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Biomedical subjects

H F Biller

Publications and source records attributed to H F Biller.

At least 55 records · Page 3Linked to original sources
PubMed1993

Extended osteoplastic maxillotomy. A versatile new procedure for wide access to the central skull base and infratemporal fossa.

Extended osteoplastic maxillotomy provides wide, direct exposure of the lateral and/or central skull base. This procedure, developed in cadavers, has been used successfully in six patients. Briefly, the maxillofacial skeleton is partially exposed via a Weber-Fergusson incision. Osteotomies in the maxilla and zygoma completely disengage the maxilla from the facial skeleton. The maxilla is mobilized on the skin and soft tissues of the ipsilateral cheek, maintaining its vascularity. Medial positioning of the anterior osteotomy through the face of the maxilla determines the extent of exposure to the nasopharynx. The lateral osteotomy can be placed anteriorly at the malar eminence or posteriorly to include the glenoid fossa, thus determining the extent of exposure to the infratemporal fossa. Concurrent use of a pterional or temporal craniotomy provides corresponding access to the cranial cavity. Miniplate fixation of the maxilla and zygoma reestablishes skeletal contour. This new, versatile procedure can be used for benign and malignant lesions of the nasopharynx and infratemporal fossa, particularly in those patients requiring preoperative or postoperative adjuvant therapy.

Craniotomy↗
PubMed1993

The innervation of the human larynx.

OBJECTIVE: To investigate the gross anatomy of the recurrent and superior laryngeal nerves (RLNs and SLNs) in 10 human larynges. METHODS: Whole larynges were processed to clear all soft tissue while leaving nerves stained. Then the main laryngeal nerves and the muscles they innervate were dissected and analyzed. RESULTS: It was found that in all larynges the RLNs and SLNs are connected by nerve branches other than Galen's anastomosis. The most consistent connection is in the interarytenoid muscle, where RLNs and internal SLNs combine in a neural plexus. A less consistent connection occurs in the piriform fossa, where a continuation of the external SLN passes from the cricothyroid muscle to the thyroarytenoid muscle. CONCLUSION: Based on these findings it is proposed that there are significant neural connections between the RLN and SLN systems. In addition, limited cross-innervation is seen from side to side in the area of the interarytenoid muscle. Other findings concern the innervation patterns within the laryngeal muscles. The posterior cricoarytenoid, cricothyroid, and thyroarytenoid muscles all appear to be composed of separate bellies based on the configuration of their nerve supply. Most notable is the region of the thyroarytenoid muscle at the vocal cord margin that is innervated by a nerve plexus of extreme complexity. The details of the innervation patterns suggest functional differences within and between laryngeal muscles.

Acetates↗
PubMed1993

A technique for displaying the entire nerve branching pattern of a whole muscle: results in 10 canine posterior cricoarytenoid muscles.

There is anatomical and histological evidence for three functionally distinct muscle bellies in the canine posterior cricoarytenoid (PCA) muscle. This study attempted to define the exact nerve branching pattern to each muscle belly in 10 dogs using a modification of Sihler's neural staining technique. The results are presented here as photographs and schematic nerve maps which illustrate the following points. 1. the final terminal branches within the PCA do correspond to the three bellies of the PCA; 2. the initial nerve branch to the PCA is usually composed of multiple fascicles which rearrange before their final branching to the three bellies; 3. there is tremendous variability of the nerve branching patterns including bilateral asymmetry within the same animal; 4. the terminal branching within each belly can be surprisingly complex and contain multiple anastomoses; 5. the fast- and slow-twitch bellies of the PCA have different terminal branching patterns. These results support the functional subdivision of the canine PCA into three distinct neuromuscular compartments. This microanatomical technique appears useful for studying the basic neuromuscular organization of laryngeal muscles and their developmental and pathological changes.

Animals↗
PubMed1993

The three bellies of the canine posterior cricoarytenoid muscle: implications for understanding laryngeal function.

The posterior cricoarytenoid (PCA) muscle is known to be active during phonation and respiration. The presence of muscle compartments (bellies) that might subserve these functions was investigated in the canine PCA by anatomical dissection and muscle fiber histochemistry. Five PCA muscles were microdissected and the origins and insertions of all muscle bundles were recorded. An additional six PCA muscles were frozen, sectioned, and stained for adenosine triphosphatase (ATPase) activity. The total number of fast- and slow-twitch fibers were counted and their proportion was determined for each region of the muscle. The PCA muscle was found to contain three distinct neuromuscular compartments. The vertical compartment is oriented at 24 degrees from true vertical, inserts on the lateral aspect of the muscular process of the arytenoid, and is composed of 65% type 2 (fast) muscle fibers. The oblique is oriented at 44 degrees from vertical, inserts on the top of the muscular process of the arytenoid, and is composed of 77% type 2 muscle fibers. The horizontal is oriented at 63 degrees from vertical, inserts on the medial aspect of the muscular process of the arytenoid, and is composed of 59% type 2 muscle fibers. The cricoarytenoid joint is capable of three arcs of motion and the physical arrangement of each compartment appears to correspond to each of these motions. Moreover, the histochemical profiles show that the activity of the three bellies is quite different. These results suggest that the different compartments of the PCA perform distinctive motions during phonation and inspiration.

Adenosine Triphosphatases↗
PubMed1993

Access to the central skull base via a modified le fort I maxillotomy: the palatal hinge flap.

We describe a modification of the standard Le Fort I maxillotomy in favor of a unilateral palatal hinge flap. Used in combination with a partial medical maxillectomy, submucous resection of the nasal septum, and contralateral inferior turbinectomy, this approach provides direct access to the entire nasal cavity, ipsilateral maxillary antrum, pterygopalatine fossa, nasopharynx, clivus, and first two cervical vertebrae. Use of the palatal hinge serves both to maintain palatal vascularity and eliminates the need for intermaxillary fixation. Facial incisions are avoided through a midfacial degloving approach. A variety of other surgical techniques used to access the central skull base are critically reviewed and compared with this new technique.

Journal Article↗
PubMed1993

Prolongation of secondary critical ischemia time of experimental skin flaps using UW solution as a normothermic perfusate.

A myriad of investigations have been published on the pharmacologic manipulation of flaps to enhance tolerance to ischemia. We recently reported a threefold increase in ischemic tolerance of the rat abdominal skin flap pedicle after 6 hours of primary ischemia and 12 hours of reperfusion. Flaps underwent normothermic perfusion washout with lactated Ringer's or U.W. solution, a newly developed organ preservation medium. Perfusion washouts were performed at one of three different points in the protocol: (1) onset of primary ischemia; (2) onset of secondary ischemia; or (3) 2 hours after onset of secondary ischemia. The last group was used to simulate the clinical situation in which flaps are discovered and salvage procedures instituted at a delayed time interval. This is the longest normothermic ischemic interval reported. We undertook the present study to determine the utility of the U.W solution in prolonging the tolerance of the flap to a second ischemic insult after a period of reperfusion. Seventy-five unilateral rat abdominal skin flaps were raised. Secondary ischemia was produced by placing a microvascular clamp across the inferior epigastric pedicle. Flap survival was assessed at 1 week postoperatively. While none of the nonperfused flaps survived 8 hours of secondary ischemia, at least 50% of the U.W. perfused flaps survived an average of 14 hours of secondary ischemia. Lactated Ringer's perfusion washout only modestly increased the ischemic tolerance. Perfusion washout in the secondary ischemic phase improved the ischemic tolerance to a significantly greater degree than in the primary ischemic interval.

Adenosine↗
PubMed1993

Hemodynamics of the rodent abdominal skin flap following primary ischemia.

The effect of varying periods of ischemia and reperfusion times on subsequent blood flow was studied in the rodent abdominal skin flap. Using perfusion fluorometry, measurements of blood flow were quantified in 60 Sprague-Dawley rats undergoing clamp-induced ischemic periods ranging from 0 to 6 hours and reperfusion times ranging from 2 to 8 hours. Flaps subjected to ischemia times of 0, 2, 4, or 6 hours require 8 hours of reperfusion time before reaching baseline levels of blood flow. Blood flow in flaps subjected to 6 hours of ischemia was statistically less than the flow in flaps ischemic for 0, 2, and 4 hours and was directly related to length of reperfusion. These results demonstrate that flap perfusion does not fully take place immediately after clamp release. The factors thought to be responsible for these findings and the implications for the design and interpretation of flap ischemia experiments are discussed.

Abdomen↗
PubMed1993

The intramuscular nerve supply of the human lateral cricoarytenoid muscle.

The lateral cricoarytenoid (LCA) muscle is one of the adductors of the vocal cords; however, some investigators believe that the lateral edge of the muscle may be involved in abduction. The possibility of functionally distinct compartments within the LCA was investigated by observing the pattern of the intramuscular nerve supply. This technique has previously clearly demonstrated neural compartments in the posterior cricoarytenoid, thyroarytenoid and cricothyroid muscles. Five adult human larynges were processed by the Sihler's stain which clears all soft tissue while counterstaining the nerves. The results of our study showed that the innervation pattern of the human LCA muscle is composed of a homogenous nerve plexus localized to the middle region of the muscle. This pattern correlates with the location of motor endplates described by prior investigators. The consistent neural pattern suggests that the LCA is composed of a single neuromuscular compartment.

Adult↗
PubMed1992

New approach to the management of airway obstruction in "high risk" neonates.

Epignathus is a rare tumor of newborns that is associated with a high mortality secondary to airway obstruction in the neonatal period. Due to recent advances in prenatal ultrasound and magnetic resonance imaging techniques, accurate in utero diagnosis of this rare teratoma will enable the health care team to prepare for "emergency" management of a difficult airway. We present a case of a newborn with a large epignathus diagnosed prenatally who underwent tracheotomy with intact maternal-fetal circulation. After airway stabilization, maternal-fetal circulation was interrupted and the epignathus was successfully removed. To our knowledge, this is the first extrauterine surgical procedure successfully performed using this technique. A new approach to airway management in "high risk" neonates involving the cooperative efforts of pediatricians, neonatologists, anesthesiologists, and otolaryngologists is presented.

Airway Obstruction↗
PubMed1992

The superior trapezius myocutaneous flap in head and neck reconstruction.

The superior trapezius myocutaneous flap, based on the paraspinous perforating branches of the intercostal vessels, is generally not a first-line choice for reconstruction of head and neck defects. However, after wound breakdown following radical neck dissection and radiation therapy, the superior trapezius flap is extremely reliable for coverage of exposed major neck vessels. The flap was used in 30 patients undergoing lateral neck reconstruction. All 30 patients had undergone prior neck dissection and all but two had undergone prior radiation therapy. There were no flap failures. The superior trapezius flap is unique among other regional myocutaneous flaps presently in use in that it has a superiorly based pedicle, which reduces the problem of gravitational pull on the suture lines of severely unfavorable recipient beds. Another advantage of using the denervated muscle of this flap is that it imposes no additional functional loss. The deficiencies of this flap are primarily related to its limited arc of rotation, thereby precluding its use when resurfacing defects that extend beyond the midline of the neck. The reliability of the superior trapezius flap after neck dissection can be explained by the angiosome concept. Based on that concept, previous ligation of the transverse cervical vessels during a neck dissection serves to simultaneously stage this flap, thereby improving its reliability and potential surface area available.

Adult↗
PubMed1992

Quantitative mapping of the effect of botulinum toxin injections in the thyroarytenoid muscle.

Spasmodic dysphonia has been successfully treated by thyroarytenoid muscle injections of botulinum toxin (Botox) with dosages ranging from 0.625 to 25 U. In some patients, excessive paralysis with resulting breathiness and aspiration have been noted. In order to maximize the efficiency of Botox injections, the histologic effects of various Botox dosages were examined in the dog. Nine canine thyroarytenoid muscles were injected with 0.5 to 12.5 U of Botox. After 24 hours, the recurrent laryngeal nerve to the injected muscle was electrically stimulated in order to deplete the glycogen within the muscle fibers. Frozen sections of this muscle were then stained for glycogen. Those fibers that retained their glycogen were presumed paralyzed by the Botox injection. The extent of paralysis was found to be dose-related from 1.0 to 7.5 U. At 10 U and above the muscle was completely paralyzed. Spread of the toxin to the lateral cricoarytenoid muscle was seen at doses as low as 1.0 U. Clearly, doses less than 10 U appear sufficient for clinical paralysis.

Animals↗
PubMed1992

Combined infrahyoid and inferior constrictor muscle release for tension-free anastomosis during primary tracheal repair.

Although tracheal stenosis is not a common clinical entity, it still presents a significant management problem, despite recent endoscopic advances. Surgical correction by resection and primary anastomosis is the preferred treatment, provided the repair can be performed without excessive tension. Various release techniques have been described in order to achieve mobility and, thereby, a tension-free anastomosis. This article presents a combined infrahyoid muscle and inferior constrictor muscle release to assure maximum mobility of the laryngotracheal complex, thus allowing tension-free closure. A series of ten patients who underwent primary repair using the combined technique is presented, and the operative technique is described. The indications, age, length of stenosis, and minimum 1 year followup of these patients are presented, as well as perioperative management and complications. The success rate with this technique is 90%.

Adolescent↗
PubMed1992

The combined sensate radical forearm and iliac crest free flaps for reconstruction of significant glossectomy-mandibulectomy defects.

The loss of motor and sensory function of the tongue following ablative surgery has a devastating effect on oral function. At the present time, there is no way to restore lost tongue musculature following partial glossectomy. The use of sensate cutaneous flaps has been shown to restore sensory feedback to reconstructed areas of the oral cavity. No single composite flap supplies a sensate soft-tissue component together with an osseous component of sufficient bone stock for functional mastication. In this article, the combination of the radial forearm free flap with the iliac crest osteocutaneous or osteomyocutaneous free flap is reported. The radial forearm free flap was used to resurface the resected portion of the tongue to provide maximum mobility and sensation. The lingual nerve was the recipient nerve for anastomosis to the antebrachial cutaneous nerves in all but one case. The iliac bone was used to reconstruct the mandible, with the iliac skin paddle or the internal oblique muscle used to reconstruct the neoridge. This combination of flaps was used in 10 patients. There was one flap failure due to vascular kinking from "piggybacking" the iliac crest to the distal end of the radial forearm flap. As a result, the use of two separate sets of recipient vessels is now advocated. Although a single composite free flap offers an excellent form of oromandibular reconstruction in most cases, it has been shown that oral function deteriorates when large areas of anesthesia are present in the oral cavity. We believe that this combination of two free flaps offers an opportunity for superior function in select patients with significant glossectomy and/or large mucosal defects.

Anastomosis, Surgical↗
PubMed1991

The lower trapezius island musculocutaneous flap revisited. Report of 45 cases and a unifying concept of the vascular supply.

The lower trapezius island musculocutaneous flap is valuable in head and neck reconstruction. It offers thin, pliable tissue and a long arc of rotation to reach virtually any defect in the head and neck. Recent reports have shown unacceptably high rates of failure and have questioned the reliability of the vascularity. We report our experience with 45 reconstructions using the lower trapezius island musculocutaneous flap. The literature is reviewed and the vascular anatomy is described in detail. The concept of angiosomes is applied to the trapezius muscle to help explain the reasons for flap failure and to provide guidelines for flap design and harvest.

Face↗
PubMed1991

Oromandibular reconstruction using microvascular composite free flaps. Report of 71 cases and a new classification scheme for bony, soft-tissue, and neurologic defects.

We describe 71 cases of oromandibular reconstruction using microvascular composite free flaps. There was an overall flap success rate of 94%, while 97% of the patients in this series had their mandibles reconstructed with free vascularized bone flaps. Fifteen patients were rehabilitated with implant-borne dental prostheses. Primary repair of discontinuity defects of the inferior-alveolar nerve using a variety of nerve grafts was performed in 16 patients. A new classification scheme for composite defects of the oral cavity involving bone, soft tissue, and neurologic defects is proposed and applied in the description of each of the patients in this series.

Adult↗
PubMed1991

The rectus abdominis free flap in head and neck reconstruction.

The rectus abdominis musculocutaneous free flap, based on the deep inferior epigastric artery and vein, has been used widely in reconstruction of the breast and extremities. The number of reports on its applications in the head and neck is limited. The rectus abdominis free flap is one of the most versatile soft-tissue flaps. The deep inferior epigastric artery and vein are long, large-diameter vessels that are ideal for microvascular anastomoses. The area of skin that can be transferred is probably the largest of all flaps presently in use. The versatility of this donor site is due to the ability to transfer large areas of skin with varying thicknesses and varying amounts of underlying muscle. We have successfully used this flap in 15 consecutive patients to reconstruct defects of the neck, face, mouth, pharynx, skull base, and scalp. No major complications involving either the recipient or donor sites occurred. The literature on the use of the rectus abdominis flap in head and neck reconstruction is reviewed in detail. The advantages and disadvantages of this soft-tissue free flap are thoroughly discussed in an effort to better define its proper place among the reconstructive options available to the head and neck surgeon.

Adult↗