The temporoparietal fascia flap for coverage of cochlear reimplantation following extrusion

Single Incision Dual Cover with Temporoparietal Fascial Flap for Exposed Cochlear Implant: A Novel Take on a Workhorse Flap

Cochlear implant surgeries have become increasingly common in India, leading to a rise in complications such as cochlear implant exposure. To address this issue, we present a novel technique involving a single incision dual cover using the temporoparietal fascial flap (TPFF) and skin flap to give durable cover for exposed cochlear implants. Materials and Methods  A retrospective study was conducted between December 2019 and December 2022 on patients who underwent the dual flap procedure for exposed cochlear implants. Results  The average defect size was 2 × 2 cm, and the average length of hospital stay was 10 days. Fourteen skin flaps were closed primarily, while two required skin grafting for donor site closure. At the time of discharge, all wounds showed successful healing with intact skin coverage over the cochlear implant device site. The average follow-up period was 12 months, during which two patients had donor site scar alopecia, while others had adequate hair growth masking the scar. All patients consistently used their cochlear implants. Conclusion  Our single-incision, dual cover TPFF + skin flap technique offers a reliable and innovative solution for managing exposed cochlear implants. With successful implant salvage and favorable postoperative outcomes, this approach demonstrates the versatility and reliability of the TPFF as an excellent option for reconstructive surgeons dealing with cochlear implant complications.

RNA base editing therapy cures hearing loss induced by OTOF gene mutation

Otoferlin (OTOF) gene mutations represent the primary cause of hearing impairment and deafness in auditory neuropathy. The c.2485C>T (p. Q829X) mutation variant is responsible for approximately 3% of recessive prelingual deafness cases within the Spanish population. Previous studies have used two recombinant AAV vectors to overexpress OTOF, albeit with limited efficacy. In this study, we introduce an enhanced mini-dCas13X RNA base editor (emxABE) delivered via an AAV9 variant, achieving nearly 100% transfection efficiency in inner hair cells. This approach is aimed at treating OTOFQ829X, resulting in an approximately 80% adenosine-to-inosine conversion efficiency in humanized OtofQ829X/Q829X mice. Following a single scala media injection of emxABE targeting OTOFQ829X (emxABE-T) administered during the postnatal day 0-3 period in OtofQ829X/Q829X mice, we observed OTOF expression restoration in nearly 100% of inner hair cells. Moreover, auditory function was significantly improved, reaching similar levels as in wild-type mice. This enhancement persisted for at least 7 months. We also investigated P5-P7 and P30 OtofQ829X/Q829X mice, achieving auditory function restoration through round window injection of emxABE-T. These findings not only highlight an effective therapeutic strategy for potentially addressing OTOFQ829X-induced hearing loss but also underscore emxABE as a versatile toolkit for treating other monogenic diseases characterized by premature termination codons.

The Role and Versatility of the Temporoparietal Fascia Flap for Coverage of Cochlear Implant Extrusion

The use of cochlear implants (CI) may be associated with different complications, being extrusion of the device one of the most common. Reconstruction of the defect with a healthy and vascularized tissue is often required. We present two patients with a CI extrusion treated with a temporoparietal fascia flap.

Salvaging Exposed Cochlear Implants

The cochlear implant (CI) procedure is one of the most efficient surgical options for the management of patients suffering from severe bilateral sensorineural hearing loss. Notably, CI exposure is one of the most commonly reported complications. Herein, we report our experience in the management of three patients with CIs complicated by implant exposure.

Hyperbaric oxygen therapy as a therapeutic option in cochlear implants extrusion treatment in infected wounds

Background: Cochlear implant extrusion as a result of infection is an uncommon, but serious complication, which can lead to implant removal as the ultimate solution.Objectives: (1) to identify the incidence of cochlear implant extrusion and its causes, (2) to report our management of patients presenting skin complications after cochlear implant surgery (3) to propose new therapeutical options with hyperbaric oxygen therapy (HBOT).Materials and methods: A retrospective analysis of medical documentation of 1250 patients who were operated on with cochlear implants in our department between 1993 and 2015. The medical charts of 25 patients were selected due to reported skin flap complications resulting in CI extrusion. Five of those patients were subsequently removed from the study because of no infection signs.Results: Non-traumatic cochlear implant extrusion occurred in 1.6% of implanted patients, and secondary treatment was effective in 90% of all cases (18 of 20 patients). HBOT as additional treatment was applied in 9 patients.Conclusions: Hyperbaric oxygen therapy can be considered as safe adjuvant treatment option in individual cases of proceeding with cochlear implant extrusion with signs of wound infection.Significance: HBOT may contribute to reducing the need for cochlear implant explantation due to infectious skin flap complication.

Outcomes of Nasal Septal Perforation Repair Using Combined Temporoparietal Fascia Graft and Polydioxanone Plate Construct

Importance

Numerous techniques are used for septal perforation repair, yet success rates remain variable. Few studies have evaluated the effectiveness of interposition grafts of polydioxanone plates combined with a temporoparietal fascia graft for septal perforation repair.

Objective

To investigate and describe the use of interposition grafts of polydioxanone plates combined with a temporoparietal fascia graft for septal perforation repair and the expansion of this technique to patients with more challenging comorbidities, including granulomatosis with polyangiitis.

Design, Setting, and Participants

A retrospective medical record review was performed of patients who underwent septal perforation repair using interposition grafts of polydioxanone plates combined with a temporoparietal fascia graft from January 1, 2015, to July 1, 2018, at Vanderbilt University Medical Center and from January 1, 2017, to July 1, 2018, at the University of Iowa.

Intervention

All patients underwent septal perforation repair with interposition grafts of polydioxanone plates and a temporoparietal fascia graft.

Main Outcomes and Measures

Assessing closure of septal perforation was the primary outcome. Secondary outcomes were resolution of presenting symptoms of septal perforation, area of perforation, length of postoperative stent and silastic sheeting placement, postoperative complications and resolution, and duration of follow-up. Preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE) scores were assessed.

Results

A total of 17 patients (12 women and 5 men; mean [SD] age, 45 [15] years) were included. The causes of perforations were iatrogenic (9 [53%]), rheumatologic (2 [12%]), and unknown or idiopathic (6 [35%]). Patients most commonly presented with nasal crusting (12 [71%]), whistling (9 [53%]), nasal obstruction (9 [53%]), and epistaxis (5 [29%]). Mean (SD) perforation size was 0.99 (1.04) cm2. Mean (SD) postoperative follow-up was 6.1 (4.1) months. A total of 15 patients (88%) had complete resolution of presenting symptoms at last follow-up. All perforations were closed with overlying mucosa at the most recent follow-up examination. Nine of 17 patients completed both preoperative and postoperative NOSE. There was a significant difference between the mean (SD) preoperative and postoperative NOSE scores (62.78 [27.74] vs 17.78 [15.83]; P = .004).

Conclusions and Relevance

Repair of symptomatic nasal septal perforations using a temporoparietal fascia graft combined with a polydioxanone plate was associated with positive outcomes. Repair of septal perforations caused by rheumatologic disease, including granulomatosis with polyangiitis, can be considered for repair using this technique. Resolution of symptoms appeared to be clinically more meaningful in evaluation of septal perforation repair than rate of perforation closure, and the NOSE scale has the potential to serve as an objective corroboration to patient-reported postoperative outcomes.

Level of Evidence

4.

Ideal Flap Cover for the Salvage of Exposed/Infected Cochlear Implants: A Case Series and Literature Review

With an increase in the number of cochlear implant surgeries there is bound to be an increase in the number of complications. A dreaded problem in any implant procedure is the implant exposure and infection. Explantation of the implant leads to an unpleasant situation to the patient and the surgeon owing to the high cost of the device. There are reports in the literature favouring the mandatory relocation or removal of the infected implants. On the other hand, there are convincing reports of implant salvage using skin, muscle or fascial flaps. In this paper we have analysed a series of cases referred to us from the departments of E.N.T for the management of implant exposure/infection. We have also reviewed similar case series reported in the literature. From 2014 to 2017 we operated six cases of exposed cochlear implant. We salvaged the implant in five cases, where we could do two layer coverage consisting of the inner temporoparietal fascial flap and outer scalp skin flap. In one case where the temporoparietal fascial flap could not be done as superficial temporal vessels were found to be injured in the previous surgery, the implant was removed due to persistent infection. All these cases were administered appropriate antibiotics for a minimum period of 3 weeks. Early double layer closure with inner temporoparietal fascial flap and outer scalp rotation flap coupled with appropriate antibiotics can salvage an infected, exposed implant.

Microvascular free tissue transfer and cochlear implants: A case series and literature review

OBJECTIVE

The use of microvascular free tissue transfer (MVFTT) for defects of the scalp and lateral temporal bone in patients with cochlear implants (CI) is uncommon. Herein, we report our experience with the utility, indications, and outcomes for MVFTT in patients with cochlear implants.

METHODS

A retrospective review of patients at our institution from September 2016 to December 2017 identified subjects with coexistent cochlear implant and ipsilateral MVFTT of the lateral temporal bone or scalp. Information including demographics, indication for MVFTT, timing of CI and MVFTT, donor site, and previous radiation to the head and neck was collected. To assess the current literature on MVFTT in CI patients, a MEDLINE search was performed using key search terms.

RESULTS

Two patients with cochlear implants and MVFTT of the ipsilateral temporal bone or scalp were identified. One patient underwent MVFTT for advanced device extrusion with stable audiometric parameters rather than locoregional reconstruction or device explantation. The second patient had primary cochlear implantation at oncologic lateral temporal bone resection (LTBR) and MVFTT for locally advanced squamous cell carcinoma and concurrent profound sensorineural hearing loss (SNHL). A literature review identifies MVFTT as an option for advanced device extrusion, treatment of osteoradionecrosis, and reconstruction after primary oncologic surgery.

CONCLUSION

MVFTT is an important reconstructive tool for patients with functional, exposed cochlear implants. Cochlear implantation for severe to profound SNHL should be considered at the time of primary oncologic surgery and MVFTT of the lateral temporal bone or scalp.

LEVEL OF EVIDENCE

IV Laryngoscope, 130:1552-1557, 2020.

Reconstruction of a scalp defect due to cochlear implant device extrusion using a temporoparietal fascia flap and a split-thickness skin graft from the scalp

Cochlear implant extrusion, which is a common complication of cochlear implants, is generally repaired by a well visualized soft-tissue flap. A 61-year-old female patient with a medical history of schizophrenia who had a skin ulcer that caused cochlear implant extrusion, but that would be a stronger statement was referred to our department for removal of the implant and reconstruction of the resultant scalp defect. Accordingly, the broad defect was covered via rotation of a temporoparietal fascia flap (TPFF) using the superficial temporal artery, with the pedicle in the preauricular region as the pivot point. Coverage of TPFF was achieved with a split-thickness skin graft using the scalp as the donor site, which led to a quick recovery after the operation and satisfactory results in terms of aesthetics. This case suggests that a TPFF might be used as a flexible flap with low donor site morbidity for reconstructing cases of cochlear implant extrusion accompanied by a large full-layer scalp defect.

Reconstruction of Deep Burn Wounds Around the Ankle With Free Fascia Flaps Transfer and Split-Thickness Skin Graft

We aimed to introduce a technique by combining free fascia flaps transfer with split-thickness skin graft for the reconstruction of deep burn wounds at the ankle. Fifteen patients from 2009 to 2016 were enrolled in this study. Patients in this series suffered from a deep burn injury around the ankle, which was accompanied with exposure of tendon and medial or lateral malleolus exposure due to severe soft-tissue defects (N = 15). All the 15 wounds were repaired combining free fascia flaps with split-thickness skin graft operations, including nine anterolateral thigh fascia lata flaps (ATFL flaps) and six superficial temporal fascia flaps (STF flaps). All the fascia flaps completely survived. Two patients showed partial grafting skin necrosis due to either wound infection or subcutaneous hematoma infection, and this was eventually healed satisfactorily after conventional dressing change. All patients achieved esthetic outcome and acceptable functionality without further revisions needed. Our present study reports a useful method that involves using free fascia flaps in combination with split-thickness skin graft to repair deep burn wounds around the ankle. This method provided reliable and durable soft-tissue coverage with good outcomes.

The Temporoparietal Fascia Flap is an Effective Strategy for Cochlear Implant Wound Coverage

OBJECTIVE

To report the rate of major soft tissue complications after cochlear implantation and to describe the use of the temporoparietal fascia (TPF) flap for such complications.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary care, University Hospital.

SUBJECTS AND METHODS

Chart review of all patients who underwent cochlear device implantation over a 5-year period to identify patients and to determine the rate of soft tissue complications. Five patients with major soft tissue complications underwent TPF flap with device salvage or explantation/reimplantation.

RESULTS

The rate of major skin complications was 6 out of 281 (2.1%) over 5 years, with 5 patients undergoing TPF flap. The average follow-up was 25.8 months (range, 5-58 months). TPF flap represented the definitive, successful solution for all 5 patients. One postoperative hematoma occurred after TPF flap, with no long-term sequelae. The average hospital length of stay was 2.2 nights (range, 1-5 nights). One patient required IV antibiotics for 4 weeks; the remaining patients were treated with a postoperative course of oral antibiotics. The original device remained in place for 4 patients, while one case required device explantation and staged re-implantation. Post-TPF flap hearing results were equal to if not superior to their preoperative results.

CONCLUSION

Major soft tissue complications following cochlear device implantation are rare. The temporoparietal fascia flap is an excellent option for reconstruction of device site soft tissue dehiscences when local wound care and primary closure are not sufficient, and can potentially prevent explantation of a functional implant.

Free Vascularized Anterolateral Thigh Fascia Lata Flap for Reconstruction in Electrical Burns of the Severely Damaged Finger

This study aimed to introduce a novel technique for reconstructing electricity-damaged fingers using a method combining the free vascularized anterolateral thigh fascia lata flap with skin grafting. From February 2015 to March 2017, 11 patients were enrolled in this retrospective case series. All patients suffered from electrical injury of the fingers and had severe soft tissue defects, with the exposure of tendon, vessels, or nerves. All finger wounds were covered using free vascularized anterolateral thigh fascia lata flaps combined with skin grafting. Eleven fascia flaps completely survived. Two patients suffered from partial grafting skin necrosis due to wound infection and subcutaneous hematoma, separately, which eventually healed after re-graft and dressing changes. All patients achieved satisfactory function and appearance without a need for repeated grafting. Except for the scar, no donor-site morbidity was reported. The present study provided an attractive option for treating electricity-damaged fingers with good outcomes and minimal donor-site morbidity.

Pediatric cochlear reimplantation: Decision-tree efficacy

OBJECTIVES

The context leading to pediatric cochlear reimplantation (CreI) can be complex. The objectives of this study were to define initial CreI indications, analyze final diagnosis and draw up a decision-tree.

METHODS

A retrospective study included patients undergoing CreI between 2005 and 2015. Demographic characteristics, CreI circumstances and technical reports were collected. Circumstances indicating CreI were classified in 3 groups: performance decrement, suspected device failure, or medical. After CreI, final diagnoses were classified in 2 groups: confirmed failure (DFail) or medical (DMed).

RESULTS

69 out of 734 cochlear implantation surgeries were for CreI (8%). Manufacturers' reports were available in 64 cases (93%). Two principal causes were found: trauma and infection. Initial indications were: performance decrement: 27%; device failure: 56%; and medical: 17%. Final diagnoses were: DFail: 72%; and DMed: 28%. Initial indication and final diagnosis were similar in 86% of cases. The majority of the 14% initial indication errors belonged to the "performance decrement" group. Traumatic causes correlated with risk of initial indication error (P=0.039).

CONCLUSION

Apart from spontaneous device failure, the two causes of CreI were infection and trauma. Using the present decision algorithm, half of the complex cases were resolved after CreI.