Biomedical subjects
Publications and source records attributed to K A Shumrick.
Endoscopic management of facial fractures has lagged behind endoscopic surgery in other areas of the body but is rapidly gaining credibility. With the subsequent development of improved instrumentation for fracture reduction and stabilization, it is foreseeable that wide-incision exposures of the facial skeleton will be reserved for only the most complicated cases.
The management of zygomaticomaxillary and midface fractures has been revolutionized in the past decade as a result of improved surgical access, rigid plating systems, and high-resolution computed tomography. Previously, virtually all midface fractures underwent mandatory orbital exploration to aid in reduction and stabilization. This article emphasizes the importance of reducing and fixating the facial buttresses involved in zygomatic complex fractures, and recommends orbital exploration on a selective basis. Criteria are given to decide which patients require orbital rim and floor exploration. If a patient's fracture does not meet these criteria, the fracture is managed by exposing, reducing, and stabilizing the major facial buttresses involved without performing an orbital exploration. Ninety-seven patients with zygomatic complex fractures were examined and treated with selective orbital rim and floor explorations. Most patients could be managed without the need for orbital exploration, and all were felt to have good fracture reduction and stability. We feel the selection criteria reliably identify patients who do require an orbital exploration and allow the treating surgeon to direct surgical treatment to the site of injury.
Joseph Carpue introduced us to the use of the forehead flap for nasal reconstruction in 1814 after he read an account of its use in India. The forehead flap was the first pedicled flap to be described in European literature and it set off an immediate search for similar flaps elsewhere on the body. In fact, this initial use of the forehead flap was so inspirational that it has been given credit for the rise of plastic surgery as a specialty. The forehead flap is well situated to replace missing nasal skin due to its excellent vascularity, close proximity, and similar histologic qualities. In fact, it is safe to say the forehead flap is the first choice for reconstruction of nasal defects larger than 2.0 cm in diameter. Over the last 180 years there has been considerable refinement in the under stage and standardization of forehead flap design. This short monograph is intended to provide refinements in forehead flap design which, in these authors' opinion, provide superior nasal reconstruction results while minimizing donor site morbidity. Some of these modifications are fairly subtle while others fundamentally affect the design of a forehead flap. Incorporating these modifications will advance the sophistication of the reconstructive surgeon and improve results.
OBJECTIVE: To develop objective criteria with which to identify patients with zygomatic complex (ZMC) or midface fractures who require a surgical exploration and treatment of the orbital component of their fracture to prevent postoperative enophthalmos, diplopia, or malar depression. DESIGN: Nonrandomized, prospective management of facial trauma patients. SETTING: Urban, university referral center. PARTICIPANTS: Ninety-seven patients with facial fractures (72 with ZMC fractures and 25 with midface fractures) who presented to the maxillofacial and oculoplastics trauma teams at the University of Cincinnati, Cincinnati, Ohio, for management. INTERVENTION: The decision whether to include an orbital exploration as part of the management plan was made based on a specific set of physical and radiological criteria that are detailed in the text. OUTCOME MEASURE: Patients were evaluated postoperatively for possible complications related to the orbital and periorbital portions of their fractures. RESULTS: Thirty-four percent of the study patients (30% of the patients with ZMC fractures and 44% of the patients with midface fractures) underwent orbital rim exposure and orbital floor exploration as part of their fracture management. Sixt-six percent of these patients (70% of the patients with ZMC fractures and 56% of the patients with midface fractures) were managed without orbital exploration. Postoperatively, none of the patients who did not undergo exploration experienced diplopia or enophthalmos and only 1 patient had a residual malar depression. CONCLUSIONS: The criteria reported herein allow surgeons to identify the minority of patients with midfacial and ZMC fractures who require an orbital exploration for optimal fracture management. Orbital exploration, and its potential complications, can be avoided in the majority of patients with ZMC and midface fractures without significantly increasing the risk of morbidity related to the orbital component of their fractures.
BACKGROUND: Desmoplastic fibroma is a benign, locally aggressive, intraosseous neoplasm with a propensity for local recurrence. Desmoplastic fibroma most commonly originates within the mandible (70% of cases), and long bones with rare lesions reported in the maxillary, frontal, and parietal bones. We report two patients with desmoplastic fibroma arising within the temporal bone. STUDY DESIGN: Case report and literature review. PATIENTS: Two patients with desmoplastic fibroma with intracranial and extra cranial growth patterns are presented. Both were young females with aural fullness and decreased hearing. INTERVENTIONS: Diagnostic and therapeutic. RESULTS: Both tumors were surgically extirpated and the patients have remained disease free for 18-48 months. Neither tumor expressed estrogen or progesterone receptors. CONCLUSION: Desmoplastic fibroma is a highly invasive local destructive lesion which is best treated by nondestructive surgical intervention. Immunohistochemical analysis may demonstrate hormonal receptors, in which case Tamoxifen may reduce recurrence.
Historically, malignant tumors that arose within the temporal bone or that intimately juxtaposed the petrous ridge portended an ominous prognosis. Perusal of the surgical literature from 1950 to 1975 strongly supports the impression that despite heroic surgical efforts many of these patients sustained significant morbidity and a high mortality rate. This report reviews data accumulated over a 10-year period study from July 1984 to June 1994 that examines the changing clinical approach to these lesions from both a diagnostic and therapeutic perspective. Analysis of data from 46 patients cared for at the University of Cincinnati Medical Center is presented with a minimum follow-up of 16 months to a long-term follow-up of 11 years. A management algorithm is presented that reflects our contemporary approach to assessment and management of this select patient population.
OBJECTIVE: The objective of this report is to review our experience and indications for the use of cancellous bone in frontal sinus obliteration and reconstruction of frontal defects. We also describe a method of minimizing iliac crest donor-site morbidity. DESIGN: Case series. SETTING: Patients treated on the Facial Plastics and Trauma Service at the University of Cincinnati (Ohio) Medical Center. PATIENTS: Ten patients were selected for frontal sinus obliteration and reconstruction of frontal defects with cancellous bone based on the following criteria: (1) complex frontal bony defects involving the frontal sinus; (2) acute trauma with loss or comminution of more than 40% of either anterior or posterior sinus wall; and (3) failure of previous frontal sinus obliteration for either chronic sinusitis or trauma. INTERVENTION: The use of cancellous bone grafts for frontal sinus obliteration and reconstruction of frontal defects. MAIN OUTCOME MEASURE: Success of cancellous bone grafts in frontal sinus obliteration and reconstruction of frontal defects. RESULTS: Follow-up averaged 26 months. Follow-up computed tomographic scans showed good maintenance of graft volume and complete frontal sinus obliteration in all patients. Seven of 10 patients reported minimal donor-site discomfort and three patients had moderate pain. CONCLUSION: Cancellous bone grafts are effective, with acceptable donor-site morbidity, for frontal sinus obliteration and frontal reconstruction in patients in whom adipose grafts would have a significant chance of complications or long-term failure.
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Recent advances in laryngology have occurred simultaneously in both the diagnostic and therapeutic realms. The advent of sophisticated voice laboratories with the ability for in-depth analysis of voice disorders has provided insights into their pathophysiology necessary to develop sophisticated procedures to treat them. Experience with these procedures has likewise provided new understanding of laryngeal function. Together these diagnostic and therapeutic modalities have allowed unprecedented advancement in treating laryngeal disorders, hitherto treated in a most unsatisfactory manner.
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Most skin cancers are amenable to cure with early diagnosis and appropriate treatment; however, skin cancers associated with genetic syndromes may give rise to some of the most relentless, deforming, and ultimately lethal skin cancers clinicians will ever encounter. This article reviews the commonly accepted genetic syndromes associated with skin cancer, details their clinical pictures and key points of recognition and diagnosis, considers associated relevant clinical concerns, and discusses therapeutic options and dangers.
The detailed arterial anatomy of the medial forehead region was evaluated using roentgenographic examinations of injected cadaver heads, anatomic dissections of injected cadaver heads, and Doppler examination of normal subjects. The supratrochlear artery was seen to be the dominant artery of the medial forehead (not the supraorbital). The supratrochlear artery exited the orbit 1.7 to 2.2 cm from the midline, passing superficial to the corrugator and deep to the orbicularis and frontalis muscles. The supratrochlear artery then passes just medial to the eyebrow and pierces the frontalis muscle, ascending the rest of the forehead in a subcutaneous plane 1.5 to 2.0 cm from the midline (paramedian position). The implications of this vascular anatomy on forehead flap design and execution for nasal reconstruction are discussed and clinical cases are presented.
The two most significant recent developments in the treatment of facial trauma are the introduction of plating systems, which provide rigid internal fixation and the development of surgical approaches that allow wide exposure of the entire facial skeleton while minimizing external incisions. These approaches (referred to as extended access/internal approaches) are hemicoronal and coronal flaps, the sublabial approach to the midface, the transconjunctival approach to the orbital floor and orbital rim, and the intraoral management of mandibular fractures. These approaches work well, and have become standard techniques for managing facial trauma; however, each one has definite technical points that need to be adhered to to assure their success. Additionally, there are situations where these approaches are not appropriate and, in fact, may even be detrimental. This article outlines our approach to facial trauma using these extended access/internal approaches and discusses the important technical factors of each approach. Our experience in treating 113 patients with 119 fractures and 161 approaches over the last 2 years is presented and the role extended access/internal approaches have played is reviewed. The indications, limitations, and possible complications associated with each approach are outlined.
Significant controversy continues as to how best to reconstruct anterior skull base defects after craniofacial resection with a view to minimizing the postoperative morbidity. Techniques varying from simple skin grafts to local and pedicled flaps, as well as bone harvested from a variety of sources have all been proposed. Careful review of the literature combined with personal experience with 34 anterior skull base defects following tumor surgery are presented in an attempt to develop a decision-making process to determine the ideal reconstructive technique for various situations.
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Conjunctivodacryocystorhinostomy is a much maligned procedure, and there are widely varying opinions about its efficacy and long-term success. We present our modification of the procedure used in 38 eyes of 29 patients over 10 years, with an average follow-up of 2.5 years, which has resulted in a very high rate of success.
Increasing nasal tip projection, rotation, and definition have classically been attempted through a variety of lobular cartilage incising or excising techniques. Resultant long-term complications, including bossing, alar notching, pinched tips, and alar collapse, have occasionally resulted from the use of these techniques. The majority of these complications have arisen secondary to a loss of structural support following the interruption of the lower lateral cartilages. This article describes the "lateral crural steal," a method of increasing nasal tip projection and nasal tip rotation while preserving the integrity of the lobular cartilage complex. The procedure uses the external rhinoplasty approach for exposure. By elevating both the dorsal and the vestibular skin from the domes of the lobular cartilages, the lateral crura may be advanced onto the medial crura to further project the nasal tip and to reorient the tip upward. This technique along with its philosophy and long-term follow-up results are presented.
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