Evidence-Based Performance Measures for Reconstruction after Skin Cancer Resection: A Multidisciplinary Performance Measure Set.

BACKGROUND: The American Society of Plastic Surgeons commissioned the multidisciplinary Performance Measure Development Work Group on Reconstruction after Skin Cancer Resection to identify and draft quality measures for the care of patients undergoing skin cancer reconstruction. Included stakeholders were the American Academy of Otolaryngology-Head and Neck Surgery, the American Academy of Facial Plastic and Reconstructive Surgery, the American Academy of Dermatology, the American Society of Dermatologic Surgery, the American College of Mohs Surgery, the American Society for Mohs Surgery, and a patient representative. METHODS: Two outcome measures and five process measures were identified. The outcome measures included the following: (1) patient satisfaction with information provided by their surgeon before their facial procedure, and (2) postprocedural urgent care or emergency room use. The process measures focus on antibiotic stewardship, anticoagulation continuation and/or coordination of care, opioid avoidance, and verification of clear margins. RESULTS: All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the stakeholder societies. CONCLUSION: The work group recommends the use of these measures for quality initiatives, Continuing Medical Education, Continuous Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.

The I-STOP Program and Narcotic Prescriptions Following Facial Reconstructive Plastic Surgeries.

OBJECTIVES: To explore the effect of e-prescribing requirements on narcotic dispersion in New York State. Slicer Dicer was used to identify patient records based on CPT codes. METHODS: We investigated the influence of New York State e-prescribing requirements on narcotic dispersion following five common facial plastics procedures. Slicer Dicer was used to identify patient records based on CPT codes.We then looked at narcotic prescription rates following those surgeries between March 2014 and March 2018 at an academic institution. RESULTS: Overall, between March 2014 and March 2018, 76.1% of the sample received a narcotic prescription following a facial reconstructive plastic surgery. Patients who underwent rhinoplasty were most likely to receive a prescription for postoperative narcotics. The implementation of ISTOP, CPT code, use of non-narcotic adjuvant, and insurance type were each significantly associated with prescription of postoperative narcotics. Surgery time and age in years were significantly associated with prescription of postoperative narcotics. Ultimately, when controlling for the aforementioned clinical and sociodemographic variables included in the study, those who underwent surgery after the implementation of ISTOP were 42.8% less likely to receive a prescription for postoperative narcotics, aOR = 0.572, 95% CI 0.356, 0.919, p = 0.021. CONCLUSIONS: New York State's ISTOP program has succeeded in reducing the number of postoperative narcotic prescriptions following facial plastic reconstructive surgeries at this academic institution. However, opioid medications can still be utilized for postoperative analgesia when clinically appropriate. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1208-1213, 2024.

The Effects of COVID-19 Surges on Otolaryngology Consults.

Objectives We aimed to evaluate the effects COVID-19 surges had on an otolaryngology service's consultation data. Methods After obtaining Upstate University Hospital institutional review board exemption to perform this research, a retrospective review analyzing otolaryngology consults at a single institution during COVID-19 surges in the years 2020 to 2021 was performed. The total consult volume and emergency department, inpatient, pediatric, adult, weekday, night, and weekend consults were assessed. Statistical analysis was used to compare these findings to the otolaryngology consult volumes and characteristics during the same time frames as the COVID-19 surges in the years 2014 to 2019. Results Based on bivariate analysis, an upward trend in otolaryngology consult volume was found over the study period. Although there was not a significant difference in consult volume during COVID-19 surges compared to historical data (p = 0.718, p = 0.695), both surge periods had significantly lower proportions of emergency department and pediatric consults (p < 0.001 for both). Conclusion Our study demonstrated that despite increasing cases of COVID-19 infection, otolaryngology consult volume remained high during surges. It was found that there has been an increase in otolaryngology consult volume at our academic center from the year 2014 to the present, a finding that was also seen in previous studies from our institution. Interestingly, consult parameters that changed when compared to the historical data included a decreased percentage of emergency department and pediatric consults during COVID-19 surges. The summation of these findings can be used to provide insight into how hospitals and otolaryngology services can prepare for the anticipated fluctuations in COVID-19 cases and associated hospitalizations.

Evaluation of Mobile and Digital Single-Lens Reflex Photography for Facial Surgical Analysis.

OBJECTIVES: High-quality perioperative photography is imperative to good surgical planning in facial reconstructive and aesthetic surgery. We explore the utility of an add-on smartphone telephoto lens to avoid the distortions noted in prior studies using smartphone cameras. METHODS: Standard perioperative photographs of the same subject were taken with three distinct cameras using a dual-ring light setup. The three camera setups iPhone 11 alone, iPhone 11 with the 58 Moment telephoto lens attachment, and a D3300 Nikon DSLR APS-C sensor camera with a 60 mm NIKKOR F2.8G ED macro lens were compared using a 47-question online survey consisting of demographic and image-specific questions sent to plastic surgeons. RESULTS: Forty-nine facial plastic surgeons completed the survey. The iPhone 11 alone was identified as having the lowest quality for central/peripheral distortion (83%), columella/caudal septum/alar anatomy (58.3%), and skin quality (38.3%). With the addition of the telephoto lens, the ability to assess all categories was significantly improved. 53.1% (n = 26) of respondents found the iPhone 11 + 58 mm telephoto lens setup to be the most useful for perioperative surgical planning. CONCLUSIONS: Smartphone photography with the addition of a telephoto lens can offer a comparable option to the DSLR with regard to photo quality and detail. SUMMARY: A telephoto add-on lens is an effective solution to overcome the central distortion seen in images taken by the iPhone for perioperative photography. This photo quality was found to be comparable to that of traditional DSLR cameras in our survey study. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:2590-2596, 2023.

Facial Trauma During the COVID-19 Pandemic.

Study Design: Retrospective cohort study. Objective: The purpose of this study is to evaluate the impact of the COVID-19 global pandemic on the regional trends in facial trauma at a tertiary care, level 1 trauma center in Central New York. Methods: The study sample was derived from the population of patients who presented with facial trauma to the emergency department at the Downtown and/or Community Campuses of SUNY Upstate University Hospital between March 1, 2020, and May 15, 2020, and compared to two historical controls in 2018 and 2019. Descriptive and bivariate statistics were calculated for study variables in each cohort. Poisson regression was used to compare incident rate ratios (IRR) with 95% confidence intervals with significance set at P < .05. Results: Sixty five patients presented during the COVID-19 pandemic, while 83 presented in 2019 and 95 in 2018. For the study period, the most common mechanism was assault in 47.7%. IRR was significantly lower than in 2018 (IRR = 1.46, P = .018), but not significantly different from 2019 (IRR = 1.28, P = .14). During lockdown, IRR was significantly decreased compared to 2019 (IRR = 1.84, P = .0029) and 2018 (IRR = 2.16, P < .001). Conclusions: The volume of facial trauma seen in Central New York appears undeterred in the absence of "shelter in place" orders. Analysis of pandemic and regional trauma variations can offer valuable insight for improved resource allocation to better prepare for potentially high-risk procedures.

Utilization of Rhinoplasty Worksheets among Practicing Facial Plastic Surgeons.

Rhinoplasty is the most commonly performed procedure by facial plastic surgeons, yet many consider it the most complex and variable surgery performed. Yet no standardized surgical worksheet has been established to document the maneuvers and anatomical changes made despite the known high rate of revision surgery. This study aimed to assess the utility and utilization of rhinoplasty surgical worksheets amongst facial plastic surgeons, as well as the perceptions and attitudes toward standardization of a common rhinoplasty surgical worksheet. METHOD: We distributed an online survey to all active members of the American Academy of Facial Plastic and Reconstructive Surgery, in order to assess trends in utilization of surgical worksheets and the willingness of physicians to adhere to a standardized worksheet to be included in patient's medical records. RESULTS: When surveyed, 84 of the 130 respondents reported using a surgical worksheet, with 63 of 84 mentioned using a variation of their own custom worksheets. Of the 84 surgeons, 45 used these worksheets "often" or "always" during follow-up appointments. However, 111 of the 130 reported "never" or "rarely" receiving a surgical worksheet from another provider for revision rhinoplasties. In total, 96 of the 130 respondents were "strongly in favor" or "in favor" of sharing worksheets with other providers and 87/130 were in favor of establishing a standardized rhinoplasty worksheet for all rhinoplasty patients. CONCLUSIONS: A majority of respondents reported using surgical worksheets for rhinoplasties with very few reporting ever receiving other surgeons' worksheets prior to revision rhinoplasties. Roughly three fourths of respondents were in favor of sharing worksheets along with a majority in favor of a standardized worksheet. This would represent a significant change in practice along with potentially increased collaboration between surgeons and subsequent advancement of patient care.

Reusable vs disposable nasopharyngolaryngoscopes: Cost analysis and resident survey.

OBJECTIVE: Assess the quality of a new disposable nasopharyngolaryngoscope (NPL) through resident feedback at multiple academic institutions and provide a cost analysis of reusable and disposable NPLs at a single academic center. STUDY DESIGN: An online survey was distributed to residents at institutions throughout the United States that have implemented use of a disposable NPL (Ambu aScope 4 Rhinolaryngo). SETTING: Cost analysis performed at a single academic center. Resident survey distributed to multiple residency programs throughout the United States. SUBJECTS AND METHODS: The survey collected demographic information and asked residents to rate the new disposable NPL and other reusable NPLs using a 5-point Likert scale. A cost analysis was performed of both reusable and disposable NPLs using information obtained at a single academic center. RESULTS: The survey was distributed to 109 residents throughout the country and 37 were completed for a response rate of 33.9%. The disposable NPL was comparable to reusable NPLs based on ergonomics and maneuverability, inferior in imaging quality (P < .001), and superior in setup (P < .001), convenience (P < .001), and rated better overall (P < .04). The disposable NPL was found to be cheaper per use than reusable NPLs at $171.82 and $170.36 compared to $238.17 and $197.88 per use for the reusable NPL if the life span is 1 year and 5 years respectively. CONCLUSION: Disposable NPLs may offer an alternative option and initial feedback obtained from resident physicians is favorable. Cost analysis favors disposable NPLs as the cost-effective option. LEVEL OF EVIDENCE: NA.

Recent developments in head and neck melanoma.

PURPOSE OF REVIEW: To provide an overview of recently published articles covering melanoma management of the head and neck region. RECENT FINDINGS: Melanoma management represents a rapidly evolving field. The advent of immunotherapy has led to significant changes in diagnosis, treatment, and surveillance for these patients. Invasive interventions including completion lymph node dissection have been largely replaced with increased surveillance driven by robust data showing no significant difference in overall survival. Studies have explored various treatment regimens that offer improved outcomes with the least adverse events, with a recent trend towards neoadjuvant therapy. Research has also shifted towards better understanding genetics and biomarkers that influence response to these medications. The best means to both identify and monitor these changes is being explored. As our understanding of this complex disease process continues to grow, prognosis in patients suffering with melanoma should continue to improve. SUMMARY: The expansion of immunotherapy use in melanoma management has led to significantly improved prognosis in diagnosed patients. Present research is largely focused on better understanding the ideal patient populations, dosing, and surveillance for these therapies. Data from these studies will be crucial in better staging and treating patients with melanoma.

Vibration Versus Ice to Reduce Cosmetic Botulinum Toxin Injection Pain-A Randomized Controlled Trial.

Botulinum toxin is the most commonly performed facial cosmetic procedure and pain at the injection site is a frequent patient concern. While various topical interventions have been described for analgesia, there have not been any studies comparing different techniques. We compared the use of a vibratory stimulus, ice pack application, and no intervention on injection site pain for cosmetic botulinum toxin injection. A prospective-, randomized-, individual-controlled study was conducted using a visual analog scale to assess pain. Patients received bilateral glabellar injections, with randomization into unilateral vibration, unilateral ice application, or vibration and ice on either side. We analyzed 88 injections on 22 patients. Mean visual analog scores were 26.5 (standard deviation [SD]: 23.1) among injections with vibration, 24.4 (SD: 22.9) with ice, and 29.4 (SD: 27.1) without analgesia. There was no significant difference in pain scale scores with the use of vibration, ice, or no topical anesthesia (P = .737). Further, pain scale scores did not differ significantly between medial and lateral injections nor did patients have a reduction in pain on either side of the forehead regardless of which method was used. While there may be a role for topical interventions to improve injection site analgesia, we maintain that consistently proper technique plays a greater role in improving patient tolerance. Future studies will continue to investigate the role of topical anesthesia in cosmetic facial injections and address patient-specific factors contributing to discomfort.

Associations between population based voting trends during the 2016 US presidential election and adolescent vaccination rates.

BACKGROUND: Politics play a role in the dissemination of public health information, including immunization-related issues. We aim to describe relationships between HPV vaccination rates and state voting patterns during the 2016 US presidential election. METHODS: We classified each of the 50 states as either "Red" or "Blue," based on whether a higher proportion of the state's casted votes were for the Republican or Democratic nominee during the 2016 US presidential election. State-specific HPV, Tdap, and meningococcal vaccination rates were obtained from the 2016-National Immunization Survey-Teen. State socio-demographic factors and HPV vaccine legislation were obtained from the US Census Bureau and National Conference of State Legislatures. Vaccination rates and socio-demographic variables were compared using independent t-tests. Multiple linear regression compared vaccination rates between "Red" and "Blue" states, adjusting for percentage of both uninsured children and educational attainment. RESULTS: Compared to "Blue" states, "Red" states had significantly lower unadjusted HPV vaccine series initiation (56% vs 66%, p < 0.05) and completion (39% vs 50%, p < 0.05) rates; yet had similar rates of Tdap (88% vs 89%, p > 0.05) and meningococcal (79% vs 83%, p > 0.05) vaccinations. After adjusting for potential confounders, the regression-adjusted mean rate for HPV vaccine initiation and completion remained significantly lower for "Red" states compared to "Blue" states (57% vs 65%, p < 0.05, and 41% vs 48%, p < 0.05, respectively). CONCLUSION: HPV vaccination rates are associated with statewide-level voting patterns. Future interventions aimed at improving HPV vaccination rates should consider engaging local and national elected leaders to be proactive in disseminating accurate and authoritative immunization information.

Septal fractures predict poor outcomes after closed nasal reduction: Retrospective review and survey.

OBJECTIVES/HYPOTHESIS: To determine outcomes of patients with displaced nasal bone fractures after closed nasal reduction (CNR). STUDY DESIGN: Retrospective patient review. METHODS: Review of all patients presenting to the emergency department of a tertiary-care, level 1 trauma hospital with a nasal bone fracture over a 2-year period, followed by telephone survey after CNR. RESULTS: Six hundred seven patients presented to the emergency department in 2015 and 2016 with a diagnosis of nasal bone fracture. Of these, 134 patients met inclusion criteria and underwent CNR without septal reduction. Those with sports-related injuries and those with a septal fracture identified on computed tomography imaging were significantly more likely to undergo CNR. Ninety-one patients completed the post-CNR telephone survey. Over 90% of patients were satisfied with the procedure. However, patients with septal fractures reported worse outcomes, as 53.6% versus 24.1% (P = .0025) disagreed that CNR improved nasal breathing. Of all patients, 11 (2%) eventually underwent septorhinoplasty, with the presence of septal fracture on imaging a significant risk factor. CONCLUSIONS: Nasal bone fractures are a common injury, often managed initially with CNR. Patients with septal fractures should be counseled on the high risk of posttraumatic nasal deformity and obstruction despite CNR. In addition, addressing a septal fracture found on imaging may be warranted with either closed septal reduction or early aggressive management given the poorer outcomes seen in the present study. Although these patients are more likely to have definitive treatment, many forego later intervention despite persistent symptoms, emphasizing the need for early intervention or close follow-up. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:1784-1790, 2019.

Audiovestibular symptoms as predictors of prolonged sports-related concussion among NCAA athletes.

OBJECTIVE: We looked to determine the rates of audiovestibular symptoms following sports-related concussions among collegiate athletes. Further, we assessed the correlation between these symptoms and the time to return to participation in athletic activity. STUDY DESIGN: Retrospective analysis of the National Collegiate Athletic Association Injury Surveillance System (NCAA-ISS). METHODS: The NCAA-ISS was queried from 2009 through 2014 for seven men's sports and eight women's sports across divisions 1, 2, and 3. Injuries resulting in concussions were analyzed for audiovestibular symptoms, duration of symptoms, and return to participation times. RESULTS: From 2009 to 2014, there were 1,647 recorded sports-related concussions, with athletes reporting dizziness (68.2%), imbalance (35.8%), disorientation (31.4%), noise sensitivity (29.9%), and tinnitus (8.5%). Concussion symptoms resolved within 1 day (17.1%), within 2 to 7 days (50.0%), within 8 to 30 days (25.9%), or persisted over 1 month (7.0%). Return to participation occurred within 1 week (38.3%), within 1 month (53.0%), or over 1 month (8.7%). Using Mann-Whitney U testing, overall symptom duration and return to competition time were significantly increased when any of these symptoms were present (P < 0.05). Duration of concussion symptom correlated with dizziness (P = 0.043) and noise sensitivity (P = 0.000), whereas return to participation times correlated with imbalance (P = 0.011) and noise sensitivity (P = 0.000). Dizziness and imbalance (odds ratio: 4.15, confidence interval: 3.20-5.38, P < 0.001) were the two symptoms with the strongest association. CONCLUSION: Audiovestibular symptoms are common complaints among collegiate athletes sustaining concussions. Dizziness and noise sensitivity correlated with the duration of concussive symptoms, whereas imbalance and noise sensitivity was correlated with prolonged return to competition time. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2850-2853, 2017.

Maxillofacial injuries among National Collegiate Athletic Association athletes: 2004-2014.

OBJECTIVE: Participation in National Collegiate Athletic Association (NCAA) sports increases annually, yet the risk of maxillofacial injuries among these athletes is unknown. We report the incidence and trends in maxillofacial injuries among NCAA athletes. STUDY DESIGN: Retrospective study of the NCAA Injury Surveillance System (ISS) representing athletes from seven men's and eight women's sports across Divisions 1, 2, and 3. Incidence of maxillofacial injuries by sport, gender, anatomic location, and injuries requiring surgery were measured. METHODS: Athlete exposure data from 2004 to 2005 through 2013 to 2014 were analyzed, along with maxillofacial injuries recorded in the NCAA-ISS. RESULTS: There were 2,017 injuries recorded, which projects to 41,204 injuries from 202,087,229 athlete events, or 2.04 injuries per 10,000 athlete events (95% confidence interval [CI], 1.68 to 2.40). Women had higher injury rates, 2.06 versus 2.03 (P = 0.016 [95% CI 0.22 to 2.09]). Highest rates were noted in men's wrestling 7.02 (95% CI, 2.84 to 11.19) and men's basketball 4.80 (95% CI, 3.57 to 6.02), and were lowest in women's ice hockey 0.61 (95% CI, 0.17 to 1.06) and women's volleyball 0.43 (95% CI, 0.20 to 0.66). No gender differences in fractures or need for surgery, but men sustained more operative fractures, 27.85% versus 17.04% (P = 0.035 [95% CI, 0.79 to 20.82]). Men's football, women's ice hockey, women's volleyball, and women's gymnastics had consistently low fracture rates. CONCLUSION: Maxillofacial injuries represent approximately 3.4% of all injuries sustained by NCAA athletes. Women had a higher injury rate, whereas men had a higher rate of operative facial fractures. Awareness and improved facial protection, especially among noncontact sports, will be crucial in reducing the incidence of these injuries. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1296-1301, 2017.

Decade review of mandible fractures and arch bar impact on outcomes of nonsubcondylar fractures.

OBJECTIVES/HYPOTHESIS: Review trends in mandible fracture management and outcomes in patients treated with and without intraoperative arch bar use. STUDY DESIGN: Retrospective chart review. METHODS: All patients with mandible fractures between October 1, 2001, and October 1, 2011, were reviewed. Excluded were those with concomitant midfacial fractures or inadequate follow-up. RESULTS: Overall, 734 patients sustained 1,312 mandible fractures. Assault was the most common etiology. The parasymphyseal, subcondylar, and angle regions were most likely fractured. In total, 85% of patients underwent open-reduction internal-fixation (ORIF). This overall number had no significant annual deviation. However, use of arch bars to achieve intraoperative maxillomandibular fixation (MMF) with ORIF decreased annually, whereas the use of manual reduction with ORIF increased annually. These trends held statistical significance. Outcomes were reviewed in patients with one or two nonsubcondylar fractures by assessing complications of malocclusion, infection, and malunion. In 228 patients meeting criteria, the incidence of complications was 12.9% in those treated using intraoperative arch bars with ORIF and 12.5% in those using manual reduction with ORIF. When assessing individual complications, there was no statistically significant difference. CONCLUSION: Our data suggest a shifting trend in mandible fracture management. Our techniques for achieving fracture reduction ideal for ORIF favors manual reduction over the use of arch bars in select cases. We found no statistical increase in the incidence of complications when using manual reduction with ORIF in patients with one and two nonsubcondylar fractures. In appropriately selected cases, manual stabilization of fractured segments is an alternative to using arch bars to achieve intraoperative MMF. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:596-601, 2016.

Anatomy of the upper lateral cartilage along the lateral pyriform aperture.

BACKGROUND: The upper lateral cartilages underlie the nasal bones cephalically, and articulate with the nasal septum medially. The authors studied the histologic and anatomical relationships between the lateral aspect of the upper lateral cartilages and the frontal process of the maxilla. METHODS: Six cadaver noses were dissected by open rhinoplasty to expose the upper lateral cartilages bilaterally. Subperiosteal dissection was performed over the medial maxillae and nasal bones to expose the perimeter of the pyriform aperture. Twelve sides were analyzed anatomically. Three cadavers were used to create six tissue specimens for histologic analysis, by resecting the tissue of the upper lateral cartilage-maxillary bone articulation en bloc. RESULTS: Grossly in all specimens, the upper lateral cartilage articulated with the frontal process of the maxilla laterally, lying deep to the coronal plane of the maxillary bone. In four histologic specimens, the upper lateral cartilage was found to underlie the frontal process of the maxilla laterally, displaying an overlapping relationship. In the other two histologic specimens, the upper lateral cartilage ended medial to the maxilla. In all specimens, the ends of the upper lateral cartilage and maxilla articulated by way of a pyriform ligament. CONCLUSIONS: The upper lateral cartilage articulates laterally with the frontal process of the maxilla by means of the pyriform ligament, with a variable amount of overlap between the upper lateral cartilage and maxilla. Relationships among the upper lateral cartilage, maxilla, and pyriform ligament affect the configuration of the lateral internal nasal valve area, and should be considered when planning internal nasal valve reconstruction.

Update on approaches to the craniomaxillofacial skeleton.

PURPOSE OF REVIEW: A myriad of surgical approaches to the craniomaxillofacial skeleton exist. Depending on the purpose of the procedure and the anatomic area to be addressed, classically used approaches include coronal approach, midfacial degloving, eyelid incisions, and other cutaneous incisions. Over the last decade, endoscopic approaches have become more popular. Whether external, transoral, or endoscopic, a detailed knowledge of the indications, anatomy, limitations, and potential complications is critical to the successful employment of these approaches. This article reviews the recent literature on classic as well as novel advancements to the craniofacial skeleton. RECENT FINDINGS: Multiple studies in the last 5 years have investigated the approaches to the craniofacial skeleton. Most of these focus on trauma. Recent advances have concentrated on external versus endoscopic approaches to the mandibular condyle, an endoscopic approach to the midface and orbit, three-dimensional imaging of the facial skeleton, and improving upon the existing classic approaches and techniques. SUMMARY: Approaches to the craniomaxillofacial skeleton continue to evolve with the refinement of classic approaches and advent of new technologies and approaches. This study reviews the recent literature and provides a comprehensive review of options for craniofacial exposure and the most up-to-date surgical options.

Upper lateral strut graft: a technique to improve the internal nasal valve.

BACKGROUND: Internal nasal valve (INV) collapse can contribute significantly to nasal obstruction and may be caused by upper lateral cartilage (ULC) collapse medially or laterally. Surgical techniques addressing INV collapse have focused more on treating the narrowed INV angle, with less consideration of the lateral INV area. This article describes a technique to improve INV patency both medially and laterally. This study analyzes the changes in minimal cross-sectional area (MCA) at the INV after graft placement and determines whether these changes are significantly different for normal versus narrow INVs. METHODS: Noses of six fixed cadavers were dissected by open rhinoplasty to release the ULCs from the septum. Upper lateral strut grafts were placed through subperichondrial pockets along the ULC undersurfaces and out over the piriform apertures into subperiosteal pockets. Grafts were secured to the dorsal septum. Acoustic rhinometry and nasal endoscopy were used to classify INVs before graft placement as narrow or normal and to assess changes at the INV after graft placement. RESULTS: Mean pregraft MCA was 0.58 cm(2). Mean MCA percent increase after graft placement was 22%. By INV type, percent increases were 51% for narrow INVs and 1% for normal INVs. Mean increases in MCA after graft placement were statistically significant for the entire group and for narrow INVs, with increases of 0.10 cm(2) (p = 0.03) and 0.22 cm(2) (p = 0.004), respectively. CONCLUSION: The upper lateral strut graft improved patency of cadaveric INVs, with statistically significant increases in the MCA most notable when placed for narrow INVs.

Tissue conservation using circular defect with dog-ear deformities excision technique.

OBJECTIVES: Compare circular defect with dog-ear deformities excision (CDDE) technique to 3:1 fusiform excision technique when removing facial lesions to analyze which technique provides superior wound closure. METHODS: Identical 1-cm circular skin defects were created on bilateral cheek, forehead, and parietal scalp on three fresh cadavers. Similarly, using four fresh cadavers, identical 2-cm circular skin defects were created on bilateral cheek, forehead, and scalp. In both the 1-cm and 2-cm circular defects (n = 19), a 3:1 fusiform excision and closure was performed on one side of the cadaver head for control. On the opposite side, CDDE excision technique was performed. The following measurements were recorded: circumferential incision length after tissue excision, average of wound widening widths after an approximation suture was placed at the halfway point, and the final incision length after primary closure. Final incision length upon closure was divided by the original defect size to obtain a final incision length to defect ratio. A paired t-test was performed on all variables for analysis. RESULTS: When using the CDDE excision technique, there were statistically significant decreases in circumference, average wound widening, final incision length in both 1-cm and 2-cm circular defects (P < .01). The final incision length upon closure to defect ratio in CDDE excision was approximately 2.5:1, whereas 3:1 fusiform excision resulted in the final incision length to defect ratio of approximately 3.5:1. CONCLUSIONS: When compared to fusiform excision technique, CDDE excision technique appears to minimize tissue excision, decrease wound widening and the final incision length.

Reconstruction of eyelid defects.

Reconstruction of the eyelids is highly complex because of their function and critical role in appearance. Optimal restoration of their form and function depends on a firm understanding of normal eyelid position, the structural support system of the eyelids, and the forces that act to keep the eyelids in precise balance. With this knowledge, the surgeon can choose among numerous reconstructive techniques to correct a deficit, depending on its location, depth, and size, while restoring normal eyelid function and an esthetically pleasing form. This article reviews the pertinent eyelid anatomy, describes methods for analysis of eyelid position before and after surgery, and discusses the structural restoration options for commonly encountered eyelid defects.

The effects of sound conditioning on gentamicin-induced vestibulocochlear toxicity in gerbils.

OBJECTIVES/HYPOTHESIS: Recent studies in animal models have shown via physiologic and histologic measures that the administration of exogenous antioxidants is protective against gentamicin-induced oto-vestibulo toxicity. In addition, studies have also shown that sound conditioning increases cochlear antioxidants. The objective of this study is to determine whether sound conditioning provides protection against gentamicin in the cochlear and/or vestibular system. STUDY DESIGN: : Prospective animal study. METHODS: Three-month-old gerbils were divided into three groups (A, B, and C). The gerbils in group A were sound conditioned only (n = 2). In group B, the animals received gentamicin on the round window (n = 2). The gerbils in group C were sound conditioned first and later received gentamicin to the round window (n = 2). The animals were ultimately sacrificed and their right cochlea and posterior crista ampullaris were removed, processed, and sectioned. The specimens were analyzed for inner hair cell (IHC) and outer hair cell (OHC) loss and vestibular supporting and sensory hair cell nuclei per micrometer of vestibular epithelium. RESULTS: The sound-conditioned group (A) had no loss of cochlear hair cells. The gerbils treated with gentamicin only (B) had a 34% decrease of OHCs and 49% decrease of IHCs. The sound-conditioned plus gentamicin-treated group (C) had a 5.5% decrease in OHCs and 12% decrease in IHCs. There were no significant differences with regards to supporting cell nuclei within the posterior crista across all groups. When compared to group A, the gerbils in groups B and C did have a 23 to 42% decrease in the number of sensory cell nuclei per micrometer of vestibular epithelium. CONCLUSIONS: Sound conditioning does appear to attenuate the effects of gentamicin in the cochlea, although not significantly altering its vestibulotoxicity. An upregulation of cochlear-specific antioxidants is believed to be an important factor. As we had a small sample size, we can only note trends in the data, but future studies with more animals and measurements of antioxidant levels after sound conditioning would be useful to quantify this effect and determine if it can be exploited clinically. Laryngoscope, 2009.