Comparison of Autologous vs Homologous Costal Cartilage Grafts in Dorsal Augmentation Rhinoplasty: A Systematic Review and Meta-analysis.

Importance: Augmentation rhinoplasty requires adding cartilage to provide enhanced support to the structure of the nose. Autologous costal cartilage and irradiated homologous costal cartilage (IHCC) are well-accepted rhinoplasty options. Tutoplast is another alternative cartilage source. No studies, to our knowledge, have definitively demonstrated a higher rate of complications with IHCC grafts compared with autologous costal cartilage grafts. Objective: To compare rates of outcomes in the published literature for patients undergoing septorhinoplasty with autologous costal cartilage vs IHCC grafts vs Tutoplast grafts. Data Sources: For this systematic review and meta-analysis, the MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for articles published from database inception to February 2019 using the following keywords: septorhinoplasty, rhinoplasty, autologous costal cartilage graft, cadaveric cartilage graft, and rib graft. Study Selection: Abstracts and full texts were reviewed in duplicate, and disagreements were resolved by consensus. Only patients who underwent an en bloc dorsal onlay graft were included for comparison to ensure a homogenous study sample. A total of 1308 results were found. After duplicate records were removed, 576 unique citations remained. Studies were published worldwide between January 1, 1990, and December 31, 2017. Data Extraction and Synthesis: Independent extraction by 2 authors was performed. Data were pooled using a random-effects model. Main Outcomes and Measures: All reported outcomes after septorhinoplasty and rates of graft warping, resorption, infection, contour irregularity, and revision surgery among patients receiving autologous grafts vs IHCC vs Tutoplast cartilage grafts. Results: Of 576 unique citations, 54 studies were included in our systematic review; 28 studies were included after applying inclusion and exclusion criteria. Our search captured 1041 patients of whom 741 received autologous grafts and 293 received IHCC grafts (regardless of type). When autologous cartilage (n = 748) vs IHCC (n = 153) vs Tutoplast cartilage (n = 140) grafts were compared, no difference in warping (5%; 95% CI, 3%-9%), resorption (2%; 95% CI, 0%-2%), contour irregularity (1%; 95% CI, 0%-3%), infection (2%; 95% CI, 0%-4%), or revision surgery (5%; 95% CI, 2%-9%) was found. Conclusions and Relevance: No difference was found in outcomes between autologous and homologous costal cartilage grafts, including rates of warping, resorption, infection, contour irregularity, or revisions, in patients undergoing dorsal augmentation rhinoplasty. En bloc dorsal onlay grafts are commonly used in augmentation rhinoplasty to provide contour and structure to the nasal dorsum.

A Consistent, Reliable Landmark to Assist in Placement of Orbital Floor Reconstruction Plates After Blowout Fractures.

OBJECTIVE: To define a reliable and consistent landmark, the superior posterior wall of the maxillary sinus, and to describe how this landmark can be used when repairing orbital floor fractures. METHODS: Retrospective chart review. Patients >18 years old diagnosed with unilateral orbital floor and/or zygomaticomaxillary complex fractures. MAIN OUTCOMES: The distance from the inferior orbital rim to the superior posterior wall of the maxillary sinus (landmark distance), and the distance from the landmark to the entrance of the optic canal were reported. RESULTS: Eighty patients were included in the study. Each had unilateral isolated orbital floor fractures (n = 46) or unilateral zygomaticomaxillary complex fractures with an orbital floor component (n = 34). The contralateral eye in all patients was uninjured, and was used as an internal control. In orbital floor fractures, the mean landmark distance was 38.8 ±â€Š1.4 mm, with a mean distance on the normal side of 38.8 ±â€Š1.6 mm (P = 0.49). Distance to the optic canal on the injured side in isolated orbital floor fracture patients was 9.0 ±â€Š0.8 mm with the same measurement on the normal side being 8.8 ±â€Š0.7 (P = 0.21). In the setting of zygomaticomaxillary complex fracture, the orbital floor length was 38.2 ±â€Š1.3 mm with a mean normal floor length of 37.8 ±â€Š1.1 mm (P = 0.18). The mean distance from the superior posterior wall to optic canal in zygomaticomaxillary complex fractured orbits was 9.2 ±â€Š1.1 mm with a normal side mean length of 9.5 ±â€Š1.0 mm (P = 0.23). No significant difference was found between the measured distances in the fractured orbit and its normal counterpart for both fracture groups. CONCLUSIONS AND RELEVANCE: The superior posterior wall of the maxillary sinus is a reliable landmark that can be used to assist in placement of an orbital floor reconstructive plate. The landmark is unchanged despite the presence of an orbital floor or zygomaticomaxillary sinus fracture.

Midface Fracture Simulation and Repair: A Computer-Based Algorithm.

We introduce a novel computer-based method to digitally fixate midfacial fractures to facilitate more efficient intraoperative fixation. This article aims to describe a novel computer-based algorithm that can be utilized to model midface fracture reduction and fixation and to evaluate the algorithm's ability to produce images similar to true postoperative images. This is a retrospective review combined with cross-sectional survey from January 1, 2010, to December 31, 2015. This study was performed at a single tertiary care, level-I trauma center. Ten patients presenting with acute midfacial traumatic fractures were evaluated. Thirty-five physicians were surveyed regarding the accuracy of the images obtained using the algorithm. A computer algorithm utilizing AquariusNet (TeraRecon, Inc., Foster City, CA) and Adobe Photoshop (Adobe Systems Inc., San Jose, CA) was developed to model midface fracture repair. Preoperative three-dimensional computed tomographic (CT) images were processed using the algorithm. Fractures were virtually reduced and fixated to generate a virtual postoperative image. A survey comparing the virtual postoperative and the actual postoperative images was produced. A Likert-type scale rating system of 0 to 10 (0 being completely different and 10 being identical) was utilized. Survey participants evaluated the similarity of fracture reduction and fixation plate appearance. The algorithm's capacity for future clinical utility was also assessed. Survey response results from 35 physicians were collected and analyzed to determine the accuracy of the algorithm. Ten patients were evaluated. Fracture types included zygomaticomaxillary complex, LeFort, and naso-orbito-ethmoidal complex. Thirty-four images were assessed by a group of 35 physicians from the fields of otolaryngology, oral and maxillofacial surgery, and radiology. Mean response for fracture reduction similarity was 7.8 ± 2.5 and fixation plate similarity was 8.3 ± 1.9. All respondents reported interest in the tool for clinical use. This computer-based algorithm is able to produce virtual images that resemble actual postoperative images. It has the ability to model midface fracture repair and hardware placement.

Assessment of a Novel Computer Algorithm for Printing a 3-Dimensional Nasal Prosthetic.

Importance: The introduction and evaluation of a novel technique to create nasal prostheses with 3-dimensional (3-D) imaging software may circumvent the need for an anaplastologist. Objectives: To describe a novel computer algorithm for the creation of a 3-D model of a nose and to evaluate the similarity of appearance of the nasal prosthesis with that of the individual's nose. Design, Setting, and Participants: A prospective pilot study with a cross-sectional survey was conducted from August 1 to October 31, 2016, at a tertiary care academic center. Five volunteers were used for creation of the nasal prostheses, and 36 survey respondents with a medical background were involved in evaluating the nasal prostheses. Exposures: A computer algorithm using a 3-D animation software (Blender; Blender Foundation) and Adobe Photoshop CS6 (Adobe Systems) were used to create a 3-D model of a nose. Photographs of 5 volunteers were processed with the computer algorithm. The model was then printed using a desktop 3-D printer. Attending physicians, residents, and medical students completed a survey and were asked to rate the similarity between the individuals' photographs and their 3-D printed nose on a Likert-type scale. Main Outcomes and Measures: The similarity between 3-D printed nasal models and photographs of the volunteers' noses based on survey data. Results: Thirty-six survey respondents evaluated 4 views for each of the 5 modeled noses (from 4 women and 1 man; mean [SD] age, 26.6 [5.7] years). The mean (SD) score for the overall similarity between the photographs and the 3-D models was 8.42 (1.34). The mean scores for each nasal comparison ranged from 7.97 to 8.62. According to the survey, respondents were able to match the correct 3-D nose to the corresponding volunteers' photographs in 171 of 175 photographs (97.7%). All surveyed clinicians indicated that they would consider using this tool to create a temporary prosthesis instead of referring to a prosthodontist. Conclusions and Relevance: This algorithm can be used to model and print a 3-D prosthesis of a human nose. The printed models closely depicted the photographs of each volunteer's nose and can potentially be used to create a temporary prosthesis to fill external nasal defects. The appropriate clinical application of this technique is yet to be determined.

Tracheostomy for Severe Pediatric Obstructive Sleep Apnea: Indications and Outcomes.

Objectives (1) To describe characteristics of pediatric patients undergoing tracheostomy for obstructive sleep apnea (OSA). (2) To highlight perioperative events and outcomes of the procedure. Study Design Case series with chart review. Setting Four tertiary care academic children's hospitals. Subjects and Methods Twenty-nine children aged <18 years from January 1, 2010, to December 31, 2015, who underwent tracheostomy for severe OSA, defined as an apnea-hypopnea index (AHI) >10, were included in the study. Data on patient characteristics, polysomnographic findings, comorbidities, and perioperative events and outcomes were collected and analyzed. Results Twenty-nine patients were included. Mean age at tracheostomy was 2.0 years (95% CI, -2.2 to 6.2). Mean body mass index z score was -1.2 (95% CI, -4.9 to -2.5). Mean preoperative AHI was 60.2 (95% CI, -15.7 to 136.1). Mean postoperative intensive care unit stay was 23.2 days (95% CI, 1.44-45.0). One procedure was complicated by bronchospasm. Thirteen patients had craniofacial abnormalities; 10 had a neurologic disorder resulting in hypotonia; and 5 had a diagnosis of laryngomalacia. Mean follow-up was 30.6 months (95% CI, -10.4 to 71.6). Six patients were decannulated, with a mean time to decannulation of 40.8 months (95% CI, 7.9-73.7). Five patients underwent capped sleep study prior to decannulation with a mean AHI of 6.6 (95% CI, -9.9 to 23.1) and a mean oxygen nadir of 90.0% (95% CI, 80%-100%). Conclusion OSA is an uncommon indication for tracheostomy in children. Patients who require the procedure usually have an associated syndromic diagnosis resulting in upper airway obstruction. The majority of children who undergo tracheostomy for OSA will remain dependent at 24 months.

A novel computer algorithm for modeling and treating mandibular fractures: A pilot study.

OBJECTIVES/HYPOTHESIS: To describe a novel computer algorithm that can model mandibular fracture repair. To evaluate the algorithm as a tool to model mandibular fracture reduction and hardware selection. STUDY DESIGN: Retrospective pilot study combined with cross-sectional survey. METHODS: A computer algorithm utilizing Aquarius Net (TeraRecon, Inc, Foster City, CA) and Adobe Photoshop CS6 (Adobe Systems, Inc, San Jose, CA) was developed to model mandibular fracture repair. Ten different fracture patterns were selected from nine patients who had already undergone mandibular fracture repair. The preoperative computed tomography (CT) images were processed with the computer algorithm to create virtual images that matched the actual postoperative three-dimensional CT images. A survey comparing the true postoperative image with the virtual postoperative images was created and administered to otolaryngology resident and attending physicians. They were asked to rate on a scale from 0 to 10 (0 = completely different; 10 = identical) the similarity between the two images in terms of the fracture reduction and fixation hardware. RESULTS: Ten mandible fracture cases were analyzed and processed. There were 15 survey respondents. The mean score for overall similarity between the images was 8.41 ± 0.91; the mean score for similarity of fracture reduction was 8.61 ± 0.98; and the mean score for hardware appearance was 8.27 ± 0.97. There were no significant differences between attending and resident responses. There were no significant differences based on fracture location. CONCLUSION: This computer algorithm can accurately model mandibular fracture repair. Images created by the algorithm are highly similar to true postoperative images. The algorithm can potentially assist a surgeon planning mandibular fracture repair. LEVEL OF EVIDENCE: 4. Laryngoscope, 2016 127:331-336, 2017.