Juan Gaztanaga, MD

• Director, Cardiac MRI/CT Program
• Winthrop University Hospital
• Mineola, New York

The natural elasticity of the skin and soft tissues renders the young person symmetrical in repose erectile dysfunction epilepsy medication purchase viagra jelly 100mg free shipping, with unilateral palsy only apparent on smiling erectile dysfunction statin drugs purchase viagra jelly visa. As a consequence of this erectile dysfunction after prostate surgery order viagra jelly 100mg with amex, the subject may attempt erectile dysfunction treatment in thailand order viagra jelly 100mg with visa, by inhibition of smile or camouflage with the hand or hair impotence zoloft discount 100 mg viagra jelly free shipping, to conceal the gross asymmetry caused by uninhibited unilateral facial activity erectile dysfunction 16 purchase viagra jelly 100mg on line. By contrast the older person, who has lost their natural elasticity, is more concerned with their static position as gravity causes their face to drift downwards, which makes the deformity clearly visible to the rest of society. Consequently, they are inhibited from going out since they become the subject of ridicule. The latter group is less concerned with regard to movement as a response to emotion, providing that the paralyzed side of the face does not swing to the contralateral side on activity. The older group, therefore, is more likely to request static support of their face with an effective short one-stage procedure. Hypoglossal facial anastomoses have many proponents worldwide and many good results have been achieved. The procedure is best carried out within a year of a paralysis developing and where mimetic muscles are known to be intact, it produces a good static position with eye closure and a well-formed nasolabial fold. In general, it does not provide movement in response to emotion, but rather stability of the nasolabial fold when the contralateral active side animates. Unwanted movements can develop in response to tongue motion and in particular during the act of eating when it can prove quite an embarrassment. Complete division of the ipsilateral hypoglossal nerve will produce paralysis of half the tongue and difficulty clearing the buccal sulcus. In order to avoid the latter, if the facial nerve is divided in the mastoid canal above the stylomastoid foramen, then sufficient length can be harvested so that the proximal end can be placed end-to-end into the hypoglossal nerve and dividing only some 30 percent Insertion of gold weight, tarsorraphy, canthopexy, lid-tightening Forehead/brow lift, limited face lift, fascial grafts Hypoglossal-facial, accessory-facial, facial-facial Temporalis, platysma, digastric, masseter From facial, cervical, sural nerves Gracilis, pectoralis minor, serratus anterior, rectus abdominis of the fascicular bundles. Interpositional nerve grafts, taken end-to-side from the twelfth nerve and placed into the proximal end of the facial nerve, are not so reliable. Surgical endeavour in the past 25 years has been directed to attempt to produce the correct static position and lateral movement of the angle of the mouth and nasolabial fold in response to emotion. They have no forehead crease lines, so the difference between each side of the face is only noticed on animation. In a 20-year-old man, the animation of one side of the forehead may be considered an embarrassment as it draws attention to the overall asymmetry of the face. Botulinus toxin injections of division of the frontal branch of the facial nerve on the contralateral side may be employed after careful discussion with, and thorough understanding by, the patient. In later life, with loss of skin elasticity, the eyebrow sometimes descends taking part of the eyelid skin with it so that vision may be partially obstructed. Our choice Chapter 223 Facial reanimation] 3079 is an ellipse of skin 1 cm wide, shaved and slid upwards beneath the forehead skin in a form of dermodesis. With subcuticular suturing and the benefit of older skin, the scar is relatively inconspicuous and the procedure is effective. Endoscopic brow lifts, although highly effective in cosmetic surgery, do not seem to be as reliable in the paralyzed forehead. More sophisticated transfers of muscle groups, for example from the contralateral frontalis muscle, do not seem to be particularly reliable, which probably relates to devascularization of the muscle fibres. Lower eyelid Elevation of the lower eyelid may be required where there is a scleral show beneath the limbus of the eye and clearly to correct epiphora. If this is unsuccessful or the depression is more severe, then a palmaris tendon sling between the medial canthal ligament and the supraorbital margin laterally can provide good elevation. Large blocks of conchal cartilage set between the infraorbital margin and the lower edge of the tarsal plate have recently become popular. The massaging action of the orbicularis on the tear flow and its siphoning effect on the lachrymal sac is important, as is the position of the lower lateral canaliculus in respect of the orbit. However, a perfectly positioned lachrymal canaliculus does not mitigate against a watering eye. Overproduction of tears by reducing the inhibition on the secretor motor fibres to the lachrymal sac via the greater superficial petrosal nerve may be an unwanted factor. The Gillies procedure, involving transferring the temporalis muscle and extending it by using the temporalis fascia passed through the upper and lower eyelids, is less popular these days although, if perfectly tensioned, satisfactory results can be achieved using this technique. The best results, however, generally relate to setting the upper eyelid sling at slightly greater tension so that the levator has to work against it, so that its function is as a tenodesis rather than a truly functioning extension of the temporal muscle. If this tenodesis action is set too tight, eventually the levator will weaken against it and a ptosis will develop. The eye In congenital unilateral facial palsy, even if the young patient does not close their eye perfectly they seem to have minimal problems with exposure keratitis. The child passes through a phase before the age of three when excess epiphora may cause them to rub their eye and develop pseudo-conjunctivitis. Eventually they learn to avoid this and by the age of four seem to have no further problems. Upper lid weighting is not required and indeed is actively disliked by the child as it may narrow the palpebral fissure and sometimes interfere with their visual field compared to the normal contralateral side. As the patient with congenital unilateral facial palsy reaches their mid-twenties, the lower eyelid descends and scleral show may be apparent. However, a unilateral facial palsy developing in adulthood is a different matter and avoidance of exposure keratitis is mandatory. Even if recovery is expected, the eye must be protected either by creams at night, tape closure or by surgery. The principle is to either allow the upper eyelid to drop, elevate the lower, or both. On blinking, the levator palpebrae relaxes and, if the upper eyelid is either loaded or sprung, the eyelid can be persuaded to close. Specially made gold weights, smoothly rounded and capable of fixation to the tarsal plate, are easy to insert and largely reliable. Fixation to the tarsal plate is essential as it significantly reduces extrusion and migration. It is desirable to use as light a weight as will effectively close the eye, and rarely is more than 1 g required (1. If carefully fixed at the right tension, excellent results can be achieved, but the risks are that if set up too strongly the spring can migrate through the skin. Lengthening the levator by division or inserting a strip of temporalis fascia are successful, but should be carried out under local anaesthetic to confirm the correct balance. The surgical treatment of unilateral facial palsy Over the age of 55, correction of facial palsy is directed to achieving good static position relatively quickly and effectively. Younger patients who have suffered from parotid cancers, where the skin may have been irradiated or where there is damage to the facial vessels, may similarly opt for a less sophisticated reconstruction. Narrow facial slings across the cheeks tend to produce an unsightly groove that is difficult to correct. Our choice of procedure is therefore for a broad sheet of tensor fascia lata fixed medially at three points, with loops to the central point of the upper and lower lips and to the modiolus, and then drawn laterally under tension fixated to the temporal fascia and the zygomatic arch. It is essential that these fascial slings are fixed to the midline of the upper and lower lips, otherwise the lips will merely drift to the animated contralateral side. Routinely, the lower lip is set a little tighter than the upper one since it is more vulnerable to swinging to the other side. Before carrying out such a procedure, care must be taken to ensure good oral hygiene since infection is a real concern and usually emanates from the mouth. Part or the whole of the masseter can be transferred into this fascial sling, but in our experience this merely produces hollowing at the angle of the mandible, swelling in the central cheek and very little useful movement. Numerous reports of transfer of the temporalis muscle have been reported, either transferring the origin or insertion with suitable extension to the angle of the mouth. Lateral excursion of the angle of the mouth can be achieved in response to command, but rarely is this an uninhibited activity in response to emotion. Retraining is required with enthusiastic physiotherapy but, as with most transferred functions, natural conversion is rarely achieved after the age of seven years. In the congenital group of patients, the first stage is usually carried out at the age of five years so that they are fully corrected by the age of seven. In order to attempt to explain this observation, we considered whether or not the number of axons passing across the cross-facial nerve graft was relevant. The neuroma at the end of the nerve was therefore examined histologically under an electron microscope and axon counts carried out. The relationship between age and the number of both groups of fibres did not seem to be particularly relevant since as many axons transversed the nerve in the older as in the younger groups. Muscle grafts Up to the age of 55, and beyond if fit, consideration can be given to attempting reconstruction with a new nerve/ muscle graft. The seventh nerve provides impulse to the facial musculature and particularly in the act of smiling in response to emotion. If the facial nerve is clearly eradicated and the mimetic muscles unlikely to recover, then functional seventh nerve axons can be persuaded to migrate into the paralyzed side by extending the functioning contralateral facial nerve with a 20 cm sural nerve graft. If the facial nerve is divided in its central part, particularly the buccal branch just below the parotid duct, then there are sufficient crossovers for no permanent damage. The paralyzed side of the face is explored via a parotidectomy incision similar to that on the animated side. The crossed facial nerve graft is defined at its fixation point to the tragus and then dissected out across the face as far as the alar base. The facial artery and vein are identified as they cross the mandible just anterior to the masseter. Having defined these anatomical In the first stage of the procedure, the face is elevated on the contralateral side using a parotidectomy incision. The cheek skin is rolled back and the buccal branch of the facial nerve found and displayed. Gentle stimulation can be used if there is doubt, but the further distal in the face the nerve is found, the less likely it is to use the opthalmic division. The sural nerve harvest is carried out via an incision just posterior to the lateral malleolus and then small transerve incisions stepwise up the leg. The sural nerve graft is then sutured to the buccal branch of the functioning seventh nerve under the microscope. Chapter 223 Facial reanimation] 3081 structures, a muscle graft is required and our first choice is the pectoralis minor. This is a rather unidirectional muscle and, when transferred, is usually sited along the line of the zygomaticus muscle. Our second choice is the latissimus dorsi which can be suitably cut down both in length and bulk. It is particularly useful where previous damage to the facial vessels has occurred and it is necessary to find the recipient vessels lower in the neck. It also has a particular benefit in Moebius syndrome since the length of the nerve is significantly longer and may be taken deep into the face for repair to the masseteric branch of the fifth nerve. Although the pectoralis minor may appear to have relatively small hilar vessels, it is very suitable for transfer to the face, has minimal donor site defect, requires relatively little trimming and is therefore less likely to develop haematoma, and finally the blood vessels may be repaired directly on its surface at 901 to the microscope rather than at an angle as occurs in the neck. In order to harvest the pectoralis minor, the muscle is approached via a 5 cm incision along the anterior axillary border. The incision is deepened to display the lateral edge of the pectoralis major and beneath this is found the lateral edge of the pectoralis minor. The dissection can proceed fairly swiftly on the anterior surface of the pectoralis minor and, quite commonly, the medial and lateral pectoral nerves passing through the pectoralis major may be divided. The deep surface of the pectoralis minor firstly reveals the medial and lateral pectoral nerve which can be demonstrated in relation to the axillary artery and joined together to coalesce as they enter the deep surface of the pectoralis minor. Immediately beneath the nerve is the hilar artery, which either comes directly from the axillary artery or at the point where the acromiothoracic trunk comes off the axillary artery. Having defined these structures, the muscle can then be divided from the second, third and fourth ribs and taken onto the face. The pectoralis minor vascularized muscle graft for the treatment of unilateral facial palsy. The principle of the muscle placement is to provide a broad origin with a relatively narrow insertion so that on smiling, the lips are parted, exposing the teeth. The muscle is arranged in such a way that its hilar structures are superficial and it is then just a matter of revascularizing the muscles on the facial artery and vein and reinnervating it on the crossed facial nerve graft. The face is closed with drainage, but we also employ an impedance monitor to assess the vascularity of the muscle. The outer wires pass a current through the muscle and the two inner wires assess the change in voltage. As blood enters the muscle, the voltage is altered and this voltage change is demonstrated as a wave pattern on the monitor. Obstruction of the vessel flow is immediately appreciated by cessation of the wave pattern. Not only do younger patients commence facial movements more rapidly, they also tend to produce the better results. Because of this, we prefer to operate on children at the age of five years and hope to complete surgery by the age of seven when they embark on their primary education. The latter provides the best chance of a good result and less likelihood of the need for adjustment. Complications of free vascularized muscle grafting To recreate the quality of smile produced by the normal eight or so muscles of facial expression is not easy and, in the final analysis, remains a question of good luck. The zygomaticus muscles, the depressor of the lower lip and the buccinator work in consort to produce a resolving force which pull the angle of the mouth laterally, the upper and lower lips in opposite directions Results In a series of 260 muscle grafts to the face in the treatment of unilateral facial palsy, 244 were employed using the pectoralis minor and 16 used latissimus dorsi (Table 223. We have graded the results the following way: zero reflects no movement, 1 is static support but no active movement, 11 is good static position and symmetrical smile with the mouth closed, and 111 is good static position, good symmetrical smile with the mouth closed and open exposing the teeth. The groups of 11 and 111 are generally considered to be a satisfactory result and Time to movement 100% 90% 80% 70% 60% 50% Table 223.

Diseases

• Richieri Costa Colletto Otto syndrome
• Labrador lung
• Kaolin pneumoconiosis
• Chromosome 7, trisomy 7q
• Panophobia
• Soft-tissue sarcoma
• Craniofacial dysostosis arthrogryposis progeroid appearance

While there is much academic discussion about which way round the nerve should be anastomosed erectile dysfunction at age 19 order viagra jelly with paypal, anatomical factors erectile dysfunction drug purchase viagra jelly 100mg overnight delivery, viz impotence questionnaire buy 100 mg viagra jelly free shipping. From the neurophysiological point of view the ideal is that the distal end of the donor nerve is anastamosed to the proximal stump of the facial nerve erectile dysfunction doctors in cincinnati buy viagra jelly australia. This may occasionally be possible if the main trunk of the nerve has had to be sacrificed impotence zinc discount viagra jelly 100mg on line. The perhaps erectile dysfunction injections trimix buy generic viagra jelly 100 mg, simplistic reasoning behind this is that all peripheral nerves dichotomize from proximal to distal. Thus reversing the orientation of the donor nerve should, potentially, divert the randomly orientated sprouting of the original nerve stump into a smaller number of nerve fibres at the distal end of the graft. The third method is nerve transfer and the donor nerve is usually the hypoglossal. If this is successfully anastomosed to the distal facial nerve, tone can be restored to the face but not normal voluntary movement. In patients in whom major ablation leaves no opportunity for nerve grafting or in a patient who has had the nerve divided for more than two years, then some type of musculoskeletal transfer can be carried out. Other reconstructive techniques may also be useful, particularly facial slings, tarsorrhaphy and facelift. The masseter or the temporalis muscle may be used to create a dynamic sling but in our department we tend to use fascia lata strips to elevate the corner of the mouth. The final strip can be attached to the zygomatic arch and if it requires tightening at a later stage this can be carried out via a superficial incision under local anaesthetic. A dynamic sling can be fashioned using the temporalis muscle and its attached fascia, but whether this provides better long-term function than the previously described methods is debatable. In our department we carry out a limited lateral tarsorrhaphy and insert a gold implant of the appropriate weight in the upper eyelid. This is effective because one-third of the motor supply to the upper eyelid comes from the sympathetic nervous system via the deep petrosal nerve and is not interrupted by parotid surgery. In node negative high-grade cancer an elective neck dissection should be carried out because of the very high risk of regional recurrence. Retrospective studies suggest that a selective neck dissection encompassing levels 1, 2 and 3 should be enough for parotid gland and submandibular disease, with of course clearance of the submental triangle in the latter case. In minor salivary gland cancer the site of the tumour dictates the level of neck dissection; half of such tumours are on the palate and a large proportion of the rest involve other areas of the oral cavity. Evidence is scarce regarding a logical treatment plan for minor salivary cancer but most authorities agree that elective neck dissection is not recommended. Whatever the site and histology, a patient with a salivary gland cancer with a node in the neck at presentation should have a radical neck dissection. Needless to say, a neck dissection can be modified as appropriate within the limits of good oncological treatment but postoperative irradiation should also be given. Surgery [Primary surgery is the treatment with the best [[chance of cure followed by postoperative radiotherapy in appropriate cases. Sacrifice of the ear and the eye may occasionally be appropriate to obtain clearance but size large enough to warrant this is an independent indicator of poor prognosis as is facial nerve involvement. Tumour adjacent to the carotid in the parapharyngeal space can be dissected off the adventitia of the artery. However, if the internal carotid is the only potentially positive margin then the internal carotid involved segment can be resected and reconstructed with a segment of long saphenous vein. Tumours involving the lateral skull base can be resected but with formidable quality of life implications and only a realistic prospect of achieving locoregional control rather than increasing survival. Options for facial nerve repair include: neurorrhaphy which involves middle ear surgery to extend the length of the facial nerve stump prior to end-to-end anastamosis; interpositional grafting at the time of primary surgery using the sural nerve but postoperative irradiation impairs facial nerve regeneration; hypoglossal transfer which allows tone but not voluntary movement to be restored; musculoskeletal transfers, such as fascial slings, tarsorrhaphy and facelifts can be helpful when there is no opportunity for nerve grafting. Clear-cut indications for postoperative radiotherapy include residual tumour, high-grade cancers and probably positive margins. Fast neutron therapy improves locoregional control but at the expense of potentially devastating damage to the irradiated site. Treatment of the neck [In node negative high-grade cancer, elective neck dissection should be carried out because of the very high risk of regional recurrence. The first is more Chapter 190 Malignant tumours of the salivary glands] 2511 scientifically rigorous, whereas the latter is useful for the treating oncologist. Recurrence rates True actuarial recurrence rates are not well described in the literature. For example, adenoid cystic carcinoma can be shown to have a potential 100 percent recurrence rate at 30 years independent of site. Mucoepidermoid carcinoma describes a wide spectrum of disease, both in terms of histology and natural history, from the relatively benign to the highly malignant. There is no significant difference between recurrence rates for the parotid gland or the submandibular gland. Recurrence or subsequent occurrence in the neck is relatively unusual in both major and minor salivary gland cancer. For minor salivary gland cancer the neck node recurrence rate at 12 and 20 years was the same at 29 0 Proportion recurred 25 50 75 100 0. As regards minor salivary glands, cancers affecting the hard palate tend to fail less often locally than cancers of the other minor sites. The natural history of various histological types of minor salivary cancer has been described previously. Locoregional failure is more likely with advanced tumours at the primary site, spread of the cancer outside the gland and the presence of neck node metastases at presentation. Survival data are not necessarily accurate as it is well known that death certification is not accurate, Proportion recurred (%) 0 25 50 75 100 0. A simple plot of high-grade, intermediategrade and low-grade tumours can be given with the expected survival differences. Not all salivary tumours can be graded in this way and even in some that can, such as mucoepidermoid carcinoma, it is fairly subjective. For this reason this chapter presents Kaplan-Meir curves for eight major histological types although the plots are often fairly complex. Adenoid cystic carcinoma has a 57 percent survival at 10 years falling to a 35 percent survival at 20 years. Mucoepidermoid carcinomas of all grades have a Proportion recurring (%) 0 25 50 75 100 0. The Liverpool experience of acinic cell carcinoma confirms the views that it is not particularly benign, having a ten-year survival of 53 percent. Very rare malignant salivary tumours have been grouped together and have a ten-year survival of 28 percent. Adenocarcinoma has a particularly poor survival of 11 percent at five years and there were no survivors at ten years. Not surprisingly, the logrank test confirms that there is a highly significant difference between the different histological types (po0. As is typical of this disease, adenoid cystic carcinoma has a relatively benign course at five years and a 72 percent survival at ten years. Other types, which could not be analyzed on their own because of the small numbers, were grouped together. They consisted mainly of adenocarcinoma with malignant mixed tumours forming most of the remainder. There was a statistically significant difference between survival for the various types (p = 0. Regrettably, large reviews are now quite old, dating from the mid-sixties to the mid-seventies; nevertheless, the Liverpool series compares well with other reported series with no major differences in survival. Minor salivary cancer occurs at any mucosal site in the head and neck, where these glands occur. The pharynx and the larynx are taken as one group and demonstrate a 74 percent ten-year survival, the nose and sinuses 52 percent and the oral cavity, excluding the palate, a 69 percent Survial distribution function 1. Chapter 190 Malignant tumours of the salivary glands Survial distribution function] 2513 0. Major salivary cancer by Survival distribution function Survival distribution function 1. These data are little different from other published series with the exception that advanced cancer in our series, tends to do a little better. In oncology, the presence of regional nodal metastases suggests a poor prognosis and salivary gland cancer is no exception. Although ten-year figures could not be calculated due to small numbers of patients surviving in the node positive group, the difference between survivals was significant (p = 0. For minor salivary gland cancer the number of patients with neck node metastases was too small to allow product limit estimators to be calculated. Nevertheless, the figures are not significantly different from other published work previously quoted. In an analysis of the Liverpool database of malignant salivary disease carried out for this chapter, categorical modelling showed a surprising lack of association between factors. Histology, in particular, has no association within the major or the minor salivary cancer group of patients. There was an association, however, across these groups of patients in that adenoid cystic carcinoma was more common in minor salivary disease (p = 0. Of more practical relevance is that recurrence at the primary site in major salivary cancer was more common in patients over 60 years of age (p = 0. No such relation was found for minor salivary gland disease and recurrence in the neck was also not associated with any other factors. As regards multivariate survival analysis, others have found age, T stage and N stage useful indicators of prognosis. In addition, pain, facial nerve dysfunction and skin invasion are useful indicators of prognosis with the addition of perineural spread and positive margins after surgical excision. The basic problem of assessing survival data using complex statistical programmes is that they, of necessity, deal with probability functions, which may or may not be accurate as regards the patient. Recent work in our department using complex mathematical algorithms such as artificial neural networks and genetic algorithms with the inclusion of various molecular variables undoubtedly improves the accuracy of prediction. It is hoped that inclusion of more molecular data into the algorithm will soon allow accurate prediction of the course of the disease in a particular individual as well as indicating the most appropriate treatment. Local, pedicled or microvascular flaps are routinely used to repair skin deficit and reconstruction of the mandible is now routine using osteocutaneous microvascular flaps. Defects in the palate can be closed by this method or, more usually, by an obturator fitted to the upper teeth or denture. Deficits to the lips, tongue, pharynx and larynx are more appropriately discussed in Chapters 192, Oral cavity tumours including the lip; 193, Oropharyngeal tumours; and 194, Tumours of the larynx, dealing with the cancer of these sites. Local invasion of tumour into the carotid artery, if the rest of the tumour is deemed resectable, is not an absolute contraindication to surgery. The carotid artery repair is straightforward using standard vascular techniques and the saphenous vein as the replacement. The main technical problem here is the accessibility of the upper end of the resected carotid artery and poor access can make anastomosis technically very demanding. If resection is felt to be impractical, balloon occlusion of the carotid preoperatively can be carried out and, if no neurological signs develop, the occlusion can be Chapter 190 Malignant tumours of the salivary glands] 2515 made permanent. One must, however, be aware that propagated thrombosis may gradually develop with disastrous consequences. As regards treatment of the neck, various deficits are well known and can be reduced by the techniques of modified neck dissections and selective neck dissections. There are various methods of ameliorating this problem including, for example, the administration of amifostine, and they are previously discussed (see under Radiotherapy). The almost unique problem encountered when dealing with salivary malignancy is damage to the facial nerve; in the hands of experienced head and neck surgeons a superficial parotidectomy even for malignancy should not be associated with more than a 5 percent risk to the nerve. Nerves may have to be sacrificed in the removal of the submandibular gland for malignancy; nerves close to the submandibular gland are the mandibular and cervical branches of the facial nerve, the hypoglossal nerve and the lingual nerve. Normally, these lower facial branches should not be damaged unless they loop particularly inferiorly to the mandible or a wide excision of soft tissue is necessary. Damage due to over retraction of the upper skin flap is, however, the commonest cause of this problem; recovery is rare. Sacrifice of the hypoglossal nerve leads to paralysis of one side of the tongue but adaptation is good and rarely causes severe problems. Damage to the lingual nerve is less likely as it is high up behind the mandible but if damage does occur it is potentially a serious problem as the loss of sensation allows repeated trauma to the tongue from dentition. Repair tends to be unsuccessful and we had one patient who finally underwent a partial glossectomy, although obviously this would not be the first-line management. Occasionally, patients develop a salivary fistula; these almost always resolve spontaneously or are incidentally cured by postoperative radiotherapy. Excessive flap retraction in submandibular surgery is the main cause of marginal mandibular nerve loss of function and rarely recovers fully. It can be dealt with by applying a graft between the skin and the graft bed or by injection of botulinum toxin A. Salivary fistulae tend to resolve spontaneously or are incidently cured by postoperative radiotherapy. This almost always involves a radical excision, followed by postoperative radiotherapy. Even with aggressive therapy the primary site recurrence rate at 20 years is more than 90 percent for major salivary cancers and nearly 75 percent for minor salivary cancer.

Before the use of free grafts and local flaps are described in detail erectile dysfunction drugs nz purchase 100 mg viagra jelly with mastercard, it is important to understand in general terms how they work erectile dysfunction treatment cialis cheapest viagra jelly. The many and varied clinical situations in which they may be used within the head and neck are discussed in those chapters that relate to the resection of the specific tumour in question impotence herbal remedies purchase viagra jelly paypal. A flap is alive at the time of harvesting and how it is subsequently treated determines whether it lives or dies injections for erectile dysfunction after prostate surgery discount viagra jelly online master card. The following free grafts have been described: split-thickness skin grafts (free skin grafts); full-thickness skin grafts (free skin grafts); composite full-thickness skin and cartilage grafts; pinch grafts (free skin grafts); dermal fat grafts; fascial grafts; chondromucosal grafts impotence remedy purchase viagra jelly 100 mg overnight delivery. A whole skin graft erectile dysfunction diet pills buy viagra jelly 100mg cheap, once cut, leaves behind no epidermal structures to allow resurfacing in the donor area and therefore the defect must be closed primarily. This therefore limits the size of the graft that can be used in clinical practice to reconstruct and resurface defects. In contrast, the split skin graft leaves adnexal remnants of pilosebaceous follicles or sweat gland apparatus, which act as foci from which the donor site can resurface by regeneration. Because of this, the donor site requires more attention, but much larger areas of split skin may be taken compared with a full-thickness graft. During its transfer from donor to recipient site, a free skin graft is completely (albeit temporarily) detached from the body and therefore is potentially a dead piece of tissue. Its lifespan while detached depends on the ambient temperature, but when wrapped in gauze, moistened in saline and stored in a fridge at 41C, it may live for up to three weeks. This is enhanced by the outgrowth of capillary buds such that a circulation of blood in the graft can be demonstrated at 48 hours. At the same time, fibres grow into the fibrin, which convert the adhesive clot into a more definite fibrous tissue attachment that increases over the ensuing days so that, by five days, reasonable anchorage has occurred. Graft take is threatened by prior radiotherapy and can be destroyed by fibrinolysing bacteria. They are conventionally designated according to their dermal component, as either whole skin grafts, which consist of the entire thickness of the dermis, or split skin grafts, which contain all the epidermis and only part of the dermis. Split skin grafts may be further divided into thin, medium or thick according to the amount of dermis harvested. These different types of skin grafts are not strictly distinct from one another, but really represent reference points on a gradation scale of increasing thickness from a graft which consists of little more than the epidermis through to the whole full-thickness skin graft. The main difference in practice is that a full-thickness skin graft is harvested using a scalpel, whereas a split skin graft is taken with either a dermatome or a Humby knife. Split thickness skin grafts A split skin graft is probably the most commonly used graft in head and neck surgery. It may be used to cover donor sites or secondary defects, to line flaps, to replace small areas of full thickness skin loss and to cover muscle when flap pedicles are exposed or rotated. Thinner grafts take more readily in difficult circumstances, such as inflammation, but thicker grafts give a better cosmetic result in the long term, because they contract less. Chapter 205 Grafts and local flaps in head and neck surgery] 2821 the speed and effectiveness of this process depend on the provision of a noninfected vascular bed, good apposition of the graft to the underlying bed without any intervening haematoma and the application of pressure to allow the process to take place. Surfaces that take a graft well are: granulation tissue; the soft tissue of the face; muscle, fascia, fat; cartilage and bone covered with perichondrium and periosteum. Bare cartilage does not usually take a graft, but if the area is small, the surrounding tissues may supply enough blood supply to facilitate a take. In principle, it does not take a skin graft, for example the bare cortical bone of the outer table of the skull and the mandible. However, the bone of the hard palate, maxilla, the walls of the orbit and the zygoma can all take a graft. In addition, if the bone is drilled to expose vascular dipole, this will take a graft or the Crane principle may be applied. This involves using a vascularized flap to cover the bone to promote a vascular bed. The flap is then transferred back to its donor site after three or four weeks leaving a new vascular bed, which will then take a skin graft. As a general rule, previous radiotherapy is not a contraindication to grafting but the tissue in question should be assessed at the time of the surgery. Extensive induration and fibrosis with small amounts of bleeding indicate that grafting may not be successful, whereas the converse would suggest that a graft will take. The surgeon should use his or her own assessment and experience to decide which tissues may or may not take a graft following radiotherapy. The adherence of a graft depends on fibrin anchorage and any surface that is considered suitable for grafting has fibrinogen together with the enzymes that can convert it into fibrin to facilitate adhesion. It is important to realize that some organisms can destroy fibrin and prevent this mechanism taking place, the main one being the bhaemolytic Streptococcus pyogenes (group A and G) which produce fibrinolysin. The site is dictated by the size of the graft required, the presence or absence of hair, the desirability of avoiding the leg (thereby increasing post-operative mobility), and access to various donor sites during extensive surgery. The skin of the leg often darkens later and for the face, the upper arms and trunk are better donor sites. The Humby knife is set depending on the thickness of the graft required, but most grafts average around 12/1000 of an inch (0. A non-hair-bearing area is used, such as the inside of the thigh, and prepared well using either a nonstaining disinfectant such as a chlorhexidine or, if necessary, povidone iodine. An assistant holds the limb in such a position that the muscles are relaxed, a hand is placed round the underneath of the leg to tighten the muscle forward, and the skin stretched so that the maximum flat area is available for taking the graft. The thickness may be assessed by holding the knife up to the light; a technique that comes with practice. The dermatome blade must be able to move smoothly and not drag on the skin, so that both it and the skin of the leg are lubricated with liquid paraffin. The skin surface is held steady and flat with two boards; the upper board is not lubricated, to maintain its fixation, but the lower board is held at the starting end of the donor site by the operating surgeon, is lubricated, moves down just in front of the dermatome and maintains skin taughtness. Firm pressure is now applied to the dermatome and cutting is achieved with a continuous movement and plenty of side-to-side action. When sufficient skin has been raised, the end of the graft is cut and placed on tulle gras to keep it moist. Chapter 205 Grafts and local flaps in head and neck surgery] 2823 adrenaline or hydrogen peroxide may be applied to reduce this and, when the bleeding has stopped, the wound is dressed using a dressing such as Opsite. Grafts may also be taken with electric dermotomes which are easier to use and able to provide grafts of predetermined and fixed thickness, but are expensive. Large grafts need peripheral clips or sutures; always use sutures for full-thickness grafts; exposed: good for large, immobile, delayed grafts. Whether the graft is applied immediately or delayed depends on a number of factors but where the recipient site is healthy, not bleeding excessively and not infected, grafts are usually placed primarily. In this situation, pressure is usually applied, which provides immobility for the graft and holds it in place with the bed until take is effected. In areas where the bed is highly vascular and likely to ooze post-operatively, meshing the graft can prevent haematoma and optimize take. When applying a split skin graft to a recipient site, it is usually laid over the wound and allowed to drape over the edges and then trimmed at the first dressing. Various materials may be used to apply pressure; for example, proflavine wool, cotton wool moistened with saline or liquid paraffin, or foam. Pressure may be maintained by the application of a tie over the pressure bolster or, in the case of the foam, this may sewn or stapled to the skin. The split skin graft is not usually sewn in place, but some form of movement prevention is sometimes helpful and, in this situation, either sutures or staples may be used. Where large areas of graft are used, easily removed absorbable tacking sutures (plain cat gut) may be placed across the area of the graft to keep it in place. Pressure methods are preferable when a graft is small and should always be used for a full-thickness skin graft. They are also preferable where a cavity is being filled or the defect is irregular in contour, such as in the orbit or around the ear. If the area to be grafted is in a suitable position where movement will not be a problem, for example the top of the scalp where pressure may be difficult to apply over a curved surface, then the graft may merely be covered with tulle gras until the patient wakes up and then exposed. The larger and less mobile the area to be grafted, the more likely it is to be suitable for delayed exposed grafting. Where there is excessive bleeding, for example the muscle pedicle of a latissimus dorsi flap exposed after repair of a neopharyngeal fistula, the technique of delayed exposed grafting is preferable. The recipient site is covered with tulle gras and moist saline dressings which should be changed every four hours and moistened with saline in between. Secondary skin grafting this method is used when neck skin has died and the lost skin and underlying tissue must be replaced. In this situation, when there are exposed major blood vessels, immediate reconstruction is required with vascularized tissue using either pedicled or free flaps to cover the vessels, since any delay and subsequent infection may lead to a carotid blow-out. When the major vessels are not exposed, the area is kept clean and moist, dressed regularly and allowed to granulate so that at the appropriate time it may be repaired with a split skin graft. Experience is needed to know when a granulating bed is ready for skin grafting, but signs of readiness for secondary grafting include: flat red granulation; no slough; marginal healing; absence of foul-smelling odour. The best indication is colour: pale pink anaemic-looking granulation tissue will not take a graft. The area should be totally free of slough and there should be evidence of marginal healing, defined as a thin blue rim growing in at the edge of the defect. It is unwise to flatten granulation tissue by the use of caustic agents, such as silver nitrate. They kill tissue locally and cause more slough, and there is no evidence to show that they improve the speed of granulation. The necrotic area is initially infected and must be disinfected and regularly dressed and cleaned and not grafted until a healthy bed of granulations has formed, which usually takes at least two to three weeks. In this situation, it is wise not to rush in and it is amazing how the body heals with time. Granulations that are sloughing, gelatinous or oedematous will not accept a skin graft because they are often infected with Streptococci, which destroy the graft. Swabs should be taken regularly and if Streptococci are grown, the appropriate systemic antibiotic (which is usually penicillin-based) should be administered until the wound is free of infection. Organisms such as Escherichia coli and the Proteus group should be regarded as opportunists and not as a contraindication to grafting. One of the main causes of infection is slough and dead tissue and these should be removed and debrided widely so that the defect may be closed from the bottom up. The wound should be dressed daily with ribbon gauze soaked initially with a local antibiotic such as metronidazole gel and, as the wound becomes clean, saline-soaked dressings are appropriate instead. For deep, narrow wounds, granulation-promoting preparations, such as Sorbison or Granuflex, may be useful. Once the area is clean and granulating properly, the defect is covered with stored split skin using delayed exposed grafting. An alternative reconstructive technique in this situation is to reduce the cavity size using free muscle transfer, for example, a rectus abdominus flap. At other sites, the newer technique of graft quilting has now superseded bolus pressure methods in the mouth. The graft is lain on the recipient site, then sewn in around the edge and also quilted over the bed to maintain fixation. Full-thickness skin grafts Under ideal conditions, the full-thickness skin graft provides a surprisingly good form of reconstruction and is often the technique of choice par excellence for small areas following removal of skin tumours in areas such as the nasal tip, parts of the pinna and the lower eyelid. The success for grafting is often not quite as good as that for split skin thickness grafting, because the plasmatic circulation takes longer to establish itself and, during this time, factors such as movement, infection and haematoma can delay the take. The other reason is that the number of cut capillary ends exposed when a thick split skin graft or full-thickness skin graft is cut is less than with a thin graft and therefore vascularization is slower. To combat this, the head and neck donor sites have a rich blood supply, which allows their vascular characteristics to be compared favourably with split skin grafts. The take is usually much better than for fullthickness grafts in non-head and neck sites. Common head and neck full-thickness skin graft donor sites include: postauricular; preauricular; lower neck. A full-thickness skin graft must have a freshly cut vascular bed and therefore it cannot be used on granulating surfaces. Moreover, the size of the graft is limited because the donor site has to be closed by undermining and primary closure. In the presence of failure, which may be partial or complete, subsequent healing by secondary intention may still give a reasonable long-term result. Alternatively, another technique, such as a local flap, may be used which will provide the appropriate lifeboat and get the surgeon out of trouble. The best material to use is polyurethane and a larger bolus than originally thought is usually required. In addition, it is particularly difficult to maintain the pressure on certain areas within the oral cavity, such as the lateral tongue border. After the graft has been marked out, it may be injected with local anaesthetic and adrenaline and then excised, carefully leaving any fat behind. During elevation, the graft may be rolled over the finger and stretched with a skin hook so that the knife dissects on to the underneath of the dermis and hair follicles are seen, so that no fat is left on the graft. An alternative technique is to take the graft, roll it over the finger afterwards and remove any excess fat with sharp pointed scissors, remembering that the less fat there is, the better the take will be. Although removing the fat after the graft has been harvested is a tedious process, it is probably easier to do for the inexperienced surgeon. To take a graft without fat requires both care and skill, since buttonholing can easily occur with excess vigour.

A negative frozen section does not exclude the presence of disease (as a frozen section is a twodimensional image of a three-dimensional tumour) xyzal erectile dysfunction cheap 100mg viagra jelly otc. The deep musculature can be approximated using interrupted resorbable sutures and Primary closure is adequate for partial glossectomy of up to half of the tongue when there is no resulting tension on the wound or decreased mobility of the tongue erectile dysfunction doctor atlanta viagra jelly 100 mg otc. Mucosal resurfacing and replacement of tongue volume then becomes the method of choice erectile dysfunction effects on women generic viagra jelly 100 mg without prescription. Historically impotence with lisinopril 100 mg viagra jelly with mastercard, pectoralis major myocutaneous flaps were used to reconstruct extensive tongue defects erectile dysfunction va rating order viagra jelly with paypal, but the poor tongue mobility and bulk of these flaps has led to their gradual replacement with microvascular fasciocutaneous or myocutaneous flaps as these have been shown to have better functional outcome diabetes and erectile dysfunction causes viagra jelly 100 mg amex, cosmetic outcome and mobility. Similarly, the use of local muscle flaps, such as masseter and cutaneous flaps, have been superseded due to the better functional outcome of microvascular free tissue transfer in large defects that may compromise function and mobility. However, when a moderate soft tissue volume replacement is required to improve swallowing function then the deficit may be best reconstructed with an anterolateral thigh flap where a greater soft tissue volume can be obtained. If one looks at the quality of speech following significant tongue reconstruction, then it is significantly worse six and twelve months after treatment than before treatment. Currently, optimal functional results are observed with the use of free flaps and, in the oral cavity and oropharynx, the best outcome is obtained by the use of thin pliable fasciocutaneous flaps, such as the radial forearm free flap and anterolateral thigh flap. There is better speech function after reconstruction with a free flap rather than with the more bulky pectoralis major flap. Intelligibility is also found to be improved for patients who undergo reconstruction by a radial forearm free flap than those who undergo a somewhat thicker lateral upper arm flap. The use of the radial forearm free flap is presently the best reconstructive option, especially when the created defect takes up multiple anatomical sites. However, others have shown that swallowing and speech can be maintained without aspiration following microvascular reconstruction of sub-total glossectomy defects. One group suggests that the bulk of the tumour should be replaced with similar muscle, even though this may not be functioning muscle. In these cases, even a small amount of residual base of tongue can allow sufficient tongue movement to allow a swallow. Other authors feel that a bulky immobile reconstruction produces a worse outcome and therefore a thin pliable radial forearm flap to replace the floor of mouth is all that is indicated. Speech and language therapy are involved at an early stage in training the patient to develop the recovery to an oral diet. Brachytherapy using iridium wire implants is an effective alternative treatment for T1/small T2 lesions of the lateral anterior tongue. The technique cannot be used adjacent to the dentate mandible as significant rates of osteoradionecrosis may occur. The results are comparable with surgical excision but some proponents of the technique argue that the functional outcome is better as no surgical resection and reconstruction occurs. It is often necessary to include the underlying sublingual glands in the resection as tumour in the anterior floor of mouth can invade along the small salivary ducts leading from the sublingual glands. Superficial defects above the sublingual glands and mylohyoid can be left to heal by secondary intention but larger defects can be reconstructed with a split skin graft. However, when the surgical defect involves the muscles of the floor of the mouth and extends into the neck then microvascular free flap reconstruction with a radial fasciocutaneous flap is indicated to reduce the risk of an orocervical salivary fistula. Similarly, lateral floor of mouth defects can be left to heal by secondary intention. When the lesion moves into a second tissue plane, such as the adjacent ventral surface of the tongue or the mandibular alveolus, microvascular reconstruction aids three-dimensional reconstructions and maintains mobility and function. In the elderly, bilateral nasolabial flaps may be used to repair small or moderate defects in the anterior floor of mouth. Pedicled flaps, such as the submental island or the facial artery musculomucosal flap,46 may also be useful in small defects of the anterior or lateral floor of mouth. The pooling of saliva in this area, where the carcinogenic products of tobacco and alcohol are concentrated, predisposes these sites to tumour. The tumours are often exophytic and are often found in the region of the opening of the submandibular ducts. In the dentate patient, an endophytic tumour presents as ulceration with craggy borders, often infiltrating into the adjacent mandible. Late presentation of such tumours show various degrees of fixation and swelling of the anterior tongue as the tumour infiltrates into intrinsic tongue muscles. Mandibular invasion in oral carcinomas ranges from 12 to 56 percent according to various studies, and involvement of the mandible occurs by direct invasion rather than by lymphatic spread. Panoral radiographs play an important role in the detection of bone invasion, especially determining the superior extent of the tumour in the bone. Routine radiographs are unable to detect initial bone invasion until 30 percent of the mineral has been lost. If mandibular involvement is superficial on the alveolar crest, then marginal resection rather than segmental resection of the mandible may be adequate. There are two basic patterns of bone involvement of the lower alveolus and gingiva. In the infiltrative pattern the tumour invades the mandible through defects in the cortical bone or periodontal space. In these cases, tumours are often found to invade the periosteum and the inferior alveolar nerve. In the expansive pattern there is no tumour invasion in relation to the periodontal space, the neurovascular canal or the periosteum. Thus the expansile pattern can be excised successfully by marginal mandibular resection. Conventional radiography cannot accurately differentiate these two types of bone involvement. Maintaining the lower border of the mandible in resection of alveolar carcinoma is important to the function. Some authors have devised a clinical algorithm on rim or segmental resection with regard to the presence Reproduced from Ref. It has been used successfully to reconstruct a wide variety of difficult oronasal mucosal defects, including defects of the palate, alveolus, nasal septum, antrum, upper and lower lips, floor of the mouth and soft palate. Survival rates for tongue and floor of mouth cancer the survival rate of tongue cancer is related to tumour thickness and is shown in Table 192. Alveolar tumours often present as discrete cauliflower-like lesions on the attached gingiva. In the edentulous patient, the alveolar process is often resorbed and tumours arising from the alveolar crest often invade into the adjacent cortical bone by direct extension. Clinically, it is often difficult to assess whether tumours arising on the attached or free mucosa of the dentate or edentulous mandible show any underlying bone invasion. The underlying periosteum is, however, a useful barrier to ingress of tumour into the alveolar process of the mandible or maxilla. Imaging Bone scintigraphy appears to be the most sensitive investigation and tomography, the most specific regarding mandibular invasion. Factor Rim resection Segmental resection Bone invasion No invasion Positive margin Negative margin Five year survival (%) 84 92 83 88 40 72 Reproduced from Ref. Segmental jaw resection is clearly indicated when tumour invades the medullary cavity or in an atrophic mandible where clear margins will not allow an adequate rim of bone. Various studies have shown that bone invasion itself contributes little to overall prognosis. Every attempt should be made to achieve negative soft tissue margins as this is the only factor identified which significantly accounts for control rate and survival during resection of mandibular bone. Based on the current literature, gross bone involvement in previously irradiated patients or in nonirradiated patients in whom there is obvious involvement of the medullary space is best managed with a segmental resection. Irrespective of this reconstruction, it is important to limit the nature of the resection unless there has been a demonstrated benefit to performing a segmental resection. It is often possible to raise the adjacent periosteum of the bone in this area to exclude any transperiosteal spread of the tumour that may suggest a segmental rather than a rim resection is required. Following delineation of the soft tissue margin, the periosteum is lifted off the adjacent bone to expose the bone for resection. The resection margin will usually be superior to the inferior alveolar nerve unless the preoperative imaging investigations suggest that the inferior alveolar nerve needs to be sacrificed to achieve adequate bony surgical margins. A reciprocating saw is then used to produce a saucerized rim resection of the mandible. The sharp edges of the bone are smoothed with a dental bur and soft tissue reconstruction of the defect usually necessitates a fasciocutaneous free flap. As most of these patients will require postoperative radiotherapy, simple split skin grafts or pedicle flaps in this area lead to a high incidence of bone exposure and osteoradionecrosis following the subsequent radiotherapy. The underlying bone can be resected with the soft tissue tumour via a segmental resection of the alveolus. If it does not compromise excision margins, then limiting the alveolectomy to just below the maxillary antrum prevents an oroantral communication or fenestration. However, the avoidance of fenestration into the adjacent maxillary antrum or floor of nose should not be undertaken if it compromises surgical resection margins. With a small fenestration or alveolectomy procedure posteriorly in the maxilla, the defect can be closed by the use of an advancement flap utilizing the buccal fat pad. If a buccal fat pad is used, a temporary acrylic dressing plate is secured to the upper maxilla to protect the buccal fat pad during subsequent epithelialization. If a more extensive defect is created, then a temporalis flap can be rotated to close over the oroantral communication, although in the elderly this is compromised by the poor cosmetic result due to hollowing of the temporalis donor site. In small defects of the posterior maxilla, no reconstruction is required if adequate prosthetic rehabilitation with obturators using osseointegrated implants in the edentulous maxilla is performed. The use of zygomaticus osseointegrated implants is necessary where a more extensive limited posterior maxillectomy is required to establish tumour clearance. Thus, the measurement of tumour thickness should be included in estimating prognosis and planning therapy for these patients. Tumours that occur on the buccal mucosa can easily gain access to adjacent structures, such as the alveolar ridges, retromolar trigone, lips and buccal spaces. The most common signs and symptoms of buccal carcinoma are pain and mucosal ulceration. Patients with submucous fibrosis may also develop squamous cell carcinoma in the affected buccal mucosa. There also appears to be a higher incidence of buccal carcinoma in Asians and those of African origin. Chapter 192 Oral cavity tumours including the lip] 2561 tobacco chewing, associated precancerous lesions such as widespread leukoplakia and erythroplakia are often present. As in most oral cancers, the presence or absence of nodal enlargement at presentation is the most important, significant prognostic factor. In patients where the tumour invades into adjacent maxillary or mandibular bone, aggressive composite resection is required. Some authors have shown that the presence of residual recurrent buccal carcinoma after primary radiation therapy as a primary treatment modality has an extremely poor prognosis. This helps determine those lesions that have escaped outside the buccal space and extended onto the mandible or maxilla or into the infratemporal fossa or parapharyngeal space. Treatment T1 carcinomas of the buccal mucosa can be excised with a suitable margin via a peroral excision. Reconstruction of the surgical defect depends on location but small defects can be left to granulate, whilst more moderate defects can be reconstructed by advancing the buccal fat pad of tissue into the defect, which allows secondary epithelialization. Split skin grafts can be used to cover the resected area using a tie-over bolster to maintain the graft in position. Local flaps, such as the facial artery musculomyocutaneous flap, can be used to reconstruct larger defects. Larger areas of mucosal loss will result in fibrosis and contracture if left to epithelialize or reconstructed with split skin grafts, and in such cases, free tissue transfer using thin fascial or fasciocutaneous flaps, such as the radial forearm flap, may be required. Reconstruction with a radial forearm free flap for buccal mucosal defects is more effective to preserve the original mouth-open width than with a pedicled buccal fat pad flap or split-thickness skin graft among the selected patients who undergo tumour resection for T2 or T3 buccal cancer. Although the tumour is exophytic, some of these verrucous carcinomas can show aggressive local infiltration and their treatment should not be underestimated. When buccal carcinomas involve a large surface area of tissue, but do not show extensive thickness of involvement, then surgical excision of such a large area creates a difficult reconstructive problem. The large surface area of mucosa requiring replacement often requires free tissue transfer or a pedicled temporoparietal fascial flap to reconstruct the defect. However, this has the disadvantage of increased morbidity from a second operative site. Superficial but widespread lesions may be suitable for photodynamic therapy as its mode of action is thought to reduce intrinsic scarring. Second generation photosensitizers can produce up to an 8 mm thickness of action which may be suitable for most superficial widespread buccal carcinomas. Caution should be used when considering this treatment option in place of standard surgical or radiotherapy techniques. Flexible nasendoscopy and antral sinoscopy will also give an indication as to the extent of spread of these tumours into the adjacent paranasal sinuses. A submucosal lump is the more common presentation with tumours of salivary gland origin. Problems with dentures or altered speech can occur less frequently, and swellings of the hard palate and ulceration are often misdiagnosed as being dental in origin. Over 50 percent of lesions extend beyond the anatomical confines of the palate at the time of presentation. This surgical approach is tailored for small tumours of the lateral maxillary alveolar ridge and hard palate.

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