Reconstructive Options for Auricular Trauma.

Given its prominent lateral position, the auricle is a common site of injury after blunt trauma. Auricular injuries can lead to both functional and aesthetic complications. A careful history and examination will help determine the mechanism of injury and identify factors that may influence repair. Auricular reconstruction is highly individualized and depends on the size, location, and nature of injury. Understanding the complex three-dimensional anatomy of the external ear is a necessity for appropriate reconstruction. This article reviews the reconstructive options for simple and complex auricular injuries based on the anatomical site and the intricate three-dimensional structures that form the auricle.

Burkitt lymphoma of the nasopharynx causing life-threatening airway obstruction: A case report.

OBJECTIVE: To describe a case of Burkitt lymphoma (BL) in a child manifesting with acute airway obstruction. To review available literature on the clinical features and characteristic presentation of this disease. METHODS: Case report with literature review. RESULTS: We present the case of an 8-year-old boy with nasopharyngeal BL manifesting initially as sore throat, nasal congestion, and snoring that progressed to dyspnea and, ultimately, acute airway obstruction requiring emergent tracheostomy. The child was treated with intensive chemotherapy and achieved complete response. CONCLUSION: This case highlights the importance of maintaining high clinical suspicion when evaluating common otolaryngologic symptoms and emphasizes the potential for Burkitt lymphoma to cause rapid patient deterioration.

Practical Considerations in Adopting New Technology for Facial Cosmetic Procedures.

The field of facial plastic and reconstructive surgery encompasses both surgical and nonsurgical facets, creating a supplemental level of care and an additional layer of complexity. Determining the "best course of care" can be very difficult in experienced situations, but even more so when considering adopting an emerging technology. A basic and practical method of analyzing a new technology requires investigating the risk-to-benefit assessment, the utility and clinical outcomes compared with other treatment options, and an introspective ethical appraisal of whether the technology is foremost for patient care purposes. Even after employing a new technology, constant monitoring and reevaluation of the results is necessary to determine if it should be continued or altered.

Revision Surgery of the Cleft Palate.

Cleft palate repairs often require secondary surgeries and/or revisions for a variety of reasons. The most common causes are symptomatic oronasal fistulas and velopharyngeal insufficiency. Complications from primary surgery, such as wound dehiscence, infection, and hematomas, contribute to the relatively high rate of revision surgery. Prevention of postoperative complications that may lead to fistula or velopharyngeal insufficiency is key, and many techniques have been described that have reportedly decreased the incidence of secondary surgery. Management varies depending on the nature of the fistulous defect and the type of velopharyngeal insufficiency. Numerous surgical options exist to fix this deficiency.

Analyzing Our International Facial Reconstructive Mission Work: A Review of Patients Treated by American Academy of Facial Plastic and Reconstructive Surgery Sanctioned Trips.

IMPORTANCE: To identify ways to improve care to underserved international populations. OBJECTIVE: To analyze the authors' data in hopes of meeting further needs. DESIGN: This is a retrospective review of medical missions using data from the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) Face to Face) Database. SETTING: International sites of AAFPRS approved surgical mission trips. PARTICIPANTS: One thousand six hundred forty-six patients who were seen by an AAFPRS mission trip between January 12, 2010 and April 27, 2017. OUTCOMES/MEASURES: Patient and mission data, procedure data, characteristics of cleft patients, patient follow-up data, repeat patient data, and factors affecting whether a patient was provided service were all evaluated. RESULTS: Patients were seen over the course of 26 trips to 6 different countries. Patients (n, mean, median age) who underwent a primary cleft lip repair only (175, 2.5 years, 0.6 years) and those who underwent a primary cleft palate repair only (268, 6.4 years, 3.6 years) were significantly older than what is identified as the upper range of normal in surgical literature (Wilcoxon Signed-Rank test Z = -4.3, P < 0.001 for lip and Z = -10.1, P < 0.001 for palate). Patients (n, median, mean rank) receiving a primary cleft palate repair were significantly younger in Peru (160, 3.0 years, 126) compared with patients in other countries (108, 5.0 years, 147) (Z = -2.1, P < 0.05). The odds of a patient returning unplanned were 2.8 (OR, 95% CI 1.52-4.98; P < 0.01) times higher if they were diagnosed with a cleft palate only and 0.91 (OR, 95% CI 0.90-0.93; P < 0.05) times lower if they were diagnosed with combined cleft lip with cleft palate at their first visit. Patients (median age, mean rank) who were provided a service (6.0 years, 724.70) were younger than patients who were not provided a service (8.0 years, 637.23) at their first visit (Mann-Whitney, U = 164,275; P < 0.001). CONCLUSION/RELEVANCE: This data indicates that disparities exist among patients treated on mission trips compared with those in higher income countries. Furthermore, the authors' data indicate that multiple mission trips to the same country within the same year decrease some of these disparities. Additionally, isolated cleft palate patients are most likely to return unplanned indicating need for standardized postoperative visits. The preferential care of younger patients with unrepaired clefts as compared with older patients and those with palatal fistulas indicates a need for additional resource allocation.

Disparities in NOSE Scores and Surgical Approaches among Patients Undergoing Functional Rhinoplasty.

Social determinants of health have been widely studied throughout medicine; however, their role relating to functional rhinoplasty has not been previously evaluated. The records of 178 patients who underwent functional rhinoplasty in a single health network from 2013 to 2016 were reviewed. The Nasal Obstruction Symptom Evaluation (NOSE) score was used to assess patient-reported symptoms, and patients with both preoperative and postoperative NOSE scores were included in this study. Basic demographics and surgical techniques were also collected. Differences between NOSE scores and surgical approaches to functional rhinoplasty on the basis of insurance type were measured. One hundred and sixteen patients were included for analysis, the mean age was 34.7 years (standard deviation [SD] = 16.2) and 57 (49.1%) were female. Twenty-one (18.1%) patients had public insurance and, of these, 18 patients had Medicaid. Patients (mean, SD) with Medicaid insurance (56.39, 15.6) had a slightly greater improvement in NOSE scores compared with patients with non-Medicaid insurance (47.90, 25.6) (p = 0.067). There was no statistically significant difference in preoperative NOSE scores or postoperative improvement in NOSE scores between patients with different health insurance. Furthermore, there was no statistically significant difference in surgical approaches. The majority of patients receiving functional rhinoplasty had private insurance. Medicaid patients trended toward a greater NOSE score improvement after functional rhinoplasty, but also had a closer association with a history of nasal trauma and prior surgery. Future study is needed to better understand the association between socioeconomic status and disparities in care. Understanding how social determinants of health affect patients may reveal potential inherent biases, improve delivery of care, and translate to better patient outcomes.

Quantitative Evaluation of Nasolabial Alterations following Nasoalveolar Molding (NAM) Therapy in Patients with Unilateral Cleft Lip.

The clinical benefit of nasoalveolar molding (NAM) is actively debated between cleft centers without clear consensus. Nasolabial measurements were performed on pediatric patients with unilateral clefts of the lip, with or without cleft palate, at an academic cleft/craniofacial center prior to and following NAM therapy between June 2015 and August 2016. The parameters of interest were: columella height and width, cleft nostril height and width, and lip width. Measurements were performed using photographs taken alongside a reference object. The image output was then scaled to the size of the reference object and the capture angle. Intraclass correlation coefficient was calculated to assess reliability of the photographic measurements. Descriptive statistics (mean, standard deviation [SD]) were calculated to characterize the pre- and post-NAM measurements. Student's t-tests were performed to compare the pre-NAM versus post-NAM measurements. The primary objective was to measure the effect of NAM on the nasal aesthetic units that are known to be anatomically aberrant in the cleft lip patient. Nine patients were included in this study. Average pre-NAM age was 2.5 weeks, and average post-NAM age was 13 weeks. Average columellar height increased from 3.70 mm (SD = 0.14) pre-NAM to 5.85 mm (SD = 1.96) post-NAM (p < 0.01); average columellar width increased from 4.71 mm (SD = 0.49) to 5.93 mm (SD = 0.71) (p < 0.01); average cleft nostril height increased from 3.54 mm (SD = 2.97) to 6.81 mm (SD = 2.98) (p = 0.01); and average cleft nostril width decreased from 15.46 mm (SD = 2.91) to 11.05 mm (SD = 1.01) (p = 0.01). Average lip width decreased from 34.61 mm (SD = 1.73) to 33.87 mm (SD = 3.67); however, this change was not statistically significant (p = 0.16). This study objectively quantifies positive changes in nasal aesthetics associated with NAM therapy, providing further evidence for its utility as a presurgical treatment modality for optimal aesthetic nasal results in the unilateral cleft lip patient. The major limitation of this study was a lack of control group, as our center universally treats complete unilateral cleft lip patients with NAM therapy. However, the authors strongly believe that the positive aesthetic nasal findings would persist if compared with a non-NAM control group.

Introduction of the American Academy of Facial Plastic and Reconstructive Surgery FACE TO FACE Database.

The American Academy of Facial Plastic and Reconstructive Surgery FACE TO FACE database was created to gather and organize patient data primarily from international humanitarian surgical mission trips, as well as local humanitarian initiatives. Similar to cloud-based Electronic Medical Records, this web-based user-generated database allows for more accurate tracking of provider and patient information and outcomes, regardless of site, and is useful when coordinating follow-up care for patients. The database is particularly useful on international mission trips as there are often different surgeons who may provide care to patients on subsequent missions, and patients who may visit more than 1 mission site. Ultimately, by pooling data across multiples sites and over time, the database has the potential to be a useful resource for population-based studies and outcome data analysis. The objective of this paper is to delineate the process involved in creating the AAFPRS FACE TO FACE database, to assess its functional utility, to draw comparisons to electronic medical records systems that are now widely implemented, and to explain the specific benefits and disadvantages of the use of the database as it was implemented on recent international surgical mission trips.

Risk of persistent palatal fistula in patients with cleft palate.

IMPORTANCE: Many individuals with a cleft palate also have an associated craniofacial syndrome or anomaly. OBJECTIVE: To investigate the predictive associations of persistent palatal fistulas in patients with previously repaired cleft palate. DESIGN, SETTING, AND PARTICIPANTS: We performed a case-control study of patients with cleft palate repairs from January 1, 1986, through December 31, 2000, at a major tertiary care hospital center in the Bronx, New York. The study population consisted of patients who had their primary surgery before the age of 3 years and had all their cleft-related treatment completed at the same hospital center. Palatal fistula was defined as a breakdown of the primary surgical repair of the palate, resulting in persistent patency between the oral and nasal cavities. Data collection was conducted by using the hospital centers' electronic medical records and patient tracking systems and confirmed by review of hard copies of patient records. MAIN OUTCOMES AND MEASURES: The Veau classification system was used to classify the preoperative cleft severity. RESULTS: A total of 130 patients were identified-23 patients with palatal fistula and 107 controls. A total of 12 girls and 11 boys were identified in the palatal fistula group and 56 girls and 51 boys in the control group. The mean patient age at the time of palatoplasty was 12.6 and 14.5 months in the palatal fistula and control groups, respectively. A statistically significant association was found between the outcome of fistula and severity of cleft, as defined by the Veau classification system (P = .01). Furthermore, for each Veau class increase, the odds of a palatal fistula increased by 2.64 (95% CI, 1.35-5.13; P = .004). No statistically significant associations were found between the outcome of fistula and the following independent variables: patient sex (P = .98), patient age at palatoplasty (P = .82), type of palatoplasty (P = .57), surgeon (P = .15), orthodontic treatment (P = .59), ear infection (P = .30), or clefts associated with syndromes (P = .96). CONCLUSIONS AND RELEVANCE: Palatal fistulas are reliably associated with severity of cleft, as defined by the Veau classification system. This knowledge gives the health care professional a more reliable method of preoperatively assessing the risk of postoperative palatal fistula in the cleft palate population. LEVEL OF EVIDENCE: 3.

An algorithmic approach to multimodality midfacial rejuvenation using a new classification system for midfacial aging.

Midfacial aging is the result of the complex interplay between the osseous skeleton, facial retaining ligaments, soft tissues envelope, facial fat compartments, and the overlying skin elasticity. As a result of the many anatomic components involved in midfacial aging, the authors proposed a classification system based on distinct anatomic factors to direct surgical treatment. Evidence based data suggest that midface rejuvenation often requires a multimodality approach to obtain desired results, especially in patients with more advanced aging and poor tissue elasticity, or those with hypoplastic midfacial skeletal structure.

Comparing rates of distal edge necrosis in deep-plane vs subcutaneous cervicofacial rotation-advancement flaps for facial cutaneous Mohs defects.

IMPORTANCE: The cervicofacial rotation-advancement flap is commonly used for facial defects. Decreasing the rate of distal edge necrosis (DEN) encountered with this flap would help prevent complications in sensitive areas such as the eyelid, lip, and nose. OBJECTIVE: To compare the untoward occurrence of DEN between 2 surgical dissection methods for reconstructive cervicofacial rotation-advancement flaps. DESIGN, SETTING, PARTICIPANTS, AND EXPOSURE: A review was conducted of 88 patients who underwent cervicofacial flap reconstruction for Mohs ablative surgery between January 1, 2003, and June 30, 2012, by the senior author (A.A.J.). All patients had periorbital, midfacial, cervical, and/or lateral temporal/forehead defects following Mohs surgical ablation. Patients were categorized into 1 of 2 groups on the basis of the surgical technique used: subcutaneous (SC) cervicofacial elevation or deep-plane (DP) cervicofacial elevation. Subcategories of smokers and nonsmokers within each group were further reviewed. Statistical analysis of DEN between categories and subcategories was performed. RESULTS: Sixty-nine patients were in the SC group and 19 were in the DP group. The mean defect size among both groups was 14.3 cm(2). The rate of active or recent smokers was 23% in the SC group and 11% in the DP group. The rate of DEN among nonsmokers in the SC group was 23% (n = 53) compared with 0% in the 17 DP nonsmokers (P = .03). The rate of smokers with DEN in the SC group was 75% and 0% in the DP group (P = .09). The mean area of DEN in the SC group was 0.8 cm(2). CONCLUSIONS AND RELEVANCE: Our statistically significant data indicate that DP dissection is a superior technique for avoiding DEN in nonsmokers. We found better outcomes in smokers as well. Thus, we strongly advocate the use of the DP approach as the criterion standard in cervicofacial flap elevation. LEVEL OF EVIDENCE: 3.

The modern minimally invasive face lift: has it replaced the traditional access approach?

Because modern facelift patients desire a less-invasive approach or minimally invasive approach to reduce visible scarring and decrease the recovery phase, achieving the surgeon's goal of optimal, reliable, and long-term aesthetic results with few complications becomes a challenge. The authors use the terms minimal access and traditional access to describe rhytidectomy approaches based solely on incision size. A short-incision, minimal-access approach with a deep-plane extended dissection is presented. A preoperative physical examination maneuver to evaluate a patient's candidacy for a minimal-access approach and guidelines for when to include platysmaplasty with the procedure to further improve cervicomental contour are described.