Addressing the Pandemic Training Deficiency: Filling the Void with Simulation in Facial Reconstruction.

OBJECTIVE/HYPOTHESIS: To assess the use of a three-dimensional (3D) printed, multilayer facial flap model for use in trainee education as an alternative method of teaching surgical techniques of facial reconstruction. STUDY DESIGN: Cohort study. METHODS: A 3D printed facial flap simulator was designed from a computed tomography scan and manufactured out of silicone for low-cost, high-fidelity simulation. This simulator was tested by a group of Otolaryngology-Head and Neck Surgery trainees at a single institution. The simulator group was compared to a control group who completed an exercise on a traditional paper facial flap exercise. Both groups underwent didactic lectures prior to completing their respective exercises. Pre- and post-exercise Likert scale surveys measuring experience, understanding, effectiveness, and realism were completed by both groups. Central tendency, variability, and confidence intervals were measured to evaluate the outcomes. RESULTS: Trainees completing the facial flap simulator reported a statistically significant (p < 0.05) improvement in overall expertise in facial flap procedures, design of facial flaps, and excision of standing cutaneous deformities. No statistically significant improvement was seen in the control group. CONCLUSIONS: Trainees found the facial flap simulator to be an effective and useful training tool with a high level of realism in surgical education of facial reconstruction. Surgical simulators can serve as an adjunct to trainee education, especially during extraordinary times such as the novel coronavirus disease 2019 pandemic, which significantly impacted surgical training. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E2444-E2448, 2021.

Reconstruction of the Nose.

Nasal reconstructive techniques have advanced significantly over the past 50 years. Modern techniques in nasal reconstruction are based on the nasal aesthetic subunits. In order to achieve ideal outcomes, reconstructive surgeons must consider differences in tissue qualities across the nasal aesthetic subunits and formulate reconstructive plans based on these differences. Local flaps, skin grafts, and several types of interpolated flaps comprise the most commonly used techniques for nasal reconstruction. Defects that involve structural or internal lining defects require reconstruction of significantly higher complexity.

Efficacy of Staged Excision With Permanent Section Margin Control for Cutaneous Head and Neck Melanoma.

Importance: Melanoma arising in chronically photodamaged skin, especially on the head and neck, is often characterized by poorly defined clinical margins and unpredictable occult extension. Staged excision techniques have been described to treat these challenging melanomas. Objective: To investigate the local recurrence rates and margin to clearance end points using staged excision with comprehensive hematoxylin-eosin-stained permanent section margin control. Design, Setting, and Participants: In this observational cohort study performed from October 8, 1997, to December 31, 2006, with a median follow-up of 9.3 years, 806 patients with melanoma on the head and neck, where clinical occult extension is common, were studied at an academic medical center. Interventions: Staged excision with comprehensive hematoxylin-eosin-stained permanent section margin control commonly known as the square technique. Main Outcomes and Measures: Local recurrence rates and margin to clearance end points. Results: A total of 806 patients (276 women [34.2%]; 805 white [99.9%]) with a median age at the time of first staged excision procedure of 65 years (range, 20-94 years) participated in the study. The estimated local recurrence rates were 1.4% at 5 years, 1.8% at 7.5 years, and 2.2% at 10 years. For each 50-mm2 increase in the size of the clinical lesion, there was a 9% increase in the rate of local recurrence (hazard ratio, 1.09; 95% CI, 1.02-1.15; P = .02). The mean (SD) margin from lesion to clearance for melanoma in situ was 9.3 (5.1) mm compared with 13.7 (5.9) mm for invasive melanoma. For melanoma in situ, margins were clear after 5 mm or less in 232 excisions (41.1%) and after 10 mm or less in 420 excisions (74.5%). For invasive melanoma, margins were clear after 5 mm or less in 8 excisions (3.0%) and after 10 mm or less in 141 excisions (52.2%). Conclusions and Relevance: Staged excision with comprehensive permanent section margin control of melanomas arising in chronically sun-damaged skin on the head and neck has favorable recurrence rates when melanoma margins are difficult to assess, and recurrence rates are high with traditional techniques.

Cervicofacial Rhytidectomy After Radiotherapy for Head and Neck Tumors.

IMPORTANCE: Whether undergoing cervicofacial rhytidectomy after radiotherapy for tumors of the head and neck is associated with increased complication rates and therefore should be avoided remains unknown. OBJECTIVE: To evaluate complication rates in patients who have undergone cervicofacial rhytidectomy after radiotherapy for head and neck tumors and compare these rates with those of patients who have not undergone radiotherapy. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of the medical records of 16 patients who underwent cervicofacial rhytidectomy after completing radiotherapy for head and neck tumors and those of 16 age-matched control participants who did not undergo radiotherapy. Patients underwent treatment from July 1, 2006, through February 28, 2014, with final follow-up on February 28, 2014. Complications after surgery were reviewed and data for surgery type, technique, radiation dose and delivery method, and time to surgery after radiotherapy were analyzed. Data were collected from June 1 through December 31, 2013, and analyzed from January 1, 2014, through June 1, 2015. MAIN OUTCOMES AND MEASURES: Rate of complications after surgery. RESULTS: The radiotherapy and control group patients were a mean of 62 years old. In the radiotherapy group, 8 of 16 were women; 14 of 16 were women in the control group. Two major complications, 1 hematoma and 1 perioperative stroke, occurred in the 16 patients who composed the study cohort. In the control group, there was 1 case of transient facial nerve weakness and 1 case of cellulitis that was successfully treated with antibiotics. Two patients experienced wound dehiscence, and no incidents of motor or sensory nerve injury occurred. Subcutaneous face-lift (3 of 3 patients [100%] vs 1 of 13 patients [8%] who underwent superficial musculoaponeurotic system and deep-plane face-lifts; P = .02) and the addition of chemotherapy (4 of 9 patients [44%] vs 0 of 7 patients who did not receive chemotherapy; P = .04) were associated with increased complications. Being older and the time from completion of radiotherapy and surgery did not show any correlation to complications. CONCLUSIONS AND RELEVANCE: Aesthetic facial surgery after radiotherapy has an increased risk for complication compared with facial surgery without radiotherapy. The incidence of wound dehiscence is elevated in the population undergoing radiotherapy but can be managed conservatively in most cases. Patients who undergo radiotherapy must be counseled on the increased risk for complications before proceeding with cervicofacial rhytidectomy. LEVEL OF EVIDENCE: 3.

A novel flap technique for repairing large lower lip defects.

UNLABELLED: There are many well-established methods for the reconstruction of the lower lip. The selection of a particular method generally relies on the amount of lip resected and the amount of lip remaining. In cases of large defects (>50% of the lip length) where direct closure and lip-switch techniques are inadequate, a perioral flap is used. All techniques for perioral flaps described until now result in an unwanted decrease in circumoral opening. The only available method that keeps the circumoral opening the same is a distant or regional free flap, and this technique is usually reserved for more extreme defects because it is more radical, technically demanding, and can pose a greater risk of complications. In this study, we describe a novel technique for reconstruction of the lower lip using a perioral flap in which the circumoral opening is kept the same. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Transcutaneous lower blepharoplasty with fat transposition.

Fat preservation lower lid blepharoplasty is the authors' preferred technique for surgical rejuvenation of the aging lower lid. Key technical refinements are overlaid on a conceptual framework developed over the past 2 decades by several investigators. The use of the orbicularis oculi muscle suspension flap is a useful adjunct to the transcutaneous approach to lower lid blepharoplasty.

Anticoagulant complications in facial plastic and reconstructive surgery.

IMPORTANCE: The decision whether to discontinue antiplatelet and/or anticoagulant medications before a facial plastic surgical procedure is a complicated and multifactorial process that involves weighing the risk of perioperative thromboembolic complications with bleeding-related complications. OBJECTIVE: To determine the complication rates in patients who undergo a range of facial plastic surgical procedures while receiving antiplatelet and/or anticoagulation therapy. DESIGN, SETTING, AND PARTICIPANTS: A total of 9204 surgical procedures from January 1, 2007, through December 31, 2012, at an academic medical center and its affiliated surgical sites were analyzed, with patients who continued receiving antiplatelet and/or anticoagulation (aspirin, clopidogrel bisulphate, and warfarin sodium) therapy during the perioperative period identified and compared with a matched case-control group of patients who did not receive antiplatelet and/or anticoagulation therapy during this period. INTERVENTIONS: Facial plastic surgery procedures and perioperative management. MAIN OUTCOME AND MEASURES: Complication rates of wound healing (dehiscence or necrosis), infection, bleeding (hematoma or ecchymosis), and return to the operating room. RESULTS: Patients who received aspirin therapy at the time of surgery were not more likely to have a complication compared with control patients (odds ratio [95% CI], 0.73 [0.45-1.17]). Patients who received warfarin had increased perioperative bleeding (odds ratio [95% CI], 3.80 [1.15-12.60]) and postoperative infections (odds ratio [95% CI], 7.29 [1.17-45.40]) compared with control patients. Serious complications (flap necrosis, dehiscence, or return to the operating room) were not increased with warfarin use. CONCLUSIONS AND RELEVANCE: This study demonstrates that patients who undergo facial plastic surgery may continue taking antiplatelet and/or anticoagulation therapy during the perioperative period safely with minimal serious complications. LEVEL OF EVIDENCE: 3.

Lower lid blepharoplasty: panel discussion, controversies, and techniques.

UNLABELLED: What is the most frequent displeasing effect you see when performing lower eyelid blepharoplasty? What surgical approach do you most frequently use when performing lower eyelid blepharoplasty? How much skin removal of the lower eyelids? When performing lower lid blepharoplasty, what is your preferred method of managing pseudoherniated fat? If you perform midface lifting during blepharoplasty, what approach do you use? ANALYSIS: Over the past 5 years, how has your technique or approach evolved or what is the most important thing you have learned in doing blepharoplasty?

Local flaps: cheek and lip reconstruction.

IMPORTANCE: The reconstruction of cutaneous defects of the cheek and lip is a foundational topic for facial plastic and reconstructive surgeons. Facial defects have a significant impact on patient quality of life that has been well demonstrated. OBJECTIVE: To review new findings that have an impact on the planning and understanding of local flaps for the reconstruction of cutaneous defects of the cheek and upper lip; recent research in facial soft-tissue anatomy and vascular anatomy is integrated into a discussion of local flap reconstruction. EVIDENCE REVIEW: A Medline search of scientific literature was conducted, with an emphasis on 1980 to the present. Search terms included cheek; lip; reconstruction; vascular anatomy, soft-tissue anatomy, aging face, outcomes, and perforator flap. Cadaveric studies were specifically sought for anatomic review, and comparison group outcome studies are preferentially cited over clinical case series. FINDINGS: Reconstruction of large medial defects of the cheek and upper lip is particularly challenging, and the V-Y subcutaneous tissue pedicle island advancement flap is valuable for repair of these defects. Outcomes analyses for local flap reconstruction are in high demand. Pedicled perforator flaps will likely see increased application for facial reconstruction in the near future. CONCLUSION AND RELEVANCE: Detailed knowledge of the soft-tissue anatomy of the cheek and lip is critical to accurate surgical planning in local flap reconstruction.

Age-related histologic changes in human nasal cartilage.

IMPORTANCE: Understanding age-related changes is important when considering cartilage-based implants or grafts during rhinoplasty and nasal reconstructive surgery. OBJECTIVE: To characterize the cellular and architectural changes in human nasal cartilage with aging. DESIGN: Laboratory study. PARTICIPANTS: Nasal septal cartilage was harvested from 50 consecutive patients undergoing septoplasty, rhinoplasty, or septorhinoplasty. INTERVENTION: Cartilage specimens were stained with hematoxylin-eosin (H&E) and safranin O for cartilage. MAIN OUTCOME MEASURES: A modified Mankin histologic grading scale was used to analyze each cartilage sample for H&E findings and safranin O staining. Higher H&E scores indicated more degenerative changes, while higher safranin O scores indicated reductions in proteoglycan content within the cartilage matrix, representing decreased active chondrocyte activity. Correlation between H&E and safranin O scores and patient age was determined. RESULTS: There was positive correlation between safranin O staining scores and age, with higher scores seen with advancing age (P = .01). A linear regression best-fit equation was determined to calculate a potential safranin O staining score for a given age. CONCLUSIONS AND RELEVANCE: We have quantitatively determined that advancing age is positively correlated with reductions in cartilage proteoglycan content and active cartilage growth. This finding not only enhances our current understanding of the natural changes that occur in cartilage with aging but may also affect surgical decision making when cartilage grafting is considered during functional, reconstructive, and aesthetic rhinoplasty. LEVEL OF EVIDENCE: NR.

Correction of caudal septal deviation and deformity using nasal septal bone grafts.

OBJECTIVES: To describe our technique of using septal bone grafts for correction and stabilization of caudal septal deviation and to evaluate the effectiveness of this technique in the treatment of the deviated caudal septum. METHODS: A retrospective review of 81 patients who underwent open septorhinoplasty using septal bone grafts for correction of a caudal septal deviation or deformity and nasal obstruction. We reviewed medical records to determine postoperative outcomes in nasal obstruction and caudal septal position. RESULTS: Of the 81 patients, we included 66 with adequate follow-up information in the analysis. Follow-up duration ranged from 1 to 72 (mean, 8) months. Postoperative examination revealed a midline septum in 55 of the 66 patients (83%). Fifty-seven patients (86%) reported resolution of nasal obstruction; 49 (74%) had a midline septum and resolved nasal obstruction at the longest follow-up. Nine patients (14%) reported postoperative nasal obstruction, of whom only 3 required revision surgery. CONCLUSION: Nasal septal bone grafts can be an effective tool in stabilizing severe cartilaginous deformities or deviations and correcting caudal septal deviation.

Full-thickness skin graft overlying a separately harvested auricular cartilage graft for nasal alar reconstruction.

OBJECTIVE: To evaluate the aesthetic and functional outcomes of a full-thickness skin graft and a separately harvested auricular cartilage graft for nasal alar defects created by Mohs micrographic surgery. DESIGN: Twenty patients with deep Mohs micrographic surgery defects of the nasal ala who underwent reconstruction with a full-thickness skin graft and an auricular cartilage graft were prospectively studied at a single tertiary care institution between 2010 and 2011 in a nonrandomized, nonblinded study. An ordinal 5-point Likert scale evaluation of overall outcomes was performed by 4 independent surgeon raters. RESULTS: The mean outcome for use of the full-thickness skin and auricular cartilage graft construct was a score of 2.3 on a scale of 1 through 5, with 1 being excellent and 5 being poor. The mean duration of follow-up was 6 months, with a range of 5 weeks to 23 months. There were no clinically meaningful losses of constructs in the patients studied. CONCLUSION: A full-thickness skin graft and a separately harvested auricular cartilage graft are valuable and reliable tools for reconstructing deep nasal alar defects that require support to prevent alar retraction or collapse, particularly when a single-stage procedure is preferred or necessary because of medical comorbidities.

Esthetic enhancements in upper blepharoplasty.

Traditional upper blepharoplasty typically involves resection of excess upper eyelid skin and muscle with or without fat excision. Well-established concepts in periorbital aging have been challenged by newer morphologic and histologic studies that have characterized the changes that occur in the various periorbital soft tissue components. Several modified or adjunctive techniques have recently emerged to improve esthetic outcomes in upper blepharoplasty. The authors review surgical technique in detail: nasal fat repositioning, orbicularis oculi preservation, increasing lateral upper eyelid fullness, lacrimal gland resuspension, internal brow elevation, and glabellar myectomy, along with complications and aftercare involved with procedures.

Nonmelanoma skin cancer of the head and neck: reconstruction.

Reconstruction of facial defects formed after resection of skin cancers is a challenging procedure. Achieving the best functional and aesthetic outcome depends on accurate preoperative planning. Reconstructive surgeons should perform a detailed analysis of the facial defect based on location, size, and depth and choose the most appropriate technique according to their experiences and patient preferences and expectations. This article reviews the preoperative analysis of facial defects, and the major principles and techniques of facial reconstruction. Discussed are reconstruction of the nose, lip, cheek, forehead, and eyelid, presenting for each technique the goals of the reconstruction, types of flaps and grafts, and surgical technique.

Outcomes following V-Y advancement flap reconstruction of large upper lip defects.

OBJECTIVE: To characterize revision surgery following V-Y subcutaneous tissue pedicle advancement flap repair of large upper lip skin defects. METHODS: Retrospective review of upper lip skin defects at least 3.0 cm(2) in area that were reconstructed with a V-Y subcutaneous tissue pedicle advancement flap at an academic tertiary care center. Depth and area of the defect, as well as involvement of the vermilion and nasal ala, were recorded as independent variables. Revision techniques were analyzed to identify patterns. RESULTS: Thirty patients were identified as having upper lip skin defects with a mean (range) area of 7.0 (3.0-14.0) cm(2) (median, 6.25 cm(2)). The defect involved the nasal ala in 4 cases and the vermilion in 3 cases. At least 1 revision surgery was performed in 14 patients (47%). Alar or vermilion involvement was a significant factor in revision by χ(2) analysis (P = .03). Larger defect size did not predict a need for revision, even among cases where the defect did not involve the ala or vermilion (P = .68). CONCLUSIONS: Reconstruction of large upper lip skin defects with a V-Y subcutaneous tissue pedicle advancement flap is associated with a 47% revision rate, and when the defect involves the ala or vermilion, the revision rate is increased. Defect size alone cannot be used to predict the need for revision surgery. Revision techniques are demonstrated.

Diced cartilage augmentation: early experience with the Tasman technique.

Numerous methods have been used for dorsal augmentation in reconstructive and aesthetic rhinoplasty. The Tasman technique is a method for dorsal augmentation using diced cartilage solidified by tissue sealant. This article describes the author's early experience using the Tasman technique and offers some helpful suggestions to surgeons who might wish to use this unique method of preparing a cartilaginous graft.

Methicillin-resistant Staphylococcus aureus-associated infections following septorhinoplasty.

Septorhinoplasty is associated with postoperative infection in less than 2% of cases, even without the use of prophylactic antibiotics. However, there is a concern that increasingly prevalent, highly virulent pathogens such as MRSA may predispose to postoperative infections. Over the past several decades, MRSA has emerged as the most important cause of antibiotic-resistant nosocomial infection. MRSA-associated infections related to nasal surgery are underreported in the literature. We present a case of MRSA-associated infection following a routine septorhinoplasty in a health care worker. We discuss the incidence of this complication and contributing risk factors. The classification of MRSA-associated infections into genotypically distinct hospital-acquired and community-acquired subtypes is reviewed, and the associated differences in epidemiology, clinical presentation, and antibiotic susceptibility are discussed. A comprehensive strategy incorporating diagnostic workup, preventative management based upon preoperative risk stratification, and treatment of MRSA-associated soft tissue infections is presented.

Patient assessment of psychosocial dysfunction following nasal reconstruction.

BACKGROUND: Postoperative psychosocial distress is a critical aspect of surgery, particularly in aesthetically sensitive areas. In this study, the authors assess the level of psychosocial distress associated with nasal reconstruction. The authors also compare postoperative distress levels associated with different reconstructive techniques throughout the healing process. METHODS: The authors conducted a prospective study of patients undergoing nasal reconstruction following excision of cutaneous malignancy. The main outcome measure was the Derriford Appearance Scale 24, a measure of psychosocial distress. The Derriford Appearance Scale was administered at preoperative assessment, 1 < x < 4 weeks, 4 ≤ x < 12 weeks, and x ≥ 12 weeks. The entire cohort was analyzed with respect to distress levels before and after surgery. Reconstructions were categorized as interpolated, local tissue, or full-thickness skin graft. Analyses were performed for reconstruction type, patient, and defect data. RESULTS: Fifty-nine patients were enrolled. Reconstructions included 14 interpolated flaps, 17 local tissue flaps, and 28 full-thickness skin grafts. For the entire cohort, distress levels were significantly higher at the first postoperative visit (p < 0.05), with normalization at subsequent follow-up evaluations. At the first assessment, the interpolated flap group had significantly higher levels of distress in comparison with the full-thickness skin graft group (p < 0.05). At late follow-up, levels of distress were equivalent. CONCLUSIONS: Nasal reconstruction is associated with short-term increases in psychosocial distress that corrects by approximately 12 weeks after surgery. Interpolated flaps cause significantly higher distress at early assessment. Distress levels at late follow-up appear to be equivalent to those following a full-thickness skin graft despite larger and deeper initial defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.