Patrick R. Burns, DPM, FACFAS

• Clinical Assistant Professor of Orthopaedic Surgery
• Division of Foot and Ankle Surgery
• University of Pittsburgh School of Medicine
• Director of Podiatric Surgical Training
• University of Pittsburgh Medical Center South Side Hospital
• Pittsburgh, Pennsylvania

Patients should be advised that rejuvenation survey will Hturn the clock back" but will not stop the aging process pain treatment of herpes zoster purchase benemid in united states online. Patients seeking a face-lift should be advised that it will not alter the appearance of the upper face iasp neuropathic pain treatment guidelines buy discount benemid 500mg. Skin Type Fair- and thin-skinned patients usually heal with more ideal scars than those with darker and thicker or sebaceous skin advanced diagnostic pain treatment center generic benemid 500 mg overnight delivery. Older patients often have finer scars than do younger patients because of their decreased skin elasticity pain treatment for rheumatoid arthritis quality 500 mg benemid. Surgery may not always be indicated; other methods may be used to correct a specific defect that is of great concern to the patient or to temporize until the patient is a better candidate for surgery acute neck pain treatment guidelines 500 mg benemid amex. Sun avoidance and protection will prevent photodamage to the skin and help prevent squinting and thus decrease vertical glabellar rhytids knee pain treatment guidelines 500 mg benemid with amex. Asymmetries It is documented that 97% of all patients have facial asym- metries (7). Styling the hair over the forehead will camouflage rhytids, although it usually cannot camouflage brow ptosis. Additionally, Botox can be injected into the lateral brows to provide several millimeters of elevation. Specifically, patients should be counseled about the general and local oomplications associated with the procedures they are contemplating, outlining the preoperative, postoperative, and swgical protocols in detail. Furthermore, although rejuvenation is achieved, aging continues and cannot be stopped or r~. The coronal lift is especially useful for patients who have both generalized ptosis and rhyti. Relative contraindication& include men with male-pattern baldness and women with high hairlines. Due to the distance between the incision and the brow, the coronal lift and its modifications are not useful to correct static or dynamic brow asymmetries. Advantages of the open lifts are the well-hidden incision within and behind the hairline and excellent exposure of the forehead musculature, allowing aco. Disadvantages include elevation of the frontal hairline, although this is an advantage in patients with a low frontal hairline. Wide surgical Wldermining increases the risk for blood acaJmulation, and tension on the wound closure may predispose to temporary or permanent hair loss, especially if the wound is not meticulously closed in multiple layers. Coronal Forehead Lift the coronal lift and its modifications are arguably the procedures of choice for rejuvenation of the upper face. Numerous recent reviews have validated its efficacy, safety, longevity, and high degree of patient satisfaction Technique the procedure is done Wlder either local intravenow sedation or general anesthesia. Note Ute hyperdynamic elevation of the brovn commonly observed in pmients with brow ptosis. B: One year following coronal forehead lift, upper and lower blepharoplasty, and deep plane face- and neck lift. C: Four years following the above-mentioned procedures-note the longevity of the open forehead lift. A curvilinear incision about 4 to 6 em posterior to the anterior hairline is marked, and a thin strip of hair is removed along the incision line. Local infiltration of anesthesia of lidocaine 1% with epinephrine 1:100,000 and bupivacaine 0. Following this, a ring block is completed by following the supraorbital maigins, the zygomas, and the scalp at the incision site. Infiltration is completed in the subgaleal plane beneath the entire area of the flap to be elevated. Prominent vessels may be seen cowsing superiorly from the suprao:rbital vessels about 2 to 3 em superior to their origin. Dissection laterally must be carried down to the zygoma; this is most safely done with the blade handle and gentle blunt dissection just above the temporalis fascia. Myopluty is performed through blunt interfibrillar scissors dissection to identify and free the corrugator muscles from the supratrochlear and suprao:rbital nerves and vessels, which are multiple and course around the muscle. The flap is dissected over the suprao:rbital rims, releasing the arrus marginalis, but not so far as to expose o:rbital fat In this way the brow is freed so that it may be elevated above the supraorbital rims. Any bleeding is meticulously controlled with bipolar cautery, taking care not to injure any neiVes. The procerus in the midline is identified and incised horizontally using unipolar cautery. Caukrization is maintained medial to the pupils to prevent injw:y to the temporal branch of the facial nerve and also to preseiVe some natllral forehead movement through the action of to about 1 UffiF~. A portion of the corrugator superdllus Is excised, and the proc:erus and frontalis ar. Excision rather than incision of the procerus and frontalis muscles may lead to contour irregularities of the glabella and forehead. The temporalis branch of the facial nem: is at risk in the region between the brow and the temporal hairline as it ttaverses this area supe:romedially. The nerve is deep within the parotid gland but becomes superficial in the subdermal fat as it crosses the zygomatic arch. It then courses deeply again to piert:e the frontalis muscle about 2 em from the lateral canthus (5). Absolute hemostasis is secured, paying special attention to superficial temporal arter:y branches in the supraauricular region. Usually, about 12 to 18 mm of skin can be excised, although this will var:y with each patient Conservative excision is indicated to prevent an overele:vated and frightened look In females, more skin may be excised &om the temporal region to create a more lateral, feminine lift. The excision usually is extended laterally to 1 to 2 em above the anterior helical root A suction drain is placed through. Ophthalmic drops and ointment are prescribed for any indications of corneal exposure. The drain is removed on the first postoperative day, and swgical staples on day G andday8. Brow Lift and Upper Blepharoplasty A special relation exists between forehead lifting or brow lifting and upper blepharoplasty. Temporary lagophthalmos is common after brow lifting, and a concomitant upper blepharoplasty will increase the degree and duration oflagophthalmos. Aggressive postoperative ocular lubrication is necessacy until full closure of the palpebral fissure occurs. This is also because the blink reflex initially may be decreased, predisposing to diy eyes. Eyelid skin can be stored as a graft for up to 3 weeks and used as a full-thickness donor graft to its original site if eyelid closure is unsatisfactory. Patients are advised that a touch-up excision of upper eyelid skin can be performed 9 to 12 months later if necessaJ:Y, although. Patients who have had a previous upper blepharoplasty and require correction of eyebrow ptosis may be candidates for any of the brow-lifting procedures; how~ the surgeon must be careful to assess the degree of redundant upper eyelid skin, the status of the tear film, and the amount of skin excised for elevation. Bilateral Temple Lift and Lateral Brow Lifting the bilateral temple lift is indicated in men or women who primarily have lateral eyebrow ptosis and upper eyelid hooding. It is advantageous in that it does not elevate the central hairline, as does the full coronal forehead lift and, because of the scar position, can be used in both men and women. Howevet it does not allow myoplasty procedures of the forehead, and its somewhat confined exposure for elevation makes it difficult to control any bleeding vessels at the supraorbital maxgin, although increased adeptneu with endoscopy has somewhat ameliorated this problem. The temple ftap is redraped superolatcrally, and the redundant skin excised; it is usually about 10 mm at its widest. The galea is closed with 3-0 polyglycolic add antitension sutures, and the skin with surgical staples. The lateral browlift is indicated in patients with a lifelong appearance of downtumed lateral brows. Other patients who may benefit from such a lift are those who suffer from lateral brow ptosis primarily as a result of excess skin. Two dissection pockets are created-one lateral to the zone of fixation and one medial to it. Laterally, dissection is carried deep to the superficial temporal parietal fascia. The two pockets are then connected &om lateral to medial, using a periosteal elevator in a blind motion, sweeping superiorly. The superior and lateral attachments to the superior orbital rim must then be released either with direct visualization or with endoscopic guidance. Dissection laterally is performed similarly to the traditional endoscopic forehead techniques. This procedure then offers all the advantages of the coronal forehead lift but does not raise the anterior hairline to an unaesthetically high level. Furthermore, resection of the redundant forehead skin reduces the vertical height of the forehead, and this often provides impn:m! It is best used in women with thick hair who are prepared to wear their hair forward to camouflage the scar in the early healing stages. It can be used in men who are not expected to lose more hair or who might be undergoing or willing to undeJgO hair transplants to camouflage the scar further, although this is rarely necessaty as the incision usually heals vety well and rarely needs camouflage. Advantaga~ of the pretrichial lift are that it allows the same wide access to the forehead musculature as the coronal lift and thus allows correction of all the components of the aging forehead. Disadvantages include the necessity for meticulous technique to obtain the finest possible scar and possibility of postoperative scar camouflage being required. The ttlchophytfc lndslon Is an Irregular beveled lndslon made just posterior to the anterior hairline. It then follows a course jwt behind the anterior hairline as a W-plasty with the limbs about 5. Trichophytic Forehead Lift the trichophytic incision is currently our preferred technique when an open approach is utilized. Then it is beveled from posterior to anterior through the dermis and subcutaneow tissues to the subgaleal plane. This effectively deepithelializes about 2 mm of the leading edge of the posterior or hair-bearing:flap and preserves the underlying hair follicles, although their shafts are excised. Galeal sutures again are used for antitension, and the wound is closed with a running 6-0 nylon suture along the forehead skin junction and with staples within the hair-bearing scalp, taking care to prevent damage to hair follicles. With further hair growth from the hair follicles below the deepithelialized portion of the posterior flap, follicles will grow through the scar itself. The ttichophytic incision has the advantage of providing an improved scar but again requires meticulous execution to achieve the desired result Inaccurate incision placement or wound tension causing strangulation of the hair follicle vasculature will compromise the result. The scar heals so wdl that most patients can wear their hair back without scar camouflage once healing is complete. B: The yurs following trichophytfc forehead lift, deep plane face-lift, and neck lift. A Chapter 185: the Aging Forehead into the subgaleal plane and myoplasty is possible. This approach is indicated in men with receding hairlines and prominent deep forehead rhytids in which the scar can be camouflaged. This preserves the sensor:y supply of the forehead, which otherwise would be lost if the midforehead incision were deepened to the subgaleal plane. Access to the corrugator supercilii and procerus muscles is possible by developing a centtal subgaleal flap inferiorly. Myoplasty can be done if indicated, and the frontalis muscle can be divided between the supraoibital ner:ves. This approach does not permit the same extent of forehead muscle myoplasty as that in the coronal forehead lift. The inferior flap is redraped superiorly, and the redundant skin is excised to correct ptosis of the glabella and medial eyebrows. If the excision is extended laterally in the subcutaneous plane, some degree of elevation of the lateral eyebrows also can be achieved. In such cases, the procedure is comparable to the indirect brow lift or midforehead brow lift. Advantages of the procedure include a direct and close approach to the glabella without distortion of the hairline. It also allows myoplasty, but it does not offer improvement of the lateral brow region or upper forehead. Its major disadvantage is a potentially unsatisfactory scar and an inability to have 3065 a satisfactory lateral brow elevation; this is minimized by maldng the scar irregular rather than symmetrical, as it follows the crease line. Beause of the direct approadt, it is more useful than a coronal lift to correct brow asymmetries and also can be more effective to correct marked ptosis of the lateral eyebrow. It can be used unilaterally to improve facial nerve paresis functionally with suture techniques, biodegradable devices, or with autologous fascia (20). Technique the inferior incision for the direct brow lift is placed just within the moat auperior growth of:fine eyebrow hairs. It should not extend medial to the medial aspect of the eyebrow, as poor glabellar scarring may result. The incision should be carried lateral to the lateral eyebrow and extended horizontally laterally in a gentle arc. The superior ind&ion is carried in a gentle arch superiorly from its medial aspect to reach a high point betm:en the lateral limbu& and lateral canthus and then gently curved inferiorly to complete the excision. The superior incision defines the new position of the eyebrow, and the point of maximal height will determine the degree of masculinity (apex more medial toward the lateral limbus) or femininity (apex more lateral toward the lateral canthus) of the ultimate brow appearance. Minimal undermining i& done inferiorly, taking care not to injure the hair follicla, with 1 to 1. Four or:five permanent sutures are placed through the orbicularis muscle at the level of the &upraorbital margin; then this suspension suture is secured to the periosteum at the level of the superior incision. This latter suture is placed in a horizontal fashion to decrease the risk of injury to brancha of the fadal nerve.

The epidermis is the uppermost layer and contains five sublayers (in order from superficial to deep): stratum corneum allied pain treatment center new castle pa buy benemid 500 mg fast delivery, stratum lucidum low back pain treatment kerala buy benemid 500 mg on line, stratum granulosum inpatient pain treatment center order benemid cheap, stratum spinosum pain medication for dogs hydrocodone benemid 500mg free shipping, and stratum basale pain medication for dogs on prednisone purchase benemid on line. The main cells found in the epidermal layer are Merkel cells jaw pain tmj treatment purchase 500 mg benemid otc, keratinocytes, melanocytes, and Langerhans cells. The dermis is the middle layer and consists of a superficial papillary region and a deep reticular region. The papillary region contains loose areolar connective tissue, and the reticular region contains dense concentrations of collagen, elastic, and reticular fibers. The dennis contains many hair follicles, sweat glands, sebaceous glands, apocrine glands, lymphatics, and blood vessels. The subcutaneous tissue is the deepest layer of the skin and connects the dennis with the underlying bone or muscle-it supplies the underlying tissue with blood vessels and nerves. With conventional long-term tissue expansion, biologic creep occurs at all levels of the skin. The thickness either stays the same or is slightly increased, and the stratified structure is preserved (10,12, 13). The changes are temporary, and the microscopic appearance of the skin returns to normal within a year or two after the conclusion of expansion. In the dennis, there is significant thinning of approximately 30% to 50% (10,14,15). There is increased metabolic activity in the fibroblasts and melanocytes with enhanced collagen synthesis and melanin production, respectively. The number of hair follicles and the pattern of hair growth remain the same, but the density of hair follicles decreases. Individual follicles may be separated by a factor of two without producing noticeable hair thinning. Given normal hair density, the scalp can be expanded by two to three times its original surface area before a change in hair amount is evident. In the subcutaneous tissue, adipose tissue thins approximately 50% with loss of adipocytes (14,15). Vascular proliferation occurs with the growth of capillaries, venules, and arterioles (16). Nerves lengthen with conventional tissue expansion, but their function is impaired (17). A dense fibrous capsule forms around the expander and contributes to the vascularity. The capsule also contributes to contracture and shrinkage of the flap after the expander is removed (18). The expander capsule thickness does not correlate with expander volume, location, or patient age (10). In the head and neck, common applications include use in posttraumatic or postoperative alopecia, male pattern baldness, expansion prior to major reconstruction, congenital microtia, and large or giant melanocytic nevi (19-21). Tissue expanders have been used in the scalp, forehead, ear, nose, cheek, and neck. The measurement of expanded flap width is measured across the base of the expander. Ttssue expansion works best in locations where there is solid bony support under the expander balloon device, such as the scalp and forehead. Approximately 50% of the scalp can be reconstructed with the use of tissue expansion (24). Use of tissue expandm for auricular defects is limited by the lack ofadequate non-hair-bearing soft tissue in the adjacent area. H~ some surgeons do use tissue expanders in the forehead prior to elevating and transposing a forehead flap. In the cheek and neck, the skin is relatively thin and there is potential for damage to the facial nerve and Wlderlying musculature with tissue expansion. Smaller volume expandm and longer-term expansion can be used to minimize complications. The arguments for extmlal ports are that they require less dissection, have painless port access, and allow for earlier detection of leaks. Tissue expanders can also be classified by twodimensional or three-dimensional expansion. Twodimensional linear skin sttetchm consist of a Dacron strip with hooks on both ends that are prestretched and placed under the previously elevated skin:Oaps-a. Two-dimensional expansion creates forces by pulling the perimeter away from the centtal portion of skin being stretched (10). Rectangular-shaped expanders are able to achieve a gain of 38% in tissue surface area. Crescent-shaped expanders are able to achieve a gain of 32% in tissue surface area (25). Tissue expanders vacy in size &om 1 to 1,000 mL, with head and neck tissue expanders usually varying from 1 to 250 mL. The stages of the tissue expansion process include selecting the ideal expander, inserting the expanda;. In selecting the most ideal expander for the patient, it is important to consider the size ofthe defect, location of the defect. General Chapter 175: Tissue Expanders principles include using the hugest possible expand~ and often more than one expander may be needed for large defects. A single l;uge expander is preferred over multiple smaller expand~ because this will give the greatest gain in tissue per volume of expansion and limit the number of operative sites. The incision for the placement should be as far from the expander as possible to prevent dehiscence during expansion and exposure of the device A small V- or U-shaped incision placed radially (perpendicularly) related to the direction of expansion is ideal (29). In the forehead, the tissue expander should be placed deep to the frontalis muscle In the face, the tissue expander should be placed superficial to the superficial muscular aponeurotic system. In the neck, the tissue expander should be placed superficial to the platysma muscle (30). The expander pocket should be dissected wider than the base of the expander in a blunt fdshion to presave the longitudinal bloody supply (4). Furthermore, the expander pocket must be large enough to allow the expander to lie completely flat without any folding, budding, or distortion. The expansion phase is often the most burdensome for the patient-both physically and emotionally. The interval and volume of expansion may vary by region and wound type Typially, 2 weeks are allowed for the wounds to heal after expander placement before the expansion phase begins. Expansion should be continued until the extended flap is approximately 20% lcuger than the size of the defect to account for tissue recoil during advancement. Inspection of the skin color (blanching), capillary refill, and direct palpation are routine when evaluating for further expansion. The final step in the process involves removal of the tillsue expander device and simultaneous reconstruction with the expanded flap. Case2 A 38-year-old woman with a neck scar from a bum injw:y as a child who had Wldergone previous revision and laser treatment with p~istent scar deformity. An incision is made in the right posterior scalp, and a subgaleal pocket was created. A large owl-shaped 1issue expander was selected to fill the planned defect site (A). The phases are the same-selecting the ideal expander, inserting the expander, expanding the expander, and removing the expander with reconstruction. There are no physiologic or metabolic changes that are seen in the setting of conventional long-term tissue expansion. A gain of 1 to 3 em of flap length can be achieved, depending on the site of expansion. Critics of this technique have claimed that rapid intraoperative tissue expansion is simply augmented Wldermining and tissue rearrangement (35,36). These complications include expander exposure or extrusion, skin necrosis or ischemia, numbness or weakness, infection, bone resorption, hematoma or seroma. Most authors would advocate that exposed expanders can be watched, with cessation of interval expansion. Ho~ it is often recommended that extrusion should be an indication for prompt removal If there is evidence of skin necrosis or infection, the tissue expander should be removed. Careful antiseptic techniques should be observed to minimize infection around the devices. It can provide additional skin with similar characteristics and aroid Winecessary donor site morbidity. The more traditional and commonplace conventional longterm tissue expansion relies on biologic creep and results in important physiologic changes at the epidermis, dermis, and subcutaneous tissue. Conventional long-term tissue expansion can be a lengthy process for both the patient and swgeon. The area over the hairy navus was shaved, and markings were made around the lesion site (A). The 1issue expander was dissected from the fibrous capsule, deflated, and removed (C). The expanded scalp tissue was advanced to the defect size-the incision dosed primarily laterallyand a small cantral area was left to granulate (D). The same patient during the expansion phase on frontal view (A) and side view (B). The tissue expander was dissected from the fibrous capsule, deflated, and removed (B). The expanded neck tissue was advanced to the defect size, and the incision was do9ed primarily (C). Intraoperative sustained limited expansion as an immediate reconstructive technique. Important physiologic changes in conventional expansion include increased mitotic activity and vascular proliferation. The scalp and forehead are optimal sites for reconstruction with tissue expanders. Stages of tissue expansion include insertion, expansion, and expander removal with simultaneous reconstruction. Complications occur in approximately 10% of cases, with the most common of being expander extrusion or exposure. The expansion of an area of skin by progressive distension of a subcutaneous balloon. Clinical and experimental evaluation of intermittent intraoperative short-term expansion. Quantitativi: analysis of the thickness of human skin and subcutaneous tissue following controlled expansion with a silioone implant Plast Reconstr Surg 1988;81:516-523. Increased survival and vasallarity of random pattern skin flaps elevated in controlled, expanded skin. Effect of capsulectomy on the hemodynamics and viability of random pattern skin flaps raised on expanded skin in the pig. External filling ports in tissue expansion: confirming their safety and convenience. Patel Scar camouflage constitutes one of the primary roles of the facial plastic surgeon, and in no other location of the body does this bear such aesthetic importance. The surgeon must possess a sound understanding of prevention and tissue handling techniques, as well as a fundamental understanding of wound healing and patient-specific risk factors in scar formation. This constitutes a challenging decision backed by a relative paucity of highlevel evidence. Well-designed, comparison-controlled trials ofvarious interventions are lacking for reasons including the following: (a) objective markers of scar improvement (colot; elevation. Despite these difficulties, strong trends do exist within the literature regarding surgical approaches to scar camouflage. Thus, the goal of this chapter is to provide the reader with a sound, evidence-based review of the available interventions for scar camouflage. The inflammatory phase (immediate onset lasting 2 to 5 days): this initially begins with hemostasis over the first 5 to 10 minutes via vasoconstriction and activation of the clotting cascade. Vasodilation follows and peaks at approximately 20 minutes before vascular tone returns to its baseline. Also beginning immediately, aggregating platelets and local phagocytic cells (predominantly neutrophils for the first 2 4 to 48 hours) release a variety of proinflammatory and chemotactic cytokines. These are the essential mediators of early wound healing and predominant cell type from 48 hours through the remainder of the inflammatory phase. The macrophages for their part phagocytize bacteria and damaged tissue and release their own milieu of cytokines, growth factors, and chemotactic agents. This subsequently promotes the arrival of fibroblasts, endothelial and epithelial cell migration, and wound contraction by myofibroblasts. The proliferative phase (day 2 through 3 to 4 weeks): Fibroblasts enter the wound around day 2, which signifies an overlap period of the inflammatoty and proliferative phases. As the inflammatory phase ends and macrophages decline in number, fibroblasts take over as the predominant cell type. Angiogenesis and wound contraction (both begin around day 4) follow and are mediated by endothelial cell migration and wound margin myofibroblasts, respectively. Reepithelialization also occurs during this phase through migration of epithelial keratinocytes from the wound margins and the bases of pilosebaceous subunits preserved in the wound at the level of the dermis. This underscores the importance of a moist wound environment that not only aids migration but also prevents excess scabbing that acts as a barrier to migration. Reepithelialization ceases when the opposing sheets of migrating epithelial cells meet and reestablish contact inhibition. The pathophysiology of this scar type is likely related to a hypoxic wound environment. Deregulation or interruptions of this wound healing process, including interventions by the surgeon, can lead to alterations in the scar that ultimately forms.

There are dearly patients who may require adjustment of expectations through more detailed counseling prior to considering surgery as their prognosis for attaining highlevel open-set speech perception might be more limited ankle pain treatment physiotherapy discount benemid 500mg with amex. Central nervous system disorders that might adversely affect normal brain function and thus performance with the implant could include previous stroke pain medication for dogs at petsmart buy generic benemid on line, degenerative diseases such as multiple sclerosis knee pain treatment by injection buy benemid 500 mg on line, dementia myofascial pain treatment center virginia cheap 500mg benemid with amex, tumors pain treatment and wellness center greensburg pa generic 500mg benemid mastercard, or infections pain medication for dogs post surgery cheap benemid 500 mg without prescription. With these caveats in mind, it is critical to recognize that setting appropriate expectations for potentially lower levels of performance are not contraindications to surgery. Rather, restoration of audition through cochlear implantation can result in dramatic improvements in quality oflife and daily function for these individuals but should be undertaken following appropriate counseling of expectations. In general, adults (~18 years) are required to have a moderate-to-profound hearing loss without medical contraindications and the desire to be a part of the hearing world. The results for aided speech perception testing vary by manufacturer and payer and are listed in Table 163. Prelingual children can be as young as 12 months of age, gain limited benefit from amplification, while being enrolled in an early intervention program. Older children with some degree of speech perception should also have specific speech perception testing results that are obtained while wearing appropriate amplification (Table 163. The reader should always seek up-to-date, detailed information on a case-by-case basis prior to considering candidacy. For young children, it remains critically important to recognize the importance of early intervention in the form of appropriately fit amplification and/or cochlear implantation in the development of speech perception, speech production, and spoken language (5). While these studies clearly document the fact that earlier is better, this must be balanced against the reality that cochlear implants, in their current format. With this in mind, it remains important to defer cochlear implantation until the age where developmentally appropriate behavioral audiometric results are valid (usually 7 to 9 months of age for visual reinforcement audiometry). One clear indication for very early implantation might include a history of meningitis with ongoing ossification. Irrespective of the type of intervention, early diagnostic and therapeutic auditorybased speech therapy is critical in assessing progress in spoken language development this single factor remains of paramount importance in deciding whether to proceed with implantation in the very young. Temporal Bone Imaging in Cochlear Implantation Diagnostic imaging of the temporal bone and brain is critical in patients considering cochlear implantation to (a) identify the etiology of hearing loss, (b) define surgical anatomy and the potential for complications or sequelae from surgery, and (c) identify factors that negatively impact upon prognosis for performance using the device. Cochlear obstruction can occur following previous cochlear inflammation in the setting of meningitis and the degree of labyrinthine obstruction that is due to ossification. Surgery for Cochlear Implantation Setup Cochlear implant swgay is performed under general anesthesia and typically takes between land 2 hours to complete. Patients with significant medical comorbidity should have a prior anesthetic risk assessment. A first-generation cephalosporin is sufficient as ear pathogens such as StreptDcoccus pneumoniae, Haemophilw infiuenme, and Pseudomonas aeruginosa should be unwual in routine cases. Receiver-Stimulator Placement and Fixation Following a skin incision, a subperiosteal pocket is created in the proposed region for the inte:rnal receiver-stimulator that is bounded inferiorly by the lambdoid suture and is Preparation the patient is situated in a supine position with the head turned to expose the postauricular region. Locating the receiver-stimulator too close to the pinna can result in unwanted interaction between the magnetic headpiece and the speech. Moreove:t placement too close to the mastoid can be problematic if skin retraction in to the mastoid results in unwanted device exposure. The use of manufacwrer-specific device templates prior to the incision can help locate the proper position. Focal injection of methylene blue through the skin and on to the bone allows for identification of the bony position for the internal device after skin elevation. Locating the device relative to the mastoid cavity following bony exposure can be ineffec:tive since mastoid size varies considerably among individual of all ages. The:final position of the receiverstimulator usually is significantly superior and posterior to the pinna. The long axis of the device creates roughly a 45-degree incline from the horizontal through the zygomatic arch. Chapter 163: Cochlear Implants and Other Implantable Auditory Prostheses 2633 strictly sized for the device being implanted (69). A bony depression can be created according to the device templates and the device fixed to bone by any one of a variety of methods (70). For adults, nearly all techniques are sufficient, while for children, simple suturing of the periosteum provides rigid fixation to bone and avoids intra- or transcortical drill holes or screws that might put the underlying dura or venous sinuses at risk (71). Electrode Insertion A smooth, resistance-free insertion of the proposed electrode array in to patent scala tympani is the goal of most implantations. The reader is referred to the individual surgical manuals for details regarding usage of the various devices. The facial recess is opened maximally using the horizontal semicircular canal, fossa incudis, chorda tym pan~ and facial nerve as landmarks. The round window niche overhang is initially identified as a bony, rounded ridge located inferior to the oval window niche and anterior-inferior to the stapedius tendon. The niche is always located posterior to Jacobson nerve on the cochlear promontory and 1 to 2 mm inferior to the oval window. It is very important to recognize that limited opening of the facial recess can result in an inferior view towards the hypotympanum with a resulting look at the air cell system rather than the promontory and round window region. Cochleostomy When describing the surgical technique for cochleostomy creation, one should keep the basic objectives in mind: open scala tympani (and not scala vestibuli), minimize collateral trauma to physiologically relevant intracochlear structures, and provide a relatively straight insertion trajectory along the longitudinal axis ofthe basal turn in an effort to allow for buckle-free electrode insertion. Currently, a variety of differing cochleostomy techniques exist that can be adapted to the clinical situation depending on the following: the electrode array to be used, the cochlear morphology, and the desire for hearing preservation (72). Such a cochleostomy is always round window related and might actually communicate with the round window membrane if higher insertion forces are not anticipated. For very long electrode arrays that are designed for complete cochlear coverage, a cochleostomy that has circumferential bony walls or a round window membrane insertion is acceptable. In these cases, cochlear length rather than cochleostomy location probably determines whether insertion resistance will be encountered. All devices have telemetry programs that allow for measurement of electrode impedances and electrically evoked compound action potentials. If a substantial number of circuits are found to be open, replacement of the device should be considered to insure that an adequate number of electrodes are available for stimulation. In such cases, the result of these measures has been shown to correlate with future performance on open-set speech perception measures (67,74). Moreovet; threshold determination for electrically evoked compound action potentials might identify a useful stimulation starting point for very young children. Special Surgical Considerations Inner Ear Malformations Congenital inner ear malformations are common (10o/o to 20%) among children undergoing cochlear implantation (75). Labyrinthine anomalies have the potential to adversely affect the electrode-neural interface, reduce electrode array insertion depths, predispose to cerebrospinal fluid gusher through the cochleostomy, and be associated with facial nerve anomalies that can create access problems for scala tympani. Similar to cases without malformations, a round window-related cochleostomy can usually be created. The bony overhang covering the actual window has to be removed to expose the actual membranous window. B: lllun-ation of typical insertion trajectories through the different round window alignments. In these cases, the window faces essentially posterior fadlltmlng a direct Insertion through the window. In these cases, the electrode can take a trajectory heading towards the bony modiolus. In such instanas, creating a largu cochlear opening and tightly packing connective tissue around the electrode array is sufficient Cerebrospinal fiuid divemion iJ not needed if the leak iJ controlled intraoperatively. Imaging that reveals a hypoplastic cochlea should be expected to have limited electrode insertion depths and for these cases, shorter arrays are helpful. Children with absent semicircular canals or external auditory canal atresia can create significant issues for cochlear access since the facial nerve is often times displaced anteriorly. Inner Ear Obstruction Cochlear obstruction can occur following inner ear infiammation from meningitis, immune-mediated ear disease, otitis media with labyrinthitis, or trauma. In these cases, the cochlear lumen can be narrowed or obliterated with fibrous tissue or bone. In cases of ongoing meningitis, intervention should be considered in the early stages so as to avoid total obstruction and inability to implant the ear(s) in question. The l~m~ral semicircular canal typically used as a surgical landmark cannot be used. Instead this single opening Into the cavity should allow the surgeon to curl the electrode Inside to generate an optimal electrode-neurallnterfaw. Approach to implantation of the obstructed cochlea should be considered in a stepwise manner. In cases of short segment obstruction resulting from either fibrosis or bone (1 to 3 mm), a typical round window-related cochleostom:y can be created by drilling through the short segment of obstruction. If more than 3 mm of drilling fails to reveal a patent cochlear lumen, a scala vestibuli insertion should be considered by moving superiorly, above. Rarely, severe fust tum ossification can make both scala tympani and vestibuli inaccessible at the cochlear base. In this situation, the trough created near the round window can be used for a short array. Great care should be exercised to avoid inadvertent injw:y to the undmurface of the labyrinthine segment of the facial nerve. Following such insertions, communication with the individual programming the device is critical to insure that proper pitch assignment is made for the retrograde electrodes. Finally, in cases of diffuse obstruction, a circummodiolar drill out is possible (76,77). Otitis Media Active otitis media is a contraindication to cochlear implantation in that inttacochlear or device exposure to viable bacteria can result in suppurative labyrinthitis with subsequent meningitis and ossification. In children, consideration of active middle ear disease is common in the winter months. There are some advocates for subtotal petrousectomy with blind sac closure in the setting of otitis media to avoid future considerations for this problem. There also remains considerable dispute regarding the significance of otitis media with effusion. Specifically, the nerve (arroW) runs onr 1he round window niche and the coc:hleostomy can be seen anterior to the nerve. In such cases, active middle ear disease should be cleared or controlled prior to implantation. One option is to consider early blind sac closure with or without obliteration and staged implantation. This avoids the long-term issues of tympanic membrane retraction, granulation, infection, and electrode exposure within a tympanic membrane perforation. Complications might be broadly categorized in to those that are medical/surgical in nature and those that are device-related. Historically, medical/surgical complications were more common than device-related issues. Minimal approaches to skin incisions and proper device location and immobilization have been key in reducing such complications. Careful attention to the surgical details described above can avoid or at least minimize many of the surgical complications outlined. Common and potentially unavoidable complications include taste disturbance from chorda tympani nerve manipulation or sacrifice (-10%), transient dizziness (-10% of adults and less common in children), and subcutaneous seroma (10%) (78). The vestibular effects of cochlear implantation have long been a concern among otologic surgeons. For children, the risk of vestibular loss remains quite small since most pediatric patients have limited, peripheral vestibular function preoperatively. Subcutaneous seroma, while common early after cochlear implant surgery nearly always resolves without the need for any intervention. Device-related complications include receiver-stimulator hard failures, suspected device malfunction. Hard failure refers to a total lack of function of the device despite properly functioning external equipment. Hard failures results from internal, receiver-stimulator problems and require revision surgery to alleviate the issue. Suspected device malfunction or soft failure is significantly more difficult to diagnose and refers to the situation where despite the presence of auditory percepts, the patient experiences aversive symptoms such as pain, shocking. Following complete exchange of the external equipment and confirmation of electrode location within the cochlear lumen by imaging. Open circuits can occur early or in a delayed fashion following cochlear implant surgery. A value judgment of electrode number and location is needed to insure adequate stimulation is available for performance. The details of revision cochlear implantation and reliability are often times complex. Fortunately, in most instances, revision cochlear implantation results in a functioning device that restores access to sound. Parents of such children should be made aware of these possible delays prior to surgery (81). Meningitis in Cochlear Implant Recipients the incidence of meningitis in cochlear implant recipients is greater than that of an age-matched cohort in the general population (82, 83). Risk factors in this population include young age, the presence of inner ear malformations, and the use of a two-part electrode system. The risk of meningitis also appears to be higher among individuals with sensorineural hearing loss without a cochlear implant although this risk appears lower than that of implanted Device-Related Internal Hard Failure. It remains diffirult to detennine whether cochlear implantation per se confers an increase risk of meningitis in subjects without the factors cited above. All potential routes of spread (middle ear, inner ear, hematogenous) should be considered in such a patient. Recent animal investigations into the mechanisms of meningitis following cochlear implantation suggest that all three routes are viable sources for such an infection (85).

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The head shadow effect is the sole exception midsouth pain treatment center reviews cheap generic benemid uk, but elimination of this alone will account for the subjective benefit knee pain treatment running purchase benemid online from canada. Pediatric Population the sound processor of the bone anchored hearing system can be fitted to infants and children in need for amplification via bone conduction (112) pain treatment for arthritis on the hip purchase line benemid. The main reason for this is the often-insufficient thickness of the bony skull pain treatment with methadone order 500mg benemid overnight delivery, making proper osseointegration impossible cape fear pain treatment center purchase benemid 500mg online. Younger children may be fitted with a bone anchored hearing system using the Softband (113 pain medication for dogs metacam generic benemid 500 mg free shipping,114). A small amount of methylene blue dye can be used to highlight the implant site through the intact skin. Then, the periosteal layer is removed from the previously marked bony implant site. The 4-mm-depth drill is used after drilling with the 3-mm burr estimating there is sufficient residual cortical bone for the longer drill bit. Many children and some adults will have limited skull thickness permitting a 3-mm-long implant only. Once the adequate depth has been determined, the hole is widened using a countersink drill. The causes are multiple and include viral infections and subsequent sudden sensorineural hearing loss, Meniere disease. Multiple other causes have been described, some of them being congenital in nature. Many affected individuals learn to cope with this disability but are left without an adequate hearing solution. These devices, however, are quite limited in terms of performance and user comfort A bone anchored hearing system provides an alternative treatment option for this population. Thus, it helps to Chapter 163: Cochlear Implants and Other Implantable Auditory Prostheses U-shaped skin incision Straight incision 2641 Complications Associated with Bone Anchored Hearing Systems the most frequently encountered complication associated with osseointegrated implants is a soft tissue reaction at the percutaneous implant site causing local infection, moisture, skin necrosis, or overgrowing over the abutment (117). Soft tissue reactions with percutaneous implants can be prevmted via extensive intraoperative soft tissue reduction. Also, the skin can be tacked down to the periosteal layer to immobilize this region. Osseointegration failure, though uncommon, is the second most common complication of this procedure. Box-shaped:skin incision (superiorly pedicled) Expected Outcomes OveralL the bone anchored hearing system seems to offer patients with a bone conduction pure tone average of less than 45 dB a high degree of hearing rehabilitation and excellent patient satisfaction (118). Once the initial healing phase of the skin-abutment interface has been completed, the device is reliable and the maintenance is generally low. As mentioned previously, a bone anchored hearing system will not provide true binaural hearing with this indication. Instead it will eliminate the head shadow effect and thus create a sensation of spatial hearing (110). Also, the patient and his family membm are carefully instructed on how to clean the abutment with its surrounding skin. Specifically, a dental appliance featuring a transducer can apply controlled oscillations to the maxilla or mandible for similar indications as conventional bone conduction devices (SoundBite, Sonitus Medical Inc. Conventional hearing aids provide amplification via the regular sound conduction apparatus of the ear. This occlusion effect is perceived as bothersome by many individuals, and some patients develop chronic otitis extema from the earmold. Acoustic distortions at the level of the tympanic membrane especially with high sound intensity levels and subsequent sound quality issues have also been described as common issues with conventional amplification. Also, many hearing aids struggle with some hearing configurations such as steeply sloping losses. In these cases, direct drive of the ossicular chain provides additional advantages over conventional technology. In these cases, the oscillating part of the device is placed on ossicular remnants, the round window, or other vibrating parts providing access to the fluid spaces of the inner ear (121). However, new fully implantable rechargeable batteries may not demonstrate any loss of capacity for several thousand recharge cycles or about 10 years. As detailed below, acquisition of the sound signal with fully implantable technology still underlies various inconsistencies and problems (37). The main reasons for this seem to be financial in nature and the fact that all devices require surgical placement. Newer indications and larger patient numbers might help to improve documentation efforts and thus help provide payers and patients with better and more accurate performance and quality of life data. Principles of Direct Ossicular or Cochlear Stimulation Conventional hearing aids receive acoustic energy through a microphone and subsequently process and amplify the signal in a speech processor. This is then transmitted through a speaker (termed receiver in hearing aid terminology) and delivered into the external auditory canal (via a sound tube and/or an earmold) to stimulate the tympanic membrane. This transducer can be either in direct or indirect contact with the intended structure. Two basic types of transducer technologies have been described: piezoelectric and electromagnetic (120,127). Piezoelectric devices use an amplifier featuring a piezoelectric crystal to generate oscillations. Piezoelectric materials (mostly ceramics) are dielectric materials with coupled electrical and mechanical properties. Applying a voltage across a piezoelectric rod, for example, causes it to bend or lengthen, in a precise and predictable voltage-dependent fashion. Within the implant, the sound signal acquired by a microphone is converted by the signal processor and then sent to the piezoelectric rod. As this rod vibrates in response to the converted auditory signal, it comes in direct contact with Historical Aspects Early attempts to actively stimulate the middle ear date back to the early 20th century. More concrete attempts were described in the 1970s and 1980s where piezoelectric systems were used for various hearing loss configurations. Also, electromagnetic devices have been studied in both the animal model and later in humans in the 1980s. Each investigation established the feasibility of active stimulation of the conductive apparatus and the potential benefit of active stimulation to patients (122). Most systems today feature semi-implantable technology similar to that used in modem cochlear implants. A transcutaneous link provides power and data to the internally placed demodulator and stimulating element More recent efforts have focused on fully implantable technology with various solutions for sound sensors and implantable microphones. It was first implanted in 1999 and feedback from the tympanic membrane required removal of parts of the ossicular chain. Due to technical difficulties, the device was eventually removed from the market Chapter 163: Cochlear Implants and Other Implantable Auditory Prostheses the intended structure of the sound-conducting apparatus (typically the incus or stapes). A critical feature of implants that use a piezoelectric ttansduce:r is the direct contact between the piezoelectric unit and the ossicles or the inner ear. The advantage of this type of transducer ia its ability to deliver more distortion-free amplification directly to the ossicular chain and the low ene:rgy consumption. Implantable middle ear hearing aids may also incorporate an electro-(fe:rro)magnetic transducer. These transducers generate a magnetic field, which then generates oscillations in a ferromagnetic medium that is nearby. Sound received from a microphone is converted by the signal processot processed, and sent to the electromagnetic transducer. Both ferromagnetic units featuring either direct or indirect contact with the ossicular chain are available. Devices directly in contact with the target structure deliver oscillations as a result of direct attachment. Ferromagnetic transducers featuring indirect contact with the ossicular chain, on the other hand, rely on electromagnetic transmission to a ferromagnetic target unit. The properties of the transmitting coil can influence the properties of the oscillating elements. The main downside of electromagnetic devices is the higher energy consumption when compared to piezoelectric technology. Direct Cochlear Fluid Stimulation Stimulation paths other than via ossicular chain have been explored. In case of a round window vibroplasty, the roWld window niche is drilled to accommodate the ttansd~ which ia placed perpendicular to the round window. To improve coupling, a small piece of fascia is placed between the roWld window membrane and the transducer. An additional tissue such as fascia or perichondrium is Ossicular Attachment Electromagnetic or piezoelectric transducers of active middle era implants are attached to various locations along the ossicular chain or the inner ear windows. Thus, the electromagnetic ena:gy is applied in a direction mimicking the natural motion of the stapes. In this system, the long process of the incus has to be removed to avoid acoustic feedback to the sensor acquiring sound information from the ossicular chain. The device on the left-hand side of the Image dCiplcts the transduOiilr picking up the acoustic signal from the body of the Incus. The~ 1ransducer Inserted through the fadal reOiilss stlmulatCis the~ head of the stapes for signal delivery. With new indications requiring fixation on the round window niche or other parts of the labyrinth. In such cases, closure of the e:xternal auditoty canal has been suggested to remove the potential cause for postoperative problems. At this point, the authors recommend alternative management options for this type of hearing impairment especially when the prognosis is unclear and/or if speech perception is substantially impaired. All three systems are approved devices for modemte-to-severe sensorineural hearing loss. This mold can be extensively vented to minimize the external auditoty canal occlusion effect. It consists of three implantable components, external testing/programming imtruments, and system accessories. This Implant generates controlled oscillations of the ossicular chain (or the cochlear ftulds) via a direct electromagnetic link. However, the clinician should keep the underlying biology of sensorineural hearing loss with potential loss of discrimination in mind. Also, indication criteria for cochlear implants continue to evolve, and many individuals with severe and some with moderate-to-severe losses are now considered cochlear implant candidates. Many retrocochlear hearing deficits often demonstrate more severe speech discrimination problems than what would be expected from the pure tone audiogram. Reasons for this dissatisfaction may include chronic external auditory canal issues from wearing the eannold or a bothersome occlusion effect. Both often require alternative attachment sites of the electromagnetic or piezoelectric transducer. For example, placement of the Vibrant Soundbridge on or near the round window has been thoroughly investigated. Thus, indication criteria include mixed or conductive losses from various causes mostly including chronic otitis media with previously failed ossiculoplasties. Many authors thus advocate closure of the external auditory canal either in a staged fashion or in a single operation. Typical results after atresiaplasty are more often than not dissatisfactory for both patients as well as the clinician. Also, surgeries often have to be coordinated with reconstructive measures of the auricle. As such, placement of the device may be performed at an earlier age before cosmetic reconstructive procedures are being considered. As a downside, some atretic ears feature virtually no landmarks, no pneumatization, a very shallow middle ear space, and an aberrant position of the facial nerve. Also, successful placement of the active portion of the device on the oval window has been described (133). Clinical algorithms may have to be established, and more data from controlled clinical trials should enhance our understanding of direct cochlear stimulation. Fully implantable systems also consist of a rechargeable battery, a sound processor, and a sensor device (either a subcutaneous microphone or a piezoelectric transducer as a sensor). In such cases, the surgical procedure typically includes a mastoidectomy and a (large) facial recess to access all middle ear structures necessary. Additional hardware such as the demodulator requires a bony recess in the postauricular area. With current technology, a standard postauricular incision is typically sufficient since it provides standard access to the mastoid and it allows proper placement of other device components. Postimplantation (Re)habilitation and Fitting After implantation, a healing period of several weeks or months is required before the device can be activated. The main underlying reason for this is proper ossicular integration of the active portion of the implant. Fitting software and amplification strategies are very similar to conventional hearing aids. Thus, a dispensing audiologist familiar with fitting conventional amplification will find the process intuitive. This has been reported mainly for alternative indications for conductive or mixed hearing losses.

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