Fat Grafting as a Novel Treatment for Xerostomia.

PURPOSE: Within the context of xerostomia, there is evidence that adipose-derived stem cells (ASCs) can differentiate into salivary gland cells in the appropriate environment. The purpose of this study was to preliminarily investigate whether fat grafting as practiced in the United States would be an effective treatment for xerostomia. METHODS: Patients were selected for the study if they were seeking treatment for xerostomia after radiation treatment to the head and neck for cancer treatment. Fat grafting was performed in bilateral parotid and submandibular glands. Visual Analog Scale (VAS) of xerostomia was used both preoperatively and postoperatively to assess the effect upon xerostomia symptoms. RESULTS: Nine patients were included in this study. All patients had complaints of long-standing xerostomia. The average preoperative VAS score was 9.1. All patients tolerated all rounds of fat grafting with no complications. The average postoperative VAS score was 6.0. Compared to preoperative scores, all patients had improvement in VAS scores. The decrease in average VAS score postoperatively (9.1 versus 6.0) was statistically significant (P = 0.007). CONCLUSIONS: Our study showed that there was improvement in xerostomia symptoms with autologous fat transfer alone. This is a novel finding for fat grafting demonstrating regenerative potential. There has been extensive basic research that has shown that adipose-derived mesenchymal stem cells can have a protective and restorative role after salivary gland radiation damage. Our case series is the first report of fat grafting having a similar reported outcome.Level of Evidence: 4.

Reductive Nasal Profileplasty.

Reductive nasal profileplasty is often the pillar of aesthetic nasal surgery. The surgeon must be knowledgable in the key tenants of preoperative analysis and examination to better approach the core elements for hump takedown. Photo imaging or morphing is a practical and technically easy means to open the discussion with the patients to determine their specific goals and ensure that these goals align with their needs functionally. Various approaches can be taken dependent upon the demands from the patient's anatomy and surgical goals planned preoperatively. The component resection technique is described in detail, as well as discussions regarding the need to predict and prophylactically treat the possible long- and short-term sequelae that can occur with reductive nasal profileplasty. Complementary procedures should also be considered to achieve the most balanced nasal and facial aesthetic.

Complications in Reductive Profileplasty.

The ability of a surgeon to create an aesthetically pleasing and functionally competent nasal dorsum weighs heavily on following the foundations of rhinoplasty, beginning with the examination and analysis. These same fundamental principles should be used and applied in secondary rhinoplasty. The most common chief complaints of those patients seeking primary rhinoplasty relates to the presence of a hump or dorsal convexity, and similarly complications surrounding the dorsum are the most common indications for secondary rhinoplasty. The surgeon must be able to appropriately evaluate and correct deformities in patients who have already undergone rhinoplasty with dorsal profileplasty. Patients can present with a wide range of postoperative deformities within the bony pyramid or middle vault, including, but not limited to, contour irregularities and internal nasal valve compromise, respectively. The authors will outline the evolving methods by which these techniques can be executed to correct deformities and give a balanced functional and aesthetically pleasing profile.

Safety and Efficacy of Expanded Polytetrafluoroethylene Implants in the Surgical Management of Traumatic Nasal Deformity.

IMPORTANCE: The ideal alloplastic implant for correction of traumatic nasal deformity has not been adequately examined. OBJECTIVE: To evaluate the safety profile and postoperative results of expanded polytetrafluoroethylene (ePTFE) implants used in functional nasal surgery (FNS) in the setting of traumatic nasal deformity. DESIGN, SETTING, AND PARTICIPANTS: We conducted a 13-year retrospective medical chart review for patients treated at a tertiary academic facial plastic and reconstructive surgery practice between July 1999 and July 2012. A total of 404 FNS procedures were performed by a single surgeon during this period, 255 to repair traumatic deformities, 35 of these involving ePTFE implants. Patient demographics, medical comorbidities, operative and technical considerations, functional and aesthetic results, complications, and postoperative course findings were collected from patient records. In addition, preoperative and postoperative photographic documents were examined. EXPOSURES: Functional nasal surgery. MAIN OUTCOMES AND MEASURES: Postoperative complications or presentations necessitating revision. RESULTS: A total of 404 patients (197 male, 207 female) underwent FNS. Of those, 255 procedures were to treat traumatic deformities. Forty patients altogether required the use of an ePTFE implant, 35 of those 40 deformities being associated with a traumatic injury. One of the 35 patients in the ePTFE-repaired traumatic deformities group experienced postoperative infection. This patient ultimately developed exposure after the infection failed to resolve with oral antibiotics, and the implant was removed. An additional patient in the ePTFE group required revision of the implant owing to contour irregularity and aesthetic concerns. No infections or other complications occurred among the 220 patients with traumatic deformity treated with autologous grafts. Analysis of other variables including sex, tobacco use, diabetes, immunosuppression, implant thickness, suture material, and prior septorhinoplasty were not associated with increased rate of infection (P > .05 for all). CONCLUSIONS AND RELEVANCE: In the setting of traumatic nasal deformities requiring FNS, ePTFE implants can be used at the level of the nasal dorsum, where soft tissue coverage is often adequate, with a low risk of complications.

Surgical treatment of the brow and upper eyelid.

Surgical management of the aging upper face has taken on a critical role in total facial rejuvenation, with a variety of techniques available. The hallmarks of the aging upper third of the face and periorbital region most commonly manifest as rhytids, brow descent, prolapse of periorbital fat, dermatochalasis, and volume loss and hollowing. The surrounding structures should be assessed individually and their relationships carefully analyzed to guide selection of the appropriate treatment. In this article, the authors explore the various approaches and techniques available for rejuvenation of the upper face, including the upper periorbital region.

Characterization of postoperative changes in nasal airflow using a cadaveric computational fluid dynamics model: supporting the internal nasal valve.

IMPORTANCE: Collapse or compromise of the internal nasal valve (INV) results in symptomatic nasal obstruction; thus, various surgical maneuvers are designed to support the INV. OBJECTIVE: To determine the effect on nasal airflow after various surgical techniques focused at the level of the INV and lateral nasal sidewall. DESIGN AND SETTING: A fresh cadaver head was obtained and underwent suture and cartilage graft techniques directed at the level of the INV using an external approach. Preoperative and postoperative digital nasal models were created from the high-resolution, fine-cut, computed tomographic imaging after each intervention. Isolating the interventions to the level of the INV, we used computational fluid dynamic techniques to calculate nasal resistance, nasal airflow, and nasal airflow partitioning for each intervention. INTERVENTION: Suture and cartilage graft techniques. MAIN OUTCOMES AND MEASURES: Nasal airflow, nasal resistance, and partitioning of airflow. RESULTS: Using the soft-tissue elevation model as baseline, computational fluid dynamic analysis predicted that most of the suture and cartilage graft techniques directed toward the nasal valve improved nasal airflow and partitioning while reducing nasal resistance. Specifically, medial and modified flare suture techniques alone improved nasal airflow by 16.9% and 15.1%, respectively. The combination of spreader grafts and modified flare suture improved nasal airflow by 13.2%, whereas spreader grafts alone only improved airflow by 5.9%. The largest improvements in bilateral nasal resistance were achieved using the medial and modified flare sutures, outperforming the combination of spreader grafts and modified flare suture. CONCLUSIONS AND RELEVANCE: Techniques directed at supporting the INV have tremendous value in the treatment of nasal obstruction. The use of flare sutures alone can address dynamic valve collapse or upper lateral cartilage incompetence without gross disruption of the nasal architecture. Using computational fluid dynamic techniques, this study suggests that flare sutures alone may improve flow and reduce resistance when placed medially, surpassing spreader grafts alone or in combination with flare sutures. The longevity of these maneuvers can only be assessed in the clinical setting. Studies in additional specimens and clinical correlation in human subjects deserve further attention and investigation. LEVEL OF EVIDENCE: NA.

Anatomy and physiology of the aging neck.

This article discusses the surgically relevant anatomic and physiologic tenets of the aging neck. Procedures performed to rejuvenate and contour the aging neck can be challenging. A thorough understanding of the underlying neck anatomy, as well as the physiology associated with aging, is critical for surgical planning, execution, and achieving aesthetically pleasing outcomes. These topics are reviewed and used as the foundation for a discussion of various other techniques.

Isolated myxoma of the external auditory canal.

The majority of neoplasms within the external auditory canal are benign. Management of these primary tumors and their local recurrences are discussed herein. We present a case of an isolated myxoma of the external auditory canal with a review of the common histopathological and radiographic features. Although rare, this highlights the possibility of encountering benign tumor types that carry associated morbidity or mortality due to manifestations outside of the head and neck.

Practice patterns in the perioperative treatment of patients undergoing septorhinoplasty: a survey of facial plastic surgeons.

IMPORTANCE The common practices used in the perioperative care of patients undergoing septorhinoplasty are diverse and controversial. A consensus statement on the preferred clinical pathway in the perioperative treatment of patients undergoing septorhinoplasty has yet to be approached formally. OBJECTIVES To investigate the perioperative treatment of patients undergoing septorhinoplasty and to identify common practice patterns based on the preferences of leading facial plastic surgeons. DESIGN, SETTING, AND PARTICIPANTS We distributed an online survey to members of the American Academy of Facial Plastic and Reconstructive Surgery. Specifically, fellowship directors and academic contact members were anonymously polled and stratified by the number of septorhinoplasties performed annually. MAIN OUTCOME AND MEASURE A cohesive clinical guide to perioperative treatment after rhinoplasty. RESULTS Of the 92 members surveyed, 67 (73%) successfully completed the survey. The distribution of respondents included 43 academicians (64%) and 24 physicians in private practice (36%). Twenty-eight surgeons (42%) performed fewer than 50 rhinoplasties a year and 39 (58%), more than 50, representing 3510 to 4549 septorhinoplasties in total among respondents. Forty-four surgeons (66%) refrained from using any packing, and 41 (61%) used intranasal splints, with polymeric silicone splints the most popular of these (n = 24 [59%]). Sixty-six surgeons (99%) used external nasal splints, including 49 (74%) who used a thermoplastic splint and 49 (74%) who left the external nasal splint in place for 7 days or longer. The most common postoperative interventions to reduce edema and ecchymosis were elevation of the head of bed by 62 (93%), ice packs by 50 (75%), and Arnica montana by 33 (49%). Only 12 surgeons (18%) used postoperative corticosteroids to reduce edema. Fifty-six respondents (84%) prohibited participation in contact sports until at least 6 weeks after surgery. CONCLUSIONS AND RELEVANCE Perioperative care and practices after nasal surgery vary among the most highly trained and leading rhinoplasty surgeons. No published communication or consensus on perioperative practices has been disseminated in this setting. Given the results from those surgeons performing the most rhinoplasties in our field, some surgeons may choose to vary their practices to coincide with those of experienced surgeons. These guidelines could facilitate future studies of patient outcomes.

Metabolic derangements in the gastrocnemius and the effect of Compound A therapy in a murine model of cancer cachexia.

BACKGROUND: Cancer cachexia is a severe wasting syndrome characterized by the progressive loss of lean body mass and systemic inflammation. Inhibiting the signaling of the transcription factor nuclear factor kappa B (NF-κB) largely prevents cancer-induced muscle wasting in murine models. We have previously shown the utility of Compound A, a highly selective novel NF-κB inhibitor that targets the IκB kinase complex, to provide clinical benefit in cancer-induced skeletal muscle and cardiac atrophy. METHODS: Using a metabolomics approach, we describe the changes found between cachectic and noncachectic gastrocnemius muscles before and after Compound A treatment at various doses. RESULTS: Of the 234 metabolites in the gastrocnemius, cachexia-induced changes in gastrocnemius metabolism reset the steady-state abundances of 42 metabolites (p < 0.05). These changes, not evenly distributed across biochemical categories, are concentrated in amino acids, peptides, carbohydrates and energetics intermediates, and lipids. The gastrocnemius glycolytic pathway is markedly altered-changes consistent with tumor Warburg physiology. This is the first account of a Warburg effect that is not exclusively restricted to cancer cells or rapidly proliferating nonmalignant cells. Cachectic gastrocnemius also displays tricarboxylic acid cycle disruptions, signs of oxidative stress, and impaired redox homeostasis. Compound A only partially rescues the phenotype of the cachectic gastrocnemius, failing to restore the gastrocnemius' baseline metabolic profile. CONCLUSIONS: The findings in the present manuscript enumerate the metabolic consequences of cachexia in the gastrocnemius and demonstrate that NF-kB targeted treatment only partly rescues the cachectic metabolic phenotype. These data strengthen the previous findings from metabolomic characterization of serum in cachectic animals, suggesting that many of the metabolic alterations observed in the blood originate in the diseased muscle. These findings provide significant insight into the complex pathophysiology of cancer cachexia and provide objective criteria for evaluating future therapeutics.

Pediatric airway abnormalities: evaluation and management.

Sleep disordered breathing syndromes in pediatric patients can lead to adverse effects in the cardiovascular system, neurocognitive function, growth, and behavior. These syndromes occur more frequently in patients with craniofacial disorders. A high index of suspicion as well as early recognition, detection, and treatment of these syndromes are considered integral to care of children with craniofacial disorders.

Oral resveratrol therapy inhibits cancer-induced skeletal muscle and cardiac atrophy in vivo.

The mechanism by which cancer mediates muscle atrophy has been delineated in the past 3 decades and includes a prominent role of tumor-derived cytokines, such as IL-6, TNFα, and IL-1. These cytokines interact with their cognate receptors on muscle to activate the downstream transcription factor NF-κB and induce sarcomere proteolysis. Experimentally, inhibiting NF-κB signaling largely prevents cancer-induced muscle wasting, indicating its prominent role in muscle atrophy. Resveratrol, a natural phytoalexin found in the skin of grapes, has recently been shown to inhibit NF-κB in cancer cells, which led us to hypothesize that it might have a protective role in cancer cachexia. Therefore, we investigated whether daily oral resveratrol could protect against skeletal muscle loss and cardiac atrophy in an established mouse model. We demonstrate resveratrol inhibits skeletal muscle and cardiac atrophy induced by C26 adenocarcinoma tumors through its inhibition of NF-κB (p65) activity in skeletal muscle and heart. These studies demonstrate for the first time the utility of oral resveratrol therapy to provide clinical benefit in cancer-induced atrophy through the inhibition of NF-κB in muscle. These findings may have application in the treatment of diseases with parallel pathophysiologies such as muscular dystrophy and heart failure.

NF-κB inhibition protects against tumor-induced cardiac atrophy in vivo.

Cancer cachexia is a severe wasting syndrome characterized by the progressive loss of lean body mass and systemic inflammation. It occurs in approximately 80% of patients with advanced malignancy and is the cause of 20% to 30% of all cancer-related deaths. The mechanism by which striated muscle loss occurs is the tumor release of pro-inflammatory cytokines, such as IL-1, IL-6, and TNF-α. These cytokines interact with their cognate receptors on muscle cells to enhance NF-κB signaling, which then mediates muscle loss and significant cardiac dysfunction. Genetic inhibition of NF-κB signaling has demonstrated its predominant role in skeletal muscle loss. Therefore, we tested two novel drugs designed to specifically inhibit NF-κB by targeting the IκB kinase (IKK) complex: Compound A and NEMO binding domain (NBD) peptide. Using an established mouse model of cancer cachexia (C26 adenocarcinoma), we determined how these drugs affected the development of tumor-induced cardiac atrophy and function. Echocardiographic and histological analysis revealed that both Compound A and NBD inhibit cardiac NF-κB activity and prevent the development of tumor-induced systolic dysfunction and atrophy. This protection was independent of any effects of the tumor itself (Compound A) or tumor-secreted cytokines (NBD). This study identifies for the first time, to our knowledge, that drugs targeting the IKK complex are cardioprotective against cancer cachexia-induced cardiac atrophy and systolic dysfunction, suggesting therapies that may help reduce cardiac-associated morbidities found in patients with advanced malignancies.

Obstructive sleep apnea in an infant with prominent glossopharyngeal muscles: therapy and outcome.

We present a case of prominent glossopharyngeal muscles causing severe obstructive symptoms in a 3-month-old child. Preoperative sleep studies and dynamic microdirect laryngoscopy were used in evaluation of the patient. Postoperative sleep studies confirmed a substantial reduction in apneic events after release of the muscle folds. The literature addresses the variant anatomy, and treatment options are discussed. To our knowledge, this is the first case report of prominent glossopharyngeal muscles leading to apneic events. We propose that in patients with prominent glossopharyngeal folds, surgical release may significantly improve symptoms of sleep apnea and in severe cases prevent tracheostomy.