The Safety and Outcomes of Simultaneous Open Rhinoplasty, Alar Reduction, and Upper Lip-Lift through One Surgery.

Background: The safety and outcomes of performing a simultaneous Alar reduction, Lip lift, and Open rhinoplasty Surgery (ALOS) through independent incisions have not been reported in any study, therefore, we aimed to evaluate the safety and outcomes of this combination procedure. Methods: This retrospective review study was conducted on all cases of simultaneous ALOS, lip-lift, and alar reduction performed from 2018-2022, at Facial Plastic Surgery Clinic, New York, USA. Alar reduction involved complete through-and-through resection of alar wedge, and the type of lip lift technique was bullhorn design with excision of skin and Superficial Musculo-Aponeurotic System. Primary open rhinoplasty with inverted V-columellar incision was performed. The follow up period ranged between 4 months to 2 years, but all of patients were followed up at 6 days, one, and two months post-operatively. Results: Fifty one cases were enrolled. We reviewed criteria of complications including infection, vascular events (such as necrosis, or partial ischemia), and poor scarring, fortunately, we did not have any infection or vascular issues. In 2 cases, columellar scar was "less than optimal", but in all other cases, this scar was "not perceivable" based on the patient survey. In 4 cases, the lip lift procedure scar was considered "less than optimal" showed slight indentation of white scar of lip lift in 9/44 cases. Additionally, all columellar and alar incisions had nearly invisible scarring. Conclusion: In primary rhinoplasty cases, without any other surgeries or previous trauma in the oronasal region, performing concomitant lip lift, open rhinoplasty, and alar wedge resection is safe and does not negatively affect vascularity or scarring.

Long-Term Follow-Up with Dorsal Preservation Rhinoplasty.

The rapid resurgence of interest in performance of dorsal preservation (DP) rhinoplasty techniques in recent years has come with scarcity of data for long-term outcomes. In this article, the authors aim to contribute to preservation rhinoplasty (PR) literature by providing long-term follow-up with dorsal preservation, specifically presenting data related to superior strip DP functional and esthetic complications, followed by a detailed analysis of the same.

Complications in Facial Esthetic Surgery.

Esthetic surgery continues to become increasingly popular both in the United States and globally. Facial esthetic procedures in particular account for a large proportion of procedures performed. This increase in popularity will inevitably result in the number of potential complications associated with these procedures. In this review, the authors describe common complications encountered with frequently performed cosmetic facial procedures and their associated management. This article is meant as a general overview and introduction to potential complications surgeons may encounter, interested readers are encouraged to further review comprehensive subspecialty literature for more detailed discussion.

Management of Facial Scars.

Scarring is a natural process of healing after damage to the skin that extends to the reticular dermis. While some scars may be socially acceptable, even admirable, scars of the face can be viewed as disfiguring or ugly. Minimizing the appearance of facial scars and optimizing their cosmetic outcome ideally begin before surgery or, in the cause of trauma, at the initial reconstruction. Even when there has been poor initial healing, a scar's appearance can be improved. Herein, we review conservative, medical, and surgical therapies to improve the appearance of facial scars.

Postoperative Free-Flap Monitoring Techniques.

Free tissue transfer is commonly employed in the reconstruction of large or complicated defects. Postoperative flap failure from microvascular compromise is an uncommon but major potential complication of this procedure. As such, many postoperative monitoring techniques devices have been developed. This paper provides an overview of the wide variety of options available for surgeons today.

Higher Complication Rates in Self-Inflicted Gunshot Wounds After Microvascular Free Tissue Transfer.

OBJECTIVES/HYPOTHESIS: Microvascular free tissue transfer is often employed to reconstruct significant facial defects from ballistic injuries. Herein, we present our comparison of complications between self-inflicted and non-self-inflicted gunshot wounds after microvascular free tissue transfer. STUDY DESIGN: Retrospective case review. METHODS: Approval was obtained from the JPS institutional review board. We performed a retrospective review of cases of ballistic facial injuries between October 1997 and September 2017 that underwent vascularized free tissue transfer for reconstruction. Comparisons were made between self-inflicted and non-self-inflicted gunshot wounds after microvascular free tissue transfer. The χ2 test was used for all comparisons. P value and 95% confidence interval (CI) were reported. RESULTS: There were 73 patients requiring free flap reconstruction after gunshot wounds to the face during the study period. There was a statistically significant difference in the rates of nonunion between self-inflicted and non-self-inflicted wounds (P = .02, 95% CI: 0.9 to 35.8) There were also no significant differences in flap failure (P = .10, 95% CI: -2.8 to 24.2), plate exposure (P = .28, 95% CI: -6.7 to 33.0), wound infection (P = .40, 95% CI: -8.9 to 31.2), scar contracture (P = .60, 95% CI: -8.1 to 25.1), and fistula formation (P = .13, 95% CI: -2.8 to 28.8) between patients with self-inflicted and those with non-self-inflicted wounds. Overall, complication rates were significantly higher in the self-inflicted group compared to the non-self-inflicted group (P < .0001, 95% CI: 32.6 to 68.6). CONCLUSIONS: Patients with self-inflicted injuries had more complications postoperatively than those with non-self-inflicted injuries. This is likely helpful in surgical planning and patient counseling. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:837-840, 2019.

The Paramedian Forehead Flap for Nasal Reconstruction: From Antiquity to Present.

Nasal reconstruction is considered the historic foundation of facial plastic surgery, and the forehead flap remains the workhorse of repair. To recreate both the aesthetic contour and function of the nose, all anatomic layers must be addressed-covering, lining, and structural support. This article reviews the noteworthy history underlying the development of the paramedian forehead flap as the primary tool in reconstruction of large nasal defects while highlighting its implications on modern nasal repair. Current developments in the use of 2-staged paramedian forehead flap reconstruction are examined and a modern technique is presented.

Preoperative radiation and complication rates after double free flap reconstruction of head and neck cancer.

INTRODUCTION: In this study, we explore whether preoperative external beam radiation affects complication rates in patients that have undergone double simultaneous free tissue transfer for head and neck defects. STUDY DESIGN, SETTING, SUBJECTS AND METHODS: Approval was obtained from the JPS Institutional Review Board. We performed a retrospective analysis of patients who underwent double free flap reconstruction of head and neck defects between August 1997 and April 2017. Minimum follow up was 6 months. Patients were grouped according to preoperative radiation status (XRT vs non-XRT). The chi-squared test was used for all comparisons. P-values and 95% confidence intervals (CI) were reported as (P, 95% CI). RESULTS: 90 flaps were performed on 45 patients. The most common flap combination utilized was fibula plus radial forearm free flap (RFF) in 17 out of 45 patients. There were no statistically significant differences in frequency of flap failure (0.35, -15.9-20.1), wound infection (0.75, -22.1-19.3), hematoma (0.16, -5.3-36.7), or fistula formation (0.69, -22.5-24.6). There were also no statistically significant differences in cardiac complications (0.57, -10.3-28.2) and DVT (0.22, -12.4-25.3). CONCLUSION: Our findings suggest that double free flap patients who had preoperative radiation are not more likely to have complications compared to non- radiated patients. Simultaneous double free flaps should be reserved for the most complex cases. Extensive discussion should be had with the patient about possible morbidity and mortality.

Evaluating the role of embolization and carotid artery sacrifice and reconstruction in the management of carotid body tumors.

OBJECTIVES/HYPOTHESIS: To review the surgical management of carotid body tumors (CBT), outcomes of carotid artery reconstruction, as well as utility of preoperative embolization. STUDY DESIGN: Retrospective chart review. METHODS: A single-surgeon case series with chart review was performed of all cases between 1997 and 2014 at a single institution. Tumor classification, major neurovascular resection, requirement for in-line carotid artery reconstruction, intraoperative blood loss, and operative time, and postoperative neurovascular complications were determined. RESULTS: In all, 96 patients with 101 CBTs underwent definitive resection disease. Vascular sacrifice was 2.9% (three) for the internal jugular vein, 8.9% (nine) for the external carotid artery, and 13.8% (14) for the internal carotid artery (ICA). ICA sacrifices were performed with immediate in-line arterial bypass grafting with vascular surgery. Permanent cranial neuropathies occurred in 4.9% (five) of patients, without cerebrovascular events. CONCLUSIONS: We recommend surgical resection as the primary approach to the management of these CBTs. In lesions involving the ICA, we recommend vein bypass grafting. We found no differences or advantages to preoperative embolization. LEVEL OF EVIDENCE: 4 Laryngoscope, 126:2282-2287, 2016.

Cutaneous squamous cell carcinoma of the scalp in the immunocompromised patient: review of 53 cases.

OBJECTIVE: We analyzed outcomes from immunocompromised patients with scalp squamous cell carcinoma (SCC) treated with surgical excision with and without radiation in order to explore 3-year disease-free survival and overall survival. STUDY DESIGN: The study design was a retrospective chart review. SETTING: This study was conducted in a private practice setting. SUBJECTS AND METHODS: The study included 53 immunocompromised patients with an average age of 63.2 years, with scalp squamous cell carcinoma. Pre-operative imaging dictated the extent of resection. Patients with bony involvement received wide local excision including full-thickness craniectomy and cranioplasty. Patients without bony involvement underwent wide local excision and outer-table calvarial resection. All patients were recommended to have post-operative radiation. Patients were followed for a minimum of 3 years. RESULTS: A total of 53 patients were included in the study. Six patients had pre-operative CT showing bone involvement and were treated with full-thickness craniectomy along with post-operative radiation. Fourteen patients without bone involvement on pre-operative CT were found to have positive bone involvement on final pathology. Forty-five patients underwent post-operative radiation. Patients treated with adjuvant radiation demonstrated a 3-year survival of 80 % and the overall survival was 62 %. In the surgery-only group, the 3-year survival was 62.5 % and the overall survival was 32.5 %. CONCLUSIONS: Immunocompromised patients with scalp SCC have a poor prognosis. Early detection and treatment are crucial. Based on our results, we recommend wide local excision with at least outer-table calvarial resection, and post-operative radiation. Despite aggressive therapy, patients may still have distant, local, or regional recurrence. LEVEL OF EVIDENCE: level 2b (retrospective cohort).

The role of elective superficial parotidectomy in the treatment of temporal region squamous cell carcinoma.

OBJECTIVE: In order to determine rates of metastasis and efficacy of elective superficial parotidectomy, we examine parotid specimens in patients with temporal region cutaneous squamous cell carcinoma treated with local excision and ipsilateral parotidectomy. STUDY DESIGN: This paper is a retrospective review. SETTING: This study was conducted at a private tertiary referral practice in Fort Worth, Texas, from 1998 to 2013. SUBJECTS AND METHODS: Ninety-three patients between ages 27 and 98 with primary squamous cell carcinoma of the temporal region greater than or equal to 2 cm were included in this study. Subjects had no evidence of adenopathy or parotid involvement on exam or imaging. Patients were treated with local excision and ipsilateral parotidectomy. The primary tumor was studied for vascular involvement and perineural invasion while the parotid specimen was analyzed for occult cancer. Patients were post-operatively followed for a minimum of three years. RESULTS: Twenty-three (24.7 %) parotid samples were found to harbor occult malignancy. Of these, nine (39.1 %) patients had vascular involvement of the primary tumor and 14 (60.8 %) had perineural invasion. Thirteen out of 58 affected males and 10 out of 35 affected females were found to have intraparotid node positivity. Vascular involvement (p = 0.0004) and perineural invasion (p = 0.0001) in the primary malignancy were found to be greater in patients with positive specimen. Sex was not statistically significant. CONCLUSIONS: In patients with cutaneous squamous cell carcinoma of the temporal region at least 2 cm in size, elective superficial parotidectomy may be a beneficial part of treatment, especially in primary tumors showing perineural and/or vascular involvement. LEVEL OF EVIDENCE: Level 2b (retrospective cohort).

Internal to external jugular vein bypass allowing for simultaneous bilateral radical neck dissection.

OBJECTIVES/HYPOTHESIS: The goal of the study was to determine the role of internal jugular vein (IJV) to external jugular vein (EJV) bypass grafting in the setting of bilateral radical neck dissection with IJV sacrifice. STUDY DESIGN: The study group consisted of eight patients who underwent bilateral radical neck dissection with IJV sacrifice. Demographic and oncologic parameters were defined for each patient, including age, gender, and pathology. Patients were monitored and evaluated for potential effects of increased intracranial pressure (ICP). Doppler ultrasonic evaluation was performed to assess patency of the site of anastamoses. RESULTS: In all, six patients underwent unilateral bypass grafting, whereas two patients underwent bilateral bypass grafts. Average age at time of surgery was 68.2 (range 56-71). Postoperatively, no sequelae of increased ICP were noted. Follow-up ultrasonic evaluation revealed patent vessels in all patients. CONCLUSION: We presently report on the use of EJV-to-IJV bypass grafting for all patients undergoing bilateral radical neck dissection for extensive neck disease. LEVEL OF EVIDENCE: 4.

Concepts in Neural Coaptation: Using the Facial Nerve as a Paradigm in Understanding Principles Surrounding Nerve Injury and Repair.

OBJECTIVES: Individuals with nerve transection face unpredictable outcomes, and microsurgical interventions have variable success. The facial nerve in particular is prone to traumatic transection and leads to debilitating sequelae. Surgeons have used multiple modalities of enhancing nerve regeneration and restoring premorbid functionality. The success of nerve regeneration is predicated on multiple physiologic factors. This article sought to collate the literature on factors influencing nerve damage and repair, using the facial nerve as a paradigm. As such, facial reanimation will also be briefly discussed as it relates to the central theme. DESIGN: A PubMed search was conducted to find articles published on nerve physiology and anatomy, as well as repair. Articles from 1947 to 2013 were studied; however, the preponderance of articles in the study was from the past 15 years to include recent advances. RESULTS: The type and severity of nerve injury, as well as timing of intervention, influence the anatomical and functional outcomes of nerve repair. As there is no uniform solution for all reconstructive challenges, multiple factors must be considered when planning an intervention. Future advances suggest a potential role for engineered nerve conduits in providing a tool for nerve regrowth. CONCLUSION: Our review has detailed mechanisms of nerve injury, physiology, interventions in nerve repair, and future direction of this expanding field. This review provides a guide for the microsurgeon in factors involved in restorative success.

Management of the thyroid gland during total laryngectomy in patients with laryngeal squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: The goal of the study was to determine the role of routine total thyroidectomy and hemithyroidectomy in patients undergoing total laryngectomy for laryngeal squamous cell carcinoma. STUDY DESIGN: The study group consisted of 343 patients who underwent total laryngectomy (98 treated with surgery alone, 136 treated following radiation failure, and 109 following chemoradiation failure). Total thyroidectomy was performed in all obstructing and bilateral lesions or if there was suspicion of contralateral lobe involvement. Hemithyroidectomy was performed in all lateralized lesions. Retrospective histopathologic analysis of thyroid specimens was subsequently performed. RESULTS: In all, 262 patients underwent total thyroidectomy during total laryngectomy, six of which demonstrated squamous cell carcinoma evident within the thyroid gland (4 from transglottic lesions, 2 from subglottic lesions). Hemithyroidectomy was performed in 81 patients, with only one patient demonstrating evidence of squamous cell carcinoma within the thyroid gland. Hypothyroidism was observed in 88% (n = 61) of patients who underwent thyroid lobectomy alone, requiring hormone supplementation. CONCLUSION: Routine surgical management of the thyroid gland should not be performed, except in cases of subglottic primary lesions, lesions with significant subglottic extension, or transglottic lesions. Despite efforts to preserve the contralateral thyroid lobe in cases of selective lobectomy, these patients often have a high rate of hypothyroidism, and a total thyroidectomy should be considered when involvement of the thyroid gland is suspected. LEVEL OF EVIDENCE: N/A.

Carotid Artery Sacrifice and Reconstruction in the Setting of Advanced Head and Neck Cancer.

OBJECTIVE: To determine oncological and neuromorbidity outcomes in patients with advanced head and neck cancer (stage IVB) requiring sacrifice and reconstruction of the carotid artery. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care referral center. SUBJECTS AND METHODS: Overall, 51 patients underwent carotid artery sacrifice during surgical treatment of the neck, in both the primary and salvage setting. All patients underwent autogenous in-line carotid artery bypass grafting with either saphenous vein or the deep femoral vein in conjunction with vascular surgery. In all, the study included 39 males and 12 female subjects, with age ranging from 39 to 82 (mean, 62.7). RESULTS: Two patients (3.9%) had a cerebral vascular accident in the immediate postoperative period. The remaining 49 patients (96%) had no neurologic sequela. Serial ultrasonic evaluation revealed 4 patients with intra-luminal thrombus within the site of reconstruction. Perioperative mortality occurred in a single patient. Disease-related mortality occurred in 9.8% (5) of patients, with an overall 2-year survival of 82%. CONCLUSIONS: We presently report the largest series of surgical treatment for advanced head and neck cancer with carotid artery involvement. We document an overall 2-year survival of 82% in the setting of low perioperative neuromorbidity and mortality rates. We therefore consider carotid artery sacrifice and autogenous vein graft reconstruction in the absence of distant metastatic disease as a viable treatment option for what was once thought to be a palliative procedure.

The role of parotidectomy in the treatment of auricular squamous cell carcinoma.

OBJECTIVE: We analyze parotid specimens in patients treated with prophylactic parotidectomy for squamous cell carcinoma of the auricle greater than or equal to 2 cm to determine rates of metastasis and the efficacy of elective resection. STUDY DESIGN: Case series with chart review. SETTING: Cancer treatment center in Fort Worth, Texas, from 1998 to 2013. SUBJECTS AND METHODS: The study included 104 patients between ages 36 and 97 years with primary auricular squamous cell carcinoma greater than or equal to 2 cm, with no evidence of adenopathy or parotid involvement on imaging. Patients underwent local excision and ipsilateral parotidectomy. The primary cancer was analyzed for vascular involvement, perineural invasion, and cartilage involvement, while the parotid specimen was analyzed for cancer positivity. RESULTS: Thirty-nine parotid (37.5%) samples were positive for carcinoma. Of these, 16 patients had primary auricular carcinomas with vascular involvement, 17 had perineural invasion, and 4 had cartilage involvement. Thirty-two of 77 affected men and 7 of 27 affected women had positive parotid specimen. Vascular involvement (P = .0006) and perineural invasion (P = .0027) of the primary lesion were significantly higher in patients with a positive parotid specimen. Cartilage involvement and sex were not statistically significant. CONCLUSIONS: Elective parotidectomy is beneficial in patients with squamous cell carcinoma of the auricle at least 2 cm in size, especially in lesions having perineural invasion and vascular involvement. For patients with positive parotid specimens, we recommend postoperative external beam radiation therapy and close surveillance.

Does the use of an acellular dermal graft in abdominal closure after rectus flap harvest impact the occurrence of post-operative hernia?

IMPORTANCE: Patients with rectus free flap harvest extending below the arcuate line are predisposed to postoperative hernia formation. As such, many authors have advocated the use of closure adjuncts to increase the integrity of the closure and prevent hernia or abdominal wall bulging. SETTING: Busy level 1 public trauma center in metropolitan Fort Worth, Texas INTERVENTIONS: Following harvest of the rectus free flap, 48 patients underwent primary closure; 24 of these patients had defects extending below the arcuate line. Forty patients were closed with an acellular dermal graft; 22 of these patients had defects extending below the arcuate line. MAIN OUTCOME MEASURE: Postoperative hernia formation and local infection rate were examined in a minimum follow-up period of 1 year. RESULTS: Regardless of closure method, no hernias were observed in the postoperative period. Using an unpaired t test and an alpha value of 0.05, there was no statistically significant difference in the infection rate between the two groups. CONCLUSION: Following rectus abdominis myocutaneous free flap harvest, the use of an acellular dermal graft in abdominal wall closure may not be of any further advantage in the prevention of hernia. LEVEL OF EVIDENCE: Retrospective (Level III).

Examining the genetics of congenital facial paralysis--a closer look at Moebius syndrome.

OBJECTIVES: The molecular underpinnings of Moebius syndrome (MBS) are diverse. This article provides a comprehensive summation of the genetic and etiologic literature underlying this disorder. Elucidating the genetic causes of the disorder can aid in earlier detection and treatment planning. DESIGN: Articles from 1880-2013 were selected and reviewed by six researchers to understand all of the molecular theories and chronicity of advancements in the literature. RESULTS: Mutations in the MBS1, MBS2, and MBS3 gene loci all have contributed to the development of MBS through various pathways. HOX family genes coding for homeobox domains, also, have been implicated in the abnormal development of the human brain. These are among the numerous genes that have been linked to the development of MBS. CONCLUSION: Our study codified nascent findings of the molecular determinants of MBS. These findings add to a growing database of MBS-associated mutations and can be used to diagnose MBS and clarify pathogenesis.