Gender Facial Affirmation Surgery; Techniques for Feminizing the Chin.

The shape and size of the chin are very important in feminizing the lower third of the face, and osseous genioplasty is commonly used in FFS. Different variations of the osseous genioplasty can be used to feminize the chin. The 1-piece genioplasty reduces the size and rounds the chin. 2-piece genioplasty reduces or increases the projection of the chin, but retains the same shape. 3-piece genioplasty also reduces or increases the projection, but has the additional benefit of narrowing the chin. This narrowing helps to create the "V" shaped lower face that is often desired by patients seeking facial feminization. Protection of the mental nerve and resuspension of the mentalis muscle is essential to prevent permanent lower lip numbness and ptosis respectively.

Developments in facial feminization surgery.

PURPOSE OF REVIEW: Facial feminization surgery (FFS) is being performed by facial plastic surgeons with increasing frequency. As insurance companies expand benefits to cover these procedures, more and more institutions are developing programs to treat transgender patients. The purpose of this review is to summarize recent literature on the subject so that those interested in this subject may have a framework to analyze these works. RECENT FINDINGS: The most significant findings are that FFS does appear to be safe with low complication rates, despite long operative times due to multiple procedures performed. Much of the recent literature is reviews of each practice's techniques. This is valuable to educate those interested in beginning to perform these surgeries. Further, these reviews can eventually be compiled into a standard of care. Virtual surgical planning is currently being used by some departments, but its value is yet to be determined. SUMMARY: FFS is performed with increasing frequency. Current literature reviews best practices with the goal of eventually establishing a standard of care.

Hairline Restoration: Difference in Men and Woman-Length and Shape.

Hair restoration has become increasingly popular in recent years with both men and women. New technologies such as follicular unit extraction and grafting have made it possible for patients to get a natural looking result with minimal downtime. Men usually experience hairline recession as a result of androgenic alopecia, while women most commonly experience thinning of the crown and vertex, with the preservation of the hairline. However, there is a growing population of women who wish to advance their hairline forward because of congenital high hairline, traction alopecia, or previous facial cosmetic surgery. There are several key differences between the female and male hairline. Understanding such differences and following certain guidelines will help the facial plastic surgeon to obtain beautiful and natural appearing results.

Cosmetic bone contouring.

PURPOSE OF REVIEW: In recent years, cosmetic bone contouring surgery has become increasingly popular, especially in East Asian countries. These procedures are also being requested by patients in the United States at an increasing rate. The purpose of this study is to provide an overview of what is involved with these procedures and their potential complications. RECENT FINDINGS: In some cultures, a wide jaw and a square face are aesthetically unpleasing, whereas an ovoid or 'melon seed face' is thought to be feminine, delicate and beautiful. Mandibular angloplasty, mandibular lateral cortex excision, reduction malarplasty, as well as genioplasty may be performed to alter the facial contour and bring about dramatic results. SUMMARY: Whether a surgeon choses to incorporate these procedures into practice or not, the craniofacial surgeons should be familiar with the procedures as well as the potential complications.

Controversies in the Management of Patients with Cleft Lip and Palate.

Cleft lip and palate is one of the most common congenital anomalies. For many years, surgeons have been attempting to reduce the severity of the deformity before the surgical repair to achieve a better outcome. The nasoalveolar molding technique uses acrylic nasal stents attached to the vestibular shield of an oral molding plate to mold the nasal alar cartilages into a more normal form and position during the presurgical period. Proponents of nasoalveolar molding claim several benefits, including improved aesthetic outcome, reduced overall costs, and a psychosocial benefit to the family. Research on these outcomes is not conclusive.

Controversies in the Management of the Trauma Patient.

Facial trauma is a significant cause of morbidity in the United States. Despite the large volume of trauma surgeries at most academic institutions, there is still controversy regarding management of many traumatic injuries. The literature lacks clear-cut best practices for most fractures. In orbital trauma, there is debate about the optimal timing of repair, preferred biomaterial to be used, and the utility of evaluation afterward with intraoperative computed tomographic scan. In repair of mandible fractures, there is debate regarding open versus closed reduction of subcondylar fractures, or alternatively, endoscopic repair.

A Staging System for Revision Rhinoplasty: A Review.

IMPORTANCE: Rhinoplasty is known to be one of the more technically challenging cosmetic procedures, with a revision rate of 5% to 15%. Reasons for revisions may range from minor deformities that can be treated in the office to major cosmetic and functional defects that require multiple surgical procedures to correct. The literature lacks a uniform scale that systematically evaluates the patient presenting for revision rhinoplasty. The TNM staging system for classifying malignant tumors was developed to aid the physician in planning treatment, providing some information about prognosis, assisting in evaluating the results of treatment, and facilitating the exchange of information. Although the patient presenting for a revision rhinoplasty does not have a potentially lethal disease, a classification system for such patients resembling that used for malignant tumors may provide similar benefits. OBSERVATIONS: As in TNM staging, we describe 3 major components that determine the overall difficulty of surgery for revision rhinoplasty. In our PGS system, "P" represents "problem," consisting of the specific anatomic anomaly with which the patient presents. The second component in our system is "G" for "graft," based on the number of grafts required. The third component of this system is "S," for "number of previous surgical procedures." In addition, we have included a category "E," for "patient expectations," which is added after the stage of the patient's condition has been determined through the PGS classification. CONCLUSIONS AND RELEVANCE: Rather than being measured in terms of survival, as with the TNM system for malignant tumors, the prognosis in revision rhinoplasty is measured in terms of what can be achieved with surgery as opposed to what cannot. This preoperative staging system may help the patient understand the complexity of the repair required and help manage expectations. The PGS system will facilitate exchange of information between surgeons who perform revision rhinoplasty. A standardized evaluation system will allow meaningful comparisons of surgical techniques and evaluations of outcomes of rhinoplasty procedures.

Genetic dysregulation in recurrent respiratory papillomatosis.

OBJECTIVES/HYPOTHESIS: Recurrent respiratory papillomatosis (RRP) is a devastating disease, caused by infection of the upper aerodigestive tract with human papillomavirus types 6 and 11. There is no cure for RRP, and surgical removal is the mainstay of treatment. The purpose of this project was to compare genes of cell cycle, apoptosis, and inflammatory cytokines in laryngeal papilloma versus normal tissue for a better understanding of the molecular mechanisms of the disease to discover novel therapies. STUDY DESIGN: Basic science research study. METHODS: Papilloma tissue was obtained from patients requiring surgical debridement. For comparison, normal mucosa was obtained from the excised uvula of patients undergoing uvulopalatopharyngoplasty. Total RNA was extracted from both groups and then probed using customized reverse transcriptase real time polymerase chain reaction gene arrays. RESULTS: The custom arrays examine expression of 84 separate genes within the cell cycle, apoptosis, and inflammatory cytokine pathways. Our findings based on 11 papilloma samples run in comparison to normal mucosa shows that the MCL-1 gene of the apoptosis pathway is significantly downregulated. cytokine genes IL1-A, IL-8, IL-18, and IL-31 are also significantly dysregulated. CONCLUSIONS: Genes of cell cycle and apoptosis are generally upregulated and downregulated, respectively, as expected in papilloma tissue, with MCL-1 achieving significance when compared to normal tissue. The finding of particular interest is that inflammatory cytokine genes were significantly downregulated, including IL1-A, IL-18, and IL-31. This finding may explain why patients infected with the virus are unable to mediate a T-cell immune clearance of their disease.

Post-tonsillectomy hemorrhage in children with hematological abnormalities.

OBJECTIVE: Tonsillectomy is a common procedure performed in children with the main complication being post-operative hemorrhage. It is uncertain if patients with hematological abnormalities face a higher risk of post-operative hemorrhage. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral hospital. PATIENTS SELECTED: All patients with a known hematologic disorder as well as children without a hematologic abnormality undergoing tonsillectomy with or without adenoidectomy in the past two years at our institution were included in this study. MAIN OUTCOME MEASURE: We sought to determine whether children with hematologic disorders are at an increased risk of post-operative hemorrhage after surgery. RESULTS: Four-hundred and sixty-two patients were identified who underwent a tonsillectomy during this time period. Fourteen patients with hematological abnormalities were identified with only one patient suffering a post-tonsillectomy hemorrhage. All patients with abnormal laboratory values prior surgery underwent medical treatment in conjunction with pediatric hematology and did not suffer a post-tonsillectomy hemorrhage. Despite a small study group, the low incidence (1/14) of post-tonsillectomy hemorrhage in patients with hematological abnormalities suggests that these patients may not be at an increased risk, especially if appropriately evaluated and treated pre-operatively. CONCLUSION: Despite small sample size the results of our study suggest that patients with coagulation disorders may not have an increased risk of post-tonsillectomy hemorrhage when evaluated and corrected pre-operatively.

Discharge after tonsillectomy in pediatric sleep apnea patients.

OBJECTIVES: Outpatient tonsillectomy has gained favor in recent years, however patients with obstructive sleep apnea/hypopnea syndrome have been excluded from outpatient surgery criteria. It is the practice of the senior author to discharge patients after tonsillectomy with a respiratory disturbance or apnea hypopnea index of 5 or less. The purpose of this study is to examine the respiratory complication rate based on respiratory disturbance or apnea hypopnea index, and co-morbidities in order to determine which pediatric patients with obstructive sleep apnea/hypopnea syndrome can be safely discharged after tonsillectomy. METHODS: All patients undergoing tonsillectomy with the diagnosis of obstructive sleep apnea made by polysomnography by a single surgeon from 2008 to 2011 were included. Decision to admit was based on respiratory disturbance or apnea hypopnea index, body mass index, and comorbidities. All inpatient notes, phone calls, and follow up visit documentation were monitored and reviewed for post operative complications. RESULTS: 104 patients were included, 74 patients were admitted post operatively, and 30 were discharged home. There were no complications in the group that was discharged home. In the group that was admitted, there was two minor and two intermediate complications, including desaturations to 92% and 83% requiring oxygen, and wheezing requiring breathing treatment. All complications occurred in patients with respiratory disturbance or apnea hypopnea index of 11 or greater. CONCLUSION: Our data suggest there is a correlation between higher respiratory disturbance or apnea hypopnea index and post operative complications. Patients with an RDI of <5.0, and minimal co-morbidities can be safely discharged home following tonsillectomy for OSAHS. Complications related to sleep apnea were not seen in patients with RDI <11.0, suggesting that patients with an RDI between 5 and 10, who are not obese and have no significant comorbidities may also be sent home after surgery.

The otolaryngologist's approach to the patient with Down syndrome.

As more patients with Down syndrome are living into adulthood, attention has focused on health factors that affect the quality of the patient's life and their ability to reach full potential. Patients with Down syndrome have several morphologic abnormalities that predispose them to problems with the ear, nose, and throat, and appropriate treatment can have a significant impact on the quality of life of these patients. Otolaryngologists are likely to see many patients with Down syndrome throughout their careers. This article reviews the literature to provide information and recommendations regarding management of Down syndrome.

Endoscopic neural blockade for rhinogenic headache and facial pain: 2011 update.

BACKGROUND: Over 45 million Americans suffer from recurrent headaches, and an estimated $11.9 million was spent on doctor's visits for rhinogenic pain last year. Sphenopalatine blocks have been described for various facial pain syndromes, but their use and the type of blockade agents remain controversial. The objective of this study was to demonstrate that endoscopic nerve blocks, using a mixture of bupivicaine and triamcinolone-40, injected into the anterior ethmoid or sphenopalatine regions, can be a relative safe and effective option for refractory pain. METHODS: The charts of all patients undergoing endoscopic neural blockade, in a private practice setting from 1998 to 2008 were retrospectively reviewed. A 1:1 mixture of 0.5% bupivicaine and triamcinolone acetonide injectable suspension was injected into the patients' anterior ethmoid or sphenopalatine neural distribution, or both, depending on the pain distribution. Charts were reviewed to assess outcomes and any adverse events from nerve blocks. RESULTS: A total of 882 nerve blocks were administered to 147 patients, over the course of 431 office visits. Four mild complications, 2 moderate complications, and no severe or permanent complications were noted. No permanent visual complications were observed. Of all the charts, 85% had documented effects of the nerve block at follow-up. Of those, 81.3% claimed improvement, 17.9% reported feeling the same, and 0.79% stated they had worse pain. CONCLUSION: Endoscopic neural blockade appears to be a relatively safe and viable option in the treatment of refractory headache and facial pain with a rhinogenic component.

Ischemic colitis secondary to ergotamine use: a case study.

A 48-year-old woman with a history of chronic migraines, initially admitted for inpatient management of intractable migraine headaches, developed new onset abdominal pain, hypotension, and diarrhea on hospital day number ten. In our institution's headache unit, patients are treated by a multidisciplinary approach, including individualized drug therapy based on diagnosis and previous response to therapy. Given the patient's hypotension and clinical appearance, she was transferred to the intensive care unit and treated for septic shock and metabolic acidosis. A bedside colonscopy revealed diffuse ischemic colitis. Final pathology after colon resection showed widespread, transmural necrosis of the colonic wall. We review the pathophysiology of ergotamine use and its potential association with ischemic colitis.