Incision Placement Research Articles

Cochlear Implantation in a Patient With Pfeiffer Syndrome and Temporal Bone Vascular Anomalies.

Pfeiffer syndrome is a rare craniosynostotic disorder resulting in premature bony fusion of the skull, which can result in abnormal temporal bone and vascular anatomy and hearing loss. Cochlear implantation in these patients requires thoughtful surgical planning given the potential for limited access to the cochlea because of subcutaneous or intratemporal vasculature. Herein, we present a patient with Pfeiffer syndrome who underwent successful cochlear implantation using preoperative Doppler ultrasound to identify large extracranial venous anatomy followed by a modified transcanal surgical approach. An adult female patient with Pfeiffer syndrome. Preoperative axial computed tomography, catheter angiography, Doppler ultrasound, and right side cochlear implant. Surgical feasibility and audiometric outcomes including aided thresholds and word recognition score. Successful cochlear implantation was performed via a modified transcanal approach with blind sac closure of the external auditory meatus. Full electrode insertion was obtained through a round window approach. No extracranial or intratemporal vessels were encountered during surgery. Patients with significant craniosynostoses and vascular malformations of the temporal bone can undergo successful cochlear implantation. Careful preoperative planning with high-resolution CT, MRA, and MRV, and/or traditional catheter angiography can assist in determining surgical feasibility and minimizing risk. We recommend preoperative Doppler ultrasound of abnormal extracranial vessels to assist in safe placement of incisions and hardware.

Abstract ES3-3: Post-mastectomy breast reconstruction: defining the effects of adjuvant treatment modalities on surgical outcomes

Abstract Post-mastectomy breast reconstruction is routinely offered immediately at the time of mastectomy, and can be performed using prosthetic or autologous techniques. Successful surgical outcomes are routine with these procedures, but can be complicated when adjuvant treatment modalities for breast cancer are employed. The most common adjuvant treatments effecting outcomes in post-mastectomy breast reconstruction are radiation, chemotherapy/hormonal therapy, and axillary lymph node dissection. Adjuvant radiation therapy has been shown to increase the complication rate in prosthetic breast reconstruction, specifically with increased rates of implant infection (22%, p=0.0), full-thickness mastectomy skin necrosis (11.5%, p=.001), and expander/implant removal (17.7%, p=0.0). Such complication rates are improvements over earlier reports, likely due to altered incision placement in nipple sparing mastectomy to the periareolar area, waiting at least 6 months following radiation completion prior to implant exchange, and the use of acellular dermal matrices (shown on multivariate analysis to reduce explantation rates in setting of radiation). With autologous breast reconstruction, adjuvant radiation has been shown to increase rates of volume flap volume loss (19.75%, p=.0001), but not flap loss rates (1.23%, p=1). The use of adjuvant chemotherapy and hormonal therapy has not been shown to negatively impact outcomes in prosthetic breast reconstruction, to any statistically significant amount. This includes tamoxifen and herceptin therapy. Similarly, the use of hormonal therapy does not significantly effect overall outcomes in autologous breast reconstruction. The use of axillary lymph node dissection has been shown to have a significant negative impact on outcomes in prosthetic breast reconstruction, compared to sentinel lymph node biopsy. On multivariate analysis, axillary lymph node dissection increased rates of breast implant loss (RR 2.0, p=.021), relative to sentinel lymph node biopsy. This is due to the decreased lymphatic drainage of remaining breast tissue, and resultant increase in infection and implant loss. Citation Format: Sbitany H. Post-mastectomy breast reconstruction: defining the effects of adjuvant treatment modalities on surgical outcomes. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr ES3-3.

Minimally Invasive Surgery in Pediatric Trauma: One Institution's 20-Year Experience.

Background:Minimally invasive surgery (MIS) for trauma in pediatric cases remains controversial. Recent studies have shown the validity of using minimally invasive techniques to decrease the rate of negative and nontherapeutic laparotomy and thoracotomy. The purpose of this study was to evaluate the diagnostic accuracy and therapeutic options of MIS in pediatric trauma at a level I pediatric trauma center.Methods:We reviewed cases of patients aged 15 years and younger who had undergone laparoscopy or thoracoscopy for trauma in our institution over the past 20 years. Each case was evaluated for mechanism of injury, computed tomographic (CT) scan findings, operative management, and patient outcomes.Results:There were 23 patients in the study (16 boys and 7 girls). Twenty-one had undergone diagnostic laparoscopy and 2 had had diagnostic thoracoscopy. In 16, there were positive findings in diagnostic laparoscopy. Laparoscopic therapeutic interventions were performed in 6 patients; the remaining 10 required conversion to laparotomy. Both patients who underwent diagnostic thoracoscopy had positive findings. One had a thoracoscopic repair, and the other underwent conversion to thoracotomy. There were 5 negative diagnostic laparoscopies. There was no mortality among the 23 patients.Conclusions:The use of laparoscopy and thoracoscopy in pediatric trauma helps to reduce unnecessary laparotomy and thoracotomy. Some injuries can be repaired by a minimally invasive approach. When conversion is necessary, the use of these techniques can guide the placement and size of surgical incisions. The goal is to shift the paradigm in favor of using MIS in the treatment of pediatric trauma as the first-choice modality in stable patients.

Scleral tunnel phacoemulsification: Approach for eyes with severe microcornea.

Cataract surgery in eyes with microcornea is associated with frequent complications such as corneal edema, posterior capsular rent, and risk of unplanned aphakia. We describe an improved surgical technique for the creation of surgical incisions during phacoemulsification in eyes with cataract associated with microcornea. A retrospective analysis of eight patients (8 eyes) operated at our center was undertaken. The mean age of the patients was 29.5 ± 10.9 years. All eyes were operated using the scleral pocket incision for phacoemulsification. This scleral pocket incision was tangential to the limbus and created approximately 2.5 mm behind limbus through which phacoemulsification probe was inserted. Because of the posterior placement of incision, the anterior chamber crowding was minimized. There was no incidence of port-site peripheral corneal edema. Fifty percent eyes developed transient central corneal edema, the intraocular lens in bag was implanted in 5/8 eyes, and none developed Descemet's membrane detachment. Mean best-corrected visual acuity improved from 1.85 ± 0.38 logarithm of minimum angle of resolution (LogMAR) to 1.26 ± 0.70 LogMAR postoperatively (P = 0.01; paired t-test). Posterior incision placement during phacoemulsification in microcornea helps achieve favorable postoperative outcomes in contrast to outcomes using clear corneal approach described in literature.

Distant blunt forceps dissection in tissue expander insertion: A novel technique.

Tissue expansion using implantable expanders is a useful means of generating surplus tissue for reconstruction of defects such as scarring following burns. The authors describe their technique of incisions distant to the desired location of expander placement, and remote dissection of the expander pocket with hydrodissection and blunt forceps. A total of 81 expanders were placed in 30 consecutive patients, 81% of whom had burn scars due for reconstruction. During preparation, no complications, such as bleeding, were encountered, except one case with severe subdermal fibrosis, in which bleeding was stopped through brief application of pressure. Postoperatively, no complications were encountered in 76% of patients; however, 16.6% exhibited surgical site infection, which was managed conservatively and was correlated with a high number of expanders implanted at once. One patient experienced hematoma formation that resolved spontaneously, and one instance of expander extrusion and subsequent removal occurred. Receiving ≥2 expanders at the same time was statistically associated with higher risk for complication(s). The authors' complication rates were moderate and comparable with open or endoscopic approaches. Time of expansion is reduced compared with the open approach due to distant incision placement and immediate usability. Cost effectiveness appeared to be better using only inexpensive forceps, rather than elaborate and costly endoscopic equipment.

A Simple Method for Proper Placement of the Inframammary Fold Incision in Primary Breast Augmentation

The inframammary incision is a very common access in breast augmentation. The incision must be positioned well to place the resulting scar in the new inframammary fold. This article presents a simple marking on patients for proper localization of the inframammary incision. Ninety-six patients who underwent primary breast augmentation were divided into 3 groups according to the volume of the used implants. A total of 90.6% of the patients had excellent postoperative scar location, and 9.4% had good results, with overall 100% patient satisfaction. Our preoperative markings offer simple, easy, and fixed measurements that facilitate proper postoperative location of the inframammary incision and hide the scar significantly.

Using an Individual Procedure Score Before and After the Advanced Surgical Skills Exposure for Trauma Course Training to Benchmark a Hemorrhage-Control Performance Metric

Test with an individual procedure score (IPS) to assess whether an unpreserved cadaver trauma training course, including upper and lower limb vascular exposure, improves correct identification of surgical landmarks, underlying anatomy, and shortens time to vascular control. Prospective study of performance of 3 vascular exposure and control procedures (axillary, brachial, and femoral arteries) using IPS metrics by 2 colocated and trained evaluators before and after training with the Advanced Surgical Skills Exposure for Trauma (ASSET) course. IPS, including identification of anatomical landmarks, incisions, underlying structures, and time to completion of each procedure was compared before and after training using repeated measurement models. Audio-video instrumented cadaver laboratory at University of Maryland School of Medicine. A total of 41 second to sixth year surgical residents from surgical programs throughout Mid-Atlantic States who had not previously taken the ASSET course were enrolled, 40 completed the pre- and post-ASSET performance evaluations. After ASSET training, all components of IPS increased and time shortened for each of the 3 artery exposures. Procedure steps performed correctly increased 57%, anatomical knowledge increased 43% and skin incision to passage of a vessel loop twice around the correct vessel decreased by a mean of 2.5 minutes. An overall vascular trauma readiness index, a comprehensive IPS score for 3 procedures increased 28% with ASSET Training. Improved knowledge of surface landmarks and underlying anatomy is associated with increased IPS, faster procedures, more accurate incision placement, and successful vascular control. Structural recognition during specific procedural steps and anatomical knowledge were key points learned during the ASSET course. Such training may accelerate acquisition of specific trauma surgery skills to compensate for shortened training hours, infrequent exposure to major vascular injuries, or when just-in-time training is necessary. IPS is a benchmark for competence in extremity vascular control.

Evaluation of lid speculum with a drape (LiDrape(®)) for preventing surgical-field contamination.

PurposeTo compare the degree of surgical-field contamination in cataract surgeries between a new draping method using a lid speculum with a drape (LiDrape®) and a conventional draping method.MethodsCataract surgery was performed on 21 eyes using LiDrape® (LiDrape® group) and on 22 eyes using a conventional draping method (conventional group). Contamination was evaluated by bacterial culture of conjunctival sac scrapings and ocular surface irrigation fluid. Conjunctival sac scrapings were collected before and after application of preoperative antibiotics. Ocular surface irrigation fluid was collected before incision placement and during surgery. Bacterial detection rate and types of organisms isolated at these four time points were examined.ResultsBacterial detection rates were significantly decreased in the LiDrape® group at all time points after the application of antibiotics compared with preapplication. Regarding between-group comparisons, the bacterial detection rate in the LiDrape® group was only significantly lower than that in the conventional group in the intraoperative sample. Propionibacterium acnes was the most common organism isolated from ocular surface irrigation fluid. The number of P. acnes in the intraoperative sample was significantly lower in the LiDrape® group compared with the conventional group. There were no significant differences in detection rates for other bacteria between the groups.ConclusionLiDrape® was as effective as conventional draping for preventing surgical-field contamination. The number of P. acnes during surgery was significantly lower in the LiDrape® group compared with the conventional group, suggesting that LiDrape® may contribute to the prevention of postoperative infection.

Using intraoperative laser angiography to safeguard nipple perfusion in nipple-sparing mastectomies.

The superior aesthetic outcomes of nipple-sparing mastectomies (NSM) explain their increased use and rising popularity. Fortunately, cancer recurrences involving the nipple-areolar complex (NAC) have been reassuringly low in the range of 1%. Technical considerations and challenges of this procedure are centered on nipple ischemia and necrosis. Patient selection, reconstructive strategies and incision placement have lowered ischemic complications. In this context, rates of full NAC necrosis are 3% or less. The emergence of noninvasive tissue angiography provides surgeons with a practical tool to assess real-time breast skin and NAC perfusion. Herein, we review our classification system of NAC perfusion patterns defined as V1 (from subjacent breast), V2 (surrounding skin), and V3 (combination of V1 + V2). Additionally, we describe the benefits of a first stage operation to devascularize the NAC as a means of improving blood flow to the NAC in preparation for NSM, helping extend the use of NSM to more women. Intraoperative evaluation of skin perfusion allows surgeons to detect ischemia and modify the operative approach to optimize outcomes.

Extensive necrotizing fasciitis after fat grafting for bilateral breast augmentation: recommended approach and management.

Extensive necrotizing fasciitis after fat grafting for bilateral breast augmentation: recommended approach and management.

Objective Comparison of Animal Training Versus Artificial Simulation for Initial Cricothyroidotomy Training

This manuscript aims to determine if there is a difference in performance outcomes after initial training with either animals or simulators. Volunteers without prior experience performing emergency procedures were randomly assigned to receive training in cricothyroidotomy on either a pig model or on an artificial simulator. Volunteers were given identical lectures and trained to proficiency. Two weeks after training, trainees were tested using human cadavers as to their performance with time, incision size, incision start location, initial placement attempt, and final accuracy. Overall success rate of the animal-trained group was 64 per cent and in the artificial simulator group, 73 per cent (P = 0.431). Median time to completion in the animal group and artificial simulator group was 143 s and 105 s (P = 0.482), and incision lengths 4.0 cm and 3.2 cm (P = 0.173), respectively. Accuracy of initially attempted incision placement and final cricothyroidotomy tube placement was also compared. Initially attempted site accuracy in the animal-trained group was 93 per cent and correct final position 79 per cent, and in the artificial group, 100 per cent (P = 0.452) and 88 per cent (P = 0.782), respectively. There was no statistically significant, objective difference in any metric between animal- and simulator-trained groups after cricothyroidotomy training. For initial training, there is no objective benefit of animal training.

Anatomy in the performance of a lower extremity fasciotomy before and after training

With shorter training hours, acquiring trauma surgical skills on-the-job is challenging for civilian and military surgeons. We hypothesize that a training course including lower extremity fasciotomy will improve knowledge of surgical landmarks, anatomical structures, and procedure time. Specifically, improved knowledge of surface landmarks will correlate with faster and successful 4 compartment decompression. Surgical residents (n=34) were tested with validated metrics performing a 2 incision 4 compartment fasciotomy on a cadaver before and after the Advanced Surgical Skills for Exposure in Trauma (ASSET) course. Surface landmarks, incision placement, surgical procedure steps, and procedure time were compared before and after training with Linear mixed models and Pearson correlation. After training, residents improved in landmark identification (+33%), incision placement (+34%), and successful 4 compartment decompression (p<0.001). More compartments were completely opened in less time (ANCOVA p<0.05; fig). Correct landmarks and incisions correlated with successful decompression (r=0.42-0.5; p<0.001). Improved surface anatomic knowledge increased successful fasciotomy. This knowledge is normally acquired on the job during residency but specific training may help accelerate the acquisition of fasciotomy skills to compensate for reduced training hours.

Reduction or discontinuation of antibiotic prophylaxis in vascular access surgery, tendon sheath incision and PD catheter placement.

Immune response in dialysis patients is suppressed and these patients are susceptible to bacterial infections. Therefore, minimal use of antibiotics in dialysis patients is recommended to avoid generating drug-resistant bacteria. However, minor surgeries including vascular access surgery, tendon sheath incision and peritoneal dialysis (PD) catheter placement are inevitable in dialysis patients and evidence-based recommendations on the judicious use of antibiotics are not currently available for these procedures. In this study, the optimal antibiotic prophylaxis for minor surgeries was evaluated. This is a retrospective study. In dialysis patients at Kawashima Hospital, a three-step reduction of antibiotic use was performed in 651 cases of arteriovenous fistula (AVF) and tendon sheath incision surgeries from July 2009 through October 2012. Moreover, general surgical guidelines-recommended dose of preoperative antibiotics only were used in 532 cases of arteriovenous graft (AVG) and PD catheter placement from January 2010 through October 2012. The surgical site was observed for 2 weeks after the surgery. In only one case of AVF surgery, redness of the skin around the stitches was noticed 5 days after the surgery, which was healed with antibiotics taken orally for 3 days. Neither AVG nor PD catheter placement demonstrated any infection at the surgical site during the 2-week observation period. Even in dialysis patients, neither pre- nor postoperative antibiotics are necessary for AVF and tendon sheath incision surgeries. AVG and PD catheter placement surgeries require only a small amount of antibiotics preoperatively.

Modified Fish-Incision Technique in Brachioplasty: A Surgical Approach to Correct Excess Skin and Fat of the Upper Arm (Restoring the Armpit Contour)

Brachial ptosis is one of the consequences of massive weight loss. At an early stage, brachial ptosis can be corrected by liposuction, dermolipectomy and liposuction, or minibrachioplasty while the most advanced stage requires extended brachioplasty. Since brachioplasty was first described, various techniques have been proposed in the management of upper extremity contour deformities. Modifications to the original technique were mainly made to shape arm contour, to obtain good morphological reconstruction with attention directed toward improving and refining the resulting scar. We describe a modified approach to the "fish incision" technique defining a preoperative marking procedure that permits the reduction of overcorrection problems to reshape and improve the contour of the armpit with camouflage of scar sequelae. Our modifications to the original technique focus on incision placement along the medial bicipital groove and armpit, based on the the drawings of the tails following dynamic lines of the armpit contour established by the underlying muscles. We drew the tails slightly with a 60° angle between the tails and the width depending on patient's arm contour and on the excess of the skin in the armpit to be removed. The modified technique has obtained satisfactory results for patients and may be considered as a new surgical approach in the management of brachial ptosis. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Correction of severe alar retraction with alar rotation flap

To investigate the therapeutic effect of alar rotation flap for severe alar retraction. Patients with severely retracted alar underwent ala reconstruction using alar rotation flaps and autogenous cartilage batten grafts. First, costal cartilage was used to reshape the nasal tip and nasal dorsum. Then cartilage patch was used to extend and thicken the retracted alar. Then the alar rotation flap was transferred to correct retracted alar. Fourteen patients with severe alar retraction underwent alar reconstruction with alar rotation flap and alar batten grafts. The alar retraction was corrected in all cases, with improvements functionally and aesthetically. No recurrence of alar retraction was noted. The incision healed with acceptable cosmetic results, with obvious scar in only one patient (one side). The alar rotation flap is an effective and reliable surgical option to correct severe alar retraction. Scar can be kept inconspicuous by precise placement of the incision within the junction of the ala and the nasal dorsum, following principles of the aesthetic nasal subunits.

Best Practices for Surgically Implanting Acoustic Transmitters in Spotted Seatrout

AbstractTechnological advances have made acoustic tracking of fish an effective means to collect unprecedented migration data. However, one must ensure that fish survive the surgical implantation and retain transmitters, and that their health and behavior are not adversely affected. We performed a laboratory study to examine the most effective surgery technique and suture material for implanting acoustic transmitters into Spotted Seatrout Cynoscion nebulosus. Six treatment groups were used to investigate two ventral incision locations (midline and off‐midline) and three suture materials (braid, monofilament, and staples). Overall survival was high for all fish undergoing surgery (75% for surgical controls, and 74% for surgically implanted fish), suggesting that acoustic transmitter implantation can be very successful for Spotted Seatrout. However, female fish had significantly higher survival (85.7%) than male fish (41.2%). Surgery time ranged from 73 to 270 s, and our results suggest that for every second that the surgery time was reduced the odds of increasing survival are 1.5%. Moreover, the surgery process versus tagging material or incision location is the primary cause of mortality. Overall, there was no one treatment that showed distinct differences in survival and transmitter retention; however, for future telemetry studies using Vemco V13 transmitters with Spotted Seatrout, we recommend researchers (1) target fish greater than 425 mm TL, (2) minimize surgery time (preferably 160 s or less), and (3) use an off‐midline incision placement closed with two sutures using braid suture material. These techniques will help ensure successful field acoustic tracking studies by increasing the likelihood of Spotted Seatrout survival and transmitter retention. Finally, these methods have applicability to other fishes, particularly Sciaenids, with high potential for success.Received January 29, 2014; accepted September 9, 2014

Board #235 - Program Innovation A Multidisciplinary Simulation and Skills-based Curriculum Improves Resident Preparedness on ACGME-required Procedural Skills (Submission #10005)

Objectives In 2013, the Accreditation Council for Graduate Medical Education (ACGME) Resident Survey included a novel set of questions for graduating PGY-3 pediatric residents on their level of preparedness to perform 13 specific procedural skills without supervision. Baseline data obtained from graduating PGY-3’s at our institution revealed that 100% reported “Agree” or “Strongly Agree” on major ACGME required procedures including lumbar punctures (LP), bag and mask ventilation, neonatal intubation and resuscitation, and umbilical catheterization. However, the survey results highlighted the importance of minor procedures including placement of peripheral intravenous catheters (IV), incision and drainage of an abscess (I&D), simple joint dislocation reductions and splinting of fractures. In these categories, over 50% of our graduating PGY-3’s reported they were not comfortable performing these procedures unsupervised. Our objective was to create a multidisciplinary simulation-based curriculum for resident trainees within our established weekly lecture series with the aim of having all residents achieve competency in performing the surveyed ACGME procedures safely and without supervision by completion of their PGY-3 year. Description We created five skills workshops for procedural training. Residents, divided into groups of six to eight, received learner-directed teaching using simulated techniques from multidisciplinary experts involving critical care nurses, orthopedic nurse practitioners, ER attendings, and general pediatricians (Figure 1). All current residents were anonymously surveyed before and after the skills workshops using a 5-item Likert scale of preparedness with the same questions as the 2012-2013 ACGME Resident Survey. Based on the Kirkpatrick evaluation model, motivation will be reported as workshop attendance rates and learning will be reported via survey results. Attendance at each component of the established simulation curricula and the novel skills workshops was > 93.5%. Survey responses were analyzed using percent change from pre- and post-curricular implementation. Our baseline survey revealed that residents did not feel well prepared to perform minor procedures without supervision (I&D=28%, IV=39%, splinting=64% dislocation=80%). Post workshops, residents showed a dramatic increase in feeling well prepared to perform minor procedures (dislocation by 300%, splinting by 189%, I&D by 88%, IV insertion by 58%). Conclusion A multidisciplinary, simulation-based procedure curriculum outside of unit-specific clinical and simulator training will address all minor reportable ACGME procedural skills and facilitate graduating pediatric resident competency in performing these procedures safely without supervision. Limitations included availability of simulated models appropriate for the time frame allotted and level of training, and multidisciplinary team availability. Future applications will include curricular development to address the translation of simulated skills into confident pediatric care at the bedside. Disclosures None

Aesthetic refinements in body contouring in the massive weight loss patient: Part 2. Arms.

The literature has witnessed an evolution in brachioplasty technique since the procedure was introduced by Thorek in 1930. Aesthetic refinements in brachioplasty have been increasingly described in the literature, and this has paralleled the rise in the massive weight loss population. The aim of this review is to share the plastic surgery experience with this challenging body region and present different approaches to achieve the best results for a broad spectrum of patients. A literature review studying brachioplasty was performed through PubMed. Throughout the literature there has been debate about scar placement, scar length, application of liposuction, drain placement, and optimization of outcomes, and differences of opinion have been compared. There is no definitive best method of brachioplasty, as evidenced by multiple classification systems which present algorithms for management depending on presentation. Not only does approach differ depending on degree of presentation, but there are also different approaches depending on author for similar manifestations. Approaches vary through incision length, incision placement, and use of liposuction. Outcomes studies similarly reveal lack of consensus. This literature review has elucidated multiple approaches to brachioplasty, and the pearls and pitfalls described may all be incorporated to produce excellent outcomes and patient satisfaction in an individualized approach.

NT-15 * STEREOTACTIC LASER THERMAL ABLATION OF RECURRENT POSTERIOR FOSSA METASTATIC LESION: DESCRIPTION OF NEW TECHNOLOGY FOR INFRATENTORIAL TUMORS REFRACTORY TO CONVENTIONAL THERAPIES

BACKGROUND: Stereotactic radiofrequency thermal ablation is a minimally invasive innovative technique that achieves real time tumor destruction. The procedure is safe and effective with real time MRI feedback. We describe the use of stereotactic radio-frequency thermal ablation of posterior fossa metastatic lesion that was refractory to surgical resection and radiosurgery. METHODS: A 67-year-old lady with pulmonary adenocarcinoma developed recurrent metastatic left cerebellar lesion, which was refractory to surgery and radiosurgery. The patient was symptomatic from this lesion and required at least debulking to improve quality of life. She underwent stereotactic radio-frequency thermal ablation using frame-less steretotaxy. Pre-operative imaging using fiducials screwed to the skull was registered in a navigation system that aided in precise placement of skin incision. A specially engineered precision access device was used to drill a 3.2-mm hole in the optimum trajectory and to place a 1.65-mm diameter laser applicator and probe. RESULTS: After confirmation of probe placement with MRI, ablation was accomplished over 2.65 x 1.22 cm of lesion under multi-planar real -time thermal imaging. The tumor approximated facial nerve exit at the brainstem. Real-time feedback with safety markers placed along the seventh cranial nerve exit zone at brainstem and middle cerebellar peduncle regulated dose and duration of therapy. The patient suffered no new neurological deficit and was discharged home the following day without any complication. At 6-month follow-up, the patient continued to show good tumor control, without new symptoms, remaining neurologically and radiologically unchanged. CONCLUSIONS: This case illustrates the utility of radio-frequency thermal ablation for metastatic lesions in the infratentorial space especially when conventional therapies have been either exhausted or found unsuitable. With safety markers protecting brainstem and cranial nerves, good tumor control can be achieved without suffering significant neurological deficit. Also, minimal invasiveness and negligible risk advocate for possibility of multiple sessions, performed safely.

Should we use fingerbreadth measurements in submandibular gland surgery? A critical appraisal of the technique.

Having observed variation in the breadth of surgeons' fingers whilst they are placing the incision for submandibular gland surgery, we aimed to examine this technique of incision siting, quantify the differences in fingerbreadths and consider any consequences of variability. Surgeons trained in salivary gland surgery were questioned on their method of incision placement for submandibular gland surgery. The breadth of index and middle fingers were subsequently measured using Vernier calipers. The majority of surgeons use a measure of two fingerbreadths below the mandible in planning their approach to the submandibular gland. There is a significant difference in the size of surgeons' fingers, particularly between men and women (mean, 4.2 cm vs 3.6 cm). Fingerbreadth measurements are somewhat arbitrary, with significant inter-surgeon variability. However, based on the results of cadaveric studies, the findings indicate that the technique is safe for marking the incision in submandibular surgery.