Tissue Expansion: Its Cost Factor To the Editor.\p=m-\Itwas very informative reading the original article on "Tissue Expansion of the Head and Neck: Indications, Techniques, and Complication" by Baker and Swanson.1 They mention that the use of skin expansion reduces overall cost of the reconstruction. It is not so in the developing countries. Although the tissue expanders are available in many countries, they are out of reach for most of the patients and the plastic and reconstructive surgery centers in the developing countries due to the high cost. Each expander costs around $400 to $500, while an average surgical procedure in our country costs only $150 to $200. Further, as the authors mention, it involves two surgical procedures, requires frequent visits to the office, and causes

refer to the fact that vocal fold stripping should be considered an obsolete procedure. I understand the point they are trying to make and do not disagree with the concept they are try-




I do think, however, as an editor, you should not allow this kind of statement to appear in the literature. The article would have had just as much validity without that comment. I, for one, would hate to be in a court of law defending a suit brought for vocal

problems following laryngeal surgery

and have to read that sentence out loud after I had performed a vocal cord stripping. Clearly, the vast majority of ear, nose, and throat surgeons across the not performing indirect, microlaryngostroboscopic surgery un¬



der local anesthesia for these kinds of

problems. I can see absolutely no use¬ ful purpose in allowing that kind of gratuitous comment to appear in the temporary deformity leading literature. I think it could have easily

to considerable labor loss. Consider-

ing all these factors, tissue expansion

is not a cost-effective procedure for an average person, at least in the developing countries. The advantages of tissue expansion over other proce¬ dures are irrefutable. AROON AGRAWAL, MCH

Pondicherry, India 1. Baker SR, Swanson NA. Tissue expansion of head and neck: indications, technique, and complications. Arch Otolaryngol Head Neck Surg.


been edited out. JEROME E. FRENCH, MD Wichita, Kan

1. Mahieu HF, Dikkers FG. Indirect microsurgery. Arch Otolaryngol

laryngostroboscopic Head Neck

Surg. 1992;118:21-24. In Reply.\p=m-\Wethank Dr French for his remark concerning the juridical problems that he feels might be incited by our statement that "vocal fold stripping should be considered an obsolete procedure. ." Dr French, in quoting our statement, however, did not include the last two words ". . for phonosurgery" of the original statement, which makes a lot of difference. Maybe for good understanding a definition of "vocal fold stripping" is required. In our view, vocal fold stripping is a procedure in which large parts, or the whole, of the vocal folds mucosa is grasped with a forceps and pulled, or cut, off the vocal ligament, .



regard of the delicacy that is required for dissection within Reinke's space. We wish to stress that the statement holds true only for phonosurgical procedures. In cases where malignant or premalignant lesions of the vocal folds are suspected, stripping is still considered good practice by most colleagues on oncological grounds. We would, however, like to give in con¬ sideration an alternative approach in such cases: to perform a videolaryngostroboscopy and take selective bi¬ opsy specimens from those lesions that are

stroboscopically most suspicious.

Lesions with a tendency toward infiltrative growth are readily de¬ tected by laryngostroboscopy. Subtle changes in the mucosal wave pattern can be detected in an early stage and can lead to early diagnosis of carci¬ noma in situ or microinvasive carci¬ noma. Vocal fold stripping with the obvious risk of voice deterioration can thus often be avoided, without com¬

promising oncological principles.

It must be clear that it never has been our intention to provide legal counselors with material to sue col¬ leagues from the United States. This is a problem with which we are not fa¬ miliar, since malpractice suits are ex¬ tremely rare in Europe. The statement has been made from a purely medical professional point of view and, in our opinion, can be maintained as such. HANS F. MAHIEU, MD, PHD FREDERIK G. DIKKERS, MD Amsterdam, the Netherlands


Vocal Fold


To the Editor.\p=m-\Iwas reading the January issue of the Archives, and came across a comment in the article on microlaryngeal surgery, by Mahieu and Dikkers,1 that upset me. In the middle of the sixth paragraph, they

Stroboscopy and Phonosurgery To the Editor.\p=m-\Weread with interest the article by Mahieu and Dikkers1 on indirect microlaryngostroboscopic

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Vocal fold stripping.

Tissue Expansion: Its Cost Factor To the Editor.\p=m-\Itwas very informative reading the original article on "Tissue Expansion of the Head and Neck: I...
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