Effects of salivary bypass tubes on fistula and stricture formation.

IMPORTANCE: Stricture and fistula formation are two of the most common long-term complications of free flap reconstruction of hypopharyngeal defects. OBJECTIVE: To examine the effects of salivary bypass tubes (SBTs) on fistula and stricture formation after free flap reconstruction of hypopharyngeal defects. DESIGN: Retrospective cohort study. SETTING: Academic tertiary care medical center. PARTICIPANTS: A total of 103 consecutive patients who underwent hypopharyngeal free flap reconstruction. INTERVENTION: Use of salivary bypass tube. MAIN OUTCOME MEASURE: Fistula and stricture formation. RESULTS: The overall fistula and stricture rates were 14.6% and 27.2%, respectively. Subgroup analysis revealed fistula rates of 7.4% in patients who received SBTs and 22.4% in those who did not (P = .048). However, no statistically significant difference between the two groups was shown with multivariate analysis. The unadjusted stricture rate was 30.6% without vs 24.1% with SBT placement (P = .51). CONCLUSIONS AND RELEVANCE: Univariate analysis showed that SBT placement significantly reduced the risk of fistula in this population. Larger multicenter studies are needed to further explore the benefits of SBT use in preventing fistula and stricture formation. LEVEL OF EVIDENCE: 3.

Rejuvenation of the lower lid and periocular area from above.

Rejuvenation of the periocular region, specifically the lower eyelid region, can be performed with a variety of methods. One finding of the aging lower eyelid region is the "Y-deformity." Elevation of the midface is a powerful tool that can significantly improve the appearance of the lower eyelid. This article addresses the elevation of the midface through two approaches: the meloplication and the subperiosteal midface-lift. In addition to midface elevation, a short discussion on canthopexy is included. Although the lower eyelid can be addressed in a variety of ways, rejuvenation of the periocular region from above should be considered in all patients, as these approaches yield good results.

Endoscopic forehead and brow-lift.

The endoscopic method of rejuvenating the brow-forehead complex has evolved into the procedure of choice for many aesthetic surgeons. Safe and reliable application of the endoscopic technique depends on several important factors. These include technical expertise with the endoscopic equipment, understanding of the surgical goals in patients seeking rejuvenation in the forehead region, and detailed comprehension of the steps involved in altering forehead anatomy during endoscopic lifting. In this article, the senior author reviews his experience with the endoscopic forehead-lift and delineates a stepwise approach to this technically challenging operation. The text also highlights important details with respect to patient care, endoscopic equipment, and surgical anatomy. "Keller's rules of fours" are introduced to summarize surgical pearls of the endoscopic forehead- and brow-lift.

New technologies in aesthetic blepharoplasty and brow-lift surgery.

New technologies are important in the advancement of any field. Two such advancements in blepharoplasty and brow lifting include use of the PlasmaBlade and fractionated CO (2) laser resurfacing. The PlasmaBlade uses pulsed radiofrequency energy with a highly insulated blade to assist with incision and dissection during eyelid surgery, resulting in minimal bruising and edema. This article describes specifically how the PlasmaBlade can be used and its typical settings. Fractionated CO (2) laser resurfacing is also a powerful tool that can significantly enhance eyelid rejuvenation. This resurfacing can address fine lines in the periocular region with limited downtime. Use of these technologies can help to improve results and shorten the recovery time traditionally associated with blepharoplasty and periocular resurfacing.

Digital imaging in rhinoplasty.

BACKGROUND: Imaging in facial plastic surgery is becoming common. With the advances of digital imaging software, modifications of preoperative images for rhinoplasty patients can help to predict outcomes. The primary objective of this study was to determine whether preoperative digital image modification in rhinoplasty patients is useful in predicting postoperative outcomes. METHODS: Patients undergoing rhinoplasty were prospectively collected and underwent preoperative digital imaging modifications using computer software. Postoperative images were compared to the preoperative modified images. Rankings for similarity were performed by patients and surgeons. Wilcoxon ranked-pairs test was used to compare the groups with a predetermined P value of 0.05, and levels of agreement were assessed using weighted kappa scores. RESULTS: One hundred twelve patients were collected and postoperative images were taken 11 months after surgery (range = 6-30 months). Frontal images were rated as poor, average, very close, or identical by patients 6.2, 52.7, 33.0, and 8.0%, and by surgeons 2.7, 61.6, 34.8, and 0.9%, respectively (Wilcoxon test, P = 0.23). Lateral images were rated as poor, average, very close, or identical by patients 1.8, 18.8, 48.2, and 31.3%, and by surgeons 0.9, 24.1, 59.8, and 15.2%, respectively (Wilcoxon test, P = 0.0024). Weighted kappa scores for agreement were 0.42 for frontal views of patients and surgeons and 0.65 for lateral views. CONCLUSION: Ratings by patients and surgeons comparing preoperative manipulated images with postoperative outcomes are predictive in approximately 75% of the patients, and lateral images are more useful for this goal. Level of agreement between patient and surgeon scoring is good for lateral images and moderate for frontal.

Time course of juvenile onset recurrent respiratory papillomatosis caused by human papillomavirus.

BACKGROUND: With the recent licensure of a new quadrivalent vaccine, many diseases caused by human papillomavirus (HPV) can now be prevented, including recurrent respiratory papillomatosis (RRP). The purpose of this study was to describe the burden and time course of juvenile onset RRP. METHODS: A retrospective chart review was conducted of children with airway papillomatosis at the Hospital for Sick Children in Toronto, Canada, between 1994 and 2004. Statistical methods included descriptive statistics of the cohort, a repeated events survival model, and nonlinear modeling equations to describe the time course of illness. RESULTS: Nine hundred twenty-six surgical procedures in 67 patients were identified through a review of surgical records. The median age at diagnosis was 3.2 years (range, 0.1-14.8 years) and the most common presenting symptom was hoarseness (75%). Adjuvant pharmacologic therapy (interferon or cidofovir) was used in 13 cases (19%). HPV types 6 or 11 were identified most commonly as the etiologic agent. Nonlinear modeling equations (exponential and quadratic) fit the observed data well, and were superior to linear models. Repeated events survival analysis identified significant prognostic variables: surgeon, adjuvant therapy, and anatomic score. A decision rule is presented that allows the time to next surgery to be predicted based on the previous surgery and the anatomic score. CONCLUSIONS: Most patients have a decelerating rate of debulking surgeries over time, well described by our nonlinear modeling equations. Factors affecting the time course of RRP include: inter-surgeon variability, the extent and severity of papillomas at the time of laryngoscopy, and the use of adjuvant medical therapies.

Meta-analysis comparison of open versus percutaneous tracheostomy.

OBJECTIVES/HYPOTHESIS: Multiple studies have been performed to characterize differences in complications and cost-effectiveness of open and percutaneous tracheostomy; however, large enough studies have not been performed to determine a clearly superior method. Our primary objective was to compare complication rates of open versus percutaneous tracheostomy in prospective, randomized-controlled trials using meta-analysis methodology. Secondary objectives included cost-effectiveness and procedure length analyses. STUDY DESIGN: Meta-analysis. METHODS: From 368 abstracts, 15 prospective, randomized-controlled trials involving nearly 1,000 patients were reviewed to extract basic demographic data in addition to complications, case length, and cost-effectiveness. Pooled odds ratios (OR) with confidence intervals (CI) were calculated in addition to subgroup analyses and meta-regression. RESULTS: Pooled OR revealed statistically significant results against percutaneous tracheostomy for the complication of decannulation/obstruction (OR 2.79, 95% CI 1.29-6.03). There were significantly fewer complications in the percutaneous group with respect to wound infection (0.37, 0.22-0.62) and unfavorable scarring (0.44, 0.23-0.83). There was no statistically significant difference for complications of false passage (2.70, 0.89-8.22), minor hemorrhage (1.09, 0.61-1.97, P = .77), major hemorrhage (0.60, 0.28-1.26), subglottic stenosis (0.59, 0.27-1.29), death (0.70, 0.24-2.01), and overall complications (0.75, 0.56-1.00). However, the overall complications trended toward favoring the percutaneous technique. Percutaneous tracheostomy case length was shorter overall by 4.6 minutes, and costs were less by approximately $456 USD. CONCLUSIONS: Our meta-analysis illustrates there is no clear difference but a trend toward fewer complications in percutaneous techniques. Percutaneous tracheotomies are more cost-effective and provide greater feasibility in terms of bedside capability and nonsurgical operation.

Fine-needle aspiration biopsy findings suspicious for papillary thyroid carcinoma: a review of cytopathological criteria.

OBJECTIVES/HYPOTHESIS: The objective was to evaluate the usefulness of standard suspect cytological features on fine-needle aspiration biopsy (FNAB) in predicting papillary thyroid carcinoma. STUDY DESIGN: Retrospective chart review of consecutive fine-needle biopsies of the thyroid. METHODS: The study was a retrospective review of consecutive patients presenting with a diagnosis of suspected (group 1) or positive papillary thyroid carcinoma (group 2). The frequency of standard cytological features (i.e., papillary architecture, multinucleated giant cell, nuclear pseudo-inclusions, nuclear grooves, micronucleoli, powdery chromatin, and psammoma bodies) were recorded for each group. These were compared using chi test. Sensitivity and specificity for both individual and a combination of features were calculated for patients in group 1. RESULTS: One hundred eight patients were eligible for the study (group 1, n = 57; group 2, n = 51). Fifty-one patients (89%) in group 1 and all patients in group 2 had a histopathological diagnosis of papillary thyroid carcinoma. Respectively, the most frequent features present on fine-needle aspiration biopsy in group 1 versus group 2 were nuclear grooves (79% vs. 88%), micronucleoli (74% vs. 86%), pseudo-inclusions (58% vs. 88%), and powdery chromatin (47% vs. 59%); P values for these features were P > .05, P > .05, P < .05, and P > .05, respectively. In group 1, the sensitivities of nuclear grooves and micronucleoli were 80% and 71%, respectively. The presence of psammoma bodies was associated with a specificity of 100%. A combination of nuclear grooves, micronucleoli, pseudo-inclusions, powdery chromatin, and multinucleated giant cells was 100% specific in detecting papillary thyroid carcinoma. CONCLUSION: In choosing the most appropriate management of a finding suspect for papillary thyroid carcinoma on fine-needle aspiration biopsy, the surgeon must be aware of the diagnostic importance of certain cytopathological features. The presence of a combination of these factors may allow a more confident surgical approach.

Oral-anticoagulant-related intracerebral hemorrhage.

BACKGROUND: The characteristics, management and outcomes of patients who suffer intracerebral hemorrhage (ICH) while taking oral anticoagulants (OAC) are relatively unreported. DESIGN: Retrospective cohort study of consecutive cases with ICH associated with OAC. SETTING: A university-affiliated tertiary care hospital in Ontario, Canada. PATIENTS/PARTICIPANTS: 368 charts of individuals with a discharge diagnosis of ICH (ICD-9 code 431) between January 1993 and May 1998 were reviewed. MAIN RESULTS: 20 (5.4%, 95% confidence interval (CI): 3.1-7.7%) of the 368 ICHs occurred in people taking OAC. The median age of patients on OAC was 74 years (S.D.+/-9.8), and 70% (95% CI: 49-91%) were female. The median INR at presentation was 3.4 (intraquartile (IQR) range 2.2-4.4). Nine of 20 (45%) patients had INR values which exceeded the target range. The case fatality rate was 45% (95% CI: 23-67%). Approximately 2.8 years after the initial ICH, 9 of the 11 patients who survived the initial ICH were still alive, and 6 had restarted OAC. CONCLUSIONS: ICH is a serious complication in patients taking OAC, and the case-fatality rate is high. Given the increasing use of OAC in patients with cardiovascular disease, the relative benefits and risks of this therapy must be weighed carefully.