Pre-tracheotomy for Potentially Emergent Airway Scenarios: Indications and Outcomes.

OBJECTIVES/HYPOTHESIS: Airway access in the setting of unsuccessful ventilation and intubation typically involves emergent cricothyrotomy or tracheotomy, procedures with associated significant risk. The potential for such emergent scenarios can often be predicted based on patient and disease factors. Planned tracheotomy can be performed in these cases but is not without its own risks. We previously described a technique of pre-tracheotomy or exposing the tracheal framework without entering the trachea, as an alternative to planned tracheostomy in such cases. In this way, a tracheotomy can be easily completed if needed, or the wound can be closed if it is not needed. This procedure has since been used in an array of indications. We describe the clinical situations where pre-tracheotomy was performed as well as subsequent patient outcomes. METHODS: Retrospective series of patients undergoing a pre-tracheotomy from 2015 to 2020. Records were reviewed for patient characteristics, indication, whether the procedure was converted to tracheotomy or closed at the bedside, and any post-procedural complications. RESULTS: Pre-tracheotomy was performed in 18 patients. Indications included failed extubation after head and neck reconstruction, subglottic stenosis, laryngeal masses, laryngeal edema, thyroid masses, and an oropharyngeal bleed requiring operative intervention. Tracheotomy was avoided in 10 patients with wound closed at the bedside; procedure was converted to tracheotomy in the remaining eight. There were no complications. Indications for conversion included failed extubation, intraoperative hemorrhage, significant stridor with dyspnea, and inability to ventilate. CONCLUSION: Pre-tracheotomy offers simplified airway access and provides a valuable option in scenarios where tracheotomy may, but not necessarily, be needed. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2802-E2809, 2021.

Neck Deformities in Plastic Surgery.

This article provides facial plastic surgeons with the insight to avoid and address common pitfalls in neck procedures. Many aesthetic issues are created from overtreatment or undertreatment of components of the neck. Using the platysma muscle as the divide, ease of access to superficial anatomy leads to overtreatment problems, whereas difficulty of access to deeper structures leads to undertreatment problems and to overall imbalances. Strategies to accurately assess and treat all structures of the neck proportionally can be used to both avoid and treat any neck aesthetic issues. The advent of minimally invasive techniques has resulted in new complications.

Neck rejuvenation by direct anterior medial cervicoplasty: the modified zigzag-plasty according to Tschopp.

BACKGROUND: Conventional cervicofacial rhytidectomy has become the standard treatment of skin excess of the ageing neck. However, some patients want to avoid an extensive surgical procedure, especially if the anterior neck is the predominant problem zone. OBJECTIVE: To report on the efficacy and safety of a zigzag-shaped skin excision combined with platysma plication. METHODS AND MATERIALS: We present a retrospective case review series of six female patients. Skin excess was marked preoperatively using the skin pinching technique, then transferred to a zigzag-shaped area and finally excised using the method according to Tschopp, which is described. Patients were followed up for at least 1 year. RESULTS: All patients (age: 55-82 years, median: 65 years) were very satisfied with the results. On an overall patient satisfaction scale of 1-10 (1 being the best), the scars were graded on average 1.85 (median: 2) 1 year after surgery. No scar hypertrophy, functional impairment, nerve damage or other serious complications were observed. CONCLUSION: In selected patients, the direct anterior zigzag-shaped excision poses an effective, safe and easy surgical option for both skin excess and fat excess and platysma banding. The technique is easily reproducible, with low morbidity and high patient satisfaction.

The Horizontal Neck Lift.

The horizontal neck lift is a procedure involving direct excision of a horizontally oriented ellipse of skin from the neck. This procedure was developed for neck rejuvenation in patients with significant horizontal creases and excess skin of the middle and lower neck, areas that often cannot be adequately addressed with traditional techniques. This article describes the procedure, indications, patient counseling, and postoperative care in detail from the senior author's (H. M.) experience.

Vacuum-assisted closure for complicated wounds in head and neck region after reconstruction.

OBJECTIVE: The aim of this study is to suggest that negative pressure wound therapy (NPWT) is an excellent alternative for managing complicated wounds after head and neck reconstruction. SUMMARY BACKGROUND DATA: Management of complicated wounds such as wound infection or persistent saliva leakage from poor wound healing with dead space is challenging in head and neck reconstruction. The NPWT is a useful device widely used in treating many complicated wounds. In this study, we applied this device on complicated wounds after head and neck reconstruction and share our experience and modifications. METHODS: From January 2004 to December 2009, 13 male patients (mean age: 50.0 years) were included. Eleven patients were reconstructed with free flap transfer and the other two patients received a local flap for repair immediately after tumour ablation. Among them, 12 patients (92%) had complicated wounds with infection and one patient (8%) with partial loss of the free flap. Eight of these 13 patients (62%) had saliva leakage and fistula formation. For those who had a free flap transfer, the vacuum-assisted closure (VAC) system was applied with modifications to the complicated wound 2 weeks later, after better neo-vascularisation around the free flap. Watertight suturing on the mucosal side is needed to ensure air sealing and enhance wound healing acquired by the VAC system. RESULTS: All wounds demonstrated adequate control of wound infection, quick obliteration of dead space and rapid growth of granulation tissue under the NPWT. Eleven patients (85%) had wound healing with secondary intention; one (8%) needed a further skin grafting; and one patient (8%) needed a free flap transfer due to partial flap loss in a severe wound infection even after the NPWT application. The average duration of the NPWT usage was 10.8 days (4-24 days); most of the wounds healed within 1 week after the NPWT application. CONCLUSION: The NPWT is an excellent alternative for managing complicated wounds after head and neck reconstruction. It is safe and comfortable for the patient and provides good results in infection control, dead space obliteration and improvement of wound healing.

Endoscopic-assisted sphincter pharyngoplasty (EASP).

OBJECTIVES: Sphincter pharyngoplasty operation was designed for the treatment of velopharyngeal insufficiency via a transoral route. Few investigators used palatal stretching sutures or palatal splitting procedures (which may affect the performance of the palate) to overcome the problem of difficult visualization. The purpose of this study is to present and evaluate the role of intraoperative nasoendoscopy during sphincter pharyngoplasty. Although Vadodaria et al. (2004) (in a cadaver study) used the endoscope to perform SP operation, this study (to our knowledge) is the first report of intraoperative nasoendoscopy in sphincter pharyngoplasty. SUBJECTS AND METHODS: This prospective study was conducted at ORL-HN Department, Zagazig University Hospitals, Zagazig University, Egypt. Seven patients with persistent postoperative hypernasality were enrolled in this work. They were prepared by head and neck physical examination and phonetic evaluation. Patients were subjected to treatment by endoscopic-assisted sphincter pharyngoplasty, a procedure that was designed to combine both a transoral and a transnasal routes via the aid of nasoendoscope. Postoperative nasoendoscopic and phonetic assessment was done for all of the patients. RESULTS: The procedure is easily conducted, done by available instruments with no extra burden over patients or hospitals. The procedure insured an under vision and well controlled steps. No major complications were recorded. Good speech outcome results were reported. CONCLUSION: Endoscopic-assisted sphincter pharyngoplasty is a new role the nasoendoscopy can play. The study demonstrates the feasibility of endoscopic assistance in sphincter pharyngoplasty, with the advantage of improved visualization of a traditionally difficult-to-expose area. There was neither increased risk to the patients nor added cost to the procedure since only widely-available instrumentation was used. The technique lessened the need for palatal stretching or splitting during the procedure.

Triple suture for neck contouring: 14 years of experience.

BACKGROUND: Preferred techniques for rejuvenation and contouring of the neck region have evolved over the past 40 years. A slender neckline is recognized as an attractive feature of youth, whereas aging of the lower face often includes ptosis of the soft tissues of the chin and banding or cording of the muscles of the anterior and lateral neck. Aesthetic rejuvenation of the face and neck involves repositioning of poorly supported soft tissues. OBJECTIVES: The authors review their 14-year experience with a technique incorporating standard submental liposuction with a method of triple suturing the medial platysmal bands associated with lateral plication of the superficial muscular aponeurotic system (SMAS)-platysma. METHODS: Between 1994 and 2008, 507 patients (451 women and 56 men) were treated with this technique which consisted of placing a first line of sutures distributing tension between the medial platysmal bands and the anterior belly of the digastric muscles, a second single suture at the distal medial borders of the platysma, and a third running suture starting at the level of the thyroid cartilage up to the supramental region. In most cases, a lateral plication of the SMAS-platysma and a "stair-like" SMAS plication were performed in order to define the cervicomandibular line and treat midface flaccidity, respectively. RESULTS: Mean follow-up was eight years. Complications included hematomas (4.6%) and seromas (3.6%). Four percent of patients underwent a second procedure approximately seven years after their primary procedure. Overall the majority of patients exhibited long-lasting results satisfactory to both patients and surgeons. CONCLUSION: The triple-suture technique for neck contouring creates a median vertical vector of traction, whereas lateral plication produces a lateral posterior oblique vector. The combination of these two procedures is an easily reproducible and reliable option for surgeons when patients are seeking a more youthful appearance of the neck.

Anterior approach to neck rejuvenation.

The anterior (submental) approach to neck rejuvenation has been described by multiple authors. The efficacy of the procedure depends on adequate release of cutaneous septae and cutaneous ligaments, which allows for skin contraction without skin resection as well as subplatysmal recontouring and platysma muscle tightening. With this procedure, the greatest improvement in appearance will be seen in the profile view. No improvement will occur above the mandibular border. The degree of profile improvement correlates best with skin quality. Because no skin is removed in this procedure, skin tightening is dependent upon skin elasticity. Therefore, those patients with poor skin quality will obtain lesser results. Patients are graded with regard to skin quality from grades I to IV, with grade I patients demonstrating ideal skin elasticity and grade IV patients demonstrating poor skin quality. The technique is described in detail, potential complications are noted, and technical limitations of the procedure are described.

Composite platysmaplasty and closed percutaneous platysma myotomy: a simple way to treat deformities of the neck caused by aging.

BACKGROUND: Although cervical skin and platysmal laxity are more apparent at the lateral area of the neck, the reported treatments focus on performing plication on the anterior midline or releasing the muscle's lateral border and tractioning it back. Because of the ineffectiveness of such methods in solving more complex cases, surgeons have been trying more efficient procedures that are also riskier and could therefore increase the complication rate. OBJECTIVE: The author describes a simple method for treating cervical laxity using composite platysmaplasty. He also reports on the use of closed platysma myotomy to treat remaining or recurrent platsymal bands. METHODS: A vertical incision was made on the platysma, parallel to the midline, followed by the creation of a flap made of skin and platysma at the area where tone loss was more evident. When this flap was pulled back, it formed a double muscle layer that pressed on the submandibular gland, pushing it back into its original position. The tightening achieved by the fixation of the flap provided excellent definition of the mandible line. The platysma bands were approached by a method of percutaneous incision of the platysma. RESULTS: Between October 2005 and December 2008, 129 patients underwent surgery. Seventeen patients underwent closed percutaneous platysma myotomy in conjunction with platysmaplasty. Four patients underwent platysma myotomy to treat platysmal bands in a secondary procedure from two to eight months after the original surgery. All patients were satisfied with the aesthetic results of treatment. The only serious complications were two cases of temporary neuropraxia of the cervical branch and one hematoma with partial necrosis of retroauricular skin. CONCLUSIONS: Composite platysmaplasty, combined with closed platysma myotomy when indicated, has a short learning curve and provides satisfactory results with a low complication rate and fast recovery. While closed platysma myotomy has been performed by the author as an independent procedure, those operations are not covered in this report and deserve a separate study.

Is the recipient vein really the main concern? A cohort study of head and neck reconstruction.

The aim of this study was to verify the role of the venous drainage system in the pathogenesis of complications in microsurgical head and neck reconstruction. In a nonrandomized cohort study, 52 consecutive cases of complex head and neck microsurgical reconstruction were evaluated. The patients were divided in two groups based on the treatment: the deep (DVDG; n = 30) and superficial (SVDG; n = 22) venous drainage groups. The complications evaluated included vascular obstruction with partial or total loss of the microsurgical flap, inadequate healing (fistulas or suture dehiscence), and infections. The arterial anastomotic site, neoplastic recurrence, use of medications and neoadjuvant radiotherapy, flap selection, tumor histology, smoking/alcoholism, and systemic diseases had no effect on postoperative complications, while the venous component influenced the overall complication rate (chi-square test, P = 0.006). A protective effect was achieved in the DVDG when the overall complication rate was considered--relative risk (RR) 0.65, 95% confidence interval (CI) 0.45-0.94. The recipient vein should be the surgeon's main concern as it influenced the outcomes of patients undergoing complex microsurgical head and neck reconstruction. A protective effect was observed when the internal jugular vein drainage system was used for this purpose.

Fractional nonablative 1540 nm laser resurfacing for thermal burn scars: a randomized controlled trial.

BACKGROUND AND OBJECTIVE: Burn scars cause permanent and disfiguring problems for many patients and limited treatments are available. Nonablative fractional lasers induce a wound healing response, which may lead to remodeling of burn scar texture. This randomized trial evaluates efficacy and adverse effects of 1540 nm fractional laser versus untreated control for burn scars. MATERIALS AND METHODS: Seventeen adult patients with burn scars of 1 year or older and Fitzpatrick skin types I-III were included in the study. Side-by-side test areas were randomized to (i) three monthly 1540 nm fractional laser treatments and (ii) no treatment. Blinded on-site response evaluations were performed 4 and 12 weeks after final treatment. Primary endpoints were change in skin texture (0-10 categorical scale), pain and adverse effects. Secondary endpoints were change in skin color and patient satisfaction (0-10 categorical scales). RESULTS: Preoperative skin texture was similar and moderately uneven in treated and untreated sites (6 (5.5-8), P = 1). Postoperative laser-treated skin appeared significantly more even and smooth compared to adjacent untreated control sides (4 weeks: 4 (2.5-6), P = 0.0015; 12 weeks: 4 (2-5), P = 0.0007). Patients were satisfied with treatments (week 12: 7 (4-8.5)) and 8/17 patients evaluated burn scars to be moderately or significantly improved. Skin redness increased transiently from laser treatments. No significant differences were found in skin pigmentation. Patients experienced moderate pain (5 (3.5-6)), erythema (17/17/16 patients, after first/second/third treatments), edema (9/9/8), bullae (3/0/3), and crusts (4/0/4). One patient had minor scarring. No adverse effects were seen in untreated control areas. CONCLUSIONS: Nonablative 1540 nm fractional laser improves burn scar texture, which raises a new potential for future burn scar treatment.

Accessory nerve lesion after cervicofacial lift: clinical and electrodiagnostic evaluations of two cases.

Two cases of accessory nerve lesion are reported that occurred within 2.5 weeks and 4.5 weeks, respectively, after surgery for cervicofacial lift. The patients were referred for electrodiagnostic examination because of persistent and unexplained unilateral shoulder pain and disability, 6 and 5 months, respectively, after face lift. In both cases clinical examination revealed severe right-shoulder weakness related to trapezius palsy, without trapezius muscle atrophy in the first case and with trapezius atrophy in the second. Electrodiagnosis revealed bilateral accessory nerve lesions in the first case and a unilateral lesion in the second case. Recovery for both cases was progressive but delayed, and both were evaluated 11 and 10 months, respectively, after the first evaluation. Clinical and especially electrodiagnostic findings suggested that the accessory nerve lesion was related to conduction block in the first case and severe axonal loss in the second case.

Carotid artery resection and reconstruction: clinical experience of 28 consecutive cases.

The aim of this study was to analyse the experience at a single institution in carotid artery resection with or without reconstruction performed as part of an oncological procedure or emergency haemostasis. A total of 28 patients were included in this retrospective study; 17 underwent ligation or resection of the carotid artery, and 11 underwent reconstruction of the carotid artery. The perioperative complications and surgical outcomes were recorded and analysed. Of the 17 patients with ligation or resection of the carotid artery, 4 developed neurologic deficit within 2 weeks postoperatively. Three patients with malignant tumours died 1 month (1) and 4 months (2) postoperatively. Of the 11 patients undergoing carotid reconstruction, no major cerebral complications were noted after operation. Colour Doppler showed patent vascular graft 1 year postoperatively in nine patients. Due to the higher complication rates both in short and long term with ligation or resection of the carotid artery, resection and revascularization of the carotid artery is advocated for patients with carotid artery involvement when possible.

Combining chin-jowl implants with local anesthesia facial rejuvenation.

Mandibular implantation is an outpatient procedure that can be used in combination with other minimally invasive cosmetic interventions. Specifically, silastic chin implants can help create a strong chin and smooth the jaw-line in carefully selected patients. A standard surgical excision tray plus a few additional simple instruments are required, and a variety of commercially available implants are available for placement via an intraoral or submental approach. Meticulous technique minimizes the small risk of nerve injury and numbness. Chin-jowl implants may be preceded by neck liposuction and immediately followed by a face-lift to achieve overall facial enhancement.

Purse-string platysmaplasty: the third dimension for neck contouring.

Techniques and concepts for treatment of the aging neck have been evolving since the late 1960s and rely on two-dimensional anterior approximation with lateral imbrication of the platysma with or without submental fat reduction, However, the medial approximation can sometimes give a "boxy" appearance to the anterior neck, especially if anterior shifting of the platysma recurs after platysmaplasty with laxity redeveloping in this midline location. The "purse-string" platysmaplasty (PSP) is a new concept in neck contouring that facilitates an enhanced definition for the cervicomandibular transition to better simulate the well-defined contour of this transition that is present in youth. It aids in the contouring of difficult poorly defined necks and in male patients. The PSP adds a "third dimension" to neck recontouring by invaginating the platysma with a plication suture and pexing the platysma, without incising it, to deeper neck fascia with a technique that adds support and definition to the neck contour. The PSP can be performed in patients undergoing a full rhytidectomy as well as in individuals having isolated neck rejuvenation. The PSP is especially helpful in rejuvenating the male lower face and neck because of the relatively heavier deeper structures of the male neck and the need to enhance definition along the jawline.