Asian rhinoplasty.

Asian rhinoplasty is one of the most challenging ethnic rhinoplasties that plastic surgeons perform because of the thick skin and soft-tissue envelope. There are three goals: pleasing the patient, achieving an aesthetically appealing result, and preserving a natural look. Of these goals, the most arduous is to satisfy the patient, as many patients have unrealistic goals and may desire an extremely narrow Western nose. Furthermore, patients may bring in celebrity or model photographs and expect that outcome, even though it may not be suitable for their face or appear over-resected and pinched. The surgeon's most important task is to attempt to persuade the patient that this result is nonfunctional, esthetically unfit, and difficult to achieve with their skin. For ethnic surgery, a clear and thorough grasp of nasal anatomy, function, and surgical techniques is paramount. An extensive preoperative discussion, including expectations, outcomes, and a detailed list of potential complications with the patient can prevent physician-patient miscommunication. Before surgery, it is essential to review the office examination, previous operative summary, photographs, nasal analysis sheet, problem list, and plan before proceeding with the surgical treatment.

Determination of perineural invasion preoperatively on radiographic images.

OBJECTIVE: Perineural invasion in head and neck cancers has important prognostic implications, and even if clinically silent, can be radiographically evident. This study analyzed the frequency of preoperative diagnosis, radiographic features, and importance of the preoperative diagnosis in treatment planning. STUDY DESIGN: Radiographic studies of 38 patients with histopathologically proven perineural spread from head and neck cancer were retrospectively reviewed and compared with preoperative reports. SUBJECTS AND METHODS: The percent agreement with pathology, kappa values, and 95 percent confidence intervals were determined for relevant nerves. Salient radiographic findings were compared with the contralateral normal side. RESULTS: Preoperative agreement was less than 10 percent for all nerves, and retrospectively was 56 percent for the trigeminal nerve and 40 percent for the facial nerve. Radiographic features included neural thickening and enhancement, and foraminal widening. CONCLUSION: Cancers of the head and neck can spread perineurally. Preoperative radiographic determination, although underreported, is imperative, because diagnosis impacts management and prognosis.

Long-term results of 100 consecutive comprehensive neck dissections: implications for selective neck dissections.

OBJECTIVE: The optimal surgical procedure for the neck in patients with squamous head and neck cancers is controversial. Selective neck dissections have replaced modified radical neck dissections as the procedure of choice for the clinically negative (N0) neck and are now being considered for patients with early-stage neck disease. We report the long-term local recurrence rates in 100 consecutive patients undergoing a radical or modified radical neck dissection for clinically positive (N+) and N0 neck disease and review comprehensively the literature reporting and comparing regional control rates for both neck dissection types. PATIENTS: The clinical records of 100 consecutive patients who underwent a comprehensive neck dissection (levels I-V) for squamous head and neck cancers with a minimum of a 2-year follow-up were retrospectively reviewed for primary site of disease, clinical and pathologic neck status, histopathologic grade, neck dissection type, and the site and time of recurrence. RESULTS: Complete data were available for 97 patients on whom 99 neck dissections were performed. Three patients died from unknown causes. Seventy-six patients with N+ disease underwent a therapeutic neck dissection, while 24 patients with clinically N0 disease underwent an elective dissection. The overall neck recurrence rate in patients with controlled primary disease was 7%. The neck or regional failure rate for patients completing the recommended adjuvant radiotherapy was 4%. Six (25%) of 24 patients with clinically N0 disease had occult metastases. The recurrence rate for this group was 4%. CONCLUSION: Further study is needed to determine the optimal surgical management of the N0 and limited N+ neck.

The efficacy of corticosteroids in postparotidectomy facial nerve paresis.

OBJECTIVE: To determine whether the administration of perioperative corticosteroids is effective in ameliorating facial nerve paresis after parotidectomy. STUDY DESIGN: Prospective, randomized, double-blinded, placebo-controlled clinical trial at a university medical center. METHODS: Patients scheduled for parotidectomy and who met inclusion criteria were invited to enroll in the protocol. They were stratified according to the anticipated surgery (superficial or total parotidectomy) and then received one of two doses of dexamethasone (0.51 or 1.41 mg/kg divided into three doses) or placebo solution immediately preoperatively and then every 8 hours for 16 hours postoperatively. The facial nerve was graded for proportion (percentage) of function at each of the four major regions (frontal, orbital, midface and upper lip, and lower lip). The early postoperative function and rate of return of function were compared among the treatment groups. RESULTS: Forty-nine patients were enrolled and evaluated (18 in the control group, 16 receiving low-dose dexamethasone, and 15 receiving high-dose dexamethasone). No therapeutic advantage of dexamethasone treatment could be appreciated with respect to the degree of early postoperative nerve function (81.3% for control patients vs. 69.5% for dexamethasone-treated patients [ =.239]). Similarly, the median time to recovery of complete facial nerve function was 60 days in the control group and was 150 days in the dexamethasone-treated patients. CONCLUSIONS: Dexamethasone administration in patients undergoing parotidectomy is not justified. Despite the relatively modest risk profile of dexamethasone, we were unable to demonstrate any benefit in patients who were treated with either low-dose or high-dose steroids compared with placebo-treated patients in a randomized, controlled trial.