oblique fractures
(see J).
c. The dynamic bendable defect-bridging (OBOB)
plate is used for areas in which there is marked
comminution or bone loss or in places in which
the placement of the straight ocr may jeopardize
the inferior alveolar nerve (see I).
2. Fractures in edentulous patients may be ideally
repaired by rigid internal fixation, but a minimum of
approximately 6 mm of cortical bone is required to
apply internal fixation for patients with atrophic
mandibles. The procedures used may include the
following:
a. The six-hole eccentric dynamic compression plate
(EOCP) (see H)
b. Lag screws for mandibles with oblique segments
c. OBOB plate for comminuted fractures or areas in
which there is bone loss or severe atrophy of the
mandible and in which placement of the straight
EOCP may jeopardize the nerve (see L)
3. Fractures occurring posterior to the tooth row (Le.,
angle fractures) may be repaired with the following:
a. The tension band plate (two-hole OCP) in combi-
nation with a four-hole OCP as a stabilization
plate (see G)
b. The lag screw for oblique fractures (see J)
c. Six-hole EOCP (see H)
d. OBOB plate for comminuted fractures or situations
in which placement of a straight plate (OCP or
EOCP) might jeopardize the nerve (see I)
4. Injuries with large segmental bone loss may be
bridged with the OBOB plate. There must be at least
four screws to fix the plate to each bony segment
(see L).
E Incorrect method. The correct bending of the plate
to fit to the contour of the mandible is important.
Incorrect bending (1) of the plate will tend to distract
the lingual cortex and (2) produce instability. Arrows
in (2) depict this distraction.
El Correct method. In combination with the eccen-
trically placed inner screw providing interfragmentary
compression beneath the plate, slight overbending (3)
of the plate allows for lingual cortical compression.
This is depicted by the arrows in (4). This slight over-
bending technique is required to allow for equal distri-
bution of the interfragmentary compression force along
the fracture line.
Continued
 FRACTURES OF FACIAL BONES

PS WITH ADAPTATION ROLLERS

E INADEQUATE BENDING PRODUCES GAP DISTRACTION AT INNER CORTEX

3 4
~)
E1
It/abn! '"
SLIGHT OVERBENDING OF PLATE PROVIDES COMPRESSION AT OUTER AND INNER CORTICES
FIGURE13-22 Continued
 FRAcnJRES OF FACIAL BONES
Compression Plating for
Treatment of Mandibular
Fractures (Continued) (Fig. 13-22)
Fracture in Row of Teeth
Highpoints
1. Patients may be anesthetized via nasotracheal intu-
bation.
2. The oral cavity should be copiously irrigated.
3. Closed reduction of the fracture is performed.
4. The tension band splint is then placed as previously
described and is stabilized with cold-cure acrylic.
5. The occlusion must be held in a fixed relationship
before opening the fracture and placing the plate.
Ernst ligatures (see C) are usually adequate, but arch
bars may be necessary if the occlusal relationships
are unstable.
6. A cervical incision is placed well below the mandible
(see Fig. 13-6) in the appropriate lines of "facial"
expression to limit scars.
a. The ramus mandibularis should be preserved,
but sacrifice of the facial artery and vein may be
required to gain exposure. Likewise, the cervical
branch of the facial nerve may be divided with-
out producing residual disability. However, the
platysma muscle should be carefully approximated
at the time of closure, because it contributes to
the depressor of the lower lip.
b. The inferior cortex of the mandible is exposed,
but only a limited stripping of anterior periosteum
should be performed (only enough for plate
placement) .
7. The reduction forceps (see 0) are placed at the infe-
rior cortex with 8- to lO-mm long and 2.7-mm wide
screws. They are positioned approximately 1 em
from the edge of the fracture. These forceps allow
for an anatomic reduction and provide for a pre-
load before the application of interfragmentary com-
pression via the compression plates.
8. The six-hole OCP is then slightly overbent (see El)
to allow for compression of both the inner and
outer cortices of the mandible.
9. The plate is then held into its position by special
plate-holding forceps. With the special eccentric
drill guide, a 2.0-mm drill bit is used to drill the
screw holes. Care must be taken to irrigate copiously
during the drilling procedure. First, the innermost
holes are drilled in the eccentric position (see B).
These are the holes that are closest to either side of
the fracture (see Bl). The depth gauge is then
placed through the plate hole as well as bone hole
to measure the screw length. The bone holes are
then tapped with a 2.7-mm tap, using a tissue pro-
tector at all times. Again, the hole should be irrigated
after the tap is removed.
10. The appropriately measured 2.7-mm diameter screw
is then placed in each of these eccentrically drilled
and tapped screw holes. Before tightening the screws,
the thumb screw of the reduction forceps (see 0)
should be loosened and the pliers held manually,
which allows maintenance of the preload without
restricting the development of interfragmentary com-
pression as the screws are tightened.
11. The remaining outer two screws at either side of the
fracture are placed in the neutral position (see Bl).
These increase the stability of the plate system.
12. Only tight screws are functional and should remain.
a. All loose screws should be removed to prevent
osteolysis and subsequent infection at the loose
screw hole.
b. Careful drilling and use of irrigation with careful
tapping prevents loose screws.
13. Hemovacs are utilized to provide drainage. The
wounds are closed. At the end of the procedure the
temporary intermaxillary fixation is removed. The
tension band splint, however, remains until 6 weeks
postoperatively, at which time it is removed.
14. Patients can be placed on a soft diet immediately,
as tolerated.
15. Good oral hygiene is important while the tension
band splint is in place.
Fracture Posterior to Row of Teeth
Highpoints
1. After closed reduction is achieved, occlusion can
generally be held into a fixed position by means of
Ernst ligatures (see C).
2. The fracture is exposed via a skin incision approxi-
mately 3 em from the angle of the mandible.
3. Reduction forceps with rollers are attached to the
inferior edge of the mandible (see 0).
4. The two-hole ocr tension band plate is first applied
at the alveolar cortical side, and the screws are placed
in the eccentric position utilizing 2.7-mm screws, as
previously described.
5. The four-hole (OCP) stabilization plate is placed at
the inferior aspect of the mandible. The inner screw
holes (closest to the fracture) are placed eccentrically,
with the outer holes placed in the neutral position.
Before tightening the inner screws, the thumbscrew
of the reduction forceps is loosened so as not to
restrict the plate function.
6. Layered closure with placement of Hemovacs is com-
pleted, and the intermaxillary fixation is removed at the
procedure's end. The patient may be placed on a dental-
soft diet immediately after fluids are well tolerated.

FRACTURE IN ROW OF TEETH
FIGURE 13-22 Continued
F The repair of fractures occurring in a row of teeth
is achieved by the use of the tension band splint in
combination with the stabilization plate. The tension
band splint is a small piece of arch bar fixed to at least
two stable teeth on either side of the fracture. It can be
further stabilized by placing cold-cure acrylic around
the arch bar and wires that fix the bar to the teeth.
Care must be taken not to allow the acrylic to contact
the gums. The tension band splint functions similarly
to the cable in a suspension bridge and greatly helps
to increase the gap stability at the tension side of
the mandible. The six-hole dynamic compression plate
(OCP) provides interfragmentary compression and
stabilization.
FRACTURES OF FACIAL BONES
FRACTURE POSTERIOR TO ROW OF TEETH
G Fixations of fractures posterior to the row of teeth
(i.e., angle fractures) use the tension band plate (two-
hole OCP) and stabilization plate (four-hole OCP). When-
ever possible the surgeon should use this technique,
because the placement of the tension band plate at
the alveolar side with the combination of stabilization
plate at the inferior side provides the maximal gap
stability.
Continued
 FRACTURES OF FACIAL BONES
Compression Plating for
Treatment of Mandibular
Fractures (Continued) (Fig. 13-22)
Fractures at Angle of Mandible
An alternate method of internal open intraoral fixation
of noncomminuted, straight line fractures at the angle
of the mandible has been described by Niederdellmann
with a follow-up of 50 patients. Usually one, at times
two, and rarely three lag screws are employed. The pro-
cedure is basically an intraoral transbuccal operation,
which eliminates wide extraoral exposure of the frac-
ture site. The author has no personal experience with
this method.
Use of Eccentric Dynamic Compression
Plate
The EOCP has outer screw holes either at the 45-degree
angle (see H) or the 90-degree angle (see Hl) to the
longitudinal axis of the plate. The 90-degree EDCP (Hl)
represents an older design. The newer 45-degree EOCP
has the outer two screw holes at a 45-degree angle to
the long axis of the plate. When using the 45-degree
plate, screws placed eccentrically in these holes produce
a force at 45 degrees to the longitudinal axis of the
plate. Therefore, when this plate is placed inferiorly,
the two inner screws (holes are oriented along the axis
of the plate) are first placed to provide for interfragmen-
tary compression beneath the plate. When the outer
45-degree screws are placed at the eccentric position,
they provide a pressure force at 45 degrees to the long
axis of the plate, thereby providing alveolar cortical com-
pression and a more even distribution of the interfrag-
mentary compression force along the entire fracture
line, which subsequently increases gap stability, and
the resultant stabilization is strengthened.
Highpoints
1. The EOCP is utilized for fixing angle fractures when
there is an inability to use the two-plate system. The
surgeon must be aware that the EOCP is not as
stable as the tension band plate stabilization plate
fixation method.
2. The steps for closed reduction include stabilization
of occlusion, exposure of fracture, and application of
reduction forceps with rollers as described in G.
3. The EOCP is bent with slight overbending (see E1).
The inner screw holes are placed eccentrically as
described previously, allowing for interfragmentary
compression. Next, the outermost 45-degree angle
screw holes are placed eccentrically. Before these
screws are tightened, the thumbscrew of the reduc-
tion forceps should be loosened to allow for the
development of the inner fragmentary compression
force by the plate without restriction. The middle 45-
degree angle screws may be placed in either the
neutral position, if there is good distribution of the
compression force around the fracture line, or in the
eccentric position, if more compression is needed at
the alveolar cortical side.
4. The wounds are closed with Hemovac drains and
removal of intermaxillary fixation as previously
described.
H, Hl, H2 Repairs of fractures distal to the posterior
tooth row (i.e., angle fractures) utilizing the EDCP.
Use of Dynamic Mandible Defect-
Bridging Plate
Occasionally, the fractures distal to the posterior teeth
are extremely comminuted and there is concomitant
bone loss. There may also be a difficulty with atrophic
mandibles that do not allow for the application of either
EOCP or the tension band plate stabilization plate
methods. The reconstruction plate (OBOB), which is
bendable in three dimensions, can provide for stabiliza-
tion of bony fragments for these patients.
Highpoints
1. Minimal compression can be provided.
2. Preferably, four screws should be placed at either
side of the fracture.
3. This is the least stable of the plate systems and should
be utilized only when necessary.
4. Approximately 6 mm of available cortical bone is
necessary to apply this system.
5. The stabilization of occlusal relationships, exposure,
and, if possible, reduction with reduction forceps is
achieved. Frequently, the reduction forceps are not
beneficial if severe comminution exists.
6. It is helpful to use an aluminum template to plan how
the three-dimensional OBDB plate should be bent.
 FRACTURES OF FACIAL BONES 617

H2

t~~·~O-G1
75° EDCP

DBDB PLATE
ECCENTRIC DYNAMIC COMPRESSION PLATE (75° OR 90°) RECONSTRUCTION PLATE
( ALSO FOR EDENTULOUS MANDIBLE)
FIGURE13-22 Continued

7. Generally, all screws are placed in the neutral posi-
tion; however, slight interfragmentary compression
can be achieved if screws are placed eccentrically:
After the termination of the placement of the OBOB
plate, the wounds are closed as previously described
with Hemovac drainage and intermaxillary fixation
may be removed. Care must be taken not to advance
the patient's diet too rapidly; generally, the patient is
kept on a dental-soft diet for approximately 6 weeks.
I Repair of fractures posterior to the row of teeth
(i.e., angle fractures) is shown using the dynamic bend-
able defect-bridging (DBDB)plate.
Continued
 FRACTURES OF FACIAL BONES
Compression Plating for
Treatment of Mandibular
Fractures (Continued) (Fig. 13-22)
Fracture in the Edentulous Mandible
Fractures occurring in the edentulous mandible are
ideally suited for repair via rigid internal fixation. Pre-
existing dentures or splints are rarely needed, because
direct repair of bony fragment without establishing
intermaxillary stabilization produces good functional
results.
Highpoints
1. The fracture can usually be reduced without stabiliz-
ing occlusal relationships.
2. The mouth is irrigated, and an appropriate incision
with exposure of the mandible is performed.
3. The reduction forceps are placed on the inferior cortex
(if there are two fractures, use two forceps) (see D).
It is important to utilize adaptation rollers to reduce
the fracture when the EDCP is to be applied.
4. The EDCP should be slightly overbent and held into
position with a bone-holding forceps. The screws are
placed as previously described by first placing the
inner screw holes eccentrically. Second, the outer
4S-degree screws are placed eccentrically as previ-
ously described. The middle 4S-degree holes should
generally have screws placed in the neutral position.
S. The wounds are closed with Hemovac drains in place.
The patient may eat a dental-soft diet as tolerated. It
is important not to have the patient wear the lower
denture for at least 6 weeks. When swelling sub-
sides, the lower denture may be worn, and, gener-
ally, patients can resume their normal diet at that
time.
6. Comminuted fractures involving the edentulous
mandible may also be repaired by utilizing the DBDB
plate. It is applied as previously described (see I).
Treatment of Oblique Fractures by
Utilizing the Lag Screw Principle
Highpoints
1. Fractures are exposed after closed reduction has
been performed and occlusion has been stabilized.
2. Fractures are reduced and held with the bone-
holding forceps.
3. The oblique fragments may be held together by
means of a towel clamp or bone-holding forceps.
Care should be taken not to fracture the cortices
when grasping the bone with these instruments.
4. The outer cortex is first drilled with a 2.7-mm
diameter bit to provide for a sliding screw hole.
S. A 2.G-mm drill guide sleeve is then placed into the
hole to allow for drilling of a 2.G-mm hole in the
inner cortex.
6. The outer cortex is drilled with the hole counter-
sunk to allow the spherical screw head to fit with-
out fracturing or displacing the bone.
7. The depth gauge is utilized to measure the screw
length so the screw will grip the entire length of the
inner cortex.
8. The inner cortex is now tapped to 2.7 mm, and the
appropriately measured 2.7-mm screw is placed.
9. The two other screws are also positioned in the
same fashion to provide for interfragmentary com-
pression and torsional stability.
10. Intermaxillary fixation may then be removed and
the patient placed on a dental-soft diet for about
6 weeks. Generally, after that time normal diets can
be resumed.
J The lag screw principle is the foundation for the
establishment of interfragmentary compression for
oblique fractures. The screw may be used by itself to
. fix long oblique fracture segments occurring within
the mandible. Preferably, three screws should be used
to fix an oblique segment to stabilize the rotational
forces and to provide for adequate rigid fixation.
K Short oblique fracture fragments may be repaired
by the combination of the lag screw and the stabiliza-
tion plate. Here, the lag screw placed through the
plate in the neutral position provides interfragmentary
compression. Allof the other screw holes through the
six-hole Dcr are placed in the neutral position, with
tapping of both cortices as previously described. When
using the lag screw with stabilization plate, no holes
should be drilled eccentrically, otherwise this willforce
overriding of the bone fragments and loosening of the
lag screw, with loss of interfragmentary compression.
Repair of Large Mandibular Defects
Utilizing the DBDB Plate
The DBDB plate is designed to be bendable in three
dimensions. It is important to utilize the special bend-
ing pliers so as not to overbend and subsequently weaken
the plate. The DBDB plate may be used for large trau-
matic defects or defects after tumor removal.
Newer, smaller reconstruction plate systems and lock-
ing plate systems (see Fig. 13-13) consisting of 2A-mm
screws (1.8-mm drills) are currently being used.
Highpoints
1. Have adequate tissue cover.

LAG SCREWS
K BRIDGING OF LARGE MANDIBULAR
LAG SCREW WITH
STABILIZATION PLATE
FIGURE 13-22 Continued
2. Have at least four screws at each side of the defect.
3. Establish a fixed occlusal relationship before bending
the plate.
4. Do not overbend the plate. Use the special pliers so
as not to weaken the plates. Use an aluminum tem-
plate (made from the resected mandible) to guide in
bending the plate so as to lessen manipulation that
would cause undue weakening of the plate.
5. The plate may be used with or without primary bone
grafting (cancellous, cortical, osteomyocutaneous, or
free vascularized).
L Bridging of large mandibular defects with the
DBOBplate is shown.
The following steps should be observed when utiliz-
ing the OBOB plate:
1. Reestablish and maintain occlusal relationships
before placing the plate.
2. Utilize an aluminum template whenever possible
to allow for more accurate bending of the plate. Try
not to rebend the plate, which will cause weakening.
3. Use a plate long enough to provide at least four
screws at each stump.
4. Drill (2.0 mm), measure depth, tap 2.7 mm, and
place 2.7-mm screws as previously described.
5. Remove any loose screws.
FRACTURES OF FACIAL BONES 61'
L
DEFECTS
6. Preferably provide adequate soft tissue coverage.
However, plates will tolerate being exposed usually
without extrusion if only a secondary closure is
possible.
7. Primary or secondary bone grafts may be utilized
. depending on the injury and defect. The plate pro-
vides a relatively stable bridge for large defects and
allows for reconstruction of anatomic relationships
and functions. If primary bone grafts are utilized,
adequate vascularized tissue must surround the
graft and plate.
8. The surgeon must provide a layered closure of
wounds with watertight closure of mucosa.
Hemovacs are placed. No pressure dressing should
be placed over the flap covering the plate to avoid
necrosis of tissue.
9. A preoperative bolus of antibiotics appropriate to
cover oral flora with a 7-day postoperative course
is recommended. Good oral and wound care is
imperative.
10. Patients must not wear a functional denture over a
plate, although they might place the denture over
the plate for cosmetic purposes. The diet should be
restricted to soft foods (e.g., chopped meats, chicken,
fish, soft vegetables). After successful bone healing
the .patient may wear functional dentures, and a
regular diet may be resumed.
For an alternate method of repair using Kirschner
wires and tie wires see Figures 14-5 and 14-6.
 FRACTURES OF FACIAL BONES
Open Reduction of Depressed
Fracture of Zygomatic Arch
With or Without Fracture of Body
of Zygoma (Gillies' Technique)
(Fig. 13-23)
Highpoints
1. The earlier the reduction, the better-usually within
48 hours.
2. Use temporal muscle as guide for placement of elevator.
3. Slightly overcorrect the depressed fragments.
Complication
• Injury to the zygomaticotemporal division of the
facial nerve or, if the fracture involves the orbit,
injury to the optic nerve or the infraorbital nerve
Alternative Technique
Keane has described another approach to the zygomatic
arch through an incision in the gingivobuccal sulcus.
An elevator is inserted beneath the depressed arch to
lift the bone.
A, B Although the extended or exaggerated Waters
radiographic view, which is the basic standby for most
facial bone fractures, is suitable, the Titterington position
is one of the specific radiographic views for depressed
fractures of the zygomatic arch. This position is
indicated in the drawings with the arrows showing the
direction of the x-ray tube. CT may be indicated if
additional injuries are suggested.
C The incision is made above the hairline and slightly
oblique. Beneath the skin and superficial temporal fascia
is encountered the superior auricularis muscle, which
is separated in the direction of its fibers. If the hairline
is low and the incision is made lower, the fibers of the
auricularis anterior are exposed. These fibers are more
horizontal than the auricularis superior and are thus
separated in a horizontal plane. Deep to these muscle
fibers lies the heavy deep temporal fascia. With care,
branches of the auricular temporal and zygomaticotem-
poral branches of the facial nerve are not transected.
These nerves are superficial to the deep temporal
fascia and vulnerable especially when transecting the
fascia (see Fig. 7-5).
D The deep temporal fascia is then incised, exposing
the temporalis muscle. This fascia may have two closely
adherent layers. The entire layer(s) of the fascia must
be incised, and the temporal muscle is used as a guide
for the placement of the elevator.
E A blunt sturdy elevator is inserted between the
deep temporal fascia and the temporalis muscle. The
instrument then slips easily and directly under the
zygomatic arch.
F A cutaway illustration shows the skin incision and
the position of the elevator superficial to the tempo-
ralis muscle and deep to the depressed zygomatic arch
and deep temporal fascia. With a gauze roll protecting
the upper skin edge and acting partially as a fulcrum,
the depressed arch is elevated and slightly overcor-
rected. The left hand is best used as a fulcrum to avoid
undue pressure on the skull.
G When there is an associated fracture of the body
of the zygoma, this fracture is reduced through the
same approach (see Fig. 13-24). Closure consists of three
or four sutures to approximate the deep temporal
fascia. The skin is then closed. A 4 x 4-inch gauze sponge
is folded three times and is used as a pressure pad over
the incision. Rarely does this type of fracture require
interosseous wiring, unless there has been undue delay
in the reduction (see Fig. 13-24F).
 FRACTURES OF FACIAL BONES 621

B D E

. Temporalis m.

FIGURE 13-23
 FRACTURES OF FACIAL BONES
Open Reduction of Depressed
Fracture of Zygoma and Portion
of Maxilla (Fig. 13-24)
Early Reduction
Highpoints
I. The earlier the reduction, the better-usually within
48 hours.
2. Use temporal muscle as guide for placement of
elevator.
3. Slightly overcorrect the depressed fragments.
4. Use a combined maneuver of elevation of depressed
segments and downward pressure on raised infra-
orbital rim.
S. Evaluate presence or absence of fracture of floor of
orbit and treat accordingly (see Fig. 13-33A to EI).
6. Evaluate vision.
Discussion
Fractures of this type may involve the orbital apex, and
any manipulation of the fragments may place the optic
nerve at risk. CT is important to evaluate the extent of
the injury. Three-dimensional CT may afford additional
information.
There may be limitation of the extraocular muscles
either secondary to edema or actual entrapment of the
inferior oblique muscle. This latter problem is verified
by the traction test of the inferior rectus muscle (see
Fig. 13-33C). Vision must be carefully evaluated before
any operative manipulation of the fracture.
When the fracture lines involve the thinner articu-
lations of the zygoma with the fronta!, temporal, or
Late Reduction
sphenoid bones, or the maxilla, the fracture may be
referred to as a tripod fracture. If there is no or minimal
displacement without entrapment of the inferior rectus
muscle, open reduction is usually not indicated.
An alternate form of internal fixation, if necessary,
can be achieved by using a mini-compression plate
(Eisele and Duckert, 1987) along the zygomaticofrontal
fracture line without the two-point fixation that may be
required when wire fixation is used (Luhr, 1979) (see
Figs. 13-26 and 13-27). For exposure to insert the mini-
compression plate, an incision is made along the lateral
brow.
Complication
• Blindness has been reported after open reduction of
the body of the zygoma using this technique. The
exact mechanism was not defined by the surgeon.
A, B The anterolateral wall of the maxilla is
depressed and comminuted, as is the body of the
zygoma. The fracture line extends through the infra-
orbital foramen with upward rotation of the lateral
portion of the infraorbital rim. The zygomatic arch may
or may not be depressed. There is associated hypo-
esthesia of the skin of the cheek and upper lip, trismus,
malocclusion, epistaxis, and a cosmetic deformity
characterized by a depression over the body of the
zygoma and maxilla. Diplopia may be present with
inferior or lateral depression of the globe.
C, D With the use of the same approach (Gillies) as
for simple depressed zygomatic arch fractures (see Fig.
13-23), a blunt elevator is inserted in the plane deep
to the deep temporal fascia. The elevator is placed
under the body of the zygoma and lateral wall of the
maxilla (see E). An outward motion is applied to the
elevator, while the thumb of the opposite hand exerts
downward pressure (arrows) on the raised lateral por-
tion of the infraorbital rim. The depressed zygomatic
arch, if present, is elevated as in Figure 13-23. Slight
overcorrection is usually desirable.
E If the posterolateral wall of the maxilla is severely
comminuted, entrance into the antrum via this tem-
poral approach is possible. Thus, the entire anterior wall
of the maxilla may be elevated. However, severe com-
minution of the anterior wall may preclude post-reduction
impaction of the fragments, and it is then necessary to
resort to the canine fossa approach with packing (see
Fig. 13-25).
F If the reduction has been delayed and the align-
ment of the fragments cannot be achieved or main-
tained, open reduction at one or all fracture sites is
necessary. Depicted is an intraosseous wire placed
through drill holes in the zygomatic arch. Extreme care
must be taken not to injure branches of the facial
nerve. This can be achieved by separating all subcuta-
neous tissue by blunt dissection down to the fracture
site. The twisted wire is bent so as not to project
against the skin or the temporalis muscle. Ideally, the
periosteum is closed over the wire.
 FRACTURES OF FACIAL BONES

Wabmtr
FIGURE 13-24

Occasionally, when the medial infraorbital rim frac-
ture is oblique and cannot be corrected nor the reduc-
tion maintained, open reduction and interosseous wiring
may be required. Simple through-and-through wires
may tend to cause overriding of the medial fragment.
To obviate this problem, a figure-eight suture with the
ends twisted on the medial side is used. The crossing
of the figure-eight suture is located within the fracture
site. A small hook is used to feed the wires within the
fracture site.
 FRACTURES OF FACIAL BONES
Early Reduction of Depressed
Comminuted Fracture of Anterior
Wall of Maxilla (Fig. 13-25)
Highpoints
1. This method is usually only effective in the early
reduction of such fractures-within 24 to 48 hours.
Later than this, interosseous wiring is necessary to
maintain reduction (see Fig. 13-28). The reduction
can also be by the use of miniplates.
2. Edema and hemorrhage may mask a severe cosmetic
deformity.
3. Antral packing is almost always necessary.
4. Always perform intranasal antrostomy for drainage
and close canine fossa incision without drainage.
S. Evaluate presence or absence of fracture of the floor
of orbit and treat accordingly (see Fig. 13-33A to El).
Complications
• Blindness as a result of too much pressure from
excess packing in the antrum, especially if there is a
fracture of the floor of the orbit
• Pneumomediastinum (Tofield, 1977).
A, B The main fracture line usually extends through
the infraorbital foramen with downward depression of
the lateral infraorbital rim. The anterior wall of the
antrum is comminuted. There is associated
hypoesthesia of the skin of the cheek and upper lip,
trismus, malocclusion, epistaxis, and usually diplopia.
The cosmetic deformity mayor may not be apparent,
depending on the degree of edema or hemorrhage.
C A small incision is made in the canine fossa. The
details of the approach are similar to those for a
Caldwell-Luc operation (see Fig. 5-2).
D The anterior wall of the antrum is exposed, demon-
strating some of the comminuted fragments. A small
elevator is then inserted into the antrum through the
site of comminution. Clotted blood is removed by suc-
tion and, with the elevator, the depressed fragments
are raised by pressure from within the antrum. Any
free fragments of bone are removed. An evaluation of
the roof of the antrum (floor of orbit) is now made (see
Fig. 13-33F to I). Care must be taken to evaluate for
the presence of a fracture through the optic foramen;
and, if one is present, reduction may require delay.
E An intranasal antrostomy through the inferior
meatus is performed (see Fig. 5-1 A and A1). No sharp
edges of bone should remain that might hamper
removal of the antral packing.
F The antrum is packed with D.5-inch gauze impreg-
nated with antibiotic ointment with one end drawn
out through the intranasal antrostomy. The other end
is left in the antrum. This packing maintains the posi-
tion of the comminuted fragments. The packing should
be lightly and gently applied if there is an associated
fracture of the floor of the orbit. The canine fossa inci-
sion is closed without drainage. Removal of the pack-
ing through the nose is started on the fifth to the
seventh day. Complete removal is accomplished over
several days. Antibiotics are necessary with antral pack-
ing. An alternate for the packing is a 3D-mL Foley
catheter with the tip removed up to the balloon. The
balloon is filled with methylene blue-dyed saline. In
the event the balloon leaks this will easily be detected.
Overinflation of the balloon should be avoided for the
same reason that overpacking is avoided-too much
pressure on the floor of the orbit if it is fractured.
 FRACTURESOF FACiAl BONES

FIGURE 13-25
 FRACTURES OF FACIAL BONES
Intraosseous Wiring for Facial
Fractures (Fig. 13-26)
When reduction is delayed beyond 48 to 72 hours or
when there is marked separation of the fracture sites,
wiring across the fracture site through drill holes is
necessary to maintain reduction, or use miniplates.
Highpoints
1. Incisions follow natural skin crease.
2. Use as small an incision as possible. Retract the skin
edges gently.
3. Use blunt dissection in subcutaneous tissue and
muscle to avoid injury to branches of the facial nerve.
4. Periosteum is usually elevated and then is closed
over the wire and fracture site.
5. Exposure at the infraorbital region affords explora-
tion of orbital floor (see Fig. 13-33F to M) for hernia-
tion of orbital contents into antrum. Treat according
to findings.
6. Drill holes should be as small as feasible. Always
take extreme care of structures behind drill hole sites
and angulate direction of holes accordingly.
7. Bend twisted wire so that surrounding soft tissue is
not irritated.
A, B Fractures sites are depicted. Extension into the
floor of the orbit is very probable. The zygomatic arch
may be fractured in more than one location. If the arch
is depressed, it can usually be elevated through the
brow incision, which is used for the approximation of
the zygomaticofrontal fracture. If this is not satisfac-
tory, a separate approach is made through the tem-
poral region (Gillies). The fracture along the infraorbital
rim is most often through the infraorbital foramen.
Any fragments of bone infringing on the infraorbital
nerve should be disengaged or removed.
C The various types of skin incisions are depicted.
The exposure in the zygomaticofrontal area can be
either through the lateral aspect of the brow (solid
line) or along a natural skin crease (broken line) lateral
to the lateral canthus of the eye. In either event, never
shave the hair of the brow. The infraorbital incision is
along a natural skin crease. If this incision is too long,
edema of the lid will persist for months. The lids may
be temporarily sutured closed to protect the cornea.
Separation of the subcutaneous tissue and muscle fibers
is by blunt dissection to avoid injury to branches of the
facial nerve, especially if the lateral canthal incision is
used.
D The periosteum has been incised (the incisions
pictured are large for clarity) and is now being gently
elevated, exposing the fracture site. Exploration of the
lateral orbital rim can be performed through the inci-
sion by extending the subcutaneous plane. Through
this incision an elevator can at times be inserted deep
to the zygomatic arch for elevation of depressed frac-
tures of this bony structure. If this is not feasible, a
separate incision can be utilized in the temporal region
(Gillies) (see Fig. 13-23).
E Small drill holes are then made 6 to 7 mm from the
edge of the fracture on each side. A malleable retractor
or other suitable instrument is inserted medially to
protect the orbital contents. The drill holes are directed
posterolaterally to avoid entering the orbit and the
cranial cavity. This is most important. Blindness and/or
meningitis are possibilities.
F Stainless steel wire (0.35 mm in diameter) is then
passed through the drill holes and twisted posteriorly
to the fracture site. The wire is then cut, leaving a
twisted section of.7 to 9 mm, which is bent in behind
the bone.
A similar exposure, drill holes, and intraosseous
wiring have been performed along the infraorbital rim
fracture. Through this incision, the floor of the orbit is
explored for fracture and herniation of orbital fat or
inferior rectus and inferior oblique muscles into the
antrum. If so, treatment is as shown in Figure 13-33.
Again, extreme care is exercised when drilling the holes
with a malleable retractor protecting the globe.
Intraosseous wiring may be required for reduction of
the zygomatic arch (see Fig. 13-24F). Not all fracture
sites may require intraosseous wiring. The decision rests
with the evaluation of the total result of reduction. Even
after all fracture sites are wired, depression of the malar
bone may still be present. Outward and upward traction
is then necessary. It is a simple matter to attach a wire
from the infraorbital rim to a Lane plate secured with
tibial bolts to the zygomatic process of the frontal bone
(see Fig. 13-34).
Closure consists of approximation of periosteum,
muscle, where necessary, and skin. Some extra time and
care at this juncture will result in a barely visible scar
if the surgeon has been mindful that his assistant has
not pulled too hard on the skin retractors. Stay sutures
rather than retractors or skin hooks may be preferred.
 FRACTURES OF FACIAl BONES

Wabr1iR
E F
FIGURE 13-26
 FRAOURES OF FACIAL BONES
"Tent Peg" Method of Reduction
and Fixation of Facial Bone
Fractures (Fig. 13-27) (Straith, 1958)
Indication
Occasionally, a fracture in the zygomaticofrontal region
of the orbital rim is so high and the superior edge of the
fracture is so close to the cranium itself that intra-
osseous wiring through drill holes would require that
the twisted ends of the wire be placed within the orbit.
To avoid this, small sections of Kirschner wire inserted
in an angle serve as pegs around which the intraosseous
wire is secured. This method is seldom referred to, yet
it is worthwhile to keep in one's armamentarium when
mini plates are not available.
Highpoints
1. Insert pegs at an angle with the distal or projecting
end away from the fracture site.
2. The projecting end of the peg needs to be only 0.5
em long.
3. Be sure that at least one peg is in bone that is not
displaced in the fracture complex.
4. Keep in mind structures that are deep to the site of
the peg insertion.
S. One must have a steady hand when inserting the
peg; otherwise, it will become loose and slip out-a
drawback against the procedure.
A, B The fracture involves the zygoma with the
infraorbital and lateral orbital rim and arch. The clinical
picture is similar to other fractures of the zygoma
except that a cosmetic deformity may not be apparent
at the time of injury. Reduction cannot be maintained
by the temporal approach (Gillies and Millard, 1957).
C A small incision is made over the fractu re site of
the lateral orbital rim. Fibers of the orbicularis oculi
muscle are separated, taking care not to injure either
sensory or motor nerve fibers. With the use of a Kirschner
drill, a Kirschner wire is inserted through a previously
made stab wound into the cortex of the bone above
the fracture site. The depth of insertion is from 0.5 to
1.0 em. The wire is placed so that the buried end is at
an angle toward the fracture site and the projecting
end away from the fracture site. The wire is cut with
about 1.5 em projecting beyond the skin surface.
D Stainless steel wire No. 0 is looped around the peg
and drawn into the wound with a clamp. If desired,
the wire may be drawn through with a needle at each
free end.
E Another peg of Kirschner wire is inserted in the
bone below the fracture site. In this case the original
incision may afford sufficient exposure to eliminate
another stab wound. The stainless steel wire is then
looped around this second peg. While the assistant
maintains the reduction, the wire is twisted and
tightened. The excess length of both pegs is now cut
off, leaving only about 0.5 em projecting beyond the
surface of the bone.
F The two pegs and wire are in place.
G The wound is closed, completely covering the pegs
and wire. The pegs are usually removed in 4 to 6 weeks,
because they project into the subcutaneous tissue,
another drawback against the technique. Nevertheless,
this facilitates ease of removal of the pegs.
 FRACTURES OF FACIAL BONES

FIGURE 13-27
 FRACTURES OF FACIAL BONES
Open Reduction of Complete
Fracture of Upper Dental Arch
of Maxilla (Le Fort I or Guerin)
(Fig. 13-28)
See page 596 for examples of the various types of mini-
plate fixation.
There are a number of methods of reduction and
immobilization of this type of fracture. Depicted are
two methods:
1. Suspensory wires (see C through F)
a. From infraorbital rim
b. From lateral orbital rim
2. Direct intraosseous wiring (see G)
Highpoints
1. Be certain that bone to which suspensory wires are
attached is not displaced or mobile as a result of
another fracture.
2. Interdental fixation using arch bars or interdental
wiring is often required to prevent malocclusion.
3. If fracture is bilateral (as pictured], fixation must be
bilateral.
4. Depending on associated intraoral and pharyngeal
injuries, tracheostomy may be necessary.
5. Evaluate and correct any injury to nasal septum.
6. Refer to Basic Principles, page 595, and the article by
Manson and colleagues (1980).
See pages 636 and 637 for use of various types of
mini plates for management of Le Fort I fractures.
A, B The fracture line extends through the base of
both maxillae, dislodging the upper dental arch.
Displacement is downward and usually posterior. This
type of fracture is called a Le Fort I or Guerin.
Suspensory Wire Technique
C, D Depicted are two types of suspension wires.
Both types are not usually required in anyone patient.
The more anterior suspension wire (22- to 25-gauge
stainless steel) is secured to the infraorbital rim in a drill
hole through the rim avoiding the infraorbital nerve.
This wire is looped over the rim and passes into the
region of the canine fossa. A needle may be necessary
to guide the two ends of the wire along the anterior
wall of the maxilla into the mouth. The displaced frac-
ture is then reduced and held in place by an assistant,
with upward pressure on the mandible closing the
mouth. The two ends of the wire may be secured to
either a lower arch bar or an upper arch bar. When
secured to a lower arch bar, occlusion is immediately
achieved and maintained when the mandible is intact.
The main caution is the fact that the jaw is wired
closed, and this should not be performed while the
patient is under general anesthesia because of the
danger of aspiration.
If the more posterior suspensory wire is utilized, this
passes behind the zygoma. A needle may be used to
pass the wire (see C), or a fine dental-type hook may be
used to draw the wire superiorly (see D). The criticism
of this maneuver is the possible contamination of the
wire and the hook from oral bacteria. These wires may
tend to displace the fracture posteriorly.
E The completion of the procedure. The posterior
suspensory wire is either secured to a tent peg (E2) or
passed through a drill hole (E3) in the lateral orbital
rim with a pullout wire.
El The suspensory wire is attached to the upper or
lower arch bar as described previously.
F A composite drawing shows the location of each
type of suspensory wire.
Direct Intraosseous Wiring Technique
G In patients who are edentulous, direct intraosseous
wiring can be utilized. By and large, if good adaptation
is achieved, occlusion will be of little concern, thus
obviating the use of Gunning-type splints (see Fig.
14-9C), which otherwise might be necessary to
achieve good occlusion.
 FRACTURES OF FACIAL BONES

F G

FIGURE 1 3-28
 FRACTURES OF FACIAL BONES
Internal Fixation of Fracture
through Middle Third of Maxilla
(Le Fort II or Pyramidal Fracture)
(Fig. 13-29)
Fractures of this type and variations thereof may well
be treated by the same methods described for Le Fort I
and III type fractures, that is, suspensory wires con-
nected to an arch bar or direct intraosseous wiring (see
Fig. 13-28F and 13-30).
Another method of treatment of the Le Fort II type is
by the insertion of a Kirschner wire through each side
of the stable malar bones and through the superior
portion of the floating pyramidal fracture.
Highpoints
1. Malocclusion must be corrected and proper occlu-
sion maintained, usually with arch bars or inter-
dental wires.
2. Sites of entry and exit of the through-and-through
Kirschner wire must not be involved in the frac-
ture-these sites must be stable and attached to the
cranium.
3. Extreme care must be utilized to keep the Kirschner
wire in an exact horizontal plane so that the orbit is
not entered.
4. Tracheostomy may be indicated.
5. Refer to Basic Principles, page 595, and the article by
Manson and colleagues (1980).
Complications
• Misdirection of wire
• Injury to orbital contents
See pages 636 and 637 for the use of various types
of mini plates for management of Le Fort II fractures.
A, B The fracture involves the body of both maxillae
extending into the antra. Displacement is downward
and usually posterior. A number of types of variations
are possible, with some extending slightly more supe-
riorly, as depicted by the dotted line, as well as through
the infraorbital foramina. Injuries to the nasal septum
are much more common with Le Fort II than with Le
Fort I. The important feature is that the fracture, as
with Le Fort I, passes inferior to the body of the malar
bone, which remains attached to the rest of the facial
skeleton.
C With the arch bars in place, the assistant carefully
maintains correct reduction and correct occlusion. A
Kirschner wire is then inserted through a portion of the
zygoma that is stable and not involved in the fracture.
If a nasotracheal anesthesia tube is used, be certain
that the wire does not pierce the tube. This method of
administering general anesthesia must be performed
with extreme care, because the introduction of a naso-
tracheal tube crosses the fracture lines and may cause
additional damage. Usually, there are severe accompany-
ing soft tissue injuries intra orally, and a tracheostomy
is preferred. The introduction of the Kirschner wire
must be in an exact horizontal plane and must pene-
trate a sufficient amount of the apex of the pyramidal
fracture. The Kirschner wire may change direction as it
is inserted. It is for these reasons that this method is
not widely used.
D The wire is driven through and through, catching
the fractured central portion of the maxilla. The point
of exit must be through stable bone attached to the
cranium. The arch bars or interdental wires of the upper
and lower dental arch are connected by rubber bands
or wire (see Fig. 13-3). The Kirschner wire may be cut
flush with the skin or be allowed to project about
1.0 cm, in which case it is covered with antibiotic oint-
ment and pad or cork. The wire can be removed in 4
to 6 weeks.
E The cross mark indicates the site of ~ntrance or exit
of the Kirschner wire.
 FRACTURES OF FACIAL BONES 633

FIGURE 13-29
 FRACTURES OF FACIAL BONES
Open Reduction of Fractures
Through Glabella, Orbit, and
Zygomatic Arch (Le Fort III
or Craniofacial Dysjunction)
(Fig. 13-30)
The important, unfortunate features of this type of
fracture are the possible damage to the cribriform plate
of the ethmoid bones, laceration or tearing of the dura,
and subsequent cerebrospinal rhinorrhea. Danger of
infection with meningitis is always present. Fortunately,
the bone in the immediate region of the optic foramen
is quite dense, and, thus, injury to the optic nerve is not
as common as one might expect. On the other hand,
this fracture may be the result of being thrown through
the windshield. Fragments of glass thus have been seen
to penetrate the fracture line and fatally injure the
globe and optic nerve. Radiographs of this fracture and
its variations must be carefully evaluated for foreign
material. When this fracture involves the frontal sinus,
additional precaution must be taken. (Refer to Basic
Principles, p. 595, and the article by Manson and
colleagues, 1980.)
Highpoints
1. Malocclusion is corrected and maintained with arch
bars or interdental wires only after the danger of
aspiration is over.
2. Eye injuries must be completely evaluated and treated
early.
3. Tracheostomy may be indicated.
4. Ensure that posterior displacement is corrected. The
basic principle is elevation and forward reduction of
the floating midfacial component.
See pages 636 and 637 for various types of mini-
plates and management of Le Fort III fractures.
A, B Views of fractures demonstrate the typical
"dishpan" deformity. The fracture lines involve the
glabella, the medial and lateral walls of the orbit, a
portion of the orbit floor, and the zygomatic arch. The
cribriform plate of the ethmoid may be fractured.
Variations may occur that can extend into the maxil-
lary antra. A skull fracture is always a possibility. Dis-
placement is downward and usually more posterior
than in Le Fort I or II. Concomitant intracranial injuries
further complicate the management as well as the
injury to the globe and serious hemorrhage. Drainage
of the orbit is performed through a small stab wound
inferiorly or laterally if bleeding continues and pressure
on the globe is increased. This is best performed imme-
diately and combined with large doses of corticosteroids
unless otherwise contraindicated.
C The basic principle in reduction is the use of a
number of intraosseous wires and suspensory wires,
depending on a complete assessment of all fractures.
After suitable intraosseous wires have been placed (see
Fig. 13-26F), suspensory wires (22- to 24-gauge stain-
less steel) are passed through a hollow needle that has
had its base removed (see Fig. 13-28). This guide needle
is inserted behind the zygoma and passed into the
alveolar labial region. The suspensory wires are thus
fed into the mouth, and the guide needle is removed
through the mouth.
C1 Close-up view details the course of the wire
through the drill holes.
D The completed reduction and fixation is shown.
Arch bars with rubber band traction are a must. At times
the operative intervention is delayed because of asso-
ciated intracranial injuries. With a protracted delay,
fibrous tissue has proliferated and adequate reduction,
especially in regard to the correction of the posterior
displacement, is not entirely satisfactory. To correct the
resulting "dishpan" deformity, some type of external
traction will be necessary. Various types of devices have
been described, including the halo frame, the Crawford
appliance, the Erich appliance, plaster skullcaps, and
traction with weights. A method using tibial bolts and
a Lane plate is illustrated in Figure 13-34.
D1 Demonstrated is the placement for the pullout
wires after the fracture has healed.
 FRACTURES OF FACIAL BONES

FIGURE 13-30
 FRAOURES OF FACIAL BONES

Techniques of the Use of

buttresses. Internal maxillary fixation is temporary and
Miniplates in Le Fort I, II, and III
used to correct the occlusion during the surgery.
Fractures (Fig. 1 3- 31 )

This discussion of utilization of miniplates for the man- Le Fort I-Complicated

agement of Le Fort I, II, and III fractures is from the
Manual of Internal Fixation in the Crania-Facial Skeleton, Technique
edited by J. Prein (1998).

Le Fort I-Basic B There is a comminuted fracture on the right and

a caudally dislocated joint. The occlusion is correct.
Refer to Figure 13-1 for examples of various types of However, the facial height on the right is too long,
mini plate fixation. owing to the comminuted area. Fixation of the Le Fort
I fracture is shown with premature contact on the
Technique comminuted side and open bite on the opposite non-
comminuted side. The mandibular condyle now is in
The surgical approach is through an upper gingivo- direct position.
buccal sulcus incision. Occasionally, exposure may be
obtained directly through soft tissue lacerations. This D Shown is fixation of the midface fracture in an
exposure is done subperiosteally of both maxillae, thus edentulous patient with the aid of the patient's den-
identifying all four anterior buttresses. In segmental tures to correct the vertical height. Fixation is with
alveolar fractures, preservation of vascular supply to plates and bone grafts because of a fracture gap of
tooth-bearing alveolar fragments may be achieved more than 5 mm. The prosthesis is fixed to the alveolar
through a segmental upper buccal incision, avoiding process and palate with 2.4-mm screws.
the infraorbital nerve, which is located approximately
1 em below the inferior orbital rim.
Le Fort II

A Illustration depicts an internal fixation of this "ideal" These are fractures that have a typical posterocortical
fracture with Y and L mini plates at anterior and medial dislocation with an open bite.

FIGURE 13-31
 FRACTURES OF FACIAl BONES 637

FIGURE13-31 Continued

Technique Le Fort III

E -Internal fixation is done with L-plates for the lateral F Shown is the Le Fort III fracture with zygomatic
vertical buttress and adaptation plate infraorbitally and fracture on the left with its usual displacement. Expo-
for the nasoethmoidal region. Inset shows fixation sure is via a modified face-lift incision. The technique is
with one Y-plate instead of two miniplates. fixation with mini plates.
 FRAcruRES OF FACIAL BONES
Internal Fixation of Fractured Hard Palate
(Fig. 13-32)
Highpoints
1. Avoid unnecessary removal of teeth.
2. Maintain correct occlusion; if arch bars or interdental
wires are necessary, they should be connected only
after the danger of aspiration is over.
3. Tracheostomy may be necessary if there are severe
lacerations of the tongue.
4. Reduce nasal fractures concomitantly.
There is a fracture through the nasal floor and hard
palate with a lateral extension into the antrum. Soft
tissue injury and nasal fractures are usually extensive.
Careful evaluation of lacerations of the tongue is manda-
tory for repair, and usually elective tracheostomy is the
safer step. Reduction can be more easily achieved with
miniplates.
A Two through-and-through angulated drill holes
are placed, one on each side of the fracture site.
These are located anteriorly as high as possible to
avoid injury to the roots of the teeth. The drill holes
exit in the hard palate. It is important that reduction
be maintained during the placement of the second
drill hole.
8, ( Stainless steel wire No. 0 or malleable silver
wire No. 30 is then inserted through the drill holes
with the loop placed anteriorly. The free ends are
pulled tight and twisted intraorally. If there is any
question of malocclusion, arch bars or interdental
wires are used and connected with rubber bands (see
Fig. 13-3).
Fractures Involving the Frontal
Sinus
Frontal sinus fractures that involve the inner table with
very minimal displacement associated with evidence of
cerebrospinal fluid leak present a dilemma as to whether
the frontal sinus should be explored. The question rests
on whether the nasofrontal duct is obstructed, and, if
so, whether this could contribute to meningitis and
possibly subdural abscess or intracranial "air." Each
patient should be evaluated individually, preferably
with neurosurgical consultation. Skull radiographs and
CT, both coronal and axial views, for evidence of air-
fluid levels in the sinus and of intracranial "air" as well
as for assessing the neurologic status of the patient aid
in the decision as to whether surgical intervention may
be indicated. Massive antibiotics, which cross the blood-
brain barrier, as well as decongestants and corti co-
steroids are utilized. Repeat radiographs aid in follow-
ing these patients. Follow-up should continue for months
after the injury.
Larrabee and associates (1980) have reported on a
review of S4 patients treated for frontal sinus fractures.
Regardless of various medical and surgical treatment
modalities, there were a large number of suppurative
complications. The problem appeared to be obstruction
of the nasofrontal duct leading to meningitis, subdural
abscess, and osteomyelitis. Their conclusions are quoted
in the following text and refer to all types of fractures
involving the frontal sinus, whether anterior or
posterior tables.
1. Exploration with reduction should be strongly
considered in every case of frontal sinus fracture,
even in apparently isolated anterior table injuries.
2. Routine obliteration in frontal sinus trauma carries a
significant complication rate and should be avoided
in favor of open reduction if possible.
3. The complication rate in fat obliteration is lower
than that with methyl methacrylate or Surgicel.
 FRACTURES OF FACIAL BONES

FIGURE 13-32

If the fracture is several days or weeks old and the One of the problems in evaluating cerebrospinal
cerebrospinal fluid leak has stopped, conservative fluid leak cessation is whether it is due to a seal off of
management is advised, because manipulation may the tear in the dura or to an obstruction in the naso-
well open the precarious adhesions that have sealed frontal duct.
the dural leak and thus lead to meningitis. These Fractures of the walls of the frontal sinus are often
patients must be followed very carefully regarding very difficult to detect on routine radiographs. Depres-
evidence of a blocked nasofrontal duct. A frontal sinus sion of the anterior wall of the frontal sinus can be
trephine (see Fig. 5-6) may be necessary as an initial completely missed on a lateral radiograph of the frontal
procedure. Later on, if necessary, an osteoplastic frontal sinus. CT is really the only radiologic study that will
approach may be warranted (see Fig. 5-8A to E). If satisfactorily evaluate the position of the bones of the
there is an associated Le Fort fracture and the maxilla frontal sinus fracture.
is still floating, conservative treatment would include Decompress the orbit in the event of entrapped air
a Barton bandage carefully placed and maintained, within the orbit, especially with evidence of fractures
possibly reinforced with plaster (Bartkowski and of the lamina papyracea of the ethmoid and/or frac-
Krzystkowa, 1982). The Barton bandage may slip on a tures of the frontal sinus. CT is excellent to delineate
patient with dentures. Consideration of the cosmetic the extent of the air as well as any cloudiness of the
deformity must be secondary to the danger of menin- ethmoidal sinus, which may indicate hemorrhage. Close
gitis and/or blindness. Reconstruction at a later date observation in the hospital is recommended until the
can be achieved in some patients with onlay autoge- patient's condition stabilizes.
nous bone grafts.
 FRACTURES OF FACIAL BONES
Fractures of Floor of Orbit
(Fig. 13-33)
Fractures of the floor of the orbit may be divided into
two main types-indirect and direct-depending on the
point of contact of the traumatic force associated with
absence or presence of a fracture of the infraorbital
rim.
1. Indirect (see D). Known as a "classical blowout"'
(Lang, 1889; Converse and Smith, 1960) or depressed
(Dingman, 1964) fracture of the orbital floor, this
fracture is due to blunt trauma to the globe resulting
in increased infraorbital pressure. This, in turn,
causes a fracture of the thin portion of the bony floor
anterior to the inferior orbital fissure. Orbital fat and
the inferior rectus and inferior oblique muscles
(supplied by the oculomotor, third cranial nerve) are
very likely to herniate into the antrum. The rela-
tively thick infraorbital rim is not fractured. The floor
of the orbit is thus fractured downward in an indirect
fashion by a referred or transmitted force.
2. Direct (see E). This fracture of the orbital floor is due
to trauma to the infraorbital rim causing an imme-
diate fracture of this rim; thus, it is a fracture of the
orbital floor by direct extension of the force. Herniation
of fat and muscle downward into the antrum mayor
may not occur.
Dingman has reported one patient sustaInIng an
injury to the infraorbital rim and maxilla resulting in an
upward herniation of the floor of the orbit-a so-called
blow-in fracture. We have had a blow-in fracture of the
roof of the orbit that did not require surgical interven-
tion. Blow-in fractures of the floor of the orbit probably
do not require surgical treatment (Lighterman and
Reckson, 1979). However, the discussion regarding sur-
gical intervention depends on the extent of the injury
as well as the clinical findings.
Refer to Basic Principles, page 595.
Signs and Symptoms-Variable
• Diplopia
• Enophthalmos. (Exophthalmos may occur with ele-
vated or blow-in type fracture.)
• Ecchymosis and edema
• Paresthesia over distribution of infraorbital nerve
with direct type
Less common features include:
• Epistaxis-early
• Narrowing of palpebral fissure after immediate
edema has subsided as a late finding
• Pupil dilated and fixed-late
• Loss of vision
A Depicted is the typical picture of a fracture of the
left orbital floor characterized by:
1. Enophthalmos. Refer to the published data by Manson
and colleagues (1980) regarding enophthalmos.
2. Downward displacement of the globe. (The elevated
or blow-in fracture has the reverse type of findings.)
This downward displacement of the globe can also
be due to a fracture of the lateral rim of the orbit,
allowing the lateral canthal ligament to drop.
B With an upward gaze, the affected eye is fixed
because of impaction of either or both the inferior
rectus and inferior oblique muscles.
C Diagnosis is aided by radiographic examination
with Waters' view and CT, both coronal and axial scans.
Instillation of air into the antrum is dangerous because
of the possibility of inducing air embolism. The trac-
tion test as depicted confirms the impaction and incar-
ceration of the inferior rectus muscle. This test consists
of grasping the tendon of the muscle and applying
slight traction. It differentiates the diplopia caused by
impaction of the inferior rectus from weakness or paral-
ysis of the superior rectus. local anesthesia is necessary.
Types of Fractures of the Orbital Floor
D Indirect (blowout). A blunt object, larger than the
bony orbit but with a circumference small enough to
hit the globe, pushes the globe inward and downward
with herniation of the inferior rectus muscle or the infe-
rior oblique muscle with or without the nerve supply
to the inferior oblique muscle. If the object causing the
trauma is smaller than the orbital bony framework (e.g.,
golf ball), there may be irreparable damage to the
globe with or without fracture.
E Direct. The force of trauma is received directly on
the infraorbital rim, thus directly fracturing the floor of
the orbit. Associated fracture of the maxilla, zygoma,
and other parts of the orbital framework occurs in vary-
ing degrees and extent.
El The blunt force is received by the maxilla, caus-
ing an elevated or blow-in fracture of the orbital floor.
Continued
 FRACTURES OF FACIAL BONES

FIGURE 13-33
 FRACTURES OF FACIAL BONES
Fractures of Floor of Orbit
(Continued) (Fig. 13-33)
Technique of Operation
Exploration of the antrum is usually indicated in early
treatment, especially when impaction of muscles is
absent or minimal. At times, all that is required to main-
tain reduction is packing the antrum with antibiotic
impregnated gauze. Antral packing must be carefully
inserted so that no pressure is transmitted to the orbital
contents, thus avoiding any injury to the optic nerve
and its blood supply and venous drainage. The approach
is via a Caldwell-Luc operation (see Fig. 5-2). When
performed, the opening should be large enough to
insert a finger to palpate the roof of the antrum. The
bone from the anterior inferior wall of the antrum thus
removed should be saved if possible for use as a bone
graft to the floor of the orbit if support for the globe
becomes necessary.
Highpoints
1. Do not injure the orbital septum (see G and H) or
lacrimal sac (see Fig. 11-1).
2. Subperiosteal elevation is done along the floor of the
orbit.
3. Completely free any impaction of inferior rectus or
inferior oblique muscles, especially posteriorly, and
accompanying nerves.
4. Check muscle mobility at close of operation using
the traction test.
S. Do not hesitate to employ a combined approach:
antrum and infraorbital.
6. Autogenous bone graft is preferred.
7. Medipore can also be used in lieu of autogenous graft.
F A choice of three incisions is shown. The highest
one has the advantage of minimal lid edema but can
cause minimal ectropion, which is usually transient.
The two lower incisions through natural creases are
somewhat more direct to the superior aspect of the
infraorbital rim but are very likely to cause lid edema.
The lid edges may be temporarily sutured together
with 6-0 silk to protect the cornea or a type of contact
lens can be used. Another incision has been described
CNray et aI., 1977) through the conjunctiva. This inci-
sion is then continued inside the orbital septum. The
inside mucosal flap can be temporarily sutured to the
upper lid for corneal protection (Maniglia, 1980).
G Cross-sectional view depicts the relationship of the
incisions to the orbicularis oculi muscle and orbital
septum (palpebral fascia). The muscle is split along its
fibers; the orbital septum is used as a guide to the
periosteum, to which it is continuous.
H The superior aspect of the infraorbital rim is exposed.
An incision is made through the periosteum along the
dotted line.
I The periosteum is then elevated using blunt dissec-
tion. This exposes the fractures and the impaction of
the inferior rectus or inferior oblique muscles. It is impor-
tant to carry the periosteal elevation sufficiently poste-
riorly to free the entire extent of the impaction. Avoid
injury to the nerve to the inferior oblique muscle and,
most importantly, the optic nerve.
 FRACTURES OF FACIAL BONES 643

PERIOSTEUM

F G

FIGURE 13-33 Continued

 FRAcruRES OF FACIAL BONES

Fractures of Floor of Orbit

(Continued) (Fig. 13-33)
J Autogenous bone graft is inserted to manage the
defect in the floor of the orbit. This bone may come
from the anterior wall of antrum if a Ca'idwell-Luc opera-
tion has been performed. The bone fragment is excel-
lent because it is thin and concave, if it is large
enough. Otherwise, an auricular cartilage graft is used
(see Fig. 12-3D, E, and G). Plastic sheets of Silastic (or
molded Silastic), Teflon, or Supermin can also be used.
The autogenous bone is preferred. Care must be taken
that the graft is inserted sufficiently posteriorly and is
reasonably secure before the wound is closed. Occa-
sionally, in using a combined approach, especially if the
operation is performed within 24 to 48 hours of the
injury, antral packing may suffice to hold the depressed
fragments of bone in position. The problem, however,
may be adhesions that develop between fracture heal-
ing sites and the muscles.
K Cross section shows the graft in place. The bony
fragments are not usually reducible unless the antrum
independent interosseous wires or miniplates. The
wire through the fracture of the zygomatic arch may
or may not be necessary. This is left until last. The
fracture of the floor of the orbit is handled as
previously described.
M Occasionally, the floor of the orbit fractures of the
direct type (see L) will require additional outward trac-
tion to maintain reduction of the depressed malar bone.
This is accomplished using the "tibial bolt" method of
traction (see Fig. 13-34).
For the technique of graft insertion for a defect of the
infraorbital rim, see Figure 11-16.
Complications
• Bone graft or plastic material may slide forward
• Ectropion or edema of lower lid resulting from skin
incision
• Increased infraorbital pressure due to hemorrhage
and edema possibly endangering vision (decompress

is explored. stat)
• Glaucoma or predisposition to glaucoma
L With direct-type fractures of the floor of the orbit • Hyphema-accumulation of blood in the anterior
that are associated with one or more fractures of the chamber of the globe
orbital rim and zygomatic arch, various types of addi- • Cataract formation
tional interosseous wires may be necessary. Depicted • Injury to optic nerve and/or its arterial supply and
are fractures that are approximated and fixed with venous drainage
 FRACTURES OF FACIAL BONES

FIGURE13-33 Continued
 FRACTURES OF FACIAL BONES
External Traction for Depressed
Facial Fracture (Fig. 13-34)
Occasionally, there is a need to maintain forward external
traction in the management of a depressed facial frac-
ture. Plaster head caps and various other frames and
devices have drawbacks, not the least of which is dis-
comfort for the patient. Depicted is a technique utiliz-
ing tibial bolts and an eight-hole Lane plate. equipment
readily available in most operating rooms.
Two situations arise when such external traction is
helpful. One is when there is severe comminution of
the fragments, making a point of forward fixation diffi-
cult to maintain. This is demonstrated in A and B. The
other situation is in a delayed reduction for a midface
fracture (e.g .. Le Fort II or Ill) when reduction, although
achieved, cannot be satisfactorily maintained, as in C
to E.
Another method of securing superior external trac-
tion is the use of a football or crash helmet. This has
been utilized in one patient with satisfactory results.
Still another and more practical method is the use of
miniplates (see p. 596).
Highpoints
1. The equipment needed consists of two tibial bolts,
each with three nuts and one eight-hole Lane plate.
2. Be sure holes drilled for tibial bolts are several sizes
smaller than the diameter of the bolts-holes 3 to
4 mm in depth suffice.
3. Holes must be placed so that they do not perforate
the inner table of the skull. which is being drilled in
the lowest portion of the zygomatic processes of the
frontal bone.
Basic Technique
1. Smaller incisions are made at the lateral edge of
both brows over the stable portion of the zygomatic
processes of the frontal bone.
2. A drill hole is made 3 to 4 mm deep in the lower
portion of each zygomatic process of the frontal bone
with a drill several sizes smaller than the diameter
of the tibial bolts.
3. Tibial bolts with three nuts are then screwed tightly
into the drill holes. One nut is used as a lock nut to
secure the tibial bolt to the bone. The head (distal
end) of the tibial bolt is cut off.
4. An eight-hole Lane plate is then slipped over the
ends of the tibial bolts with one nut above and one
nut below the plate. Both tibial bolts are bent slightly
to the midline to accommodate the plate. The two
nuts are then tightened on each bolt securing the
plate in position. The ends of the bolts are guarded
with sections of plastic or rubber tubing.
5. The Lane plate now serves as the point of external
traction to which wires and rubber bands may be
secured.
6. Traction is continued for about 3 weeks.
A There is a comminuted fracture of the left infra-
orbital rim with depression of the left malar bone and
separation of the left frontomaxillary suture line and
zygomatic arch. Because of the comminution of the
medial portion of the infraorbital rim, it is not possible
to maintain adequate reduction despite the usual
wiring methods. External traction is necessary.
B The tibial bolts and lane plate are in position.
Through a small incision over the infraorbital rim, '-0
wire is secured through drill holes to the major depressed
fragment. The wire is brought out through the skin
and secured to the Lane plate. Other wires may be
necessary to correct medial or lateral displacement.
C A midface fracture of the Le Fort type II is depicted
with inward and downward displacement causing a
"dishpan" deformity. There is an associated fracture of
the malar bone with fracture of the zygomatic arch.
Because the fracture is more than 2 weeks old, ade-
quate forward reduction cannot be maintained by the
usual suspension and intraosseous wires. These wires,
although very effective in the correction of the down-
ward displacement, are ineffective in maintaining the
forward reduction necessary to correct the "dishpan"
deformity. These suspension wires may tend to pull the
floating fragment posteriorly. Anterior, forward, and
outward tractions are necessary.
D After the suspending wires are secured to the
upper dental arch bar and the other fracture sites are
reduced and wired as depicted, the midface fragment
cannot be maintained in a forward position. The tibial
bolts and lane plate are then utilized, forming a pur-
chase site for external traction. A Kirschner wire is
passed through the frontal processes of each maxilla
and bent in triangular fashion. The Kirschner wire is
then connected with 1-0 wire or heavy rubber bands
to the Lane plate. To aid in correct occlusion, the upper
dental arch bar is approximated to the lower dental
arch bar.
E Shown is an anterior view of the bent Kirschner
wire through the nose.
 FRACTURES OF FACIAl BONES 641

c D E
FIGURE 13-34
 FRAGURES OF FACIAL BONES
Management of Zygomatic
(Malar) Fractures
Douglas W Klatch
The word zygoma in Greek means "to yoke" or "to
unite." In reality, the malar bone forms a strong buttress
to unite the midface to the skull base. Likewise, the
zygoma unites the mandible to the maxilla through the
broad-based masseteric fibers.
The malar bone is unique in that it affects the sym-
metry of the central face and contributes to the integrity
of the floor and lateral wall of the orbit. The latter rela-
tIonship mandates early repair of malar fractures to
avoid potential orbital dystopia, diplopia, exophthalmos,
and potential lid dysfunction. Depression of the arch
may indeed affect mastication by limiting the mobility
of the coronoid process. This is a less common occur-
rence than expected.
Failure of repair of the zygoma also provides a flat-
tened and frequently widened cheek region. Although
disfiguring, if this were the only sequela of nonrepair,
delay to repair would not be consequential. However,
failure to fix the orbit within the first 72 hours increases
orbital complications and produces less desirable results
than obtained by immediate zygomatic fracture repair.
Highpoints
I. The malar bone is not a tripod but has five distinct
bony attachments.
a. Frontozygomatic
b. Sphenozygomatic
c. Temporal zygomatic (arch)
d. Zygomaticomaxillary vertical component
e. Infraorbital rim (zygomaticomaxillary-horizontal
component)
2. Incisions:
a. Local
(1) Infrabrow or upper blepharoplasty
(2) Subciliary, transconjunctival, mid lid
(3) Gingivobuccal (canine fossa approach)
(4) Temporal (Gillies): this approach is not gen-
erally beneficial except for isolated arch frac-
tures.
b. Regional incisions (hemi-coronal)
c. Incision choices: the more complicated the frac-
ture, the greater the need for regional in combi-
nation with local incisions.
3. The contribution of buttresses to repair:
a. Frontozygomatic: a strong buttress, which adjusts
the height of the malar bone. It provides little
benefit to establish the projection of the malar
eminence and provides poor reference for com-
plex facial fractures.
b. Zygomatic arch: a weak bone but provides excel-
lent relationship for projection and width of the
malar bone.
c. Sphenozygomatic: provides excellent projection
and width relationships for the lateral orbit. Rarely
is this bone severely fractured, and therefore it
provides an excellent key to positioning complex
malar orbital fractures.,
d. Zygomaticomaxillary (vertical component): excel-
lent lower facial buttress providing both position-
ing for height and rotation of the malar bone.
e. Infraorbital rim (zygomaticomaxillary horizontal):
this is a weak and often comminuted buttress;
however, when the central midface is stable it
provides an excellent control of malar width.
Likewise, this buttress must be reestablished to
reposition the floor.
4. Early anatomic repair with stable reduction maxi-
mizes the functional and cosmetic results. Rigid
internal fixation optimizes this result.
5. Care of soft tissues:
a. The surgeon must use careful soft tissue tech-
niques to ensure the best possible scar formation.
b. Re-suspension of the facial aponeurosis is required
to support the cheek and lids and provide normal
palpebral folds.
6. Failure to re-suspend the fascia of the face produces
sagging of the soft tissues and the appearance of
premature aging.
7. Before repair an accurate history should be obtained
and physical examination performed. Cranial nerve
function must be assessed with careful ophthalmo-
logic examination. This should be obtained by consul-
tation with an ophthalmologist. Cranial nerves II, III,
IV, V, VI, and VII may be injured. Direct globe injury
is also important to detect, because it will delay
fracture repair. Blindness may occur with or without
globe injury.
8. Radiographic examination: CT provides the best infor-
mation for classifying the type and extent of fracture.
9. Choice of materials for repair: titanium plates between
1.0 and 1.5 mm provide adequate stability for most
instances. Generally, 1.3-mm plates provide excel-
lent stability and adequate low profile, making them
less palpable. Bioresorbable plate materials such as
polylactic acid plates may be utilized. Generally, plates
of 1.5 mm in thickness are adequate and there is
minimal comminution. However, when there is more
significant comminution, application of bioresorbable
plates is more difficult and these plates provide less
reliable stability for comminuted fracture repair.

Treatment
1. Simple fractures without displacement may be
observed. Delay to repair does not affect the ultimate
result.
2. Simple fractures with displacement:
a. Rarely is closed reduction adequate.
b. Generally, repair requires the fixation of at least
two buttresses to provide adequate stability.
(1) These fractures may be approached with local
inCISions.
(2) Usually, the repair of the rim and zygomatico-
maxillary and/or the frontozygomatic buttress
is adequate to provide an anatomically stable
repair.
(3) The orbit needs to be explored with reduction
and repair of fractures to ensure correct orbital
position and function.
3. Complex or comminuted fractures:
a. Bicoronal incision is frequently required to con-
trol the zygomatic arch. This approach allows
control of both the sphenozygomatic and fronto-
zygomatic buttresses.
b. The orbit generally requires an extensive repair
utilizing alloplast or bone grafts in combination
with anatomic repair of the rims to reestablish
orbital continuity.
c. The larger incisions require careful repair of the
soft tissue as previously mentioned.
Repair of Simple Fractures
Evaluation with CT helps to assess the extent of injury
and plan the buttresses requiring repair, which will
provide the best anatomic reduction and stabilization.
Incisions
1. The sublabial canine fossa approach (Keane) provides
excellent exposure to repair the zygomaticomaxillary
buttress.
a. The surgeon should save all fragments to reestab-
lish the correct length of the buttress.
b. Care in dissecting superiorly is required to avoid
injury of the infraorbital nerve.
c. The rim may be inspected and, if not comminuted,
may be repaired by this approach if there is com-
minution or difficulty in gaining adequate access.
The application of a local orbital incision will
simplify this repair.
d. A finger may be placed beneath the arch of the
zygoma to help elevate the fracture as well as feel
the reduction of the arch and the lateral rim of the
orbit.
e. A large hook placed via a stab incision beneath
the level of the malar eminence is most useful in
FRAGURES OF FACIAL BONES
reducing severely impacted or rotated zygomatic
fractures. The small stab incision is closed with
single sutures and produces a very acceptable scar.
f. Occasionally, the reduction will be stable with a
single plate placement at the zygomaticomaxil-
lary buttress. If this provides inadequate stability
or reduction, then other buttresses may be repaired
until adequate anatomic stability is achieved.
g. Plate choices of either 1.3- or 1.5-mm plates are
adequate to provide stability unless there is signifi-
cant comminution. When there is significant bone
loss of greater than 1 cm in more than one but-
tress, it is recommended to use bone grafts to
provide adequate healing.
2. Orbital incisions: most surgeons generally use either
the subciliary or the transconjunctival incision. Lateral
extension of the transconjunctival incision requires
a lateral canthotomy. Either of these incisions when
correctly performed and repaired provides excellent
results. Each requires technical proficiency to avoid
lid complications.
a. Repair of the infraorbital rim establishes the normal
width of the malar bone. Likewise, the anatomic
reduction and stabilization of the rim is mandated
to allow precise repair of the orbital floor.
b. Adequate stability is provided by 1.0- to 1.3-mm
plates.
c. Once the rim is anatomically repaired and the
lateral and medial orbit relationships are recon-
stituted, either alloplastic materials or bone grafts
may be utilized to repair comminution of the
floors or walls of the orbit.
3. Approach to the frontozygomatic buttress: either the
infrabrow or preferably the superior blepharoplasty
incision provides access and excellent cosmesis.
a. This buttress is frequently repaired in combina-
tion with rim repair for less complex fractures.
b. One must remember that this buttress controls
the height but not rotation or projection of the
malar bone.
c. Using 1.5-mm plates is generally sufficient. The
periosteum should be closed over the plates and
the fascia repaired to reestablish the superior
palpebral fold and to prevent less palpability of
the plate.
4. Techniques of plate placement: it is helpful after the
reduction of the fracture is completed to place only
the inner two screws of the plates loosely into posi-
tion. This allows for the fracture to be slightly mobile
in facilitating the precise anatomic reduction of the
fracture before fixing all of the screws. Once the
reduction is precisely achieved, all screws may be
placed and tightened.
5. After adequate stabilization is achieved, the perios-
teum is carefully closed to cover the plates and re-
suspend the facial muscles.
 FRACTURES OF FACIAL BONES

6. Careful skin closure with monofilament permanent Potential Complications

suture ensures the best resultant scar.
• Eye
Repair of Complex Fractures • Blindness
• Orbital dystopia
1. A regional coronal approach is mandated to control • Exophthalmos
the malar relationships to the stable skull base. • Ectropion
a. Repair of the zygomatic arch provides projection • Diplopia
with the malar eminence and helps control the • Restricted eye movement
facial width. The surgeon must realize that the • Lens detachment
arch of the zygoma is quite fat and a classic mistake • Ruptured globe
is to try to round the arch in the midpoint, which • Detached retina
tends to shorten the projection of the malar emi- • Desensitized cornea
nence and widens its position in relation to the
central face. Nerve Injuries
b. The zygomaticosphenoid buttress should be
checked either infraorbitally or in the temporal • Weakness of cranial nerve VII-temporal division,
fossa to establish the width and projection of the orbital division
lateral orbit. • Injury to second division cranial nerve V
(1) Repair of this buttress is best achieved by • Injuries to cranial nerves III, IV, and VI
reflecting the anterior attachment of the tem-
poral muscle and securing the bone within Malposition of Malar Bone
the anterior temporal fossa with 1.3- to
I.S-mm miniplates. • Widened upper face and orbit
c. Careful exploration and repair of the orbit is man- • Malposition of maxilla if it is also fractured with the
dated. Repair of the infraorbital rim and lateral injury-resultant dental occlusion abnormalities
orbit help to reconstitute the orbital position and • Possible impairment of mandibular function
to more precisely repair the walls of the orbit.
2. Regional incisions help to expose the orbit and lower Poor 50ft Tissue Repair
the facial attachments.
a. Previously mentioned subciliary or transconjunc- • Scar
tival incisions provide exposure to the rim and • Failure to restore normal facial appearance
floor and walls of the orbit.
b. The canine fossa approach provides access to
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 14
Excision of Cysts of the Mandible
Cysts of the mandible are similar to the odontogenic
cysts of the maxilla (see Fig. 5-12). They are benign,
arising from embryonic epithelial roots or remnants,
and hence have an epithelial lining. However, squa-
mous cell carcinoma has been seen to arise from these
cysts. When they recur, careful histologic evaluation is
necessary.
Highpoints
I. Preserve teeth and mandibular nerve if resection of
cyst wall is not compromised.
2. Attempt to remove cyst intact.
3. Scrupulously remove all remnants of cyst wall if the
wall fragments. Use electrocautery if all else fails.
4. Devitalized teeth require root canal therapy.
Radicular Cyst (Fig. 14-1)
A radicular cyst (dental root or dentoperiosteal) may
occur as the result of an apical abscess or at the site of
a previous extraction. As the cyst enlarges, it may
decompress through a small perforation in the most
prominent portion. With the large radicular cyst, there
is considerable bone absorption and danger of fracture.
This type of cyst may be either entirely filled with
liquid or semisolid.
653
 cvm AND TUMORS INVOLVING THE MANDIBLE
Excision of Cysts of the Mandible
(Continued)
A An elliptical incision is made over the most promi-
nent portion to include, if present, the drainage site.
With large cysts, there is usually no overlying bone in
this region. If bone is present, it is removed with fine
forceps. If no drainage site is present, the incision is
then made over juxtaposed normal bone, developing
a mucoperiosteal flap as depicted in A 1• Preserve, if
possible, the neurovascular bundle; however, the bundle
is sacrificed if necessary. Avoid medial dissection, if
possible. In any event, do not injure the lingual nerve
(N). If the approach depicted in A 1 is used, the
thin overlying bone is resected to facilitate removal of
the cyst.
B The mucous membrane is left intact at the
drainage site, but medially and laterally it is separated
by blunt dissection using a fine nasal freer.
C If traction is necessary, the cyst is grasped with
blunt forceps at the ellipse of the mucous membrane
left attached to the cyst wall. Dissection is continued
with the freer. If the cyst is reasonably symmetrical, it
can be removed intact; if it is large and irregular, it
usually fragments. Diligent and meticulous dissection
is necessary to remove all these fragments of the cyst
wall. The cyst wall is made up of epithelial cells, and
any remaining cells in the bony defect will tend to
cause a recurrence.
D A D.5-inch gauze strip soaked with liquid nitro-
furazone (Furacin) or iodoform (NU Gauze) is inserted
in the bony defect. If necessary, sutures of nylon are
placed over the gauze strip to keep it in place. The
wound heals by secondary intention. If the approach
depicted in A1 is utilized, the mucosa is approximated
over the surgical defect, and the drain is brought out
in a more dependent portion of the wound (01).
 CYSTS AND TUMORS INVOLVING THE MANDIBl.£

c o

FIGURE 14-1
 CYSTSAND TUMORS INVOLVING THE MANDIBLE
Dentigerous Cyst (Fig. 14-2)
A dentigerous cyst represents an anomaly of the teeth
and, hence, on an x-ray film, teeth in various stages of
development are noted within the cystic cavity.
Highpoints
1. Preserve teeth and mandibular nerve if resection of
cyst wall is not compromised.
2. Attempt to remove cyst intact.
3. Scrupulously remove all remnants of cyst wall if the
wall fragments. Use electrocautery if all else fails.
4. Devitalized teeth require root canal therapy.
Complications
• Fracture of mandible
• Recurrence
• Injury to viable teeth
Aneurysmal Bone Cyst
In the head and neck, these cysts are rare, occurring for
the most part in the mandible in patients younger than
age 2D and more often in females than males. They also
occur in the vertebrae and long bones. The cause of
these cysts is obscure; they may develop possibly
secondary to trauma with arteriovenous fistula or false
aneurysm. Characteristically, their gross appearance is
spongy with blood-filled spaces, and they are prone to
severe bleeding during surgical exploration. The sur-
geon must beware! Conservative management appears
to be the treatment of choice, consisting primarily of
thorough local curettage.
A A horizontal incision is made at the most
dependent level of the tumefaction. The overlying
bone is removed with fine bone forceps or a diamond
bur, or if it is very thin it may be undermined and
outfractured with a nasal freer.
B The edges of the bony defect are trimmed with
rongeurs, taking care not to break the cyst wall.
C Using a fine nasal freer, the cyst wall is separated
from the bony cavity. If the cyst wall fragments, every
remnant must be carefully removed. The wound is
packed with a D.5-inch strip of gauze soaked with
nitrofurazone liquid or iodoform. If possible, the mucosa
is approximated with nylon, and the gauze strip drain
is brought out through the most dependent portion of
the wound, attempting more primary healing. Other-
wise, the healing is by secondary intention, requiring
up to 4 months, depending on the size of the defect.
D Depicted is the neurovascular bundle, which, if
feasible, is preserved; however, the bundle is sacrificed
if necessary.
 CYSTS AND TUMORS INVOLVING THE MANDIBlE

FIGURE 14-2
 CYSTSAND TUMORS INVOLVING THE MANDIBLE
Marginal Segmental Resection
of Mandible (Fig. 14-3)
Highpoints
1. Procedure is suitable for moderately sized benign
lesions of the mandible when curettage has failed or
is not indicated (not usually performed for cysts).
2. It is not suitable for malignant bone lesions.
3. Mandibular and cervical branches of the facial nerve
are preserved.
4. Extended disease is evaluated by panoramic radi-
ography (Panorex) or spiral computed tomography
(CT) with thin overlapping cuts; dental occlusal films
or Panorex can sometimes provide more information
than a routine CT scan.
Complications
• Fracture of mandible
• Recurrence
A Cross section of mandible in vicinity of second
molar tooth, depicting underlying mandibular lesion.
Although ameloblastoma is considered benign in that
it rarely metastasizes,it is locally invasive.Care must be
exercised that adequate resection is performed.
Curettage alone is not adequate. Radiographs do not
show the full extent of these tumors, because they
extend at least 1.3 cm beyond their apparent delin-
eation on an x-ray film. For large ones, resection of the
entire ascending ramus and a portion of the body of
the mandible to beyond the mental foramen is required.
This encompasses the entire neurovascular canal,
along which such tumors may spread.
B An oblique or horizontal slightly curved upper
cervical incision is made 2 to 3 cm below the angle of
the mandible. Extreme care must be taken to avoid
injury to the mandibular branch and, if possible, to the
cervical branch of the facial nerve. This latter nerve
may also playa part in depressingthe lower lip through
its innervation of the platysma muscle. This muscle is
continuous with and more or lessblends with some of
the other muscles connected to the lower lip, espe-
ciallythe depressoranguli oris (triangularis)(Hollinshead,
1954), depressor labii inferioris (quadratus labii infe-
rioris), as well as the risorius muscle.
C An upper skin flap containing the platysma and
possibly a portion of the triangularis is elevated. The
external maxillary artery and anterior facial vein are
doubly ligated and transected. The mandibular branch
of the facial nerve crosses these vessels, lateral or
superficial to them and deep to the platysma muscle.
The nerve is best carefully retracted superiorly with the
distal cut ends of the vessels.The cervical branch of
the facial nerve is retracted inferiorly. The anterior two
thirds of the masseter muscle is transected, thus
exposing the region of the angle of the mandible. The
tail of the parotid and a portion of the submaxillary
salivary gland are likewise exposed. The dotted line
depicts the incision to be made in the oral mucosa in
the molar region.
D The oral cavity is entered, exposing the second
molar tooth. The third molar tooth has been previously
removed.
E Diagrammatic representation is presented of the
lesion that is within the mandible and the bone to be
resected.The x-ray films of the mandible are used as a
guide to map out the area to be resected, keeping in
mind that an ameloblastoma extends beyond the
radiographic delineation. An estimated 1.5 to 2.0 cm
of normal bone is used for the margins. A sagittal
plane saw is used to resect the block of mandible
including the second molar tooth. A cut between the
first and second molar teeth asdepicted is only utilized
if the root of the remaining first molar is not injured.
Otherwise, the first molar tooth is removed and the
cut made through the tooth socket. Small portions of
bone marrow are curetted along the free margins on
the remaining mandible. These specimens are sent for
"frozen section" (smeared on glass slides) and
histologically evaluated for adequacy of resection if the
lesion is an ameloblastoma. Bleeding from the
mandible is controlled with cautery. If the remaining
strut of bone is extremely thin, support can be
achieved with an inlay iliac bone graft (see Fig. 14-8C).
If an inlay bone graft is planned, drill holesfor tie wires
or for a mandibular bar can be done before the
resection of the segment of mandible. The drill holes
are best placed well away from the anticipated cuts, in
case removal of additional bone is necessarybased on
the immediate histologic examination of samples of
the bone marrow at the cut edges of the bone.
F Becausethere may not be a sufficient oral mucous
membrane to line the resulting defect in the bone, the
cavity is packed with strip gauze impregnated with an
antibiotic ointment. The edges of mucous membrane
partially cover the packing, and the end of the packing
is brought out into the oral cavity. The transected por-
tion of the masseter muscle is repaired. The platysma
and triangularis muscles are reapproximated, and the
skin is closed.
 CYSTS AND TUMORS INVOLVING THE MANDIBLE 659

FIGURE 14-3
 CYSTS AND TUMORS INVOLVING THE MANDIBLE
Resection of Large Benign Tumors
of Mandible (Fig. 14-4)
Highpoints
1. Segmental resection of mandible is usually indicated
in any large benign tumor.
2. Immediate reconstruction of mandible is performed
utilizing bent Kirschner wire or Steinmann pin with tie
wire on each end (see Figs. 14-5 and 14-6), secondary
bone graft (see Fig. 14-9), a compression plate (see
Fig. 13-22J to L), or a free microvascularized bone
graft (see Chapter 24).
3. Continuity of mandibular division of facial nerve is
preserved in cheek flap.
4. Although rare, an ameloblastoma can be malignant,
and a complete histologic evaluation must be made.
The tumor must not be violated, otherwise recurrence
is almost certain.
5. If there is any question of malignant change in the
frozen section, then at least a suprahyoid (levels I-II)
or preferably a supraomohyoid (levels I-II-III) (JEM)
or a standard radical neck dissection (levels 1-I1-III-
IV) (JML) should be performed.
Usually, adequate exposure can be obtained by a hori-
zontal oblique incision following a natural skin crease
4 em below the body of the mandible. The incision is a
visor-type incision that extends 2.5 to 5 em across the
midline to the opposite submandibular area. This inci-
sion is similar to the one depicted in Figures 14-9B and
14-lOA. The lateral extension of the incision reaches
the lobule of the ear and thence up to the area of the
tragus as necessary. Care must be taken not to injure
the main trunk of the facial nerve and its branches. The
visor flap (Schweitzer) thus contains the muscles of
facial expression, with the overlying branches of the
facial nerve and the portion of the parotid salivary gland.
The plane of dissection is anterior to the mandible
without violating any capsule surrounding the tumor
or the tumor itself. The masseter muscle is thus exposed,
as depicted in Figure 14-4C and D. The visor flap con-
cept allows for avoiding the incision in the lower lip;
thus there is no "lip split."
A This horizontal extension must be at least 4 cm
below the edge of this horizontal portion of the
mandible to avoid injury to the mandibular division of
the facial nerve, which hangs like a hammock below
the ramus. An alternate incision is a lip split along the
dotted line, which affords additional exposure if
absolutely necessary. Another alternate incision rather
than a midline lip incision is an incision that starts
just medial to the oral commissure (Robson). See
Figures 16-6 for additional information about skin
incisions.
B A cross-sectional view depicts the local invasive
characteristics of an ameloblastoma. The area resected
is outlined by the dotted line.
C The full-thickness cheek flap is turned laterally by
incising the gingivobuccal gutter and the attachments
of the buccinator muscle to the mandible. The external
maxillary artery and anterior facial vein are ligated and
divided as close as possible to the capsule of the sub-
maxillary gland. This preserves the mandibular division
of the facial nerve, since the nerve is superficial to
these vessels. The insertion of the masseter muscle on
the mandible requires sectioning, depending on the
extent of the tumefaction, to expose adequate margins
of the mandible.
The visor flap can be reflected higher to expose the
notch of the mandible, using small Deaver retractors.
This requires additional dissection as well as transection
of the masseter muscle. The mandibular notch is thus
exposed, and the mandible can then be transected
just below the notch, leaving the coronoid process and
the condyle in place. The condylar portion thus serves
as an anchor for a bent Steinmann pin, which is secured
in place using a tie wire (see Fig. 14-5D). It must be
emphasized that the Steinmann pin must be bent and
secured with the tie wire; otherwise a straight wire
unsecured in the condyle, or in any remnant of the
ascending ramus of the mandible, could migrate
through the glenoid fossa into the cranial cavity. A
complete segmental resection of the mandible could
also be reconstructed with a free vascularized fibular
graft (see Chapter 24) or a plate equipped with a
condylar head (see Fig. 14-6D).
D Depending on the nature of the lesion, a satisfac-
tory margin of normal bone is left with the specimen.
In an ameloblastoma 2 cm is considered safe. This
horizontal portion is transected with a Gigli or sagittal
plane saw near the angle, with partial transection of
the masseter muscle. A lower incisor tooth has been
removed to facilitate transection anteriorly. The saw
cut is thus away from the root of the more medial
tooth. This aids in maintaining the viability of the
remaining tooth. Any teeth that are fragmented are
removed. When the angle of the mandible is resected,
the stylomandibular ligament is transected (see
Figs. 17-3D and 22-33C and D).
Continued
 CYSTS AND TUMORS INVOLVING THE MANDIBLE

Parotid gland

\
Submaxillary salivary gland

FIGURE 14--4
 CYSTS AND TUMORS INVOlVING THE MANDIBLE
Resection of Large Benign Tumors
of Mandible (Continued) (Fig. 14-4)
E The horizontal portion with tumefaction has been
removed by an incision through the floor of the
mouth, transecting the origin of the mylohyoid muscle
from the inside of the mandible along the mylohyoid
line. The anterior belly of the digastricus muscle may
also require transection, depending on the extent of
the mandible resected. If there is encroachment of the
ameloblastoma on the submaxillary and sublingual
salivary glands, these are excised with the section of
mandible preserving, if feasible, the twelfth nerve and
the lingual nerve.
When the resection is carried up to the mandibular
notch, the internal pterygoid muscle is transected,
with possibly the external pterygoid muscle (see
Fig. 15-11 K). A branch of the internal maxillary artery
will usually be encountered, which is doubly ligated
and transected. The stylomandibular ligament is also
transected.
With the resection of large benign tumors requiring
through-and-through segmental resection of the body
of the mandible, the wound is contaminated. Thus it is
not wise to insert a primary bone graft for reconstruc-
tion. The simplest, easiest, and fastest reconstruction
of the mandible can be achieved with a bent Steinmann
pin with tie wires (see Fig. 14-5). Because the pin
involves minimal foreign material and because its
stabilizing horizontal portion-from each end of the
transected mandible-is bent inferiorly, local soft
tissue suffices for adequate closure. A flap (e.g., a free
microvascularized flap) is thus not always necessary. If
desired or indicated, after the wound heals, a second-
stage procedure with a free nonvascularized bone
graft can be inserted through the same surgical inci-
sion. Another advantage is the minimal risk of infec-
tion. This second stage is rarely necessary and often
not desired by the patient, who is quite satisfied with
just the Steinmann pin reconstruction and the use of
local flaps.
F Anatomy of submandibular area with submandibular
and sublingual gland removed (after Hollinshead).
Reconstruction of the defect could be done by a
number of methods:
1. Steinmann pin with or without bone graft (see
Fig. 14-5)
2. Plate without bone graft
If a bone graft is utilized with either of the above
two procedures, then it is staged:
a. Plate or pin
b. Wound healed 4 to 6 months later: a free autog-
enous bone graft
3. Immediate vascularized bone graft (see Chapter 24)
Free non vascularized bone grafting is not performed
immediately because of the danger of loss of the non-
vascularized bone in the presence of a contaminated
wound due to the entry into the oral cavity. On the other
hand, a secondary nonvascularized bone graft can be
utilized after initial stabilization with either pin or plate,
after complete wound healing. The surgical approach
then is entirely extraoral, and thus the wound not
contaminated.
 CYSTS AND TUMORS INVOLVING THE MANDIBLE

Mand. br.
facial n.
Masseter m.
Sublingual gl.

Parotid gl.

Mylohyoid m.

Lingual n. and submaxillary ganglion

Submandibular duct

Digastric m.

Deep lingual artery

Genioglossus m.

Sublingual artery
t
Glossopharyngeal n.
on stylopharyngeus

FIGURE 14-4 Continued

 CYSTS AND TUMORS INVOLVING THE MANDIBLE

Mandibular Reconstruction Options

(See Figs. 14-5 to 14-11)
To simplify a few of the options, but not necessarily
Mandibular reconstruction, like a number of head and eliminating other options, a simplified scheme to aid
neck surgical procedures (e.g., reconstruction of the the decision making is as follows:
hypopharynx), has run the gamut from the very simple
to the very complex with various preferences for trans- I. Metallic-stainless steel or tantalum
posed pedicle flaps and microvascular procedures (see A. Plate
Chapter 24). The various procedures used for recon- B. Steinmann pin with tie wires
struction include the following: the use of a Steinmann II. Stages
pin (combined with tie wires), metallic (titanium or stain- A. Primary stage-free vascularized
less steel) plates, or plastic (Dacron and polyurethane) 1. With soft tissue
trays with marrow/cancellous bone (see Fig. 14-lOH), a. Skin island
bone grafts (iliac, rib, scapular spine, or clavicle), micro- b. Muscle
vascular transfers of bones and soft tissue, pedicle and 2. Without soft tissue (soft tissue achieved with
free osteomyocutaneous flaps, bank bone, metallic plates, local or distant flaps depending on the defect
resected mandible reused after freezing in liquid nitro- and other factors)
gen, and various combinations of these methods. A B. Secondary stage-free nonvascularized autogenous
review of some of these procedures is included in the bone
article by Lawson and co-workers (1982).
Factors that must be taken into account in mandibular To further simplify these options, the following
reconstruction are the following: methods are the basic reconstruction approaches to the
immediate stabilization of the remaining mandibular
I. Stabilization of the mandible fragments:
2. Sufficient soft tissue coverage over whichever device
or graft is utilized 1. Steinmann pin with tie wires
3. Infection and/or contaminated wound as a result of 2. Plates
entering the oral cavity or oropharynx 3. Free microvascular osseous grafts fixed with:
4. Operating time a. Plates
5. Reasonable function b. Interosseous wires
6. Cosmetically acceptable results c. Screws
7. Cost effectiveness d. Steinmann pin
8. Complications relative to specific procedures 4. Intermaxillary fixation: during reconstruction and/or
9. Inclusion of the maxillofacial prosthodontist in the post operation-l to 2 days
preoperative planning stages. Otherwise, the recon- 5. External fixation devices: very rarely used
struction may not be usable for prosthodontic reha-
bilitation (see Chapter 3). Donor Sites

There are four other factors that dictate the method- 1. Fibula-used for segmental or virtual total recon-
ology of reconstruction, two of which depend on the struction of the mandible. This is one of the better
etiology of the defect and whether it is (1) secondary to free bone grafts with or without a skin island: there
trauma or (2) secondary to ablative surgery and two may be some limitations of the skin island owing to
others that depend on whether the reconstruction is (1) short septocutaneous vessels.
best done immediately or (2) delayed. a. Good length
All these factors are interconnected and related. For b. Straight and can be tailored
example, mandibular defects due to trauma may have c. Thick cortical bone; thus it will accept various
more local soft tissue for coverage than do defects due types of plates and screws for interosseous
to ablative surgery for neoplastic disease; at times it is fixation.
just the opposite. In the latter group, there are variations; d. Accepts osteointegrated implants
that is, there will be more soft tissue available after 2. Radial forearm flap-bone is very thin; hence this
reconstruction for ameloblastoma than for malignant can only be used as an ancillary support, such as in
neoplasms. Immediate reconstruction using a consider- a marginal resection of the mandible or in combina-
able amount of "hardware" or with inadequate soft tion with a Steinmann pin or plate.
tissue coverage is more likely to result in poor wound 3. Iliac crest-can also be used as free non vascularized
healing and possible infection and osteonecrosis. flap (see Fig. 14-9E)

4. Scapula
5. Second metatarsal
6. Rib-too thin
The choice of the just listed methods depends on
many factors: availability of instrumentation, availability
of skilled microvascular surgeon, time consumed for
the method, medical status of the patient, and in some
situations cost of the plates or other instrumentation.
The surgeon must be aware of the complications related
to the method chosen at both the donor site and the
recipient site when using bone grafts. Other con-
siderations are mandibular drift, malocclusion, deglu-
tition, diet, feasibility of using of a dental prosthesis,
mastication, and cosmesis.
It is recommended that in preoperative planning, the
prosthodontist is involved. A mold may be made, for
example, before treatment with preoperative chemotherapy.
Thus, an excellent representation of the lesion before
treatment is available. This can help guide the surgeon
in performing uncompromised surgery (see Chapter 3,
p.132).
The factor of additional operating time necessary to
perform free microvascular osseous myocutaneous
procedures, especially in older patients or patients with
borderline medical status, must be taken into the deci-
sion making regarding the method of reconstruction. In
any event, reconstructive procedures that in themselves
do not stabilize the mandible and thus require inter-
maxillary wires for fixation beyond a few days is
another burden to the patient who has had extensive
ablative surgery. It compounds the discomfort during
the postoperative period.
The author (JML) has relegated most mandibular
reconstruction after significant ablative surgery to the
use of the bent Steinmann pin secured with tie wires.
Soft tissue coverage of the pin can be easily achieved
with either local tissue or distant flaps, for example, a
pectoralis major myocutaneous flap. This is because
the horizontal portion of the pin is below the mandible
where there is usually sufficient soft tissue to cover it.
If additional soft tissue is necessary, this horizontal
portion may be well within the scope of a levator scapu-
lae flap or, if necessary, a pectoralis major myocuta-
neous flap, which has been used to reconstruct a
portion of the oral cavity or the oropharynx.
Stabilization is usually accomplished by this method
alone, depending on the extent of the reconstruction. It
adds minimal time to the operation and requires no
special instruments or a second surgical team. It is
immediate and at the same time allows for subsequent
delayed reconstruction, if desirable. Cosmetically, it is
good to excellent; and from a functional point of view,
the patients are satisfied, although not all are able to
wear full dentures or eat all solid foods. It must be
CYSTS AND TUMORS INVOLVING THE MANDIBlE
emphasized that the method is not perfect; there are
complications, which are listed in the following text.
One must keep in mind that after several months of
stabilization, regardless of the methods used, usually
sufficient scar tissue and accommodation occur so that
reasonable cosmesis and function is attainable.
Reconstruction of Mandible Using
Steinmann Pin and Tie Wires
(Modified from Gaisford et al., 1961)
Differentiation between the Kirschner wire and the
Steinmann pin is simply a question of size. The Steinmann
pin is used for reconstruction of the mandible, whereas
the Kirschner wire (although the Steinmann pin is pre-
ferred) can be used in other situations where the torque
is not great, for example, in intermedullary pinning
when joining a mandibulotomy. Regardless, tie wires
are always utilized.
A bent Steinmann pin with tie wires is illustrated in
Figure 14-5. Depicted are various applications and modi-
fications of this technique that can be utilized at the
time of the ablative surgery. The method is simple and
fast, and, if necessary, the Steinmann pin can be later
removed and replaced with an autogenous bone graft,
as shown in Figures 14-902, E, and F and 14-100. This
has seldom been necessary or desired by the patient.
This basic method using a Kirschner wire was first
described by Gaisford, Hanna, and Gutman in 1961. In
the original description of this reconstruction they
utilized a Kirschner wire that was not secured to the
ends of the transected mandible. Hence, the wires will
separate from the mandible. The tie wires are an absolute
must in this type of reconstruction. Our modification is
the use of tie wires at either end of the bends in a
Steinmann pin to stabilize it to the mandible.
Our original concept was to stabilize the transected
ends of the mandible at the initial ablative surgery with
a minimum of "hardware" in a contaminated field.
After the wound healed, definitive reconstructive surgery
could be done through an external incision avoiding
entry in the oral cavity or oropharynx. However, after the
first two patients who had secondary reconstruction,
all subsequent patients except those with chin recon-
struction were satisfied with the initial reconstruction,
even despite the broken Kirschner wires. The next step
in the evolution of this type of reconstruction was to
use a heavier material. Thus the Steinmann pin (l/8 or
7/64 inch) was used, which was simply a heavier
Kirschner wire. A Kirschner wire can be used as a tem-
plate (easy to bend) to make a model for the heavier
Steinmann pin. The bends in the wire can thus be "fine
tuned" to fit the defect and serve as the model for the
Steinmann pin. Primary stabilization and reconstruction
of the mandible is achieved by bent Steinmann pin and
 666 CYSTS AND TUMORS INVOLVING THE MANDIBLE
Reconstruction of Mandible Using
Steinmann Pin and Tie Wires
(Modified from Gaisford et al., 1961)
(Continued)
tie wires, whereas bone grafts are reserved for a second
stage, if necessary.
The Steinmann pin is preferred to a mandibular
plate for a number of reasons:
1. There is more hardware with the plate.
2. To secure the plate, at least two screws on either end
of the mandible stumps are necessary, preferably
three. More bone is exposed during the surgical
procedure and thus involves more soft tissue
dissection proximally and distally.
3. Larger soft tissue flaps are needed to cover a plate
than a Steinmann pin. Bending the wire inferiorly
places it in a much more ideal location to be covered
by soft tissue.
4. A Steinmann pin does not require any special
instruments.
5. The cost is $6 to $8 per Steinmann pin, compared
with $900 to $1200 for a mandibular plate. Although
no special instruments are required to facilitate the
bends except for locking pliers (Vise-Grip) and pliers,
a device has been constructed to bend the Steinmann
pin rather than using these basic tools (see Fig. 14-5E).
This device could also be used to facilitate bending
for other purposes, for example, plates or bars.
6. There is less chance of tissue slough with the smaller
Steinmann pin than the larger mandibular plate.
7. The Steinmann pin is preferred over the plate for
subsequent radiation therapy because there is less
scatter radiation with the Steinmann pin.
Mandibular Reconstruction Using
Steinmann Pin (Fig. 14-5)
Busic Concept
1. It is an immediate, easy, and rapid method of stabi-
lizing the mandible.
2. A minimum of soft tissue is necessary for coverage
because the horizontal bar of the pin is lower in the
wound than if a mandibular plate were used.
3. Less hardware is necessary.
4. It is suitable for secondary free non vascularized au-
togenous bone grafting. Usually the iliac bone graft
(see Fig. 3-5) is performed after complete healing,
usually 6 to 18 weeks after the initial operation, via
an external incision. Do not enter the oral cavity.
This secondary procedure is optional for the body and
the portion of the ascending ramus of the mandible,
depending on the patient's wishes. However, this is
usually advised for reconstruction of the anterior
arch of the mandible, because prolonged pressure on
this Steinmann pin eventually may cause pressure
necrosis of the skin of the chin (see Fig. 14-9).
5. At times temporary intermaxillary wiring is used to
maintain the proper occlusion while the Steinmann
pin is fixed into place during the surgical procedure.
After the fixation is achieved, then the intermaxillary
wires can be removed or left in place for 24 to 48 hours.
Highpoints
I. Use the heaviest Steinmann pin that can be bent
with pliers and a vise grip. The bending device can
bend heavier wire.
2. The length and bend of the midportion of the
Steinmann pin must exactly approximate the section
of the mandible removed. The resected portion of
the mandible is used as a template. The Kirschner
can be used as a trial-and-error template.
3. Whenever possible use two tie wires to secure the
vertical bent portion of the Steinmann pin to the
transected remaining ends of the mandible. This is
very important, because it secures the Steinmann
pin and prevents dislodgement, migration, and
rotation of it.
4. The Steinmann pin must be surrounded by soft
tissue, either local or distant flaps (e.g., pectoralis
flap or microvascular free flap).
5. Avoid dead space in the wound.
6. Avoid tension of skin over the wire.
7. Avoid the use of metals of different galvanic potential.
8. The Steinmann pin is the only stabilization of the
reconstructed mandible. Intermaxillary fixation is
usually not necessary except as in Figure 14-50,
although it would aid in obtaining an improved
occlusion in any type of reconstruction (temporary;
only at time of reconstruction for 24 hours). Gunning
splints can also be used in the edentulous patient
with cross-splint wire fixation to improve occlusion
(see Fig. 14-9C and D). After a composite resec-
tion, the patient is more comfortable without these
additional forms of fixation.
9. Obtain immediate postoperative radiographs and
then radiographs two or three times during first
year and annually thereafter or check the position
of the wire.
10. Round the edges of the transected mandible to
avoid pressure of overlying mucosa or soft tissue
closure on any sharp edges.
11. Before the segmental section of the mandible is
removed, drilled holes are placed in the remaining
portion of the mandible 6 to 8 mm from the cut end
with two holes in each end. These holes will carry

the tie wires and should be slightly larger than the
tie wires.
12. Tie wires are 5.0 stainless steel (the ones that are
used for closure of the sternum-just remove the
needle).
13. Two tie wires are used on either end.
14. Kerf's grooves are cut into the ends of the mandible
where the pin can be set in and further secured
(see Fig. 14-902).
15. Measure segment: measure and shape a template
using a thin Kirschner wire, which is molded to an
exact replica of the segment removed. This would
be the two ends and the inferior edge of the segment
removed. Angles are critical. Be careful that the
proximal angle follows the remaining portion of
the body angle and/or ascending ramus.
16. Horizontal holes are drilled in both ends of the
mandible with a bit that is one size smaller than
the Steinmann pin to be used.
17. The Kirschner wire is then checked for proper fit-
ting and also for the occlusion. The Kirschner wire
template may be modified to achieve the perfect
occlusion.
18. The Steinmann pin is now bent to follow the shape
of the template Kirschner wire using either basic
tools (locking pliers and pliers) or a special tool
(see Fig. 14-5E).
CYSTS AND TUMORS INVOLVING THE MANDIBLE
19. The horizontal bar of the template should follow the
curvature of the mandible. This is very important
to achieve proper bite.
Complications
• Broken Kirschner wire: this is usually a result of too
small a diameter of wire; it is of little concern as long
as the tie wires remain intact. The Steinmann pin is
now substituted for the Kirschner wire to minimize
breakage. The Steinmann pin can break. A broken
Kirschner wire or Steinmann pin does not require
removal. Enough fibrous tissue is formed by the
time this occurs to maintain the bite.
• Externally exposed pin (seldom): avoid tight closure
of overlying skin flaps.
• Migration: this has not occurred with the bent
Steinmann pin or Kirschner wire with tie wires. This
could be a serious problem if the Steinmann pin is
not bent and secured with tie wires. Migrating wire
could conceivably injure any vital structure (e.g.,
vessels, eye, and brain).
• Postoperative radiation therapy over a Steinmann
pin can result in slough of the overlying skin and
exposure of the wire.
• Minimal drift and minimal malocclusion may occur.
 CYSTSAND TUMORS INVOLVING THE MANDIBLE
Mandibular Reconstruction Using
Steinmann Pin (Continued) (Fig. 14-5)
A The reconstruction of the horizontal (body) of the
mandible is shown for involvement by a squamous cell
carcinoma of the lateral border and base of tongue
and juxtaposed floor of mouth. The tumor is fixed to
the mandible. Marginal resection of the mandible is
too risky regarding the margins of the attached soft
tissue being free of disease. This has been combined
with a radical neck dissection. The Steinmann pin is
covered by local soft tissue flaps; at times the levator
scapulae muscle is used for additional bulk. Intraorally,
the Steinmann pin is covered with a pectoralis major
myocutaneous flap. Kerf (see Fig. 14-9D2) is made in
each end of the mandible to receive the vertical limb
of the Steinmann pin. The inferior alveolar canal can
be suitable to receive the embedded portion of the
Steinmann pin. Otherwise, holes are drilled using a
portion of the Steinmann pin that is the same diameter
as the prosthesis or with a drill bit that is one size
smaller. Drill holes should be placed to avoid the roots
of the teeth. Tie wires of malleable stainless steel of the
heaviest possible diameter (e.g., size 5, similar to wire
used to close a median sternotomy) are placed through
the drill holes. Two tie wires are used at each end.
These wires are most important to prevent dislodge-
ment, migration, and rotation of the prosthesis. The
tie wires prevent the bent Steinmann pin from under-
going extrusion from the mandible. When properly
placed and tightened, the reconstructed mandible is
stable, thus making intermaxillary fixation usually
unnecessary.Intermaxillary fixation may be used during
the fixation of the Steinmann pin and occasionally left
in place for 1 or 2 days but no longer.
A1 Example of Steinmann pin.
8 The body of the mandible with angle and portion
of the ascending ramus has been resected. This has
been combined with a radical neck dissection. The
procedure is similar to that described in A. Again, two
tie wires are used at each end to secure the pin in
place and prevent any migration. Migration can be
serious, especially if the end of the Steinmann pin is
directed superiorly, because it could enter the cranium
via the glenoid fossa. The tie wires also prevent the
bent Steinmann pin from undergoing any type of extru-
sion from the mandible. The "critical angle" demon-
strates the angle of the bend when the Steinmann pin
enters the proximal end of the mandible, which
should be carefully calculated to avoid passing the
Steinmann pin between the condyle and the coronoid
process. Again, it is emphasized that the proximal bent
Steinmann pin must not extrude through the condyle.
The tie wires must be secure, otherwise there could be
a perforation of the glenoid fossa. This calamity has
been seen with a "free Kirschner wire" entering the
brain. The surgeon (elsewhere) evidently was not aware
of the importance of the tie wires and the bend in the
Steinmann pin. If there is any question regarding the
position and location of the wire during the surgical
procedure, an intraoperative radiograph would be
advisable. It is also advised to obtain postoperative
radiographs, particularly in the event that the end of
the pin has passed between the condyle and the
coronoid process. No complications have been seen
regarding this placement. However, radiographic moni-
toring is advised over a period of time. In addition, this
end of the Steinmann pin should be blunt rather than
sharp. There must be a minimum of at least2.5 to 3.0 cm
of the condylar portion of the mandible remaining for
this type of reconstruction.
81 This depicts the removal of· the mandible
through the angle of the mandible. The admonition
regarding "critical angle" again applies where the
proximal end of the Steinmann pin is directed into the
condyle and not the coronoid process.
Continued
 CYSTS AND TUMORS INVOlVING THE MANDIBLE

FIGURE 14-5
 CYSTS AND TUMORS INVOLVING THE MANDIBLE
Mandibular Reconstruction Using
Steinmann Pin (Continued) (Fig. 14-5)
C The same principle as depicted in A is applied
acrossthe anterior portion of the mandible. In this posi-
tion it is very important that there is no tension of the
skin of the chin over the wire. This results in a some-
what shorter chin profile but is still a very acceptable
simple form of reconstruction. The anterior floor of the
mouth that is resected with the juxtaposed mandible
is closed with a portion of the tongue (do not tether
the tongue), pectoralis major myocutaneous flap, or
free microvascular flap depending on the soft tissue
defect. Levator scapulae muscle flap (see Fig. 22-36)
aids in closing the suprahyoid dead space if the distant
transposed flap does not have sufficient bulk.
D The drawing shows reconstruction of virtually the
entire hemimandible. The coronoid process has been
resected with preservation of the condyle. Only one tie
wire can be placed in the condyle. Nevertheless, the
Steinmann pin is bent and secured. This is most
important to prevent migration through the glenoid
fossa and then superiorly into the cranium. The end of
the Steinmann pin must not enter the glenoid fossa.
With this extensive reconstruction, intermaxillary wires
on the contralateral side are of help in maintaining the
occlusion. Reconstruction of this magnitude might be
better achieved with a plate and attached condylar
head (see Fig. 14-6D). The described reconstruction
has been used, and there is no displacement with
excellent occlusion and patient satisfaction. It was
eventually replaced with a plate with the attached
condylar head. Note: The reverse angle of the bend of
the Steinmann pin in D is to keep the pin away from
the main trunk of the facial nerve.
E This device is used for bending Steinmann pins
(built for Lore and Parks by Palma Tool and Die,
Lancaster, NY).
 CYSTS AND TUMORS INVOLVING THE MANDIBLE 671

E
FIGURE 14-5 Continued
 CYSTSAND TUMORS INVOLVING THE MANDIBLE

Other Options Relative to Mandibular

Reconstruction B The Kirschner wire is broken but has minimal
displacement. The patient was satisfied and did not
1. Autogenous bone grafts (see Fig. 14-8) desire additional second-stage reconstruction. He
2. Second-stage iliac bone graft (see Fig. 14-9) could chew almost everything, except steak. The wire
3. Resection and reconstruction of the body of the was left in place.
mandible (see Fig. 14-10)
4. Microvascular technique (see Chapter 24) C The broken Kirschner wire was repaired with a
a. Osseous section of a Fraser suction tip used as a sleeve. This
b. Osseous cutaneous, myocutaneous patient was the only one who had interdental wires
because the hemimandible had been resected with
Soft Tissue Coverage preservation of only the condyle. Note the S-shaped
bend in the proximal end to prevent the Kirschner
If a pedicle flap is chosen, a pectoralis major myocu- wire from entering the glenoid fossa.
taneous flap is preferred over the forehead flap because
of the following reasons:
o and E represent anterior mandibular reconstruc-
tion: the patient in 0 had a Kirschner wire placed and
1. It avoids donor site scar.
later an autogenous bone graft; the patient in E was
2. There is no planned fistula.
satisfied with only the Kirschner wire.
3. There are no multiple stages.
4. There is more bulk in the pectoralis major myocuta-
neous flap than in a forehead flap. This aids in a D Although very satisfactory and asymptomatic, the
more adequate coverage of the Steinmann pin and Kirschner wire in C was later replaced (Klotch) with a
also more tissue if a secondary bone graft is to be used. plate equipped with a condylar head. As a long-term
In addition, the blood supply of a forehead flap can management consideration, it is now over 15 years
be jeopardized if the flap folds over the Steinmann since the patient's operation. His diagnosis was
pin or plate. ameloblastoma. His quality of life is very good; his bite
is good but not perfect. He sustained a blow to the
If the procedure does not involve a neck dissection, reconstructed mandible without any deformity.
then the forehead flap could be considered. A free
microvascular skin flap would in most situations be a E Reconstruction of the entire anterior portion of the
better choice. mandible is done for the so-called Andy Gump defor-
If a microvascular flap is chosen, the following aspects mity. This patient survived nearly 11 years without any
are considered: additional reconstruction other than the Kirschner wire
and finally succumbed to a myocardial infarction. She
I. Fibula had no recurrence of her carcinoma, which had involved
a. Better for osseous portion: solid cortex, stronger, the anterior floor of the mouth and the mandible.
straight, and suitable for shaping Although she did not wear a denture, ate soft foods,
b. Poorer for cutaneous portion: shorter septal cuta- and occasionally drooled, she stated, "I'm fine and
neous vessels satisfied." She declined any secondary bone graft.
2. Radius Care must be taken to avoid tension of the skin over
a. Poorer for osseous portion: thin bone-needs the wire, especially anteriorly.
plate or Steinmann pin for support or used as
overlay (e.g., margin of mandible) F, G, H Postoperative photographs of patient in E.
b. Better for skin replacement: pliable, free of hair,
longer vessels-excellent for oral cavity

Results of Reconstruction With Kirschner

Wire and Steinmann Pin (Fig. 14-6)

A Radiograph shows Steinmann pin replacing the

entire body and portion of the ascending ramus of the
mandible on one side. The preference is for two tie
wires at each end, whenever possible.
 CYSTS AND TUMORS INVOLVING THE MANDIBLE

FIGURE 14-6
 CYSTS AND TUMORS INVOLVING THE MANDIBLE

Evaluation of 34 Patients With Mandibular

Reconstruction Utilizing Kirschner Wires TABLE 14-1 Details of 34 Patients With
or Steinmann Pins (Lore, Lee, Kokocharov, Mandibular Reconstruction Using Kirschner
and Niemiec) (Fig. 14-7, Table 14-1) Wires or Steinmann Pins

1. Average age was 50 years (range: 21 to 78). Diagnosis

2. The median follow-up was 6 years (range: 1 month Squamous cell carcinoma 29 patients
to 15 years) (4 patients were lost to follow-up). Verrucous carcinoma 1 patient
3. Radiation therapy was performed in eight patients Leiomyosarcoma 1 patient
(two preoperative and six postoperative). Osteosarcoma 1 patient
Malignant mixed tumor 1 patient
Ameloblastoma (benign) 1 patient
If there is a problem requiring removal, a Kirschner
wire or Steinmann pin is much easier to remove than a 'Jypes of Resection
mandibular plate or bar. With the change from the These are shown in Figure 14-7.
smaller Kirschner wire to the larger Steinmann pin, the Soft Tissue Reconstruction
incidence of broken devices has decreased. Not all broken Primary closure 13 patients
Kirschner wires or Steinmann pins require removal. Pectoralis major flap 12 patients
Levator scapulae flap 4 patients
The postoperative and long-term management of this
Other 5 patients
type of reconstruction has a lower morbidity than that
of plate reconstruction. Diet
Regular 17 patients
Soft 7 patie!11s
Liquid 2 patients
MANDIBULAR RESECTION TYPE 4 patients
Thbe feeding/PEG
(N = 34) 4 patients
Lost to follow-up
Complications (13/34 patients)
6 patients 12 patients Broken wire/pin 8 patients
Extrusion 2 patients
Exposure of wire/pin 2 patients
Infection 1 patient
Cost Containment
Wire/pin $6-$8
Anterior Body Plate $900-$1200
(Plus specialized instrumentation)

PEG. percutaneous endoscopic gastrostomy.

8 patients 8 patients

Body and angle Subcondylar and angle

FIGURE 14-7

Reconstruction of the Mandible Using
Plates With or Without Free Autogenous
Nonvascularized Bone Grafts (Fig. 14-8)
Free nonvascularized autogenous bone grafts for
mandibular reconstruction are usually applicable
under two circumstances:
1. As the primary procedure when the defect is small
and the pathology is benign. The oral cavity must
not be entered to avoid contamination of the wound
if a graft is used. Fixation of the graft can be done
with an onlay plate (A).
2. As a secondary procedure after stabilization of the
transected mandible with either a mandibular plate
or a Steinmann pin (B and C). Oral cavity must not
be entered.
Iliac bone (see Figs. 3-5 and 3-6) is preferred. Rib
(see Fig. 3-5) could be used for very short segments as
a superior margin overlay for a marginal mandibular
resection. The sources of autogenous bone (e.g., ster-
num, spine, scapula, or clavicle) are not usually used
for reasons ranging from too thin cortical bone to the
possible violation of the neck (clavicle) if there is a pos-
sibility of a malignant lesion with cervical metastasis.
It is important that the correct occlusion of the remain-
CYSTS AND TUMORS INVOLVING THE MANDIBLE
ing portion of the mandible be maintained during the
insertion and fixation of the graft.
Highpoints: A, C, D
1. Adequate exposure is possible proximally and
distally to the defect. Periosteum of the mandible to
be reconstructed is usually preserved.
2. Adequate measurement of the defect is possible: the
plate is placed over the intact mandible and holes
are drilled proximally and distally to the defect.
Templates can be used for this step, which is done
before resection.
3. There must be at least two screws at each end.
4. There must be good soft tissue coverage.
5. To achieve and maintain good occlusion, temporary
intermaxillary fixation can be used during the place-
ment of the plate; this is optional.
6. Free nonvascularized bone graft must not be done at
the primary procedure when the oral cavity is entered.
There is a danger of osteomyelitis.
7. Do not denude bone graft.
8. Internal fixation is preferred using plates, wires, or
screws.
9. The length of a free nonvascularized bone graft must
be no greater than 5 em because of a problem of
cortex "disintegrating."
 CYSTS AND TUMORS INVOLVING THE MANDIBLE
Reconstruction of the Mandible Using
Plates With or Without Free Autogenous
Nonvascularized Bone Grafts (Continued)
(Fig. 14-8)
A This step is applicable only proximal to the last
molar near or at the angle. A 2-cm resection is done of
a portion of the body of the mandible for a benign
tumor without entering the oral cavity. A plate and a
free nonvascularized bone graft are utilized.
Highpoints: B (Robert Perry)
1. Incise through the original upper neck incision,
which was made for a radical neck dissection.
2. Note danger of injury to the ramus mandibularis of
the seventh nerve.
3. Identify inferior border of the mandible and plate,
which was placed 4 months previously.
4. Open pseudocapsule around the plate with a cautery.
5. Develop pocket behind plate.
6. Stay out of oral cavity. If it is entered, terminate
procedure and come back another day.
7. Decorticate ends of the previously transected
mandible to aid the "take" of the bone graft.
8. Free bone graft from the iliac crest (no longer than
5 cm defect for bone graft).
9. Secure blocks of corticocancellous bone to the plate,
and pack remaining spaces with compressed cancel-
lous bone to improve bone density.
B Reconstruction was done with a titanium plate
with secondary iliac bone graft 4 months after the
primary procedure. A free autogenous bone graft was
obtained from the iliac crest. The second stage of the
procedure was performed without entry into the oral
cavity to prevent contamination.
B1, B2 Radiographs were taken after reconstruction.
C Incomplete resection spares the inferior margin of
the mandible where the remaining mandible is thin;
hence it requires a graft for support. A bone graft can
then be used as a secondary procedure after the oral
portion of the wound is healed as described in B.
D Virtual total hemimandibular reconstruction for
recurrent ameloblastoma is shown with plate and
attached condylar head (see Fig. 13-28D). At 15-year
follow-up the result is very good.
Potential Complications of Plate Reconstruction
• Infection
• Fracture of the plate
• Extrusion and exposure intraorally or externally
• Pain and swelling associated with infection
Other types of reconstruction are shown in Figures
14-9A to F and 14-100, E, and H. Mandibular recon-
struction has been demonstrated by using bank bone
that has been cored out and then packed with autog-
enous bone marrow from the iliac crest. The cortex of
the bank bone acts as a strut and encasement for the
autogenous bone marrow, protecting the latter from
invasion of fibrous tissue. The use of a Millipore filter
and tantalum trough packed with autogenous marrow
serves a similar purpose (DeFries et aI., 1971).
 CYSTS AND TUMORS INVOLVING THE MANDIBlE

A B

c D

FIGURE 14-8
 CYSTSAND ruMORS INVOLVING THE MANDIBLE
Resection and Second-Stage
Reconstruction of Anterior Portion of
Mandible Using Iliac Bone Graft
(Fig. 14-9)
Primary stabilization of the remammg portions of
mandible with a bent Kirschner wire (now replaced
with Steinmann pin because of increase of diameter to
reduce incidence of broken Kirschner wire) and tie wires
(see Figs. 14-5 and 14-6) has been successfully used as
a permanent restoration, with the longest period of
follow-up of one patient being 11 years and another
patient 7 years. Both patients had soft tissue recon-
struction with tongue flaps. Hence, a second-stage
reconstruction using an autogenous bone graft may be
used when there is skin breakdown over the Kirschner
wire or Steinmann pin, which is used to reconstruct the
chin. This complication can be avoided by utilizing
additional soft tissue, for example, from the pectoralis
major myocutaneous flap, which could also serve as
coverage for the floor of the mouth defect. This can
only be fully appreciated after the ablative surgery and
assessment of the availability of local tissue for cover-
age. At times, the ventral surface of the tongue and the
remaining floor of the mouth may suffice. The axiom
the simpler the better just as long as the tongue is not
tethered should be followed, and it should be ensured
that there is adequate soft tissue coverage over the
Kirschner wire or Steinmann pin.
The Gunning splints or interdental wires are offered
as an option if the surgeon is concerned about adequate
stabilization and proper occlusion. [n our experience,
these devices have not been necessary. Their avoidance,
we believe, is a great comfort to patients during the post-
operative period. A Barton-type dressing may actually
serve the same purpose.
There may be a problem with the usual pectoralis
major myocutaneous flap in that the muscular pedicle
may be too bulky to reach a small defect in the floor of
the mouth anteriorly (see Fig. 8-3C). Pectoralis major
myocutaneous flap can be then modified by developing
a long skin paddle with a randomized distal end. This
randomized portion may be satisfactory for the floor of
mouth but would not be adequate for soft tissue bulk
to cover a Steinmann pin. [n addition, increased length
can be achieved by resection of the medial third of
the clavicle (see Fig. 8-2G and pp. 1041 to 1045). An
alternative for soft tissue coverage in the floor of the
mouth is the microvascular radial forearm flap (see
Chapter 24). When the defect extends along the side of
the floor of the mouth posteriorly to the angle of the
mandible, as depicted in Figure 14-10, the pectoralis
major myocutaneous flap is an expeditious choice (see
figures in Chapter 8 relative to the pectoralis major
myocutaneous flap).
Highpoints
1. Do not compromise the extent of ablative surgery
to facilitate the reconstructive phase.
2. No incision modification is necessary with use of a
pectoralis major myocutaneous flap.
3. The incision should not overlie the planned loca-
tion of the Steinmann pin. A visor flap (Schweitzer)
is ideal if exposure is adequate.
4. Avoid ligation of the superficial temporal artery
and the posterior auricular artery if at all possible
when using a forehead flap. This flap is very
seldom used.
5. Always stage the procedure-allow a minimum of
6 to 12 weeks for autogenous free bone graft.
6. Immobilization of the mandibular fragments to the
maxilla is necessary only if Steinmann pin fixation
is not stable, and should be continued to the time
of the reconstruction phase.
7. Keep use of excessive hardware to a minimum.
8. The oral cavity should not be entered at the second
reconstruction stage.
9. Make a template for the iliac bone graft during the
first stage before the shaping of the graft. This
template is made at the time of the original ablative
surgery from the resected portion of the mandible.
10. An adequate amount of autogenous cancellous
bone appears to be the vital factor in bone graft
regeneration.
11. Tracheostomy is precautionary.
12. An option: a microvascular osteocutaneous flap does
not require a staged procedure (see Chapter 24).
Complications
• Absorption of bone graft
• Breakdown of overlying skin
• Wound infection
• Asymmetry of reconstructed mandible
A Carcinoma arises from the alveolar process with
invasion of the anterior portion of the mandible and
the adjacent floor of the mouth. The dotted line depicts
the area of resection that is combined with a radical
neck dissection in the predominant side and a suprahyoid
dissection on the opposite side. This suprahyoid dis-
section is a virtual necessity because of the extent of
the resected mandible. If nodes are positive on the
contralateral side, a complete radical neck dissection
preserving, if feasible, the internal jugular vein should
be done at another stage. On the other hand, if
staging the neck dissection involves cutting through
tumor, simultaneous neck dissection may be the lesser
of two evils. Immediate cytologic smears from the tran-

FIGURE 14-9
sected mandibular stumps are examined for evidence
of bone marrow involvement by tumor. If positive,
additional mandible is resected or disarticulation is
performed.
B The upper horizontal incision is carried across to
the opposite side (B1) and is placed well below the
chin so it does not overlie the Steinmann pin and
reconstructed mandible. The upper chin flap is then
raised as a visor without transecting the lip (see Fig.
14-10 and also Fig. 16-61).
C After the ablative surgery, the free ends of the
mandible are spaced and locked and with a Steinmann
pin bent in the manner depicted. Note that the pin
has a forward bend to simulate the projection of the
chin (see 01 and Figs. 14-5 and 14-6). A groove (kerf,
see 02) is cut in each end of the mandible for the
CYSTS AND TUMORS INVOLVING THE MANDIBLE
vertical limb of the Steinmann pin. Small tie wires
placed through drill holes help keep this portion of the
wire in position.
Depicted is an edentulous patient in whom Gunning-
type splints are fixed to the mandible and maxilla.
Only if fixation with Steinmann pin and tie wires is not
stable and there is a question of adequate and reason-
ably good occlusion should the splints be applied. This
has not usually been necessary.Circumferential wires
fix the lower splint to the mandible. A Rowe-type peri-
alveolar introducer is being inserted through the alve-
olar processof the maxilla to facilitate wire fixation for
the Gunning splint. Be certain that the bent anterior
portion of the Steinmann pin conforms to or is slightly
smaller than the portion of the mandible removed.
This avoids skin tension over the wire.
Continued
 CYSTS AND TUMORS INVOLVING THE MANDIBLE
Resection and Second-Stage
Reconstruction of Anterior Portion of
Mandible Using Iliac Bone Graft
(Continued) (Fig. 14-9)
D When a Gunning-type splint is indicated (very
rarely), the upper splint is secured to the lower splint
with the use of wire attached to the hooks in the splint.
In this manner, there is complete immobilization of the
two mandibular fragments to the maxilla in reasonably
good occlusion.
Dl Outline of Steinmann pin for reconstruction of
the chin. The horizontal portion is bent forward.
D2 Detailed view of fixation of the Steinmann pin to
the cut ends of the mandible. The depth of the kerf
should be at least the diameter of the pin. This depth
should be taken into account when calculating the
horizontal portion of the pin; for example, if the kerf is
one-eighth inch deep, then the horizontal portion of
the pin should be one-fourth inch longer.
If the area resected is such that the remammg
tongue and lip can be utilized for closure, care must be
taken so that an oral cripple does not result from a
tongue fixed to the floor of the mouth or mandible. All
suture lines must avoid tension. Avoid placing any
suture line directly over the Steinmann pin. If, on the
other hand, adequate tensionless closure cannot be
achieved with local tissue, the oral defect will require a
transposed flap. Pectoralis major, apron, forehead, or
deltopectoral flaps may be used (see Figs. 8-4A and B,
8-6A and B, 8-lOA to D, 14-5, and 14-6). These phases
of reconstruction have priority over any contemplated
bone graft and must precede a bone graft. This
reconstruction is performed at the time of the ablative
surgery to cover the Steinmann pin and the floor of the
mouth defect.
Occasionally, wound breakdown occurs or pressure
over the Steinmann pin causes skin breakdown. If the
Steinmann pin has been in place for 4 to 5 weeks,
enough fibrosis has occurred and relative fixation of
the mandibular fragments has been achieved. The hard-
ware is then removed through skin breakdown, and
reconstruction is begun 2 weeks after complete wound
healing. The problem with this complication is skin con-
tracture, which, if severe, may require a transposed flap.
E After a minimum of 6 to 12 weeks, second-stage
reconstruction may be performed. All wounds must be
well healed. If the original lesion appeared to be aggres-
sive or nodes were positive, a delay of 3 to 6 months
is preferred.
The upper horizontal cervical incision is opened. The
ends of the mandible are exposed, and the Steinmann
pin is removed. The alternate method is to leave the
pin in place and insert the bone graft. Fixation can be
with tie wires, screw, or Kirschner wire as depicted in
F. Extreme care must be used to avoid entrance into
the oral cavity. Such an inadvertent opening could cause
doom to the bone graft because of possible infection
and fistula formation.
With the fixation of the mandible to the maxilla
undisturbed, the mandibular defect is measured, or,
better yet, a template is cut from sheet plastic. An iliac
bone graft is removed as depicted in Figure 3-6. The
graft is shaped as shown in F. Kirschner wires or
Steinmann pins are inserted through the graft into
the mandibular fragments, one on each side (see
Fig.13-3F).
El Radiograph shows the wires.
F A view from above shows the iliac bone graft in
position. The mortise configuration of the graft yields
excellent support and an interlocking effect that
increases strength. It is quite easy to shape if a previous
template is cut and fitted. At this time, the upper chin
flap is tried for size over the template. Skin closure
must not be under tension. If a template is not used,
shaping the bone graft can be tedious and haphazard.
A sagittal plane saw and bone-holding forceps are
used for shaping. If the closure of the original wound
at the first stage requires a transposed flap, a pectoralis
major myocutaneous flap is used.
Closure of the cervical incision is performed without
tension. The main problem in closure may be some
dead space inferior to the bone graft. This must be
carefully closed by suturing the under layer of the skin
flap to the surrounding soft tissue deep below the
graft. Again, the advantage of the pectoralis major flap
is its bulk. Another flap that will add bulk is the levator
scapulae flap (see Fig. 22-36).
G, H These photographs show a patient who had
the procedure shown in Figure 14-9A and B with
resection of both horizontal rami of the mandible
between the first and second molar teeth bilaterally.
This location was further verified on postoperative
radiographs, which delineated the mandibulotomy at
approximately 3 cm from the angle of the mandible.
The soft tissue resection included a left classical radical
neck dissection and a right suprahyoid dissection with
floor of the mouth and ventral portion of the tongue.
The twelfth nerve was preserved bilaterally.
D

H
FIGURE 14-9 Continued
 CYSTS AND TUMORS INVOLVING THE MANDIBLE
Resection and Second-Stage
Reconstruction of Anterior Portion
of Mandible Using Iliac Bone Graft
(Continued) (Fig. 14-9)
Reconstruction
1. The upper denture is wired to the maxilla and fixed
to the lower partial denture.
2. The remaining anterior tongue is sutured to the inner
portion of the lower lip.
3. A bent Kirschner wire (this was in 1968 when a
Kirschner wire was used instead of a Steinmann pin)
was used as first-stage reconstruction of the mandible
(see Fig. 14-90' and 02). (Although tie wires were
not used at that time, there was no separation of the
Kirschner wire from the bone graft; now we would
recommend a Steinmann pin with tie wires.)
4. At 5 months postoperatively, the Kirschner wire caused
a pressure break through the skin in one area but
was not removed.
5. At 7 months the patient underwent a second-stage
reconstruction with a free iliac bone graft (see Fig.
14-9£ and F).
The patient was very satisfied with the results and
was able to eat "everything" except that meat needed to
be ground. Primary healing of the bone graft was veri-
fied radiographically.
At 3 years, the patient desired augmentation of the
mandible and cancellous bone was placed in a Millipore
filter, which in turn was placed in a Vitallium mesh. This
procedure was done without entering the oral cavity
through an incision on the inferior border of the
mandible. At 4 years, removal of Vita Ilium mesh
occurred in the vicinity of the chin. The end result was
that the patient had a primary healing of the bone graft
with good quality of life. The patient died of lung
cancer 7 years after surgery. The head and neck had no
evidence of disease.
Resection and Reconstruction of Major
Portion of Body of Mandible With Bent
Steinmann Pin and Tie Wires and
Forehead Flap (Fig. 14-10)
Although a forehead flap is an option, it is seldom
utilized. A pectoralis major myocutaneous flap is the
preference among transposed flaps, or a microvascular
free osseous or osteocutaneous flap can be utilized. The
forehead flap is a consideration when a pectoralis major
flap has already been used and the patient is not suit-
able for a microvascular flap. This may occur with radi-
ation failures, with recurrent disease at various locations
and at various times. Before the use of a forehead flap,
a contralateral pectoralis major flap is used if feasible.
It is strongly recommended that the CO2 laser not
be used in any of the resections related to the neo-
plastic lesions as depicted in this chapter, as well as in
Chapter 15. Three disasters resulted in recurrence and
advanced disease and two in early death (performed
elsewhere) .
Highpoints
I. Do not compromise the extent of resection for ease
of reconstruction.
2. When there is invasion of the inferior alveolar canal,
the tumor can spread along the inferior alveolar
canal with the inferior alveolar nerve.
3. The forehead flap may be delayed or not delayed.
If possible, delay the flap, because loss of the distal
end of this long flap can occur. Always delay the
flap when preoperative radiation has been used.
4. Preserve, if possible, ipsilateral superficial temporal
and posterior auricular arteries that supply the flap.
It is best to preserve the external carotid artery from
which these vessels arise, although some surgeons
believe that this vessel may be sacrificed (MacGregor,
1963).
5. Do not extend the inferior incision of the forehead
flap below a horizontal imaginary line extending
from the lateral canthus of the eye to avoid injury
to the zygomatic branch of the seventh nerve, which
supplies the orbicularis oculi muscle.
6. Avoid compression of a forehead flap pedicle either
by zygomatic arch or by Steinmann pin.
7. Immobilize mandibular remnants with a bent
Steinmann pin and tie wires (see Figs. 14-5 and
14-6).
8. Use extreme care to approximate the oral mucosa
surrounding the mandibular remnants to the edges
of the forehead flap.
9. At the reconstructive stage, performed 6 weeks or
later, the following is accomplished:
a. Forehead flap is divided and the pedicle is returned
to the donor site.
b. Orocutaneous fistula is closed.
c. If there is sufficient soft tissue present and the
wound is not contaminated by the orocutaneous
fistula, additional mandibular reconstruction can
be performed if desired by the patient, such as
free autogenous bone grafting (see Fig. 14-9);
otherwise, it is delayed until a later stage. Addi-
tional soft tissue can be obtained from a pec-
toralis major or deltopectoral flap.
10. Secondary mandibular reconstruction can be accom-
plished by one of the following methods, although
this is usually not necessary.
a. Iliac bone graft (see Fig. 14-9).
b. Frozen bone bank mandible is hollowed and
packed with autogenous cortical bone.

FIGURE 14-10
c. Millipore filter with tantalum trough packed with
autogenous medullary bone
d. Plastic replacement
e. Other methods as outlined under Mandibular
Reconstruction
11. Two of the most important dicta for mandibular
reconstruction are the noncontaminated wound
and adequate immobilization of any type of bone
graft. Immediate reconstruction using a bone graft
is usually not successful.
12. Do not shave scalp hair in the region of the distal
portion of the forehead flap that will be used for
the reconstruction, thus avoiding hair-bearing tissue
in the flap.
A Horizontal skin incisions are utilized for the radical
neck dissection, thus forming a type of visor flap over
the mandible. Thus, the lower lip is not transected in a
vertical plane unless exposure demands otherwise. Then
an incision is made just medial to the opposite com-
missure of the lips (Robson). Exposure is a sine qua
CYSTS AND TUMORS INVOLVING THE MANDIBLE
non, and more often than not this incision is necessary.
The base of the forehead is depicted with a posterior
extension to include the posterior auricular artery as
well as the superficial temporal artery. The inferior
incision of the forehead flap does not extend below
the level of the lateral canthus of the eye, thus sparing
the zygomatic branch of the seventh nerve to the
orbicularis oculi muscle.
A 1 Anterior view of the extended forehead flap. The
utilized portion of the flap should be not be hair bear-
ing. A delay of 2 weeks is recommended, especially if
the patient has had preoperative radiation therapy,
because the blood supply of the remaining tissue in the
ablative area may be poor. Because the author treats
all patients with stage III and IV disease with preoper-
ative induction chemotherapy, the delay is of no con-
cern. Very few patients are not candidates for the
chemotherapy (see Chapter 3).
Continued
 CYSTS AND TUMORS INVOLVING THE MANDIBLE
Resection and Reconstruction of Major
Portion of Body of Mandible With Bent
Steinmann Pin and Tie Wires and
Forehead Flap (Continued) (Fig. 14-10)
B Depicted is the lesion that extends across the mid-
line with direct involvement of the mandible, the floor
of the mouth, and the ventral portion of the tongue.
The dotted lines indicate the lines of resection. Exten-
sion of the resection to include a portion of the base of
the tongue and tonsillar region can be performed and
the defect closed very satisfactorily with the forehead
flap when it is delivered into the oral cavity via the sub-
zygomatic approach (see Fig. 8-10A to D). Nonethe-
less, a pectoralis major myocutaneous flap is preferred
for this extensive reconstruction.
C The operative site is shown after the ablative sur-
gery, which consists of a left radical neck dissection;
right suprahyoid neck dissection; and resection of a
major portion of the body of mandible, floor of mouth,
and partial ventral glossectomy. The chin visor flap is
elevated upward, and the forehead flap is mobilized.
At the time of bone transection immediate cytologic
smears can be made to evaluate cancellous bone spread
of the neoplasm.
D A bent Steinmann pin with two tie wires at each
end has been inserted to stabilize the mandibular rem-
nants following the technique depicted in Figures 14-5
and 14-9D1. The forehead flap is sutured in place
using continuous 3-0 sutures for the mucosa to skin
layer. Interrupted second and third layer sutures are
placed for additional support. The forehead flap enters
the wound at the posterior end of the upper horizontal
cervical incision (Millard). The inferior margin of the
flap now becomes superior or anterior and is sutured
to the mucosa of the lower lip. The superior margin of
the flap now becomes the inferior or posterior margin
and is sutured to the remaining portion of the tongue,
the floor of the mouth, if any remains, and the mucosa
overlying the ends of the mandible. It is this latter area
in which extreme care is necessaryfor watertight closure
without tension. Two Jackson-Pratt suction systems are
used as well as a firm dressing to aid in immobilization
of the mandible. If breakdown does occur, proper local
care will usually result in satisfactory healing.
The donor area is covered with one continuous split-
thickness skin graft taken, if feasible, from the anterior
chest wall, if not hair bearing, or from the thigh. A word
of caution regarding the entrance of the forehead flap
through the upper cervical incision: if the flap crosses
the Steinmann pin or it is in any way kinked, it is safer
to bring the flap into the oral cavity via the subzygo-
matic approach, as depicted in Figures 8-1 OA to D.
E Closure of wound shows the entrance of the flap and
the small orocutaneous fistula (arrow). A split-thickness
skin graft from the thigh is used as a temporary dressing
over the exposed pedicle of the flap. Secondary recon-
struction in the author's experience in most patients
has not been necessarywith the proper use of the bent
Steinmann pin and tie wires when this has been com-
bined with adequate soft tissue coverage, utilizing the
pectoralis major myocutaneous flap. Nevertheless,
several methods are depicted in the following steps.
Continued
 CYSTS AND TUMORS INVOLVING THE MANDIBLE

Inside of lower lip and chin visor flap

Forehead flap

Tongue

FIGURE 14-10 Continued

 CYSTS AND TUMORS INVOLVING THE MANDIBLE
Resection and Reconstruction of Major
Portion of Body of Mandible With Bent
Steinmann Pin and Tie Wires and
Forehead Flap (Continued) (Fig. 14-10)
F This demonstrates the much preferred pectoralis
major myocutaneous flap. It is brought under the
upper neck flap, reaching the oral cavity via the site of
the previously resected mandible and preferably under
or over the Steinmann pin. The distal skin paddle with
muscle forms the floor of the mouth and lateral border
of the tongue. If there is not enough bulk, especially
anteriorly, a contralateral pectoralis major myocuta-
neous flap is brought up anteriorly to close the defect.
If a contralateral pectoralis major myocutaneous flap is
used, a pedicle is necessary as depicted in Figure 8-2N
and 0, to avoid "violating" the contralateral neck. The
other course would be to do a simultaneous bilateral
neck dissection preserving the internal jugular vein on
the contralateral side or use a levator scapulae muscle
flap (see Fig. 22-36). Bilateral simultaneous radical
neck dissections can be a problem and ordinarily are
not advised. The cervical lower chin flaps cover the
Steinmann pin. Care must be taken to avoid as much
tension as possible over the pin. At times the pin
projection may have to be lessened to avoid this
pressure. No suture line should be performed over the
Steinmann pin.
G This is a schematic sagittal view through the ante-
rior area of the reconstruction. The distal portion of
the skin paddle of the pectoralis major flap is sutured
to the inner aspect of the lower lip. Every attempt is
made to form a sulcus between the lip and the flap.
The proximal end of the skin paddle is sutured to the
remaining mucous membrane of the oral cavity or
oropharynx depending on the extent of the defect. A
portion of this proximal skin paddle may be used to
cover a portion of the horizontal bar of the Steinmann
pin as well as other bare areas. The horizontal bar of
the Steinmann pin is covered by local tissue because it
is inferior to the level of the mandible. There are times
depending on the amount of soft tissue that the
pectoralis major flap is more adapted to pass over the
horizontal bar of the Steinmann pin. Decision to place
the pectoralis major flap over the horizontal bar is
based not only on the amount of local soft tissue but
also on the premise that there must not be any com-
pression of the pectoralis major flap by the Steinmann
pin. At times, a levator scapulae muscle flap can like-
wise be used to give bulk deep to or up to the hori-
zontal bar on the pin (see Fig. 22-36).
H Depicted is the use of Vitallium mesh formed in
the shape of a trough or cage. Within the trough are
packed portions of medullary bone taken via a trephine
(2 to 2.5 cm) opening made in the iliac bone. Richter,
Sugg, and Boyne (1968) suggest the use of a Millipore
filter (cellulose acetate with a size of 0.45 ~m) to line
the trough to prevent the invasion of fibroblasts into
the fragments of the medullary bone. Fixation of the
Vitallium mesh to the remnant ends of the mandible
must be firm, with adequate immobilization of all por-
tions of the mandible. Cuts in the mesh are made in
unopposing fashion to facilitate contouring the mesh.
Small screws are placed at each end of the mesh into
the remaining stumps of the mandible. This type of
reconstruction, as all types, should be performed as a
second stage through an external incision that does
not violate the oral cavity. There must be a sterile field.
Immobilization of the reconstructed mandible must be
complete. A serious drawback is the breakdown of over-
lying skin. Corgill and Han have introduced preformed
mandibular replacement sections of Vitallium mesh for
mandibular reconstruction. Conley has devised VitaIlium
mandibular bars with flanged ends for fixation to the
transected ends of the mandible.
Summary
Although the use of the forehead flap in secondary
reconstruction as described has been utilized, the author
prefers the Steinmann pin system with a primary pec-
toralis major myocutaneous flap as the definitive one-
stage method of reconstruction. Free microvascular
cutaneous and iliac bone grafts are an option (see
Chapter 24). The discussion under H may be primarily
of historical interest. However, the use of medullary
bone is important as "packing" around or in spaces
where free nonvascularized bone is utilized.
 CYSTS AND TUMORS INVOLVING THE MANDIBLE

tongue
-contralateral
side
skin paddle
genioglossus m. -ipsilateral
side
geniohyoid m. pect. major
flap

Lateral View
F G

H
FIGURE 14-10 Continued
 CYSTS AND TUMORS INVOLVING THE MANDIBLE
Marginal Resection of Mandible, Partial
Glossectomy, and Radical Neck Dissection
for Carcinoma of the Floor of the Mouth
(Fig. 14-11)
The concept of marginal and total resection of the
mandible has changed appreciably. The evidence that
the lymphatic channels draining the floor of the mouth
and tongue pass directly into the periosteum of the
mandible has been questioned (Marchetta et aI., 1964).
Hence, it would appear that too many mandibles have
been unnecessarily resected when the tumor has not
directly invaded the periosteum. When the mandible
itself is involved, there is no question that mandibular
resection must be performed. It is the opinion of the
author that when this has occurred a more extensive
resection of the mandible should be performed, because
spread of the tumor may well occur along the neuro-
vascular bundle. The crux of the problem is deciding
what is an adequate distance between gross disease
involving the floor of the mouth and the periosteum of
the mandible. MacGregor makes an important point-
invasion of mandible is more likely via a tooth socket.
If there is any question about resection when the
tumor is close to the mandible without evidence of
invasion, it still seems best to perform a marginal
resection of the mandible rather than leave the
mandible intact. On the other hand, if the lesion is in
contact with the mandible and there is the slightest
doubt as to the involvement of bone (see Chapter 3),
one of us (JML) now reverts back to resection of the
entire segment of mandible, with immediate stabiliza-
tion and reconstruction of the mandible using Steinmann
pin with tie wires (see Figs. 14-5 and 14-6). The results
have been satisfactory, being comparable to those of
marginal resection as far as cosmesis and function are
concerned. Another method of reconstruction is the
use of a plate (see Fig. 14-8).
When there is an inadequate amount of local soft
tissue present for closure, thus binding down the tongue
and cheek, a transposed pectoralis major myocutaneous
flap, apron flap, forehead flap, or deltopectoral flap (for
all, see Chapter 8) is indicated to keep the patient from
becoming an oral cripple. A microvascular free flap with
or without an osseous component is another option. It
must be appreciated that there is no flap that can
function as normal tongue. In the past, possibly the
resection of the entire body of the mandible was
prompted by ease of closure of the operative defect
rather than adequate ablative surgery.
When the mandible is preserved, a pull-through
procedure can be performed. The problem with this
procedure is that there is restriction of exposure. It is
usually better to transect the mandible and then to
rewire the cut ends of the mandible with a short
Kirschner wire or Steinmann pin, both with tie wires
for stabilization.
The following technique is based on the concept of
the so-called mandibular swing, which is further depict-
ed in Figure 23-7. It is important to note that most
radiation oncologists prefer not to treat any portion of
the mobile tongue.
Highpoints
I. Perform tracheostomy.
2. Resect liberal portion of the tongue.
3. Remove entire inner cortex and alveolar ridge of
hemimandible.
4. Resect all tissue in continuity.
5. Remove all fragments of teeth with exposed roots.
The transection of the mandible should pass through
an extracted tooth socket rather than between two
teeth.
6. Avoid creating an oral cripple by judicious use of
transposed flaps and grafts.
A Anesthesia can be commenced under general
endotracheal intubation and the tracheostomy per-
formed at the close of the operation. An alternative
method is to perform the tracheostomy under local
anesthesia and then convert to general anesthesia. In
any event, an extension on the tracheostomy tube with
an anesthesia adaptor and cuff is routine. The original
design was a metal tube (Lore-Lawrence) with an exten-
sion for anesthesia and an applied cuff.
The neck dissection incision is as depicted as an alter-
native dotted line medial to the commissure (Robson).
Other alternate neck dissection incisions are depicted
in Figures 16-6. Regardless of the incision chosen, the
extension through the lower lip is not made until the
upper portion of the neck dissection is reached.
B Cross-sectional view demonstrates the area of
resected tissue at the level of the primary lesion in the
floor of the mouth. A partial glossectomy is included.
The marginal resection of the mandible includes the
alveolar ridge and the entire inner cortex of the body
of the mandible.
 CYSTS AND TUMORS INVOLVING THE MANDIBLE

o Hyoid bone

FIGURE 14-11

C Diagrammatic surface view shows the portion of
the tongue, floor of mouth, and alveolar ridge that is
resected. Because the lesion is located anteriorly, the
resection of the alveolar ridge extends beyond the
midline.
D A classic radical neck dissection is performed (see
Fig. 16-3) except if there are no clinically positive
nodes in the upper internal jugular chain. If this is the
case, then the spinal accessory nerve is preserved.
Continued
 CYSTS AND TUMORS INVOLVING THE MANDIBLE
Marginal Resection of Mandible, Partial
Glossectomy, and Radical Neck Dissection
for Carcinoma of the Floor of the Mouth
(Continued) (Fig. 14-11)
E The submental triangle is then dissected, removing
all nodes and adipose tissue across the midline to the
opposite anterior belly of the digastricus muscle.
Separation of the cheek flap from the outer cortex of
the mandible is begun, leaving the periosteum intact.
This incision is made along the gingivobuccal sulcus.
F The insertion of the anterior belly of the digastricus
is cut. One tooth is extracted at the site of transection
of the mandible. Drill holes are made for the tie wires
plus kerfs to recess tie wires. A clamp is inserted
through the floor of the mouth close to the mandible,
and the Gigli saw is drawn through.
\
FIGURE14-11 Continued
G With the Gigli saw or sagittal plane saw preferably,
the upper half and inner half of the mandible is cut.
The transection is through the middle of the tooth
socket so the remaining teeth are not devitalized. To
cut between the two teeth would jeopardize the via-
bility of the remaining teeth. The direction is then
changed 90 degrees to the horizontal, and the cut is
extended across the midline as shown by the dotted
line. An attempt is made to resect the inner cortex of
the lower portion of the mandible that remains. If this
is not possible, it is removed separately with a sagittal
plane saw (G1). Any tooth fragmentsare removed.
H The tongue is split down the midline to the pos-
terior third and then the incision is curved laterally.
The mylohyoid musclesare separated along the raphe.
The cheek flap is further mobilized to a point beyond
the last molar tooth. The dotted line is the cut to free
the upper and inner margin of the mandible to be
resected.
Continued
Ant. belly digastricusm.
Submax.salivary gland
Hyoid bone
 CYSTS AND TUMORS INVOlVING THE MANDIBLE

F G

FIGURE 14-11 Continued

 CYSTSAND TUMORS INVOLVING THE MANDIBLE
Marginal Resection of Mandible, Partial
Glossectomy, and Radical Neck Dissection
for Carcinoma of the Floor of the Mouth
(Continued) (Fig. 14-11)
I A sagittal plane or coping saw is used to resect the
inner cortex and alveolar ridge of the mandible. The
coping saw is ideal, because its flexibility permits it to
follow the natural contour of the bone; however, this
saw is rarely available anymore. The outer cortex is
stabilized with a bone-holding forceps, with care taken
not to fracture the bone. This horizontal cut is through
the base of the tooth socket. If a portion of any tooth
remains in the retained mandible, it is removed. The
cut is best done to clear all teeth. However, enough
mandible is left for support.
J TO L The angle and extent of the mandibular
resection are shown in these schematic drawings
the mandible. In J the outer aspect is demonstrated;
is an end-on view; L shows the inner aspect.
M The incision is then carried across the posterior
third of the tongue anterior to the circumvallate papillae.
This incision reaches the saw cut behind the region of
the last molar tooth.
The remaining portion of the mandible is retracted
outward, again with extreme care not to fracture the
bone, exposing the structures between the resected
portion of the tongue and the inner resected portion of
the mandible. These include the sublingual gland and
adjacent muscles, that is, the hyoglossus, genioglossus,
geniohyoid, and mylohyoid. All these structures are
removed in continuity with the standard neck dissec-
tion. The anterior and posterior bellies of the digas-
tricus muscle as well as a portion of the stylohyoid
muscle are likewise included with the contents of the
digastric triangle, that is, the submaxillary salivary gland
and lymph nodes in continuity if possible with the
radical neck dissection. The lingual and hypoglossal
nerves are also sacrificed. All the previously mentioned
muscles that are attached to the hyoid bone are
resected close to the hyoid bone, leaving the bone
intact.
N Reconstruction is begun by stabilizing the mandible
using a short section of a Steinmann pin inserted in
either end of the exposed marrow cavity. A piece of
stainless steel or malleable silver wire is passed through
the holes and twisted tight.
Continued
It is at this point of the operation that a decision is
made regarding the use of a transposed distant flap.
This decision is based on a number of factors:
of
K
1. General condition of patient as to ability to tolerate
additional operating time
2. Availability of sufficient soft tissue to cover the
mandible or, if totally resected (segmental resection),
to cover the Steinmann pin or Kirschner wire
3. Evaluation as to whether a transposed flap will lessen
the fixation of the tongue and lessen the possibility
of an oral cripple
If a transposed flap is utilized, the pectoralis major
myocutaneous flap is preferred. Additional length of
this flap can be achieved by removing the medial third
of the clavicle, if necessary (see Fig. 19-9).
A radial forearm cutaneous osseous flap could be used
for lining of the oral cavity and mandibular support.
However, there may not be enough soft tissue bulk.
Support, if necessary, may be accomplished with a
mandibular plate. At the second stage a free autoge-
nous bone graft could be used (see Fig. 14-8C).
 CYSTS AND TUMORS INVOLVING THE MANDIBLE

FIGURE14-11 Continued
 CYSTS AND TUMORS INVOlVING THE MANDIBLE
Marginal Resection of Mandible, Partial
Glossectomy, and Radical Neck Dissection
for Carcinoma of the Floor of the Mouth
(Continued) (Fig. 14-11)
o Three or four 2-0 chromic catgut sutures are used
as the first layer of the soft tissue closure. These sutures
pass through the muscles of the tongue, go under the
mandible, and include any soft tissue remaining above
the hyoid bone and thence grasp the platysmal musCle
in the skin flap. They are tied over the mandible. See
the figures in Chapter 8 for closure using a pectoralis
major myocutaneous, apron, forehead, or deltopectoral
flap. Pectoralis major myocutaneous flap is preferred.
In any event, to minimize dysphagia the tongue should
not be tethered. This flap or free microvascular flap will
aid in the formation of lingual vestibule so necessary
for prosthodontic reconstruction (see Chapter 3). Other-
wise a secondary procedure may be necessary.
P A second layer of mattress sutures of 3-0 chromic
catgut is used to approximate the tongue musculature
to the platysma. The exposed mandible is covered
with this row of sutures by including a portion of the
opposite skin flap and the floor of the mouth.
Q A third layer of mucosal sutures of 3-0 chromic
catgut completes the intraoral reconstruction. Before
the lower lip is closed, 0.5 to 1.0 cm of the lower lip
on the cheek flap may be excised to tighten the lip
reconstruction. This tends to prevent any drooling.
The lower lip is approximated in three layers-mucosa,
muscle, and skin-using 5-0 nylon for the vermilion
and skin closure. The vermilion line must be exactly
approximated.
R The neck incisions are closed in two layers using
continuous 4-0 chromic catgut for the platysmal
muscle and 5-0 continuous nylon for the skin. Suction
(Jackson-Pratt) catheters as used in the standard neck
dissection complete the operation.
The pectoralis major myocutaneous flap reconstruc-
tion is depicted in Figures 14-lOE to G. The flap may be
brought over the posterior aspect of the resected margin
of the mandible or enter the oral cavity under the pos-
terior aspect of the body of the mandible. Choice depends
on minimum pressure of the flap by the mandible.
Rl The pectoralis major flap keeps the contralateral
mobile tongue in a more natural position. The problem
with the flap is that it is adynamic.
Complications
• Fracture of remaining mandible
• Dysphagia
• Lack of adequate lingual vestibule
 CYSTS AND TUMORS INVOlVING THE MANDIBLE

FIGURE 14-11 Continued

 CYSTS AND TUMORS INVOlVING THE MANDIBLE

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Anand SV, Davey WW, Cohen B: Tumours of the jaw in West Africa. of mandibular defects using a split sternum pectoralis major
Br J Surg 54:901-917,1967. osteomusculocutaneous transfer. Br J Plast Surg 34: 11-16, 1981.
Anderson R: Prosthetic replacement of the hemisected mandible. Gregor RT, Davidge-Pitts KJ: Trapezius osteomyocutaneous flap for
Cleve Clin Q 25: 18-20, 19S8. mandibular reconstruction. Arch Otolaryngol 111:198-203, 1985.
Anlyan AJ: Immediate reconstruction of mandibular defects with Heck WE: Odontogenic tumors and cysts. Laryngoscope 62:1097-1111,
autogenous bone chip grafts_ Am J Surg 110:564-567, 1965. 1952.
Arlen M, Tollefsen HR, Huvos AG, Marcove RC: Chondrosarcoma of Hollinshead WH: Anatomy for Surgeons, Vol I, The Head and Neck.
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Atkinson CH, Harwood AR, Cummings BJ: Ameloblastoma of the jaw. Ju DMC: Localized anesthesia of the mental nerve: A significant sign
Cancer 53:869-873, 1984. of cancer of the mandible. Am J Surg 110:573-579, 1965.
Barrs OM, Helms CA, Katzberg RW, Dolwick MF: Arthrotomography Lawson W, Loscalzo U, Baek S, et al: Experience with immediate and
of the temporomandibular joint. Arch Otolaryngol 107:337-339, delayed mandibular reconstruction. Laryngoscope 92:5-10, 1982.
1981. Lee KW, Loke SJ: Squamous cell carcinoma arising in a dentigerous
Bernstein PE, Bone RC, Feldman PS: Ewing's sarcoma of the mandible. cyst. Cancer 20:2241-2244, 1967.
Ann Otol Rhinol Laryngol 88:105-108, 1979. Leipzig B, Yau PC: Pindborg tumor of the mandible_ Otolaryngol Head
Boyne PJ: Regeneration of alveolar bone beneath cellulose acetate Neck Surg 90:69-74, 1982.
filter implants. J Dent Res 43:827, 1964. Lowell SH, Mathog RH, Maisel RH: Combined flap wire reconstruc-
Broadbent TR, Woolf RM: Vertical ramisection for prognathism. Plast tion of the oral cavity. Ann Otol Rhinol Laryngol 87:340-345, 1978.
Reconstr Surg 60:735-743, 1977. MacDougall JA: Management of surgical mandibular defects. Am J
Bromberg BE, Song IC, Radlauer CB: Surgical treatment of massive Surg 110:562-563, 1965.
bony ankylosis of the temporomandibular joint. Plast Reconstr Surg MacFee W: Transverse incisions for dissections. Ann Surg 151.
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Brown KE: Fabrication of implant supportive frame for autogenous MacGregor IA: The temporal flap in facial cancer: A method of repair.
bone marrow graft in mandibular reconstruction. Proceedings of Third International Congress of Plastic Surgery, Washington, DC,
the Tenth Annual Cancer Congress, Houston, Texas, May 1970. 1963.
Cantania V, Molinari R: Surgical removal of the mandible and pros- McGuirt WF, Scruggs MS, Koufman JA: Hypercalcemia secondary to
thetic replacement of the lower jaw_ Proceedings of the Tenth a pseudoparathormone-secreting ameloblastoma. Arch Otolaryngol
International Cancer Congress, Houston, Texas, May 1970. 107:487-490, 1981.
Cesteleyn LM, Boateng EA: Surgical correction of mandibular prog- McQuarrie DG: A simple prosthesis for immediate functional restora-
nathism with a functionally stable osteosynthesis of the mandibu- tion of the mandible after surgical treatment for advanced oral
lar body. Br J Plast Surg 36: 16-21, 1983. cancer. Proceedings of the Tenth International Cancer Congress,
Chambers RG, Mahoney WD: Osteogenic sarcoma of the mandible: Houston, Texas, May 1970.
Current management. Am J Surg 36:463-471,1970. Marchetta FC, Sako K, Badillo J: Periosteal lymphatics of the mandible
Cislaghi E, Cantania V: Constructive evolution of the immediate and intraoral carcinoma. Am J Surg 108:505-507, 1964.
mandibular prosthesis. Proceedings of the Tenth International Millard DR, Campbell RC, Stokley P, Garst W: Interim report on
Cancer Congress, Houston, Texas, May 1970. immediate mandibular repair. Am J Surg 118:726-731, 1969.
Conley JJ: A technique for immediate bone grafting in treatment of Millard DR, Dembrow V, Shocket E, et al: Immediate reconstruction
benign and malignant tumors of the mandible and review of 17 of the resected mandibular arch. Am J Surg 114:605-613, 1967.
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DeFries HD, Marble HB, Sell KW: Reconstruction of the mandible: resection of the anterior arch of the lower jaw. Plast Reconstr Surg
Use of a homograft combined with autogenous bone and marrow. 39:153-161,1967_
Arch Otolaryngol 93:426-432, 1971. Miyamoto Y, Tani T: Reconstruction of mandible with free osteOCu-
Dingman RO, Constant E: A fifteen year experience with temporo- taneous flap using deep circumflex iliac vessels as the stem. Ann
mandibular joint disorders: Evaluation of 140 cases. Plast Reconstr Plast Surg 6:3S4-361, 198!.
Surg 44:119-124,1969. Mladick RA, Horton CE, Adamson JE, Carraway J: A simple tech-
Dingman RO, Crabb we, Oneal RM. Ponitz RJ: Sternocleidomastoid nique for securing a K-wire to the mandible. Plast Reconstr Surg
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Giordano A, Brady 0, Foster C, Adams G: Particulate cancellous mar- Pathol 54:625-636, 1970.
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90:2017-2036, 1980. Edinburgh, E & S Livingstone, 1968.

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Sanerkin NG: Malignancy, aggressiveness, and recurrence in giant
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Schwartz HC: Osteonecrosis of the jaws: A complication of cancer
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Shore NA, Schaefer MC: Temporomandibular joint dysfunction. NY
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Sharp GS, Helsper JT: Radiolucent spaces in the jaws. A new guide
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Shramek JM, Rappaport I: Panoramic radiography in head and neck
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CYSTS AND TUMORS INVOlVING THE MANDIBlE 697
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414-418,1981.
Stenstrom SJ: New technique for intraoral rami section of mandible.
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Thompson ERE: Sagittal genioplasty: A new technique of genio-
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 15 ORAL CAVITY AND
OROPHARYNX
The discussion of basic mandibular resection and recon-
struction in Chapter 14 also included oral cavity and
oropharyngeal malignant neoplasms. The references to
Chapter 14 are as follows:
Floor of the mouth: pages 678 to 682, Figure 14-9
Floor of the mouth and tongue: pages 682 to 695,
Figures 14-10 and 14-11
Parapharyngeal space: see Chapter 23
Other approaches to the oropharynx are in Chapters 14,
20,21 (see Fig. 21-5), and 23.
Excision of Dysplasia (Leukoplakia)
and/or Erythroplasia (Erythroplakia)
of Tongue and Buccal Mucous
Membrane (Fig. 15-1)
When areas of "leukoplakia" and "erythroplakia" (both
clinical, not histologic, terms) fail to respond to the
conservative treatment of oral and dental hygiene,
vitamin B complex, and elimination of irritants such as
alcohol and smoking, local surgical excision is indi-
cated. Retinoids, calcipotriol, and bleomycin applied
topically have been variably successful in the treatment
of oral leukoplakia.
Discussion
The differential clinical diagnosis of leukoplakia, or a
white patch, runs the gamut, indicating some type of
keratosis, fungus infection, or lichen planus as well as
other less common disease processes. Hence, all white
patches are not precancerous. There is a high probability
of this condition especially in the user of tobacco
whether through the smoking form (cigarettes, cigar,
pipe) or the smokeless form (snuff or chewing tobacco).
The cytologic and histologic examination is thus vital,
because either leukoplakic or erythroplakic lesions can
be various forms and degrees of atypia, dysplasia,
carcinoma in situ, or squamous cell carcinoma with
microinvasion, or in some areas they can be associated
with frank invasive squamous cell carcinoma.
Atypia is a cytologic abnormality characterized by
hyperchromatic nuclei and an increased nucleocyto-
plasmic ratio, whereas dysplasia (in various degrees) is
698
a histologic abnormality characterized by atypical cells
arranged in a disorganized pattern involving various
degrees of thickness within the still benign epithelium.
Lichen planus has been associated with squamous
cell carcinoma, occurring either simultaneously or at a
later date. Whether there is a causal relationship between
these two entities is a moot question. A careful exami-
nation of all cutaneous surfaces should be performed
when lichen planus is suspected.
There may be an etiologic relationship between
Candida albicans and leukoplakia. Cawson (1966) has
supported this theory by experimental work in the chick
embryo, showing that Candida implanted on respiratory
epithelium will cause squamous metaplasia and keratosis.
Thus, in the medical management of leukoplakia every
effort should be made to treat Candida if it is present.
Local use of mycostat (Nystatin) in the form of vaginal
suppositories placed in the oral cavity or by oral sus-
pension-I mL (100,000 units], dropped in the mouth
four times daily and held in the mouth for as long as
possible before swallowing-appears warranted. This
antifungal agent may likewise be used systemically, yet
its absorption into the plasma is minimal. Ketoconazole
(hepatic toxicity) is another septicemic antifungal
agent with rather rapid plasma levels.
Highpoints
1. Full-thickness mucous membrane excision is needed.
2. Primary closure is done.
A, B The area of leukoplakia along the lateral border
of the tongue is excised. Closure is facilitated in a staged
fashion as the excision proceeds. This aids in retraction
and hemostasis.
C, D Leukoplakia on the undersurface of the tongue
is excised in a similar fashion, taking care not to obstruct
Wharton's duct with any sutures.
E, F Using similar technique, a lesion of the buccal
mucous membrane is excised. For large areas involving
this region, wide undermining of mucous membrane
allows primary closure. Interference with Stensen's duct
is to be avoided.
 ORAl CAVIlY AND OROPHARYNX

FIGURE 15-1
 ORAl CAVITY AND OROPHARYNX
Excision of Dysplasia (Leukoplakia)
and/or Erythroplasia
(Erythroplakia) of Tongue and
Buccal Mucous Membrane
(Continued) (Fig. 15-1)
The specimen must be carefully labeled as to the exact
location for a serial histologic study to rule out invasive
carcinoma. This can be done with sutures or by apply-
ing silver nitrate to one edge (Jobe and Briggs). Addi-
tional surgical resection is then indicated.
In the evaluation of leukoplakia, erythroplakia, or
other questionable intraoral lesions, staining (in situ)
with 1% toluidine blue has proved helpful (Shedd and
Strong). The area is cleansed with 1 % acetic acid; the
dye is applied, and then the area is cleansed with the
acetic acid and water. Suspicious areas will stain a very
deep blue. False-positive results are due to inflammatory
ulcers, trauma, and debris characteristically located on
the dorsum of the tongue. Remember, false-negative results
also occur, and excisional biopsy must be performed.
Excision of Carcinoma In Situ or
Small Limited Carcinoma of
Tongue (Fig. 15-2)
Highpoints
1. Adequate lateral and deep margins are obtained.
These must be checked by histologic sections,
preferably frozen section.
2. Full thickness of tongue is excised where possible.
3. Stay suture of heavy silk is used through the tip or
edges of the tongue for exposure.
A An elliptical excision is made around a midline,
centrally located lesion.
B The depth of the resection reaches below the level
of the floor of the mouth. Bleeding will occur along
the lateral margins from branches of both lingual
arteries. Careful hemostasis is necessary. A deep layer
of 3-0 chromic catgut sutures is placed, followed by
deep mucosal sutures of nylon.
C The completed closure is shown.
D A laterally located tumor is easily excised with a
through-and-through incision.
E, F A single through-and-through interrupted layer
of sutures of nylon facilitates closure.
G For midline tumors located at the tip of the
tongue, a V-type of resection is performed. Again the
incision is through the entire thickness of the tongue.
H Closure is begun posteriorly where a deep layer of
3-0 chromic catgut is passed through the lateral borders
of the defect and the floor of the mouth. The more
anterior sutures of nylon are tied on the underside of
the tongue.
I A second muscle layer of 4-0 chromic catgut is
used.
J The mucosa is approximated with nylon.
 ORAL CAVilY AND OROPHARYNX

I
j

FIGURE 15-2
 ORAl. CAvrTY AND OROPHARYNX
Excision of Small Midline Cancer
of Anterior Third of Tongue
(Fig. 15-3)
Highpoints
1. Obtain adequate lateral and deep margins. These
must be checked by frozen section.
2. Full thickness of tongue is excised where possible.
3. Stay suture of heavy silk is used through the tip or
edges of the tongue for exposure.
A With traction sutures in the tip of the tongue, an
incision is made as outlined.
B The incision is carried deep to the anterior
branches of the lingual arteries, sparing them if
possible.
C A fish mouth type of dissection is utilized. Other
branches of the lingual arteries will require identifi-
cation, ligation, and transection.
D Closure is commenced in layered fashion using
chromic catgut.
E Mucosal sutures of nylon are placed deep to
include muscle.
F The final closure is shown. If any portion of the
margin loses its blood supply, debridement will be
necessary later. However, healing with adequate
function is the rule.
G If feasible, a single midline closure is preferred to
avoid the four-point closure depicted in F.
 ORAL CAVITY AND OROPHARYNX

FIGURE 15-3
 ORAl CAVI1Y AND OROPHARYNX
Median labiomandibular
Glossotomy (Trotter Approach to
Base of Tongue, Pharynx, and Base
of Skull) (Fig. 15-4)
Highpoints
1. lracheostomy is necessary.
2. Direct approach is used for large benign or low-grade
malignant lesions at the base of tongue, posterior
wall of pharynx, tip of epiglottis, and chordoma.
3. There is minimal cosmetic and functional deformity.
4. The procedure does not violate the neck for
possible future radical neck dissection.
5. Injury to superior laryngeal nerves that may be vital
for adequate swallowing is minimized. This point
is open to question, because some surgeons sacrifice
both superior laryngeal nerves, claiming that these
nerves are not essential to the act of deglutition.
6. This approach is usually not suitable when con-
comitant radical neck dissection is indicated for
high-grade malignant lesions at the base of the
tongue. The usual lateral approach is better. Com-
bined neck dissection for malignant lesions of the
pharynx is possible, but then care must be taken to
preserve the lingual arteries and external carotid
artery whence the lingual artery arises. Otherwise
there may be atrophy of half the tongue. Discon-
tinuity of the operation may also be a criticism.
7. For lesions of the posterior pharyngeal wall, this
approach must be weighed against the advantages
of the trans hyoid or suprahyoid approach (see
Fig. 21-sA).
8. All considerations taken into account, this proce-
dure has limited application but should be in the
armamentarium of all head and neck surgeons.
9. Incision through the tongue must be in "dead"
center.
10. The mandibulotomy approach with mobilization of
the mandible through the floor of the mouth and
transection of the mylohyoid muscle (so-called
mandibular "swing") is usually preferred by the
author (JML) (see Chapter 23, Fig. 23-7).
11. One advantage of this approach versus some of the
other approaches is the fact that the cheek flap is
left attached to the mandible.
A Midline incision is made after a tracheostomy. The
incision is stopped at the vermilion border. The dotted
line depicts an alternate incision made just medial to
the commissure of the lip following a natural skin
crease. Cosmetically, this may be an improvement over
the midline incision. There may be a problem, how-
ever, with this incision in that the terminal branches of
the ramus mandibularis are placed in jeopardy and are
transected.
A 1 Cross section shows the location of the three
types of lesions that can be resected via this exposure:
base of tongue, posterior oropharyngeal and hypopha-
ryngeal wall, and tip of the epiglottis.
B Four drill holes with two connecting kerfs or slats
are made before mandibular section. The kerfs facili-
tate the recession of the wires used for final closure.
Martin and colleagues (1961) recommend placement
of dental wires preoperatively to support the sectioned
mandible during the healing phase. The use of a short
section of Kirschner wire inserted into each side of the
mandible (see G) eliminates this necessity. A curved
clamp is inserted under the symphysis for the intro-
duction of a Gigli saw. A sagittal plane saw is preferred.
C The mandible is sectioned at the symphysis in
stepwise fashion with the Gigli saw, with care being
taken to avoid injury to the incisor teeth. The exposure
is carried below the hyoid bone only when additional
exposure is necessary for lesions of the extrinsic larynx.
In such instances, the hyoid bone may be transected.
Continued
 ORAL CAVIlY AND OROPHARYNX

I
'. I.
"
~1
/
~

FIGURE 15-4
 ORAL CAVITY AND OROPHARYNX
Median Labiomandibular
Glossotomy (Trotter Approach to
Base of Tongue, Pharynx, and Base
of Skull) (Continued) (Fig. 15-4)
D The tongue and suprahyoid region are then tran-
sected exactly in the midline, with the line of incision
extending downward along the mylohyoid raphe. If
the malignant lesion is large, the incision is made
along the floor of the mouth between the mandible
and the tongue. The mandible then can be reflected
farther laterally to afford more exposure-the so-called
"mandibular swing" (see Fig. 23-7). If the lingual nerve
is in the way, it is transected and then reanastomosed
at the time of closure.
E Depicted is a large benign bulky tumor, which is
resected along the dotted lines. It is unlikely to be of
minor salivary gland origin because these tumors
"practically never arise exactly in midline" (Batsakis).
Malignant salivary gland tumors (e.g., adenocystic
carcinoma), depending on their size, may require at
least a hemiglossectomy or total glossectomy. Because
they arise on the lateral border of the tongue and
spread by direct extension, margins are difficult to
ascertain, hence the radical resection of the primary
tumor. Lymphatic spread is between 14% and 16%
whereas vascular spread is significant (40% [Spiro D. By
retraction of the soft palate, exposure of the posterior
wall of the hypopharynx and oropharynx can also be
achieved for resection of large lesions. However,
similar exposure can be obtained with the transhyoid
approach. The exposure of the tip of the epiglottis is
excellent. Resection of the entire posterior wall of the
hypopharynx and oropharynx is quite easily
performed, including a portion of the nasopharynx.
Deaver retractors on either side of the split tongue
afford excellent exposure. Additional exposure can be
obtained by extending the incision on one side of the
epiglottis. Closure of a pharyngeal defect is performed
using a dermal graft.
F The lingual wound is closed in three layers using
4-0 nylon for the mucosa and 2-0 chromic catgut for
the muscular layers.
G The mandibulotomy is approximated and fixed
using a short bent section of Kirschner wire or Steinmann
pin. For added strength in muscular patients a recon-
struction plate may be used (see Fig. 13-22A). The
wire fixation is preferred with insertion in drill holes in
the medullary portion of the bone. Two wire sutures
tied or twisted and buried in the kerfs complete the
fixation. The suprahyoid muscles along the mylohyoid
raphe are then approximated in layers.
Atrophy of a portion of the tongue can occur if the
incision in the tongue has not been in the midline or if
a radical neck dissection has been performed with sac-
rifice of the external carotid artery or the lingual artery.
 ORAL CAVIlY AND OROPHARYNX

FIGURE 15--4 Continued

 ORAL CAVITY AND OROPHARYNX
Resection of Stage Tl Carcinoma
of the Midline of the Floor of the
Mouth (Fig. 15-5)
Highpoints
1. Wide local incision is done to include the distal ends
of Wharton's ducts.
2. Depth of resection depends on the extent of disease.
3. Frozen sections on margins and depth of specimen
are required.
4. Transected ends of Wharton's ducts are reimplanted
through stab wounds lateral to the resected area.
5. If the lesion is affixed to or overlying the inner table
of the mandible, a marginal resection of the mandible
is performed. An extension of the operation is then
indicated as depicted in Figures 14-11A to H and ls-GA
to £1.
6. Carcinomas that are resectable are not usually treated
with radiation; there is too much movement and no
better survival than if treated surgically.
Complications
• Obstruction to Wharton's ducts, leading to enlarge-
ment of the submandibular salivary glands
• Devitalization of tip of tongue
A Dotted lines indicate the area to be resected,
including Wharton's ducts. One or both orifices of
Wharton's ducts may be obstructed by the neoplasm.
This can cause enlargement of one or both of the
submandibular salivary glands and raises the question
of whether there is metastasis to the submandibular
triangle. Needle aspiration may be an aid in the diagnosis,
especially if the cytology is positive for metastatic
disease.
Two possible steps are then available: One is to resect
the contents of the triangle at the primary operation.
The other is to observe the submandibular area after
the reimplantation of the ducts. If the findings persist,
namely, enlargement of the submandibular glands,
then a suprahyoid dissection is usually indicated. If a
frozen section indicates metastasis, then a complete
radical neck dissection is the treatment of choice.
The depth and lateral extension of the neoplasm
determine the area to be resected. The first muscle to
be encountered directly inferior is the genioglossus and
deep to that is the geniohyoid and the mylohyoid and
skin under the chin (see p. 732).
Take care not to sacrifice both anterior branches of
both lingual arteries. It is better not to sacrifice either
lingual artery if commensurate with adequate resec-
tion. There are few, if any, vessels of the tongue that
cross the midline. This may devitalize the tip of the
tongue when the resection is extended inferiorly and
posteriorly for T2 lesions.
B Wharton's ducts have been reimplanted through
stab wounds lateral to the resected area. Three fine
nonabsorbable sutures are used to secure each duct to
the mucosa. These sutures are later removed. A small
polyethylene tube is inserted into each duct and
secured with sutures. The tubes are later removed. As
much of the defect is closed by approximation of the
mucosa as possible. The remaining mucosal defect can
be left to granulate in, or a small dermal graft can be
sutured in the defect. Careful examination of the
submandibular triangle is performed for the life of the
patient to detect early evidence of metastasis.
An extended nasolabial flap (see Fig. 6-23) (Trible,
1969) can be brought through the cheek to close larger
defects; however, the flap crosses the dental line and
this can devitalize the flap. It is seldom, if ever, used.
 ORAl CAVI1Y AND OROPHARYNX

B
FIGURE 15-5
 ORAl CAvrrv AND OROPHARYNX
Inlay Graft to Floor of Mouth for
Carcinoma (After Corso and Gerold,
1962) (Fig. 15-6)
Highpoints
1. Extended resection of carcinoma of the floor of the
mouth and juxtaposed tongue may result in a number
of disabilities owing to the absence of a labioalveolar
gutter:
a. Difficulty in swallowing
b. Difficulty in wearing a suitable denture
c. Difficulty in speech
2. Reconstruction may be achieved with split-thickness
epidermal or dermal grafts, tongue flaps, or trans-
posed flaps from the forehead (see Figs. 8-lOA to 0
and 14-10) or from the cervical region as an apron
flap (see Fig. 8-6A and B), a deltopectoral flap (see
Fig. 8-4A and B) or a pectoralis major myocutaneous
flap (PMF) (see Fig. 8-2A), or a combination of these.
A radial forearm flap is another method of recon-
struction (see Chapter 24). The depicted inlay graft
or buried stent procedure is a refinement of the skin
graft technique. The choice of procedure depends
primarily on the extent of the initial procedure.
3. This inlay graft technique may be used primarily or
secondarily. The primary method is depicted in A
through G, the secondary method in H and I.
4. It can be utilized only when the mandible is pre-
served or with marginal resection of the mandible
and may be combined with a radical neck dissection
if sufficient tongue remains.
5. When the lesion is less than 1.5 to 2 cm, a radical
neck dissection is usually not performed in the
absence of clinically palpable lymph nodes.
6. Serial computed tomography (CT) with bone windows
and an algorithm may be helpful to evaluate involve-
ment of the mandible. Direct invasion of the cortex
is rarely encountered. Firm fixation detected on phys-
ical examination is more important than the CT.
Magnetic resonance imaging (MRI) serves to evaluate
periosteum with cortex and marrow (see Fig. 15-8
and the section on bone imaging in Chapter 3).
Primary Technique
A Depicted is a cross section of a carcinoma of the
floor of the mouth juxtaposed to the mucosa at the
inner edge of the alveolar ridge. Radiographs do not
reveal bone involvement. There is no gross deep
extension. The size is just under 2 cm, and no cervical
lymph nodes are palpable nor detected on CT or MRI;
hence, no radical neck dissection is done. The area
resected is outlined.
B The margin of the mandible is resected with a
sagittal plane saw along with the floor of the mouth
and adjacent tongue. A frozen section is done to
evaluate adequate depth of resection. A portion or all
the sublingual gland is also excised, usually with
sacrifice of the lingual nerve and the submandibular
(Wharton) duct. The duct is identified at its cut end for
final suturing to the cut mucosa edge.
A rubber or soft plastic section of tubing similar in
size to a No. 24 rectal tube with a circumference of
about 3 cm is used as a stent for the skin graft. Split-
thickness epidermal skin 0.018- to 0.022-inch thick or a
dermal graft of 8 to 10 cm is wrapped around the sten!,
with the raw surface outward with the epidermal graft.
With the dermal graft, the deeper layer is outward. The
advantage of dermis over epidermis is that the dermis
contracts much less and assumes the characteristics of
mucosa more so than epidermis. Dermalon adhesive is
utilized to secure the graft to the stent with a few
interrupted 4-0 chromic catgut sutures for support. Do
not stretch the skin graft over the stent, because this
would tend to lessen the thickness of the graft.
C Before the stent with graft is buried, any sharp
edges of the cut mandible are smoothed with a rasp.
The mucosal edges of buccal wall are then approxi-
mated to the mucosa of the tongue using 4-0 nylon.
D, E Three circumferential sutures of 3-0 nylon are
then placed through the tongue musculature, around
and beneath the stent and mandible, and tied over a
gauze sponge or dental roll soaked with liquid nitro-
furazone (Furacin) or an antibiotic ointment. This
maneuver tends to eliminate any dead space and
adapts all the tissue together.
El To minimize obstruction to the submandibular
salivary gland duct, the cut proximal end of the duct
is sutured with three 5-0 nylon sutures to the cut edge
of the mucosa.
Continued
 ORAL CAVITY AND OROPHARYNX

CIRCUMFERENTIAL
SUTURE

MUCOSA
Wab~
FIGURE 15-6
 ORAL CAVITY AND OROPHARYNX
Inlay Graft to Floor of Mouth for
Carcinoma (Continued) (After Corso
and Gerold, 1962) (Fig. 15-6)
F, G In 1 week to 10 days the circumferential sutures
are removed and an incision is made directly over the
stent. The incision goes through the overlying mucosa
and the underlying skin graft. The stent is removed,
thus exposing the skin graft. No additional molds or
stents are necessary.
Secondary Technique
Although the same technique applied for primary recon-
struction is feasible in a secondary reconstruction,
Corso and Gerold (1962) have utilized an external
approach. The indications and circumstances are the
same except that scarring has already occurred with
some fixation of the tongue and absence of the
labioalveolar gutter.
H Depicted is the skin incision along the inner edge
of the mandible; the location and the length corre-
spond to the absent gutter. Dissection is continued
upward along the inner aspect of the mandible to the
oral mucosa without perforating the mucosa.
I Once the area is completely exposed, a similar
stent with skin graft is buried. The circumferential
sutures are not necessary. The skin is closed in layers.
The stent is then removed in 7 to 10 days, as shown in
F and G.
 ORAL CAVITY AND OROPHARYNX

FIGURE 15-6 Continued

 ORAl CAVITYAND OROPHARYNX
Resection of Malignant Tumors of
the Oral Cavity and Oropharynx
With Extension Above Into the
Nasopharynx and Below to the
Hypopharynx With Cervical
Metastasis With or Without
Involvement of the Mandible
Including the Parapharyngeal Space
Surgical resection in these areas is modified depending
on the location and extent of the neoplasm. The
accessibility of the neoplasm determines, for the most
part, the surgical approach. The scope of the ablative
surgery must not be reduced for any reconstructive
procedure with the assumption that postoperative
radiotherapy will "handle it." There is a marked differ-
ence of opinion regarding the treatment of the primary
tumor, whether it be by surgery alone, irradiation alone,
or a combination of both, or irradiation alone (external
beam or brachytherapy) or preoperative chemotherapy
with uncompromised surgery and selective radiotherapy
(see Chapter 3 in section on survival data including
recurrence at primary site and neck). There is little dif-
ference of opinion that metastatic cervical lymph-
adenopathy be treated by neck dissection, either classic
radical dissection usually preferred by the author (JML)
or selective neck dissection. The author (JML), depend-
ing on resectability (able to resect for cure) and oper-
ability (whether the patient is medically suitable for
major surgery) utilizes the preoperative chemotherapy
regimen. The neck dissection is usually the classic
radical neck dissection; the suprahyoid neck dissection
is used in selective situations, for example, in anterior
oral cavity lesions when there is no definitive metas-
tasis and for histologic examination and frozen section.
Remember, skipped metastasis can occur: the suprahyoid
area may be negative, yet lower in the neck may be
positive for metastatic carcinoma. If metastasis is pres-
ent, then the classic radical or modified radical neck
dissection is done. Currently, many surgeons use selec-
tive neck dissections. The other indication for the
suprahyoid neck dissection is when this is combined
with oral cavity lesions when a radical neck dissection
is done on the ipsilateral side and there is concern about
the contralateral side relative to metastatic disease.
Bilateral radical neck dissection is almost always staged.
Emphasis is placed on the importance of wide mar-
gins at the site of the primary resection to minimally
include (1) the ulcer, (2) the indurated surrounding
area, (3) any additional extent as suggested by CT or MRI,
and (4) at least some of the edematous surrounding
area and possibly all of the edematous area if feasible.
Emphasis is also placed on the spread of disease to the
parapharyngeal space (see Chapter 23).
Approaches
Approaches to these tumors depend on location and
can, in general, be accomplished by one of the follow-
ing: (1) direct intraoral; (2) mandibulotomy without
resection of mandible (see Fig. 15-7, which demon-
strates three sites); (3) resection of a portion of the
mandible; and (4) median labiomandibular glossotomy
(see Fig. 15-4). For additional approaches to the base of
the tongue see pages 732 to 741.
Discussion
The direct intraoral approach facilitates resection of the
anterior floor of the mouth, anterior mobile tongue,
buccal wall, anterior alveolar ridge, and anterior
gingiva. A mandibulotomy can be done at three sites
(Fig. 15-7):

ii
FIGURE15-7
I. Midline: Skin incision is midline, lower lip,
stepped to midportion of the chin or around natural
skin crease or just medial to the commissure through
an incisor tooth socket. It is indicated when the
neoplasm extends to the midline or anterior floor of
the mouth or originates posteriorly from the region of
the posterior or base of tongue. Otherwise avoid
this approach because of the cosmetic loss of the
incisor tooth (referred to as "mandibular swing"; see
Fig. 23-7).
Ii. Lateral: Incision is similar to that used for the
midline mandibulotomy or the area can be
approached through elevation of a mobilized superior
cervical skin flap, through the socket of the first or
second premolar tooth, just anterior to the mental
foramen through which the mental branch of the
inferior alveolar nerve passes.Thus, the mental nerve
may be preserved. It is sensory to the lower lip and
chin, and its branches "communicate freely with the
seventh cranial nerve" (Gray's Anatomy, 24th ed., p.
914). Unfortunately, transection of the lingual and
inferior alveolar nerve, which is the largest branch of
the mandibular division of the trigeminal nerve, may
ORAL CAVITY AND OROPHARYNX
be necessaryto facilitate exposure of the posterolateral
and base of tongue, lateral and posterior oropharynx,
tonsil, superior and inferior posterior alveolar ridges,
and palate, aswell as provide a limited gateway to the
inferior lateral wall of the nasopharynx and the
superior portion of the hypopharynx as well as the
parapharyngeal space (see Chapter 23, Figs. 23-2 to
23-6).
III. Region of the angle of the mandible (see Figs.
15-9A to F,17-3, and 22-33). Incision is made proximal
to the last molar tooth, thus facilitating exposure of
the base of the tongue, lateral wall of the oropharynx,
tonsil, palate, and parapharyngeal space.
To enhance this area of exposure, transection is
done of the stylomandibular ligament, with or without
removal of the styloid process, and other muscles
attached to the styloid process-the stylopharyngeus,
styloglossus,and the stylohyoid. This facilitates further
reflection of the transected mandible. Transection of
the other muscles attached to the mandible, for
example, the mylohyoid and pterygoid, may further
enhance the exposure.
 ORAL CAVITY AND OROPHARYNX
Resection of the entire body or ascending ramus or
segmental portion of the mandible is done (see Fig. 14-11).
This is primarily done when the neoplasm arises from
a tooth socket or retromolar trigone or when neoplasm
is adherent to the mandible (see Figs. 14-9 and 14-10
and 15-11).
The median labia mandibular glossotomy (Trotter
approach) (see Fig. 15-4) provides access to the base of
the skull, posterior oropharynx, superior hypopharynx,
and inferior nasopharynx.
Bone Involvement: Mandible (See also
Chapter 3)
Actual direct invasion of the cortex is rare. This usually
occurs via a tooth socket, for example, an extraction, or
periodontal regional disease or from retromolar trigone
carcinoma; it may also be related to an alveolar ridge
with absent dentition. However, if there is tumor fixed
to the periosteum and cortex, this in itself is believed
an indication to consider removing the underlying
cortex, because with removal of only the periosteum
the adjacent cortex remains and then the margin would
be a to 1.0 mm, which is hardly adequate. The answer
to this dilemma is treatment with ionizing radiation
postoperatively and preservation of the mandible. This
is not believed to be a worthy risk. It is better to remove
the adjacent bone, either the margin if possible or
segmental resection of the mandible with reconstruc-
tion. Marginal resection of the mandible can be a rather
tricky procedure unless it is on one of the presenting
ridges of the mandible. For example, in the area of the
angle a medial lateral marginal resection is not possible
whereas an anterior or posterior margin at the angle is
feasible. Whether sufficient bone remains for support is
still of concern.
The routine use of postoperative radiotherapy does
not appear warranted, especially in a younger patient
because the long-term effect of radiotherapy is very
questionable. One of the reasons for routine postopera-
tive radiotherapy is the fact that the surgeon does not
wish to remove additional mandible because of the fear
of cosmetic problems. Modern reconstructive surgery,
prosthodontics, and advanced rehabilitation should
encourage the surgeon and the patient to perform the
indicated surgery and to not compromise.
It is very interesting to compare this with some data
that were reported comparing mastectomy Ilumpectomies
in younger women and in older women. The older
women have better results than the younger women,
and it was suggested that the surgeons with the younger
women do a more conservative surgical procedure
because of cosmetics. The lead researcher in this article,
Dr. Frank Vicini of the William Beaumont Hospital in
Royal Oak, Michigan, states "you have to do bigger
surgeries to make sure you've got all the cancer cells."
Figure 15-8 is a schematic drawing that illustrates
muscles with evidence on MRI of invasion by a
neoplasm that is adherent to the periosteum (narrow
black line). The cortex appears intact, yet the marrow
is grayish rather than white. It is suggestive of an
infection or a neoplasm in the marrow. This finding
plus the muscle with neoplasm adherent to the
periosteum is an indication to resect bone. Stripping of
the periosteum from the cortex yields virtually a "0"
margin. (Drawing courtesy of Daniel Broderick, MD.)
Vicini concluded by saying "post-surgical radiation can-
not compensate for too small a cut."
Evaluation with MRI can be very informative, because
changes in the marrow may occur. For example, the
normal marrow has a whitish hue owing to its fat
content. If it is grayish, it is abnormal, not necessarily
neoplastic but possibly edematous.
Guidelines
1. In advanced squamous cell carcinoma involving
the lateral oropharyngeal wall and base of tongue,
the following continuous structures can be involved:
nasopharynx, soft and hard palate, superior alveolar
ridge, posterior oropharynx, superior hypopharynx
inferiorly to the superior portion of the pyriform
sinus, lateral portion of the tongue on the ipsi-
lateral side or lateral side in the case of the base of
the tongue, epiglottis and the lingual epiglottic
fold, posterior floor of the mouth, inferior alveolar
ridge, and the mandible with cervical metastasis.
The rule of thumb is resection of all the areas as
governed by the extent of the disease with free
margins on frozen section. Planned reconstruction
preoperatively is paramount but must likewise be
flexible. When the lesion extends superiorly (e.g.,
palate and superior alveolar ridge) it may extend
into the parapharyngeal space (see Chapter 23) at
the area of the pterygoid plates and muscles and
reach the eustachian tube. A portion of the antrum
could also be involved.
2. With mandibulotomy, midline or lateral, opposite
one of the premolar teeth or at the angle of the
mandible and particularly associated with the
segmental resection of the mandible, preservation
of the lingual nerve and inferior alveolar nerve may
not be feasible, depending on the extent of the
disease and the amount of lateral reflection of the
proximal mandible.
3. The reader is referred to the previous section on
modifications of mandibulotomy with mandibular
"swing" (see Fig. 15-7):
a. Midline

~
Periosteum
Cortex
•••••• '#
... .•.
t: .•.•. ~ "Mij,rrow ' .
••
.'" .
'. "
Cortex
Periosteum =========::;::
~
b. Lateral at premolar area
c. Angle of the mandible. This requires mobiliza-
tion of the cheek flap. The degree depends on
the area to be resected.
4. Mandibulotomy is usually done through an extracted
tooth socket, not between the teeth. The mylohyoid
muscle and anterior belly of digastric are transected.
5. Primary carcinoma of the oral cavity, oropharynx,
or tongue may be attached to the cortex of the
mandible or arise in a tooth socket. Thus, if fixa-
tion is present or very close to the mandible, for
example, 1 to 2 mm, segmental resection of the
mandible or marginal resection (see Fig. 14-11A to
H) should be performed. Direct invasion is seldom
through the cortex. Actual cortical invasion is
usually related to the site of the tooth socket. If
there is any question regarding marrow involve-
ment, the marrow at the cut ends can be smeared
on slides and reviewed as a frozen section at the
time of surgery.
6. Resection of the entire body of the mandible
involves resection of the following muscles from
anterior to posterior on the lateral border: mentalis
(levator), quadratus labii inferioris (depressor of
the lip), and triangularis (depressor of the angle of
the mouth). On the medial aspect of the mandible,
the following muscles are involved: genioglossus,
geniohyoid, anterior belly of the digastricus, mylo-
hyoid, and superior pharyngeal constrictors.
7. Resection of the pterygoid muscles from the ptery-
goid plate. If disease actually involves the pterygoid
muscles, remove a portion of the pterygoid plates.
This would be an exposure of the parapharyngeal
space (see Chapter 23, Figs. 23-2 to 23-6).
8. Extent of oropharyngeal cancer into the nasopharynx
can be resected by either incising or removal of the
soft palate and removal of a portion or all of the
ORAL CAVI1Y AND OROPHARYNX
}
>,
}
FIGURE 15-8
hard palate. This resection can reach the inferior
edge of the eustachian tube orifice. Lateral dissec-
tion of the deeper portion of the nasopharynx is
hampered by the base of the pterygoid process.
Actually, this may serve as a barrier to the spread
of the tumor laterally, unless it invades bone.
However, as one resects farther posterior and supe-
rior, the base of the skull is apparent. The internal
carotid artery is in jeopardy from its entrance into
the parapharyngeal space as it progresses supe-
riorly. The internal carotid artery then leaves the
operative site at the external orifice of the carotid
canal. This artery passes then through the carotid
canal, which is posterior to the foramen lacerum.
This is associated with a fibrocartilaginous plate. In
addition, the vessel may be tortuous, making it
more vulnerable. If there is spread into the para-
pharyngeal space, the dissection places the internal
carotid artery in greater jeopardy.
9. When the superior portion of the pyriform sinus is
included in the resection, the superior edge of the
remaining portion of the pyriform sinus is sutured
around its edge approximately 180 degrees to any
remaining tissue, thus maintaining the orifice of
the pyriform sinus. Any bare areas in the vicinity
of the pyriform sinus and inferior portion of the
hypopharynx are covered with dermal graft and
not a PMF. The important potential problem is bulk.
Bulk can lead to a "chute" for the food into the
larynx or hampers action of the arytenoid cartilage.
This same precaution must be taken when recon-
struction after a lateral hypo pharyngectomy is
performed. The area more superior may be closed
with a thin tongue flap (see Fig. 21-7) and more
inferiorly with a dermal graft. In any event, do not
suture any flaps or graft to the arytenoid region or
aryepiglottic fold.
 ORAl CAVITY AND OROPHARYNX
10. Avoid ligation of the external carotid artery if
microsurgical reconstruction is planned. At least
preserve a major branch as close as possible to the
reconstruction.
11. The spinal accessory nerve is sacrificed if there is
evidence of metastatic disease in the vicinity of the
superior internal jugular chain of lymph nodes or
if previous surgery has been performed in this
upper cervical area. An example is a patient who
has had an open biopsy of the superior internal
jugular nodes.
12. Resect the tail of the parotid and higher if indicated
(see Figs. 17-3 and 17-6G to I).
13. Transect or remove the posterior belly of the digas-
tric, stylohyoid, styloglossus, and stylopharyngeus
muscles with portions of the styloid process. This
depends on the extent of the lesion. CT and MRl may
be a great aid in this decision (see section on para-
pharyngeal space in Chapter 23, Figs. 23-2 to 23-6).
14. When resecting a portion of the upper alveolar
ridge, remove a portion of the pterygoid plate, which
is juxtaposed to and continuous with the ridge.
15. Preserve the mucous membrane on the medial
aspect of the whole or remaining portion of the
mandible, commensurate with adequate resection
of disease. This remaining mucous membrane serves
as a suture line for a juxtaposed flap.
16. When preoperative chemotherapy is used, pretreat-
ment tattooing is most important in cancer of the
oral cavity, oropharynx, and any extension to the
nasopharynx or hypopharynx.
17. At times "continuity" resection is impossible (e.g.,
with resection of the base of the tongue, the lateral
border of the tongue, and the oropharynx all in one
mass with the neck dissection separate). "Continuity"
is easier to obtain when the resection includes a
portion of the styloid process, the posterior belly of
the digastric, and stylohyoid and stylopharyngeus
muscles or when a segment of the mandible has
been removed (see Chapter 23, Figs. 23-2 to 23-6,
relative to the parapharyngeal space).
18. The posterior facial vein offers a landmark for the
ramus mandibularis of the seventh cranial nerve,
but not always. This is of some concern when ele-
vating a cheek flap below the mandible, especially
if the patient has been operated on previously.
19. Incision of the lip should be stepped.
20. Incision inferior to the lip can pass through the mid-
line or laterally on the ipsilateral side just medial to
the commissure following a natural skin crease.
21. Abandon the concept of planned fistula if at all
possible; this rules out the forehead flap except in
situations in the section on description of forehead
flap (see pp. 401 and 444). A microvascular face
flap usually replaces a forehead flap on face recon-
struction (see Chapter 24).
22. Tracheostomy and percutaneous endoscopic
gastrostomy (PEG) are always done.
23. If at all feasible and commensurate with adequate
resection, preserve the 12th nerve and the superior
laryngeal nerve. Resection of these structures is,
however, usually eventually compensated for.
24. Do not preserve the uvula when the line of resec-
tion is close to the uvula.
25. Carcinoma arising in the palatine tonsil at times
defies identification, being very small (e.g., 5 mm
and hidden in a fold of the lymphoid tissue or
follicle). Palpation is very important for diagnosis
of the larger lesions. General anesthesia may be
necessary before searching for and locating the
small lesions.
26. PMF is the preferred pedicle flap for most recon-
structions. The levator scapulae flap serves for addi-
tional bulk in the upper cervical area or around the
reconstruction of the mandibular palate or Steinmann
pin (see p. 1331 and Fig. 22-36D). When using a
PMF flap, consider removal of the medial third of
the clavicle (a) for extra length and (b) to close the
dead space above the clavicle.
27. PMF can be used with a plate or Steinmann pin
over or under the flap. Position is based on minimal
compression of the flap.
28. If there is any question regarding the viability of a
PMF at the close of the operation, visualize the flap
with a flexible nasolaryngoscope.
29. Use the distal portion of the flap with minimal bulk
at the reconstructed base of the tongue.
30. Reconstruction of the base of the tongue:
a. Retroadvance remaining tongue to the lingual
side of the vallecula or more inferiorly if a
portion or all of the epiglottis is removed (see
Fig. 15-13D and E and Fig. 21-7). Attempt to
prevent the epiglottis or part thereof from being
pulled too far forward. Sisson has suggested
suturing the tip of the epiglottis to the posterior
pharyngeal wall, leaving the lateral areas open
in an attempt to direct food laterally into the
pyriform sinuses. The inferior oropharynx and
oral cavity may be packed with gauze soaked in
antibiotic solution to control any ooze from the
tongue closure.
b. Use a PMF.
31. Parapharyngeal space dissection approach (see
Chapter 23, Figs. 23-2 to 23-6):
a. Use deep lobe parotid resection (see Figs. 17-3
and 17-6).
b. Use oropharyngeal and nasopharyngeal resec-
tion, with elevation of the cheek flap starting
along the upper cervical radical neck dissection
incision to include the tail of the lateral lobe of
the parotid salivary gland as well as resection of
the posterior facial vein with the specimen.

Expose and preserve the seventh cranial nerve.
Resect the pterygoid muscles and a portion of
the pterygoid plate, especially if the nasophar-
ynx is involved.
c. When deep resection is involved, the internal
carotid artery is in jeopardy: use intraoperative
Doppler study.
d. The other approach to the parapharyngeal space
is an extension of approach "b" to include a
total parotidectomy. This is necessary when
there is extensive disease into the space that
has been previously exposed to radiation.
e. When there is evidence of extensive disease in
the space, it is better to have proximal control
of the internal and external carotid arteries and
the internal jugular vein as well as identification
of the vagus nerve in the upper cervical area.
L Under these conditions, arteriography or MR
angiography is advised if there is constriction or
distortion of a vessel.
g. It is also advised under these circumstances to
be prepared for temporary occlusion and recon-
struction of the internal carotid artery for repair
or reconstruction (see Figs. 22-26E to G/22-33D).
h. Walloon occlusion of the vessel done preopera-
tively to evaluate intracranial blood flow has a
significant risk of stroke and hence is of some
question.
l. Liberal use of frozen section is advised if margins
of disease are difficult to evaluate.
J. Evaluate the bony external auditory canal, which
may need resection and possible temporal bone
resection (see Figs. 23-13).
k. Resect seventh nerve that is encased in tumor.
Reconstruction with a sural nerve graft is feasible
(see Fig. 3-8 and Chapter 7, p. 380).
1. Resect mastoid process if disease is adherent.
m. Mark any disease that is nonresectable at the
base of the skull with titanium clips; this is an
aid in postoperative radiotherapy.
n. Consider treatment of any residual disease at
the base of the skull with a gamma knife.
32. Closure of large defects of the lateral oropharyn-
geal wall, for example, resection of the tonsil, can
be done with PMF or a free microvascular flap;
contiguous structures, for example, a portion of the
tongue, hypopharynx, and a portion of the oropha-
ryngeal wall, may be closed with advanced local
flaps.
33. Whenever feasible without compromising adequate
resection of a neoplasm, local mucosal flaps for
primary closure of the primary lesion can achieve
excellent reconstruction with good function,
especially in swallowing and speech.
34. Microvascular construction (see Chapter 24). At
times, primary closure or a PMF will achieve similar
ORAL CAVI1Y AND OROPHARYNX
results. Selection is based on the extent of the
defect and the reconstructive method that achieves
specific function, namely, good swallowing and
reasonably good voice with no aspiration.
35. Mandibulotomy is done for retropharyngeal node
dissection. In the incision along the floor of the
mouth, care is taken not to injure the lingual nerve
or the 12th nerve. Specific care is needed when
closing the wound so that Wharton's duct is not
obliterated with a suture. The other nerve to be
careful of during this approach is the seventh
cranial nerve.
36. Suggest using tattoos of oral cavity and oropharynx,
hypopharynx, and nasopharynx extensions of
tumor, even without preoperative chemotherapy, to
help establish extent of disease at the time of sur-
gery. At times the extent of disease can better be
ascertained under general anesthesia than under
topical anesthesia. Using both approaches may be
necessary. The decision relative to the area of
resection is based on:
a. Office examination, direct visualization, palpa-
tion (most important). particularly at base of
tongue
b. CT and MRI. CT can be misleading in evaluation
of oral cavity and oropharynx (for example, see
Fig. 23-2 of a thyroglossal duct cyst that was
seen on MRI but not on CT).
37. Although the pathology and these guidelines have
been primarily related to squamous cell carcinoma,
the surgical principles also apply to the high-grade
salivary gland neoplasms as well as to the rarer
adenosquamous cell carcinomas. This latter group
has been reported to occur in nasal, oral, and laryn-
geal cavities as well as in the pharynx. There also
has been a question as to whether the adenosqua-
mous cell carcinomas of the floor of the mouth and
lower alveolar ridge were, in fact, a result of radio-
therapy. However, in the surgical management of
these tumors there is a significant modification and
that is that a wider and more aggressive surgical
procedure is recommended. Although preoperative
chemotherapy has not been used in salivary gland
neoplasms, preoperative chemotherapy may have a
place in adenosquamous cell carcinomas for the
squamous cell component. Postoperative radiotherapy
appears to be indicated if there is any question
regarding the adequacy of resection in either of
these carcinomas. The downside of preoperative
chemotherapy in the adenosquamous cell carcinoma
may be the fact that although the squamous cell
carcinoma portion may respond to the chemotherapy,
the adeno portion most likely would not and,
hence, there would be a delay in the treatment of
this latter component, owing to the preoperative
chemotherapy. This, however, is speculative.
 ORAL CAVITY AND OROPHARYNX

Resection for Carcinoma of Tonsil,

A A radical neck dissection with a parotid extension
Soft Palate, or Base of Tongue by has been performed (see Fig. 17-6). The cheek flap is
Mandibulotomy and reflected farther upward, and the gingivobuccal sulcus
Reconstruction (Fig. 15-9) (See also is entered. A Gigli saw is passed through this opening.
Fig. 15-7 Part iii and Figs. 17-3 and The saw cut is begun behind the last molar, or a molar
22-33) tooth is extracted and the saw cut begun there. This
cut should be anterior to the lesion. The cut is made in
Carcinoma of the tonsil, soft palate, and base of the stepwise fashion, because this lends more support for
tongue has given rise to a marked difference of opinion the reconstruction. A sagittal plane saw may be used.
regarding therapy for the primary lesion. On the other
hand, the metastatic neck disease is almost universally B With a heavy skin hook, the anterior fragment of
treated by radical neck dissection. These primary mandible is retracted forward and the posterior
lesions may be treated by radiation when the histology fragment backward. The lingual nerve is exposed and
is totally undifferentiated squamous cell carcinoma preserved. If the saw cut was started behind the last
without any evidence of differentiation with or without molar and performed deep to the mucosa, the mucosa
chemotherapy or by surgery or a combination of both. may still be intact. If so, this is opened along the
The surgery of the primary lesion may be done in dotted line, thus forming a flap of mucosa to be
continuity or independently of the neck dissection. One excised with the lesion.
author (JML) prefers treatment with preoperative
chemotherapy, uncompromised surgery, and selective C The lesion in this case is small and located on the
radiotherapy (see Chapter 3, pp. 132 to 141). This posterior tonsillar pillar. The area to be excised
technique is depicted in Figure 15-11. A portion of the includes the tonsil, the anterior pillar, an adjacent
mandible is resected if the tumor is fixed to the portion of the base of the tongue, a section of soft
mandible, if there is evidence of invasion, or if it is in palate, and the entire lateral and juxtaposed posterior
very close proximity to the mandible. oral pharyngeal wall behind the posterior pillar. An
Another approach is either a peroral approach or a incision is made along the dotted line as deep as
median anterior trans labial pharyngotomy (Trotter feasible, keeping in mind the location of the internal
approach) (see Fig. 15-4A to C) for lesions of the base carotid artery.
of the tongue. The technique of resection of a primary
lesion of the tonsil at the time of the neck dissection is D With an Allis clamp on the turned back flap of the
described here. With slight modification, this can be mucosa, the incision made in the adjacent base of the
adapted to lesions of the base of the tongue and soft tongue is extended downward to include muscle. It
palate. then is curved backward to enter the vallecula. This
This type of mandibular section also affords an frees the edges and depths of the specimen. Some
approach to the parapharyngeal space (see Figs. 23-2 to undercutting may be necessary here, especially along
23-6). the base of the tonsil. The proximity of the internal
The major drawback of this approach may be limi- carotid artery to the base of the tonsil is kept in mind.
tation of exposure. If this is the case, the lateral or the Branches of the ascending palatine, lingual, external,
midline mandibulotomy with an incision along the and internal maxillary arteries are encountered. If trou-
ipsilateral floor of the mouth is preferred. The mandible blesome bleeding occurs, the external carotid artery is
is "swung" laterally to expose the oropharynx and base ligated, if not already done, unless microvascular
of the tongue (see Figs. 14-11 and 15-14). This is reconstruction is planned.
currently the preferred approach.
E The area is shown after the resection.
Highpoints
F Closure is begun by suturing the cut surface of the
1. Allow adequate margins on all sides and especially tongue anteriorly to any remnant of tongue either
in the depth around the lesion; if there is any doubt, laterally or medially or to adjacent mucosa. Sutures of
resect the mandible. 2-0 or 3-0 chromic catgut or nylon are used.
2. Usually perform parotid extension of the radical Continued
neck dissection when there is large metastasis in the
region of the tail of the parotid (see Fig. 17-6).
 ORAL CAVITY AND OROPHARYNX

Masseter m.

FIGURE 15-9
 ORAl CAVllY AND OROPHARYNX
Resection for Carcinoma of Tonsil,
Soft Palate, or Base of Tongue by
Mandibulotomy and Reconstruction
(Continued) (Fig. 15-9) (See also Fig. 15-7
Part iii and Figs. 17-3 and 22-33)
G The mucosal edges that can be reached through
the neck wound are approximated with 4-0 chromic
catgut. The remainder of the defect is handled
intraorally by one of five methods. One method is to
allow the mucosal defect to heal by secondary inten-
tion. This may result in a pharyngeal fistula. Three
other methods are as shown in steps H, I, and J. Still
another method is the use of a tongue flap (Hl). If the
defect is large, transposed flaps (e.g., PMF) are utilized
(see Figs. 8-1 and 8-2A to H, 14-1 OD to H, and 15-11 J
to P). A free microvascular flap is another option (see
Chapter 24).
H Primary closure is used if possible.
H1 Tongue flap closure is not recommended.
I Split-thickness skin graft is shown with pressure
pack of gauze or cotton soaked with antibiotic liquid.
This pack may be held in place with cross-ties (inset).
J A relaxing incision similar to one done in a cleft
palate repair aids in primary closure of larger palate
defects. The site of the relaxing incision heals by
secondary intention.
K The mandible is immobilized with intramedullary
Steinmann pins or Kirschner wires and secured by
stainless steel or malleable silver wire through drill
holes. The wound is closed as in a standard neck
dissection.
 ORAL CAVIlY AND OROPHARYNX

Stylohyoid m.

Hyoglossus m. Post. belly

digastricus m.
Sternocleidomastoid m.

FIGURE 15-9 Continued

 ORAl CAVl1Y AND OROPHARYNX

Resection of Hemimandible,
lateral Oropharyngeal Wall, and B The resection of the primary lesion with radical
Portion of Soft Palate and neck dissection is shown. The lip has been split to
develop a large cheek flap. This affords excellent
Hemiglossectomy With exposure of the oropharyngeal and palatal area as well
Reconstruction Using a Forehead as exposure for mandibular disarticulation. Adequate
Flap Versus Pectoralis Major Flap resection of the contents of the parapharyngeal space
(Fig. 15-10) must be performed, especially if trismus is present (see
Chapter 23, Figs. 23-2 to 23-6).
The ideal reconstruction of the depicted defect is the The forehead flap is introduced deep to the
utilization of a bent Steinmann pin with tie wires (see zygomatic arch that has been transected in two
Figs. 14-5 and 14-6) and a PMF. This method is simple locations and left attached to the overlying skin (see
and allows for a one-stage procedure with acceptable Fig. 8-" A to J). The arrow depicts the rotation of the
cosmetic and reasonably good functional results. flap so that the raw area is faced downward.
Shown is an alternate method without mandibular
stabilization utilizing a forehead flap, which can result C The flap is sutured to the soft palate and the
in a scarred forehead. An alternative if operation time remaining oropharyngeal mucosa. The distal end of
is to be limited is to suture a cheek flap as shown in the flap is sutured to the edges of the tongue and the
Figure 14-110 to R. cheek and the remaining floor of the mouth anteriorly.
No attempt is made to reconstruct the mandible,
Highpoints because the line of resection does not cross the midline.
Care is taken to avoid making an oral cripple.
1. Refer to page 682.
2. Extreme care is taken in the dissection of the D The completed closure is shown. The dotted lines
para pharyngeal space (see Chapter 23). represent the course of the flap deep to the zygomatic
arch and cheek. In 6 to 8 weeks the forehead flap
Complications pedicle is returned to the donor site.

• Early recurrent disease with a large lesion E The preferred reconstruction of this defect is with
• Lack of mobility of reconstructed area with pooling a PMF. This can be done with a double paddle as
of saliva and food: oral cripple indicated, or a wider flap can be brought up into the
• Mandibular drift oral cavity and then at the time of placement and
• Difficulty in mastication of solid food suturing the double paddle can be developed. The
important provision for use of the double paddle is
For PMF reconstruction, see Figure 8-30. For del- that there is adequate blood supply to both paddles
topectoral flap reconstruction, see Figure 8-5. For use (see Fig. 8-30).
of bent Steinmann pin with tie wires, see Figures 14-5,
14-6, and 14-902 F The PMF is brought over the Steinmann pin, which
is used to reconstruct the mandible and is sutured as
delineated along the lateral border of the tongue and
A The tumor extends from the soft palate, the then superiorly into the defect in the oropharynx and
tonsillar region along the lateral border of the tongue, palate. The muscle delineated inferiorly is a portion of
and the floor of the mouth, with fixation to the the levator scapulae flap, which is adding bulk to the
mandible. The dotted line depicts the area resected with reconstructed area of the mandible (see Fig. 22-36).
disarticulation of the mandible. This affords excellent
exposure of the parapharyngeal space.
 ORAL CAVITY AND OROPHARYNX

c D

--_._~
i
I

Ii Steinmann pin

i E I
----'---'I
I
L ..

Levator scapulae flap

FIGURE 15-10
 ORAL CAVITY AND OROPHARYNX
Combined Radical Neck Dissection,
Partial Glossectomy or
Hemiglossectomy, and
Hemimandibulectomy Including
Retromolar Trigone (Fig. 15-11)
Indications
These operations are performed for carcinomas of the
floor of the mouth and tongue that involve the
mandible or for primary carcinoma of the gingiva or
the alveolar ridge of the mandible with or without
extension to the upper alveolar ridge. Whether only the
horizontal portion or both horizontal portion and
ascending ramus are resected depends on the location
and extent of the lesion. Other applications of these
operations are large carcinomas of the tonsil (also see
Fig. 15-9) with deep infiltration and carcinomas of the
base of the tongue. A portion of the palate is included
along with a portion of the upper alveolar ridge and
floor of antrum and lateral wall of the nasopharynx
when the neoplasm extends superiorly. It is paramount
to extend the dissection laterally to remove as much as
possible of the juxtaposed parapharyngeal space soft
tissue: muscle with pterygoid plates as indicated, adipose
tissue, and any nodes. This is an area that is prone to
recurrence. All these patients have routine CT and/or
MRI preoperatively, postoperatively, and at regular
intervals for the first 3 years (e.g., every 4 months and
after that every 6 months).
In malignant tumors of the tongue in which an
extended or hemiglossectomy is performed with
preservation of all or part of the mandible, closure of
the defect is achieved by a PMF or an apron, forehead,
or deltopectoral flap (see figures in Chapter 8). Resec-
tion of the mandible is not indicated solely to facilitate
ease of closure. When mandible is not involved, the
approach to the posterior and base of tongue and
oropharynx with extension superiorly is accomplished
with mandibulotomy (see Fig. 15-7).
Highpoints
1. Tracheostomy is necessary.
2. Resect all tissue in continuity if feasible.
3. Resect a liberal portion of the tongue.
4. Resect a portion of the maxilla when necessary.
5. Remove all fragments of teeth with exposed roots.
The transection of the mandible should pass through
an extracted tooth socket rather than between two
teeth.
6. Avoid creating an oral cripple with judicious use of
transposed flaps and grafts.
7. The following steps cover the resection of various
extensions of squamous cell carcinoma of the oral
cavity and oropharynx. They are divided as following:
a. A and D: Basic approach
b. B, C, F, G, H, I: Carcinoma of the tongue, floor of
the mouth, and body of the mandible
c. J and K: Carcinoma of retromolar trigone
d. M: Cancer of the lateral wall of the oropharynx,
upper alveolar ridge, portion of maxilla, and
palate
8. See section on resection of base of the tongue
(pp. 732 and 733) and total glossectomy (p. 740,
Fig. Is-lsE and F).
9. Although areas overlap as described in the following
three figures, three areas are specifically depicted:
a. Posterior third and lateral base of the tongue with
floor of the mouth and juxtaposed body of the
mandible (see Fig. IS-lIB and C).
b. Retromolar trigone (see Fig. 15-111 and K).
c. Oropharynx and tonsil extending superiorly to
involve upper alveolar ridge (see Fig. IS-11M).
A The standard radical neck dissection incision is
extended upward across the lower lip. An alternate
incision is along the dotted line just medial to the
commissure. A tracheostomy may be performed at the
beginning or the end of the operation. In either case,
the hypopharynx is packed with gauze.
B Diagrammatic representation of the extent of
resection for carcinoma of the tongue and the floor of
the mouth involving the horizontal ramus (body) of
the mandible.
C Similar lesion is viewed intraorally.
D The standard neck dissection has been carried up
to the level of the hyoid bone laterally. The submental
area has been dissected, and the lower lip is split in the
midline.
D1 The area of resection of a more extensive lesion,
which involves the upper gingiva, includes a portion of
the maxilla and palate when the floor of the antrum
and parapharyngeal space are involved.
E A lower lip visor incision (see Fig. 16-61) can be
used when the neoplasm is located anteriorly but not
posteriorly. Exposure with this type of incision is inade-
quate for a posterior location of the neoplasm. If the
lesion is located at the posterior third or base of the
tongue without mandible involvement a mandibulotomy
is utilized (see Fig. 15-7).
Continued
 ORAL CAVITY AND OROPHARYNX

FIGURE 15-11
 ORAL CAVITY AND OROPHARYNX
Combined Radical Neck Dissection,
Partial Glossectomy or
Hemiglossectomy, and
Hemimandibulectomy Including
Retromolar Trigone (Continued)
(Fig. 15-11)
F An incisor tooth, canine tooth, or bicuspid (pre-
molar) tooth is removed depending on the anterior
extent of the tumor. A Gigli saw is inserted through the
floor of the mouth, and the mandible is sectioned
through the midportion of the socket of the removed
tooth. In this case, the origin of the anterior belly of
the digastric muscle has been freed.
G The cheek flap is reflected laterally at least to the
masseter muscle. Depending on the site of transection
of the mandible, the mylohyoid muscle is sectioned. In
this case it is transected at the raphe and along its
insertion on the hyoid bone. In more lateral mandibular
resections, the anterior belly of the digastric muscle
and the median half of the mylohyoid are preserved.
In either case, the submaxillary salivary gland and
associated lymph nodes are left in continuity with the
resected portion of mandible.
H The tongue is sectioned in the midline if the
tumor location warrants a hemiglossectomy. Less
tongue is removed in carcinoma of the gingiva. The
incision is carried through the floor of the mouth and
connected with the incision originating in the mylo-
hyoid muscle. The sublingual gland is usually included
in the resected specimen.
I Posteriorly, the tongue incision takes a wide sweep
around the lesion and meets the inner aspect of the
mandible well behind the grossly diseased area. If this
incision reaches the molar area, the horizontal ramus is
sectioned behind the last molar tooth with a Gigli saw
or sagittal plane saw.
Continued
 ORAL CAVI1Y AND OROPHARYNX

FIGURE 15-11 Continued

 ORAL CAVI1Y AND OROPHARYNX
Combined Radical Neck Dissection,
Partial Glossectomy or
Hemiglossectomy, and
Hemimandibulectomy Including
Retromolar Trigone (Continued)
(Fig. 15-11)
J If the posterior tongue incision meets the region of
the angle of the mandible, the ascending ramus is
resected wholly or in part. In either case, the cheek
flap includes virtually all soft tissue of the cheek. Thus,
the facial nerve within the parotid is not injured. A
variable amount of mucous membrane from the upper
gingiva is removed depending on the extent of the
resection. Depicted is an area resected for a tumor in
the retromolar trigone. Involvement of the mandible
requires an extension of the resection anteriorly.
K A diagrammatic oblique external view of the hori-
zontal portion and ascending ramus of the mandible is
shown. The masseter muscle has been transected
between its origin from the zygomatic process of the
maxilla and zygomatic arch (not shown) and its inser-
tion to the lateral surface of the ascending ramus and
coronoid process. If the entire ascending ramus requires
resection, this entails disarticulation with transection of
the attachments of the temporalis muscle to the coro-
noid process and the anterior border of the ascending
ramus of the external (lateral) pterygoid muscle to the
condyle and joint capsule and of the internal (medial)
pterygoid muscle to the inner aspect of the angle of
the mandible. This is rarely necessary. If the ascending
ramus is transected below the mandibular notch, the
temporalis muscle and the external pterygoid muscle
are left intact. This remaining portion of mandible
serves as a good anchor for a bent Steinmann pin with
tie wires (see Figs. 14-5 and 14-6). With this type of
reconstruction a transposed distant flap would be
necessary. The PMF is preferred.
L A view of the same region from below demon-
strates the interrelations of the muscles and their
insertions. Not shown is the stylomandibular ligament,
which is a thickened band of the deep cervical fascia
extending from the styloid process to the region of the
angle of the mandible. With the resection of a major
portion of the internal pterygoid muscle, associated
contents of the para pharyngeal space are likewise
resected. This extension of disease can be seen on CT
and MRI.
M When the tumor extends along the upper
gingiva, the line of resection includes a portion of the
upper alveolar ridge, which in turn requires resection
of a portion of the floor of the antrum. A sagittal plane
saw with a small blade is used to resect the bone, as
depicted along the dotted line.
The primary lesion is now removed in continuity
with the contents of the neck dissection. The structures
included will vary slightly depending on the extent of
the primary tumor. In the more extensive resections,
this will include the sublingual gland and adjacent
muscles, that is, the hyoglossus, genioglossus,
geniohyoid, and mylohyoid. The anterior and posterior
bellies of the digastric muscle as well as a portion of
the stylohyoid muscle are included, with the submaxil-
lary salivary gland and adjacent lymph nodes. These
muscles are detached along their attachments to the
superior edge of the hyoid bone, which is left intact.
The lingual and hypoglossal nerves are also included in
the resected specimen when a significant portion or
half of the tongue is resected. These nerves may other-
wise be preserved.
N A PMF is brought into the oral cavity and
oropharynx either under or over the Steinmann pin
with minimum pressure on the flap. A bilobed PMF
(see Fig. 8-30) may be necessary depending on the
extent of the resection (for an alternative method of
closure without flap, see Fig. 14-11 P and Q).
o A PMF is sutured to a portion of tongue,
remaining mucosa of the oropharynx, and palate. The
floor of the antrum is either closed with the flap or
better left open and covered with a prosthesis. If
additional muscle bulk is needed, a levator scapulae
flap or trapezius flap can be used (see Fig. 22-36).
The cut edges of the lower lip are approximated
using three-layer closure: mucous membrane, muscle,
and skin. If there is lax lower lip, 0.5 to 1.0 em can be
excised per dotted line. If this is done, be sure there is
no tension over the Steinmann pin.
P The neck incisions are closed in two layers using
continuous 4-0 chromic catgut for the platysma mus-
cle and 5-0 continuous nylon for the skin. Drains or
suction catheters are used as in the standard neck dis-
section to complete the operation. Immediate cytologic
smears are performed on the transected mandibular
stumps or margins for any evidence of bone marrow
involvement with tumor. If marrow is involved, addition-
al mandible is resected or disarticulation is performed.
 ORAL CAVITY AND OROPHARYNX

Upper and lower

head of ext.
pterygoid m.

Int. pterygoid m.

FIGURE 15-11 Continued

 ORAL CAVITY AND OROPHARYNX

Base of Tongue Resection of Base of Tongue

Anatomy of the Tongue (Fig. 15-12)
Sagittal section through the tongue just lateral to the
midline is shown. The "cut-out area" depicts the
intrinsic tongue musculature.
Approaches to resections of the base of the tongue are
contingent on a number of factors, namely, histology,
whether benign or malignant, size, involvement of
other contiguous structures (e.g., mandible, retromolar
trigone, lateral oropharyngeal wall, lateral hypopharyn-

sup. pharyngeal
constrictor m.
Sup. longitudinal m.

Lingual aponeurosis
- ~
Palatoglossus m.
Lingual mucosa
I Palatine tonsil
Genioglossus m. I
Styloglossus m.
I.

Frenulum of tongue
Hyoglossus m.
Inf.longitudinal m.

Genioglossus m. Inf. pharyngeal

constrictor m.

Mylohyoid m.
FIGURE 15-12

geal wall, palate, and epiglottis), concomitant radical
neck dissection, as well as the problem of preservation
of the function of the larynx, especially if the epiglottis
must be removed. When aspiration is almost certain, and
both hypoglossal nerves require excision, laryngectomy
has been advocated almost as a routine procedure.
Nevertheless a trial period by closure of the glottis with
suture approximation of the stripped vocal cords or by
infolding and approximation of the aryepiglottic folds
has been successful. This conservation approach is
preferred, because a laryngectomy can then be per-
formed at a second stage if necessary. When the
epiglottis can be spared, Sisson has described suturing
the tip of the epiglottis to the posterior pharyngeal wall
to act as a "watershed," thus directing food toward the
pyriform sinuses.
The alternative option is preservation of the larynx
with a trial period of assessment regarding aspiration.
The approach is "trial and error"-leaving the larynx in
place if there is any possibility that aspiration may not
occur. This can be ascertained by the attitude and
commitment of the patient, which may be by far the
best yardstick. A cuffed tracheostomy tube is neces-
sary, remembering that the inflated cuff can compress
the esophagus and thus make evaluation regarding
aspiration continue over a protracted period, requiring
considerable patience on the part of both patient and
surgeon. Removal of all or part or none of the epiglottis
depends entirely on the necessary extent of the ablative
surgery and must not be influenced by preservation of
structures simply to facilitate an easier reconstruction.
All stages of removal or preservation of the epiglottis
have been seen with and without any clear-cut effect
on influencing swallowing or voice.
ORAL CAVITY AND OROPHARYNX
The type of reconstruction depends primarily on the
extent of the surgical defect, as well as the approach
that was utilized for the ablative surgery. For example,
large surgical defects with segmental resection of a
portion of the mandible lend to the use of a PMF. Other
somewhat lesser defects may be achieved by retroad-
vancement of the tongue (see Fig. 15-130 and E). On
somewhat smaller defects, a posterior flap can be
developed. This flap entails the lingual mucosa and the
lingual aponeurosis (see Figs. 15-12 and 21-7).
Approaches to Base of Tongue
A number of procedures are described depicting the
various procedures to approach and to resect the base
of the tongue:
1. Mandibulotomy (see Figs. 15-7, 15-9, and 15-14).
2. Segmental resection of the mandible (see Fig. 15-11).
3. Median labiomandibular glossotomy (see Fig. 15-4).
4. Transhyoid, suprahyoid, or anterior pharyngotomy
(see Fig. 21-4).
5. Lateral pharyngotomy (see Figs. 15-9 and 21-5).
The most important aspect of the approach to the base
of the tongue is adequate exposure. This is the prime
deciding factor in the use of the various approaches.
The reconstruction of the surgical defect depends
on the ablative approach. An approximation of the
remaining mucosa and muscle is often adequate. If,
however, this binds the remaining portion of the tongue,
then a transposed distant flap is utilized. The one cur-
rently preferred is the PMF, which can aid in the
closure of not only the base of the tongue but also the
lateral hypopharyngeal and oropharyngeal walls.
 ORAL CAVITY AND OROPHARYNX
Resection of Base of Tongue via Midline
Mandibulotomy (Mandibular Swing)
(Fig. 15-13)
A, A 1 The skin incision and the midline mandibu-
lotomy are shown. The midline approach usually affords
an increased area of exposure compared with a lateral
or angle mandibulotomy. The cosmetic aspects may
be a drawback; however, the patients rarely complain.
The alternate is the lateral mandibulotomy.
Mandibulotomy through the angle of the mandible is
too restrictive for the entire base of the tongue. A less
than 50% resection of the base of the tongue may be
accomplished via the angle mandibulotomy (see
Fig. 15-9). The lip and mandible are cut in stepwise
fashion as depicted in A and AI. For additional descrip-
tion, see Figure 15-4A to C.
B The incisions are made along the floor of the
mouth away from the mandible to preserve the
mucous membrane to facilitate closure with a future
PMF. As the posterior portion of the tongue is
approached, identify and attempt to preserve the
lingual and inferior alveolar nerves. They may require
transection for additional exposure, however. If fea-
sible, a neurorrhaphy can be attempted at the time of
closure. The mucosal cut is outlined with electrocautery.
The complete resection is done either by cold knife or
by cutting cautery. The problem with using a cold
knife is bleeding; the problem with the cautery is loss
of margin for complete evaluation. If cautery is used
with a neoplasm that reaches the cauterized margin,
additional margins with frozen sections are done.
C A schematic view from above shows the area able
to be resected. The approach would be the same as in
A and B.
D A schematic sagittal view shows the extent of
resection (A to A'). If the neoplasm reaches or is close
to the base of the vallecula, the epiglottis or a part
thereof is removed.
E The dorsum of the tongue is advanced, bringing A
to Al. If the epiglottis is not removed, do not suture
the tongue flap to the epiglottis. Even with the
epiglottis removed, the patient can swallow without
aspiration or may encounter some coughing. With the
epiglottis removed, it is better not to suture the
remaining portion of the tongue flap to the inferior
margin of the resection (see Fig. 21-7 for details of
tongue flap). If necessary, a PMF can be utilized, but
unless other contiguous portions of the oropharynx
are resected, a flap is not usually necessary.
When minimal or no bulk is needed, simple advance-
ment of mucosa, lingual aponeurosis, and superior longi-
tudinal muscle (see Fig. 15-12) are often feasible (see
Fig. 21-7). If larger coverage is necessary without bulk,
a microvascular flap may be used (see Chapter 24).
 ORAL CAVITY AND OROPHARYNX

B c

D E
FIGURE 15-13
 ORAL CAVITY AND OROPHARYNX
Midline Mandibulotomy
(Mandibular Swing) (Fig. 15-14)
This is an excellent approach to the middle and posterior
portion and base of the tongue to extensive tumors of
the palate with or without extension into the maxilla to
contiguous superficial involvement of the tonsillar
region with involvement of the mandible and pharyn-
gomaxillary space, and to the base of skull. If there is
deep extension of the neoplasm in the tonsil region and
evidence of fixation to the periosteum of the mandible,
then a midline mandibulotomy is not done. A segmental
resection of the involved mandible is performed, thus
affording access to section of the neoplasm and the
parapharyngeal space (see Fig. 15-7 showing resection
of segment of the mandible). If the neoplasm is adherent
only to the upper margin of the mandible, then it is
possible to perform a marginal resection of the mandible
and a midline mandibulotomy. However, do not preserve
a portion of the mandible if there is any evidence either
by fixation or MRI regarding adherence to the perios-
teum. MRI can demonstrate adherence or extension to
within millimeters of the periosteum.
The periosteum can be stripped off the bone without
any gross or even microscopic evidence of involvement
of the bone, but the margin of the specimen is either 0
or just a few millimeters. To depend on postoperative
radiotherapy to eradicate this potential source of
recurrence is believed contentious.
The more anterior lesions do not require section of
the glossopalatine fold. In short, this approach is the
most widely used for exposure and resection of these
lesions. It affords excellent exposure and is readily
combined with a radical neck dissection as indicated.
Obviously, if a segment of the mandible requires resec-
tion, the midline mandibulotomy utilized for the
mandibular resection is not used unless the segment of
the mandible to be resected extends to the midline.
Under such circumstances, access to the neoplasm is
via the segment of the mandible resected.
A The mandible is transected in the midline as
described in Figure 15-13. Depicted in the accom-
panying plate is an extensive neoplasm involving the
palate, superficial tonsillar region, and posterior third
of the tongue. This lesion is free of the mandible, and,
hence, the mandible can be spared. An incision is
made along the floor of the mouth, leaving, if possible,
a narrow rim of mucosa along the inner table of the
mandible to facilitate placement of sutures for the
reconstruction utilizing a PMF. The lingual nerve and
twelfth nerve are included in the resected specimen,
which likewise includes the posterior half and base of
the tongue, the lateral oropharyngeal wall, including
the tonsil, the involved soft palate and hard palate,
and the inferior portion of the maxilla with the lateral
wall and floor of the nasal cavity and septum, as
required. The resection is carried superiorly to include
the lateral wall of the nasopharynx and the eustachian
tube orifice, if necessary. The pterygoid plates and a
major portion of the pterygoid muscles are included in
the surgical specimen, thus reaching the base of the
skull.
B The dashed line indicates the osseous resection,
including the pterygoid plates. The eustachian tube is
transected within the para pharyngeal space. Extreme
care is taken not to injure the internal carotid artery
and related nerves; the artery is approximately 1.5 cm
from the posterior edge of the lateral pterygoid plate
as it enters the carotid canal and turns anteromedially.
If the vessel is exposed it should be protected with a
transposed muscle flap or a turned-in flap of prevertebral
fascia, which is then covered with a dermal graft.
C The defect is reconstructed with a split PMF. The
technique of this split pectoralis flap is described in
Figure 8-30. A prosthesis is utilized to close the palatal
defect. Closure of the mandibulotomy is described in
Figure 15-4G.
When the lesion is less extensive, the resection is
easily modified to include only those structures neces-
sary for removal of the neoplasm, which emphasizes
the versatility of this approach. The reconstruction is
then modified depending on the defect. The twelfth
nerve may be spared if a minimal portion of the tongue
is resected.
 ORAL CAVlTY AND OROPHARYNX

SUBLINGUAL GLAND

12th NERVE

FORAMEN OVALE
MEDIAL
GLENOID
PTERYGOID
FOSSA
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AUDITORY TUBE

STYLOID
PROCESS

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FORAMEN LACERUM

B c
FIGURE 15-14
 ORAL CAVITY AND OROPHARYNX
Resection of Base of Tongue and
Total Glossectomy (Fig. 15-15)
Figure lS-lSA and B depicts in schematic fashion two
base of the tongue lesions with involvement of contin-
uous structures. Parts E and F depict total glossectomy.
A The lateral portion of tongue extends to the base
of the tongue and invades the floor of the mouth with
adherence to the body of the mandible. The dotted
lines indicate the resected area. Although a portion of
the ipsilateral tip of the tongue may be preserved, if
there is any doubt regarding the adequacy of resec-
tion, a hemiglossectomy with extension across the
midline and posterior third of the tongue and base of
the tongue is performed (see Fig. 15-10A to D). PMF
reconstruction is preferred.
B The entire base of the tongue and the lateral
oropharyngeal wall up to the superior alveolar ridge
and palate is involved. This resection, as outlined by
the dotted lines, includes the superior alveolar ridge,
which in turn includes the floor of the antrum. The
para pharyngeal space (see Chapter 23) structures-
pterygoid muscles with the pterygoid plates, adipose
tissue, any lymph nodes, and portion of the lateral wall
of the nasopharynx up to the eustachian tube orifice-
are all resected. Extension into the parapharyngeal
space is notorious for recurrent disease in this area and
is usually an indication for postoperative radiotherapy
if there is any doubt regarding the adequacy of the
resection. Resection of the mandible may entail a
disarticulation of the temporomandibular joint.
Reconstruction is performed with a PMF, possibly
bilobed (see Figs. 15-1 OD and 8-3B and D).
C A typical PMF has been elevated. PMFs are pre-
sented in detail in Figures 8-2 and 8-3. The depicted
flap is via resection of the medial third of the clavicle
(see Fig. 19-9), which:
1. Affords additional length.
2. Avoids compression of vessels over the clavicle.
3. Fills in supraclavicular area, especially over the com-
mon carotid artery after a radical neck dissection.
4. Minimizes bulk over an intact clavicle if pectoralis
major muscle is left intact.
5. Frees a portion of the pectoralis major muscle from
its attachment to the resected clavicle.
6. Protects the subclavian vein.
Variation to accomplish some of the same objectives
can be achieved by careful transection of the pectoralis
major muscle from its origin on the clavicle with
extremely careful preservation of the vascular pedicle.
Another modification depicted is the preservation of
the lateral thoracic artery. This vessel is either a branch
of the thoracoacromial artery or the subscapular artery
or it arises directly from the axillary artery. This is
almost always necessary if side by side dual pedicles
are used (see Fig. 8-3D). It also is advised in the female
patient with extremely pendulous breasts that project
over the lateral thoracic wall. Since its origin varies,
mobilization may require a partial transection of the
pectoralis minor muscle and almost always transection
of the horizontal fibers of the pectoralis major muscle.
As the flap is brought superior, it covers the carotid
artery system and lends bulk to the neck after a radical
neck dissection. Access to the oral cavity and orophar-
ynx is either via the area of the resected segment of the
mandible or medial to the mandible if left intact with a
midline mandibulotomy. If a Steinmann pin is used for
reconstruction, the flap passes over or under the
Steinmann pin, depending on the space available. In
any event, avoid compressi,on. The same applies for the
flap in relation to a mandibular plate; however, this is
usually deep or medial to the plate. Again, the better
available space without compression indicates a better
course of the flap. Although ideally the rotation of the
flap is avoided, the flap almost always requires rotation
up to 180 degrees to achieve the proper location of the
skin paddle relative to the defect. At times, if just bulk
is needed, then no skin paddle is utilized.
 ORAL CAVITY AND OROPHARYNX

,
I
I
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A

Cut portion of
peel. major

B
FIGURE 15-15
 ORAL CAVIlY AND OROPHARYNX
Resection of Base of Tongue and
Total Glossectomy (Continued)
(Fig. 15-15)
Another modification when additional muscle bulk
is needed, for example, in a total glossectomy, is tran-
section of the clavicular portion of the PMF from its
insertion on the humerus. This portion requires preser-
vation of the lateral thoracic artery. This muscle flap is
passed underneath the main pectoralis flap that has the
skin paddle. To facilitate additional length, the medial
third of the clavicle is removed. The paddle of skin is
sutured to any remnant of the mucous membrane on
the medial aspect of the remaining portion of the
mandible with "slings" placed around several teeth to
take the tension off the mucous membrane closure.
Portions of the flap are sutured to the oropharyngeal
defect. The medial/posterior portion of the flap is sutured
to the depth of the vallecula. Unfortunately, this has a
tendency to fix the epiglottis if, in fact, the epiglottis is
preserved.
D A PMFis passed under a Steinmann pin. The distal
portion of the paddle is used for reconstruction of the
base of tongue, and the proximal portion of the
paddle is used to reconstruct the floor of the mouth
and lateral oropharyngeal wall. Advancement of local
mucosa of the palate is used to close the superior
portion of the surgical defect.
E This is a schematic depiction of a total glossectomy
resected in continuity with the posterior portion of the
body of the mandible, the angle of the mandible, and
a portion of the ascending ramus of the mandible as
well as the floor of mouth. The depth of the resection
into the extrinsic muscles of the tongue depends on
the extent of the disease. If at all feasible, the mylo-
hyoid muscle may be preserved ifthis is commensurate
with adequate ablative surgery (see Fig. 15-12).
In total glossectomy, the reconstruction involves a
major portion of bulk to reconstruct the floor of the
mouth and the tongue. The best that can be hoped for
is an adequate closure.
Although the larynx can be preserved in total glos-
sectomy, nevertheless, extreme care must be taken in
the postoperative period to evaluate aspiration. If aspi-
ration does, in fact, occur, then a total laryngectomy
would be the procedure of choice.
In total glossectomy with preservation of the larynx,
speech may be relatively satisfactory. On the other
hand, if it is not and there is any question of aspiration,
then the procedure to do is a total laryngectomy and
voice rehabilitation.
A PMF has been successful in patients after total
glossectomy. These patients have had reasonable
speech and ability to swallow without aspiration. In
one patient, a subtotal epiglottectomy was performed.
This amounted to a 75% removal, yet the patient is
able to swallow and speak.
F This depicts the PMF reconstruction of the floor of
the mouth. The flap goes deep or medial to the
Steinmann pin, which is being used for reconstruction
and stabilization of the mandible. Important in the
utilization of this PMF is that as much bulk as possible
be transposed to the surgical defect. The postero-
lateral portion of the paddle is sutured to the mucosa,
forming the inferior portion of the vallecula.
One author (JML) has three patients with total glos-
sectomy and preservation of the larynx. Two patients
had squamous cell carcinoma treated with preoperative
chemotherapy, surgery, and no radiation. The first patient
had no evidence of disease at 7 years and 2 months,
had intelligible speech, and was able to swallow pureed
foods. The second patient, in addition, had subtotal
mandibulectomy with bilateral neck dissection, unin-
telligible speech, and inability to swallow. This patient
died 3 years after the surgery with no neoplasms evident
at autopsy. Multiple lung abscesses were secondary, no
doubt, to aspiration. This patient should have had a
total laryngectomy shortly after the definitive surgery.
The third patient had adenoid cystic carcinoma involv-
ing the major portion of the lateral and base of tongue.
Treatment was with surgery (no chemotherapy, no
irradiation). The patient was alive at 5 years without
disease at the primary site or any recurrence in the
neck. Speech is intelligible, and he can eat anything.
He holds meat in his hand as he chews it. Pulmonary
metastasis was detected during the past year, but his
condition is stable.
 ORAl CAVI1Y AND OROPHARYNX

F
FIGURE 15-15 Continued
 ORAl. CAVI1Y AND OROPHARYNX

Resection of Lesions of the Buccal Do not assume any lesion is benign until it is proved
Wall to be so. Calamities have occurred with physicians
following highly suspicious lesions (e.g., keratosis or
Buccal Wall lesions: Benign, keratosis-like), only to find squamous cell carcinoma
Premalignant, and Malignant Squamous has been smoldering. This is a tragedy because if
Cell Carcinoma untreated or if treatment is delayed then these carci-
nomas can become among the worst of all oral cavity
Predisposing Factors and oropharyngeal neoplasms. They can extend to
involve the entire oropharynx, palate, and alveolar
• Smoking ridge (superior and inferior) and into the parapharyn-
• Chewing tobacco geaI space (see Chapter 23) with or without trismus.
• Snuff There is a temptation to treat some of these benign-
• Betel nut (with slaked lime) appearing lesions with the CO2 laser. Do not use this
modality. It may destroy margins; and if vaporization is
Differential Diagnosis utilized, the entire lesion will be destroyed. No
specimen will then be available for careful histologic
I. White area on the mucous membrane can be due to: evaluation.
a. Dysplasia or atypism-so-called leukoplakia, a There are three types of buccal wall squamous cell
clinical term and not a histologic diagnosis- carcinoma:
precancerous I. Exophytic
b. Fungus infection, for example, Candida-can be 2. Ulcer, infiltrative
associated with cancer 3. Verrucous carcinoma
c. Lichen planus-can be associated with cancer
d. Scar formation, which may be due to trauma Buccal Wall: Benign Lesions (Fig. 15-16)
from biting mucous membrane or irritation by
dentures The underlying potential problem is the differentiation
e. Verrucous hyperplasia-may be premalignant between benign and malignant lesions. If reasonably
f. Keratosis certain that the lesion is benign, complete excision is
g. Pemphigus vulgaris recommended under local anesthesia. If suspicious of a
2. Reddish area on the mucous membrane can be due premalignant or outright malignant lesion, see the
to: following discussion relative to diagnosis and manage-
a. Inflammation ment. In any event, the entire lesion must be removed
b. Erythroplasia-possibly premalignant with liberal use of frozen section as indicated. The
c. Squamous cell carcinoma within areas of ery- Stensen duct orifice is preserved if feasible. If not, the
throplasia-may be clinically indistinguishable. duct is reimplanted or left free. A stent usually is not
Toluidine blue staining may be of aid. necessary. At times a benign lesion, for example, a
3. Superficial ulceration-may be associated with cavernous hemangioma and rarely a lipoma, may require
keratosis and so-called leukoplakia or erythroplakia general anesthesia because a hemangioma may extend
(which are not histologic diagnoses but clinical impres- to the edge of or around the masseter muscle. Bleeding
sions) or early carcinoma. Toluidine blue staining could be troublesome under local anesthesia. Closure
(see Chapter 3, page 91) may be of aid in selecting is usually achieved with an advanced flap of mucous
area to sample if a lesion involves virtually the entire membrane. If the defect is too large, a dermal graft is
mucosa of the buccal wall. Do not be satisfied with used. "Stealing mucous membrane" from the nasal
a random punch biopsy. It is better to excise the septum has been reported but hardly ever indicated.
entire area in question. Toluidine blue is of no use in The purpose would be to avoid a scarring complication,
inflammatory ulcerative lesions because it can give which can occur with a dermal graft.
a false-positive result.

FIGURE 15-16
A Dotted lines depict the area of resection, allowing
at least a 3- to 5-mm gross margin. Depth of this
resection depends on the histologic type of the lesion.
Preoperative biopsy may be helpful and can be
selected based on positive toluidine blue staining.
Nevertheless, frozen section must be done as indi-
cated. If at all possible, a rim of mucous membrane is
preserved in the superior and inferior gingival buccal
sulci for suturing of the dermal graft.
B If a full-thickness graft is utilized, it is secured with
a bolus of gauze soaked with antibiotic solution. The
suture material preferred is nylon or Prolene.
The gauze bolus can also be used with a dermal
graft. A significant problem postoperatively is contrac-
ture of the dermal graft, which is worse with a split-
thickness graft (which is not used) and less with a full-
thickness graft.
ORAL CAVITY AND OROPHARYNX
C Cross section shows the position of the gauze
bolus. If necessary, an opposing second gauze bolus
can be placed over the cheek and sutured in place
with through-and-through sutures.
To quote from Hayes Martin's textbook Surgery of
Head and Neck Thmors, "Because the tissues of the
cheek are in a completely relaxed state when the mouth
is closed, split skin grafts tend to shrink and result in
the formation of localized pockets with marked restric-
tion in the ability to open the mouth. With full-thickness
grafts, there is a greater chance of failure to 'take: but
once healed, the danger of shrinkage is much less."
See Highpoints under Reconstruction of Buccal Wall
Lesions on page 746.
 ORAL CAVITY AND OROPHARYNX

Plan for Resection of Premalignant and Neck Dissection

Malignant lesions of the Buccal Wall
Radical or modified radical neck dissection is done for
The depth of resection depends on the exact diagnosis clinically palpable nodes or nodes larger than I cm
of the lesion. It also should be noted that significant seen on CT or MRI. For most lesions with an NO neck,
involvement of the buccal wall can be either the pri- a selective neck dissection is done, even for T3 and T4
mary lesion or a secondary invasion from the orophar- lesions.
ynx or floor of mouth.
A basic outline of appropriate resection according to Surgical Margins
diagnosis is shown in Table 15-1. It may be multi-
centric. See Chapter 3, page 91, for commonly used If margins are in doubt, check with intraoperative
terminology for squamous epithelium. frozen sections.

Diagnosis 1teatment

Dysplasia Resection of the mucous membrane (see Fig. IS-IE and F)

Carcinoma in situ Resection of mucous membrane and immediate underlying tissue:
buccinator muscle
Verrucous carcinoma with local extension Resection of mucous membrane, buccinator muscle, fat pad

Squamous cell carcinoma, invasive but Resection of mucous membrane, buccinator muscle, and entire fat pad
limited to mucosa and submucosa with portion of masseter muscle

Squamous cell carcinoma, invasive but
limited to mucosa and submucosa with
retromolar trigone involvement
Squamous cell carcinoma, widely invasive,
with deep ulcer involving skin and bone
Squamous cell carcinoma, widely invasive,
with deep ulcer involving skin and bone,
lateral wall of the oropharynx with
anterior and posterior pillars, palate, and
upper alveolar ridge
Minor salivary gland
Low-grade mucoepidermoid carcinoma
High-grade mucoepidermoid carcinoma and
adenocarcinoma
Basal cell carcinoma
Squamous cell carcinoma
Dermatofibrosarcoma protuberans involving
skin of cheek
Resection of mucous membrane, buccinator muscle, and entire fat pad,
plus segmental resection of the mandible (see Fig. IS-IIJ and K)
Wide resection of primary lesion, through and through, including the skin
and segmental resection of the mandible
Wide resection of primary lesion, through and through, including the skin
and segmental resection of the mandible and all areas involved with
the dissection of the para pharyngeal space (the pterygoid muscles and
plates) and the floor of the antrum. Margins should be at least 1 to
1.5 em where feasible.
Wide resection: 50% can be malignant
Wide resection
Wide resection of primary lesion, through and through, including the skin
and segmental resection of the mandible and all areas involved with
the dissection of the para pharyngeal space (the pterygoid muscles and
plates) and the floor of the antrum. Margins should be at least 1 to
1.5 em where feasible.
Local excision with 0.5- to 1.0-cm margins
Wide resection, margins of at least 1 to 1.5 em: depth of resection
depends on extension of disease
Resection of entire skin lesion with at least l-cm margins or more and
buccal wall at the center of the lesion with resection of alae nasi and
lips as indicated by extension of disease: exposure of peripheral
branches of the seventh nerve; tarsorrhaphy: Stensen's duct resected
and proximal ligation (if possible. re-implant in mucous membrane).

Masseter Muscle
In any of the advanced carcinomas, resection of part or
all of the masseter muscle may be necessary. This may
include the parotid salivary gland in invasive malignant
lesions involving the cheek.
Facial Lymph Node
Potential metastasis of these invasive malignant lesions
can be to the facial lymph nodes:
1. Infraorbital (maxillary)
2. Buccinator-on buccinator muscle opposite angle of
the mouth
3. Supramandibular-on outer surface of the mandible,
anterior to masseter muscle, and in contact with
facial artery and vein
Minor Salivary Gland Neoplasm
The degree of malignant differentiation may vary, for
example, from the low-grade mucoepidermoid carcinoma
arising in a minor salivary gland through intermittent
grade to high grade and very high grade. The more
squamous cell components there are, the higher the
level of malignancy. Frozen section is freely utilized
when there is the slightest suspicion of malignant
lesion. "Since the foregut is abundantly supplied with
a submucosal lymphoid component, it is not unusual
to find aberrant tissue within the lymph nodes of the
head and neck-these aberrant occurrences can occur
in tonsils-the body of the mandible, lower neck,
hypopharynx, middle ear, sternoclavicular joint, along
the thyroglossal duct tract," and other areas.
Secondary Involvement of the Buccal Wall
For example, for a primary lesion of retromolar trigone
the resection can include, depending on the extent of
disease, a portion of the body and the ascending ramus
of the mandible, the masseter muscle, partial maxillec-
tomy, the soft palate with uvula, the lateral oropharyn-
geal wall, a portion of the base of the tongue, the tail
of the parotid salivary gland, and juxtaposed portion of
the deep lobe of the parotid. Exposure and preservation
of the seventh cranial nerve or at least the zygomatic
temporal division is done. It also could include a
parapharyngeal space dissection with the pterygoid
muscles and the pterygoid plate. If there is indication
of extension into the nasopharynx toward the
eustachian tube orifice, this area is also resected. The
main area of possible recurrence is in the vicinity of the
parapharyngeal space (see Chapter 23).
ORAL CAVilY AND OROPHARYNX
Radical Resection of Buccal Wall With
Mandibulectomy Associated With
Oropharyngeal and Retromolar Trigone
Invasion: Advanced Squamous Cell
Carcinoma
Highpoints
Pretreatment
1. Very careful evaluation of the extent of the disease is
necessary. This is a very lethal disease.
2. Tattoo either in the office or under general anes-
thesia, whether or not preoperative chemotherapy is
to be used. This lesion can involve the lateral wall
oropharynx and tonsil, mandible, floor of the mouth
up to the posterior third of the tongue, palate, poste-
rior alveolar ridge, parapharyngeal space, pterygoid
muscles, parotid salivary gland, facial lymph nodes,
submandibular triangle, and lateral neck. Cheek
evaluation is very important; for example, if there is
the slightest puckering of the skin or the lesion is
within several millimeters of the skin, resect the skin.
3. Use of CT and MRI aids in the evaluation of the
extent of disease.
Surgical
1. Percutaneous endoscopic gastrostomy (optional)
2. Tracheostomy
3. Classic radical neck dissection includes sublingual
salivary gland if close to spread on the floor of the
mouth; also included is the posterior belly of the
digastric muscle if metastatic disease extends beneath
the muscle from highest internal jugular node.
4. Use a midline lip-stepped incision extending infe-
riorly to meet the upper horizontal skin incision for
the neck dissection.
S. Preserve, if possible, the ramus mandibularis. It is
entirely included in the cheek flap. At times this is
impossible.
6. Make every effort to preserve the zygomatic tem-
poral division of the seventh nerve; expose the
main trunk of the seventh nerve if necessary.
7. Reflect the buccal wall with cheek up to the
anterior site of the mandibular resection.
8. Remove tooth (could be canine or premolar) and
do mandibulotomy through tooth socket. Posterior
site of transection depends on the extent of
disease; however, it should be at least through the
anterior portion of the angle of the mandible.
Further posterior resection depends on the extent
of disease. A marginal resection of the mandible
(see Fig. 14-11F to R) is performed only if there is
 ORAL CAVilY AND OROPHARYNX
no adherence to bone. Full segmental resection of
the mandible is always done with a retromolar trigone
lesion with adherence to cortex.
9. Resect buccal wall as per tattoo marks or more if
area is suspicious. The juxtaposed floor of the
mouth and a portion of the tongue and mandible
and sublingual gland may be included.
10. Resect at least the mucosa extending superiorly
along the ascending ramus of the mandible; the
posterior site of mandibular transection may include
this area.
11. Remove the lateral wall of the oropharynx and tonsil
if there is the slightest indication of involvement
(see Fig. 15-11).
12. It is usually possible to preserve the twelfth nerve;
the lingual and inferior alveolar nerves may require
transection to obtain improved exposure of the
parapharyngeal space.
13. Perform a parotidectomy; the extent of resection
depends on the disease.
14. Remove the contents of the parapharyngeal space
including internal and external pterygoid muscles
and plates if the parapharyngeal space is invaded
by the neoplasm.
15. When palate and superior alveolar ridge are
involved, then these structures must be removed.
This involves removing a portion of the antrum.
16. Do not compromise on mucosal resection; obtain
frozen sections of margins, especially when they
look suspicious.
17. Preserve, if feasible,S to 7 mm of mandibular and
maxillary mucous membrane along the gingival
buccal sulcus for suturing of PMF.
18. Separate the buccal wall from the cheek, from the
commissure of the lip to the site of the mandibular
resection posteriorly. Use tattoo marks as guide. If
this point is more posterior, use deeper resection to
include the buccinator muscle, fat pad, and portion
of the masseter muscle and portion of the oropha-
ryngeal mucous membrane as involved up to the
premolar tooth.
19. Reconstruct using a PMF and Steinmann pin with
tie wires (see Fig. 14-5) or mandibular plate.
Cheek Flap Mobilization
1. Without the resection of the mandible, for example,
use a visor flap: transect two muscles on the lateral
border of the mandible:
a. Buccinator
b. If flap extends posteriorly, use a portion of the
masseter muscle. The platysma muscle has some
fibers inserted into the mandible below the oblique
line (lower external edge of the mandible) and
other fibers into the skin and subcutaneous tissue
(Gray's Anatomy). When the mandible is not
resected, the fibers attached to the oblique line of
the mandible are not transected. However, the
fibers to the skin and subcutaneous tissue are
transected to mobilize the mandible.
c. If extension is anterior, transect depressor labi
and the depressor angularis muscles.
2. With the mandible included in the cheek flap, tran-
sect muscles on the medial border of the mandible,
mylohyoid and, if flap extends, the anterior belly of
the digastric and genioglossus muscles.
With mobilization of a cheek flap, care must be
taken not to injure the nerve supply or the small mus-
cles of expression. These nerves are via small branches
from the various large branches of the main divisions
of the facial nerve. They arise medially. Nevertheless, it
is important not to elevate a flap so far anteriorly and
medially that these small branches will be transected.
Usually the guideline is I to 2 cm from the commissure
of the lips. These small nerves are involved in the
superficial musculoaponeurotic system. In summary,
elevation of the cheek flap is relatively safe in the
parotid area but can become dangerous in the area
anterior to the parotid gland.
Reconstruction of Buccal Wall lesions
Highpoints
1. Reconstruct buccal wall with underlying buccinator
muscle with or without fat pad:
a. Use dermal graft (possibly local mucosal flaps).
b. Use radial forearm microvascular flap.
c. Use forehead flap (see Fig. 8-10).
a. Use a full-thickness graft.
2. Reconstruct buccal wall with contiguous areas, for
example: oropharynx, tongue, floor of the mouth:
a. Use a PMF.
b. Use a microvascular flap.
3. Reconstruct entire buccal wall with overlying skin of
the cheek:
a. Use a PMF with or without dermal graft on the
buccal wall.
b. Use a microvascular free flap, for example, an
abdominal flap for the cheek and then a dermal
graft for the buccal wall attached to the inner
portion of the abdominal flap. A gracilis myocuta-
neous microvascular flap can be used, if indicated
(see Chapter 7).
c. Use a forehead flap (see Fig. 8-llA to N).
4. When there has been a segmental resection of the
mandible:
a. Use a Steinmann pin with tie wires.
b. Use mandibular plate.

Resection of Carcinoma of the
Retromolar Trigone and the Buccal Wall
(Fig. 15-1 7; see also Fig. 15-11 J and K)
This patient had extensive dysplasia with possible
multiple areas of carcinoma in situ of the juxtaposed
buccal wall with invasive squamous cell carcinoma of
the retromolar trigone extending into the buccal wall.
The carcinoma was contiguous with the dysplasia and
hence a complete resection of the buccal wall along
with the invasive carcinoma was performed with seg-
mental resection of the mandible.
The surgery involved a percutaneous endoscopic
gastrostomy and tracheostomy with right classic radical
neck dissection. A segment of the body and major por-
tion of the angle of the mandible was resected. Also
resected was the entire right buccal wall, retromolar
trigone, and mucosa extending superiorly along the ante-
rior edge of the ascending ramus of the mandible and
a portion of the oropharyngeal mucosa. A portion of the
masseter muscle was resected as well. The mandible was
reconstructed with a bent Steinmann pin and a PMF.
A
FIGURE 15-17
ORAL CAVI1Y AND OROPHARYNX
A Skin incision is outlined. This forms the cheek-
buccal wall flap, which is mobilized posteriorly to the
premolar tooth, which is the anterior site of tran-
section of the mandible. A traction suture is through
the commissure of the lip. This flap is a further
development of the upper neck dissection flap and
contains the ramus of the mandible of the seventh
nerve, which is preserved.
B This shows the cheek-buccal wall flap reflected
laterally and posteriorly to the lower premolar tooth
region, which will be extracted and will be the site of
the anterior segmental resection of the mandible. The
area of resection is outlined. Note the narrow rim of
mucous membrane left on the anterior portion of the
mandible, which will be used to suture the PMF in the
reconstructive phase. Stensen's duct is included in the
resection.
Continued
 ORAl CAVITY AND OROPHARYNX
Resection of Carcinoma of the
Retromolar Trigone and the Buccal Wall
(Continued) (Fig. 15-17; see also Fig. 15-11 J
and K)
C Depicted is a separation of the buccal wall
anteriorly extending posteriorly to the solid line (C and
D), which includes mucosa, submucosa, and bucci-
nator muscle from the cheek flap. This is extended
down to the fat pad as delineated in D. When this
separation reaches the premolar tooth (the anterior
end of the transection of the end of the mandible), the
dissection now proceeds deeper, including the entire
buccal wall and fat pad and a portion of the masseter
muscle. The mandible is transected through the tooth
socket of the premolar tooth using a sagittal plane
saw. At this point, the lower portion of the incision
courses down into the gingival lingual sulcus, thus
encompassing the entire mandible.
o This depicts the buccal wall resection starting at
the anterior commissure of the lip, extending supe-
riorly and inferiorly to the respective sulci. The solid
vertical line corresponds to the solid line in C, which
depicts the deeper resection posteriorly and laterally
down to the subdermal fat pad. Anterior to this line
the dissection extends to the fat pad. For clarity
purposes, the buccal wall portion of the resection is
not depicted. The vertical dotted line indicates the
mucous membrane resected along the anterior edge
of the ascending ramus of the mandible. The dashed
lines indicate the segment of mandible resected. The
entire section is done en masse including the entire
buccal wall, buccinator muscle, fat pad, and segment
of the mandible, with a portion of the masseter
muscle. The reconstruction utilizes a bent Steinmann
pin with tie wires and a PMF.
Although it did not occur in this patient, if the mucous
membrane involvement along the anterior edge of the
ascending ramus of the mandible is adherent along the
presenting margin, this margin of the ascending ramus
of the mandible extending up to the coronoid process
may be removed along with the overlying mucous
membrane. Portions of the temporalis and masseter
muscles are inserted on this area of the mandible. If
resection of the margin of the mandible does not
suffice relative to adequate ablative resection, then the
ascending ramus of the mandible is removed along
with the segment involving the angle and the body.
E Cross section is shown through the anterior area of
resection-the buccal wall. This includes the mucosa,
the submucosa, and the buccinator muscle.
El Cross section is shown through the buccal wall at
the area where there is a segmental resection of the
mandible. The resected area includes the mucosa,
submucosa, buccinator muscle, fat pad, and a
juxtaposed portion of the masseter with the segment
of the mandible. At the upper margin of the resection,
the cut edge includes:
1. Mucosa to which the edge of the PMF is sutured
2. The edge of the fat pad (all else is removed
posterior to solid line [see C and DJ)
3. The edge of the resected masseter muscle
F The completed graft of PMF is shown. The tongue
is not tethered-the flap is not sutured to the tongue.
This allows free motion of the tongue. The flap
inferiorly covers the Steinmann pin. This coverage of
the Steinmann pin can be either medial or lateral to
the pin, depending on the location of the PMF (see
Figs. 14-1 OF and 15-11 Nand 0).
Continued
 ORAL CAVITY AND OROPHARYNX

cut edge of
masseter m.
retromolar portion
::------..of tu mor
no.t staged)

c •
--_._~ o

facial m. of
expression masseter m.
remnant

F
FIGURE 15-17 Continued
 ORAL CAVITY AND OROPHARYNX
Resection of Carcinoma of the
Retromolar Trigone and the Buccal Wall
(Continued) (Fig. 15-17; see also Fig. 15-11 J
and K)
G Coronal section is shown through the region of
the second molar tooth. This demonstrates the fat pad
lateral to the buccinator muscle and the masseter
muscle lateral to the fat pad and the relation to the
section of mandible resected as depicted on E.
G
FIGURE 15-17 Continued
H Coronal section is shown just beyond the third
molar tooth depicting the external and internal
pterygoid muscles with the hamulus of the medial
pterygoid plate around which the tendon of the tensor
veli palatini glides. The hamulus is easy to locate by
palpation, thus helping to orient this dissection.
I Postoperative radiograph shows the area of seg-
mental resection of the mandible with reconstruction
using a Steinmann pin and tie wires.
 ORAL CAVITY AND OROPHARYNX

FIGURE 15-17 Continued

 ORAL CAVIlY AND OROPHARYNX

Excisions of Lesions of Soft and

Hard Palate (Fig. 15-18)
Indications
These lesions include premalignant and benign tumors.
The use of skin graft and rotation flaps is not necessary,
because healing can occur by secondary intention.
Such reconstruction-type closure, however, speeds
recovery and lowers the morbidity when the defect is
large.
A An elliptical excision of a lesion of the soft palate,
including the fascia of the muscle, is made with the
long axis of the ellipse in the vertical plane. Lateral
mucosa-relaxing incisions similar to those used in cleft
palate repair are made to facilitate closure.
D The mucosa is excised down to the periosteum. If
the lesion is suggestive of a mixed tumor of a minor
salivary gland, the periosteum is removed with the
specimen.
E, F When the periosteum is excised, the cortical
bone may be perforated in several areas with a small
drill to prepare a bed for a free split-thickness graft.
Four sutures are left long to hold a small pressure
dressing of cotton soaked with liquid povidone-iodine
(Betadine) or antibiotic ointment. The sutures are tied
over the cotton in a manner similar to the technique
used in free grafts to the tip of the nose (see Fig. 6-25).
G Another method of closure is a rotation flap with
a free graft to the flap donor site. The flap does not
include the periosteum.

B Horizontal mattress sutures of 4-0 and 5-0 nylon H The flap of mucosa has been rotated over the
are placed for vertical approximation. This prevents operative defect. Split-thickness skin is sewn over the
shortening of the palate. donor site. Because periosteum is present at the donor
site, the split-thickness skin is more likely to survive.
C The circular excision for a lesion of the hard palate Cotton-soaked liquid povidone-iodine or antibiotic
is outlined. ointment is again applied as a pressure dressing over
the free skin graft.
Continued
 ORAL CAVI1Y AND OROPHARYNX

A B

FIGURE 15-18
 ORAL CAVITY AND OROPHARYNX
Excisions of Lesions of Soft and
Hard Palate (Continued) (Fig. 15-18)
I Depicted is a benign minor salivary gland tumor
involving the soft palate. A fine-needle aspiration may
give an indication of the nature of the neoplasm. If the
tumor is benign (as determined by frozen section), a
through-and-through resection is performed as
indicated by the circumferential dotted line, including
a portion of the periosteum of the hard palate and
laterally to the hamulus and the pterygoid muscu-
lature. Closure may be achieved by a contralateral
relaxing incision as shown by the dotted line and the
arrow. This closure is similar to that used in the repair
of a cleft palate (see Fig. 10-8).
If the frozen section indicates a high-grade malig-
nant minor salivary gland tumor, additional resection is
indicated as described in the following:
J The dotted lines outline the area to be resected in
a high-grade malignant minor salivary gland tumor.
This includes the major portion of the soft palate and
hard palate, floor of the antrum along with the
superior alveolar ridge, base of the nasal septum, and
ipsilateral wall of the oropharynx and nasopharynx, as
well as the pterygoid plates and portion of the internal
and external pterygoid muscles. The resection is
carried up to the eustachian tube orifice.
K The resection defect is outlined in J. Frozen
sections are obtained on all margins and nerves for
perineural invasion. If positive, the involved area is
further resected until the frozen sections are clear.
When there is any question regarding the adequacy of
the resection, postoperative radiotherapy is advised.
The bare areas of the defect are covered with
dermal graft rather than thick flaps to facilitate careful
follow-up for any recurrence. The palatal defect is filled
with an obturator for the same reason.
Kl Bone area is resected. The dotted line passes
through the base of the pterygoid plates (of the
pterygoid process) and floor of the antrum with a
partial maxillectomy including a major portion of the
hard and soft palate.
Continued
 ORAL CAVITY AND OROPHARYNX

,
\
\

LATERAL PTERYGOID M.

Foramen ovale

Pterygoid process
Pterygoid plates

FIGURE 15-18 Continued

 ORAl CAVITYAND OROPHARYNX

Excisions of Lesions of Soft and

Hard Palate (Continued) (Fig. 15-18)
K2 Posterior and superior is the foramen lacerum,
deep to which is the internal carotid artery covered by
a fibrocartilaginous plate, as well as other important
landmarks and structures as labeled. Care must be
taken when removing the plates that none of these
structures is injured. The middle meningeal artery
(branch of the internal maxillary artery) is the largest
vessel that supplies the dura mater. It passes through
the foramen spinosum. If disease reaches this area at
the skull base, extreme care must be taken to leave
enough length to the vessel for adequate ligation.
Care must be taken not to avulse the vessel. If gross
disease must be left behind, it may be wise to label the
area with a clip. The gamma knife would be a con-
sideration to deliver "coned radiotherapy."
K3 The dashed lines indicate the internal carotid
artery in the carotid canal. The foramen ovale transmits
the mandibular nerve, the accessory meningeal artery,
and, at times, the lesser superficial petrosal nerve.
K4 Auditory canal relationships are shown.
K5 Coronal section in the region of the anterior
fascial pillar and tonsil. This clearly demonstrates the
lower portion of the external pterygoid muscle arising
from the lateral pterygoid plate (also has upper
portion arising from the great wing of the sphenoid)
and the internal pterygoid muscle arising from the
pterygoid fossa and medial side of the lateral
pterygoid plate.
Continued

Glenoid fossa

12th n.
Glossopharyngealn.
Jugular vein In!. carotid a.
I

I
/

/ Pterygoid plate

Foramen
spinosum Foramen
lacerum
External orifice
of carotid canal
Jugular fossa

FIGURE 15-18 Continued

 ORAL CAVITY AND OROPHARYNX

(~
Facial n. Internal auditory canal

Levator veli
palatini m.
Medial pterygoid

Post. belly
of digastric
Occipital a.
11th n.

Pharyngeal n. branches
Int. carotid a.
Sup. cervical
sympathetic ganglion

FIGURE 15-18 Continued

 ORAL CAVITY AND OROPHARYNX
Excisions of Lesions of Soft and
Hard Palate (Continued) (Fig. 15-18)
L Baseof the skull is shown. The dotted line indicates
the osseousresection. The proximity of the great vessels
and nerves at the base of the skull are depicted.
Obviously, there are numerous important relationships
in this area. One that should be emphasized is the
distance between the internal carotid artery and the
posterior edge of the lateral pterygoid plate. This dis-
tance is approximately 1.5 cm and must be kept in
mind when resecting the lateral pterygoid plate. The
styloid process overlies the internal carotid artery.
Additional emphasis is placed on the danger of possible
injury to the internal carotid artery. The foramen lacerum
is located at the base of the medial pterygoid plate.
The inferior aspect of the foramen lacerum is filled
with a fibrocartilaginous plate, above which passesthe
internal carotid artery after it passesthrough the orifice
of the carotid canal. This orifice is posterior to the
foramen lacerum.
Inferior view of relationship of base of the lateral
and medial pterygoid plates to the internal carotid
canal external orifice is not shown. The internal carotid
artery after entering the carotid canal turns postero-
medially within the canal for a distance of approxi-
mately 1.5 cm. At that point, which is covered by the
fibrocartilaginous plate of the foramen lacerum, the
vessel turns upward through the base of the skull. This
vessel lies above this fibrocartilaginous plate. The
proximity of the internal carotid artery as well as the
proximity of the mandibular nerve and accessory
meningeal vesselsin the foramen ovale and the middle
meningeal artery and the foramen spinosum must be
clearly understood when dissecting in this area.
 ORAL CAVllY AND OROPHARYNX

FORAMEN OVALE

MEDIAL
PTERYGOID
PLATE
GLENOID
FOSSA

AUDITORY TUBE

L
FIGURE 15-18 Continued
 ORAL CAVITY AND OROPHARYNX
Resection of Extensive Benign Minor
Salivary Gland Tumors of the Soft Palate
Histologically benign, locally spreading minor salivary
gland tumors of the oral cavity and oropharynx can
have superior and combined superior and inferior spread
in the parapharyngeal space (see Chapter 23), as well
as lateral extension into the space. Examples of two
types are outlined relative to the various surgical
approaches and structures resected.
Two initial exposures and approaches (options for
skin incisions) include the following:
1. Via a stepped lip and chin incision, described
previously (see Fig. 15-11A).
2. Visor flap (Schweitzer), which avoids the midline
incision and is facilitated by bilateral submandibular
skin incisions. These incisions can extend to the
region of the angle of the mandible and the tubercle
of the maxilla. These incisions are made sufficiently
inferior to avoid injury to the ramus and mandibu-
laris branch of the facial nerve. Because the nerve is
deep to the platysmal muscle, the muscle attach-
ments to the oblique line of the mandible are not
transected. The fibers of the muscle to the skin and
subcutaneous tissue are transected; thus the muscle
is not elevated with the skin flap, thereby protecting
the nerve although the nerve itself is not identified.
In addition, the infraorbital nerve is like-wise pre-
served but it is identified.
An incision is made in the inferior gingival buccal
sulcus bilaterally to further mobilize the visor flap. Five
to 7 mm of mucosa is preserved on the lateral portion
of the mandible to facilitate closure of the mucosa. This
incision is not necessary when a midline lip incision is
used, because the skin flap and the mandible are
rotated together laterally.
lWo options to expose the tumor site include:
1. Midline or lateral mandibulotomy.
2. Midline mandibular glossotomy. This can be combined
either with the visor flap or the more preferred
midline lip incision.
Case 1 (Fig. 15-19A)
Described is a young female patient with a recurrent
pleomorphic adenoma in a minor salivary gland located
in the palate, which now requires a resection very similar
to malignant minor salivary gland tumor. A pleomor-
phic adenoma, although histologically and morphologi-
cally benign, can, in fact, have significant spread and
even invasion to contiguous structures.
When the patient was age 13, a benign pleomorphic
adenoma was enucleated from a concavity of the hard
palate. There was no evidence of any bone destruction.
The specimen indicated it was completely excised;
margins were clear. The specimen measured 3 x 2.5 x
2 em with an intact capsule.
The patient returned at age 28 with a recurrent
2 x 2.4 em mass in exactly the same location as the
primary tumor. CT and MRI suggested bony invasion of
the posterior right superior alveolar ridge, pterygoid
plate, and hard palate. Follow-up 19 years later showed
no evidence of local or metastatic disease. CT and MRI
suggested bony invasion of the posterior right superior
alveolar ridge, pterygoid plates, and hard palate.
Minor Salivary Glands
These tumors, although they are benign, can displace
bone, which can sometimes simulate a malignant tumor.
Ten to 20 percent of all salivary glands arise from sites
other than the major salivary glands: palate, tongue,
lips, nasopharynx, sinuses, and larynx. Approximately
half of these minor salivary gland tumors are malignant
(Batsakis). However, bone erosion can occur, as well as
soft tissue, yet these tumors are considered histologi-
cally benign but simulate a malignant neoplasm.
An observation relative to the defect in the adjacent
bone (e.g., hard palate) is that the defect is a noninfil-
trative compression of bone, with a bony sclerotic rim
between the bone and the tumor. The tumor is still
histologically benign. This is a pressure phenomenon.
The pathogenesis is unknown.
Highpoints for Case 7
1. Tracheostomy was performed.
2. Exposure and approach:
a. A visor flap (chosen by the patient for cosmetic
reasons) with bilateral cervical submandibular
incisions was used; the ramus mandibularis was
avoided.
b. Bilateral incisions were made in the superior
gingival buccal sulci (canine fossa), posterior to
the region of the tubercle of the maxilla.
e. Cheek flap was elevated without platysmal mus-
cle. Ramus mandibularis is deep to this muscle.
d. Infraorbital nerve was identified and preserved.
e. Midline mandibulotomy was performed, lateral
retraction: incision of floor of mouth and tran-
section of mylohyoid muscle was necessary for
mobilization of mandible.
f. The lateral pterygoid plate was exposed.
g. Exposure was enhanced by anterior traction on
the tongue, upward traction on the maxilla, and
lateral retraction of the oropharyngeal wall with

Case I
FIGURE 15-19
the hemimandible. The visor flap exposure, how-
ever, is not as effective as a midline lip incision.
h. Incision through the right superior gingival buc-
cal sulcus was extended and deep in exposing
the two pterygoid muscles, which were transect-
ed. No evidence of gross tumor was found.
Frozen section of the muscle stumps showed no
tumor. Nevertheless, because of the CT and MRI
findings, the pterygoid plates were transected
near their base at the pterygoid process with a
sagittal plane saw (with care not to violate the
internal carotid artery).
1. Transection of the pterygoid plates with the sagit-
tal plane saw was now extended across the floor
of the antrum encompassing the superior pos-
terior alveolar ridge up to the first molar tooth,
which was extracted. This is the site of the
anterior cut through the alveolar ridge and forms
the line where the hard palate is transected.
J. The hard palate was transected horizontally to
the midline and then anteriorly to its attachment
to the soft palate.
k. Included in the resection was 1.5 cm of soft
palate by transecting the remaining palatine
muscles (tensor veli palatini and the glossopala-
ORAL CAVITY AND OROPHARYNX
tinus). The descending palatine artery was
suture ligated and the stump was covered with
local soft tissue.
l. Pulsation of the internal carotid artery was felt
deep and lateral to the pterygoid muscles.
m. Frozen section of soft tissue showed margins free
of tumor.
n. The intact specimen, a portion of the hard and
soft palate, and a portion of superior alveolar
ridge with the pterygoid plates were removed.
o. Frozen section of soft tissue showed margins free
of tumor: decalcified bone, no tumor.
p. Follow-up at 19 years showed no evidence of
local or metastatic disease.
Reconstruction
1. Dermal graft was used for any bone and soft tissue
regions of the resected area. This was primarily over
muscle, stump, and adipose tissue.
2. Approximation of the mylohyoid and any portion of
the depressor labia and anguli muscles that had
been transected was done.
3. Palatal defect (use of obturator); a flap should not be
used because it can hide early recurrent disease.
 ORAL CAVITY AND OROPHARYNX
Resection of Extensive Benign Minor
Salivary Gland Tumors of the Soft Palate
(Continued)
A legitimate question could be asked regarding why
the resection was so extensive because the tumor was
benign. The answer is that with resection of a recurrent
pleomorphic adenoma, a prudent procedure is the sur-
gical resection of all suspicious tissue, soft and bone, as
delineated at the time of surgery based on the image
findings. A third recurrence could be tragic, especially
in a young patient.
Case 2 (see Fig. 15-19B)
This patient presented with a large, smooth mass in the
soft palate extending superiorly to the junction with
the hard palate and to the inferior tonsillar region. It
measured 5 cm vertically and 4 cm horizontally.
Surgical Technique
1. Tracheostomy was performed.
2. Incisional biopsy sample after frozen section
showed benign pleomorphic adenoma.
3. Initial evaluation of extent of tumor via transpalatine
incision indicated neoplasm extending into the para-
pharyngeal, oropharyngeal, and nasopharyngeal
spaces superiorly and inferiorly extending to the
lower third molar tooth, adherent to the mandible
and the deeper structures of the parapharyngeal
space. The hamulus of the medial pterygoid plate
was identified.
4. Exposure and approach:
a. Midline labiomandibuloglossotomy was performed
with midline incision to just above the hyoid
bone (see Figs. 15-4A to C and 15-5).
b. Posterior extent of incision through the base of
the tongue was to within 1 cm of the hyoid bone.
c. Both halves of the tongue with intact cheek flaps
were retracted laterally, thus affording exposure
inferiorly, medially, and laterally.
d. Additional exposure inferiorly was necessary, hence
a combined transcervical approach was used. The
cervical incision from just above the hyoid bone
was extended to the mastoid process with a curved
or linear incision. The cervical flap contained the
platysma muscle with the ramus mandibularis of
the seventh nerve.
e. The bifurcation of the carotid artery as well as the
internal and external carotid arteries were exposed
as well as the internal jugular vein.
f. The cervical facial division of the facial nerve
with the ramus mandibu\aris was identified and
preserved along with the greater auricular nerve.
The skin flap with the branches of the seventh
nerve was left attached to the mandible and was
an advantage over the visor flap.
g. The posterior belly to the digastric muscle and the
stylohyoid muscle were exposed. Superior to these
muscles, the parapharyngeal space was entered.
Frozen section of a large lymph node indicated it
was benign.
h. The styloid process displaced by the neoplasm
was removed, which facilitated exposure into the
parapharyngeal space. Neoplasm was adherent to
the medial aspect of the mandible in the region of
the angle and extended into the cervical area.
There was concern regarding the possible origin
of the neoplasm from the deep lobe of the parotid
salivary gland. However, the neoplasm capsule
was not involved with the parotid gland. Pulsa-
tions of the internal carotid artery could be felt
posterior and lateral to the neoplasm. This vessel
and branches of the external carotid artery were
carefully protected. The twelfth nerve with the
ansa was identified and preserved.
i. Dissection extended superiorly into the para-
pharyngeal space with the internal carotid artery,
posteriorly, and laterally, with extreme care not to
violate the capsule of the neoplasm.
J. Neoplasm was removed intact. All margins were
free of disease.
Reconstruction
The palate was reconstructed by suturing the right side
of the soft palate to the lateral oropharyngeal wall.
Mandibulotomy was closed with the Steinmann pin
and tie wires (see Fig. 15-4G).
 ORAL CAVI1Y AND OROPHARYNX

Case II
FIGURE 15-19 Continued
 ORAl CAVlTV AND OROPHARYNX
Resection of Carcinoma of Soft
Palate (Fig. 15-20)
Highpoints
1. Carcinoma involving the soft palate without
extension into the hard palate may be treated by
surgery or by radiation. Surgery is preferred because
of the complication of xerostomia and mucositis
from radiation.
2. Surgical excision must have at least a 2-cm free margin.
3. The procedure may be extended to include the hard
palate and alveolar ridge as indicated.
4. Rehabilitation is more easily and simply accomplished
with an obturator. In addition, the obturator facili-
tates an easy exposure for examination of recurrent
disease. A PMF can be used and has a definite indi-
cation when combined with radical neck dissection,
resulting in a lateral nasopharyngeal and oropha-
ryngeal defect (see Fig. 8-2A). The flap is utilized to
close the lateral defect rather than to reconstruct the
palate.
5. Spread of the metastatic disease from cancer of the
palate includes not only the usual internal jugular
lymph nodes but also the para pharyngeal lymph
nodes and possibly the parapharyngeal space (see
Chapter 23). Radical neck dissection should be
extended to include these parapharyngeal lymph
channels. Recurrent disease may well appear along
the lateral oropharyngeal and hypopharyngeal walls.
Retropharyngeal lymph nodes and parapharyngeal
space can also be involved.
6. Tracheostomy is indicated.
A An incision is made with a Bovie scalpel outlining
the extent of resection. Bleeding at this stage is
controlled with coagulation. The entire soft palate and
soft tissue over the hard palate, including the perios-
teum, are included. Because the bulk of the lesion is
more on the left side, the resected area includes a
portion of the lateral oropharyngeal wall and tonsil. In
the resected specimen are the muscles of the soft
palate (i.e., pharyngopalatine, glossopalatine, uvular
muscles, and tensor and levators), the inner layer of
mucous membrane, and the hamulus, depending on
the extent of the lesion.
B The resected area. The distal portion of the hard
palate has been removed with rongeurs. Frozen sec-
tions have been performed on the margins, because
carcinoma of the palate may spread submucously.
Care must be taken to ligate all large vessels, because
postoperative bleeding may occur. These include the
greater and lesser palatine arteries and the ascending
palatine artery and veins.
C A dermal graft is sutured in place with continuous
4-0 nylon or absorbable suture material. The graft
covers all bare areas.
D A pressure dressing consisting of absorbent cotton
impregnated with liquid povidone-iodine or antibiotic
ointment is held in place with retention sutures of
3-0 nylon. A maxillary obturator/speech aid will be
necessary to correct palatopharyngeal inadequacy (see
the section on dental and periodontal considerations
in Chapter 3, p. 161).
Approaches to the larger tumors involving the soft
palate with lateral extension deep to the lateral wall of
the oropharynx and into the parapharyngeal space
leading deep to the parotid salivary glands and into the
upper cervical region include the following:
1. Median labiomandibular glossotomy (see Fig. Is-4A
to C).
2. Median labiomandibular-f1oor of mouth approach
(mandibular swing) with or without submandibular
cervical approach (see Figs. 14-11 and 15-14).
3. Peroral with mandibular cervical approach with or
without lateral mandibulotomy posterior to the third
molar tooth (see Fig. 22-33).
If the surgical approach reaches the region of the
parotid salivary gland, exposure of the main trunk of
the facial nerve may be necessary (see Figs. IS-18K and
Land 17-1).
 ORAL CAVI1Y AND OROPHARYNX

FIGURE 15-20
 ORAL CAVI1Y AND OROPHARYNX
Excision of Ranula (Fig. 15-21)
A ranula is a retention cyst or mucocele of the sublin-
gual gland or minor salivary glands located in the floor
of the mouth. These cysts may have a cervical exten-
sion with submandibular swelling (so-called plunging
ranula) and represent a pseudocyst. When this occurs,
the surgical approach is the same as for resection of the
submandibular salivary gland (see Fig. 16-12). Another
type of cyst was closely related and adherent to the
intrinsic muscles of the tongue with no definite
connection to either the sublingual or submandibular
gland (JML). The submandibular gland and the
sublingual salivary gland were removed with the cyst.
This cyst tends to support the theory of origin from the
first branchial cleft (see pp. 828 and 836).
Highpoints
1. Resect entire cystic wall preferably with the sublin-
gual gland.
2. With recurrent ranulas, always resect the sublingual
gland.
3. Avoid injury to the lingual nerve and the submandibular
duct, and, if possible, the terminal branches of the
hypoglossal nerve.
4. If resection of the entire cyst is not possible, marsu-
pialization can be performed by suturing the remain-
ing edges of the cystic wall to the mucous membrane.
S. If the submandibular duct has been transected, the
proximal end is brought out through the mucous
membrane closure and sutured to the mucous
membrane.
6. Identification of the course of the submandibular
duct may be achieved if necessary by inserting a
small plastic tube with the aid of a punctum dilator
into the lumen.
7. Warning: there is little chance of confusing a tumor
of the sublingual gland with a ranula because of the
difference of consistency. Virtually all tumors of the
sublingual gland are malignant and require composite
resection similar to a carcinoma of the floor of the
mouth (see Fig. 14-11A to E).
8. Ligation of all blood vessels is meticulous.
Complications
• Immediate postoperative hemorrhage
• Recurrence, especially if the sublingual gland is not
removed with the cyst
• Injury to submandibular duct (Wharton's) or lingual
nerve
A Typical cystic swelling of the floor of the mouth is
shown. The orifice of the submandibular duct may be
distorted. The dotted line represents the mucous
membrane to be excised with the cyst. It is useless to
attempt to preserve this overlying mucous membrane.
Furthermore, the mucous membrane may be very
adherent to the cystic wall as well as contain the up to
20 excretory ducts of the sublingual gland with, or
commonly without, a major duct (see Fig. 14-4E for
additional anatomy).
B With an Allis clamp or small tender grip forceps,
the overlying mucous membrane is gently grasped.
The dissection is begun posteriorly, identifying the
lingual nerve.
C Using first sharp and then careful blunt dissec-
tions, the sublingual gland with the overlying cyst is
retracted forward. This exposes the underlying hyoglos-
sus muscle. Small terminal branches of the hypoglossal
nerve may be identified in this area deep to the lingual
nerve and are of little consequence, because the main
trunk of the nerve is beyond the surgical field. The
clamp is under the submandibular duct (Wharton's),
which is preserved.
D The mucous membrane is approximated with
interrupted nylon sutures.
 ORAL CAVITY AND OROPHARYNX

LINGUAL N.

SUBLINGUAL GLAND

A B

"

'\ HYOGLOSSUS M. ,I
,
\ Ii
\i,

C D
SUBMANDIBULAR
DUCT

',0 GENIOGLOSSUS M.

FIGURE 15-21
 ORAl CAVIlY AND OROPHARYNX

Resection of Hemangioma and

Neurofibroma of Tongue C Lateral fishmouth wound is shown after resection.
(Fig. 15-22) Bleeding is controlled with ties and electrocautery.

Highpoints D Closure is done with continuous nylon sutures.

1. Controlled resection is far superior to use of scle-
rosing solutions, which may irreparably injure the
entire tongue.
2. If the area resected is extremely large, a tracheostomy
may be indicated.
A Cross section of tongue demonstrates depth of
resection.
B Surface area of tongue is excised.
This same technique is used for localized neurofibroma
of the tongue. If the hemangioma or lymph heman-
gioma is more diffuse, the CO2 laser, with either the
cutting or vaporization technique, can be used (mandible
absent for visualization purposes).
Malignant change has been reported in 5.5% (Holt
and Wright, 1948) to 16% (Preston et a!., 1952) of
cases, but these are old figures, and some pathologists
believe that the actual incidence is lower.
Do not use the CO2 laser for premalignant or
malignant lesions.
 ORAL CAVITY AND OROPHARYNX

FIGURE 15-22
 ORAl. CAVIlY AND OROPHARYNX

Tonsillectomy and Adenoidectomy

(Fig. 15-23) A With a Jennings mouth gag and the base of the
tongue depressed, the tonsil is grasped with an Allis or
Highpoints similar type tonsil clamp. The anesthetist or assistant
uses the Yankauer suction tip to retract the soft palate.
1. Perform adenoidectomy first, because more time is (Whenever the suction tip is used as a retractor, the
necessary for bleeding to cease in the nasopharynx. rubber suction tubing should be folded and occluded
2. Careful initial dissection of capsule of tonsil is when open anesthesia is used. This avoids undue loss
important to develop correct surgical plane. of the anesthetic agent through the suction.) By
3. Clamp as many blood vessels as possible before retracting the palate and gentle outward traction on
their transection. the tonsil, the mucosa of the posterior tonsillar pillar is
4. Rely on ligatures rather than gauze plugs and drugs exposed and drawn taut. The mucosa of the posterior
to control bleeding. pillar is incised starting at the superior pole. Only the
5. Consider these operations as major procedures. mucosa is incised, thus exposing the capsule of the
6. Be careful of internal carotid artery, which may lie in tonsil. For a clean dissection, this is most important.
or close to the tonsillar fossa. Before surgery check
the lateral and posterolateral walls of the oropharynx B The remaining mucosa of the superior pole and
by inspection and palpation for any pulsation. the mucosa of the anterior pillar are incised and the clamp
7. Electrodissection may have a higher incidence of reapplied to grasp the capsule at the superior pole.
postoperative bleeding than sharp dissection with The serrated back portion of the knife (Neivert) is used
ligation of dominant vessels. to separate the capsule of the tonsil from its fossa.
8. A folded sheet or small soft sandbag is placed under
the patient's shoulders to hyperextend the head and C The clamp is reapplied in a horizontal plane, and
neck. further blunt dissection is performed at the superior
pole to expose the superior pole vessels.
Adenoidectomy
D These vessels are clamped proximally and cut
Highpoints distally with scissors.

1. Avoid injury to eustachian tube orifice. E A slipknot of 2-0 or 3-0 catgut is placed around the
2. Completely remove as much lymphoid tissue as clamped vessels and drawn tight with another clamp.
possible. This is the only place in surgical technique in which
such a knot is justifiable.
Complications
F The anterior pillar is retracted with a Herd
• Hemorrhage, shock retractor, and the capsule is further separated by blunt
• Aspiration of blood, especially during the postopera- dissection. Metzenbaum scissors can also be used for
tive period, which may be secondary to vomiting further dissection. The middle tonsillar vessels, if iso-
• Postoperative airway obstruction -7 respiratory lated, should be clamped, transected, and tied in a
arrest -7 cardiac arrest similar fashion.
• Septicemia (extremely rare)
• Needles of the suture ligatures may break; use heavy G When the dissection has reached the inferior pole,
needle. a snare is used to complete the removal of the tonsil.

If bleeding persists and becomes totally uncontrol- H Invariably, an inferior tonsillar pole of lymphoid
lable, perform a tracheostomy and pack the oropharynx. tissue remains. This is removed with the snare.
An endotracheal tube could be substituted for 24 to
48 hours.

Capsule
G H
FIGURE 15-23
I The fossa is then carefully inspected, and any
bleeding vessel is clamped and tied. Suture ligature
may be necessary. Deep sutures are to be avoided,
because the internal carotid artery could be injured.
After control of bleeding, a soft gauze sponge with
string attached is placed in the fossa for a few minutes.
ORAL CAVIlY AND OROPHARYNX
Point applications of a silver nitrate stick may be used
to control areas that are oozing blood. When local
anesthesia is used, the identical technique is followed,
except that no mouth gag is necessary.
Continued
 ORAl CAVITYAND OROPHARYNX
Tonsillectomy and Adenoidectomy
(Continued) (Fig. 15-23)
J TO L Lymphoid tissue in the nasopharynx may be
removed by any of a number of methods. An adeno-
tome (K) removes the bulk of the tissue. The instru-
ment is inserted from one side with the tip pointed
slightly to the midline, to avoid injury to the eustachian
tube orifice. The maneuver is repeated from the
opposite side and then from the midline.
A curet (J) and basket punch (L) remove smaller
areas of lymphoid tissue that cannot be grasped with
the adenotome. Loose fragments of lymphoid tissue
thus freed must be carefully removed with suction or
forceps. Bleeding is controlled with pressure from one
or two gauze rolls inserted with strings attached,
,---
I
•"
FIGURE 15-23 Continued
which may be impregnated with tannic acid powder
on moistened gauze or silver nitrate sticks. Continued
bleeding may be due to additional fragments of
lymphoid tissue, which must be removed. Clotted
blood must also be removed, and this may be aided by
instilling water in the anterior nares. Rarely, uncon-
trollable bleeding requires a postnasal packing (see
Fig. 6-3A to F).
M A Yankauer pharyngeal speculum is ideal for
inspection of the operative site. Another technique is
the insertion of a rubber catheter through the nose
and out the mouth with traction for inspection. If a
bleeding site is seen, a silver nitrate stick is applied.
Tannic acid powder or bismuth subgallate powder on
a moist sponge may control minimal ooze.
"
I/}'
I
I
I J

Salivary Duct Calculi
(Fig. 15-24A to C)
Calculi impacted in the ducts of the major salivary
glands cause painful swelling of the salivary glands;
often they may be removed by simple dilatation of the
orifice of the duct. If dilatation does not facilitate
removal of the calculus, incision over the calculus in
the case of the Wharton's duct (submaxillary) or inci-
sion of the orifice in the case of the Stensen's duct
(parotid) is the next procedure. Repeated calculi in any
one gland, especially the submandibular, are indica-
tions for excision of the gland.
A A punctum dilator is inserted in the orifice of
Wharton's duct. Tetracaine 2% is applied topically. An
optical loop may be needed to locate the exact site of
the orifice. Dilatation is begun with a NO.1 dilator or
smaller and increased to a NO.6 dilator if possible.
B When the calculus is of such a size that dilatation
is fruitless, a small incision is made directly over the
calculus and the calculus is removed. Tetracaine 4% is
used topically. The incision is not sutured.
A with 6-0, 7-0, or 8-0 nonabsorbable sutures. An optical
FIGURE 15-24
ORAL CAVllY AND OROPHARYNX
C An incision in the edge of the orifice of Stensen's
duct is made over a punctum dilator, using topical 4%
tetracaine as the anesthetic. Another technique is the
insertion of narrow pointed scissors to cut the edge of
the orifice. The incision is not sutured.
Repair of Laceration of the Stensen
Duct (Parotid) (Fig. 15-24D)
Deep lacerations of the cheek that sever the Stensen
duct and any major branch of the facial nerve are best
handled with primary repair of the duct and nerve.
D After a punctum dilator has been inserted in the
natural duct orifice, a piece of fine polyethylene tubing
is passed through the orifice of the duct into the
wound. The lateral end of the duct is usually located
easily by having the patient chew a section of lemon,
thus producing a copious flow of saliva in the wound.
The polyethylene tube is then passed into the lateral
end of the duct. Two sutures of very fine catgut (5-0)
are passed through and through the transected ends
of the duct for approximation. The polyethylene tube
acts as a stent and is removed in 48 to 72 hours.
This same technique is used in the delayed repair of
the duct. The facial nerve branches are anastomosed
loop or operating microscope facilitates such operative
procedures. For details on reimplantation of the
Stensen duct, see Figure IS-6EI.
 ORAl. CAVITY AND OROPHARYNX
Reconstruction and
Relmplantatlon of Stensen's Duct
in the Buccal Wall
Indications
• Stenosis secondary to fibrous tissue of the orifice of
Stensen's duct
• Resection of buccal wall with distal portion of Stensen's
duct for malignant neoplasm of buccal wall
Highpoints
1. Careful evaluation is done to make sure that a
neoplasm is not the cause of the obstruction.
2. Probing of Stensen's duct should first be attempted
to dilate the strictured area and also to ascertain the
presence or absence of a calculus.
3. A sialogram is helpful.
The technique is an exploration of the stenotic area
with its resection followed by reimplantation of the duct
into the mucosa of the buccal wall at a more proximal
location. The duct wall is sutured to the opening in the
buccal mucosa using 6-0 nylon sutures in at least three
to four locations.
Complications
• The possibility of scarring and recurrence of the
stenosis
The technique is similar to that described for the
reimplantation of the Wharton's duct, illustrated in
Figure IS-6EI. See Figure IS-24C and 0 for repair of a
laceration of Stensen's duct.
Pierre Robin Syndrome (Fig. 15-25)
(After Routledge, 1960; Randall, 1964)
Characteristics
• Micrognathia (more accurately retrognathia)
• Glossoptosis
• Respiratory obstruction in varying degrees
• Other anomalies, such as cleft palate, heart disease,
otologic deformities, hydrocephalus, mental retarda-
tion, deformities of fingers and toes, major ocular
deformities, and tongue-tie, mayor may not be present.
Choanal atresia and tracheoesophageal fistula should
be included in the differential diagnosis. Combina-
tions of these other anomalies are referred to as the
Treacher Collins syndrome.
Not all patients with this syndrome require an
operation; conservative management by placing the
infant in the prone position may suffice. If the infant is
quiet in the resting state, an operation usually is not
necessary.
Indications for Operation
• Moderate to severe respiratory obstruction: there is
a prolapse of the tongue against the posterior pha-
ryngeal wall and pressure on the epiglottis.
• Persistent feeding problems despite the prone posi-
tion: aspiration pneumonia, failure to gain weight
• Discrepancy of 1 em or more between mandibular
and maxillary arches
Highpoints
1. Emergency treatment: pull tongue forward with
deeply placed suture or towel clip through tongue
and insert nasopharyngeal tube: avoid tracheostomy
if at all possible.
2. Carefully plan general anesthesia: intubation can be
difficult.
3. Tongue is attached to lower lip in a horizontal plane
(Routledge, 1960; Randall, 1964).
4. Avoid injury to Wharton's ducts.
S. Release ankyloglossia if present.
6. Maintain fixation of tongue to lower lip for 10 to 18
months.
7. Repair cleft palate in usual fashion after the second
stage of release of tongue to lower lip is performed
and all danger of respiratory obstruction is past.
Complications
• Suture avulsion
• Torn tongue
• Failure of operation may require a tracheostomy,
which is associated with all the serious complica-
tions of a tracheostomy in an infant: edema of
trachea, plugging of the small tube, and difficulty of
extubation before the age of 10 to 12 months.
 ORAl CAVI1Y AND OROPHARYNX

FIGURE 15-25

A, B Cross section of basic pathologic anatomy is
shown. With the retroposition of the mandible, the
suspensory apparatus of the tongue musculature,
hyoid bone, and epiglottis is lacking. The tongue and
epiglottis occlude the supraglottic air passage. B indi-
cates the further obstruction caused by an associated
cleft palate with the tongue locked in a posterior
position or protruding into the nasopharynx.
C Horizontal incisions are made in the tongue and
lower lip.
Continued
 ORAl CAVITYAND OROPHARYNX
Pierre Robin Syndrome (Continued)
(Fig. 15-25) (After Routledge, 1960;
Randall, 1964)
D Cross section of incisions and approximation of
inferior mucosal edges with 4-0 chromic catgut or 5-0
nylon continuous everting sutures.
E A 2-0 nylon suture is inserted below the chin and
brought out through the lip incision and thence through
the tongue incision and placed as far posteriorly into
the base of the tongue as possible, slightly off the
midline. Reverdin's needle is well adapted to this
maneuver. The suture is then passed through a disk of
silicone rubber or button and passed back through the
tongue slightly to the opposite side of center. The
suture is then returned to the point of beginning. Both
ends are then passed through another disk of silicone
rubber or button beneath the chin. A suture of 0 silk is
secured to the disk or button at the base of the tongue
to facilitate retrieving this button when this suture is
FIGURE 15-25
removed in 1 to 2 weeks' time. A continuous suture of
4-0 chromic catgut or 5-0 polyglactin (Vicryl) approxi-
mates the superior mucosal edges of the tongue in
everting fashion. Gavage feedings are usually necessary
during the immediate postoperative period. Usually,
there is little residual deformity as the mandible and
tongue mature; however, occasionally retrognathia
persists and additional reconstructive procedures are
necessary.
F Lewis and colleagues (1968) have described
another technique utilizing fascial strips passed
through the tongue between the middle and posterior
thirds of the tongue and thence through the floor of
the mouth and secured to the anterior or inferior
surface of the mandible with stainless steel wire. The
advantage of this procedure is that it obviates a
second-stage release operation. The fascial strip must
not be placed too far posteriorly, because this might
cause the anterior portion of the tongue to fall over
the fascial loop, resulting in secondary obstruction.
 ORAL CAV11Y AND OROPHARYNX

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