Soft and Firm Alloplastic Implants in Rhinoplasty: Why, When and How to Use Them: A Review of 311 Cases.

BACKGROUND: Modern rhinoplasty is not just a reduction procedure. An optimal nasal esthetic result occasionally requires augmenting the nasal tip, the dorsum or the lateral wall with autografts or alloplasts. A large number of nasal implant types have been reported in the medical literature. OBJECTIVE: The goal of this article is to demystify the role and indications of nasal implants in rhinoplasty. As well, it offers both the novice and experienced nasal surgeon a basic, simplified and organized approach to the use of soft and firm nasal implants in rhinoplasty. METHODS: This article presents the authors experience with 311 rhinoplasties using both soft and firm alloplastic implants. The indications for both types of alloplasts are discussed, the surgical technique detailed and the outcomes analyzed. RESULTS: A total of 311 nasal implant cases were reviewed. This series revealed a low incidence of postoperative infection (5.57% for soft implants and 0.1% for the firm ones). The revision rate was 2.7% for the soft implants group and 7.1% for the firm implants group. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Use of the Novel Hourglass Shaping Sutures to Create a Natural Middle Vault Shape as Illustrated by Three-Dimensional Modeling.

SUMMARY: The middle vault plays a major aesthetic and functional role. Excessive narrowing of the middle vault can occur in the absence of appropriate middle vault reconstruction. This can result in both aesthetic flaws and functional issues. Spreader flaps combined with our hourglass shaping sutures technique yield a natural middle vault appearance and prevent unwanted functional and aesthetic complications.

Powered Rhinoplasty: A Simple Step-by-Step Approach.

SUMMARY: Reduction of a nasal hump and nasal base narrowing are very common steps during a primary rhinoplasty procedure. The greatest difficulty is to obtain stable fracture lines, a natural appearance, beautiful dorsal aesthetic lines, and the absence of palpable or visible irregularities, especially in the long term. The surgeon strives for a reproducible technique, which seems to be more feasible with mechanical osteotomies (powered or piezoelectric) than with traditional manual osteotomies. The aim of this article is to describe powered osteotomy in a step-by-step fashion to provide a clear guideline for rhinoplasty surgeons.

Diagnostic Approach to Congenital Cystic Masses of the Neck from a Clinical and Pathological Perspective.

BACKGROUND: neck cysts are frequently encountered in pediatric medicine and can present a diagnostic dilemma for clinicians and pathologists. Several clinical items enable to subclassify neck cyst as age at presentation, anatomical location, including compartments and fascia of the neck, and radiological presentation. SUMMARY: this review will briefly describe the clinical, imaging, pathological and management features of (I) congenital and developmental pathologies, including thyroglossal duct cyst, branchial cleft cysts, dermoid cyst, thymic cyst, and ectopic thymus; (II) vascular malformations, including lymphangioma. Key Messages: pathologists should be familiar with the diagnostic features and clinicopathologic entities of these neck lesions in order to correctly diagnose them and to provide proper clinical management.

The Modified Sliding Alar Cartilage Flap: A Novel Way to Preserve the Internal Nasal Valve as Illustrated by Three-Dimensional Modeling.

BACKGROUND: Preservation of the scroll area is essential when performing rhinoplasty to achieve a good functional outcome. This is of particular concern with tip-plasty procedures. The objectives of this study were (1) to describe a novel tip-plasty procedure consisting of sliding the cephalic portion of the alar cartilage beneath its caudal portion to preserve the scroll area and (2) to present the authors' prospective case series, which includes Nasal Obstruction Symptom Evaluation and peak nasal inspiratory flow scores to objectively evaluate functional outcomes. METHODS: The modified sliding alar cartilage surgical technique is described and illustrated by intraoperative photographs and videos and by three-dimensional modeling software. A prospective study of all patients undergoing tip-plasty with alar reduction by the sliding alar cartilage technique was performed from September of 2016 to December of 2017. Peak nasal inspiratory flow and Nasal Obstruction Symptom Evaluation scores were collected preoperatively and at 1 week and 6 months postoperatively. RESULTS: Twenty-five patients were included in the study. Aesthetic outcomes were good, with no major complications. The average preoperative peak nasal inspiratory flow score was 114 liters/minute (95 percent CI, 108.1321 to 119.8679 liters/minute), whereas the average score at 6 months postoperatively was 115.82 liters/minute (95 percent CI, 106.6241 to 125.0159 liters/minute; p = 0.513). The average preoperative Nasal Obstruction Symptom Evaluation score was 17.2 (95 percent CI, 15.99655 to 18.40345), whereas the average score at 6 months postoperatively was 15.2 (95 percent CI, 13.18131 to 17.21869; p = 0.08353), indicating no significant change. CONCLUSION: The sliding alar cartilage is a simple technique allowing tip definition while maintaining nasal airway function by preserving the crucial anatomical scroll area. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Lower lateral crural turnover flap combined with alar batten graft for the long-term result of the treatment of alar convexities.

INTRODUCTION: Concave lower lateral cartilages not only cause an esthetic defect but can also lead to external nasal valve insufficiency. The objective of this article is to analyze the combination of two well-known surgical techniques: turning over the alar cartilages as well as the addition of grafts in order to obtain satisfying esthetic and functional long term results. MATERIALS AND METHODS: From August 2016 to July 2018, 62 rhinoplasties, a combination of both primary and revision cases, were performed at the Rouen University Hospital in France. Six of these involved the correction of concave alar cartilages. The turnover technique alone or in combination with Batten grafts was performed. RESULTS: Immediate and 3-months post-operative esthetic results using the turnover flap technique were satisfactory. Alar batten grafts were occasionally employed in order to maintain the newly positioned alar cartilages and avoid long-term contour depressions. CONCLUSION: The combination of these two techniques seems to be an interesting solution to maintain long-term esthetic results.

Teaching communication skills to OTL-HNS residents: multisource feedback and simulated scenarios.

BACKGROUND: Effective communication has been linked to a reduction in adverse events and improved patient compliance. Currently in Otolaryngology - Head and Neck Surgery (OTL-HNS) residency programs, there is limited explicit teaching of communication skills. Our objective was to implement an educational program on communication skills for residents using multisource assessment in several simulation-based contexts throughout residency. METHODS: For three consecutive years, OTL-HNS residents were recruited to participate in a total of nine simulation-based clinical scenarios in which communication skills could be honed. This educational program was designed to provide instruction and practice of challenging ethics scenarios, with communication efficacy as a secondary goal. To facilitate this goal, a multisource assessment was paired with a debriefing process that involved attending staff, observing and participating residents, standardized patients, and invited content experts. RESULTS: Seventeen residents completed the curriculum for at least two consecutive years from 2009 to 2011. The internal-consistency reliability of the scenarios ranged from 0.88 to 0.96. The intraclass correlation was 0.19, as expected in this context. There was no statistical difference in the mean ratings of performance across post-graduate year (PGY) level (p = 0.201). Results from the random-intercept regression indicated that, on average, a learner's mean rating at baseline was 3.6/5 and increased significantly by 0.25 points per year (p < 0.05) as assessed by OTL-HNS staff members and peers. No significant improvement across time was found for ratings by non-medical assessors. CONCLUSION: Implementing an educational program focused on communication skills using a multisource assessment in various contexts has shown to be potentially effective at our institution, and resulted for yearly improvement and consolidation of performance of OTL-HNS residents as judged by faculty and residents. The inclusion of a multisource assessment in the simulation curriculum is key to allow for the representation of different perspectives on communication skills, for both the assessment and the debriefing process. Future studies are needed to explore the possibility of fully integrating this educational program into residence training in order to support deliberate communication skills teaching.

Treatment of Keloid Scars with Botulinum Toxin Type A versus Triamcinolone in an Athymic Nude Mouse Model.

BACKGROUND: Keloid scarring is a serious condition that mostly affects patients of African or Asian descent. Often disfiguring, this condition can have devastating psychosocial consequences. To date, no treatment modality has been proven ideal. The authors' objectives were (1) to determine the efficacy of botulin toxin type A injection for the treatment of keloid scars compared to steroid injection and to control saline injection (this was achieved through a basic science animal model using athymic nude mice and implanted human keloid tissue); and (2) to analyze the histopathologic changes that occur in an organized keloid scar following botulinum toxin type A injection as compared to steroid and saline injections. METHODS: Keloid scars from four patients were excised and implanted subcutaneously into 28 mice. Three small keloid tissue samples were implanted in each of the 28 mice. One week after implantation, each implant received one of three injections: botulinum toxin type A (treatment drug), saline (control), or steroid injection (first-line gold standard). The keloid tissue was extracted 3 weeks after implantation. Weight analysis, immunohistochemistry, and standard hematoxylin and eosin pathologic analysis were performed on each extracted tissue sample. RESULTS: Paired t test analysis of pretreatment and posttreatment tissue weights revealed a statistically significant difference between the treatment and control groups (p < 0.05). Analysis by a blinded pathologist confirmed fewer collagen bundles in the treatment group. Immunohistochemistry with Ki-67, a marker of cell proliferation, revealed significantly less staining in the treatment groups. CONCLUSION: Botulinum toxin type A could be an effective treatment for keloid scars.

A longitudinal simulation-based ethical-legal curriculum for otolaryngology residents.

OBJECTIVE: To develop, implement, and evaluate a longitudinal, simulation-based ethics and legal curriculum designed specifically for otolaryngology residents. METHODS: Otolaryngology residents were recruited to participate in a yearly half-day ethical-legal module, the curriculum of which spanned 4 years. Each module included: three simulated scenarios, small-group multisource feedback, and large-group debriefings. Scenarios involved encounters with standardized patients. Residents' ethical-legal knowledge was assessed pre- and postmodule with multiple-choice questions, and ethical reasoning was assessed by a variety of evaluators during the simulated scenario using a locally developed assessment tool. Participants completed an exit survey at the end of each module. RESULTS: Eighteen residents completed four modules from the academic years of 2008 to 2009 to 2011 to 2012. The first year was considered a pilot module, and data were collected for the following 3 years. Knowledge of legal issues improved significantly among residents (mean at pre = 3.40 and post = 4.60, P < 0.05). Residents' ethical reasoning skills also improved across years (mean 3.60/5 in 2009-2010, 3.76/5 in 2010-2011, and 4.33 in 2011-2012, P < 0.05). Survey results revealed a statistically significant self-perceived improvement in ethics reasoning skills (mean pre = 3.62, post = 4.86, P < 0.05). Participants reported that the curriculum was relevant to their practice (85%), that the debriefings were of high quality (83%), and that they would recommend this module to others (88%). CONCLUSION: To our knowledge, this is the first study exploring a longitudinal simulation-based ethical-legal curriculum tailored to otolaryngology-head and neck surgery residents. This educational program resulted in a both objective and subjective improvement in legal and ethics knowledge and skills. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:2501-2509, 2017.

Pierre Robin sequence: review of diagnostic and treatment challenges.

Pierre Robin sequence is not a rare condition and paediatric specialists caring for respiratory related issues are likely to encounter cases in their practice. There have been a few recent reviews on the topic, mostly focusing on the surgical interventions performed for cases with severe airway obstruction. In the present review, we will highlight the different challenges that remain today in the global evaluation of infants afflicted with this condition through a thorough review of the medical literature, giving the clinician a full scope of the disease and of the various management options. The need for an improved objective evaluation of airway obstruction and for a better classification will be emphasized. We are therefore proposing a novel classification scheme that will better account for respiratory and feeding difficulties in these infants. Finally, many knowledge gaps persist regarding this condition, underlining the necessity for further research both in the genetic field and regarding the outcome of therapy.

The relationship between upper airway collapse and the severity of obstructive sleep apnea syndrome: a chart review.

BACKGROUND: We sought to determine the ability of the endoscopic Mueller maneuver (MM) to predict the severity of OSAS based on upper airway (UA) collapse. METHODS: This chart review retrospectively analyzed the results of endoscopic Mueller maneuvers examining the UA on 506 patients suspected of having OSAS. There were 3 areas of UA collapse that were evaluated: velopharynx (VP), base of tongue (BOT), and lateral pharyngeal walls (LPW). A sleep study was done after the examination to assess the severity of OSAS based on the apnea-hypopnea index (AHI). RESULTS: A total of 506 patients met criteria for OSAS, with 194 mild cases (5 ≤ AHI < 15), 163 moderate cases (15 ≤ AHI < 30) and 149 severe cases (30 ≤ AHI). At the VP, 30 patients had minimal collapse (mean AHI = 17); 41 patients had moderate VP collapse (mean AHI = 25); 392 patients had severe VP collapse (mean AHI = 27). At the BOT, 144 patients had minimal collapse (mean AHI = 19); 187 patients had moderate BOT collapse (mean AHI = 24); 175 patients had severe BOT collapse (mean AHI = 33). At the LPW, 158 patients had minimal collapse (mean AHI = 20); 109 patients had moderate LPW collapse (mean AHI = 25); 120 patients had severe LPW collapse (mean AHI =33). The correlations found between VP collapse, BOT collapse, and LPW collapse and OSAS severity were: r = 0.069 (95% CI; -0.022, 0.16), r = 0.26 (95% CI; 0.18, 0.34) and r = 0.22 (95% CI; 0.12, 0.31), respectively. CONCLUSIONS: In this study, the degree of collapse of the UA at all levels, especially at the BOT and LPW levels, correlate significantly with the severity of OSAS. The Mueller maneuver helped identify patients with severe sleep apnea based on UA collapse. The MM cannot be used to diagnose OSAS, but can be a valuable tool to help the physician estimate the severity of sleep apnea and the urgency to obtain a sleep study.

Lund-Mackay and modified Lund-Mackay score for sinus surgery in children with cystic fibrosis.

OBJECTIVE: Patients with cystic fibrosis (CF) frequently present with severe sinonasal disease often requiring radiologic imaging and surgical intervention. Few studies have focused on the relationship between radiologic scoring systems and the need for sinus surgery in this population. The objective of this study is to evaluate the Lund-Mackay (LM) and modified Lund-Mackay (m-LM) scoring systems in predicting the need for sinus surgery or revision surgery in patients with CF. METHODS: We performed a retrospective chart review of CF patients undergoing computed tomography (CT) sinus imaging at a tertiary care pediatric hospital from 1995 to 2008. Patient scans were scored using both the LM and m-LM systems and compared to the rate of sinus surgery or revision surgery. Receiver-operator characteristics curves (ROC) were used to analyze the radiological scoring systems. RESULTS: A total of 41 children with CF were included in the study. The mean LM score for patients undergoing surgery was 17.3 (±3.1) compared to 11.5 (±6.2) for those treated medically (p<0.01). For the m-LM, the mean score of patients undergoing surgery was 20.3 (±3.5) and 13.5 (±7.3) for those medically treated (p<0.01). Using a ROC curve with a threshold score of 13 for the LM, the sensitivity was 89.3% (95% CI of 72-98) and specificity of 69.2% (95% CI of 39-91). At an optimal score of 19, the m-LM system produced a sensitivity of 67.7% (95% CI of 48-84) and specificity of 84.6% (95% CI of 55-98). CONCLUSION: The modified Lund-Mackay score provides a high specificity while the Lund-Mackay score a high sensitivity for CF patients who required sinus surgery. The combination of both radiologic scoring systems can potentially predict the need for surgery in this population.

The new Genetico-Racial Skin Classification: How to maximize the safety of any peel or laser treatment on any Asian, Caucasian or Black patient.

The popular skin classifications, notably the 'Fitzpatrick' and 'Obaji' classifications, are primarily based on skin colour. Other criteria are occasionally considered, such as the degree of skin oiliness, thickness, sensibility, etc. Although these classifications are easy to understand and apply, their simplicity limits their precision, sophistication and applicability.The new genetico-racial skin classification proposed herein suggests that skin response to any peel or laser treatment is genetically programmed and is, therefore, linked to the genetic and racial origin of the patient. In other words, in addition to skin colour, the patient's facial features and ancestry should be taken into account when classifying any skin.The new genetico-racial skin classification enables the physician to determine with great precision, and before any peel or laser treatment, the level of the patient's suitability and the expected postoperative outcomes; therefore, reducing the likelihood of complications.

'Universal retraction suture' for the overprojecting nasal tip.

Achieving a proper nasal tip projection is a crucial element of a successful rhinoplasty. A large number of correction methods and manoeuvres have been proposed in the medical literature as solutions for the prominent nasal tip, thus complicating the surgeon's strife to choose the ideal plan of action. In the present article, a single straight-forward technique, christened the 'universal retraction suture', is suggested to tackle the overprojecting tip in a simplified, controlled and efficient fashion.

Pneumatic video-otoscopy teaching improves the diagnostic accuracy of otitis media with effusion: results of a randomized controlled trial.

BACKGROUND: the diagnostic accuracy of otitis media with effusion (OME) has been shown to be poor among medical students, residents, and practicing physicians. OBJECTIVE: to determine if the use of pneumatic video-otoendoscopic examination (VOE) improves the diagnostic accuracy of OME among residents. METHODS: pediatric residents were randomized into a "pneumatic" examination group (intervention) and a "still" examination group (control). The control group viewed a set of 25 still VOE images of the tympanic membranes of both normal and OME ears. The intervention group viewed the same still images but with the addition of pneumatic VOE assessments. Each resident documented each of his or her diagnoses as normal or OME. The accuracy of assessment for both the static and the pneumatic methods was compared. RESULTS: twenty-nine pediatric residents participated in this study: 15 in the intervention group and 14 in the control group. The overall diagnostic accuracy was 91% for the intervention group versus 78% for the control group (p  =  .0003). CONCLUSION: pneumatic video-otoscopy teaching improves the diagnostic accuracy of OME among residents.

Nipple reduction - An adjunct to augmentation mammaplasty.

Nipple hypertrophy is an occasional deformity in Asians and a rare one in Caucasians. Lately, it has been showing up more often in plastic surgeons' offices across North America and elsewhere, owing to the influx of Asian immigration worldwide, as well as to the rising interest in esthetic surgery among Asian communities.A simplified technique for nipple reduction is described herein. It is very easy to execute, delivers accurate results and is extremely safe. It tackles both the excessive 'projection' and the less frequent excessive 'width' of the nipple. It may be used separately or incorporated as an adjunct to mammary augmentation or mastopexy. Excellent esthetic results are obtained, while both the nipple innervation and its lactiferous ducts are preserved. The patient's and surgeon's satisfaction is high.

Predicting the results of rhinoplasty before surgery: Easy noses versus difficult noses.

A major problem for many rhinoplastic surgeons is the ability to predict, before surgery, the difficulty of the procedure (whether the rhinoplasties will be technically easy or technically difficult to perform) and the success rate of the result (whether the rhinoplasty will likely give good results or poor ones).The present paper outlines a systematic approach to nasal analysis, allowing the surgeon to consistently estimate, before surgery, the degree of technical difficulty of each rhinoplasty, as well as predicting its future result in terms of patient satisfaction. This preoperative evaluation is based on the analysis of the skin texture and the osteocartilagenous framework on lateral and frontal views. It allows for the nose to be classified as green (easy), yellow (moderate) or red (difficult), depending on two factors: the degree of surgical difficulty and the expected patient's satisfaction with the result.The essence of the present paper is to introduce a simple, systematic approach to assist the novice rhinoplastic surgeon to assess the complexity, the risks and the expected outcome of a rhinoplasty in the preoperative period, rather than postoperatively.