The technique of total lower lip reconstruction with a composite radial forearm-palmaris longus free flap was further refined in this report. A ventral tongue flap enhanced the lip aesthetics by recreating the vermilion. Lip suspension was enhanced by securing the palmaris tendon to the malar eminences as well as to the cut ends of the orbicularis oris muscle. The patient achieved oral continence as well as dynamic movement of the lip during speaking and swallowing.

Objectives/Hypothesis: The head and neck surgeon's fascination with parotid surgery arises from the gland's spectrum of histopathological presentations, as well as the diversity of its morphological features. A mass arising in the mid-cheek region may often be overlooked as a rare accessory lobe parotid neoplasm. This report serves to revisit the topic of accessory parotid gland neoplasms to emphasize proper management, particularly the surgical aspects, so that consequences of salivary fistula, facial nerve paralysis, and recurrence are avoided. Study Design: This is a retrospective review of our experience with four accessory parotid gland neoplasms and five other masses mimicking this lesion. Methods: A literature review and retrospective chart review. Results: Over a 6-year period, we have encountered four true accessory lobe tumors, all pleomorphic adenomas. These presented very similarly to four other more commonly encountered masses not of salivary origin and one normal but hyperplastic accessory parotid gland. All were removed through a wide parotidectomy-style approach modified by extending incisions anterosuperiorly and inferoanteriorly. The only complication was a minor salivary fistula in one patient. There were no permanent facial paralyses. Conclusions: Accessory parotid gland neoplasms are rare and may present as innocuous extraparotid midcheek masses. A high index of suspicion, prudent diagnostic skills (including fine-needle aspiration [FNA] biopsy followed by computed tomography [CT] imaging), and meticulous surgical approach (extended parotidectomy-style incision and limited peripheral nerve dissection when possible) are the keys to successful management of these lesions.

Several composite free flaps have been described for use in oromandibular reconstruction. Particularly in extensive defects, there may be no single flap which combines sufficient bone stock with thin, pliable, soft tissue. By combining two free flaps, the best osseous and soft-tissue elements may be independently selected, to yield a result superior to that achievable with one free flap alone. Thirteen patients underwent reconstruction of extensive oromandibular defects using the free fibula for mandibular reconstruction and the free radial forearm flap for oral lining and soft-tissue reconstruction. Mandibular defects were usually extensive, involving over half of the mandibular contour. Soft-tissue defects were all complex and involved multiple surfaces of the oral, oropharyngeal, and nasopharyngeal mucosa. All patients were operated on in the supine position by two surgical teams (extirpative and reconstructive) working simultaneously. Each free flap was supplied by its own set of recipient vessels. The mean total operating time was 12 hr. Postoperative courses were without mortality or significant morbidity. There were no flap failures. Soft-tissue and osseous reconstructions healed completely. Aesthetic contour was judged good to excellent in 11 patients. Soft and solid diets were achieved in five patients, with six patients on a purée or liquid diet. Oral competence was present in 11 patients. Speech was excellent to good in six patients and fair in four patients. The mean follow-up has averaged 18 months. Three patients have died of recurrent disease, and two of unrelated causes. The remaining eight patients are currently free of disease. In combining the free flaps, the best tissue for bone and soft-tissue reconstruction was selected independently. The two-team approach avoided excessive operating time and operating team fatigue. The added degree of freedom provided by the two free flaps with their independent pedicles made insetting easier, compared to working within the limitations of a single composite flap. For extensive oromandibular defects, the simultaneous free fibula and radial forearm free flaps provided ideal osseous and soft-tissue reconstruction, with acceptable operating times and reasonable functional results.

The CHARGE association is a collection of multisystem congenital anomalies including choanal atresia. A review of the literature failed to identify any specific findings that suggested the need to alter the management of choanal atresia in these patients. Our review of 24 patients with choanal atresia managed between 1974 and 1986 identified nine patients with the CHARGE criteria. These nine patients demonstrated a higher prevalence of surgical failures than the patients without the CHARGE association. The reasons are discussed, and computed tomographic scans demonstrate the anatomic findings of a more contracted nasopharynx and narrowed posterior choanal region. Thus, successful repairs require a more radical resection of the posterior nasal septum and lateral bony walls that can be achieved only with a transpalatal approach. The preoperative airways of CHARGE association patients are also at increased risk of obstruction and may require intubation or tracheotomy during the early life of the patient.