Defining the Safe Entry Point in Deep Plane Facelifting with Novel Landmark for the Buccal Branch of the Facial Nerve.

Background: In deep facial surgery, accurate preoperative landmarking of branches of the facial nerve is helpful in avoiding inadvertent facial nerve injury. The objective of our study was to determine the accuracy at which the intersection point of two bisecting lines that join facial surface landmarks can be used to accurately locate the buccal branch(es) of the facial nerve, specifically at the deep plane entry point (ie, intercept landmark). Methods: Thirty-three cadavers were dissected to determine the position of the buccal rami relative to the intercept. Results: Buccal rami crossed the intercept in 12.12% of specimens (0 mm from intercept, n = 4). Buccal rami passed superiorly in 66.67% of specimens (3.71 ±â€…3.28 mm from intercept, n = 7) and inferiorly in 21.21% of specimens (2.44 ±â€…0.92 mm from intercept, n = 7). Noteworthy, buccal rami were located within 1 cm of the intercept landmark with 96.97% accuracy (32/33 cadavers). Conclusions: These data suggest that this novel intercept (1) reliably locates the buccal branch of the facial nerve as it courses distal to the parotid gland, and (2) helps define a "safe zone" for entry into the deep plane where the likelihood of encountering the facial nerve is extremely low.

Treatment of acquired partial oculomotor nerve palsy with dexamethasone - A case report.

INTRODUCTION/IMPORTANCE: Oculomotor nerve palsy is an acquired condition caused by injury to the third cranial nerve. Patients present classically with their eye in a "down and out" positioning, ptosis and abnormalities in most extraocular movements causing diplopia. Ocular dysfunction may be due to a variety of different etiologies, such as aneurysm, microvascular disease, trauma, and viral infections. Clinical prognosis is usually quite good and is often self-limiting. CASE REPRESENTATION: We present a case of an otherwise healthy 40-year-old male who awoke one morning with moderate diplopia, unable to focus with binocular vision and developed eyelid ptosis two days later. He was previously infected with the Omicron variant of COVID-19; however, a rapid test could not confirm it. No intracranial or vascular pathology were identified on CT head, CT angiogram, or MRI. Repeat COVID-19 PCR test was negative. He was assessed by a neuro-ophthalmologist and was diagnosed with left partial oculomotor nerve palsy presumed secondary to viral microvascular injury. COVID-19 infection seemed likely given the history but could not be confirmed. The specialist recommended monitoring the patient without any treatment, with no recommendation of corticosteroid use. CLINICAL DISCUSSION: Cranial neuropathy guidelines for viral palsies involving the 7th or 8th cranial nerve are treated with corticosteroids. After considering the risks, the patient elected treatment with a left eye patch and a dexamethasone taper. Full return of function in all extremes of gaze was restored less than 2 months after onset. CONCLUSION: Given the complete and timely recovery, it may be reasonable to consider corticosteroids for all cranial neuropathies.

Operating Room Noise and Team Communication during Facial Plastic and Reconstructive Surgery: A Multicenter Study.

Operating room (OR) noise contributes to team miscommunication. In facial plastic and reconstructive surgery (FPRS), many cases are completed under sedation. This creates a unique environment wherein patients are aware of OR noise. The objectives of this study were to quantify noise and evaluate team members' perspectives on communication inside of FPRS ORs. This study was completed across three surgical institutions. Objective noise measurements were recorded with SoundMeter X. A communication questionnaire was delivered to OR team members following each case. Four hundred and twenty-three noise measurements were recorded during facelift/neck, eye/brow, rhinoplasty, and fat transfer/lip surgeries. The mean and maximum noise levels were 66.1 dB (dB) and 87.6 dB, respectively. Measurements during cases with general anesthetic (221/423, 52.2%) had higher noise measurements (70.3 dB) compared with those with sedation (202/423, 47.8%) (69.7 dB) (p = 0.04). The OR was louder with suction on (72.3 dB) versus off (69.3 dB) (p <0.00). Suction (34.5%) and music (22.4%) were the largest noise contributors according to questionnaire replies. Intraoperative noise, awake patients, and suctions/music may negatively impact FPRS OR communication. Innovation to improve FPRS intraoperative communication should be considered for effective patient care.

Effect of strontium citrate on bone consolidation during mandibular distraction osteogenesis.

OBJECTIVES/HYPOTHESIS: Mandibular distraction osteogenesis (MDO) involves a lengthy consolidation phase where complications can occur. Strontium is an element that has been shown to improve bone healing. The objective of this study was to determine whether strontium citrate can be used to enhance bone healing during MDO in a rabbit model. STUDY DESIGN: Prospective animal model study. METHODS: Custom-made MDO devices were placed on 20 New Zealand White rabbits. After a 7-day latency period, distraction was performed at 1 mm/day for 5 days. The study group rabbits (n = 10) received oral strontium citrate; the other 10 rabbits served as controls. Mandibles were removed at the end of the consolidation period (4 weeks). Formation and healing of new bone were evaluated with microcomputed tomography, histology, and a three-point bending mechanical test. RESULTS: New bone formed in all animals, but the consolidation process was enhanced in rabbits that received strontium. The histological analysis showed that study group rabbits had more mature bone. Microcomputed tomographic images demonstrated significantly higher bone density for study group animals, and the three-point bending test results demonstrated that the maximum load of the study group specimens was significantly greater than that of the control group mandibles. CONCLUSIONS: Strontium citrate improved the formation of new bone in the current rabbit model of MDO. The prolonged consolidation period may be shortened with strontium citrate, which may also have the potential to reduce complications. LEVEL OF EVIDENCE: NA Laryngoscope, 127:E212-E218, 2017.

In search of the optimal processing technique for fat grafting.

OBJECTIVE: Unpredictability in graft retention remains a significant drawback of fat grafting. Processing of fat grafts has been the focus of several studies to improve graft survival. The objective of this study was to systematically review the outcomes of different fat graft processing techniques with the goal of (1) deriving clinically oriented insights and (2) identifying gaps in knowledge to stimulate future research. METHODS: PubMed, EMBASE, and Cochrane Databases were searched to identify studies that compared different fat graft processing techniques. Outcome measures of interest were any subjective or objective measures of fat graft survival or reports of adverse events. RESULTS: A total of 2056 abstracts were generated from the literature searches; 13 studies met the criteria for data extraction and analysis. Processing methods assessed included decantation, washing, gauze filtration, and centrifugation. Each processing method was found to be better than other methods, depending on the outcome measure used to study graft survival. As well, several studies found statistical equipoise in the outcome measures when analyzing the results of the different techniques. Adverse events were rarely reported and did not correlate with any processing method in particular. CONCLUSIONS: No firm concluding recommendation can be made to deem 1 processing technique superior to the others. However, it would seem that techniques, which use a combination of gentle washing and centrifugation, strike the optimal balance of preserving adipocyte viability while removing bulk of the contaminants.

Tympanic membrane manipulation to treat symptoms of patulous eustachian tube.

OBJECTIVE: Patulous eustachian tube (PET) can have a significant negative impact on a patient's quality of life. Previous work has demonstrated that temporarily mass loading and stiffening the tympanic membrane significantly reduces these symptoms. This study examined KTP laser myringoplasty (LM) and cartilage tympanoplasty (CT) as a means to manipulate the tympanic membrane to alleviate PET symptoms. STUDY DESIGN: Retrospective case review. SETTING: Academic tertiary care referral hospital. PATIENTS: Patients (n = 20) were identified from the senior authors' (M.B.) specialty eustachian tube disorders clinic. Patients met previously established diagnostic criteria for PET. All patients had a clinically apparent flaccid segment of the eardrum and had symptom improvement after simple mass loading of their eardrum in the clinic. INTERVENTIONS: Patients in this study received either KTP LM (10 patients, 15 ears) or CT (10 patients, 11 ears) to treat their flaccid eardrum segment in an attempt to alleviate PET symptoms. MAIN OUTCOME MEASURES: Preoperative and postoperative questionnaire scores and tympanometry measurements were compared. RESULTS: Patients undergoing CT for PET had a significant reduction in their symptoms of autophony (p ≤ 0.001), conducted breath sounds (p = 0.001), and aural fullness (p = 0.009). KTP LM did not significantly reduce symptoms. CONCLUSION: Cartilage tympanoplasty provides a safe and accessible surgical option for the treatment of PET and significantly reduces the symptoms of autophony, conducted breath sounds, and aural fullness. Further studies are needed to investigate whether addressing PET symptoms simultaneously from both the tympanic membrane and the eustachian tube orifice can improve patient symptoms even further.

Differential expression of transforming growth factor-beta in benign vs. papillary thyroid cancer nodules; a potential diagnostic tool?

BACKGROUND: Thyroid nodules are common, but only 5% of nodules are found to be malignant. In North America, the incidence of thyroid cancer is increasing. Fine needle aspirate (FNA) biopsy is the diagnostic test of choice. Unfortunately, up to 20% of FNAs are non-diagnostic. A specific molecular marker for thyroid cancer is desirable. Evidence suggests that cell signaling through transforming growth factor beta (TGF-ß) is important in the development of thyroid cancer. We sought to compare the expression of TGF-ß in malignant and benign thyroid nodules. METHODS: From 2008-present, thyroid nodule tissue from thyroidectomy specimens was prospectively collected and stored at -80°C. RNA extraction and reverse transcription was performed on 47 samples (24 papillary thyroid cancer and 23 benign nodules). Quantitative PCR using SYBR green was performed to detect TGF-ß-1 and -2. Resulting CT values were normalized against ß-actin. Gene expression was calculated using the 2(-ΔC)T method. RESULTS: A significantly greater expression of TGF-ß1 (p < 0.0001) was detected in the group of malignant thyroid nodules compared to benign nodules. There was no difference in the expression of TGF-ß2 (p = 0.4735) between the two groups. CONCLUSIONS: In this study, we demonstrated that expression of TGF-ß1 but not TGF-ß2 is significantly increased in papillary thyroid cancer compared to benign thyroid nodules. This may serve as a potential diagnostic marker for papillary thyroid cancer.

Endoscopic stapling versus external transcervical approach for the treatment of Zenker diverticulum.

OBJECTIVE: To compare endoscopic stapling versus external transcervical approaches in the treatment of Zenker diverticulum. DESIGN: A 10-year retrospective institutional review was performed to identify all patients treated for Zenker diverticulum. SETTING: Academic tertiary care centre. METHODS: Patients treated surgically for Zenker diverticulum were identified through an electronic records search. Patient charts were reviewed, and patients were interviewed at follow-up. MAIN OUTCOME MEASURES: Patient age, sex, duration of symptoms, procedural time, time to oral liquids, length of posttreatment hospital stay, and post procedure patient satisfaction were recorded and compared. RESULTS: Ten patients treated endoscopically were compared with eight patients treated via an external approach. There were no significant differences in patient age, sex, and duration of symptoms. The external technique took significantly longer (110.88 +/- 59.61 minutes) than the staple technique (19.50 +/- 6.47 minutes) (p < .0001). There was no significant difference in time to full oral liquids (p = .11). The postsurgical hospital stay (4.71 +/- 1.98 days) was significantly longer for the external technique compared with the staple technique (2.30 +/- 2.83) (p = .03). Patient symptom relief was reported as completely resolved or improved in all cases, regardless of treatment type. CONCLUSIONS: Endoscopic stapling of Zenker diverticulum achieves operative success and patient satisfaction comparable to those of traditional external transcervical techniques, with significantly decreased operative times and hospital stays, allowing for more efficient use of resources.

Genetic analysis of the influence of neuroantigen-complete Freund's adjuvant emulsion structures on the sexual dimorphism and susceptibility to experimental allergic encephalomyelitis.

The induction of organ-specific autoimmune diseases, such as experimental allergic encephalomyelitis (EAE) the principal animal model of multiple sclerosis (MS), relies on the use of complete Freund's adjuvant (CFA) emulsions. In this study we report that the physical structure of the particles comprising neuroantigen-CFA emulsions significantly influences the genetic control of the incidence and sexual dimorphism seen in EAE. Immunization of (B10.S/SgMcdJ x SJL/J) F(2) mice segregating the quantitative trait loci (QTL) controlling EAE in susceptible SJL/J and resistant B10.S/SgMcdJ mice with emulsions consisting of particles where the Mycobacterium tuberculosis and neuroantigens are localized on the phase surfaces led to severe EAE in 98.8% of the mice, overriding all sex-specific and non-sex-specific genetic checkpoints. In contrast, F(2) mice immunized with emulsions where the bacterial products and encephalitogens are buried inside the water/oil vesicles exhibited a significant reduction in disease incidence (7.5%) and a sexual dimorphism (5% male versus 10% female). A genome scan identified QTL on chromosomes 7 and 11 controlling the sexual dimorphism as a function of the physical structure of the emulsion. The chromosome 11 QTL co-localizes with eae6b, and with Il12b and heptatitis A virus cellular receptor 2 (Havcr2, formerly known as Timd3), both of which are candidate genes for this QTL. Sequence analysis of the SJL/J and B10.S/SgMcdJ alleles indicates that both gene products are structurally monomorphic. Expression analysis also excluded both as candidates for this sex-specific QTL. These results reinforce the importance of gene-environment interactions in initiating and propagating autoimmune disease of the central nervous system, particularly in the context of susceptibility to MS and disease heterogeneity.