Corneal Neurotization-Indications, Surgical Techniques and Outcomes.

Corneal neurotization is a promising surgical approach for the treatment of moderate to severe neurotrophic keratopathy. This technique aims to restore corneal sensation by transferring healthy nerves, either directly or via a conduit, to the anesthetic cornea. This review provides a report on the current state of development, evidence, and experience in the field. We summarize the data available from clinical reports and case series, placing an emphasis on the diversity of the surgical techniques reported. While these data are encouraging, they also highlight the need for a consensus in reporting outcomes and highlight how the next step will involve validating putative outcome parameters when researching and reporting corneal neurotization surgery.

Clinical Assessment for Lower Eyelid Blepharoplasty with Attention on Negative Prognostic Indicators.

In the present report, a comprehensive approach on the assessment of the lower eyelid for blepharoplasty is provided. Important items such as anatomical key areas and surgical factors are discussed. Proper management of lower eyelid deformities requires an understanding of both intrinsic and extrinsic anatomical factors resulting in the unfavorable outcome.

The Management of Chemosis after Blepharoplasty.

Chemosis is a common, though typically temporary complication of both upper and lower blepharoplasty surgery, though it is much more common after the latter. It occurs due to extravasation of fluid into the subconjunctival space precipitated by desiccation, inflammation, and manipulation of the conjunctiva and associated lymphatic drainage. Intraoperatively, minimizing surgical exposure and manipulation as well as maintaining a moist ocular surface can reduce the risks. Postoperatively, we propose a stepwise approach, starting with lubricants and escalating to increasingly potent anti-inflammatories with compression bandaging and surgery reserved for persistent cases.

A Buccal Space Approach for Midface Free Flap Reconstruction.

This article describes a transbuccal approach to reach the facial vessels. The anatomy of this intraoral approach is predictable, minimizing the risk of facial nerve dysfunction. This technique provides the possibility of free flap midface reconstruction with short pedicles and avoids the need to use vein grafts. Moreover, it is esthetically preferable. Through cadaver dissection and anatomical drawings, we describe extensively the different surgical steps. Using the combination of the previous knowledge and recent anatomical understandings, we can provide a reliable step-by-step approach to find the facial artery and vein through a transbuccal approach for microvascular midface free flap repair.

Multi-material 3D bioprinting of porous constructs for cartilage regeneration.

The current gold standard for nasal reconstruction after rhinectomy or severe trauma includes transposition of autologous cartilage grafts in conjunction with coverage using an autologous skin flap. Harvesting autologous cartilage requires a major additional procedure that may create donor site morbidity. Major nasal reconstruction also requires sculpting autologous cartilages to form a cartilage framework, which is complex, highly skill-demanding and very time consuming. These limitations have prompted facial reconstructive surgeons to explore different techniques such as tissue engineered cartilage. This work explores the use of multi-material 3D bioprinting with chondrocyte-laden gelatin methacrylate (GelMA) and polycaprolactone (PCL) to fabricate constructs that can potentially be used for nasal reconstruction. In this study, we have investigated the effect of 3D manufacturing parameters including temperature, needle gauge, UV exposure time, and cell carrier formulation (GelMA) on the viability and functionality of chondrocytes in bioprinted constructs. Furthermore, we printed chondrocyte-laden GelMA and PCL into composite constructs to combine biological and mechanical properties. It was found that 20% w/v GelMA was the best concentration for the 3D bioprinting of the chondrocytes without comprising the scaffold's porous structure and cell functionality. In addition, the 3D bioprinted constructs showed neocartilage formation and similar mechanical properties to nasal alar cartilage after a 50-day culture period. Neocartilage formation was also observed in the composite constructs evidenced by the presence of glycosaminoglycans and collagen type II. This study shows the feasibility of manufacturing neocartilage using chondrocytes/GelMA/PCL 3D bioprinted porous constructs which could be applied as a method for fabricating implants for nose reconstruction.

Health utility of rhinectomy, surgical nasal reconstruction, and prosthetic rehabilitation.

OBJECTIVES: Advanced nasal malignancies may require rhinectomy, which can have profound psychosocial impacts. Rhinectomy defects can be rehabilitated through surgery or prosthetics. We seek to understand the health utility of the rhinectomy defect, surgical, and prosthetic reconstruction, which have not been previously studied. STUDY DESIGN: Prospective clinical study METHODS: Adult naïve observers (n = 273) ranked the utility of five randomized health states (monocular blindness, binocular blindness, post-rhinectomy nasal defect, postsurgical reconstruction, and post-prosthetic rehabilitation). Health utilities were measured using visual analogue scale (VAS), standard gamble (SG), and time trade-off (TTO). One-way analysis of variance (ANOVA) with post hoc Scheffe's test and the independent samples T-test for a priori comparisons were performed. Multiple linear regression was performed using participant demographics as independent predictors of utility scores. RESULTS: Health utilities (VAS, SG, TTO) were reported as follows (mean ± SD): monocular blindness (0.71 ± 0.21, 0.84 ± 0.20, 0.85 ± 0.19), binocular blindness (0.48 ± 0.25, 0.68 ± 0.28, 0.63 ± 0.28), post-rhinectomy nasal defect (0.59 ± 0.24, 0.74 ± 0.24, 0.74 ± 0.24), postsurgical reconstruction (0.88 ± 0.16, 0.90 ± 0.18, 0.89 ± 0.13), and post-prosthetic rehabilitation (0.67 ± 0.22, 0.80 ± 0.23, 0.82 ± 0.20). Both surgical reconstruction (P < .001) and prosthetic rehabilitation (P < .001) significantly improved health utility. SG and TTO utility scores were inversely associated with observer age (P < .001) and participants who identified themselves as non-Caucasians (P < .05) in post-rhinectomy nasal defect, post-nasal surgical reconstruction, and post-nasal prosthetic rehabilitation health states, while higher levels of education were directly associated with SG scores (P < .05), respectively. CONCLUSION: This is the first study to demonstrate the significant negative impact of the rhinectomy nasal defect on health utility. Rehabilitation by surgical or prosthetic techniques significantly increases health utility as rated by naïve observers. Laryngoscope, 130:1674-1679, 2020.

Evaluation of Societal Health Utility of Facial Palsy and Facial Reanimation.

IMPORTANCE: The severity of a health state may be quantified using health utility measures. The utility of flaccid unilateral facial paralysis and unilateral moderate to severe postparalytic facial nerve syndrome with synkinesis may be challenging to discern from photographs alone. OBJECTIVE: To determine the societal health utility of flaccid unilateral facial paralysis, unilateral moderate to severe postparalytic facial nerve syndrome, and post-facial reanimation using standard video. DESIGN, SETTING, AND PARTICIPANTS: This survey study was conducted at the Massachusetts Eye and Ear and the Harvard Decision Science Laboratory from June 14, 2017, to August 3, 2017. Healthy adult naïve observers were recruited through advertising in the Cambridge, Massachusetts, area. Participants (n = 298) completed the web-based, interactive survey in person. The survey comprised clinical vignettes consisting of symptom summaries, videos, and pictures depicting 5 health states. MAIN OUTCOMES AND MEASURES: Adult naïve observers ranked the utility of 5 randomized health states (flaccid unilateral facial paralysis, unilateral moderate to severe postparalytic facial nerve syndrome, post-facial reanimation, monocular blindness, and binocular blindness) according to the visual analog scale (VAS), standard gamble (SG), and time trade-off (TTO) measures. Standard videos of patients' facial function were used. RESULTS: In total, 377 naïve observers were recruited and completed the survey in its entirety. Of the 377 participants, 298 (79.0%) were included for analysis. Among the 298 participants, 151 (50.7%) were female, 146 (49.0%) were male, with a mean (SD) age of 33.0 (15.1) years. No differences in health utility scores (SD) were observed between flaccid unilateral facial paralysis and unilateral moderate to severe postparalytic facial nerve syndrome (VAS: 0.598 [0.213] vs 0.629 [0.207]; SG: 0.714 [0.245] vs 0.748 [0.237]; TTO: 0.716 [0.248] vs 0.741 [0.247]). Both health states rated substantially worse than monocular blindness (VAS: 0.691 [0.212]; SG: 0.817 [0.204]; TTO: 0.826 [0.196]) and post-facial reanimation (VAS: 0.742 [0.189]; SG: 0.833 [0.206]; TTO: 0.838 [0.19]). CONCLUSIONS AND RELEVANCE: Health utility scores for flaccid unilateral facial paralysis and unilateral moderate to severe postparalytic facial nerve syndrome appeared to be equivalent and worse than that for monocular blindness, whereas scores for post-facial reanimation were substantially higher than the scores for the 2 facial movement disorders. These findings may provide insights into the societal advantages of facial reanimation surgery. LEVEL OF EVIDENCE: NA.

Minimal Nasolabial Incision Technique for Nasolabial Fold Modification in Patients With Facial Paralysis.

IMPORTANCE: Creation of symmetrical nasolabial folds (NLFs) is important in the management of the paralyzed face. Established techniques use a linear incision in the NLF, and technical refinements now allow the linear incision to be omitted. DESIGN, SETTING, AND PARTICIPANTS: This retrospective case series was conducted in a tertiary care setting from February 2, 2017, to June 7, 2017. Participants were all patients (N = 21) with peripheral facial paralysis who underwent NLF modification that used the minimal nasolabial incision technique at the Massachusetts Eye and Ear Infirmary Facial Nerve Center from February 1, 2015, through August 31, 2016. MAIN OUTCOMES AND MEASURES: Patient-reported outcome measures using the validated, quality-of-life Facial Clinimetric Evaluation (FaCE) Scale; clinician-reported facial function outcomes using a validated electronic clinician-graded facial paralysis assessment (eFACE); layperson assessment of the overall aesthetic outcome of the NLF; and expert-clinician scar assessment of the NLF. RESULTS: Of the 21 patients who underwent NLF modification that used the minimal nasolabial incision technique, 9 patients (43%) were female and 12 (57%) were male. The mean age was 41 (range, 9-90) years; 17 patients (81%) were adults (≥18 years) and 4 (19%) were children (<18 years). Overall, significant improvements were observed after NLF modification in all outcome measures as graded by both clinicians and patients. The mean (SD) scores for total eFACE were 60.7 (14.9) before the operation and 77.2 (8.9) after the operation (mean difference, 16.5 [95% CI, 8.5-24.2]; P < .001). The mean (SD) static eFACE scores were 61.4 (20.6) before the operation and 82.7 (12.4) after the operation (mean difference, 21.3 [95% CI, 10.7-31.9]; P < .001). The mean (SD) FaCE quality-of-life scores were 51.3 (20.1) before the operation and 70.3 (12.6) after the operation (mean difference, 19.0 [95% CI, 6.5-31.6]; P  =  .001). The layperson self-assessment of the overall aesthetic outcome of the NLF modification was higher among the group who had the minimal nasolabial incision than it was for the group who had a historical nasolabial incision (mean [SD], 68.17 [13.59] vs 56.28 [13.60]; mean difference, 11.89 [95% CI, 3.81-19.97]; P < .001). Similarly, the expert-clinician scar assessment of the NLF modification was higher for the group who had the minimal nasolabial incision than it was for the group who had a historical nasolabial incision (3.78 [0.91] vs 2.98 [0.81]; mean difference, 0.80 [95% CI, 0.29-1.32]; P  =  .007). CONCLUSIONS AND RELEVANCE: The minimal nasolabial incision technique for NLF modification is effective in rehabilitating the NLF in facial paralysis without adding a long linear scar to the central midface. LEVEL OF EVIDENCE: 4.

Free gracilis muscle transfer for smile reanimation after treatment for advanced parotid malignancy.

BACKGROUND: The purpose of this study was to characterize the outcomes of free gracilis muscle transfer for delayed smile reanimation after radical parotidectomy. METHODS: A retrospective chart review of patients who underwent free gracilis muscle transfer for smile reanimation after radical parotidectomy between 2003 and 2016 was performed. Patient-reported quality of life (Facial Clinimetric Evaluation Scale [FaCE]), physician-reported facial function ("eFACE" facial grading scale), and oral commissure excursion were compared preoperatively and postoperatively. RESULTS: Twelve patients were identified with prior surgery and adjuvant therapy (radiotherapy in 6 cases and chemoradiotherapy in 6 cases). Significant postoperative improvements were demonstrated for ipsilateral commissure excursion with smile (preoperatively: -2.2 mm [SD 2.3 mm] vs postoperatively: 7.9 mm [SD 2.5 mm]; P = .002), with meaningful smile achieved in 11 of 12 cases (91.7%). The average duration of facial paralysis before intervention was 72 months (range 12-204 months). CONCLUSION: Free gracilis muscle transfer is an option for dynamic smile reanimation in select patients who have undergone treatment for advanced parotid malignancy.

A Comparison of Costal Cartilage Warping Using Oblique Split vs Concentric Carving Methods.

IMPORTANCE: Warping of costal cartilage is well described; however, its strength and abundance still make it a desirable graft material, especially in complex reconstructive rhinoplasty. Despite multiple methods of cartilage harvest, carving, and preimplantation treatment being developed over the years, warp remains a challenging clinical problem. OBJECTIVE: To assess whether the 30° oblique split method of preparing costal cartilage grafts produces less warping of the graft than the current standard of harvesting the central segment of a rib using the concentric carving method. DESIGN, SETTING, AND PARTICIPANTS: This in vitro cadaveric study evaluated the warping of costal cartilage grafts using the oblique split method with an angle of 30° or the concentric carving method during a 3-month period beginning in December 2014. MAIN OUTCOMES AND MEASURES: Millimeters of warp from baseline (at 1 hour) and at 1, 2, and 3 months, measured in the frontal and lateral planes. RESULTS: Among 74 costal cartilage grafts (using the oblique split method with an angle of 30° in 41 and the concentric carving method in 33), the mean amount of warp in the frontal plane was between 1.12 mm (95% CI, 0.96-1.28 mm) and 1.57 mm (95% CI, 0.94-2.20 mm) for the oblique group and between 1.18 mm (95% CI, 0.98-1.38 mm) and 1.29 mm (95% CI, 0.86-1.72 mm) for the concentric group during the 3-month period. There was no statistically significant difference in the frontal plane between the 2 methods at 1 hour (P = .45; 0.10 mm, 95% CI, -0.38 to 0.17 mm), 1 month (P = .32; 0.13 mm, 95% CI, -0.13 to 0.40 mm), 2 months (P = .50; 0.28 mm, 95% CI, -0.55 to 1.11 mm), or 3 months (P = .15; 0.22 mm, 95% CI, -0.08 to 0.52 mm) using the t test, regression analysis, or panel data analysis. Similarly, no significant difference was found in the lateral plane at 1 hour (P = .89; 0.04 mm, 95% CI, -0.49 to 0.56 mm), 1 month (P = .82; 0.07 mm, 95% CI, -0.56 to 0.70 mm), 2 months (P = .29; 0.40 mm, 95% CI, -0.36 to 1.17 mm), or 3 months (P = .63; 0.22 mm, 95% CI, -0.70 to 1.13 mm) using the t test. Two grafts were excluded due to desiccation. CONCLUSIONS AND RELEVANCE: The 30° oblique split and concentric carving methods of costal cartilage graft carving are equivalent in terms of the amount of warp. The oblique split method may be superior because of easier carving and the increased volume of material. LEVEL OF EVIDENCE: NA.

Characterisation of the surface structure of 3D printed scaffolds for cell infiltration and surgical suturing.

3D printing is of great interest for tissue engineering scaffolds due to the ability to form complex geometries and control internal structures, including porosity and pore size. The porous structure of scaffolds plays an important role in cell ingrowth and nutrition infusion. Although the internal porosity and pore size of 3D printed scaffolds have been frequently studied, the surface porosity and pore size, which are critical for cell infiltration and mass transport, have not been investigated. The surface geometry can differ considerably from the internal scaffold structure depending on the 3D printing process. It is vital to be able to control the surface geometry of scaffolds as well as the internal structure to fabricate optimal architectures. This work presents a method to control the surface porosity and pore size of 3D printed scaffolds. Six scaffold designs have been printed with surface porosities ranging from 3% to 21%. We have characterised the overall scaffold porosity and surface porosity using optical microscopy and microCT. It has been found that surface porosity has a significant impact on cell infiltration and proliferation. In addition, the porosity of the surface has been found to have an effect on mechanical properties and on the forces required to penetrate the scaffold with a surgical suturing needle. To the authors' knowledge, this study is the first to investigate the surface geometry of extrusion-based 3D printed scaffolds and demonstrates the importance of surface geometry in cell infiltration and clinical manipulation.

The midline central artery forehead flap: a valid alternative to supratrochlear-based forehead flaps.

IMPORTANCE: This study clarifies the pedicle geometry and vascular supply of a midline forehead flap for nasal reconstruction. It reports on the vascular reliability of this flap and its ability to reduce hair transposition to the nose, a major complicating factor of previous forehead flap designs. OBJECTIVE: To compare the vascular reliability of 3 different pedicle designs of the forehead flap in nasal reconstruction (classic paramedian, glabellar paramedian, and central artery flap design) and evaluate hair transposition rates and aesthetic results. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of patient data and outcomes retrieved from computer files generated at the time of surgery, supplemented by data from the patient medical records and photographic documentation, from a tertiary referral nasal reconstructive practice, within a secondary-care hospital setting. The study population included all consecutive patients over a 19-year period who underwent primary forehead flap repair of nasal defects, with more than 3 months of postoperative follow-up and photographic documentation. INTERVENTIONS: Three sequential forehead flap patterns were used (classic paramedian flap, glabella flap, and central artery flap) for nasal reconstruction over the study duration. MAIN OUTCOMES AND MEASURES: Data collected included patient characteristics, method of repair, complications, functional outcome, and patient satisfaction score. For cosmetic outcome, photographic documentation was scored by a medical juror. RESULTS: No forehead flap had vascular compromise in the first stage. Partial flap necrosis was reported in subsequent stages in 4 patients (1%), with no statistical difference in the rate of vascular compromise between the 3 flap designs. Hair transposition to the nose was lower in the central artery forehead flap (7%) compared with the classic paramedian (23%) and glabellar paramedian (13%) flaps (P < .05). Photographic evaluation in 227 patients showed that brow position (98%) and color match (83%) were good in the majority of the patients. CONCLUSIONS AND RELEVANCE: In this series, the central artery forehead flap was as reliable (in terms of vascularity) as the glabellar and classic paramedian forehead flap. Its use resulted in a statistically significant reduction in transfer of hair to the nose in our series. LEVEL OF EVIDENCE: 3.

Current thoughts and developments in facial nerve reanimation.

PURPOSE OF REVIEW: To present the most current literature regarding the management of acute and chronic facial paralysis. This review will focus primarily on smile reanimation in the setting of acute and chronic facial paralysis. The management of the flaccid and the hypertonic face will be discussed. RECENT FINDINGS: Recent developments include advances in neural repair with fibrin glue and the use of cadaveric nerve grafts as interposition grafts. Advances in nerve substitutes have been shown to limit donor-site morbidity and provide similar outcomes to autografts. Techniques for muscle transfer continue to evolve to improve smile outcomes. SUMMARY: The goal of facial reanimation surgery is to restore meaningful facial movement. The goal should be to have quality-driven clinical practice guidelines to better facilitate patient care. This process must be initiated by facial reanimation surgeons deciding to use consistent outcome measures to report their results. Currently, it is impossible to make a direct comparison between different surgical techniques because of inconsistent methods of evaluation. Despite the lack of consistent quantitative evaluation, there have been many exciting advances in the field.

Ophthalmoplegia secondary to raised intracranial pressure after unilateral neck dissection with internal jugular vein sacrifice.

BACKGROUND: Neck dissection is commonly performed in the management of head and neck malignancy and may involve internal jugular vein (IJV) sacrifice. Potential complications include intracranial hypertension. This is well documented after bilateral neck dissection, although only scattered reports exist after unilateral IJV sacrifice. METHODS: A 54-year-old man underwent unilateral left modified radical neck dissection for T1N2b squamous cell carcinoma of the tongue base. He presented 13 days postoperatively with symptoms of headache and diplopia. RESULTS: Investigations revealed intracranial hypertension and bilateral abducens nerve palsies. He was treated with serial lumbar puncture, and his symptoms improved over the course of 2 weeks. CONCLUSIONS: Intracranial hypertension sufficient to cause visual disturbance is a serious complication of unilateral neck dissection. Head and neck surgeons must be aware of this and have a low threshold for investigation of the signs and symptoms of intracranial hypertension in the postoperative period. © 2010 Wiley Periodicals, Inc. Head Neck, 2011.

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.

Getting the basics right-staging in head and neck cancer.

The cornerstone of oncology literature and therefore medical practice is the ability to compare outcomes of treatment modalities for different stages of cancer. The head and neck represents a complicated anatomical region with multiple tumour sites and sub-sites. Modern management necessitates accurate staging to allow meaningful discussion between all members of the multidisciplinary team. Variations in techniques utilized for staging laryngeal cancer may lead to inconsistencies in staging and result in inaccuracies in interpreting comparative interventional studies. We call for standardisation in assessment of head and neck cancers in order to maximize the accuracy of clinical staging. We suggest a schema that we currently use in our institution for staging of all head and neck cancers and a schema for upper aero-digestive tract endoscopy.