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• Careful preoperative and postoperative photographs are an essential part of facial plastic surgery for medical and legal documentation, publication, patient education, and lectures. Computers play an increasing role in many aspects of the medical practice. A method of filing photographs and procedures and a related data base system allows rapid access by multiple factors, including name, procedure, age, surgeon, assistants, anesthetic, complications, dates of all photographs, multiple procedure subheadings, and so on. Additional variables can be added as a data base for analysis of operation results and postoperative recall of patients. This system is based on a personal computer (IBM-PC Computer) and readily available software. The system allow simple entry and retrieval of photographs on any of the multiple variables. We found it to be a superb adjunct to photography in facial plastic and reconstructive surgery. ( Arch Otolaryngol 1985;111:178-181)

The forerunners of the midline forehead flap date back to ancient India. The flap, as modified in this presentation, is often the treatment of choice for reconstructing significant full-thickness defects of the nose. The flap described is designed as a musculocutaneous flap incorporating skin, subcutaneous tissue, muscle, and aponeurosis. The enhanced vascularity of this flap allows precise thinning and tailoring at the distal end. A stepwise description of flap design is outlined.

• Ptosis of the brow is a significant and often unrecognized portion of aging of the upper face. It contributes to both cosmetic and functional aging. Correction is often mandatory prior to blepharoplasty in that functional problems may be worsened without elevating the brow. Direct and coronal browlifts are the most common approach to the problem. Midforehead browlifts have been reserved for men with receding hairlines. We have, for the past three years, performed midforehead browlifts on all our patients needing ptotic brow correction. Our review of 72 patients treated in this way, including 52 women, shows excellent and long-lasting cosmetic and functional improvement. There have been few complications, and the resultant incisional scars have been very well accepted. Therefore, we feel that the midforehead browlift, performed as we describe, is the ideal surgical correction for the ptotic brow. ( Arch Otolaryngol Head Neck Surg 1989;115:163-168)

Conventional closure of surgical defects in skin may cause unsightly protrusions (dog ears). Fusiform excisions with angles of 30 degrees or less reduce protrusion but may require excision of larger volumes and lengths of healthy skin and subcutaneous tissue than may be desirable. M-plasties reduce these requirements while still allowing use of 30 degrees angles at maximum. Applications and technical details are described and illustrated.

Many surgical procedures in otolaryngology, particularly those in the areas of facial plastic surgery, are best performed under a local anesthetic. The majority of these procedures may be done on an outpatient basis and require an intravenous analgesic of some form. This analgesic must be safe, predictable, easy to administer, have a rapid onset, and provide good amnesia. A short recovery period is imperative. Diazepam has been widely used in the outpatient setting, since it generally fulfills the requirements listed. However, the recovery time is often prolonged and unpleasant for the patient. Butorphanol tartrate, a synthetic narcotic, provides rapid analgesia in an intravenous dose, fulfills the other requirements for an analgesic agent suitable for outpatient use, and has a relatively short duration. Butorphanol tartrate has been used in an intravenous drip form for outpatient surgical procedures for the past 18 months. Its use in 400 cases representing a broad spectrum of facial plastic procedures has been closely monitored in both the operative and postoperative periods and the results tabulated. We have found butorphanol tartrate to be an excellent agent for local anesthetic procedures in the outpatient setting.

The face lift alone is seldom adequate treatment for the aging face. Rhinoplasty, brow lift, and blepharoplasty frequently are done to enhance the effect of the face lift itself. Other procedures must be considered for treatment of specific areas of the face. A presentation of the authors' techniques for dealing with these areas is given. A general presentation of make-up techniques and overall skin care is included as a guideline for the staff of the surgeon dealing with the aging face. Proper make-up, hair styling, and skin care can greatly aid the patient in enhancing her self-image.

A study of 13 patients with laryngeal papillomas is presented, with an analysis of epidemiologic factors, electron microscopic study of the lesion, and therapeutic trial of frequent microlaryngoscopic surgery and application of idoxuridine. Five of the nine children in this group were delivered by mothers who had condyloma accuminatum at time of delivery. These five children developed symptoms and required surgery much earlier than the other four. This correlation is shown to be statistically significant. The electron microscopic study of tissue specimens from all our patients failed to find any actual virus particles. The comparison study with skin and genital warts, however, showed ultrastructural details linking the three lesions. Results of the therapeutic program showed an overall improvement in frequency of recurrence, but no complete cures. This improvement is felt to be related to frequent complete surgical excision, and not to application of idoxuridine.

Summary Argon laser photocoagulation has become the treatment of choice for vascular cutaneous lesions of the head and neck. In children under age 12 years the results have been poor in more than 50% of cases. This is the result of limited response and increased risk of hypertrophic scarring. Except for infants with complications of capillary hemangiomas of infancy we would not recommend argon laser treatment in children under the age of 12.

• The Shaw heated scalpel is now widely used in head and neck surgery because it provides better hemostasis intraoperatively. Concerns persist over the immediate and long-term effects of this instrument on wound healing. This study compares heated and unheated Shaw scalpel incisions in the skin of 7-week-old piglets. Tensile strength measurements and histologic evaluations were made at frequent intervals up to nine weeks after incision. Histologic studies showed no differences in the two groups at any time in the study. Tensile strength of wounds was significantly less two weeks after incision in the Shaw scalpel group, but following that time, the wounds increased in strength, and by seven weeks, the two groups were equal in this respect. Thus, we conclude that the Shaw scalpel wounds in pigs are, ultimately, similar to standard scalpel wounds, although there is a period of diminished tensile strength. ( Arch Otolaryngol Head Neck Surg 1987;113:282-285)

• We used a Dacron-urethane mesh tray filled with cancellous bone for mandibular reconstruction in 17 patients. Five patients with traumatic defects and two with benign tumors developed solid, functional mandibles. Among ten patients with squamous cell carcinoma, eight had successful reconstruction; one required a second procedure. Mandibles of two of three patients with osteoradionecrosis were successfully reconstructed, but only one of three primary reconstructions was initially successful. The Dacron-urethane mesh tray has the advantage of being stiff but malleable. It easily fits the defect, is radiolucent, and may be used either before or after radiotherapy. We recommend delayed reconstruction, adequate soft-tissue coverage, good immobilization of the mandible, no intraoral contamination, especially with osteoradionecrosis, and hyperbaric oxygen in patients who have been irradiated or have osteoradionecrosis. ( Arch Otolaryngol Head Neck Surg 1986;112:53-59)

A pair of temporal bones obtained from a thoracopagus conjoined twin revealed malformation of the facial nerve and vestibular fenestra (oval window) on one side, and underdeveloped petrous bone and aplastic inner ear apparatus on the other.

• Treatment of the protruding fat pads in the lower blepharoplasty is a problem for most surgeons performing this procedure. The problems usually encountered are reviewed, the lid anatomy discussed, and a method of correcting the defect without surgically interrupting the orbital septum is presented. Tightening of the orbital septum may be produced with proper application of electrosurgical current. A total of 364 cases have been done, with a maximum follow-up of 42 months. Results show that this provides a safe and effective method of achieving the desired improvement in the bulging lower lid. (Arch Otolaryngol1984;110:521-524)

In Reply .—We thank Drs Gates and Garner for their comments. It has been clearly shown that when used for intermittent claudication, the beneficial effect of pentoxifylline may take several weeks to become apparent. We do not know the effects of this drug in skin flap survival, and this may not necessarily be equivalent. Our study was designed after reports in the literature showing enhanced skin flap survival in rats, with pentoxifylline given seven to ten days postoperatively and starting 24 hours preoperatively or less. 1,2 We intended to extend similar treatment schedules in a different animal model, the domestic pig. We do agree that there is a potential clinical benefit of this drug and that it deserves further work. We cannot comment on the result of Drs Gates' and Garner's study since the animal model used was not mentioned. We look forward to seeing more articles regarding work with

Although all the consultants agreed that this patient deserved to be treated, they disagreed as to the method. Dr. Wise suggested excision of the scar with postoperative irradiation. Dr. Thomas would excise the scar, inject the lesion with steroids intraoperatively and postoperatively, and apply a pressure dressing. Dr. Cook would not operate at all and favored intralesional injection of steroids. When used, Kenalog was the steroid preparation of choice. Dr. Wise would not use steroids in this situation because of the possible complications of skin atrophy, change in pigmentation, and telangiectasias. Dr. Thomas would avoid low-dose irradiation for fear of inducing a head and neck malignancy. Dr. Cook would avoid all surgical intervention, believing that it would only compound the present problem. All consultants agreed that the patient deserved close follow-up, and that he was at risk for similar scar formation in the future. They also pointed out the genetic predisposition for his offspring to have similar problems.

• Gillies' corner stitch (GCS) has been generally accepted for closure of skin flap tips because it is commonly believed that this stitch provides the best chance for survival of a flap tip that may have a compromised blood supply. There are no experimental data, however, to support such an assumption. To test the hypothesis that other stitches might be equally efficacious, we evaluated flap tip survival after closure with two different suture techniques, the GCS and a vertical loop stitch (VLS). Factors used to evaluate flap tip viability were the measurement of RBC movement in the flap tip by laser Doppler technique and measurement of the length of flap tip necrosis. In our model, the GCS is not superior to the VLS in terms of flap tip survival. ( Arch Otolaryngol 1984;110:450-453)

A thorough review of basic concepts of surgery of the cleft nose was presented by Robert Bumsted, MD, at the spring scientific meeting of the American Academy of Facial Plastic and Reconstructive Surgery in Denver. The author reviewed a series of 200 cases that occurred over a ten-year period. He performed maneuvers to enhance columellar length and to reposition the alar base at the time of the primary cleft lip repair at approximately 10 weeks of age. Alar base implants of irradiated autogenous cartilage are inserted intraorally with extreme overcorrection of the alar base support. Septoplasty and turbinate resection surgery are performed at the age they become necessary for maintenance of adequate nasal airway. The ultimate rhinoplasty repair work during the teenage years is performed through an external rhinoplasty approach with total freeing of the lateral crura from vestibular skin and an asymmetrical V-to-Y columellar lengthening procedure. The overall surgical

Michael D. Maves, MD, Janusz Bardach, MD, D. Bradley Welling, MD, and David E. Schuller, MD, of the University of Iowa (Iowa City) reported the fate of irradiated homologous cartilage when used in various surgical procedures to reconstruct the face. This is a follow-up of a group of patients described by Schuller et al in 1977, and it was presented at the spring scientific meeting of the American Academy of Facial Plastic and Reconstructive Surgery in Denver. These workers reported a ten-to 15-year assessment of approximately 40% of patients from the original series who had undergone graft implantation. The authors report that checkup at up to ten years after the implant showed 28% of the grafts underwent total reabsorption of the grafted implant. In the 11-to 16-year period, however, the astonishing total of 75% of the grafts became totally reabsorbed. The numbers involved in the study are certainly adequate to

In Reply.—We thank Dr Velanovich for his comments on the statistical analysis in our report. He brings up good points, none of which we can argue with. We did treat each flap as an independent unit, knowing that this may or may not be justified. In interpreting our results, we were careful not to state that the results in the control and study groups were the same. We stated only that there was not a statistical difference in results, which does not necessarily mean the results are the same, as pointed out by the beta coefficient. We are happy to see interest in this drug and hope to see in the literature that more work has been done with pentoxifylline.