- Email: [email protected]
Does the face protect the brain?
1024
CURRENT LITERATURE
blepharoplasty. Arroyo has described an alternative surgical technique of returning herniated fat to the orbit cavity by continuous suturing of the capsulopalpebral fascia (CPF) to the periosteum of the lower orbital rim. This report documents 26 cases of standard blepharoplasty on one side and CPF repair on the opposite-side eyelid. All results were examined at 6 weeks and 6 months postoperatively. Comparable aesthetic outcomes were found for either technique but shorter operating time with less intravenous sedation was needed for CPF repair and less intraoperative pain and bleeding was found in the CPF group. Reasons for this findings were thought to be no need for traction and fat resection during the procedure. Conclusions drawn by the authors were that this technique is a safe and effective alternative to standard blepharoplasty.-J. BROKLOFF Reprint Luistana
requests to Dr Parsa: St, Suite 807, Honolulu,
Posttraumatic Gustatory Trigeminal Neuropathic 12:287, 1998
Queens Physican HI 06913.
Building
II,
1329
Neuralgia: A Clinical Model of Pain. Scrivani SJ. J Orofac Pain
Six cases are reported in which the primary complaint was episodic, recurrent facial pain that was triggered by a taste stimulus. The pain first occurred days to weeks after head and neck surgery. Patients reported that a food stimulus placed in the mouth evoked episodic, electric shock-like pain in a preauricular location on the surgical side. The smell of food, or less reliably, emotional excitement could also trigger pain. Mandibular movements did not evoke the pain, and between laminating attacks there was either no pain or only mild discomfort. Following an episode of pain, there was a refractory period during which the pain could not be elicited. Physical examination showed a preauricular sensory loss of variable distribution. No abnormal sweating or vasomotor findings were clinically apparent. No odontogenic, muscular, salivary gland, neurologic, or psychological pathology was found to explain the clinical symptoms. The pain was not relieved with standard doses of anticonvulsants that are commonly used to treat trigeminal neuralgia. The duration of the recurrent pain symptoms in this group was 8 to 132 months without remission. Gustatory neuralgia may be a discrete syndrome that results from abnormal interactions between salivary efferent fibers and trigeminal sensory afferent fibers in the injured auriculotemporal nerve. The unique features of the disorder make it a potentially useful clinical model for the investigation of autonomic/sensory interactions in neuropathic pain.-J.D. MANcuso Reprints
dibles, respectively. All patients underwent successful decannulation at an average of 3.8 months postdistraction. Average hyoid advancement was 14.5 mm with a range of 8 to 25 mm based on serial cephalometric films. Conclusions drawn by the authors were that distraction osteogenesis is an effective means to decammlate tracheostomy dependent patients with mandibular deficiencies-J. BROKLOFF Reprint Johnson
requests to Dr Cohen: Department Ferry Rd, Suite 500, Atlanta, GA
of Plastic
Surgery,
975
30342.
Common Problems Seen by the Plastic Surgery Emergency Room Service. Shook JE. Clin Plast Surg 25:619, 1998 Traumatic wounds are among the most common problems encountered in the emergency setting. When one looks specifically at pediatric patients in the emergency department, a review from the Children’s Hospital of Philadelphia reveals that approximately 10% of their patients present for management of traumatic injuries. Of the 7,440 injured children who were reviewed in this study, 93% were less than 14 years of age and 61% were boys. The most common forms of injury were abrasions and contusions (32%) and lacerations (27.6%). The most common site of injury was the head and face (40%). When dealing with children in the emergency department, it is important to keep in mind that both the wound itself and the child who has incurred the wound are being treated. Wound anesthesia and/or sedation of the patient is necessary to achieve optimal cosmetic and functional results. The use of sedation requires an understanding of monitoring, assessment of physical status, dietary intake, and pharmacology. A combination of topical anesthesia, local anesthesia, and oral, rectal, intramuscular, or intravenous sedatives may be required for the repair of a complex wound. Occasionally, stronger pain control may be required, and morphine, meperidine, fentanyl, or a combination of agents may be required. Immunization status should be evaluated and tetanus immune globulin or antitoxin as well as tetanus toxoid should be administered as indicated. Antibiotic prophylaxis is often given to decrease the likelihood of developing a wound infection after a bite. The most appropriate oral outpatient antibiotic is amoxlcillin with clavuionic acid. The question of rabies exposure should be assessed (especially for raccoon, skunk, fox, and bat bites) and the appropriate rabies postexposure prophylaxis administered.-R.H. HAUG Reprint requests to Dr Shook: Department of Pediatrics, Medicine Section, Baylor College of Medicine, Houston,
Emergency TX 77030.
not available.
Early Decannulation With Bilateral Mandibular Distraction for Tracheostomy-Dependent Patients. Williams JK, Maull D, Grayson BH, et al. Plast Reconstr Surg 103:48, 1999 Hypoplastic development of the mandibular framework causing retropositioning of the base of the tongue can lead to inadequate hypopharyngeal space. Tracheostomy is an effective treatment for children with this problem but can be associated with increased morbidity and severe social problems. This article is a review of four tracheostomydependent patients who underwent bilateral unidirectional mandibular distraction. The four patients had 21.3 mm and 20.8 mm of advancement on the left and right hemiman-
Does the Face Protect the Brain? Keenan HT, Brundage SI, Rivara FP. Arch Surg 134:14, 1999 The relationship between facial fractures and traumatic brain injury is controversial. Some studies show an increased risk of brain injury with the presence of facial fractures while others claim that facial fractures protect against brain injury. In this study, the researchers used a large database of individuals with injuries from bicycle crashes to examine the association between traumatic brain injury and facial fracture using a case-control design. Subjects were recruited from the emergency departments (EDs) of seven hospitals in the Seattle, WA area. Patients who sought care for a bicycle-related traumatic brain injury in the ED of a study hospital during the period from March 1,1992
1025
CURRENT LITERATURE to August 31, 1994 were enrolled in this study. They were classified by injury into two groups: those with intracranial injuries and those with concussions. Control subjects were defined as bicyclists treated in the same EDs who reported hitting their helmet, head, or face or sustaining an injury to their head or face, without any traumatic brain injury. This control group was chosen to include only those bicyclists at risk of traumatic brain injury and/or facial fracture. Facial injury was defined as any injury to the jaw, lips, cheeks, nose, ears (external), eyes (external), forehead, or mouth (intraoral). Facial fracture was defined as injury to the maxilla, orbits, zygoma, or mandible. There were 203 bicyclists with traumatic brain injuries, of whom 62 had an identifiable intracranial injury and 141 suffered a concussion. A total of 81 patients sustained facial fractures. According with the study’s results, the risk of intracranial injury in those bicyclists with facial injury was increased almost lo-fold, and the risk for all brain injuries including concussion was doubled. The authors do not imply that facial fractures cause traumatic brain injury, but suggest that blunt impact with enough force to break facial bones could also produce brain injury. These results disagree with the previously reported decreased risk of traumatic brain injury in patients with facial fracture. This study only examined one population, bicyclists who crashed, so the authors cannot comment on other mechanisms of injury that are reported as causes of facial fractures such as motor vehicle crashes or assaults. This case-controlled study shows no evidence that facial fractures are protective of traumatic brain injury.H. PATINO Reprints request to Dr Rivara: Department of Pediatrics and Epidemiology, Harbor View Injury Prevention and Research Center, Box 359960, 325 Ninth Ave, University of Washington, Seattle, WA 981042499; e-mail: [email protected] The Lacrimal Keyhole, Orbital Door Jamb, and Basin of the Inferior Orbital Fissure: Three Areas of Deep Bone in the Lateral Orbit. Goldberg RA, Kim AJ, Kerivan KM. Arch 0phthalmo1116:1618,1998 Traditional lateral orbital decompression surgery, used to treat Graves orbitopathy, is limited in the degree of orbital expansion that can be achieved. Previous studies calculating increases in orbital volume or the degree of reduction of proptosis after traditional lateral decompressions showed that adequate volume expansion could not be achieved with the traditional technique. However, additional orbital expansion may be gained if the thicker, deep areas of the lateral wall are removed. The authors calculated the volume of bone in three areas of the deep lateral orbit that are available for removal in decompression surgery. Also, a threedimensional computer reconstruction of an orbital computed tomography (CT) scan was created demonstrating these three areas. The designation of these three areas of bone in the lateral orbit-the lacrimal keyhole, the sphenoid door jamb, and the basin of the inferior orbital fissure were conceptual rather than anatomical structures. These three areas of orbital bone were analyzed by measuring preoperative and postoperative orbital volumes and predicted bony expansion volumes in nine patients (17 orbits) who underwent deep lateral decompression surgery. Orbital volumes were measured by means of digitized CT scans. Eleven normal orbits were also studied to estimate the amount of potential bone available in the deep lateral orbit. A threedimensional computer reconstruction of an orbital CT scan
was created, and the three areas of potential bone were demonstrated within it. The average volumes of the basin of the inferior orbital fissure, the sphenoid door jamb, the lacrimal keyhole, were 1.2,2.9, and 1.5 mL respectively, and the total of the three regions was 5.6 mL. A significant amount of interpatient variability, especially for the doorjamb region, was found. More volume expansion was achieved through the coronal approach versus the eyelidcrease approach. Orbital decompression surgery of the deep lateral wall can provide adequate volume expansion and reduction of proptosis because of the amount and location of potential space that exists in the three areas of deep bone.-A.J. LIBUNAO Reprint requests to Dr Goldberg: 100 Stein Plaza, Los Angeles, CA 90095-7006. Detection of Serum Antibodies Against cytomegalovirus, Varicella Zoster Virus and Human Herpesvirus 6 in Patients With Recurrent Aphthous Stomatitis. Ghodratnama F, Wray D, Bagg J. J Oral Path01 Med 28:12, 1999 For many years there has been interest in the possible role of viruses, particularly the herpes group of viruses, as an etiologic factor in recurrent aphthous stomatitis @AS). The aim of this study was to examine the involvement of human herpesvirus(HHV-6), cytomegalovirus, and varicella zoster virus (VZV) in RAS by detection of specific IgG and IgM class immunoglobulins against these viruses. In this study, sera from 22 patients with RAS, 24 patients with oral lichen planus (OLP), and 15 healthy controls were screened for IgG and IgM class antibodies to human cytomegalovirus @XV), VZV, and HHV-6. Commercially available enzyme-linked immunosorbent assay and immunofluorescence kits were employed. There were no significant differences in the prevalence of IgG antibodies to HCMY, VZV, or HHV-6 among the three patient groups. However, specific HHV-6 IgM was detected in 21 (95%) of the RAS patients and 17 (71%) of the lichen planus patients compared with 8 (53%) of the controls. This difference between RAS patients and controls was statistically significant. In conclusion, The results of the serological investigations presented in this study provide no evidence to support HCMV or VZV as an etiologic agent in RAS. Although there are no established clinical manifestation of HHV-6 infection in the oral cavity, RAS may prove to be one of the features of HHV-6 reactivation.-N. ASSUDMI Reprint requests to Dr Ghodratnama: Glasgow Dental Hospital and School, NHS Trust, Glasgow, Scotland. How to Select Counsel Defense: The Plaintiffs Plast Surg 26:79, 1999
and Participate in Your Own Perspective. Horan DW. Clin
From the plaintiff’s perspective, the counsel who represents a defendant during the discovery and trial phase of the lawsuit is an extremely important determinant of the outcome of the litigation. The most desirable lawyer will be the one who is an experienced partner who has already tried at least five lawsuits to verdict. Most defense law firms have only a handful of such experienced litigators. The doctor’s only consideration when a lawsuit is filed against him, is to get the best possible representation. Meet with your attorney as soon as possible, have a list of questions ready, determine whether your interest or that of the insurance carrier is in mind primarily, and perhaps hire your own attorney.-R.H. HAUG
CURRENT LITERATURE
blepharoplasty. Arroyo has described an alternative surgical technique of returning herniated fat to the orbit cavity by continuous suturing of the capsulopalpebral fascia (CPF) to the periosteum of the lower orbital rim. This report documents 26 cases of standard blepharoplasty on one side and CPF repair on the opposite-side eyelid. All results were examined at 6 weeks and 6 months postoperatively. Comparable aesthetic outcomes were found for either technique but shorter operating time with less intravenous sedation was needed for CPF repair and less intraoperative pain and bleeding was found in the CPF group. Reasons for this findings were thought to be no need for traction and fat resection during the procedure. Conclusions drawn by the authors were that this technique is a safe and effective alternative to standard blepharoplasty.-J. BROKLOFF Reprint Luistana
requests to Dr Parsa: St, Suite 807, Honolulu,
Posttraumatic Gustatory Trigeminal Neuropathic 12:287, 1998
Queens Physican HI 06913.
Building
II,
1329
Neuralgia: A Clinical Model of Pain. Scrivani SJ. J Orofac Pain
Six cases are reported in which the primary complaint was episodic, recurrent facial pain that was triggered by a taste stimulus. The pain first occurred days to weeks after head and neck surgery. Patients reported that a food stimulus placed in the mouth evoked episodic, electric shock-like pain in a preauricular location on the surgical side. The smell of food, or less reliably, emotional excitement could also trigger pain. Mandibular movements did not evoke the pain, and between laminating attacks there was either no pain or only mild discomfort. Following an episode of pain, there was a refractory period during which the pain could not be elicited. Physical examination showed a preauricular sensory loss of variable distribution. No abnormal sweating or vasomotor findings were clinically apparent. No odontogenic, muscular, salivary gland, neurologic, or psychological pathology was found to explain the clinical symptoms. The pain was not relieved with standard doses of anticonvulsants that are commonly used to treat trigeminal neuralgia. The duration of the recurrent pain symptoms in this group was 8 to 132 months without remission. Gustatory neuralgia may be a discrete syndrome that results from abnormal interactions between salivary efferent fibers and trigeminal sensory afferent fibers in the injured auriculotemporal nerve. The unique features of the disorder make it a potentially useful clinical model for the investigation of autonomic/sensory interactions in neuropathic pain.-J.D. MANcuso Reprints
dibles, respectively. All patients underwent successful decannulation at an average of 3.8 months postdistraction. Average hyoid advancement was 14.5 mm with a range of 8 to 25 mm based on serial cephalometric films. Conclusions drawn by the authors were that distraction osteogenesis is an effective means to decammlate tracheostomy dependent patients with mandibular deficiencies-J. BROKLOFF Reprint Johnson
requests to Dr Cohen: Department Ferry Rd, Suite 500, Atlanta, GA
of Plastic
Surgery,
975
30342.
Common Problems Seen by the Plastic Surgery Emergency Room Service. Shook JE. Clin Plast Surg 25:619, 1998 Traumatic wounds are among the most common problems encountered in the emergency setting. When one looks specifically at pediatric patients in the emergency department, a review from the Children’s Hospital of Philadelphia reveals that approximately 10% of their patients present for management of traumatic injuries. Of the 7,440 injured children who were reviewed in this study, 93% were less than 14 years of age and 61% were boys. The most common forms of injury were abrasions and contusions (32%) and lacerations (27.6%). The most common site of injury was the head and face (40%). When dealing with children in the emergency department, it is important to keep in mind that both the wound itself and the child who has incurred the wound are being treated. Wound anesthesia and/or sedation of the patient is necessary to achieve optimal cosmetic and functional results. The use of sedation requires an understanding of monitoring, assessment of physical status, dietary intake, and pharmacology. A combination of topical anesthesia, local anesthesia, and oral, rectal, intramuscular, or intravenous sedatives may be required for the repair of a complex wound. Occasionally, stronger pain control may be required, and morphine, meperidine, fentanyl, or a combination of agents may be required. Immunization status should be evaluated and tetanus immune globulin or antitoxin as well as tetanus toxoid should be administered as indicated. Antibiotic prophylaxis is often given to decrease the likelihood of developing a wound infection after a bite. The most appropriate oral outpatient antibiotic is amoxlcillin with clavuionic acid. The question of rabies exposure should be assessed (especially for raccoon, skunk, fox, and bat bites) and the appropriate rabies postexposure prophylaxis administered.-R.H. HAUG Reprint requests to Dr Shook: Department of Pediatrics, Medicine Section, Baylor College of Medicine, Houston,
Emergency TX 77030.
not available.
Early Decannulation With Bilateral Mandibular Distraction for Tracheostomy-Dependent Patients. Williams JK, Maull D, Grayson BH, et al. Plast Reconstr Surg 103:48, 1999 Hypoplastic development of the mandibular framework causing retropositioning of the base of the tongue can lead to inadequate hypopharyngeal space. Tracheostomy is an effective treatment for children with this problem but can be associated with increased morbidity and severe social problems. This article is a review of four tracheostomydependent patients who underwent bilateral unidirectional mandibular distraction. The four patients had 21.3 mm and 20.8 mm of advancement on the left and right hemiman-
Does the Face Protect the Brain? Keenan HT, Brundage SI, Rivara FP. Arch Surg 134:14, 1999 The relationship between facial fractures and traumatic brain injury is controversial. Some studies show an increased risk of brain injury with the presence of facial fractures while others claim that facial fractures protect against brain injury. In this study, the researchers used a large database of individuals with injuries from bicycle crashes to examine the association between traumatic brain injury and facial fracture using a case-control design. Subjects were recruited from the emergency departments (EDs) of seven hospitals in the Seattle, WA area. Patients who sought care for a bicycle-related traumatic brain injury in the ED of a study hospital during the period from March 1,1992
1025
CURRENT LITERATURE to August 31, 1994 were enrolled in this study. They were classified by injury into two groups: those with intracranial injuries and those with concussions. Control subjects were defined as bicyclists treated in the same EDs who reported hitting their helmet, head, or face or sustaining an injury to their head or face, without any traumatic brain injury. This control group was chosen to include only those bicyclists at risk of traumatic brain injury and/or facial fracture. Facial injury was defined as any injury to the jaw, lips, cheeks, nose, ears (external), eyes (external), forehead, or mouth (intraoral). Facial fracture was defined as injury to the maxilla, orbits, zygoma, or mandible. There were 203 bicyclists with traumatic brain injuries, of whom 62 had an identifiable intracranial injury and 141 suffered a concussion. A total of 81 patients sustained facial fractures. According with the study’s results, the risk of intracranial injury in those bicyclists with facial injury was increased almost lo-fold, and the risk for all brain injuries including concussion was doubled. The authors do not imply that facial fractures cause traumatic brain injury, but suggest that blunt impact with enough force to break facial bones could also produce brain injury. These results disagree with the previously reported decreased risk of traumatic brain injury in patients with facial fracture. This study only examined one population, bicyclists who crashed, so the authors cannot comment on other mechanisms of injury that are reported as causes of facial fractures such as motor vehicle crashes or assaults. This case-controlled study shows no evidence that facial fractures are protective of traumatic brain injury.H. PATINO Reprints request to Dr Rivara: Department of Pediatrics and Epidemiology, Harbor View Injury Prevention and Research Center, Box 359960, 325 Ninth Ave, University of Washington, Seattle, WA 981042499; e-mail: [email protected] The Lacrimal Keyhole, Orbital Door Jamb, and Basin of the Inferior Orbital Fissure: Three Areas of Deep Bone in the Lateral Orbit. Goldberg RA, Kim AJ, Kerivan KM. Arch 0phthalmo1116:1618,1998 Traditional lateral orbital decompression surgery, used to treat Graves orbitopathy, is limited in the degree of orbital expansion that can be achieved. Previous studies calculating increases in orbital volume or the degree of reduction of proptosis after traditional lateral decompressions showed that adequate volume expansion could not be achieved with the traditional technique. However, additional orbital expansion may be gained if the thicker, deep areas of the lateral wall are removed. The authors calculated the volume of bone in three areas of the deep lateral orbit that are available for removal in decompression surgery. Also, a threedimensional computer reconstruction of an orbital computed tomography (CT) scan was created demonstrating these three areas. The designation of these three areas of bone in the lateral orbit-the lacrimal keyhole, the sphenoid door jamb, and the basin of the inferior orbital fissure were conceptual rather than anatomical structures. These three areas of orbital bone were analyzed by measuring preoperative and postoperative orbital volumes and predicted bony expansion volumes in nine patients (17 orbits) who underwent deep lateral decompression surgery. Orbital volumes were measured by means of digitized CT scans. Eleven normal orbits were also studied to estimate the amount of potential bone available in the deep lateral orbit. A threedimensional computer reconstruction of an orbital CT scan
was created, and the three areas of potential bone were demonstrated within it. The average volumes of the basin of the inferior orbital fissure, the sphenoid door jamb, the lacrimal keyhole, were 1.2,2.9, and 1.5 mL respectively, and the total of the three regions was 5.6 mL. A significant amount of interpatient variability, especially for the doorjamb region, was found. More volume expansion was achieved through the coronal approach versus the eyelidcrease approach. Orbital decompression surgery of the deep lateral wall can provide adequate volume expansion and reduction of proptosis because of the amount and location of potential space that exists in the three areas of deep bone.-A.J. LIBUNAO Reprint requests to Dr Goldberg: 100 Stein Plaza, Los Angeles, CA 90095-7006. Detection of Serum Antibodies Against cytomegalovirus, Varicella Zoster Virus and Human Herpesvirus 6 in Patients With Recurrent Aphthous Stomatitis. Ghodratnama F, Wray D, Bagg J. J Oral Path01 Med 28:12, 1999 For many years there has been interest in the possible role of viruses, particularly the herpes group of viruses, as an etiologic factor in recurrent aphthous stomatitis @AS). The aim of this study was to examine the involvement of human herpesvirus(HHV-6), cytomegalovirus, and varicella zoster virus (VZV) in RAS by detection of specific IgG and IgM class immunoglobulins against these viruses. In this study, sera from 22 patients with RAS, 24 patients with oral lichen planus (OLP), and 15 healthy controls were screened for IgG and IgM class antibodies to human cytomegalovirus @XV), VZV, and HHV-6. Commercially available enzyme-linked immunosorbent assay and immunofluorescence kits were employed. There were no significant differences in the prevalence of IgG antibodies to HCMY, VZV, or HHV-6 among the three patient groups. However, specific HHV-6 IgM was detected in 21 (95%) of the RAS patients and 17 (71%) of the lichen planus patients compared with 8 (53%) of the controls. This difference between RAS patients and controls was statistically significant. In conclusion, The results of the serological investigations presented in this study provide no evidence to support HCMV or VZV as an etiologic agent in RAS. Although there are no established clinical manifestation of HHV-6 infection in the oral cavity, RAS may prove to be one of the features of HHV-6 reactivation.-N. ASSUDMI Reprint requests to Dr Ghodratnama: Glasgow Dental Hospital and School, NHS Trust, Glasgow, Scotland. How to Select Counsel Defense: The Plaintiffs Plast Surg 26:79, 1999
and Participate in Your Own Perspective. Horan DW. Clin
From the plaintiff’s perspective, the counsel who represents a defendant during the discovery and trial phase of the lawsuit is an extremely important determinant of the outcome of the litigation. The most desirable lawyer will be the one who is an experienced partner who has already tried at least five lawsuits to verdict. Most defense law firms have only a handful of such experienced litigators. The doctor’s only consideration when a lawsuit is filed against him, is to get the best possible representation. Meet with your attorney as soon as possible, have a list of questions ready, determine whether your interest or that of the insurance carrier is in mind primarily, and perhaps hire your own attorney.-R.H. HAUG