Defining the protruding ear.

OBJECTIVE: Although protruding ears are one of the most frequently occurring congenital deformities in the craniofacial area, there is no clear consensus in literature as to the definition. Our aim was to provide a clear delineation for the definition of prominent ears, deduced from the anthropometry of normal (nonprotruding) ears. METHODS: We performed a prospective cohort study to assess the anatomy of the normal auricle in children using computer-assisted anthropometry in photographs of 102 children aged 5 to 18 years. We compared the anatomy to retrospectively assess photographs of 44 patients who were listed for prominent ear correction. RESULTS: Our results show that protrusion differs statistically between sexes. In view of these data, an ear could be defined as prominent when the upper protrusion exceeds 21.5 mm or the lower protrusion exceeds 20.0 mm in boys and the upper protrusion exceeds 17.5 mm or the lower protrusion exceeds 15.5 mm in girls. Using these demarcations, 87.5% of our operated prominent ears would qualify as a prominent ear. In addition, we found that prominent ears have larger auricular lengths and consequently larger surface measurements compared with normal ears (P = 0.001). Up to 19.3% of the normal ears showed an asymmetry of more than 3 mm concerning protrusion. CONCLUSIONS: Protrusion differs significantly between sexes. This indicates that different criteria should be used to judge protrusion in boys and girls. None of our prominent ears exceeded only the demarcation in the lower protrusion, suggesting that upper protrusion plays a larger role in the perception of prominence than lower protrusion and should therefore be the main objective of corrective otoplasty. Furthermore, the variation of asymmetry of protrusion in the normal population indicates that an often used success criteria in otoplasty of an asymmetry less than 3 mm may be too strict.

Reconstruction of nasal tip and columella.

Reconstruction of nasal tip and columella defects is demanding area with a range of reconstructive options, varying in complexity depending on requirements from simple skin grafting to multiple stage reconstruction with regional flaps. A framework is suggested to aid the reader in choice of reconstruction by classifying the defect based on size and the requirements of one to three layer (full thickness) reconstruction.

Eighteen years of experience in Mohs micrographic surgery and conventional excision for nonmelanoma skin cancer treated by a single facial plastic surgeon and pathologist.

OBJECTIVES/HYPOTHESIS: To determine and compare the efficacy of Mohs micrographic surgery (MMS)- and conventional excision (CE)-confirmed resection of nonmelanoma skin cancers (NMSCs). STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective cohort study of NMSCs treated in a tertiary referral center by a single facial plastic surgeon and a group of five histopathologists over an 18-year period. The treatment modality was either MMS or CE. The primary outcome measure was recurrence of disease. The secondary outcome measure was the size of resulting surgical excision defect. RESULTS: Between 1990 and 2008, 795 patients were treated with MMS and 709 with CE. The median follow-up period for MMS was 24 months and for CE 16 months. Disease recurred in 6/795 and 7/709 patients, respectively (P = .78). Analysis of the resection defects with general linear models adjusted for localization and primary or recurrent disease showed significantly smaller defects after MMS (P = .008). CONCLUSIONS: This study demonstrates that: 1) MMS and CE are safe in terms of recurrence rates in NMSCs; 2) MMS can be performed adequately by an experienced facial plastic surgeon in close collaboration with a group of pathologists; and 3) the advantage of MMS is that resection defects can be minimized in important aesthetic and functional areas, such as the nose and eyelid, possibly facilitating the reconstruction.

How well are European Society of Cardiology (ESC) guidelines adhered to in patients with syncope?

The ESC guidelines on syncope were published in 2001 and updated in 2004. Adherence to the recommendations enables early stratification of low and high risk patients and prevents unnecessary investigations and admissions. Vasovagal syncope (VVS) is the commonest cause of syncope in all age groups and a low risk condition. The study objective was to determine whether the ESC guidelines were adhered to prior to referral to a syncope unit; 100 consecutive patients with unexplained syncope (52 +/- 23 (15-91) years); 53 female. Sixty-six patients had VVS. Forty nine (75%) of patients with VVS had undergone unnecessary investigations prior to diagnosis and 31 (47%) were admitted to hospital for investigation. Research from other countries confirms that adherence to the ESC guidelines expediates accurate diagnosis, improves resource utilization and reduces health care cost. Greater awareness amongst Irish practitioners of guidelines may improve syncope management and reduce costs.

Nasal valve surgery; our experience with the valve suspension technique.

OBJECTIVE: To describe and evaluate our experience with the surgical technique of nasal valve suspension for treating nasal valve insufficiency. METHODS: Twenty patients with nasal valve insufficiency underwent nasal valve suspension (a total of 33 sides). The patients were prospectively studied and their nasal patency was rated per side pre- and postoperatively, by subjective self-evaluation on a scale from 1 to 10. RESULTS: Post-operatively 7 sides (21%) were rated as unchanged, on 17 sides (52%) the improvement was from 1 to 3 out of 10, and on 9 sides (27%) 4 or more out of 10. The average post-operative improvement for all sides was 2.3 out of 10. In five patients (25%) complications occurred, such as pain, inflammation and suborbital swelling and three eventually underwent a re-exploration of the surgical area, resulting in a permanent scar in one patient. CONCLUSIONS: Although nasal valve suspension may be beneficial for some patients, based on our experience, we would not recommend this technique as first line treatment for nasal valve insufficiency. In this series we found relatively limited improvement in most patients and a far higher complication rate compared with other nasal valve procedures we have had experience with in the past.

Reconstruction of dorsal and/or caudal nasal septum deformities with septal battens or by septal replacement: an overview and comparison of techniques.

OBJECTIVES: The objectives of this study were to describe and compare two techniques used to correct nasal septum deviations located in the dorsal and/or caudal septum. STUDY DESIGN: The authors conducted a retrospective clinical chart review. METHODS: The authors conducted a comparison of functional and technical results between surgery in the L-strut of the septum in 114 patients with septal battens or by septal replacement by subjective self-evaluation and by examination of the position of the septum during follow up. RESULTS: There was subjective improvement in nasal breathing in 86% of the septal batten group and in 94% of the septal replacement group. This difference was not statistically significant. The technical result was judged by examining the position of the septum during follow up as midline, slightly deviated, or severely deviated. The septum was significantly more often located in the midline during follow up in the septal replacement group than in the septal batten group. CONCLUSION: Treatment of deformities located in the structurally important L-strut of the septum may be technically challenging and many functional, structural, and esthetic considerations must be taken into account. On the basis of this series, both septal battens and septal replacement techniques may be considered for correction of deviations in this area. The functional improvement rates were not significantly different between the techniques, although during follow up, the septum appeared to be significantly more often located in the midline in the septal replacement group. The techniques are described and their respective advantages and potential drawbacks are discussed.

Endonasal spreader graft placement as treatment for internal nasal valve insufficiency: no need to divide the upper lateral cartilages from the septum.

OBJECTIVE: To describe and evaluate results of a surgical procedure to treat internal nasal valve insufficiency with the use of spreader grafts placed via an endonasal approach without division of the upper lateral cartilages from the nasal septum. DESIGN: Eighty-nine patients with complaints of nasal obstruction, at least partially due to internal nasal valve insufficiency, underwent this operation on 120 sides in a private practice setting. Only autologous material was used, and 3 different techniques for fixating the grafts were evaluated. All patients were prospectively studied, and subjective self-assessment was used to quantify the result of the operation. RESULTS: On 53 sides (44%) nasal breathing was described as "optimal," and on 53 sides (44%) the result was deemed "improved." On 13 sides (11%) no change was noted, and on 1 side (1%) the postoperative situation was judged to be worse. CONCLUSIONS: When opting for spreader grafts to treat internal nasal valve insufficiency, one does not necessarily need to perform an external approach, nor is separation of the upper lateral cartilages from the septum required. The endonasal technique presented herein is less invasive and can be used in conjunction with other procedures aimed at improving nasal patency.

Continent small-intestine reservoir construction: a tapered intussusceptum promotes sustained continence.

Developed for the study of dialysis in the continent jejunal reservoir (CJR), a novel, uncomplicated approach to achieve continence in construction of a small-bowel reservoir is presented. We utilize a technique of constructing a continent nipple valve, which entails the reduction or tapering of the intussusceptum prior to invagination into the reservoir. We have thus far performed the procedure successfully in 21 dogs. All animals have achieved absolute continence. Complications have occurred in two animals, neither complication involving the nipple valve. Pressure-volume cytometry in nine animals demonstrates continence in the awake animal at pressures of up to 40 cm H2O (volumes being limited by animal discomfort due to reservoir distention). In postmortem studies, reservoir capacities of > 1000 ml and pressures of > 70 cm H2O have been attained without loss of continence or prolapse of the nipple valve. Continence is sustained even when the reservoir and nipple valve are subjected to high intraluminal pressures. Incorporating a tapered intussusceptum, the continent reservoir provides absolute continence without the use of cumbersome mesh fixation or lithotropic intraluminal staples.

Survival of human sperm following controlled- and noncontrolled-rate cryopreservation.

The purpose of this study was to develop a noncontrolled-rate (NCR) method of freezing semen in cryovials which could be used as a backup to controlled-rate (CR) freezing when the CR freezer was being utilized for freezing of human embryos or oocytes. Semen was frozen with three concentrations of glycerol (0%, 3.75%, 7.5%) in cryoprotective media in a CR freezer or using a newly developed NCR method of freezing. Semen was thawed in 40 degrees C water or in air at room temperature (RT). Controlled-rate freezing and 40 degrees C thawing resulted in significantly greater postthaw sperm motility and motility index compared with NCR freezing and RT thawing. Sperm velocity and linearity were not significantly effected by rate of freezing or thawing except when there was no glycerol present in the cryoprotective media. Postthaw motilities following CR-40 degrees C, NCR-40 degrees C, CR-RT and NCR-RT freezing-thawing were 25.6%, 24.8%, 21.6% and 18.3%, respectively. Because NCR freezing resulted in only a 0.8% decline in motility compared with CR freezing when semen was thawed at 40 degrees C it appears that this new NCR method of freezing can be successfully used as a backup to CR freezing when the CR freezer is being used for embryo or oocyte cryopreservation.